A Theoretical Model of Calming Technology: Designing to Mitigate Stress and Increase Calm

Neema Moraveji, Marily Oppezzo, Stephanie Habif, Roy Pea Calming Technology Lab, Stanford University, Palo Alto, CA
Abstract Calming technologies are systems that induce cognitive, physiological, and/or affective states of calm for their users. For the purposes of this paper, we operationalize calm as restful alertness, or a state where one is present and able to perform in a sustainable manner. We first describe motivation for calming technologies based on the relaxation response and psychophysiological research on stress. A working definition of the different aims and types of calming technologies follows. A theoretical model of calming technologies is presented based on observed characteristics of calming technology prototypes. Implications for future research are discussed. Stress & Stressors, Calm & Calmors Stress is a causal or correlational factor to the six leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide (APA, 2011). Specifically we are interested in stress as it refers to distress, which differs from eustress, positive stress, or general stimulation (Selye, 1975). Stress can be absolute (objective and universal to all humans) or implied (subjective to the person in question) (Lazarus, 1966). A stressor is a source causing stress (Selye, 1975). Four determinants can characterize stressors (Mason, 1968), (Dickerson & Kenney, 2002): they are interpreted as novel; feel unpredictable; trigger a feeling of lack of control; and trigger feeling a social evaluative threat. Chronic exposure to stressors can lead to serious negative cognitive, physiological, and affective health consequences (see more below). For a comprehensive review of the physiology of stress, see Lupien, McEwen, Gunnar and Heim (2009). The stress response is counteracted by the relaxation response, a coordinated physiological response characterized by decreased arousal, diminished heart rate, respiratory rate, and blood pressure, in association with a state of wellbeing (Benson, 1983). Often induced through progressive relaxation (Vaitl, et al., 2005), the relaxation response is clinically shown to help mitigate the negative effects of stress (Lang, 2000; Vasterling, 1993; Syrjala, et al., 1992). Some clinically effective relaxation techniques encourage one to let go. Others enable one to reach an attentive and calm state based on self-directed attention and self-regulation of the body and mind. For example, meditative practices often produce an aroused and focused state, rather than the inert and un-aroused, relaxed state often associated with meditation (Cahn & Polich, 2006). We operationalize calm as restful alertness or, a state where one is present and able to perform in a sustainable manner. Many literatures have identified the biological, emotional, and cognitive value of calm states. Mind/body practices that elicit calm have been practiced for thousands of years (Benson, 1983) and a recent national survey indicated that these techniques are used by 30% of the US adult population today (Barnes, 2002). Beyond various personal practices, a number of calming therapies are administered through modalities including haptic (e.g., touch, caress), environmental (e.g., eco-therapy), mental or mindset (e.g., cognitive re-framing, meditation), auditory (e.g., soothing tones), and olfactory (e.g., lavender as a calming smell). Paralleling Selyes (1975) stressors, we use calmors to describe both practices and therapies that produce calm states. Calmors, like stressors, can be implied (subjective) or absolute (objective). Calming Technology Calming technologies (CTs) are systems that induce cognitive, physiological, or affective states of calm (Moraveji, Oshidary, Pea, Fogg, 2011). They do so by delivering or inspiring the user to self-initiate calmors. Inducing a state of calm can occur by triggering a conscious thought, a change in perception, behavior, and/or knowledge state. Because CT does not necessarily seek to automate behavior (i.e., its goal is producing a state) or to track behavior as its primary goals, it differs from both persuasive technology (Fogg, 1997) and personal informatics (Li, Dey, Forlizzi, 2010), respectively. In practice, some persuasive and personal informatics tools do aim to induce calm. We distinguish two fundamental types of calming technology: calm-dedicated and calm-augmented. Calm-dedicated systems are created explicitly and solely for calming purposes (e.g. an application that encourages calm breathing

patterns) while calm-augmented systems are meant for a primary function but include calming elements (e.g. a word processor with restricted features and soothing tones). A review of existing calming technologies is beyond the scope of this paper, but a number of tools are reviewed in the Prototypes section below. To describe how different CTs can produce the desired state in their users, we describe below three areas where stress has negative consequences: cognitive, physiological, and affective. Cognitive Health and Stress Stress can have a number of negative effects on cognition and memory (Lupien, et al., 2009). Even mild acute uncontrollable stress can cause a rapid and dramatic loss of prefrontal cognitive abilities (Arnsten, 2009); more prolonged stress exposure has been shown to cause architectural changes to the prefrontal cortex (PFC) (Arnsten, 2009), decrementing working memory, behavior regulation, and attention regulation (Goldman-Rakic, 1996). CTs can promote calm cognition by sustaining ones attention or eliminating distractions, increasing self-regulation, and increasing focus on solutions (rather that roadblocks) when solving problems. The benefits of CTs delivering physiological calmors, for example, can be cognitive in nature. Physiological Health and Stress The physiological effects of chronic stress have been and continue to be extensively studied. There are negative cardiovascular and neurological (Sapolsky, 1996) effects of chronic stress. Allostatic load (McEwen, 1999) is the physiological consequence of chronic exposure to fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress (Taylor, 2006). It can accrue as a result of four processes: 1) frequent activation of the stress response, 2) failure to habituate to repeated stressors of the same kind, 3) failure to shut off the stress response appropriately, and 4) inadequate reaction to the stress response. CTs counteract these physiological behaviors, actions, or states in myriad ways such as promoting calm respiratory patterns (Ley, 1994), reducing muscle tension (Peper, et al., 2003), eye-movement desensitization and reprocessing (EMDR) (Ironson, et al., 2002), and triggering progressive relaxation (Vaitl, et al., 2005). Affective Mental Health and Stress Prolonged stress is a major risk factor for depression (Mazure & Maciejewski, 2003) and exposure to traumatic stress can cause post-traumatic stress disorder (PTSD) (Southwick, et al., 2005). Stress can also exacerbate schizophrenia (Dohrenwend et al., 2005) and bipolar disorder (Hammen & Gitlin, 1997). CTs can mitigate these issues by inspiring and motivating users to maintain a positive short- and long-term outlook, savor current and past experiences, and reframe negative situations. A Theoretical Model of Calming Technology Based on prototypes such as those described below, we propose a theoretical model shown in Figure 1.

Figure 1. A theoretical model of calming technology.

Nature of Stress CTs should be designed with some understanding of the nature of stress, how it emerges, and its effects on the body, cognitively, physiologically, and emotionally. By identifying the stressors characteristics (e.g., novelty, inadequate coping skills, etc.) in the domain where the person is feeling stressed, (e.g., productivity, relationships, etc.), one can begin to isolate the particular sub-components of the domain that actually are stressful. For example, many people feel stress when opening their e-mail inbox. Rather than targeting the inbox as a whole, the designer can identify exactly what is stressful about reading e-mail in the inbox e.g., the possible social evaluative threat of not responding to e-mails fast enough. Calming Mechanisms To be effective, CT design should consider the mechanisms through which a stimulus can have a calming effect (and insights from the vast literature on different calming therapies). CTs can elicit different sensory experiences or aim to directly mitigate the specific characteristics of stressors. These main methods of designing calming mechanisms into a technology include: a) reducing or eliminating the presence of effects of a stressor or b) introducing or magnifying calmors, or c) both. CTs that introduce novel calmors, for example, can attempt to expose people to experiences that consciously or subconsciously increase calm in their daily lives. User-Centered Design (UCD) An understanding of UCD and interaction design is fundamental for evaluating and designing methods of embedding calming mechanisms, and for understanding how stressors became embedded into an existing technology in the first place. To the extent that one develops understanding of how the user is experiencing his or her context one will be more effective in targeting implied stressors. Furthermore, stress has been shown to effect people differently at different ages (Lupien, et al., 2009); thus a CT targeting a teen stressor in his or her teens may be ineffective for senior citizens. Illustrative Examples This section draws upon a number of calming technology prototypes to illustrate the utility of the theoretical model described above. In Spring 2011, an author of this paper co-taught a course in the Computer Science department at Stanford University entitled Behavior Design for Calming Technology (Fogg, Moraveji, 2011). In this projectbased course, students were asked to create a number of mobile prototypes that induced a state of calm in their users. They studied aspects of stress and stressors, chose a calming mechanism that was appropriate to their chosen domain, and then deployed, assessed, and iterated on their prototypes. We highlight three mobile applications below to illustrate how they informed the model. 5 Words: This prototype sends a text message to students at the culmination of a lecture. It asks them to consolidate their understanding of the lecture in 5 words or less to describe its most interesting insight. Later, a list of the top 10 insights from peers in the class is sent to all who responded. Users then vote on which they like best and, at the end of the day, a final text is sent to all students with the insight that received the most votes. This prototype addresses a specific stressor: the lack of control when feeling overwhelmed after a lecture. The calming mechanism substitutes this by asking the user to do something relatively simple: produce a five-word insight. By doing this, students can feel theyve consolidated their knowledge and also rest assured they will see insights from their peers. The timing of the initial text message and the length of the response were both designed with an understanding of the users context. LookFwd: The goal of this interactive prototype is to induce a calm state at the beginning of ones day by making salient in ones mind something positive to look forward to that day. A text message is sent to a users phone, with a different template each day that prompted two words: something to look forward to and a qualifier. For example: Fill in the blank: Today, Im looking forward to (food dish) at (place). Later in the day, users saw responses or aggregate summaries about responses from peers. There was a 78% compliance rate over 7 days, 60% of which was a response via text message within 30 minutes. In this example, the stressor addressed is the feeling of impending overwhelm when waking at the start of the day. The service introduces a calmor by scaffolding a positive intention and visualization method. The designer understood that text messages are one of the first things seen when the target user wakes up in the morning. They also understood that seeing peer responses would motivate them to participate by responding.

SMS Morphine Drip: In this prototype, the target users are injured athletes who are experiencing stress as a result of physical pain. Personalized and generic SMS-based calmors such as soothing messages, images, inspiring stories, and pain assessment prompts are delivered via text message. The system operates in either a user-initiated pull manner, where the user texts an SOS when in pain, or system-initiated push, where a pain check is sent out during the users typical peak pain times of the day. This gives users a sense of control over their own pain management, and seeks to decrease the subjective cognitive and emotional suffering that accompanies physical pain. Discussion and Future Work The growing public, academic, and policy interest in sustainable means of healthful living and optimal human performance provides fertile growth opportunities for calming technology. With the increase of chronic diseases and a changing focus from disease management to preventative behavior and health promotion, finding effective ways to increase calm in peoples lives is crucial. Additionally, with the intense societal focus and value on improving productivity, efficiency, and life management, calming technology provides a necessary counterbalance. The CT concept originates from a desire to increase awareness surrounding a state of being, rather than doing; we believe that without adequate balance between the two states, both health and productivity will suffer. An interesting irony is that CT inhabits a space that is often thought to contribute to the very problem, stress, which CT hopes to correct: technology. It also suggests an obligation of HCI designers to consider the potential negative health impacts that their programs can inadvertently incur. For example, outfitting a new word processing application with a calm-augmentation CT could mitigate the common risk of mindless, efficiency driven, necktensing usage that typically accompanies work productivity-enhancing technologies. At first glance, calming technologies may be easily dismissed as vague, difficult to define, and with design goals that are difficult to specify. However, the theoretical model described above helps formalize and specify exactly how calming technologies produce calm states. By understanding how stress occurs, appropriate calmors can be designed into technologies to augment their primary function or the lives of their users. We are engaged in a several initiatives to initialize a scholarly foundation for evaluating and designing technologies in this field. Just as stressors contain four determinants, our lab is working towards defining the determinants of calmors. We are also working on a predictive model of calming technology that can help model effects in the design process of calming technologies. Third, we are developing a set of design principles for calming technology based on our extensive expertise in prototype design, deployment, and iteration with users. Further, we are building a calming potential index so that different tools can be evaluated and compared against one another. This index would also be a useful metric for technology consumers; by giving them a quantified way of assessing the potential calmors or stressors in their tools, they can make informed choices and design their environments accordingly. Just as a person wants to know the amount of dietary fiber a food they eat may be contributing to ones dietary health, it would be informative to know how much calming a product may or may not be adding to ones state. Conclusion Stress has a measureable effect on human health and performance. Our theoretical model of calming technology guides the development and analysis of CTs that increase the state of restful alertness in users through cognitive, physiological, or affective means. We used descriptions of three prototypes to illustrate how the model can be applied for a variety of stressors and calmors. The discussion described pressing research issues in CT, namely evaluation methods, predictive models, and design principles. References 1. 2. 3. 4. 5. 6. American Psychological Association. http://www.apa.org/helpcenter/stress-effects.aspx. Retrieved July, 2011. Antonovsky, A. (1987). The salutogenic perspective: Toward a new vision of health and illness. Advances, 4: 4755. Arnsten, A.F.T. (2010). Stress signaling pathways that impair prefrontal cortex structure and function. National Review of Neuroscience, 10(6), 410-422. Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1997). Self-Efficacy: The Exercise of Control, New York: WH Freeman. Barnes, PM. Complementary and alternative medicine use among adults: United States, 2002.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.

Benson, H. (1983). The relaxation response: its subjective and objective historical precedents and physiology. Cahn, B.R., & Polich, J. (2006). Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological Bulletin, 132(2), 180-211. Csikszentmihalyi, M. 1990. Flow: The psychology of optimal experience, New York: Harper. Emmons, R.A., & McCullough, M.E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2). Dohrenwend, B.P., Shrout, P.E., Link, B.G., Skodol, A.E., Stueve, A. (1995). In Mazure, C.M. (Ed). Does Stress Cause Psychiatric Illness? (pp. 43-65). Washington DC: American Psychiatric Press. Glanz, K., & Bishop, D.B. (2010). The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health, 31, 399-418. Gochman, D.S. (1982). Labels, systems and motives: some perspectives on future research. Health Education Quarterly, 9, 167-174. Goldman-Rakic, P.S. (1996). The prefrontal landscape: implications of functional architecture for understanding human mentation and the central executive. Philosophical Transactions of the Royal Society B: Biological Sciences, 351(1346), 1445-53. Grol, R.P., Bosch, M.C., Hulscher, M.E., Eccles, M.P., Wensing, M. (2007). Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Quarterly, 85, 93-138. Hammen, C., & Gitlin, M. (1997). Stress reactivity in bipolar patients and its relation to prior history of disorder. American Journal of Psychiatry, 154(6), 856-7. Lazarus, R.S. (1966). Psychological Stress and the Coping Process. New York: McGraw-Hill. Lupien, S., McEwen, B., Gunnar, M., Heim, C. (2009). Effects of stress throughout the lifespan on the brain, behavior, and cognition. Nature Reviews - Neuroscience. June 2009, Vol 10. Mazure, C.M., & Maxiejewski, P.K. (2003). A model of risk for major depression: effects of life stress and cognitive style vary by age.Depression and Anxiety, 17(1), 26-33. McAlister, A.L., Perry, C.L., Parcel, G.S. (2008). How individuals, environments and health behaviors interact: social cognitive theory. In K. Glanz, B.K. Rimer, & K. Viswanath (Eds.), Health Behavior and Health Education: Theory, Research, and Practice. (pp. 167-88). San Francisco: Jossey-Bass. 4th Ed. Peper, E., Wilson, V., Gibney, K., Huber, K., Harvey, R., Shumay, D. (2003). The Integration of Electromyography (SEMG) at the Workstation: Assessment, Treatment, and Prevention of Repetitive Strain Injury (RSI). Applied Psychophysiology and Biofeedback. Vol. 28, Number 2. Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, 1102-1114. Rosenstock, I.M., Strecher, V.J., & Becker, M.H. (1988). Social learning theory and the health belief model. Health Education Quarterly, Summer, 15(2): 175-83. Rothmann, S. I. (2004, July). Resilience in organizations. Second European Conference on Positive Psychology, Italy. Salanova, M. P. 2004. Engagement and burnout: Analyzing their associated patterns. Psychological Reports, 94: 10481050. Sandi, C., & Pinelo-Nava, M.T. (2007). Stress and memory: behavioral effects and neurobiological mechanisms. Neural Plasticity, 78970. Sapolsky, R. (1996). Why stress is bad for your brain. Science. Vol. 73, August. Schaufeli, W., & Salanova, M. (2004, July). Towards a truly occupational health psychology. Second European Conference on Positive Psychology, Italy. Seligman, M.E.P., Steen, T., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410-421. Selye, H. (1975). Confusion and controversy in the stress field. Journal of Human Stress 1: 3744. Southwick, S., Rasmusson, A., Barron, X., Arnsten, A.F.T. (2005). In Vasterling J.J., Brewin, C.R. (Eds). Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives. (pp. 27-58). New York. Vaitl, D., Birbaumer, N. Gruzelier, J., Jamieson, G.A., Kotchoubey, B., Kubler, A., et al., (2005). Psychobiology of altered states of consciousness. Psychological Bulletin, 131, 98-127. Will, J.C., Farris, R.P., Sanders, C.G., Stockmyer, C.K., Finkelstein, E.A., (2004). Health promotion interventions for disadvantaged women: overview of the WISEWOMAN projects. Journal of Womens Health, 13, 484-502.