Chronic: How Understanding Your Pain Can Change Your Pain

Danna Krouham Efter

How Understanding Your Pain Can Change Your Pain

CHRONIC

How Understanding Your Pain Can Change Your Pain

Danna Krouham Efter

To my husband, David

For your unconditional love, support; for picking me up when I need it, and keeping me going to the finish line.

To my dad, Alexander Oliver

For years of guidance, mentorship, nurture, and teaching me than I am capable of doing anything.

“Keeping your body healthy is an expression of gratitude to the whole cosmos- the trees, the clouds, everything.”

Thich Nhat Hanh

Finley Health p.98 Psychological p.114 Belly Brains p.124 Conclusion p.144 Acknowledgements p.146 Glossary p.148 Bibliography p.154

DESIGN MANIFESTO

My personal view on design.

Creativity and design are both part of our innate, childhood approach to life. If we lose this essence, we end up designing without soul or purpose.

Design is inherently kind; it encompasses every possible need of the audience you want to reach. It is purposeful, transmits emotion, brings joy to our lives, and inspires us. A successful design is impermanent and transformative, visible and invisible; it pushes its observers to do more and be better, and dictates how an experience is lived. But above all else, it is intended to be shared.

My definition of impermanent design is knowing that the process has to be fluid and constantly evolving. There is no such thing as a finished design (physical or abstract). Our thought processes, ideation, and executions are purely ephemeral, so why do we think we should build for permanence? Life, ideas, and thoughts are always being reshaped. We are continuously growing, so let’s build on embracing this change.

Design has to be ethical, honest, efficient, sustainable, conscious, empathetic, creative, and versatile to transmit emotion and leave a lasting impact on the spectator or user. Design has to be specific enough to be user-centric, addressing users’ needs, but broad enough to be life- and planet-centric, taking a holistic approach.

As problem identifiers and solution creators, let us keep in mind who we are serving and why we are serving them. My philosophy is that designing for all is not designing at all.

Let us design for impact, for systems, for change. Never focus on just an artifact. This expression is not necessarily tangible. It’s more a way of thinking: seeing things, and perceiving what they are, what they are not, and what they could be.

We are designing for a future that looks challenging, dynamic, and full of opportunities. Tomorrow’s design projects will require a more thoughtful approach, faster creative processes and turnarounds, further flexibility and adaptability for new technologies, and a broader and more holistic approach.

As impermanence is key both in design and in life, this manifesto is also meant to be impermanent. It is susceptible to change in the same ways that I am, as a flowing, evolving, and growing being.

What do we know about pain?

“English,” wrote Virginia Woolf, “which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver of the headache… The merest schoolgirl, when she falls in love, has Shakespeare, Donne, Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.”1

Pain is not merely a phenomenological experience, damaged tissue, or a bodily or emotional reaction. Instead, each of these is a single factor in a more complex system. This fact is not surprising, given that all of our sensory systems work this way. In each case, several components work together to provide information about the world. Our pain system is no exception. Its components take readings of pressure, temperature, and chemical activity in our tissues in order to determine whether damage to our bodies is occurring. As with all sensory systems, the pain processing system is complex. It is a welltuned system designed to monitor certain aspects of the world to promote our well-being.

But we must issue an important caveat: Pain is the product of a complex sensory system fighting for attention. Our conscious perception of pain is a result of both nociception (detection of painful stimuli) and the activity of the pain inhibitory system (PIS). Despite the fact that nothing about painful experiences is profoundly mysterious, they are neither random nor inexplicable.

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with or

1 Woolf, Virginia, On Being Ill, 1926, 34.

resembling that associated with actual or potential tissue damage.”2 Although this definition makes sense, it is not entirely correct. Humans are an emotional, psychological, and social species. Neuroscience has also taught us that no single pain center in our body is responsible for feeling and experiencing pain. Thoughts, emotions, and attentional processes live in parts of our brain that contribute to and may be responsible for pain expression. Some examples of occurrences in your mind and body are: registering the emotional unpleasantness of pain; encoding pain intensity and pain location; and initiating movement away from painful stimuli, painful memories, and points of fear, anxiety, and other emotions. Our brains bundle all of this together by integrating sensory, cognitive, and emotional pieces of information to engender and regulate pain.

But why do we have pain? How does it actually work? We might all think that it would be wonderful to live without pain—who needs pain? Well, the contrary is actually true. Pain evolved alongside humans as a life-saving mechanism, acting as a warning system built to respond to danger or lifethreatening situations, ensuring your safety and well-being. Pain that doesn’t bother you or catch your attention fails to protect you, as there is no behavior change, leaving you at risk of getting hurt. Feeling pain is in fact a good thing; people born without the ability to feel pain don’t live very long3 because they don’t have this warning system that acts as an initial defense mechanism.

2 “IASP Announces Revised Definition of Pain.” International Association for the Study of Pain (IASP), July 16, 2020. https://www.iasp-pain.org/publications/iasp-news/ iasp-announces-revised-definition-of-pain/.

3 Zoffness, Rachel. “Pain Science 101.” Chapter 1. In Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 9. Oakland, CA: New Harbinger Publications, Inc., 2020.

Dr. Rachel Zoffness, M.S., Ph.D., pain and health psychologist, leading global pain expert, and author of The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, explains that “despite the fact that we experience pain in our bodies, pain is actually constructed by the brain.”4

emotions, memories, and thoughts, which change the meaning we assign to our experience with pain. When we include this information as we try to understand pain, we learn that pain is not always an indicator of tissue damage. Rather, “pain is an interpretation, your brain’s best guesstimate based on all available information.”6

She further shares that evidence of this comes from the medical phenomenon known as phantom limb pain. According to the Mayo Clinic, “Phantom pain is pain that feels like it’s coming from a body part that’s no longer there.”5 If pain lived exclusively in the body, no limb would mean no pain. This prompts us to look elsewhere, and science tells us to look at the brain.

Your brain produces pain when there is reason to protect you from any harm or danger. The nociceptors, which are sensory receptors in our body, collect information around us and alert us to potential damage by detecting extremes in temperature, pressure, and chemicals. This collection of information comes from context, experiences,

4 Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 10.

5 “Phantom Pain.” Mayo Clinic. Mayo Foundation for Medical Education and Research. Accessed March 28, 2022. https://www.mayoclinic.org/diseases-conditions/ phantom-pain/symptoms-causes/syc-20376272.

Although there is a lot of information on how pain behaves inside our body, pain is still a subjective experience that presents itself in various forms. We are used to having to express our pain level on the best-known Wong-Baker pain rating and faces scale7 (typically 0-10 where zero means no pain, and ten means worst pain). Although this tool was created to help children communicate pain to doctors, it’s now widely used across the medical field for people of all ages. Even though tools like these exist to help us express our pain, we mainly get challenged by them. When a patient chooses a high number such as nine on the pain scale, doctors usually push back with, “Pain nine would probably mean that you lost a limb; do you feel that much pain?” Our answer is most likely to be no, and this comparison makes us minimize our pain and tell our brain and body that maybe it doesn’t hurt as much. This pushback causes people to doubt whether their pain is real, and hinders the process of trying to understand their pain in order to fix or terminate it.

6 Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 10.

7 Wong-Baker FACES History.” Wong-Baker Faces Foundation. Accessed February 20, 2022. https://wongbakerfaces.org/us/wong-baker-faces-history/.

The Pain Management Workbook by Rachel Zoffness, M.S., Ph.D.

Pain is an interpretation, your brain’s best guesstimate based on all available information.

Pain frequently carries with it fear, anxiety, and dread. These emotions perpetuate the chronic pain cycle, leading to pain continuation and intensification, as we’ll soon discover. However, we can interrupt this cycle when we understand how pain works, what it signals and what it doesn’t, what makes it worse, and what alleviates it.8 Research suggests that understanding your pain can actually change your pain. Increased confidence and motivation, reduced catastrophic thinking, more accurate pain perceptions, lower impairment, improved physical performance, fewer doctor’s appointments and medical procedures, and less pain are all possible outcomes of pain education.

Pain is a complex, subjective experience that presents in myriad ways. If you feel pain, it’s real, and no doctor, specialist, or any other person should tell you otherwise.9 Some pain comes and goes quickly, disappearing within weeks or a few

months. This is called acute, or short-term, pain and is commonly the result of an injury, surgery, or acute illness. When pain persists beyond the expected healing time, typically lasting six months or longer, it’s called chronic or persistent pain. According to the 2019 National Health Interview Survey (NHIS), 50.2 million American adults (20.5%) reported pain on most days or every day.10 I am aware that I’m not able to change the lives of 50.2 million adults over the span of eight months, but I can change the lives of a few by educating them about pain, specifically chronic pain.

Chronic, or ongoing, pain can be linked to a condition such as migraines, cancer, or arthritis. Conversely, it can also be related to emotions (anxiety, depression, anger), cognitive factors (thought, beliefs, perceptions), environmental context (stressors, traumatic experiences, physical environment), and social factors (family, socioeconomic status, access to care).11 Chronic pain can interrupt your life; it can make you quit work or hobbies, stay indoors all day, break social interactions, terminate your sex life, and prevent you from fulfilling your goals and dreams. It may even cause you to hate life itself. By understanding our pain, we might be able to prevent these intense reactions.

Until recently, pain was typically considered a biomedical problem requiring medications and surgeries. Now, however, we now understand that it’s much more. As mentioned, multiple factors influence the pain we feel, such as emotions, perceptions, environmental context, and cultural

8 McAllister, Murray J. “What Is Chronic Pain Syndrome: Chronic Pain Syndrome Symptoms.” Institute for Chronic Pain. Institute for Chronic Pain, April 27, 2012. https://instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/ chronic-pain-syndrome.

9 Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 8

10 Yong, Jason R, Peter M Mullins, and Neil Bhattacharyya. Issue brief. Prevalence of Chronic Pain Among Adults in the United States. Vol. 163. PAIN, Februrary 2022. The Journal of the International Association for the Study of Pain, n.d.

11 Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 4

History of the Wong-Baker FACES® Pain Rating Scale Wong-Baker FACES® Foundation

and social considerations. This view of chronic pain affirms that it is not just biological, but biopsychosocial (short for biological, psychological, and social). This model, introduced in 1977 by American internist and psychiatrist George L. Engel, states:

“To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of healthcare, a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the healthcare system. This requires a biopsychosocial model… The boundaries between health and disease, between well and sick, are far from clear and never will be clear, for they are diffused by cultural, social, and psychological considerations.”12

To Engel’s point, chronic pain is most likely to be treated as a biomedical problem while excluding psychosocial factors, leaving critical aspects of pain unaddressed, unidentified, and poorly treated.13 In order to effectively treat it, we have to understand that the biological, psychological, and social aspects are interconnected and equally important, and that one cannot exist without the other two.

I believe that design can be used to solve wicked problems, and almost one in five Americans suffering from chronic pain sounds like a wicked problem.

Design is about creating solutions for people in creative and sustainable ways that are human-, life-, and planet-centric.

Design is the synthesis of both art and science—art by expressing the designer’s vision, thoughts, and feelings; and science by approaching a problem in a comprehensive and systematic way.

Chronic pain is an urgent issue. As previously mentioned, 50.2 million Americans are affected by chronic pain. Besides being personally distressing, chronic pain also has an enormous economic and financial impact on most countries. A study conducted by doctors at Harvard University and Harvard Medical School notes that people with “chronic pain reported missing significantly more workdays than those without chronic pain (10 days versus fewer than 3 days),” and the total economic impact of chronic pain on Americans is nearly $80

12 Engel, George L. “The Need for a New Medical Model: A Challenge for Biomedi cine”, 386. University of Rochester Medical Center, 1977. https://www.urmc.rochester. edu/MediaLibraries/URMCMedia/medical-humanities/documents/Engle-Challengeto-Biomedicine-Biopsychosicial-Model.pdf.

13 Darnall, Beth. Psychological Treatment for Patients With Chronic Pain. Firsted. Washington, DC, WA: American Psychological Association, 2019.

“The treatment of a chronic pain patient has become a multidisciplinary effort.”

- Wilbert E. Fordyce, Ph.D.

billion in lost wages.14 Chronic pain’s toll on the economy is part of a larger system where healthcare has profoundly failed Americans. Pain scientist, psychologist, author, and associate professor at Stanford University, Beth Darnall, Ph.D., comments that patients with chronic pain are stigmatized as “hard” or “difficult to treat.” These patients have received numerous treatments, including medication and surgical interventions, but these are not necessarily right or effective for them; these treatments are just the most expedient way out.15 Acute and chronic pain have to be treated differently every single time, and the contemporary American healthcare system tends to treat chronic pain as if it were acute.

THESIS

THE PAIN JOURNEY

People with chronic pain deserve to learn that they can be healthy and happy even with some pain. I’m here to educate and help people realize that health should not be interpreted as the absence of disease, but rather as the enhancement of one’s capabilities to live in plenitude.

In this thesis, we will dive into the biopsychosocial sphere as individual representations of each component—biological, psychological, and sociological—to further acknowledge these elements. We will learn how they interact with and influence one another to create the experience of pain.

I invite you on this journey of discovering what chronic pain is and how understanding our pain can actually change our pain. By designing a suite of tools and experiences with a unified biopsychosocial approach, I believe we can help people understand their pain and ultimately reclaim control over their mind, body, and soul. This thesis is meant to serve as a learning experience by planting a seed in the reader’s mind into unfolding the power those in pain have over their pain.

14 Reno, Jamie. “Chronic Pain: The Impact on

Americans

2021. https://www.healthline.com/health-news/chronicpain-the-impact-on-the-50-million-americans-who-have-it

Healthline,

Darnall, Psychological Treatment

With Chronic

Biopsychosocial Approach with David Toomey

Biological components of health and pain include:

• Genetics

• Age

• Tissue damage

• Inflammation

• Disease severity

• Brain function

• Mechanical and anatomical dysfunction

• Immunological issues

These factors are commonly treated with medications and surgical interventions, but this mostly helps to solve for acute pain, not chronic pain.

Biological Psychological

The psychological components of health and pain encompass cognitive, emotional, and behavioral factors, including:

• Emotions

• Thoughts

• Beliefs

• Mood

• Stress

• Meaning we assign to our pain

• Memories

• Past experiences

• Expectations

• Coping behaviors

These factors are commonly treated with psychological or psychiatric interventions, medications, journaling, art, spirituality, exercise, and more. These treatments are more successful for dealing with chronic pain, but the right therapy must be paired with the right person.

Sociological

The sociological components of health and pain include societal, cultural, environmental, and economic factors, such as:

• Trauma

• Lack of social support

• Broken relationships

• Access to healthcare

• Age, culture, race

• Inadequate housing

• Income

• Abuse

• Hunger

• Isolation

These factors might be treated through psychological, medical, or political interventions and might be the most difficult to address and solve for. They are, however, part of sociological systems that are not always in one’s control, making it harder to break the vicious cycle.

PSYCHO

IMPACT & AUDIENCE

Who is this for? How relevant is this?

AUDIENCEIMPACT

SUFFERERS OF CHRONIC PAINWHY IS THIS RELEVANT?

According to the 2019 National Health Interview Survey (NHIS), “50.2 million American adults (20.5%) reported pain on most days or every day.”

Chronic pain also has an enormous economic and financial impact on most countries. A study conducted by doctors at Harvard University and Harvard Medical School notes that people with “chronic pain reported missing significantly more workdays than those without chronic pain (10 days versus fewer than 3 days), and… the total economic impact of chronic pain on Americans at nearly $80 billion in lost wages.”16

In this section, I identify the stakeholders of the work contained in this thesis, Chronic: How Understanding Your Pain Can Change Your Pain

Over the course of my interviews with subject matter experts (SMEs), I spoke to doctors, therapists, psychologists, nutritionists, dietitians, chefs, health and wellness entrepreneurs, clinical assistant professors, product designers, natural language processing (NLP) engineers, and Ph.D. research fellows. I also spoke with patients suffering from chronic depression, trauma, anxiety, arthritis, back pain, joint pain, and chronic side effects from medical and/or surgical interventions.

The end-group users I’m targeting are people who are currently experiencing or who have experienced chronic pain from a biological, psychological, and/ or social perspective.

I am here to help people realize that health should not be interpreted as the absence of disease, but rather as the enhancement of one’s capability to live in plenitude.

DESIGN CHALLENGE

Unifying the Biopsychosocial sphere.

BREAKING IT DOWN

TACKLING THREE CHALLENGES

To further understand how the biopsychosocial model developed by Dr. George Engel works, I will be individually unpacking what each component means to provide further insight into how each of them behaves in the context of pain.

For the biological component, we are going to learn how to feel pain; for the psychological component, how to be aware of pain; and finally for the sociological component, how to express and see pain.

BIOPSYCHOSOCIAL

UNIFYING THREE SPHERES

The causes of pain—and the most effective methods for treating it—are biopsychosocial. This means that these three components are interconnected and equally important when understanding, diagnosing, and treating chronic pain. These domains will always overlap to produce and reduce pain and symptoms. Because our brain and body are always connected, our social health, emotional health, and physical health are also inextricably intertwined.17

Taking care of or addressing one domain affects all domains.

By discovering the power of pain education, we are able to understand our pain from the inside out, including how it works, and how to interrupt the cycle of fear, dread, and anxiety to ultimately reclaim our health and well-being.

STRUCTURE

ORDER OF DOMAINS

To uncover what these domains of pain mean, we will begin looking at the sociological sphere in order to understand how we as human beings express and relate to pain. We will then continue with the biological and end with the psychological sphere.

RESEARCH

METHODS

Overview of methodologies.

PROCESS

VARIETY OF RESEARCH METHODOLOGIES

A variety of methodologies were used in the creation of this work, including interviews with numerous subject matter experts, user research, social experiences, and literature reviews. From the insights gathered, three design provocations were created to reflect the biopsychosocial sphere, prioritizing plenitude.

This work interrogates the current health landscape that has failed us, and suggests pathways to use

BACKGROUND

INTEGRATION OF PREVIOUS EXPERIENCES

This work is informed by my personal lived experiences with undiagnosed arm, chest, and shoulder chronic pain for the past twelve years;

27 05 | Research Methods critical and multidisciplinary thinking to create new solutions for, seeing, feeling, expressing, and being aware of pain. Ultimately, it intends to reveal a holistic approach to pain management, as the three components of the biopsychosocial sphere are always present during our relationship with pain.

Myself talking to people during the pain lab experience.

and from the tremendous influence my father, endocrinologist, internist, and the leading functional medicine doctor in Mexico, has had on my life. Drawing from my experience being brought up by a doctor, my approach to life and ultimately my point of view have been indirectly inspired by the methodologies of functional medicine. I have utilized this perspective during the research process to create the following design proposals.

TYPES OF MEDICINE

FUNCTIONAL vs. CONVENTIONAL

Conventional medicine, sometimes known as western medicine, analyzes the body from a biophysical standpoint, using the study of physics to comprehend how the body functions. It typically concentrates on treating the signs and problems of a particular area. Surgery, radiation therapy, and prescription medications are all examples of possible treatments.

On the contrary, finding the underlying cause of disease is the emphasis of functional medicine. By treating the underlying causes of health problems rather than merely the symptoms, functional doctors seek to restore health by working with their patients to understand how and why sickness occurs. The patient will learn about the specific genetic, biochemical, and behavioral aspects that affect their health from a functional doctor.18

18 Early, Janet. “Conventional, Integrative, and Functional Medicine: What’s the Dif ference and Which Is Right for You?” SteadyMD, January 22, 2021.

SECONDARY RESEARCH

BOOKS, SCIENTIFIC PUBLICATIONS, AND POPULAR MEDIA

30 Secondary research included reading books, scientific articles, and journals; following health and wellness influencers and trends on social media; being immersed in current political and social news; and unfolding the relationship between our current health needs as a society and what the government health system looks like.

PRIMARY RESEARCH

CONVERSATIONS WITH SUBJECT MATTER EXPERTS

I had the opportunity to talk with over 20 subject matter experts about patient-doctor relationships; the current healthcare system in the U.S., including insurance; and depression and anxiety, mental health, and social conduct.

This included conversations with doctors, therapists, psychologists, nutritionists, dietitians, chefs, health and wellness entrepreneurs, clinical assistant professors, product designers, natural language processing (NLP) engineers, and Ph.D. research fellows, as well as patients suffering from chronic depression, trauma, anxiety, arthritis, back pain, joint pain, and chronic side effects from medical and/or surgical interventions.

SOCIOLOGICAL

How do we see and express pain?

PAIN LANDSCAPE

CURRENT METHODS OF EXPRESSION

Because pain is a highly subjective experience, it is usually hard to find a means of expression to communicate what we are feeling and our level of

pain to others. Pain behaviors are typically classified into verbal pain behaviors such as exclaiming or describing pain, and non-verbal pain behaviors such as vocalizations, facial expressions, body movements, or physiological changes. These pain behaviors are commonly considered to serve either a communicative function, such as self-reporting or making a facial expression, or a protective function, such as limping.19

19 Kappesser, Judith. “The Facial Expression of Pain in Humans Considered From a Social Perspective.” Phil. Trans. R. Soc. (2019) B3742019028420190284. http://doi. org/10.1098/rstb.2019.0284.

Feelings and Emotions Chart by kids2learn

“Let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.”

– Virginia Woolf, On Being Ill

Verbal Pain Behaviors

Because we all experience pain differently, sometimes it’s difficult to know how to explain the degree and type of pain to your health provider when you need help or guidance. The better you are able to describe your pain, the quicker and more successfully the provider can match you with the best treatment. Because verbally describing our pain can be hard, tools have been designed to help us measure pain, such as the Wong-Baker FACES® Pain Rating Scale and the McGill Pain Questionnaire.

Although the previously shown tools and questionnaires help us choose words and numbers, they still don’t provide the most accurate information regarding our pain experience. Pain is subjective, and my scale doesn’t necessarily have to be the same as another person’s scale, especially if we have different health conditions.

The Facial Expressions of Pain

Facial expressions are a significant kind of social communication that have been studied in humans for decades. The Facial Action Coding System (FACS), which allows experienced researchers to code over 40 distinct muscle movements, has been utilized extensively in pain research. Some research groups discovered prototypical movements, known as Action Units, not only for “fundamental emotions” like happiness, anger, sadness, surprise, fear, and disgust, but also for a variety of other emotions. Further emotional events, such as pain, were also discovered to have prototypical facial

The McGill Pain Questionnaire (MPQ), developed by Dr. Ronald Melzack in 1975, is a self-reporting measure of pain composed of 78 words, which respondents choose to best describe their experience of pain.

The Wong-Baker FACES Pain Rating Scale was developed in 1983 by Donna Wong and Connie Baker to help children effectively communicate their pain.20

“Wong-Baker FACES History.” Wong-Baker Faces Foundation.

gestures. Human pain facial expressions include the lowering of the brows, squeezing of the eyes, wrinkling of the nose, raising of the upper lip, and opening of the lips.

RELEVANCE

Example of facial expressions cataloged by the FACS.21

Observers of human pain facial expressions were able to accurately discern pain from a range of other facial expressions. In both experimental and clinical contexts, this pain face is regularly expressed in humans of all ages. Pain-related facial expressions have also been observed in rodents, rabbits, cats, and horses, despite certain distinctions between humans and other species.22

Multiple factors, such as emotions, perceptions, environmental context, and social elements, influence the pain we feel; pain is a biopsychosocial expression. One in five Americans currently lives with chronic pain, and many of those living with pain, any type of pain, have never had the opportunity to interact with their pain outside of therapy, social circles, or their bedroom. If pain scales and word lists have not helped us really express pain, what can?

CONVERSATIONS (SMEs)

WHY THIS MATTERS ART THERAPY DISCOVERY

After much research around different methods of pain expression, I learned how art therapy offers a new perspective on dealing with, talking, and seeing pain. Kelsey A. Skerpan, MA, ATR-BC, LMHC, Sheila Fontanive, MPS, LCAT, ATR-BC, and Ronit Nestel, LCAT, offered inspiration for this project.

21 Cohn, Jeffrey F., Zara Ambadar and Paul Ekman. “Observer-based measurement of facial expression with the Facial Action Coding System.” (2007).

22 Kappesser, Judith. “The Facial Expression of Pain in Humans Considered From a Social Perspective.”

CREATIVE EXPRESSION INTRODUCTION TO ART THERAPY

According to the American Art Therapy Association, “Art therapy is an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.” Facilitated by a professional art therapist, art therapy effectively supports personal and relational treatment goals as well as community concerns. Art therapy is used to strengthen cognitive and sensorimotor functions, build emotional resilience, stimulate insight, improve social skills, minimize and resolve disputes and discomfort, and advance societal and ecological transformation.23

Learning about art therapy gave me the opportunity to rethink pain expression, and to understand that talking about pain and “seeing” pain relieves feelings of isolation and can help people view pain from a different perspective.

– Kelsey A. Skerpan, M.A., ATR-BC, LMHC

During my conversation with Kelsey A. Skerpan, she mentioned that art therapy is a helpful tool for many people. Sometimes therapists have to remind people that it’s not about the art, it’s about the process. As language is a comfortable means of communication, art may be intimidating for others, making them feel as if they’re not creative enough However, what’s important is how it feels doing it, the sense of release and liberation.

I was also curious about what makes this type of therapy stand out from others. Clinical psychologist Ronit Nestel provided the answer:

23

About Art Therapy. American Art Therapy Association. (n.d.). Retrieved May 11, 2022, from https://arttherapy.org/about-art-therapy/.

“We give the tools for people to use their hands and use their creative minds to break those barriers down and be able to express themselves fully and honestly.”

“Art Therapy works as a tool to externalize the problem, giving it a form, color and texture, so one is able to materialize it and make it more manageable.”

– Ronit Nestel, Clinical Psychologist Specialized in Art Therapy

ART THERAPY

ANOTHER WAY TO HELP MANAGE PAIN

Poorly managed pain not only increases physical stress and compromises healing, but can also lead to loss of hope, feelings of helplessness, and a lessening sense of control and personal efficacy. By shifting your mental focus away from the painful input, art therapy can help you feel less pain. It is more than just a distraction; it is a method of teaching you how to relax and change your mood so that the pain does not rule your mental state.24

“When people are in pain, they often lose their sense of control since their pain dictates what they can and cannot do,” says Kelsey A. Skerpan. “Engaging in art therapy helps them reclaim ownership in their lives in terms of what art they choose and the steps they take to create something unique. It can provide a powerful form of self-expression as well as a creative outlet.”

Skerpan also mentions that art therapy cannot replace the need for pain medication, but it can be used in conjunction with it to help people cope with their suffering. It can aid in the rehabilitation process and enhance quality of life by helping people better manage the stress and anxiety symptoms that come with pain.25 Alongside using a creative mindset to work around pain, mind-body treatments—including art therapy—also help with the healing process.

Mind-body treatments are frequently used to help chronic pain sufferers realize the entire impact chronic pain has on their lives, with an emphasis on phenomenology, self-management, and the biopsychosocial paradigm. Patients who get mindbody therapies benefit from a better knowledge of how psychological and physical ailments are linked. Yoga, meditation, psychotherapy, and art therapy are all examples of mind-body treatments.

By definition, art therapy is a type of psychotherapy that blends visual art-making with psychotherapy in order to foster self-discovery and understanding.26

Art therapy, in particular, “assists people in resolving conflicts and issues, developing interpersonal skills, managing behavior, reducing stress, increasing selfesteem and self-awareness, and achieving insight.”27 As a result, patients can benefit from art therapy by becoming more aware of how psychosocial variables can influence their symptoms in both positive and negative ways, using both verbal and nonverbal communication.28

Taking these learnings into consideration, I was inspired to design an intervention that would help people reframe their pain. Talking about pain and “seeing” pain relieves the tension of feeling isolated and can help see it from a different perspective.

24 Solan, Matthew. “Art Therapy: Another Way to Help Manage Pain.” Harvard Health, July 12, 2018. https://www.health.harvard.edu/blog/art-therapy-another-way-to-helpmanage-pain-2018071214243.

25 Solan. “Art Therapy: Another Way to Help Manage Pain.”

26 Lee, Bonnie & Angheluta, Anne-Marie. (2011). “Art Therapy for Chronic Pain: Ap plications and Future Directions.” Canadian Journal of Counselling and Psychotherapy 45. 112–131.

27 Lee & Angheluta. “Art Therapy for Chronic Pain: Applications and Future Directions.”

28 Lee & Angheluta. “Art Therapy for Chronic Pain: Applications and Future Directions.”

How might we understand, express, release their internal

we help people express, and internal pain?

GOAL

HELP PEOPLE RELATE DIFFERENTLY TO PAIN

Help people understand, express, and release their internal pain by acknowledging it, physically visualizing it, and sharing it.

As therapies most often take place indoors, I wanted to challenge this by taking them out of uncomfortable and exposing environments, and offering a more humane and community-based approach. Humans are destined to live and interact as communities, so why should therapy be treated any differently?

OBJECTIVES

Prototype a collaborative vision of chronic pain.

1 in 5 Americans currently lives with chronic pain. Many of these people have never had the opportunity to interact with their pain outside of therapy, social circles, or their bedroom. In most of these instances, the person feels and sees pain at the individual scale, making it frightening to face this pain. What if people could collaborate in representing their own pain?

Engage the pained in a public and shared experience.

I provided people with the tools to be able to see and interact with this pain on a group level, allowing them to understand that they are not alone, because we are all humans who experience pain. When people share their pain with others, they realize that there are many different ways of feeling pain, making it easier for them to manage and have a relationship with their pain.

Get people to understand their pain by visualizing it.

People are used to talking about pain or placing it on a numbers scale, so I wanted to give them the opportunity to actually see their pain by relating it to tangible materials. They were able to bring their senses into the experience and have an honest conversation about their feelings.

Via artstherapycenter.com

PAIN LAB WHY ART THERAPY?

PUBLIC INTERACTIVE THERAPY BENEFITS OF ART THERAPY FOR CHRONIC PAIN

To take the intersection of chronic pain and art therapy one step further, I envisioned a publicfacing experience called pain lab: WHERE PAIN TRANSFORMS. This intervention took place on Sunday, March 27, 2022, in Fort Greene Park in Brooklyn. Each participant who approached the pain lab stand had the opportunity to interact with their pain through the senses of sight (represented by color), smell, and touch.

At a high level, this experience explores an imagined use case of group or public therapy with art materials as the tool for expression. Pain lab expands the field of when and where we can express our pain and the use of tangible materials to do so, something not many people are familiar with. As art therapy “is not simply a distraction, but rather a way to teach you how to relax and alter your mood so the pain doesn’t control your emotional state,”29 pain lab proposes a new area of self-expression while being engaged in the learning process of managing one’s chronic pain.

Art therapy helps people use their art to relate to their pain. Every stroke, drawing, or doodle—no matter how creative or uncreative you consider yourself—has a deeper meaning that can be examined with a licensed art therapist. Art therapy is a mind-body experience, arising from the belief that your mental state can affect your physical state, and the other way around. Because the creative process is central to this type of therapy, it can complement pain medications or be integrated into a chronic pain management plan. As art is a subjective field, art therapy modalities include but are not limited to drawing and painting, printmaking, mixed media, woodworking or ceramics, dancing and singing, knitting, cooking, meditation, and writing.

There are four powerful ways art therapy can have an alleviating impact on chronic pain.

1. It can distract you from your pain

Being immersed in the process of creating art often shuts you off from the outside world. When you’re creating art, your attention is off of your suffering. Instead of being preoccupied with the potential ongoing pain, your mind is concentrated on the task at hand. This can provide a much-needed break and lessen your sense of discomfort.

Additionally, you can discover that you have

more control over your pain. By engaging with art and choosing how you participate in it, you’re taking charge of your suffering.30

2. It helps with mental health

Mood and pain are tightly linked. Chronic pain sufferers are three times31 more likely to experience anxiety or depression. But art therapy can be helpful. A 2018 study32 found that regardless of a person’s gender, age, or diagnosis, at least 30 minutes of art therapy had a substantial positive impact on their pain, mood, and anxiety levels. It can improve your emotional resilience while also assisting in the relief of stress and despair.33

3. It helps others see and understand what you are experiencing

It can be nearly impossible to express how your suffering is impacting you at times, though art has the ability to bring a metaphor to life. It might highlight important ideas of what you’re feeling but unable to put into words. According to studies34, art can help you be more hopeful, redefine yourself, face new limitations and boundaries, and work towards adjustments and acceptance.

You can strengthen your relationships with loved ones by sharing your art. You might also demonstrate to them how your pain causes internal conflict, and if they can witness your

struggle against pain rather than just hear about it, perhaps they will relate to it better.

30 Cohen, Sarah. “4 Benefits of Art Therapy for Chronic Pain.” Pain Resource, May 13, 2019. https://painresource.com/chronic-pain/4-benefits-art-therapy-for-pain/.

31 Smith, Kathleen. “Chronic Pain and Depression.” Psycom, June 9, 2022. https://www. psycom.net/depression/depression-signs-symptoms/chronic-pain-and-depression.

32 Shella, Tamara A. “Art Therapy Improves Mood, and Reduces Pain and Anxiety When Offered at Bedside during Acute Hospital Treatment.” The Arts in Psychotherapy 57 (2018): 59–64. https://doi.org/10.1016/j.aip.2017.10.003.

33 Cohen. “4 Benefits of Art Therapy for Chronic Pain.”

34 Cohen. “4 Benefits of Art Therapy for Chronic Pain.”

4. It’a an outlet for self-expression

When you, for example, paint or draw, it may initially appear as though you are just “creating something nice.” However, the creative process can inspire you to go within, express, and explore your inner self in new ways—unleashing suppressed emotions, presenting your actual self, and so on—that might otherwise be challenging. In difficult circumstances, it’s easy to get lost in our words and the stories we tell ourselves. By avoiding that script, participating in art enables you to fully immerse yourself in the experience. It gets to a deeper, frequently unspoiled and unaltered spot inside.

Via @alyserurianidesign

BITS AND PIECES DESIGNED INTENTIONALLY

Everything about this experience was purposefully thought out and designed. While publicly sharing your pain might seem absurd, it’s important to note that humans often have a hard time simply talking about their pain and feelings. By providing participants with art materials as a means of expression and not having someone else analyze the result, there is the potential to mitigate feelings of judgment, confusion, and shyness that may occur in a traditional psychotherapy environment. The following tools and materials were thoughtfully selected to convey a feeling of comfort, safety, privacy, and free expression.

Instruction Mat

Participants were provided with a private space and an instruction mat so that they wouldn’t be scared of engaging with the activity because they don’t know what it is or how it works. The instruction mat shared a brief introduction of what the activity is about, why it exists, and six simple steps on how to participate. The instruction mat was meant to mitigate any external noise or interaction while helping participants run the process seamlessly. When participants don’t have to ask questions or engage with the mediator (me), they can truthfully immerse themselves in expressing and sharing their pain.

Test Tubes

We can all relate to test tubes within a medical environment, from going to the lab to get blood drawn, or conducting science experiments in school, but most of the time, we associate test tubes with blood, danger, or pain. My goal was to give the test tubes a new meaning. I wanted the container to be something familiar to people for various reasons: I wanted them to feel comfortable handling something they knew and to understand the depth of the experience since test tubes are normally found in medical and scientific environments. I also wanted to provide them with the opportunity to use something as serious and sterilized as a test tube, and give it a new, harmless meaning by filling it with fun and colorful art materials to represent their pain.

Art Materials

As previously learned, almost any materials can be used as a medium to participate in art therapy—the important part is how you feel when you use them and what you learn from the process. I incorporated three senses into the experience: sight, smell, and touch. I chose them because they are senses that can be represented by tangible materials, and are not harmful or messy in any way. Each category had three options for the participants to choose from, each one with its own scale (e.g., hard to soft, light to dark) and intricacies. Choosing six materials was definitely a challenge since I wanted to provide a range of options that was wide, yet small and simple enough for people to understand and not feel challenged by the activity. The following are the materials I selected and some feelings or mindsets that they can represent.

• Sight (represented by color)

» Dark beads: darkness, sadness, loneliness.

» Colored beads: happiness, boldness, variety, scattered.

» Light beads: purity, softness, calmness, peacefulness.

• Smell

» Epsom salt: relaxed, purity, balance.

» Wasabi peas: bitterness, strength, resilience.

» Matches: heat, pain, brightness.

• Touch (represented by textures)

» Sponge: bouncy, squishy, uneven.

» Sandpaper: rough, coarse, discomfort.

» Soft yarn: warmth, comfort, sympathy.

Exhibition Rack

As the instruction mat mentions, “Only when you see, understand, and share your pain, can you change it.” The final step, sharing your pain with others to see on an exhibition rack, is hard, painful, and completely out of people’s comfort zone. A main reason why everything was anonymous was so participants don’t feel attached to what they represented as their pain. Another motive behind exhibiting the test tubes was for people to visually see that they are not alone, that others have pain just like they do, and that others are able to physically represent it in the same ways. When finalizing the selection of materials and giving the test tube a descriptor, participants had to place their test tube on the rack, leaving their pain behind.

BEHIND THE SCENES BUILDING PROCESS AND SETUP

The table setup was inspired by a medical diagnostic laboratory, and I greeted participants while wearing a lab coat. I specifically chose this uniform to inspire a sense of ease, trust, and safety to participants. The table includes the previously mentioned pieces (instruction mat, test tubes, art materials, and exhibition rack) and was divided into four separate areas to give participants privacy.

I drew a model to better understand measurements, the desired layout, and materials needed. Next, I sourced all the materials—including printed materials and laser-cut pieces—built the exhibition rack and test tube stands, and proceeded to create a full-scale prototype at home to visually see how all pieces came together.

The next big challenge was transporting everything from my house to Fort Greene Park. I had a couple of classmates help me with the task while documenting everything through video and photography. Although it was a windy day, I had a successful setup, so much so that people began approaching me and asking me what company I worked for. It was when I shared that this was a student project for my Master’s Thesis that they became more than happy to participate.

It took 45 minutes to complete the set-up, bearing in mind that everything required a specific order and placement. The setup included a table covered in a white cloth, four individual instruction mats with test tubes, four sets of art material packages, and the exhibition rack for people to place their test tubes after filling them. As people approached the table, I began by introducing myself and then shared what the experience was and how they could participate.

OUTDOOR DESIGN INTERVENTION HOW IT WORKS

1. Participants discover the experience in Fort Greene Park.

OUTDOOR DESIGN INTERVENTION HOW IT WORKS

1. Participants discover the experience in Fort Greene Park.

2. They find an open placemat and begin reading instructions.

OUTDOOR DESIGN INTERVENTION HOW IT WORKS

1. Participants discover the experience in Fort Greene Park.

2. They find an open placemat and begin reading instructions.

3. They fill their test tubes to visually represent their pain.

OUTDOOR DESIGN INTERVENTION HOW IT WORKS

1. Participants discover the experience in Fort Greene Park.

2. They find an open placemat and begin reading instructions.

3. They fill their test tubes to visually represent their pain.

4. They give their pain a one-word descriptor to encompass their feelings.

OUTDOOR DESIGN INTERVENTION HOW IT WORKS

1. Participants discover the experience in Fort Greene Park.

2. They find an open placemat and begin reading instructions.

3. They fill their test tubes to visually represent their pain.

4. They give their pain a one-word descriptor to encompass their feelings.

5. Participants place their test tube on the exhibition rack and share their pain with others.

Find video at: vimeo.com/697781814

PLAYING THE ROLE ESTABLISHING TRUST

In order for the participants to open up about their pain and engage in the experience with full honesty, I purposefully scripted a few prompts and questions to be shared at the beginning to establish a level of vulnerability. I let them know that I was not a certified art therapist, nor was I formally trained in the psychology field; rather, I was a design student fully committed to helping people express their feelings in a visual way to get them to understand their pain in a tangible manner.

As I began introducing myself (always stating my Master’s Degree candidate status) and sharing the purpose of the project and the definition of chronic pain, I let participants take a peek into my personal life as I ultimately shared what my pain was and how I represented it in my test tube. I did this in order to level with people and make them feel comfortable, helping them understand that this is an open space for all people, even the designer of the experience.

Many participants quickly engaged with the experience without needing much guidance. It was the people who were hesitant to approach me who took their time to ask what was going on and then became fully immersed in the activity. These people were so committed that they vocally shared their chronic pain with me and others surrounding the table, creating a sort of group therapy where people jumped into the conversation, sharing their experiences with similar pains. This surfaced valuable insights and learning experiences that I will deeply cherish.

USER RESEARCH AND TESTIMONIALS HIGHLIGHTS AND OPPORTUNITIES

After filling their tube and placing it in the exhibition rack, some participants kindly shared their thoughts with me.

Broaden materials section

“I think I had limited options to choose from so these constraints leaned me towards getting more abstract.”

“It was an interesting variety of materials, and it’s not necessarily what I think of when thinking about pain, but it gave me the opportunity to get more abstract.”

“I had trouble with the colors and how to associate them with pain. I would also have liked a bit more textures since that’s what I gravitated the most towards, like a stress ball.”

It’s not just verbal anymore “We never talk about what pain actually feels like, we just compare it to something else. So when I try to put it in, not words, but actually express it, it kind of opens a new door.”

“I’m a writer, so you might think I express pain through words. But my own pain, I begin by trying to identify if I’m actually trying to work with my pain and the actual sensations of it. Is it spreading? Is it bubbly? That kind of language. But my first instinct is expressing pain through movement, so I really did enjoy this exercise.”

This was definitely something new “This was a fun exercise, no one has ever asked me to describe my pain like this, it’s mostly numbers on a scale of 1 to 10. I tried to just turn my left brain off and start sensing and relating to the materials.”

“There is something playful about this, so it’s interesting to think about pain not as your enemy. I might go home and look for things that I might use to describe my pain now.”

INSIGHTS LEARNINGS AND TAKEAWAYS

I had the privilege of interacting with almost 70 people over the course of a five-hour experience. I conversed with kids, teens, and adults. What most surprised me was that the personal definition of pain depending on the age group. Kids mostly leaned towards the physical, like an arm pain. Meanwhile, young adults and adults expressed pain more as a complete thought; the pain of being with someone you don’t like, the pain of losing someone, getting fired, or being forever sick. As people came and left, these are a few learnings I discovered:

An Opportunity

Most people had never had the opportunity to tangibly represent and share their pain, and they believed it was releasing and beneficial. Even if they were not fully convinced, this experience planted a seed to open their minds to other methods of selfexpression, and ultimately therapy. This opportunity gave participants the agency they needed to take control over their pain.

A Habit

Many people were interested in continuing this practice of visualizing their pain to help them further understand it. It was also provoking to see children and adults have conversations about what pain meant and felt to them. As many were captivated by the experience, they shared that they would share this experience with friends and family.

The Social Acceptance

People truly want to change the negative paradigm around expressing pain freely. They want to know that it’s okay to share their pain with others, that it’s encouraged in order to understand it and heal. We are all humans and we all feel pain, so let’s make this a universal action.

The Diversity

People of all ages and identities have pain although many don’t know how to express it. It was interesting meeting people from diverse backgrounds and to learn their social norms around pain. Pain lab explored how different people could express pain with the same means and materials, it was magical.

BIOLOGICAL

How do we feel pain?

PAIN LANDSCAPE

WHEN PAIN PREVENTS YOU FROM LIVING

Although estimates of its frequency and effects vary greatly, chronic pain is one of the most prevalent chronic illnesses in the United States. The National Health Interview Survey (NHIS), a sizable householdbased annual survey that provides useful insights into the health statuses of U.S. adults nationwide, received a new set of questions about pain in 2019. The NHIS is conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention. According to a review of the latest

“89% of patients will google their health symptoms before going to their doctor. Turning to Dr. Google, people say they want to see how serious their health condition is before going to an actual doctor.”35

NHIS data and findings from Brigham and Women’s Hospital and Mass Eye and Ear, 50.2 million Americans (20.5%) endure chronic pain.36

Because the pain is too much to bear, many people with chronic pain visit doctors and specialists more often than others not living with constant pain. One significant reason is that doctors normally specialize in one single organ/body part and are not inclined to consider all other aspects besides the pain itself: sleep, diet, exercise, habits, interpersonal relationships, stress, and more. Yet people’s entire lives can be severely impacted by chronic pain.

It can restrict one’s capacity to engage in job and social activities, destroying morale and degrading quality of life. The linked risks of despair and suicide are two particularly unsettling elements of chronic pain. People claim that they can experience chronic pain in all social, practical, and emotional spheres of their lives, with no boundaries.

Patients are fully aware of the absence of public awareness of chronic pain and its effects. As a result, people are ill-equipped to ask for assistance or take the necessary steps to control their condition as soon as it manifests.

RELEVANCE

WHY THIS MATTERS

People’s emotional health and physical health are affected by untreated chronic pain, which limits their capacity for productive job and family engagement. Most people who experience pain feel constantly exhausted, powerless, or unable to think or behave normally. When pain takes over people’s lives, any answer might seem valuable; that’s where Dr. Google comes in. Countless people, if not the majority—including myself—do online research when something feels off. If you, like myself, have done this, then it’s extremely likely that cancer has shown up among the results.

36 “One in Five American Adults Experience Chronic Pain.” ScienceDaily. ScienceDaily, April 20, 2021. https://www.sciencedaily.com/releases/2021/04/210420092901.htm.

Besides being personally distressing, chronic pain also has an enormous economic and financial impact on most countries. A study conducted by doctors at Harvard University and Harvard Medical School found that people with “chronic pain reported missing significantly more workdays than those without chronic pain (10 days versus fewer than 3 days),” and the total economic impact of chronic pain on Americans is nearly $80 billion in lost wages.37

37 Reno, Jamie. “Chronic Pain: The Impact on 50 Million Americans.” Healthline. Healthline Media, April 25, 2021. https://www.healthline.com/health-news/chronic-painthe-impact-on-the-50-million-americans-who-have-it.

That’s right, you and I are part of the 50% of patients using search engines to self-diagnose who see “cancer” appear at least once on the first page of our results.

– Dr. Robert Jason Yong, medical director of the pain management center at Brigham and NHIS study’s corresponding author.

CONVERSATIONS (SMEs)

KNOWING WHEN IT’S TIME TO VISIT THE DOCTOR

After much secondary research, I shifted towards conversations with pain experts and patients. I wanted to get a first-hand deep understanding of what pain means to them and its role in their lives.

A few insights surfaced while synthesizing common denominators between all these patients living with chronic pain:

1. They don’t want to be a burden to others, so they refrain from sharing that they are in pain.

2. They are not sure when it’s time to visit the doctor.

3. Doctors have never asked them about their lifestyle while trying to diagnose them.

89 08 | Biological 4. They feel alone and unheard in this painful process.

“Given the overall scale and impact of pain on Americans, we see that a multimodal, multidisciplinary approach to treating pain is even more important than what we have been emphasizing over the past few decades.”

The problem begins patients don't it's time to visit letting time lapse further affecting as their condition from acute to chronic.

begins when know when visit the doctor, lapse and affecting their health condition escalates chronic.

EXISTING DIGITAL TOOLS

SYMPTOM ASSESSMENT APPS

My aforementioned primary and secondary research led me to dig deeply into how people currently manage their pain. What contemporary tools help the pained throughout their journey? This query uncovered a world of symptom checker apps that are empowering patients to take control of their health.

In the last ten years, the internet has supplanted general practitioners (GPs) as the go-to source for health information. As previously mentioned, 89% of people Google their symptoms before visiting a doctor. Online search engines like Google and Bing weren’t created to give medical advice, thus they run the danger of providing inaccurate or misleading results.

One promising alternative is specialized symptom assessment software (apps), which asks patients questions about their demographics, pertinent medical history, and symptoms using a structured questionnaire or multiple-choice format. These software programs employ a variety of computational techniques to recommend one or more illnesses (e.g., common cold vs. pneumonia) that may explain the symptoms. Then, they recommend follow-up actions for patients (e.g., self-care at home vs. seeking urgent consultation), frequently in addition to providing the user with evidence-based disease information.38

38 Gilbert, Stephen, Alicia Mehl, Adel Baluch, Caoimhe Cawley, Jean Challiner, Hamish Fraser, Elizabeth Millen, et al. “How Accurate Are Digital Symptom Assessment Apps for Suggesting Conditions and Urgency Advice? A Clinical Vignettes Comparison to GPS.” BMJ Open 10, no. 12 (2020). https://doi.org/10.1136/bmjopen-2020-040269.

ACCURACY

GENERAL PRACTITIONERS VS. APPS

One peer-reviewed study, published in the journal BMJ Open, compared 200 primary care scenarios or “vignettes” drawn from the NHS 111 telephone triage service to eight of the most popular symptom assessment apps and a control group of seven GPs. Ada, Babylon, Buoy, K Health, Mediktor, Symptomate, WebMD, and Your.MD were among the apps put to the test in relation to three different criteria: the range of content covered, the accuracy, and the safety of the advice provided in comparison to a GP appointment. The study discovered that GPs offered 100% coverage, while the coverage for the conditions in the vignettes ranged from 51.5% with Babylon to 99% with Ada, with an average overall of 69.5%. On the final metric, the majority of apps generally provided safe guidance, but just three came close to the 97% grade for doctors. Ada once again took the top spot among them with 97%, followed by Babylon with 95% and Buoy with 80%.

Dr. Hamish Fraser of Brown University’s Centre for Biomedical Informatics noted that symptom assessment apps are being used by tens of millions of patients each year in the U.S and UK alone, and he said the study is a significant signal of how beneficial they are.39

“Compared to a similar study from five years ago, this larger and more rigorous study shows improved performance with results closer to those of physicians,” according to Fraser. “It also demonstrates the importance of knowing when apps cannot handle certain conditions.”40

Fraser also suggests the findings might also be used to identify which applications are suitable for observational research followed by randomized controlled trials, which would constitute clinical testing.

39 Taylor, Phil. “Study

Differences

Symptom Checker

Pharmaphorum. Pharmaphorum, December 16, 2020. https://pharmaphorum.com/ news/study-finds-big-differences-between-top-symptom-spotting-apps/.

Retrieved from The Medical Futurist

40 Taylor, Phil. “Study Finds Big Differences between

Symptom Checker

AN OPPORTUNITY

DESIGNING FOR PREVENTION

As we previously learned, symptom assessment apps can benefit patients by providing guidance and information about possible conditions, but they still don’t succeed in helping patients understand and track their symptoms before they become a condition, a chronic condition. Also, these apps don’t consider any lifestyle patterns the patient might be experiencing, for example, stress, exercise, personal relationships, sleeping habits, and diet. These factors are directly related to how symptoms arise and what conditions they might lead to. We need to see patients through a holistic lens, not through an organ lens.

Starting from the root, the problem begins when patients don’t know when it’s time to visit the doctor, letting time pass by and further affecting their health as their condition worsens from acute to chronic. Chronic pain brings in fear, anxiety, and discomfort, and it is substantially more expensive to care for since it’s more time-intensive. Narrowing it down, chronic musculoskeletal pain disorder is the underlying diagnosis for 70% to 80% of those living with chronic pain. Among the top 12 causes of disability in the United States, musculoskeletal disorders cause more than one-third of years lived with disability and are among the leading causes of disability worldwide.40

We need something that can find real-time patterns and translate them into an assessment that the patient can share with multiple doctors, including lifestyle habits. Maybe this tool doesn’t need to suggest a condition you have, but can rather help you understand when it’s time to visit a doctor and encourage you to share this information with multiple specialists to get to the bottom of it.

With this information, we see that there exists the opportunity to ultimately avoid an acute pain turning into a chronic pain nightmare. Preventative measures could eliminate the pain from the source and not just treat the symptoms.

“I went to the doctor to get checked after a few months of pain and it turned out I had an aneurysm. If I had listened to my body sooner, I could’ve avoided surgery.”

– Maria D., English Teacher

How might we way for patients musculoskeletal pain to avoid their symptoms escalating acute to chronic

we design a patients with musculoskeletal chronic their escalating from chronic pain?

GOAL HELP PEOPLE RELATE DIFFERENTLY TO PAIN

Help people with physical chronic pain track their symptoms and avoid permanent damage or pain.

As existing symptom assessment apps are widely used and many times accurate, I wanted to challenge these by taking a step back and starting from the root. I do believe that many conditions can avoid turning chronic by learning to understand our body’s signals and patterns. I want to introduce a tool that is educational, accessible, and meant to be shared with healthcare professionals.

OBJECTIVES

Help patients know when it’s time to visit the doctor.

No person should suffer the consequences of unattended pain. The average person is not a healthcare professional thus should not be expected to understand the severity of their symptoms. With a digital tool that finds patterns and translates them into actionable suggestions, patients can feel at ease knowing that their symptoms are being constantly tracked and will get notified if something needs professional attention.

Accompany and guide them without diagnosing.

My goal is not to diagnose people but to guide them into finding the best care for their current situation. Even though many people would like to be diagnosed before visiting the doctor, it is more valuable to go a few steps further and actually prevent a condition from even existing in the first place. This tool helps patients track their symptoms and keep them from escalating into something worse.

Educate people to take agency over their health.

Although we are not professionally trained to know how to read every signal our body shows, we can start learning how to read them and know when it’s time to seek professional help. As people start understanding the patterns this tool provides, they will become aware of their symptoms as they appear. After a few logs, they will know how to read their body and know when it’s time to take their symptoms seriously.

Via medstack.com

Diet and lifestyle factors account for almost 80% the causes of chronic diseases.

42 McGowan, Mike. “What If Doctors Were Paid to Keep People Well?” Center for Nutrition Studies.

lifestyle account % of of all diseases.

FINLEY HEALTH

AI-BASED SELF SYMPTOM ASSESSMENT RECORDING APP

Tackling the intersection of digital assessment tools, education, and lifestyle medicine, I envisioned finley health, an AI-based self-symptom assessment app combined with lifestyle medicine that helps patients to get a precise reference of symptoms and recommendations for professional diagnoses.

I wanted to challenge all digital assessment tools that currently give you the answers and diagnose you with the help of technology. Prevention is not something embedded in us and that we think about on a daily basis. But what if we change this misconception of only visiting a doctor when I’m already sick?

Today, the U.S spends more than $3.6 trillion annually on healthcare, while Big Pharma profits globally now surpass $1.25 trillion. Maintaining people’s “health,” or lack thereof, is big business. What if we could shift the healthcare system into prioritizing health, and start treating patients when they are healthy? Ancient Chinese doctors were paid for keeping their patients healthy. It was only when they got sick, that the doctor would stop getting paid until they were healthy once again.43

Finley health adopts an ancient Chinese-like system where our priority is people’s wellness and overall health. Finley health would profit from keeping patients healthy, not sick.

43 McGowan, Mike. “What If Doctors Were Paid to Keep People Well?” Center for Nutrition Studies.

TRACKING FOR PREVENTION

HOW IT WORKS

Finley is your best-in-class health companion. It works similarly to a health diary where you begin by logging individual symptoms that arise at any given time. Finley’s AI technology will search for patterns in your logs, and after the patient has entered the same symptom multiple times, they will have to complete a symptom and pain assessment questionnaire to better understand where those symptoms are coming from, followed by a lifestyle questionnaire to examine further possible causes.

Patients can then share tracking and assessment results with their Primary Care doctor, which will aid the doctor in reaching a better and more accurate diagnosis to recommend further treatments.

TRACKING FOR PREVENTION

HOW IT WORKS

Finley also has the advantage of being available on the go when pairing the app with your Apple Watch, so you can always follow up on your symptoms.

Finley health helps patients with wellness and plenitude preventing their reaching the chronic

helps pain reach plenitude by their pain from chronic stage.

PSYCHOLOGICAL

How can we be aware of pain?

PAIN LANDSCAPE

TALKING ABOUT DEPRESSION

Depression is a common but significant mood illness (sometimes known as major depressive disorder or clinical depression). It produces severe symptoms that interfere with your ability to function on a daily basis, including sleeping, eating, and working. As one of the most recurrent mental disorders in the United States, the National Institute of Mental Health (NIMH) estimates that 8.4% of US adults had at least one episode of major depression in 2020.

115 10 | Psychological 44 “Depression.” National Institute of Mental Health. U.S. Department of Health and Human Services. Accessed February 24, 2022. https://www.nimh.nih.gov/health/top ics/depression.

Via WIRED | The Perils of Moderating Depression on Social Media

“We should make it clear that getting help isn’t a sign of weakness—it’s a sign of strength–and we should ensure that people get the treatment they need.”

– Michelle Obama

In order to be diagnosed with depression, symptoms must be present every day for at least two weeks. In accordance with the NIMH, there are various forms of depression, a few of which are brought on by certain events.

• Major depression: characterized by depressive symptoms that have persisted for at least two weeks and are typically disruptive to one’s capacity to work, sleep, study, and eat.

• Dysthymia, or persistent depressive disorder: characterized by less severe depressive symptoms that persist for at least two years on average.

• Perinatal depression: severe depression that develops during pregnancy or right after giving birth (postpartum depression).

• Seasonal affective disorder: a mood illness with depressive symptoms that peak in the spring and summer and are correlated with variable levels of sunlight during the fall and winter.45

Clinical depression can result from a variety of factors. A single factor may be the cause of the sickness for some people, while different variables may be at play for others, and people frequently experience depression for no obvious reason. I

decided to narrow down on dysthymia or persistent depressive disorder (PDD) since it lasts at least two years on average, making it a chronic condition.46

The vast majority of people who seek treatment for depression experience recovery. Depression is relatively treatable. Antidepressant medications, psychotherapy, or a combination of the two are the most common treatments. Although both may show positive results in recovery, medications have been widely abused and, in some instances, caused a more serious problem like addiction.

RELEVANCE

WHY THIS MATTERS

As previously stated, 21 million American adults had at least one episode of major depression in 2020, out of these, 1.5% are affected by PDD.

3.3 million Americans live with depression every day.

Living a normal life and maintaining recovery might be difficult when one has a mental condition. The National Alliance on Mental Illness shares that the following are some of the ways mental illness can affect people’s lives, as well as how that impact might spread.

45 “Depression.” National Institute of Mental Health. U.S. Department of Health and Human Services.

46 “Depression.” Mental Health America. Accessed April 30, 2022. https://www.mhana tional.org/conditions/depression.

An estimated 21 million adults reported depression in 2020.

– National Institute of Mental Health

Individual

• Cardiovascular and metabolic illnesses are 40% more likely to affect those with depression than the wider public. These problems are almost twice as likely to develop in people with major mental illness.

• Adults in the United States with mental illness have a higher unemployment rate (6.4%) than those without (5.1%).

Family

• Adults with mental or emotional health issues are cared for by at least 8.4 million people across the country.

• An average of 32 hours per week are spent by caregivers of adults with mental or emotional health disorders doing unpaid care.

Community

• For all Americans under 45, mood problems are the leading reason for hospitalization (after excluding hospitalization relating to pregnancy and birth).

• Serious mental illness costs the U.S economy $193.2 billion in missed wages every year.47

CONVERSATIONS

THE POWER OF NUTRITION

Because my father is a doctor, I grew up knowing that nutrition has a huge impact on our current and future health; it can dictate if we develop any future conditions. I decided to focus my primary research on the relationship between psychology, body, mind, and food and understand the scientific research behind this.

These are a few insights that surfaced while synthesizing experts’ input on the relationship between food and chronic pain.

• “Letting people have meal choices has a huge impact on their health. When they are sick, they don’t feel in control of their body, but when they are given options, that mindset shifts and suddenly they are in control of their bodies.”

– Ananda Kaplan, RDN

• “People who experience depression due to genetics or chemical imbalances are not solely responsible for their improvement. Context, lifestyle, and environment also have a huge impact.” – Sharon Bistre, LPC, LCSW

• “Diet is an extremely important and vital part of your overall health, but it’s not the only one. Exercise, sleep, relationships, work/life balance, and spirituality are just as crucial. Once we find a way to balance these, or most of these, is when we are reaching well-being.”

– Paulina Poumian, Health Coach

Unknown

BRAINSTORM

IDEATION SESSION

For this ideation session, I started by creating a list of things that I learned from my previous research and subject matter expert conversations. I took this list and organized them in sticky notes to get a visual perspective on how I could break those down.

The next exercise was to list four things that “sucked” about each issue/observation. The purpose of this is to really dig deep and think about four problems about that issue; it’s asking why about that why. I

tried to get as detailed and specific as possible in order to gather more information for the next part of the session.

PROVOKING THOUGHTS

SERVICE DESIGN

Taking into account the research I conducted, I was intrigued about how the most common treatments for depression are most likely medicines and/ or therapy (this is on one of the “It sucks that…” sticky). After selecting a tangible problem I could start solving, I proceeded to createing a list of service solutions I could be able to design.

Considering the background I had and that my sister is a specialized nutritionist, I decided to dig deeper

into the sticky that reads “A service that provides natural prevention treatments for depression”. What a better natural treatment than food!

FOOD AS MEDICINE

HEALING THROUGH EATING

meals in 24 countries.

There is a lot of research published on the relationship between diet and depression, and most of it points to the Mediterranean diet. It is considered one of the healthiest diets in the world and is the most studied.

A randomized controlled study, published in 2019, found that self-reported symptoms of depression dropped significantly in just three weeks in young adults who changed from a highly processed, highcarbohydrate diet to a Mediterranean diet.48

A meta-analysis conducted by a group of multidisciplinary doctors at Linyi People’s Hospital in China states, “A dietary pattern characterized by a high intake of fruit, vegetables, whole grain, fish, olive oil, low-fat dairy and antioxidants and low intake of animal products was apparently associated with a decreased risk of depression. A dietary pattern characterized by high consumption of red and/or processed meat, refined grains, sweets, high-fat dairy products, butter, potatoes and high-fat gravy, and low consumption of fruits and vegetables is associated with an increased risk of depression.”49

Wanting to learn more about healthy diets around the world, I dug into the book What The World Eats. In 2005, American Photographer Peter Menzel and writer Faith D’Aluisio traveled the world documenting what the world eats, showcasing

AN OPPORTUNITY

DESIGNING TO HEAL

One can argue that experiencing depression increases our propensity to consume unhealthy foods. Thus, we should ask which came first, the depression or the diet? Fortunately, this question has been studied. As reported by Harvard Health Publishing, another sizable analysis focused solely on prospective research, examining baseline diet before estimating the likelihood that study participants would later experience depression. Researchers discovered that eating well—for instance, following a Mediterranean diet— was related to a noticeably lower likelihood of experiencing depression symptoms.50

Based on these findings, I took the opportunity to design both for people diagnosed with clinical depression, and for other groups propense to develop depression in the future. Studies have shown successful results in alleviating symptoms, now is the time to take those learning and apply them to our everyday lives.

48

https://doi.org/10.1371/journal.pone.0222768.

49 Li, Ye, Mei-Rong Lv, Yan-Jin Wei, Ling Sun, Ji-Xiang Zhang, Huai-Guo

Li. “Dietary Patterns and Depression Risk: A Meta-Analysis.” Psychiatry Research 253 (April 2017): 373–82. https://doi.org/10.1016/j.psychres.2017.04.020. 50 Tello, MD, Monique. “Diet and Depression.” Harvard Health, January 29, 2020. https://www.health.harvard.edu/blog/diet-and-depression-2018022213309.

120 As we see different diets, we can also see how depression rates vary, from 5.9% in the U.S, to 3.7% in Guatemala. These learnings led me to uncover a new opportunity: I could help people with depression follow a specific diet meant to heal and revert symptoms.

United States: The Revis family of North Carolina. Food expenditure for one week: $341.98. Favorite foods: spaghetti, potatoes, and sesame chicken.

Guatemala: The Mendozas of Todos Santos - Food expenditure for one week: 573 Quetzales or $75.70

Family Recipe: Turkey Stew and Susana Perez Matias’s Sheep Soup

How might we people with diagnosed chronic depression symptoms through

we help diagnosed depression revert through food?

GOAL

FOOD AS A MEDIUM TO HEAL DEPRESSION SYMPTOMS

Heal, relieve, and revert chronic depression symptoms through food.

I wanted to replicate the previously mentioned studies in a more appealing and friendly way. Everybody has the right to health, and my goal is to provide this through food. The easiest way to get access to many people’s kitchens is through subscription boxes, so I wanted to design a service that would ultimately provide wellness.

OBJECTIVES

Educate people about the power of food. Encourage Cognitive Behavioral Therapy.

Digestion begins when we start thinking about or looking at food. If we see something colorful, natural, and healthy, our minds will associate that with positivity and send good signals to our stomach, thus resulting in the successful digestion and absorption of nutrients. We all eat, so why don’t we eat something good for the body that can help revert conditions such as depression?

Having control over what food we choose and then cooking encourages Cognitive Behavioral Therapy, thus contributing to relieving and reverting existing symptoms of depression. This can be used as a coping technique and release stress while cooking something healthy.

Help people understand that it’s not their fault.

Many people believe that being diagnosed with depression is somehow their fault. As previously mentioned, symptoms appear for multiple reasons. What’s most important is to help people understand that no matter the underlying cause, they can take control of their depression and alleviate their own symptoms. They have the power to regain their health and ultimately reach the happiness they want.

Via Shutterstock | @Innart

BELLY BRAINS

MEAL KIT DELIVERY SERVICE FOR PEOPLE WITH DIAGNOSED DEPRESSION

128 Tackling the intersection of diet, nutrition, and depression, I envisioned belly brains, a meal kit delivery service for people with diagnosed chronic depression. This kit is designed to heal the mind and body by working with nutritional foods that boost mood and energy levels.

THE LANDSCAPE

WHAT’S OUT THERE

Although there are countless meal kit delivery services out there, none of them are meant to nourish both the body and mind. Belly brains benefits customers by providing fast and easy meal prep kits that have a positive impact on the mind and body.

Via The Creative Bite

HOW IT WORKS

A SUBSCRIPTION TO A MOOD BOOST

As a subscription-based and time-based system, we begin to see improvements in mood and energy after a few months of eating belly brains.

1. David has been diagnosed with clinical depression eight months ago. Not wanting to think about dinner, he decides to order delivery pizza.. like most nights, and is very excited to eat it!

2. David receives a friendly text message from his friend Blake inviting his for a night run. David makes up an excuse and says he’s busy with work.

3. David is not actually working. He feels extremely tired after a heavy meal and decides it’s best to relax on the couch for the rest of the evening.

4. Having to choose what to have for dinner the next night, David decies to order take-out again and watch some TV.

5. Once again, David receives a friendly invitation from his collegue Danielle for a yoga session. Again, David declines by making up another excuse.

6. David is not only tired after work, he’s also extremely tired during work. He constantly feels with little to no energy, but is not sure why.

7. It’s during a TV break that David sees something interesting!

8. He sees an ad about belly brains; a meal kit delivery service food people with diagnosed depression intended to heal and relieve symptoms through food.

9. David decides to give belly brains a shot and orders a box.

10. He begins by taking all bags out of the box and choosing a meal from the selection.

11. Following instructions, David chops and cooks all ingredients provided by belly brains.

12. It’s time for lunch! David takes the first bit and absolutely loves it. He starts getting a clear vision of all the benefits he could take by eating this healthy and delicious.

13. David has so much energy and goes out to practice some long overdue yoga at the park.

14. Continuing with the energy boost, David stays in the park to enjoy some reading time.

15. David snaps out of his vision and is excited about what he saw and felt. This food is gloriuos!

16. Wanting to feel that exact same way every day, David purchases more belly brains meals. He now knows that having a healthy gut improves his mood.

HOW IT WORKS

A SUBSCRIPTION TO A MOOD BOOST

By showing customers how to eat and what to eat, belly brains also serves as an educational experience, so customers can apply these same learnings when making independent nutrition decisions.

Through powerful, intentional, and foods, belly brains to heal, relieve, revert chronic symptoms for

powerful, and nutritious brains intends relieve, and chronic depression for U.S adults.

CLOSING THOUGHTS

Conclusion.

For this exploration, I have learned that we have the power to take control over our own health. I’ve shared several manifestations of what we could do with tools designed with the intention of creating health in a space filled with noise and worry.

These tools should not be used as final solutions, but rather as starting points to keep imagining and designing through informed research and first-hand experience. The responsibility of providing health cannot be left to scientists, doctors, and health/tech companies only. We need more designers and the general public to engage with the health and well-being of themselves and of those around them. We need to be mindful that health leads to happiness, and happiness leads to a longer and more prosperous life.

The biopsychosocial viewpoint of pain explored throughout this thesis is meant to reveal the power those in pain have over their pain, proving that understanding one’s pain can help change that pain.

I hope these tools and experiences with a unified biopsychosocial approach can help people understand that even with pain, we can ultimately reclaim control over our mind and body, and live in plenitude.

ACKNOWLEDGEMENTS

Special thanks.

This work could not have been completed without the support and encouragement of my husband, David, my parents, Alexander and Miriam, and my sisters, Ariela and Ronit. Thank you for always being my best cheerleaders and being by my side during this rollercoaster of a journey. Special thanks to Allan Chochinov, Products of Design chair, for taking a chance on me, pushing my limits to show me what I’m capable of, and constantly challenging me to become a better person– it’s an honor having you as a mentor.

Grateful to Sam Potts, thesis instructor and book magician, for his wonderful guidance and encouragement, and for always listening when no one else understood. Much appreciated to the thesis year faculty: Emilie Baltz, Alexia Cohen, Bill Cromie, Megan Ford, Kristine Mudd, Andrew Schloss, Sinclair Smith, and Krissi Xenakis.

And also infinite thank yous to Rachel Abrams, Paola Antonelli, Hlynur Atlason, Karan Bansal, Ayse Birsel, Matthew Borgatti, Evie Cheung, Michael Chung, Jenny Clark, Steven Dean, Andrew Dent, Baoqi Ding, Chester Dols, Marc Dones, Qiting Fang, Siddhant Goyle, Alexandre Hennen, Alice Hennessy, Felix Ho, Anne Keating, Kristina Lee, Erika Lindsey, Crystal Lou, Jane Luca, Gaoming Lyu, Marko Manriquez, Shanti Matthew, Jonathan Melendez-Davidson, Sigi Moeslinger, Toshi Mogi, Julie O’Brien, Isabell Park, Regena Paloma Reyes, Jennifer Rittner, Andrew Schloss, Jason Severs, Ceci Shayo, Becky Stern, John Thackara, Richard Tyson, Masamichi Udagawa, Elspeth Walker, Rob Walker, James Wynn, Wen Xie, Zekun Yang, Susan Zhang, and Margarita Zulueta.

GLOSSARY

Vocabulary.

A

ACUTE PAIN

Acute pain, as defined by the Cleveland Clinic, “usually comes on suddenly and is caused by something specific. It is sharp in quality. Acute pain usually doesn’t last longer than six months. It goes away when there is no longer an underlying cause for the pain . . . [and] you can go on with life as usual.”51 Causes of acute pain can include broken bones, cuts, burns, dental problems, surgery, and labor and childbirth.

ANXIETY

The American Psychological Association defines anxiety as “an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure.”52 Types of anxiety disorders include generalized anxiety disorder, panic disorder, social anxiety disorder, and various phobia-related disorders.

ART THERAPY

According to the American Art Therapy Association, “Art therapy is an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.

“Art therapy, facilitated by a professional art

51 “Acute Pain vs.

52

Psychological

therapist, effectively supports personal and relational treatment goals as well as community concerns. Art therapy is used to improve cognitive and sensorimotor functions, foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills, reduce and resolve conflicts and distress, and advance societal and ecological change.”53

B

BIOPSYCHOSOCIAL

This biopsychosocial model developed by Dr. George Engel includes the patient, the illness, and the circumstances before diagnosing. As Engel describes in The Need for a New Medical Model: A Challenge for Biomedicine, “By evaluating all the factors contributing to both illness and patienthood, rather than giving primacy to biological factors alone, a biopsychosocial model would make it possible to explain why some individuals experience as ‘illness’ conditions which others regard merely as ‘problems of living,’ be they emotional reactions to life circumstances or somatic symptoms.”54

C

CHRONIC PAIN

According to the Cleveland Clinic, “Chronic pain is pain that is ongoing and usually lasts longer than six

53 About Art Therapy. American Art Therapy Association. (n.d.). Retrieved May 11, 2022, from https://arttherapy.org/about-art-therapy/.

54 Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” 387.

months. This type of pain can continue even after the injury or illness that caused it has healed or gone away. Pain signals remain active in the nervous system for weeks, months, or years. Some people suffer chronic pain even when there is no past injury or apparent body damage.”55 Conditions linked to chronic pain, according to the Cleveland Clinic, include arthritis, back pain, cancer, fibromyalgia, headaches, and nerve pain.

The stress of chronic pain affects the body and can manifest in physical ways such as a lack of energy, a change in appetite, limited mobility, and tense musculature. Chronic pain can also result in emotional reactions. Anger, anxiety, and depression are a few examples given by the Cleveland Clinic, as well as fear of re-injury, which might, in turn, limit a person’s ability to resume regular activities such as work, childcare, or hobbies.

COGNITIVE BEHAVIORAL THERAPY (CBT)

The American Psychological Association defines Cognitive Behavioral Therapy (CBT) as “a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness.”56 CBT treatment usually involves efforts to change thinking and behavioral patterns. CBT places an emphasis on helping individuals learn to be their own therapists, and to focus on what is currently happening in their lives, rather than what has led up to their difficulties.

55 “Acute Pain vs. Chronic Pain: Differences & Causes.” Cleveland Clinic, Last Reviewed December 8, 2020. https://my.clevelandclinic.org/health/articles/12051-acute-vschronic-pain.

56 “What Is Cognitive Behavioral Therapy?” American Psychological Association. American Psychological Association, July 2017. https://www.apa.org/ptsd-guideline/ patients-and-families/cognitive-behavioral.

The Mayo Clinic defines depression as a “mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn’t worth living.”57

D FDEPRESSION FACIAL ACTION CODING SYSTEM (FACS)

Dr. Paul Ekman, Ph.D. in clinical psychology, developed the first tool for objectively measuring facial movement along with W. Friesen in 1978. The Facial Action Coding System is a “comprehensive, anatomically based system for describing all visually discernible facial movement. It breaks down facial expressions into individual components of muscle movement, called Action Units (AUs).”58

“FACS is used across many different personal and professional settings. It is often used in various scientific settings for research. It is also used by animators and computer scientists interested in facial recognition.

57 “Depression (Major Depressive Disorder).” Mayo Clinic. Mayo Foundation for Medical Education and Research, February 3, 2018. https://www.mayoclinic.org/ diseases-conditions/depression/symptoms-causes/syc-20356007.

58

“Facial Action Coding System.” Paul Ekman Group, January 30, 2020. https://www. paulekman.com/facial-action-coding-system/.

“FACS may also enable greater awareness and sensitivity to subtle facial behaviors. Such skills are useful for psychotherapists, interviewers, and anyone working in communications.”59

result of local inflammatory process).62

PPAIN

MMUSCULOSKELETAL PAIN

Musculoskeletal pain is pain that affects the bones, joints, muscles, tendons, and ligaments. Common causes of musculoskeletal pain include bone fractures, joint dislocation, direct impact to muscles, bones or joints, overuse injuries, poor posture, and sprains.60

The current International Association for the Study of Pain (IASP) definition of pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”63

NNOCICEPTION

The nociceptive system “consists of neurons which are activated by stimuli potentially threatening the integrity of our body,”61 according to author Munetaka Hirose, M.D., Ph.D.

Hirose explains that nociception is the physiological process protecting body tissues from damage, and it is an important part of the body’s “fight or flight” response. Nociceptors can be activated by three types of stimuli within the target tissue, according to Hirose: temperature (thermal), mechanical (e.g., stretch/strain), and chemical (e.g., pH change as a

59

“Facial Action Coding System.” Paul Ekman Group.

60

“Musculoskeletal Pain: Types, Causes, Symptoms & Treatment.” Cleveland Clinic. Accessed May 12, 2022. https://my.clevelandclinic.org/health/diseases/14526musculoskeletal-pain#:~:text=Musculoskeletal%20pain%20affects%20provider.

61 Hirose, Munetaka. “Chapter 21: Nociception During Surgery.” In Features and Assessments of Pain, Anaesthesia and Analgesia, 235–45. Elsevier Academic Press, 2021.

IASP further expanded this definition with six key points. First, they say, pain is a personal experience influenced by biological, psychological, and social factors. Second, pain and nociception are distinctly different phenomena. Activity in sensory neurons cannot be the only inference for pain. Third, IASP states that individuals learn the concept of pain through their life experiences. As such, the fourth point states that when a person reports that they are experiencing pain, it should be respected. The fifth point is that because pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. Finally, IASP’s sixth point is that a verbal description of pain is only one of several possible ways to express pain; an inability to communicate does not negate a human’s or animal’s experience of pain.

62 Physiopedia contributors, “Nociception,” Physiopedia, https://www.physio-pedia. com/index.php?title=Nociception&oldid=246340 (accessed April 11, 2022).

63 “IASP Announces Revised Definition of Pain.” International Association for the Study of Pain (IASP).

PAIN BEHAVIORS

Clinical psychologist and founding member of the International Association for the Study of Pain and the American Pain Society, Wilbert E. Fordyce, clarifies that the “behaviors of patients which indicate presence of a pain problem are pain behaviors. To complete the circle, pain behaviors are behaviour. The significance of that is that pain behaviors, as behaviour, are subject to influence by whatever factors influence behaviour.”64

PSYCHOLOGY

Psychology is the scientific study of the mind and behavior. In the book Visualizing Psychology, authors Siri Carpenter and Karen Huffman write that the four main goals of psychology are to describe, explain, predict, and change the behavior and mental processes of others.65

A physician obligated more than organ, the whole must view his world.

64 Fordyce, Wilbert E. “Behavioural Science and Chronic Pain.” Postgraduate Medical Journal 60, no. 710 (1984): 865–68. https://doi.org/10.1136/pgmj.60.710.865.

65 Carpenter, Siri, and Karen Huffman. “Appendix B.” In Visualizing Psychology, 3rd ed. Hoboken, NJ: Wiley, 2013.

physician is obligated to consider than a diseased

more than even whole man–he view the man in world.

Harvey Williams Cushing 1869-1939

WORKS CITED

Bibliography.

DESIGN MANIFESTO

No works referenced in this section.

02

LANDSCAPE

1. Woolf, Virginia, On Being Ill, 1926, 34.

2. “IASP Announces Revised Definition of Pain.” International Association for the Study of Pain (IASP), July 16, 2020. https://www.iasp-pain. org/publications/iasp-news/iasp-announcesrevised-definition-of-pain/.

3. Zoffness, Rachel. “Pain Science 101.” Chapter 1. In Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 9. Oakland, CA: New Harbinger Publications, Inc., 2020.

4. Zoffness, Rachel. “Pain Science 101.” Chapter 1. In Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 9.

5. “Phantom Pain.” Mayo Clinic. Mayo Foundation for Medical Education and Research. Accessed March 28, 2022. https://www.mayoclinic.org/ diseases-conditions/phantom-pain/symptomscauses/syc-20376272.

6. Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 10.

7. “Wong-Baker FACES History.” Wong-Baker

Faces Foundation. Accessed February 20, 2022. https://wongbakerfaces.org/us/wong-bakerfaces-history/.

8. McAllister, Murray J. “What Is Chronic Pain Syndrome: Chronic Pain Syndrome Symptoms.” Institute for Chronic Pain. Institute for Chronic Pain, April 27, 2012. https:// instituteforchronicpain.org/understandingchronic-pain/what-is-chronic-pain/chronic-painsyndrome.

9. Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 8.

10. Yong, Jason R, Peter M Mullins, and Neil Bhattacharyya. Issue brief. Prevalence of Chronic Pain Among Adults in the United States. Vol. 163. PAIN, Februrary 2022. The Journal of the International Association for the Study of Pain, n.d.

11. Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 4.

12. Engel, George L. “The Need for a New Medical Model: A Challenge for Biomedicine”, 386. University of Rochester Medical Center, 1977. https://www.urmc.rochester. edu/MediaLibraries/URMCMedia/medicalhumanities/documents/Engle-Challenge-toBiomedicine-Biopsychosicial-Model.pdf.

13. Darnall, Beth. Psychological Treatment for Patients With Chronic Pain. Firsted. Washington, DC, WA: American Psychological Association, 2019.

14. Reno, Jamie. “Chronic Pain: The Impact on the 50 Million Americans Who Have It.” Web log. Healthline. Healthline, April 25, 2021. https:// www.healthline.com/health-news/chronic-painthe-impact-on-the-50-million-americans-whohave-it.

15. Darnall, Psychological Treatment for Patients With Chronic Pain.

SOCIOLOGICAL

IMPACT AND AUDIENCE

16. Reno, Jamie. “Chronic Pain: The Impact on the 50 Million Americans Who Have It.”

19. Kappesser, Judith. “The Facial Expression of Pain in Humans Considered From a Social Perspective.” Phil. Trans. R. Soc. (2019) B3742019028420190284. http://doi. org/10.1098/rstb.2019.0284.

20. “Wong-Baker FACES History.” Wong-Baker Faces Foundation.

DESIGN CHALLENGE

17. Zoffness, Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life, 4.

05

RESEARCH METHODS

18. Early, Janet. “Conventional, Integrative, and Functional Medicine: What’s the Difference and Which Is Right for You?” SteadyMD, January 22, 2021.

21. Cohn, Jeffrey F., Zara Ambadar and Paul Ekman. “Observer-based measurement of facial expression with the Facial Action Coding System.” (2007).Kappesser, Judith. “The Facial Expression of Pain in Humans Considered From a Social Perspective.”

22. Kappesser, Judith. “The Facial Expression of Pain in Humans Considered From a Social Perspective.”

23. About Art Therapy. American Art Therapy Association. (n.d.). Retrieved May 11, 2022, from https://arttherapy.org/about-art-therapy/.

24. Solan, Matthew. “Art Therapy: Another Way to Help Manage Pain.” Harvard Health, July 12, 2018. https://www.health.harvard.edu/ blog/art-therapy-another-way-to-help-managepain-2018071214243.

25. Solan. “Art Therapy: Another Way to Help Manage Pain.”

26. Lee, Bonnie & Angheluta, Anne-Marie. (2011). “Art Therapy for Chronic Pain: Applications and Future Directions.” Canadian Journal of Counselling and Psychotherapy. 45. 112–131.

27. Lee & Angheluta. “Art Therapy for Chronic Pain: Applications and Future Directions.”

28. Lee & Angheluta. “Art Therapy for Chronic Pain: Applications and Future Directions.”

36. “One in Five American Adults Experience Chronic Pain.” ScienceDaily. ScienceDaily, April 20, 2021. https://www.sciencedaily.com/ releases/2021/04/210420092901.htm.

PAIN LAB

29. Solan. “Art Therapy: Another Way to Help Manage Pain.”

30. Cohen, Sarah. “4 Benefits of Art Therapy for Chronic Pain.” Pain Resource, May 13, 2019. https://painresource.com/chronic-pain/4benefits-art-therapy-for-pain/.

31. Smith, Kathleen. “Chronic Pain and Depression.” Psycom, June 9, 2022. https://www.psycom. net/depression/depression-signs-symptoms/ chronic-pain-and-depression.

32. Shella, Tamara A. “Art Therapy Improves Mood, and Reduces Pain and Anxiety When Offered at Bedside during Acute Hospital Treatment.” The Arts in Psychotherapy 57 (2018): 59–64. https:// doi.org/10.1016/j.aip.2017.10.003.

33. Cohen. “4 Benefits of Art Therapy for Chronic Pain.”

34. Cohen. “4 Benefits of Art Therapy for Chronic Pain.”

37. Reno, Jamie. “Chronic Pain: The Impact on 50 Million Americans.” Healthline. Healthline Media, April 25, 2021. https://www.healthline. com/health-news/chronic-pain-the-impact-onthe-50-million-americans-who-have-it.

38. Gilbert, Stephen, Alicia Mehl, Adel Baluch, Caoimhe Cawley, Jean Challiner, Hamish Fraser, Elizabeth Millen, et al. “How Accurate Are Digital Symptom Assessment Apps for Suggesting Conditions and Urgency Advice?

A Clinical Vignettes Comparison to GPS.” BMJ Open 10, no. 12 (2020). https://doi.org/10.1136/ bmjopen-2020-040269.

39. Taylor, Phil. “Study Finds Big Differences between Top Symptom Checker Apps.” Pharmaphorum. Pharmaphorum, December 16, 2020. https://pharmaphorum.com/news/studyfinds-big-differences-between-top-symptomspotting-apps/.

40. Taylor, Phil. “Study Finds Big Differences between Top Symptom Checker Apps.”

41. Flynn, Diane M. “Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments.” American Family Physician Vol. 102,8 (2020): 465-477.

BIOLOGICAL

35. “Every State’s Most Googled Medical Symptoms.” Eligibility, March 19, 2019. https:// eligibility.com/medicare/states-most-googledmedical-symptom.

FINLEY HEALTH

42. McGowan, Mike. “What If Doctors Were Paid to Keep People Well?” Center for Nutrition Studies. https://nutritionstudies. org/what-if-doctors-were-paid-to-keeppeople-well/#:~:text=Ancient%20Chinese%20 doctors%20were%20paid,to%20keep%20 their%20patients%20healthy.

43. McGowan. “What If Doctors Were Paid to Keep People Well?”

Adults – a Randomised Controlled Trial.” PLOS ONE 14, no. 10 (2019). https://doi.org/10.1371/ journal.pone.0222768.

49. Li, Ye, Mei-Rong Lv, Yan-Jin Wei, Ling Sun, Ji-Xiang Zhang, Huai-Guo Zhang, and Bin Li. “Dietary Patterns and Depression Risk: A Meta-Analysis.” Psychiatry Research 253 (April 2017): 373–82. https://doi.org/10.1016/j. psychres.2017.04.020.

50. Tello, MD, Monique. “Diet and Depression.” Harvard Health, January 29, 2020. https:// www.health.harvard.edu/blog/diet-anddepression-2018022213309.

11

BELLY BRAINS

PSYCHOLOGICAL

44. “Depression.” National Institute of Mental Health. U.S. Department of Health and Human Services. Accessed February 24, 2022. https:// www.nimh.nih.gov/health/topics/depression.

45. “Depression.” National Institute of Mental Health. U.S. Department of Health and Human Services.

46. “Depression.” Mental Health America. Accessed April 30, 2022. https://www.mhanational.org/ conditions/depression.

47. “Mental Health By the Numbers.” NAMI. National Alliance on Mental Illness. Accessed May 1, 2022. https://www.nami.org/mhstats.

48. Francis, Heather M., Richard J. Stevenson, Jaime R. Chambers, Dolly Gupta, Brooklyn Newey, and Chai K. Lim. “A Brief Diet Intervention Can Reduce Symptoms of Depression in Young

No works referenced in this section.

GLOSSARY

51. “Acute Pain vs. Chronic Pain: Differences & Causes.” Cleveland Clinic.

52. “Anxiety.” American Psychological Association. Accessed May 12, 2022. https://www.apa.org/ topics/anxiety.

53. About Art Therapy. American Art Therapy Association.

54. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” 387.

55. “Acute Pain vs. Chronic Pain: Differences & Causes.” Cleveland Clinic, Last Reviewed December 8, 2020. https://my.clevelandclinic. org/health/articles/12051-acute-vs-chronicpain.

56. “What Is Cognitive Behavioral Therapy?” American Psychological Association. American Psychological Association, July 2017. https:// www.apa.org/ptsd-guideline/patients-andfamilies/cognitive-behavioral.

57. “Depression (Major Depressive Disorder).” Mayo Clinic. Mayo Foundation for Medical Education and Research, February 3, 2018. https://www. mayoclinic.org/diseases-conditions/depression/ symptoms-causes/syc-20356007.

58. “Facial Action Coding System.” Paul Ekman Group, January 30, 2020. https://www. paulekman.com/facial-action-coding-system/.

59. “Facial Action Coding System.” Paul Ekman Group.

60. “Musculoskeletal Pain: Types, Causes, Symptoms & Treatment.” Cleveland Clinic. Accessed May 12, 2022. https://my.clevelandclinic. org/health/diseases/14526-musculoskeletalpain#:~:text=Musculoskeletal%20pain%20 affects%20bones%2C%20joints,speak%20 with%20a%20healthcare%20provider.

61. Hirose, Munetaka. “Chapter 21: Nociception During Surgery.” In Features and Assessments of Pain, Anaesthesia and Analgesia, 235–45. Elsevier Academic Press, 2021.

62. Physiopedia contributors, “Nociception,” Physiopedia, https://www.physio-pedia.com/ index.php?title=Nociception&oldid=246340 (accessed April 11, 2022).

63. “IASP Announces Revised Definition of Pain.” International Association for the Study of Pain (IASP).

64. Fordyce, Wilbert E. “Behavioural Science and Chronic Pain.” Postgraduate Medical Journal 60, no. 710 (1984): 865–68. https://doi. org/10.1136/pgmj.60.710.865.

65. Carpenter, Siri., Karen Huffman. “Appendix B.” In Visualizing Psychology, 3rd ed. Hoboken, NJ: Wiley, 2013.

CHAIR, MFA PRODUCTS OF DESIGN AT SVA

Allan Chochinov

THESIS ADVISORS

Allan Chochinov

Alexia Cohen

Sam Potts

Andrew Schloss

EDITOR

Jamie McGhee

© Copyright, 2022 by Danna Krouham Efter

All rights reserved.

For inquiries, please contact: dkrouham@sva.edu or visit dannakrouham.com

School of Visual Arts

MFA Products of Design 136 West 21st Street New York, NY 10011 productsofdesign.sva.edu

Products of Design Thesis

School of Visual Arts

New York City 2022