Show Me How It Hurts Health, Communication and Visual Metaphor
A DESIGN THESIS BY REBECCA WIENER
Show Me How It Hurts Health, Communication and Visual Metaphor Rebecca Wiener
Received and approved:
Primary thesis advisor
Edvin Yegir
May 2011
Secondary thesis advisor
Sandie Maxa
May 2011
Chairperson
Jeffrey Bellantoni
May 2011
MFA Candidate
Rebecca Wiener
May 2011
Show Me How It Hurts Health, Communication and Visual Metaphor Rebecca Wiener
Bachelor of Arts, Visual Art & History School of Liberal Arts, Brown University May 2004 Š 2011 Rebecca Wiener A thesis submitted in partial fulfillment of the requirements for the degree of Master of Fine Arts, Communications Design School of Art and Design, Pratt Institute May 2011
TABLE OF CONTENTS
INTRODUCTION
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PROCESS & METHODOLOGY Body as Map Body as Machine Physical Experience as Visual Experience
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THE CAPSTONE PROJECT Research & Development Language & Form The Prototype The Application The Exhibition
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CONCLUSIONS & FURTHER DIRECTIONS
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ANNOTATED BIBLIOGRAPHY
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13 26 38
46 49 56 66 74
INTRODUCTION
What’s Wrong? “ English, which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache... let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.” VIRGINIA WOOLF Experts put the rate of misdiagnosis in the U.S. at forty percent—a terrifying statistic. (Alfano) But blame doesn’t rest solely on the shoulders of doctors and hospitals. The doctor-patient relationship demands that we as patients be aware of our health and medical history, and communicate our concerns effectively and comprehensively to our caretakers. Too often we act as passive participants, expecting to hear a diagnosis without first describing the symptoms or volunteering that there are any symptoms at all. Doctors have very limited time to spend with each patient, and if they don’t know where to look or what to look for, a problem could go unexamined until it threatens our lives. Despite their very advanced degrees, doctors can’t read minds. So the question becomes, why aren’t we telling our doctors what’s wrong? I know that in my case, the answer is “for a lot of reasons.” To start, I don’t like going to my doctor’s office. I always have to wait to see her, I feel rushed once she finally gets to the exam room, I don’t know what questions to ask and frankly, I don’t always know what is happening in my body. It can seem impossible to bridge the gap between feeling bad and describing what sort of “bad” I feel, so I either approximate with words I’ve used before and hope for the best, or I never get to the exam room in the first place. Modern Western medicine is verbal; we are taught to describe our problems with straightforward adjectives and nouns. But too often, talking about pain is like dancing about architecture—in translation, the range, depth and context of sensations is lost. And although they are treated as such, words are not facts and some symptoms can be embarrassing to name. To help patients communicate their pain non-verbally, some hospitals and doctors’ offices use the Wong-Baker 3
fig. 1
fig. 2
INTRODUCTION
FACES Pain Rating Scale ( fig. 1), a scale of severity from one to ten with matching facial expressions. Many pain management clinics use the McGill Pain Questionnaire ( fig. 2), a long checklist of overlapping adjectives and a body chart onto which patients can mark the pain’s location. The intention of these tools is excellent. By giving patients a visual reference, the charts are able to circumvent some of the problems with written and spoken language. But the use of these methods is extremely limited, as is their usefulness: There is no opportunity to mark discomfort that is not pain or to indicate change over time; the charts are only intended to be filled out at the clinic or hospital, not at home or whenever the problem starts; and they don’t allow the patient to fit their symptoms into a larger system of understanding. We need new ways to communicate what is happening in our bodies that are personal, flexible, evocative and connected. More than a universal sign for “headache,” we need a way to articulate—to ourselves first and then, to others— the qualities of a specific headache. In graphic design, this kind of qualitative description is created through visual metaphor. Deeply resonant with the viewer but without pretense of universality, visual metaphors serve to express sensations without limiting their meaning. Mark Johnson and George Lakoff argue in Metaphors We Live By that metaphors can in fact expand our understanding by helping us see a subject in a new way. And because our reactions to visual stimuli are intuitive, they can create better bridges for empathy when we’re trying to communicate to friends, family and health professionals. But above all, visual metaphors can help us get to know our bodies, their histories and their habits, and apply that knowledge to a holistic vision of our health. Only then can we be our own advocates, in the doctor’s office and in our own homes. In my thesis exploration, I used my own health experiences to experiment with three different metaphors for the body and its sensations: “body as map,” “body as machine” and “physical experience as visual experience.” After investigating how visual metaphors can expand my understanding and articulation of my own body and health, I created a health log system as my capstone project to show how visual metaphor can be an invaluable tool for communicating—first to ourselves and then, to others—what’s happening inside our bodies.
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INTRODUCTION
Why Health? “ To have pain is to have certainty, to hear about pain is to have doubt.” ELAINE SCARRY I was a sickly kid. In the years leading up to high school, I had scarlet fever, mono, pneumonia twice, chronic headaches and stomachaches, countless bouts of strep throat and an allergic reaction to ant bites that kept me from sitting “Indian-style” for two weeks. I visited the school nurse at least once a week for years and got to know the inside of doctors’ offices pretty well. But I also played sports constantly: gymnastics, tennis, basketball, cross-country, volleyball. So over the course of my childhood and adolescence, I heard both doctors and coaches tell me about my body and its abilities (or inabilities). The ideas of my body and its needs in the exam room and on the court were entirely different animals. I went to my doctor for shortness of breath, he told me it was “just stress” and sent me home; I went to my basketball coach and she taught me to relax by closing my eyes and picturing the knots in my shoulders slowly unwinding. I visited the nurse for a headache and I was told to lie down until it went away; I confessed to my volleyball coach I was having trouble with my serve, he suggested I go through the correct motions until the action was inscribed in my muscles. I’ve been told by more coaches than I can count that my body is a machine, a building, a precious commodity, a creature with its own mind, a book, an engine, a tree—every time followed by the suggestion that I take care of it as such. But to my doctors, my body was always just a symptom: a stomachache or rash walking around, disconnected from who I am and unrelated to the stomachache or rash from the week before. Visualizing and metaphor-making have long been a natural part of athletic training. But too often, the medical field lacks these strategies for understanding and treating patients. Athletes are also regularly expected to practice by themselves, pay close attention to how their bodies act and react, and make notes about progress and goals. In my experience, not a single doctor has encouraged me to think rigorously and systematically about my body or health. I was diagnosed with Irritable Bowel Syndrome (IBS) about five years ago. The gastroenterologist to whom I was referred immediately started me on a regimen of daily powdered laxatives and prescription medication. My body reacted terribly. I returned to the doctor asking for an alternative, but she told me there was no other way to control my condition. Frustrated, I researched online and started keeping a food diary. By simply trying to pay attention my body’s reactions and needs, I very quickly discovered which foods and activities were problematic, and which could help me take care of myself. My immune system 6
INTRODUCTION
is still not going to win any awards, but (knock on wood) I’ve been healthy ever since. My mother recently started having stomach problems and I encouraged her to pay close attention to her body and track her symptoms. She was amazed at how just tuning in to the cause and effect inside her body could help her manage her symptoms. Now I can’t get her to stop telling me about it.
Why Metaphor? “ The greatest thing by far is to be a master of metaphor.” ARISTOTLE
In Poetics, Aristotle writes that metaphor “consists in giving the thing a name that belongs to something else.” (Sontag, 93) But whether defined in terms of literature, semiotics or cognitive science, metaphor-making is not supplantive, it is expansive. Along with a name, the thing inherits all of the qualities of that something else. To call a girl a flower is to remark on her beauty. But the flower metaphor also paints the girl as delicate, precious and natural—and more than that, it points to this moment as the blooming, preceded by budding and followed by fading. The girl not only acquires the superficial qualities of the flower, but also its narrative, history and cultural symbolism. In this sense, metaphor consists as much in reframing as in renaming. In Metaphors We Live By, Mark Johnson and George Lakoff’s definitive book on cognitive metaphors, the authors write that “the essence of metaphor is understanding and experiencing one kind of thing in terms of another.” (Johnson and Lakoff, 5) They argue that that we understand the world largely through this methodology. It is “as much a part of our functioning as our sense of touch, and is as precious.” (Johnson and Lakoff, 239) The language we use to describe an argument, for instance, reveals that we understand the concept of “argument” in terms of metaphors such as “argument is war.” We say, “he attacked my position” or “I gained ground on that front” to illuminate certain aspects of what an argument is and downplay others. We do this naturally; it is just how we think. But by becoming aware of the power of metaphor, we can make clearer decisions about how we use them to communicate. We can also create new metaphors, which can help us see concepts in new ways and make new connections. In fact, Johnson and Lakoff write that “new metaphors have the power to create a new reality.” (Johnson and Lakoff, 143) Metaphors can also help us escape the limiting binary of objective versus subjective. When we talk about our bodies and our health, the issue of what is “real” 7
INTRODUCTION
and what is “real to us” is always present. Dr. Eric J. Cassell, clinical professor of Public Health at Cornell University Medical College, writes about objective and subjective knowledge in diagnosis in his book The Nature of Suffering. Cassell points out that objective and subjective have very specific meanings in medicine, different from those in philosophy. “ ...the reading on the clinical thermometer is an objective measure of an elevation of body temperature. The feeling of feverishness is subjective because a feeling can only be experienced by the subject. The patient who has the fever has ideas about its meanings that are also considered subjective. But subjective in this instance has the connotation of idiosyncratic—unique to this subject. Subjective in the sense of a feeling experienced by a subject and subjective in the sense of idiosyncratic ... are two different meanings of the word ‘subjective.’ Medicine holds a third sense of subjective—your statement that you feel feverish is also considered subjective; that is, your words, in general, are considered by doctors to be subjective.” (Cassell, 171) Cassell finds this last definition of subjective to be inconsistent and inaccurate. Yes, a feeling can only be felt by the one experiencing it, but once that sensation is communicated and brought outside the subject, the expression is empirical fact as much as a temperature reading. The thermometer makes observable an invisible experience of temperature and a patient makes observable the invisible experience of feeling feverish. So then it is a matter both of expressing physical sensation and of making it understandable to an outside observer. In Body in Pain, Elaine Scarry argues that the problem with pain is that it is entirely objectless, lacking “referential content.” (Scarry, 162) This objectlessness makes comprehensible expression impossible—how can you tell someone how you feel if you have no common reference point? But through use of the imagination, she says, we can conjure objects to connect with pain, thereby endowing sensations with a body and a weight, and making them relatable to others. Johnson and Lakoff call metaphor-making “imaginative rationality,” drawing attention to metaphor’s ability to create and expand understanding while still remaining tethered to reason. This balance is necessary to traverse the objective / subjective divide. However, in “Illness as Metaphor,” Susan Sontag writes that society has always constructed powerful metaphors about our bodies, and warns that metaphors that can be dangerous and destructive. Twelve years later, she explains her condemnation of metaphors in the essay “AIDS and Its Metaphors.” During her own experience with cancer, a disease that has been painted as a “demonic pregnancy” and an affliction of the sexually repressed, “it was [Sontag’s] doleful 8
INTRODUCTION
observation, repeated again and again, that the metaphoric trappings that deform the experience of having cancer have very real consequences: they inhibit people from seeking treatment early enough, or from making a greater effort to get competent treatment. The metaphors and myths, I was convinced, kill.” (Sontag, 102) Johnson and Lakoff agree that just as history is written by the victors, “people in power get to impose their metaphors.” (Johnson and Lakoff, 157) To combat these imposed concepts, Sontag maintains that we must think about illness in a way that is “most purified of, most resistant to, metaphoric thinking.” But I believe that the better recourse is fighting fire with fire: We need to take responsibility for our own metaphor-making about our bodies and health. We need to construct metaphors powerful enough to defend and protect us.
Why Visual Metaphor? “ One picture is worth ten thousand words.”
CHINESE PROVERB
If metaphor can expand our understanding, then visual metaphor extends that reach to places language can’t access. In Body in Pain, Scarry writes that “physical pain does not simply resist language but actively destroys it.” (Scarry, 4) Recourse lies in making that intangible sensation visible. Once it is “lifted into the visual world,” pain can become externalized and objectified. (16) Johnson and Lakoff speak about this transference from idea to object as well, a process that allows us to “refer to [experiences], categorize them, group them, and quantify them—and, by this means, reason about them.” (Johnson and Lakoff, 25) We can start to control ideas and sensations that were previously unreachable. The visual also adds dimension to metaphors by helping us see relationships that become clear through visual qualities, such as direction, shape, color, texture and movement. Throughout this thesis, I use the term “visual metaphor” to connect image-based manifestations of metaphor with cognitive and verbal ones. But what I talk about when I talk about visual metaphor is rooted in semiotics. The images I use in my exploration are signs that draw meaning for the maker and the viewer first from form (the signifier) and then from what that form represents (the signified). Beyond that dyadic relationship, the connotations around both signifier and signified create a chains of meaning. To take my earlier example of the girl and the flower, let’s say I make a pen-and-ink drawing of a flower to represent a girl. The idea of a flower, the image of this particular flower and the way in which I drew the flower all transfer meaning, pulling from the viewer’s personal and cultural experiences as well as my own as the maker. Every aspect of the drawing branches out into a chain of meaning, and so each visual quality— 9
INTRODUCTION
direction, size, shape and so forth—adds depth and complexity. Metaphor is an overarching structure connecting signs, allowing one signified to act as a signifier referring to a different signified. (Chandler) In the case of my example, metaphor is what connects the flower and its chains to the girl and hers. Semiotics reminds us that signs are necessary for communication. The editors of Data Flow write that visual metaphors in the form of “ciphers, objects, and illustrations” are exactly what have allowed humans to develop “collective and collaborative thought.” (Data Flow, 3) This is true for many reasons. Visual information is processed by the brain more efficiently than verbal language. (Treib, 82) Whereas we absorb verbal language sequentially, the visual is taken in as a totality, a gestalt. Not only is this form faster, it maintains the integrity of simultaneous experience in first an idea’s communication and ultimately the way the receiver processes it. Through the use of visual metaphor, you can give someone a snapshot of an experience instead of a list. (St. Clair, 89) For Scarry, being able to share felt-experience is essential to empowering someone in pain. “Whatever pain achieves,” she writes, “it achieves in part through its unsharability, and it ensures this unsharability through its resistance to language.” (Scarry, 4) We may not be able to remove pain, but we can gain power by telling others about it. In The Nature of Suffering, Dr. Eric J. Cassell argues that the visual can help create that reference point for communication. “The feelings or thoughts evoked by an object or event are certainly private, but the object of reference is not. The color red may be sensed slightly differently by each of us, but all of us who are not color-blind are able to act in a consistent fashion when asked to distinguish red from green. The fact that aesthetic knowledge can be shared is particularly important in the context of medicine, because it means that even the nonmeasuraable can provide a stable basis for clinical opinion and action.” (Cassell, 102) Beyond making an idea shareable, visual metaphors can make it resonant. Seeing has historically been conceived as an intimate and powerful act. Plato writes in Timeaus that light flows from the eyes to a seen object, creating a physical bridge between the object and the soul. In Art and Visual Perception, Rudolph Arnheim references Theodor Lipps’s early 20th century theory of empathy to demonstrate how strong this connection can be. When we look at an object (or line, or shape), we understand the physical forces affecting it and can project our own “kinesthetic feelings” onto it. (Arnheim, 448) That is a complicated way of saying that not only can an object lead us to feel empathy toward its maker, it can make us feel empathetic for the object itself through its visual and physical qualities. The visual is a powerful thing.
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INTRODUCTION
This thesis is not ... • advocating for self-medication or self-diagnosis, or denying the importance of seeing a primary-care doctor on a regular basis and specialists as needed. • prescribing an official visually-based patient record-keeping system. • arguing against the use of verbal and written medical histories in doctors’ offices, hospitals and clinics. • focusing on the experiences of those suffering from serious illnesses or severe chronic conditions. • conducting a study on the therapeutic benefits of visual expression.
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My Year of Metaphorical Thinking “ Information is control.”
JOAN DIDION
Metaphors are all around us; which ones we choose to use and how we choose to use them is the challenge. They have the ability to frame a subject as fascinating or terrifying, possible or out of reach, helpful or hurtful. Indeed, the wrong kinds of metaphor, ones that “deform” one’s understanding of a subject as in Sontag’s examples, are dangerous. But the right kinds of metaphor have an equal ability to transform. For my thesis exploration, I’ve chosen three visual metaphors—body as map, body as machine and physical experience as visual experience—that I believe can empower us as caretakers of our bodies and our health. All three of these metaphors represent our experiences in ways that may be more unfamiliar to traditional Western medicine and conceptions of illness, the self and the body than to Eastern traditions, feminist theory and cognitive science. They question our Western assumptions, they help us understand ourselves better, and by allowing us to frame our bodies in ways that suggest strength, reason and beauty, they can be tools to improve our health, to help us thrive. I do not intend to forcefully supplant other views of the body with this one. Rather, this experimentation is about expanding our understanding of ourselves through a multiplicity of visions. And, to use a slightly unflattering metaphor, I am the guinea pig.
Body as Map “ There is a great deal of unmapped country within us which would have to be taken into account in an explanation of our gusts and storms.” GEORGE ELIOT One weekend in September, I flew to San Francisco to visit two friends who had recently moved across the country. In the spirit of the city, we decided to get our auras read on the second day of my trip. My friends knew of a place in Japantown and we headed out, a little unsure of what to expect. Here’s how it went: We 13
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arrived at a small corner shop filled with Asian-flavored tourist-enticing tchotchkes, inquired about having our auras read and were led into a back room filled with old VHS tapes. A bench lined one wall of the cement-floored room and flapping behind it was an school-picture-style pull-down screen. The proprietor of the shop rushed around, turning on an old Macintosh computer and a dot matrix printer, and dragging out an enormous machine hooked up to biofeedback sensors—the Aura Camera 3000. One by one, we sat on the bench, put our hands on the sensors, smiled (or stared) on cue and were handed both a Polaroid photo of ourselves with clouds of color swirling around us (fig. 3) and a twopage print-out with a diagram of the photo and an explanation of its significance (fig. 4). The Aura Camera 3000 had read our auras. While we were waiting to pay, we examined each other’s artifacts, giggling over how one red splotch purportedly indicated “unrelenting perfectionism” and a white swath gave its bearer “magical powers.” The proprietor rushed over to disabuse us of our simplistic readings. “No no!” she exclaimed. “It means different things for different people!” She proceeded to enhance and contradict the printouts and the Polaroids, telling us she was an expert giving us a true reading. We left the shop thoroughly charted, photographically, electronically, verbally and expertly. I began researching auras, chakras and the Aura Camera 3000. The process was fascinating to me—and more than that, it felt familiar. Didn’t I go into that shop to be diagnosed? Wasn’t I told that only an expert could interpret what was happening in and around my body? Didn’t I leave just a little bit confused? Much of the literature I was reading about auras seemed to indicate that with practice, we can see and even control our own auras. And that analyzing our own auras can help us change bad energy into good and essentially redraw the lines of our energy forces. But the specter of the “expert” kept reappearing in the narrative, wresting away interpretive power. In San Francisco, the aura expert gave me a map of my energy and the key to deciphering it. But shouldn’t I be able to be my own cartographer? The relationship between mapping, knowing and controlling is a complicated and ancient one. Mapping has always been a language of definition, of making clear what was murky, of giving ownership to what was wild. During the Renaissance, Ptolemy and Toscanelli’s perspectival maps divided the world into a grided, organized surface (fig. 5). Even though these maps—and so many that have come afterwards—were terribly flawed, they helped Europeans gain the terms and tools with which they would endeavor to understand the world around them, a landscape that was “no longer to be thought of as a heterogeneous assemblage of frightening unknowns.” (Isaak, 160) If we likewise think of our bodies as territories, as landscapes that can be mapped, or as maps themselves of our health, we can cast ourselves in the role of explorers. Our bodies are then navigable; self-education is self-discovery. 14
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Maps are tools for exploring the real but they are also visions of a reality we could never see unaided. In The Power of Maps, artist, author and cartographer Denis Wood credits maps with giving us “a reality that exceeds our vision, our reach, the span of our days, a reality we achieve no other way. We are always mapping the invisible or the unattainable or the erasable, the future or the past, the whatever-is-not-here-present-to-our-senses-now and, through the gift that the map gives us, transmuting it into everything it is not... into the real.” (Wood, 5) In this way, mapmaking can also help us uncover the interconnectedness within a system or landscape. From ancient times to modern day, cartographers did not map simply to conquer, but to chart paths and relationships previously unseen; the New World was, of course, “discovered” during a search for a new passage to the Spice Islands. And maps are unique in their ability to communicate layers of history in a single image. I grew up in Texas, a state that has belonged to six different countries according to six different borders. In my years of Texas history tutelage, I was taught that those borderlines tell the story of battle, victory, secession and compromise. Our bodies can similarly communicate our stories with their bumps, bruises and scars. Just as map symbols represent meaningful buildings, routes and borders, physical marks on my body are encoded with significance by my own experiences. This transforms the body into more than an artifact of history: it is also a legible visual record of past and present. The idea of the body as a map is not a new metaphor. In fact, it is in many ways how we were made. Developments in neuroscience in recent years have revolutionized how we understand how we understand. Not only are we able to map the brain’s functions and connections, but scientists have discovered that the brain contains within it a map of the body. Each point on the human body corresponds to a point in the brain—although, the order and size of these points correlate in sometimes unexpected ways. (Ramachandran) Another neural mapping model demonstrates that our brain contains maps of nerve bundles, which receive sensory information. As we experience different sensations with different results, those maps grow and change to guide us toward experiences that benefit us and away from unnecessary ones. Over time, the collection of our experiences builds a map of our understanding of the world within our own brains. (Isaak, 171) Eastern medicine and philosophy have long believed the body to be a map of itself and its functions. In reflexology, the body is directly mapped onto the feet and the hands, allowing healers and patients a sort of built-in remote control for accessing different organs and systems. In traditional Chinese medicine (kanpo), physicians read the body to find “a unique pattern of imbalance” in yin and yang, serving as referees in a battle for territory. (Picone, 469) The concept of energy or lifeforce (ki) is central to acupuncture and other Eastern and syncretic treatments. Ki runs along meridians of the 17
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body, connecting one region to another (fig. 6). To uncover the root of a problem, a healer will follow the path of ki. For instance, in kanpo, the liver is the locus of anger and the eyes are along the same meridian as the liver. So an eye infection could be attributed to excessive anger, just as the pollution in a river can be traced back to its source. Because mapping gives the cartographer power and control over his subject, the act of mapping has a dark complementary history to the triumphant one of exploration. Phrenology and physiognomy, pseudosciences that claim to be able to map intelligence, personality traits and aptitude to head shape have been used by Nazis, slave traders and despots to justify unjust acts for centuries. In “Illness as Metaphor,” Susan Sontag points out that the language of war and territory is used almost exclusively in discussing illness, a vernacular that first entered the field in the 1880s when medicine was professionalized in Europe and the United States. (Sontag, 66) A disease invades and doctors look for a new plan of attack; the patient’s body is the passive battlefield. And during that time of physician professionalization in the 19th century, the concept of “hysteria” was used to chart and validate a physical locus for a wide range of emotional, medical and social symptoms—all supposedly attributable to secretions from or an enlargement of the female reproductive system. (Ehrenreich and English, 132) So it is important that we incorporate into the metaphor “body as map” an image of ourselves as the cartographers of our own bodies. This way we gain access to the empowering aspects of mapping and avoid the over-deterministic and paternalistic pitfalls. Engineers and scientists, artists and designers have used the visual metaphor of the body as map directly in their work. The National Institutes of Health (NIH) is currently working to complete a comprehensive, anatomically detailed 3D visualization of the male and female bodies, with the explicit intention to “produce a system of knowledge structures that will transparently link visual knowledge forms to symbolic knowledge formats such as the names of body parts.” Google has created their own 3D map of the human body: Google Body, a detailed model that anyone can navigate using the Chrome web browser. You can zoom, isolate distinct areas and systems, search for specific organs and bones, and share your findings with other people (fig. 7). In her 2006 masters project in Communication Design at London College of Communication, Emotionally Vague, Orlagh O’Brien asked 250 people of all ages from around the world to visualize emotions by drawing where they felt the emotion on their body. Her intention was to explore how people can participate in the process of creating images of their emotions, rather than relying on cliches or photographs. She layered all of the results of her survey, generating a 18
fig. 7
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surprisingly consistent map of felt-emotion on the human body (fig. 9). In designer April Greiman’s seminal poster “Does It Make Sense?,” she uses her own naked body as the landscape and maps her visual and verbal interpretations of science and technology on top of it. The title of the piece references a quotation from philosopher Ludwig Wittgenstein, included in the poster: “It makes sense if you give it sense.” Through the act of mapping technology onto her own body using the very digital tools she is discussing, Greiman makes sense out of this brave new computerized world (fig. 10). Barbara Kruger’s famous 1989 montage Untitled (Your body is a battleground) is an act of coercive metaphor-making. The artist employs her signature red, black and white palette and Futura Bold combined with a black-and-white image of a woman’s face split down the middle, one side transformed into a photo negative. The woman’s face is divided between two territories, good and evil, and Kruger is forcing the viewer to accept a new vision of her body as a call to action (fig. 11). During my own exploration of the visual metaphor of the body as map, I was particularly inspired by the Aura Camera 3000 and my research on ancient and Eastern forms of body mapping. My first fully-formed project toward my thesis was the Do-It-Yourself Aura Coloring Book (fig. 12). I decided to take the experience of getting my aura read and transform it into an enjoyable exercise in mapping my feelings. In aura reading, colors indicate specific characteristics, ideas and abilities, and different parts of the bodies represent specific aspects of the self. The location of a color around the body indicates what part of you is being affected by its associated characteristics, ideas and abilities. Using the friendly style and inviting tone of classic coloring books, I designed pages that explain and demonstrate the simplified basics of auras, chakras and their interpretation. The rest of the book is a sort of diary, 40 pages containing the same body outline and a few lines for notes or explanation. Because an aura changes from one moment to the next, a diary or log format encourages the user to chart those changes and create a record of his or her own energy. I included in the project a set of crayons with custom labels, so the user can easily see which color indicates which characteristics without having to flip back to the explanation section. I took one of the books as my own and colored my interpretation of my energy during important moments in the past year. The process of channeling my energy with a crayon was fun, freeing and a little uncomfortable. But once I got into the hang of visualizing my nebulous state of being, it was hard not to think in colors as I went through my day. (This morning I’m feeling a little brown around the edges.) To witness my coloring book in action and provide my colleagues with a little nostalgic release, I scheduled a day of sitting in a common area of the Pratt GradComD studios with a stack of coloring book pages and two sets of crayons. 20
ANGER
JOY
fig. 9
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FEAR
SADNESS
fig. 12
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I invited passersby to come, sit and color for a while. People all seemed to enjoy themselves and some stunning images came out of the afternoon. But what was most interesting to me was that each person’s approach to coloring his or her aura was unique. Some colored with broad heavy strokes, some generated rainbows within rainbows, and one person even blended the waxy colors of his aura with his finger. Not only was each person’s map different, but each person’s map-making technique was also distinct (fig. 13). After making the Aura Coloring Book, I started researching ancient, Eastern and alternative forms of body mapping beyond chakras. Almost all of the maps I looked at have been used to chart emotion and personality as well as health and anatomy. I soon realized just how many body maps are built onto the ones that came before—just as geographic maps are—but also, how many conflicted with each other. As I began to extract and project the maps onto an image of my own body, I stepped back and saw how these lines and shapes formed new territories and absorbed old ones (fig. 14). The image was beautiful, and the kind of sense it made drew me back to Greiman’s piece. The act of drawing those maps onto my body and the resulting gestalt of information helped me grasp how my body interacts with the history of medicine and science. And how those layers of color, lines, shapes and symbols, separated by time and distance, communicate with each other to create a visual process of anatomical discovery and revision. I decided to name my project Sense and Sensibilities, a nod to Greiman’s work and to the search these maps are engaged in to define what makes a body a body and a person a person. The title also cannot help but reference Jane Austen’s similarly-titled novel, which explores in part the relationship between reason and emotionality. This exercise may not have given me concrete definitions of my body’s functions, but it familiarized me with mapping symbology and coding systems, helped me understand how scientists and healers visualize how the body works, and expanded my toolbox for understanding my own landscape. Thinking about ourselves as the cartographers of our bodies can start us on the journey toward transforming them.
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Body as Machine “ The human body is a machine which winds its own springs.” JULIEN OFFRAY DE LA METTRIE
A map is a record and a guide; a machine works. Playing sports in my childhood taught me that there is a firm relationship between cause and effect. If I practice, I’ll get better. If I sleep well, I’ll have energy. Listening to my body and giving it what it needs seems like the obvious choice. But what we do naturally for the machines in our life—laptops, iPhones, coffee makers, cars—we have a harder time doing for ourselves. This is in part because we think that we work differently from machines, that “it’s not so simple” as input and output, that there is some magic in our mix. That concept of magic—call it the soul, the will, or the higher self—stands between us and an understanding of our minds and bodies as one interconnected system. In The Meaning of the Body, Mark Johnson writes that “[m]ind/body dualism is so deeply embedded in our philosophical and religious traditions, in our shared conceptual systems, and in our language that it can seem to be an inescapable fact about human nature.” (Johnson, 2) Our bodies themselves are working to hide the connection from our consciousness. Because we need our hearts to constantly beat, our lungs to reliably expand, necessary physical processes like these are run by our autopilot while we go about our daily business. But if that autopilot is injured and one of these processes breaks down, the interconnectedness of our minds and bodies becomes strikingly clear. On an episode of the public radio program Radiolab, the neurologist and writer Oliver Sacks tells the story of a man who woke up one morning without proprioception—the unconscious ability to perceive our own bodies in space through the feedback loop between mind and body. He could no longer do even the simplest movements that require spatial awareness: sitting up, reaching, to say nothing of picking up a fork or walking. After years of practice, he was able to train his conscious mind to direct each minute element of each action he wanted to produce. Now, when he walks down the street, he is telling his foot to lift at a specific angle, move a certain distance and step down with a particular force—and he must look at his muscles while this is happening to replace with visual feedback what would usually be feedback from his nervous system. This process takes so much concentration that, according to Dr. Sacks on Radiolab, if a pretty girl walks by, he will most likely fall down. Seen with this lens, it is much clearer how the body is indeed a machine—a very complex machine incorporating disparate and complicated processes and mechanisms, but a machine nonetheless. If it is “the body’s own tendency toward self-concealment that allows for the possibility of its neglect or deprecation,” then uncovering 26
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the truth of those hidden processes can help us attend to and value our bodies and our health. (Johnson, 6) The visual metaphor of the body as machine opens up many doors for understanding and action. In “Cyborg Manifesto,” philosopher and scholar Donna Haraway argues that in our modern era, we are all cyborgs. In her definition, the cyborg transcends restrictive dualisms of all kinds: physical, cultural, political, scientific and gendered. It is an empowered border-jumper and revolutionary, “a condensed image of both imagination and material reality, the two joined centres structuring any possibility of historical transformation.” (Haraway, 150) Haraway fully embraces cybernetic technology and scientific advancements as bringing us closer to a fluid existence. To her, the idea of a return to nature as resistance against technology is both antiquated and ignorant of the world and bodies we live in. Throughout the essay, Haraway’s language is incendiary and hyperbolic—as is often the case with manifestos—but her intent is to propose a new visual metaphor for ourselves, one that “can suggest a way out of the maze of dualisms in which we have explained our bodies and our tools to ourselves.” (181) That metaphor is the body as a cyborg of its own imagining and making. An empowered and independent machine. Some Eastern traditions employ visualizations of the body’s mechanisms in order to gain greater understanding and control over its functioning. In her essay “The Ghost in the Machine: Religious Healing and Representations of the Body in Japan,” anthropologist Mary Picone quotes one modern Japanese healer’s practice of introspection: “I could concentrate on my body until it became as though it were made of glass and I could see all its functioning.” She also mentions some Buddhist meditation techniques in which the practitioner visualizes the organs and bones one by one as a way to connect with the physicality of the body and its energy. (Picone, 474) But Picone points out that in kanpo, karma is still seen as the primary cause of illness. A sufferer may have done something wrong or hurtful to others, his ancestors may have committed an immoral act, or the individual may just be “too passionate, too attached to this world.” (481) This last phrase immediately recalls Sontag’s descriptions of the mythology swirling around tuberculosis in the 19th century. TB, or consumption as it was often called, was believed to be a result of too much passion, “afflicting the reckless and sensual.” (Sontag, 21) And according to Sontag, as recently as the 20th century, cancer was painted as “a disease of insufficient passion, afflicting those who are sexually repressed, inhibited, unspontaneous, incapable of expressing anger.” (21) Both of these characterizations of illnesses, as well as kanpo’s concept of karma, cast the sufferer as transgressor and the suffering as punishment. In this drama, the very real cause-and-effect relationship within the body is veiled with emotional and accusatory tones, replacing 27
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responsibility with blame and turning the brain into the tyrant to the body’s oppressed subject. This is the deformation to which Sontag referred in “AIDS and Its Metaphors,” and it cripples the way we currently think about our bodies and our health. If we can look to the body as machine metaphor, it will allow us to stop blaming ourselves for what we can’t control—personality, emotions, our ancestors—and start taking responsibility for what that we can—nutrition, exercise and awareness. Like mapping, the idea of the machine can be a controversial one. Dystopian futures are imagined in Hollywood every day, wherein humans turn out to be murderous animatronics or a “smart” robot goes rogue. But that perspective is slightly dated; Russians don’t make good movie bad guys anymore, and neither do machines. Haraway believes the key to understanding the cyborg metaphor is the evolution from mechanical to cybernetic technology, and I agree. As technology becomes more invisible, more integrated into our lives—more like the hidden processes of our own bodies—we understand that it can entertain us, assist us and empower us... and maybe even heal us. In 1984, Apple broadcast its famous Orwellian ad warning consumers that the tyranny of IBM was turning them into androgenous drones. Only Apple—in the form of a tanned, athletic, Scandinavian-looking woman wielding a hammer—could save them from a future of cold conformity (fig. 15). Twenty years later, Apple began a highly successful campaign for the iPod that relies on a visual metaphor of the cyborg: the unified silhouette of a user and his or her iPod, joined joyfully in form and movement (fig. 16). If machines aren’t so scary anymore, can’t we understand that they’re not so different from us either? We’ve seen plenty of Terminators in popular culture, but positive, empowering interpretations of the body as machine metaphor also appear in the work of developers, designers and artists. In November 2010, Microsoft launched Kinect, a console-free gaming system wherein the user can control movement with his or her own body. And now Microsoft is developing Skinput, a system that turns a user’s hand and arm into a keypad (fig.17). The aim of the prototype is to give users access to the wide range of functions in devices like the iPhone but without the machine object. In Skinput, the user and machine are seamlessly united, a melding that allows the form to disappear and its functionality to remain, embedded within the user. Of course, this type of human-machine bridging exists in the medical field as well. As of 2005, cochlear hearing implants have been entirely internal, with no external components. And advances in prosthetics are expanding the ways in which they replicate and even enhance the body’s mechanics. In developing the Cheetah Flex-Foot, the Icelandic company Ossur created a prosthetic leg that aims to improve on the human limb’s functionality rather than imitating its appearance (fig. 18). The Flex-Foot 28
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works so well, that in 2007 double-amputee Oscar Pistorius competed in the able-bodied South African Championships—and won his race. In 2009, for a project called e-Chromi, designers James King and Alexandra Daisy Ginsberg worked with Cambridge University biology students to genetically engineer bacteria that produce pigments (fig. 19). Each type of bacteria was designed to produce a different color, serving as a visual signifier for specific infections. If this project were to be put into application, someone who accidentally ingested an illness-inducing bacteria would be able to look at his or her own feces for the colorful evidence. It is clear that King and Ginsberg understand our bodies as machines in the most basic and essential way: if something goes into your digestive system, it is going to come out. By creating a color-coding system, e-Chromi uses design to help the body communicate with itself, highlighting for the naked eye evidence that already exists. In her performance work, the artist Marina Abramovic addresses the physicality of the self and the interconnectedness between mind and body. In the 1980 piece Rest Energy, Abramovic and her partner Ulay held a bow and arrow between them, balancing for hours like a see-saw gently seeking equilibrium (fig. 20). Abramovic held the body of the bow and Ulay pulled the string taut, with the arrow aimed at Abramovic’s heart. The performance was at once a visual metaphor for the precarious nature of relationships—one slip and Ulay could very well have pierced her heart—and an exercise in physical self-regulation. As their heart rates increased, it became harder for the artists to maintain their balance; they had to monitor and control their bodies’ sympathetic reactions in order to ensure the safety of themselves and their partner. Each artist was acutely aware of the processes in his or her body, as well as within the new organism they formed through their balancing interdependence. I began my own exploration of the body as machine visual metaphor with a collection of Venn diagrams that helped me define the space where machines and humans intersect over the course of my research (fig. 21). Then I moved on to a different sort of diagram: a flow chart. Like most of us, I can tend towards self-blame and accusation when something goes wrong with my body. I went through a few years during high school and college where I labeled some foods “bad” and others “good” and measured my strength of will on the balance of my intake. Sometimes skipping the gym can still feel like a moral failing rather than a choice. And when my IBS acts up and I try to think about what could have instigated it, it is often difficult not to feel guilty for eating the wrong thing or letting down my guard. But having IBS has helped me question these tendencies. In order to understand what my body needs, I’ve had to revisit the idea of “good” and “bad” foods and decisions. What may be “good” in our strictest cultural 31
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definition of healthy—raw vegetables, oatmeal, milk—can actually be very difficult for my digestive system to deal with. And what is often painted as “bad”—cheese, oil, bread—can help me have enough energy to get through my day. Inherent in my definition of the body as machine metaphor is the idea that each body is a unique machine. My machine may just need more calories and less roughage than someone else’s. For my thesis exploration, I wanted to dissect my own struggle with moral causation in visual form. The flow chart was originally created in 1921 as a tool for communicating complex engineering processes through information architecture and was later adapted to do the same for computer systems in 1947. Using that form, I charted my own process of selfdiagnosis, beginning with the problem “I feel sick” and running through the algorithm of evaluation, diagnosis and treatment (fig. 22). Making my internal process visible helped me see my habits more clearly, and encouraged me to change the flow of blame. My third project visualizing the body as machine metaphor is a series of five flipbooks titled A Kiss Is Still a Kiss: A Rube Goldberg Machine. Each of the flipbooks shows a visualization of one of the biological processes that moves a person—or, in this case, me—to kiss someone, reframing an emotional moment as a mechanical process (fig. 23). With the materials and style of the piece, I tried to evoke the visual language of old fashioned exercise workbooks to help readers feel that this lesson is both instructional and their own. The form of the flipbook itself dramatically extends what is a nearly instantaneous internal process into one that becomes accessible to the reader—essentially, a slow motion closeup, a trope that we are familiar with from instructional videos, sports broadcasts and scientific explanations. The form also helps the reader activate the process, giving them agency within the piece and reminding them of agency within their own bodies. The title of the project, underlined through its repetition on each of the flipbook covers, reassures us that regardless of how mechanical the process may seem, a kiss is still a kiss. It remains as sweet, even when called “a confluence of chemical and physical events.” I believe that understanding the complex mechanics of our bodies does not prevent us from understanding ourselves as dynamic and empowered creatures. Quite the opposite: It helps us further realize our potential.
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Physical Experience as Visual Experience “ If I paint a wild horse, you might not see the horse... but surely you will see the wildness!” PABLO PICASSO This third metaphor, physical experience as visual experience, is the most abstract, but perhaps the easiest to embrace—especially for designers. We are taught that every experience can be expressed visually. But the metaphor “physical experience as visual experience” implies not only that one form can be used to express the other, but also that they are simultaneous and interconnected processes. To return to Lipps’ theory of empathy mentioned earlier, when we look at an object or image, we project our own kinesthetic feelings onto it in order to understand its placement and meaning in space. (Arnheim, 448) This means that when we see, we are actually having a physical experience. Lipps was working in the 1900s, but his theories are strengthened by cognitive science. Scientists have shown that the same areas of a person’s brain light up when watching an activity and performing the activity. As Johnson puts it in The Meaning of the Body, “My understanding of bodily actions performed by others is based on the activation of my own bodily sense of performing such an action.” (Johnson, 40) He also writes that based on the way the brain creates meaning, our very definition of basic visual qualities is rooted in physical experience. “Such concepts as curved, twisted, diagonal, vertical, zig-zag, straight and circular get their meaning primordially from our bodily postures, our bodily movements, and the logic of those movements.” (Johnson, 26) The designer Frances Butler discusses this idea’s resonance within graphic design in her essay “Dance & Play in Visual Design: Visual Manifestations of Physical Experience.” She argues that “[v]isual experience parallels, both theoretically and actually, the actions and responses inherent in the rhythmic structure of dancing and the freely outlined elements of play.” (Butler, 173) This is why the rhythm and movement established within a book or designed piece can activate the viewer’s experience so readily and thoroughly. Many Eastern traditions and practices understand and use this interconnectedness to access new planes of experience. In some practices of Eastern Mysticism, yantra are used to concentrate and focus the mind during meditation. These elaborate circular images made up of symbols and patterns are two-dimensional in form, but multi-dimensional in meaning (fig. 24). To those who use yantra in meditation and spiritual practice, they are a kind of sacred architecture that houses the Universe’s energy. The physical act of meditation takes place within this architecture, the visuals of the yantra an activation and representation of the process. For the meditation practitioner, the physical experience and visual experience is one. 38
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Artists and designers who can make the interconnectedness between physical experience and visual experience manifest are translators of a sort. In 2005, the artist Jonathan Harris launched the website We Feel Fine, “an exploration in human emotion.” This online project allows visitors from all over the world to contribute words and images about how they are feeling at a given moment. The website then codes those feelings and the contributor’s statistical information, and displays macro visualizations of how the world—as represented by the contributors—is feeling in real time. Because the display is instantaneous, the project feels less like an exercise in infographics and more like a fluid translation of felt-experience into seen-experience (fig. 25). Designer, educator and director of Yale’s MFA program in Graphic Design Sheila Levrant de Bretteville believes in the aesthetics of collaboration. In her essay “Some Aspects of Design from a Woman Designer,” she describes projects she worked on in the early 1970s for The International Design Conference in Aspen and the feminist artists newspaper Everywoman. For both projects, she transformed the design process into a collaborative collage. On the first day of the design conference, she distributed cards to participants and asked them to write down their thoughts. She then glued all of the cards together into pages without attention to hierarchy, then cheaply and quickly printed these pages as a newspaper, and handed out the final results to attendees on the conference’s last day. De Bretteville created a special issue of Everywoman in a similar fashion: She assigned each woman artist two pages for their essay and space for a large photo of themselves. After receiving the writings and photos, de Bretteville collected the pages into a newspaper without hierarchy or a unifying system. In both of these works, de Bretteville’s aim was to make collaboration part of the visual and reading experience, not just part of the making process. The physical experience of collaboration birthed the designed works’ aesthetics. The feminist conceptual artist Hannah Wilke, whose earlier work relied heavily on self-portraiture, was diagnosed with lymphoma in 1987. After undergoing aggressive treatment for years, she decided to document her last year of life fighting cancer and the effects of chemotherapy. The resulting series of selfportraits, The Intra-Venus Photographs, make visible and visual the painful internal turmoil of her illness. Each photograph of Wilke is a visual metaphor for the process of dying, and the collection is almost a silent-film strip of a physical transformation (fig. 26). Janine Antoni, another feminist artist working a decade later, created Gnaw, an affecting sculptural work about the physicality of beauty. Antoni had two 600-pound cubes produced, one of lard and one of chocolate. She then proceeded to chew off chunks from each, using the removed bits to later mold boxes of chocolates and lipsticks. The final piece consists of the two cubes, now mangled, torn and covered in teethmarks (fig. 27). The aggression and determination with which the artist attacked the cubes is present within those battle scars; the viewer absorbs the drama of the process visually. 41
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I didn’t really choose to make work about physical experience; it came to me by force. During the fall semester of this year, I fainted in my studio while discussing my thesis topic with a professor. I had delayed my lunch to squeeze in that meeting, the studio was overheated and I was dehydrated. So I fainted. Afterward, I was shaken and unnerved, but physically healthy—especially after the professor brought me a sandwich. He told me I had to make work about the experience, and after thinking about it, I decided to make a book that showed the event as I had felt it, as a series of images and an underlying current of terror. I had a very specific vision for how I wanted the book to function. I laid down on the studio floor where I was when I came back to awareness and took photographs of the ceiling, its pipes, its crannies. I manipulated the photos to make them eerie, unfamiliar and slightly ominous, mirroring them on each spread to create something of a vortex toward the book’s gutter. I arranged the photos—one mirror on each spread—with white space on all sides, framing and narrowing the viewer’s perspective, as mine had been just before and just after I fainted. As for the current of terror, I looked back at a poem I love, “Fear” by W.S. Merwin. The poem is a stream of consciousness, running through complete, partial and barely articulated elements of the world that invite anxiety and dread: “fear in fear the name the blue and green walls / falling of and numbers fear the veins that / when they were opened fear flowed from and / these forms it took a ring a ring a ring.” (Merwin, 23) For me, that was the texture of my mind dropping out of the world and into a void. On the book’s pages, I placed the text of the poem behind the ceiling images, its heads and tails jutting out from either side. I constructed a narrative flow with the photos, each spread moving closer to opening up into a white expanse, a visualization of my experience both of passing out and waking up. Finally, after much debate, I added a third layer, my own voice on top of the images. This voice—quieter, slower, more reasonable—is the narrator, telling the story as if it has already happened as the viewer goes through the visual experience for the first time (fig. 28). When the reader interacts with my book, I want him or her to see the physicality of the event, its conflicting perspectives and voices, its plodding and inevitable descent, the complete lack of control. I named the book very simply for what it was: Fear, W.S. Merwin or The Time I Fainted in My Studio. The process of making it was much more emotional than I ever imagined. Revisiting the visual experience again and again in order to clarify my expression proved tough but ultimately rewarding. I feel more intimately tied to this book than any other piece I’ve made, and experientially connected to the reader who relives the event with me. My second project about physical experience as visual experience was much more orchestrated. I wanted to create an experiment that looks at how individuals visualize the qualities of physical sensations. In putting together Show 42
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Me How It Feels, a creative survey, I chose descriptive terms from the McGill Pain Questionnaire—such as “itchy,” “dull,” “sharp,” “cold”—and created a simple layout with large spaces under each adjective for the participant to draw how that sensation feels to them. I included positive sensations that aren’t in the McGill Questionnaire—such as pleasant and warm—to see if these drawings would turn out differently than their more negative counterparts. I gave everyone in the Pratt GradComD MFA program a printed copy of the survey and asked them to return their responses a week later. I also sent seven members of my family a PDF version of the survey; not a single one decided to participate. But almost all of my cohorts in the MFA program did. The results of the survey were energetic and varied (fig. 29). Some participants drew images and objects, some lines, some shapes. To see if there was coherence among responses to a single sensation, I grouped the drawings for each word on a single page. For many of the adjectives, the drawings were strikingly similar in tone, texture and directionality. “Numb,” for instance, garnered airy, minimally-marked responses; “sharp” featured the threatening triangle. But some words, like “crampy,” did not seem to resonate with the participants. There was little coherence in the group of responses, but also each individual drawing of “crampy” was murkier than drawings for other words. My instinct that positive sensations would create different drawings turned out to be right: the drawings for “warm” were soft and glowing, whereas those for “hot” were sharper and more dynamic. I was enchanted with the collection of drawings, and I was sure that this survey was the beginning of a larger project about the visual expression of felt-experience.
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Research & Development “ Teach a man to fish and you feed him for a lifetime.” CHINESE PROVERB
Each of the three metaphors I explored—body as map, body as machine and physical experience as visual experience—gave me a unique, faceted perspective on the subject of my body and my health. In Metaphors We Live By, Johnson and Lakoff remind us that metaphor-making is inherently about multiplicity. No single metaphor is “sufficient to give us a complete, consistent, and comprehensive understanding” of a subject. However, if we collect different metaphors that successfully satisfy the same purpose, a coherent understanding emerges (Johnson and Lakoff, 89). To create my capstone project, I honed in on my intentions for each metaphor and worked to expand on the intersection points. As I defined them, the three metaphors are methods of recording, visualization and communication. When we employ them, we cast ourselves as cartographers, engineers and interpreters. And at the heart of each one is the intention to make external and sharable processes that are internal and invisible. Earlier in my thesis exploration, I made an experimental book called Patient PKD (fig. 30). I was reading and thinking about the doctor-patient relationship at the time, and I wanted to make an expressive design piece that spoke about a potent visual metaphor for that relationship: the medical chart. While these records are essential for doctors and nurses, they speak a different language to me as a patient. The medical chart reeks of secrecy, paternalism and obfuscation. It is antiquated in its form, coded beyond my comprehension and housed in a place I don’t like to go; it is a representation of myself and my history over which I have no control. So many of these connotations arise from the fact that the medical chart is the only representation of my health history. Why can’t we create parallel forms? Ones that are legible and can inform us first about the patterns and history of our bodies. A combination of visual metaphors will allow us to map our bodies’ histories, understand how it works and visualize physical experiences, creating personal counterparts to our official medical records, ones to which we 47
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have primary access and over which we have complete control. If we can do that, we can become guardians of our health. In my thesis exploration thus far, I had been both subject and designer. For my capstone project, I wanted to create a system that gives other people the context and tools to do their own exploration. Whereas the Show Me How It Feels survey asked participants to freely channel a sensation, a personal health log demands a fully-realized system for communication. Not everyone is a visual person and not everyone feels comfortable “drawing how they feel.” My older sister, a psychoanalyst, mother and teacher, refused to participate in Show Me How It Feels. She said she didn’t see the point—that “itchy” was best represented by the word “itchy,” not a drawing. My mother, who didn’t so much refuse to participate as she did forget to respond to my email until the survey was over, told me that she found it a little intimidating. She was not a designer, she said. Maybe the way she expressed itchy wouldn’t mean anything to anyone else. For people like my sister and mother, I needed to create a container for meaning, to co-design their log with them. In “Meaning,” an essay for the first Looking Closer collection, John J. Rheinfrank and Katherine A. Welker write about the changing role of the designer. No longer should we hand meaning fully-formed to a viewer. Rather, we can be “creators of the ‘clay’ from which people can craft powerful objects—and even new object types.” (Rheinfrank and Welker, 167) Social networking sites are this sort of clay, so is YouTube, so is Mint.com. I hoped that with clarity of purpose and design, I could make a visual health log that welcomes participation.
Language & Form “ The ability to convert ideas to things is the secret of outward success.” HENRY BEECHER WARD This health log needed a language and a form for its application. For the former, I decided to create a visual lexicon for physical sensations and health experiences, drawing on the responses to my Show Me How It Feels survey. Using only the sensation categories that garnered resonant responses, I created graphic blackand-white patterns informed by the participants’ drawings (fig. 31). These twelve patterns represent “sensations,” defined as location-specific pain, discomforts and feelings, and they would be able to contract and expand to cover as much of the body as is affected by the sensation. I added two more categories of health experience to my growing lexicon: “marks,” location-specific marks such as bumps and bruises, and “events,” moment-specific occurrences that have no location, 49
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itchy
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cold
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such as vomiting and fainting ( fig. 32). For both of these categories I created graphic black-and-white symbols. To help distinguish between categories, each “mark” symbol is an outlined shape filled with a pattern and each “event” symbol is a solid black form. With twelve sensation patterns, six mark symbols and six event symbols, I felt I had the beginnings of a working system of signs with the potential to communicate and record observations of health. With my attempt to create a usable system, comes the question of the unique versus the universal. Didn’t I argue earlier that metaphors can allow for specificity rather than generality? In Symbol Sourcebook: An Authoritative Guide to International Symbols, Henry Dreyfuss writes that “It now appears that in some increasingly important areas we need an adjunct to our sophisticated speech and need to work our way back to the simple universality of an understandable, albeit limited, symbology.” (Dreyfuss, 19) Adjunct and understandable are the key words here for my purposes. I intend the system of signs to serve as shorthand, pointing at a full description that only the user can fully understand. Unlike words, which can too often seem precise but fall short of full expression, these symbols do not have to communicate the full range of feeling; they only have to be expressive enough to be useful markers. In this way, I am also emphasizing that the log cannot and should not replace a doctor-patient relationship. It is a tool to help people understand their health and habits, one that can transform them into well-informed and keenly-aware patients when they communicate with their doctors. In The Nature of Suffering, Dr. Eric J. Cassell writes about the relationship between the individual and the universal in medical diagnosis. The process of diagnosis is dialectical, he says, moving between the abstract knowledge of disease and the specific knowledge of the patient. Both the general and the specific are necessary for a full picture of health, and “universal categories... can either promote or hinder individualization; the choice lies with the person utilizing them.” (Cassell, 168) In the construction of my health log system, I am deliberately using a universal symbology as the building blocks for individual expression. By offering a common language that is used and interpreted idiosyncratically, I hope the system can offer that essential back and forth between the general and the specific. Now, how the lexicon is used. Physical sensations, marks and health events do not exist in a vacuum. They are tied to locations on the body and moments in time. I wanted the visual health log to enable users to make maps of their health, snapshots of moments of feeling that could be compiled into a timeline. I used the schematic of the human body—loose in its adherence to biology and neutral in age—that I used for the Aura Coloring Book. I hoped that this impressionistic shape would further encourage users to think of the process as one of shorthand, instead of precise measurement. The body schematic serves as the landscape 52
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onto which the lexicon is mapped. Each log entry can be labeled with a date and time, and has a place for users to write contextual notes. “Sensations” can be applied wherever they are felt on the body, “marks” wherever they appear, and “events” can be placed to the side of the form because they have no specific locus on the body itself. Finally, the form. The question of paper versus plastic did not linger too long in my mind. I wanted the end result of this project to be digital. The Obama administration is currently urging hospitals to move toward a universal digital record-keeping system. And it’s not just lip service: The 2009 economic recovery package allocated around $27 billion in incentives toward the initiative. The administration understands that the conversion to digital is more than a logistical shift—even though that is a very tall order in itself. As Dr. David Blumenthal, the national coordinator for health information technology, told the New York Times, “[t]his is a big social project, not just a technical endeavor.” (Lohr) Where paper record-keeping seems dated, messy, hierarchical and imprecise, digital feels standardized, organized, modern and democratic. What the administration is asking from hospitals and doctors is that they embrace a new visual language of doctor-patient care. I think it only makes sense for my visual health log to exist in the digital realm, especially if it is intended to be a counterpoint to the existing medical record-keeping system. Using the log on a home computer helps users feel safe and comfortable, and being able to maintain the log on a mobile device during the day increases its functionality. The patterns and symbols are easily clicked and dragged onto the body, actions most people are much more familiar with than drawing. Finally, making the log digital allows many more possibilities for data aggregation and interpretation. The digital direction also speaks directly to my thesis’s interest in visual metaphor. Some icons in user experience design are visual metaphors. In fact, most digital interfaces rely on a group of commonly understood visual metaphors that help users understand each element’s purpose and role. The Apple operating system has windows, a desktop, folders and documents: the parts of a virtual home office. In reality, these pieces could be programmed to look like anything. But by using familiar visual metaphors, interfaces make users feel comfortable and give them reference points for interacting with digital information. Apple is particularly adept at this transformation, so much so that most people understand the digital world in terms of the metaphors they’ve created—and will stubbornly resist new ones. But as digital users, we are evolving. In 1895, moviegoers who watched L’arrivée d’un train en gare de La Ciotat ran out of the theater as a train came barrelling through on-screen. Now, we are so familiar with the language of film that we don’t even expect our documentaries to be “real.” As a contemporary culture, we are not nearly as versed in the language 53
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of the Internet, but we are moving towards fluency every day. We don’t need website buttons to affect a look of cartoonish three-dimensionality anymore and we understand when—and have come to expect that—photos enlarge with a click or a swipe. These adaptations are allowing interface design to become more nuanced and complex, and helping new ideas find realization in digital form. To my mind, right now is the perfect time for a project like mine. Of course, the Internet is already teeming with health websites and applications. But so many of them have the same attitude toward health as popular magazines: Being healthy is about losing weight... or self-diagnosing that mole on your back as cancer. As of this writing, the top 25 iPhone apps in the App Store’s Healthcare & Fitness section are all diet or work-out programs—with the exception of two menstrual cycle apps. WebMD is, of course, one of the most popular browser-based health tools. In 2010, the site was reported to have received over 83.3 million average monthly unique visitors. But WebMD has been criticized by healthcare providers for trying to replace doctors’ visits, rather than encouraging health education and preventative care. The site provides patients with the illusion of a legitimate doctor-patient diagnosis, and too often patients will either try to self-medicate without seeing a real doctor, or will go to the doctor demanding a specific treatment that may not be appropriate to his or her needs. iTriage is an online and mobile application that takes WebMD one step farther. You enter your symptoms into the application and in turn, it diagnoses you and recommends healthcare providers you should visit near your location. The application includes an image of the body, but you aren’t able to interact with it in a meaningful way. If you select “abdomen” from a pull-down menu as the area of concern, the app simply highlights that general area on the body and pulls up a list of explicitly abdomen-related symptoms to choose from. But there are ways to use digital tools to meaningfully enhance self-care. As her masters’ project at the MIT Media Lab in 2006, designer Jeana Frost built tools for diabetes patients to investigate the relationship between behaviors and changes in their blood sugar. Users took photos of their daily actions and uploaded them to a website, where Frost’s scripts integrated these photos and the patients’ glucose meter readings into visualizations of their blood glucose levels, helping patients connect cause to effect. Frost’s project, entitled Visualizing Health, helped patients learn to take care of themselves by connecting visuals to data (fig. 33). While my system, as I’ve developed it, focuses more on wellcare and is not geared toward specific illnesses, I believe that the structure I’m creating could be used for diseases and syndromes that require monitoring and maintenance, like diabetes and IBS. The central point of the visual health log is to encourage users to think about health differently and to feel empowered to take responsibility for their bodies and their care. 55
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An interesting example of this sort of shift in a different area of self-care is Mint, a browser-based and mobile application that helps users manage all aspects of their finances. Whereas in the past, you might have some information with the bank, some information with your student loan lender and other information with your credit card, Mint gives you a holistic view of your financial situation at any moment and over time (fig. 34). The application visualizes trends in spending and saving in a few different ways, and helps users create and track a budget. The tone of the website is friendly, eager and at times a little nudgy— Mint will send you exclamation point-laden email notifications when you’re hit with an ATM fee or you’ve spent more on clothes than you did the month before. If you choose, Mint will also send your information to TurboTax, an online tax assistance program, eliminating the need for an accountant as well as a financial planner. As a user of Mint, I am still a little nervous about giving all of my financial data to a website, but I find the thoughtful interface and design to be reassuring and the infographics of my spending to be elucidating. By giving me the tools to holistically understand my finances, Mint truly has helped me feel more responsible.
The Prototype “ In theory there is no difference between theory and practice. In practice there is.” YOGI BERRA Although I was sure that the end result of my capstone project would be a browser-based application and accompanying mobile device app, I needed to test the system’s usability with an analog version. I created paper prototypes and asked 20 participants to keep a record of their health for two weeks, adapting and adding to the system as they saw fit. I also made a prototype for myself to use for the duration of my thesis exploration. But because this project centers around usability, I had to design the paper prototype to function in its own right, not just as a sketch for a digital model. To start, I decided to make the packets with a limited palette. While I can’t deny that the decision was in part economically-motivated, sticking to white, black and the beige color of a manila folder helped the packet look clean, professional and informative. I used white stickers within the packet as a subtle and neutralized reference to medical filing systems, and I printed the folder with a thin black diagonal pattern to give the piece some energy and take it outside of the realm of pure utilitarianism. I chose Helvetica Neue and Chronicle as the typefaces for this project—Helvetica Neue for its clarity, unthreatening 56
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authority and strong graphic qualities, and Chronicle for its elegant but accessible humanism. I built the folders to be six by nine inches, a size that is small enough to fit into a purse but large enough to display symbols legibly and make writing comfortable (fig. 35). The packages unfold into three sections. On the far left panel is a sticker with a brief form for the participant’s statistical information—gender, age, city, occupation, and start and end date of use. Stapled into the seam between the first and second panels is a short booklet containing instructions and a completed example, two pages of the lexicon and two blank pages where participants can add new symbols and patterns to the lexicon as needed. On the far right panel is a pocket with a spiral-bound notepad tucked inside. Each page of the notepad has a grey shape of a body and four lines beneath it, one for the day and time and the rest for any notes the participant wants to include for that record (fig. 36). The booklet opens to the left of the notepad because most people are righthanded, and this way they can refer the lexicon comfortably as they write. For an early mock-up of the prototype, I perfect-bound the notepad, making it look like a doctor’s prescription pad. While this was aesthetically appealing, I realized that both the reference to prescriptions and the inclination to rip out a page after it’s filled out were out of step with my intentions for the project. With the spiral binding, a participant can keep all of the records together, while still being able to open the packet to a clean page every time. Finally, I placed each folder into a fitted plastic sheath with a resealable top, a simple gesture that made the packets more durable and more exciting to receive. I added a small numbered sticker to each one to help me keep track of the 20 anonymous packets. I knew that a survey of 20 would be in many ways statistically insignificant. But I believed that by carefully selecting the participants with an eye towards diversity in age, gender, occupation and location, and only asking people I knew well and trusted—and who, hopefully, trusted me—I could get enough qualitative and anecdotal feedback to help me further develop the project. I asked friends, family, teachers and classmates, lawyers, designers, writers and producers, ranging from 23 years old to 66, to be a part of the prototype testing. I sent packages to Washington, DC, San Francisco, Houston and Boston, set up hand-offs all around Manhattan and Brooklyn, and crossed my fingers. Perhaps naively, I assumed that after each participant used their packets for two weeks, they would get in touch with me about returning them. But it took mild to aggressive nudging on my part to get all of the packets home safely. Every aspect of these now-artifacts was fascinating. First of all, about half of the participants kept the plastic sheath on their booklet, carefully sealing and resealing it with each use. Twelve people removed the numbered sticker—I don’t know 59
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whether by accident or as an intentional gesture for anonymity. Ten of the 20 participants abstained from filling out the statistical sticker on their booklets. When I received the first two like this, I asked the participants if they had forgotten to fill it out. Both of them said they had felt uncomfortable giving me that information, knowing it would be displayed at my thesis exhibition. When I received eight more with blank stickers, I realized this was a popular concern. As I was designing the packets, I felt that by simply leaving off participants’ names, their anonymity would be secure. But I underestimated just how intimate the records were that I was asking people to keep, and how much privacy the participants needed to feel at ease. While in the digital version of this health log, users would never have to give any personal information to anyone, the need for privacy in my prototype testing was important feedback for the project. The way that the participants used the booklets to record what was happening in their bodies was of the most interest to me. Some participants recorded every day, leaving the body blank if there were no issues that day, and some recorded more than once a day but abstained for days at a time. Some wrote a specific time for each entry, some a time span and some just the date. No one made more than 15 entries for their entire two week period. Every participant was able to clearly draw the symbols or patterns they wanted to use—even people with little or no artistic background. Fifteen participants created new patterns and symbols (fig. 37). Eight of them created new symbols in the lexicon for variations on “fatigue” or “exhaustion”; six for “anxiety.” But even with these new marks incorporated, most people stuck to three to five symbols or patterns for the whole two weeks. Every single participant used the notes area to record the context for the issue, speculation on the cause and specificity as to the location or severity of the sensation. Some even ventured outside the notes area and wrote qualifying words or statements next to the marks they used (fig. 38). These results were consistent with my own experience using the log. I immediately created a pattern for “fatigue” and used it more frequently than any other symbol. I also stuck to five symbols the whole time, and I used the notes area to help contextualize the visualization. But over the course of two weeks, I created 29 entries, and I was slightly surprised that no one else even approached that number. But I recognized during my own process that it definitely took effort and intention to keep up that frequency of record-keeping. After most of the booklets were returned, I sent out a survey to the participants about their experience using SurveyMonkey, an online tool that allows respondents to reply to surveys anonymously. This step also required multiple nags—SurveyMonkey will send reminder emails to recipients who have not yet responded—and I have yet to receive my twentieth and final survey response. In creating the survey, I tried to give participants a few different ways to tell me 60
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Participant Survey 1. What are some adjectives you would use to describe your experience using the health log? 2. Did using the log effect any changes in how you think about yourself, your body or your health? In what way? 3. Did you learn anything about yourself or your body during these two weeks? If so, what? 4. What was the hardest thing about using the log? What was the most interesting or most fun thing about using it? 5. Would you use a log like this or similar to this if it weren’t for an experiment—just for yourself and you never had to show it to anyone else? 6. What would you change about the log to improve it for your own use? 7. Would you be more interested in using a health log system if it were digital? If so, what form would be the most useful for you: a website, iPhone app, or a combination of the two? 8. Do you have to use visual or creative thinking in your job or everyday life? If so, how? 9. Do you suffer from any chronic health condition? If you feel comfortable, please elaborate. 10. Is there anything you want me to know about the log, the experiment or your experience?
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how they felt while using the health log and after the experience, as well as gather specific feedback for improvements. The lists of adjectives I received for the first question were remarkably consistent. The first few for each person were words such as “useful,” “rewarding,” “thought-provoking,” “fun,” “engaging,” and “enlightening.” And then at the end of the list, there was almost always one single thud, such as “time-consuming,” “a little annoying,” “taxing,” “tedious” and “cumbersome.” In response to the second question, every participant apart from one said the experiment made them more aware of their bodies and changed how they thought about their health. But how it changed was split down the middle: about half felt it made them feel less sick, neurotic or hypochondriacal, and the other half remarked—with a bit of horror—that as it turns out, they were not as healthy as they had thought. Almost all of the respondents credited the experiment with giving them a better sense of patterns in their health, and a few found the log useful as a real-time record of fleeting sensations. One participant wrote, “physical experiences of pain are hard to encode into memory. I can remember the feeling of food sickness being truly excruciating, for instance, but I can’t imagine what that pain actually felt like. There’s something too slippery about it.” In response to question four, participants felt that the hardest things about the process were remembering to do it and making do with a limited range of symbols. The most interesting aspect for almost every respondent was using the symbols and learning about patterns in his or her health. According to one participant, “The most fun part was remembering how I felt on a certain day because I could visually remember what I had drawn on that day’s page.” But when asked if they would use a system like this if it weren’t for my project, the responses were mixed. Most agreed that if there were some chronic condition to track or a specific reason they wanted to keep a record, they would use the log. But some were anxious to return to blissful ignorance after the experiment ended: “I think I would not, because it made me more aware of bodily complaints. The more aware you become, the more real they become. I am lucky enough to not need to be that in touch with my body.” For question number six, participants suggested that system could be improved with more nuance in the marking and a broader range of symbols. Before even getting to question seven, more than a few respondents offered that it would be helpful if it were digital. So it wasn’t surprising that the participants almost unanimously agreed that they would be more likely to use the system if it were digital, especially if it included an iPhone application. Finally, when I asked if they had anything else to communicate to me about the process or the log, more than half of the participants wrote that they 65
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enjoyed the experiment—even those who said they might now use a similar log in their regular lives. In addition to the general comments, there were a couple user-experiencespecific pieces of feedback that were important to note. Privacy was a big concern for two respondents, given that many of the things they were marking were embarrassing. Also, the orientation of the figure of the body was a little confusing—was it like a mirror or a photo? In other words, where was right and left? I realized this was an issue when I was using the log myself. A few male participants also made off-handed comments about the curvy hips and legs of the body schematic on the notebook. Clearly, it was not as neutral as I had thought. Armed with a glut of feedback, I got to work on the digital application version of the health log system.
The Application “ Design is not just what it looks like and feels like. Design is how it works.” STEVE JOBS Keeping records of any kind can be laborious and annoying. Keeping a record of the intimate and hard-to-pin down qualities of your body can feel like a punishment. With the Show Me How It Hurts booklet, I tried to lighten this burden by introducing visual symbols, encouraging shorthand note-taking and giving participants a hand-crafted booklet. In order to improve the system for the digital application, I would have to incorporate feedback from the paper prototypes and reconsider every aspect of the interface design with an eye towards ease of use, familiarity and rewarding results. I decided to start by thinking of the application as a whole made of parts: mobile applications for the iPhone and iPad with which users can record sensations and events anywhere at any time, and a “home base” browser application that offers record-making but also provides overviews of a user’s recording history and trends in his or her reports. These overviews and trends would give users incentives to keep up with their records, and help them learn more about the patterns in their health—something all of my prototyping participants enjoyed about the process. Because digital records can be so fluidly stored and represented, this would be one of the key benefits to the digital iteration of my project. Mint uses information visualization for these areas to great effect, and has a similar relationship between its mobile and browser applications. iTunes does as well, with the home library working as the mothership where users can organize playlists and download new songs, and iPhones, iPods and iShuffles acting as satellite ships that come 66
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in to dock for updates before going back out into the world. These systems are familiar to us and and a similar relationship between mobile device and home computer would be intuitive to most users of my digital iteration. Next, I had to tackle the language. During my surveys and testing, I was struggling with the word “log.” I had chosen it because it felt official while remaining neutral, avoiding the sentimentality of “diary” or “journal” and the coldness of “record book” or “ledger.” But I knew it wasn’t working to encourage the feeling I wanted to create around the process. I needed more of a balance between the personal and the official, and more suggestion of openness for users. I decided that for the digital iteration, I would call it a notebook. For me, the word “notebook” speaks to almost any field or process—cartographers, engineers and translators certainly use them—and remains warm enough to feel personal without feeling sentimental. The physical folder I created for my paper prototype was also much more akin to a notebook than a log both in terms of the way a user moved through it and the structure it provided for note-taking. And I intended to build an interface that aligned with those qualities. Ultimately, what I was creating was a product and that product needed a name. Again, balance was key. This time, I focused on finding a name that allowed users to understand the purpose of the product while not overtly referring to medicine or illness; this notebook is not for diagnosis and not for doctors. From my prototyping and participant survey, I also knew that privacy was of the highest priority, so the name should remain a bit obtuse to protect users from nosy relatives or coworkers. I decided on the word “tabula,” which translates to “slate,” but comes from the Roman word for a note-taking tablet. Tabula’s Latin origins felt like just the right amount of reference to the medical field. The word is also associated with “tabula rasa,” both a commonly-used phrase meaning “blank slate” and an epistemological theory that states all knowledge is formed through experience and perception. Finally, to create the logotype for the product, I put “tabula” in all lowercase cursive to make it warmer and more approachable. For this thesis, I decided to work on the browser application. It was important to work out its functionality and interface of the product’s “home base” first because it incorporates all of the component parts. Those decisions would then guide the mobile applications. But I still needed to design the browser application with the other platforms in mind. Because Tabula is a tool that depends on a user’s comfort and familiarity with its system, I wanted there to be as much similarity in interface across platforms as possible. For me, this meant that the browser window would have a fixed width and length, and all of the action would occur on one screen, with a user clicking through to alternate tabs rather than 67
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scrolling down or across. This restriction would also simplify the user’s experience with the application—what you see is what you get—and help create a visual metaphor of a folder or notebook, allowing users to feel more comfortable with Tabula, and more intuitively understand how it works and what it’s for. In laying out the website, I created a background of an open folder with three tabs: Notebook, Overview and Settings. Because of the privacy issue, I knew it was important to complete the narrative inherent in visual metaphor of the folder: When you arrive at the site your folder is closed and it only opens after you enter your name and password (fig. 39). I decided to use a variation on the color palette of the manila folder, closely related to the Show Me How It Hurts booklets. The folder background is a soft manila yellow, the interior “papers” a subtle off-white, and the icons and type are in shades of gray, black being reserved for the symbols and patterns within the lexicon. As a highlighting tool and the signature color of the product, I chose a light blue, almost aquamarine, which reads as friendly and appealing, but subdued. Blue is the world’s most common favorite color and its lighter shades have been shown to be calming and focusing. In fact, in a 2009 study that looked at how color impacts cognitive task performances, blue was found to enhance subjects’ abilities specifically in tasks that required imagination and creative thinking. (Lehrer) I also made an effort to use as few words as possible throughout the application, instead employing variations on the common language of digital iconography: arrows, clocks, pens, locks, and so forth. I felt that this would make the entire process more intuitive and “quieter,” and prime the user to be thinking in visual terms, rather than verbal ones. For the Notebook section of the application, I wanted to replicate the experience of the Show Me How It Hurts booklet as closely as possibly, while improving the process according to the feedback I received, and enhancing it with the digital tools the format provides. To simplify the recording process across platforms, I gave the user the ability to create and name individual palettes (fig. 40). Each palette holds a limited number of patterns and symbols that the user might need for a particular situation. For instance, during the winter I am more likely to need the symbol for a runny nose and the patterns for cold and stiff. Rather than taking the time to scroll through a lengthy lexicon, I can go to the Winter Palette I created and everything I need is right there. The browser application can display all of a user’s Palettes, and allow the user to create new ones and edit or delete existing ones. Then, once a mobile device is connected, the user can transfer selected palettes to the mobile device. This relationship is similar to how playlists work in iTunes and across Apple mobile devices. When a user clicks on the Notebook tab, the application opens with a clean entry page on the right and the user’s last used Palette on the left. In that left panel, the 68
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user can toggle between palettes, as well as edit existing palettes and create new ones. Once the user has found the symbols they need, they can drag them one at a time onto the body form on the right side of the folder. To change the shape or size of a pattern, the user drags the pattern onto the approximate location on the body and then redraws the area with the cursor; the application will fill that area with the pattern (fig. 41). Users can also mark the entry with a time stamp, make contextual notes and bookmark the page with a coded color. When the time icon is clicked, the application automatically provides the current date and time, but the user can edit it if the entry takes place over a period of time, or if the entry is for an event that happened at a different time. The notes icon gives the user a blank box in which to type notes, and the user can chose from one of three colors to bookmark the page. These colors have no inherent meaning, but the user can create their own codes. For instance, I may be interested in tracking my stomach issues, my energy level and my headaches. With the colored bookmarks I can sort entries into one of these three categories so that I can explore each issue individually in the Overview section (fig. 42). Users can view their records in a number of different ways in the Overview section. First of all, they can see a visualization of their entries in a Timeline, Calendar or Trends format. Within all three sections, a user can choose to see visualizations of all of their entries, or just of those tagged with a particular colored bookmark. This way, if a user wants to investigate a history of stomach problems, they won’t have to sift through various colds, bumps and bruises to get at the relevant data. And within all three sections, a user can choose to export that particular screen as a PDF Snapshot, which is then saved in their account. The user can print out or email the Snapshot to a doctor, friend or anyone with whom they want to share that specific information. In the Timeline section, a user’s entries are arranged linearly, the figures marching across the screen from past to present. This section gives three scale views of the timeline, with the largest scale showing five entries at once. The user can scroll through the timelines and roll over specific entries for more information about the date, time and details of the entry (fig. 43). The Calendar section shows a user’s entries arranged in a traditional calendar format, with the symbols, patterns, bookmarks and notes displayed for each entry. The user can choose to see a year, a month or a week at a time, and can also click through to past calendars (fig. 44). Whereas the Timeline view shows entries one immediately after the next, regardless of the length of time in between, the Calendar view always displays days and times that have no entries, giving a user a sense of the frequency and concentration of health issues. In the Trends section, a user can see infographic representations of trends in their records: most commonly used symbols and patterns, most commonly used words within the notes, 71
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number of bookmarked and unmarked entries, number of entries for each hour of the day and most commonly marked area of the body (fig. 45). Again, the user can see this section in terms of a year, a month or a week. By clicking the “+” icon, they can also expand each trend module to display more details about that type of information. Despite the myriad views and displays in this section, it was important that Trends communicate a broad view of a user’s history, not a precise analysis. Because the nature of the data is impressionistic, the trends from that data are too; Tabula can only give the user a quickly-digestible picture of what’s happening in their body according to their own reports. If a user were to feel that the application was offering a specific, expert diagnosis, the point of the project would be lost. By clicking on the Settings tab, users can change their account and personal information, such as language and gender (I created a male figure and slightly modified the existing female figure), tell the application to send them a reminder to record at regular intervals (fig. 46), and manage their palettes, snapshots and trends (fig. 47). This is also where users can sync up their mobile devices with their home computers and transfer individual settings and entries. When a user logs out, a goodbye message appears and the site is redirected to the sign-in page: the folder is closed once again. After creating wireframes and then more fleshed out designs for Tabula in Illustrator, I made an AfterEffects animation of the process of a start-to-finish user interaction with the browser application. This animation helped my product come to life for me, my advisors and anyone who visited my thesis exhibition in mid-April at Pratt’s Manhattan Campus.
The Exhibition “ The public is the only critic whose opinion is worth anything at all.” MARK TWAIN Making work is one thing; presenting it in a way that makes sense to others is always a whole other can of worms. Because the projects in my thesis exploration are so diverse in scale, form and style, for my exhibition I needed to create a setting that could give them a context and a common ground. I decided on an alternate vision of a doctor’s waiting room. Traditional waiting rooms are very strange places. I have always felt that their design is dishonest. With carpeting, low lighting, framed seascapes and padded chairs, these spaces are awash in signs that whisper “comfort,” “leisure” and “relaxation.” But the uniformity in this design strategy across offices and cities—isn’t that maroon color unmistakable?— and the actual purpose of the space tell another story. These are places where 74
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we are held in limbo, waiting to hear what’s wrong with us, knowing there is something wrong with everyone else in the room and in all the rooms like it across the country. For my thesis exhibition, I wanted to create a space that spoke to this tradition, but was more transparent, informative and patientfocused. In the place of watercolor paintings on the wall, I hung my diagrammatic posters. On the table, I put the Do-It-Yourself Coloring Book, as well as my other experimental books. In plastic brochure-holders on the wall, I put the 20 Show Me How It Hurts booklets with my participants’ notes. And on a screen across from the chairs, I played a walk-through of the Tabula browser application. At the very beginning of the installation process, I decided to cover the walls with a subtle wallpaper made of the sensations patterns I had created for my capstone project. I hoped that this space would make visitors feel comfortable and encourage them to explore—and maybe even learn something about new ways to think of their bodies and health (fig. 48). Maybe that strategy worked a little too well. Three people felt comfortable enough to take Show Me How It Hurts booklets home with them, and one person stole one of the five A Kiss Is Still a Kiss flipbooks. But other less anonymous feedback during the opening night was much more helpful. So many people came up to me to tell me about their health problems. Their doctors wouldn’t listen, they said, isn’t it so frustrating? In these conversations, it seemed like my thesis had opened a floodgate of experience. Suddenly, strangers felt familiar enough to tell me they had just gone to the gynecologist, that the symbol I made for diarrhea was so right on. The idea of self-care and personal awareness resonated deeply with every one of the visitors I spoke to at the opening. And my visual approaches to addressing these needs excited them. At the end of the night, I felt sure that my thesis had landed on solid ground.
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What’s Next? “ If we are facing in the right direction, all we have to do is keep on walking.” BUDDHIST PROVERB My experimentation and capstone project have led me to an interesting place. I’m happy with Tabula and with the work that contributed to it. But I think that if I am going to do this thesis justice, I need to keep moving forward. The Tabula personal health notebook demands an iPhone application; I don’t think the project will be complete without it. And the system itself could be tightened and expanded. I agree with the feedback from my Show Me How It Feels participants: the lexicon needs to grow and become a searchable database of signs. As it exists now, tabula is flexible enough for users to interact with in ways that suit their needs, but it could offer more specific options for people with chronic conditions and more guidance in general. I think the application should provide users with ready-made palettes for different issues and illnesses, and the database of signs should be searchable by condition as well as name. Finally, I think that testing this system with a larger sample size and with people who are experiencing particular chronic conditions could open up the doors to enormous improvements in the system’s functionality and could take it from the experimental to the practical. I would love for this project to have a life after Pratt.
What Have We Learned? “Know thyself.”
ANCIENT GREEK APHORISM
In researching, writing and designing this thesis over the course of many months, I realized how essential iteration is to every aspect of the creative process. My ideas started really to become things once I dove into prototyping, testing, surveying and revising... and repeating. Even within the individual visual experiments, producing multiple iterations helped me incorporate feedback 79
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and push my ideas forward. In general and for this thesis especially, I want my design work to be simple, useful and direct. But in my experience, “simple” requires days upon days of reducing, testing and remaking. This thesis process helped me understand how much harder and more labor-intensive it is to make something useful than something that is beautiful. My research and design exploration of health, communication and visual metaphor stretched out far and wide—to San Francisco, science fiction and my own studio floor. But everything started making sense in the overlap among the visual metaphors I investigated. In that space it became clear why I had chosen each metaphor, and I understood what my thesis is really all about: creating a new methodology for understanding our bodies and taking care of our health, one that emphasizes visualizing, record-keeping and personal responsibility. Visual metaphors are essential to this methodology because of their unique ability to give the invisible a form, and expand ideas while simultaneously making them feel familiar. But the process does not stop there. The personal responsibility part requires a little bit more work. It is undeniably difficult and often unpleasant to begin taking stock of our health (fig. 49). No matter how easy and fun I or any other designer can make a tool, it won’t work unless someone decides to use it. But isn’t that the point? The effort needed to record what is happening in our bodies helps us value our sensations and health events as information. And the process of trying to pay attention—no matter the results—is the most important part of all. The Tabula personal health notebook is all about process. Users can see visualizations of the totality of their records, but the goal is not self-diagnosis; it is self-knowledge. If users keep up with the notebook and start to understand their health patterns, they can learn to anticipate their bodies’ needs in everyday life. If someone can remember that a particular stomachache usually strikes after a meal with dairy, while the stomachache is happening—or better, when choosing what to eat for lunch—then the tool I’ve created is working to improve their lives. In that sense, I’ve designed the training wheels, not the bike. And that is perhaps not the best business model. But as designers we have a responsibility to do more than create new products; we have to make tools to help people be better at all the things they do already. Our health is our most important resource and affects every single aspect of our lives. If we can learn to take care of our bodies, we can improve the quality of our own lives in real and tangible ways: fewer sick days, lower health insurance premiums, more time with our families. As a designer, I am able to contribute to that learning, and I cannot think of a more worthwhile endeavor.
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fig. 49
ANNOTATED BIBLIOGRAPHY Abramovich, Marina. Interview with Bernard Goy. Journal of Contemporary Art. June 1990. http://www.jca-online.com/abramovic.html Interview with the artist about the evolution of her work. Abramovic discusses the relationships between the physical and the visual, and the artist and the audience in her work from the 1980s. Alfano, Sean. “Because the Doctor Isn’t Always Right.” CBS Sunday Morning. 7 May 2006. http://www.cbsnews.com/stories/2006/05/07/ sunday/main1596112.shtml?tag=contentMain;contentBody. News story about the high incidence of misdiagnosis in U.S. hospitals, featuring the expert opinion of Dr. Robert Wachter, chief of Medical Services at University of California, San Francisco, and author of Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. Arnheim, Rudolph. Art and Visual Perception. Los Angeles. University of California Press: 1974. Seminal book about the relationship between the human brain and visual art, which focuses on Gestalt theory—a holistic view of neuroscience and perception. Brody, Jane E. “Not Just Small Talk: Quality-of-Life Questions at Medical Exams.” New York Times. 15 Nov. 2010. http://www.nytimes. com/2010/11/16/health/16brody.html?ref=science. Article that appeared in the paper’s Science section by the Times’ Personal Health columnist addressing the importance of quality-of-life questions in diagnosis, patient care and treatment choices, as well as the changing role of the patient as primary health advocate. Boyd, E.B. “Microsoft Wants You to Control your Phone by Touching Yourself.” Fast Company. 28 Feb.2011. http://www.fastcompany.com/ 1732673/microsoft-skinput-hands-free-device-controllers Web article from FastCompany.com’s Silicon Valley reporter describing Microsoft’s new experimental project Skinput, software that reads the body’s vibrations and translates it into instructions. Butler, Frances. “Dance & Play in Visual Design: Visual Manifestations of Physical Experience.” Looking Closer: Critical Writings on Graphic Design. ed. Michael Beirut, William Drenttel, Steven Heller, DK Holland. New York. Allworth Press: 1994. 173-176. Essay about the relationship between physical experience and visual form in graphic design, focusing particularly on book design. 83
ANNOTATED BIBLIOGRAPHY
Cassell, Eric J. “The Measure of the Person.” The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 1994. 164-199. Chapter by retired doctor, Weill Medical College of Cornell University professor and author Eric J. Cassell about the doctor-patient relationship as it relates to the patients felt-experience and expression. Chandler, Daniel. “Semiotics for Beginners.” http://www.aber.ac.uk/media/ Documents/S4B/. Online explanation of semiotics by the British visual semiotician, prepared as lessons for his students at Aberystwyth University in Wales. de Bretteville, Sheila Levrant. “Some Aspects of Design from the Perspective of a Woman Designer.” Looking Closer Three: Classic Writings on Graphic Design. ed. Michael Beirut, Jessica Helfand, William Drenttel, Steven Heller, Rick Poynor. New York: Allworth Press, 1999. 238-245. Essay by the director of the Yale University Graduate Program in Graphic Design on the difference between traditionally “female” and “male” values, roles and processes in life, work and graphic design. Dick, Philip K. Do Androids Dream of Electric Sheep. 3rd ed. New York: Del Ray, 1996. Seminal science fiction novel, first published in 1968, about a dystopian post-Apocalyptic future wherein androids are attempting to pass for human and empathy is the determining distinction between man and machine. Dreyfuss, Henry. Symbol Sourcebook: An Authoritative Guide to International Graphic Symbols. New York: McGraw-Hill Book Company, 1972. A reference book of universal symbols, compiled and introduced by the industrial designer Henry Dreyfuss. Ehrenreich, Barbara, and Deirdre English. For Her Own Good: Two Centuries of the Experts’ Advice to Women. New York: Anchor Books, 2005. A history of the medical profession and its treatment and understanding of women as patients and professionals. Haycock Makela, Laurie and Ellen Lupton. “Underground Matriarchy.” Looking Closer 2, No 2: Critical Writings on Graphic Design. ed. Michael Beirut, Steven Heller, William Drenttel, DK Holland. New York. Allworth Press: 1997. 136-141. An essay in conversation form, originally published in Eye Magazine in 1994, about the female voices in design and design history, including Sheila Levrant de Bretteville, Muriel Cooper, Carol Devine Carson and Mildred Friedman. 84
ANNOTATED BIBLIOGRAPHY
Haraway, Donna. “A Cyborg Manifesto: Science, Technology, and SocialistFeminism in the Late Twentieth Century.” Simians, Cyborgs and Women: The Reinvention of Nature. New York: Routledge, 1991. 149-181. Essay originally published in Socialist Review in 1985 by feminist and history of science scholar Donna Haraway about the cyborg as a metaphor for postmodernist states in gender, technology, science and politics. Isaak, Jo Anna. Feminism & Contemporary Art. London and New York: Routledge, 1996. A collection of essays that explores the effect of feminist theory on art practice throughout the mid- to late 20th century. Johnson, Mark and George Lakoff. Metaphors We Live By. 2nd edition. Chicago: University Of Chicago Press, 2003. A definitive and now-classic book on how the mind uses metaphor as a framing device to understand complex ideas, relationships and the world in general. Johnson, Mark. The Meaning of the Body. Chicago: University of Chicago Press, 2007. Johnson’s follow-up to Metaphors We Live By, in which he explores the bodily origins of meaning and language through cognitive science and philosophy. Klanten, Robert, Nicolas Bourquin, Thibaud Tissot and Sven Ehmann. Data Flow: Visualising Information in Graphic Design. 4th printing. Berlin, Germany. Gestalten: 2008. A reference book and collection of examples of information visualization from the past decade. La Mettrie, Julien Offray de. Man a Machine. French-English. Translation by Gertrude Carman Bussey. 4th edition. La Salle, Illinois: Open Court, 1987. Essay by French physician and philosopher Julien Offray de La Mettrie, first published in 1748, in which he rejects the then-popular Cartesian mind-body dualism in favor of the materialist metaphor of the human as a machine. Lehrer, Jonah. “The Psychology of Architecture.” Wired.com. 14 Apr. 2011. http://www.wired.com/wiredscience/2011/04/the-psychology-ofarchitecture/. Web article by “The Frontal Cortex” columnist Jonah Lehrer discussing recent experiments around the influence of architecture and aesthetics on the brain’s functioning.
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Lohr, Steve. “Carrots, Sticks and Digital Health Records.” New York Times. 26 Feb. 2011. http://www.nytimes.com/2011/02/27/business/ 27unboxed.html?_r=1. Article that appeared in the Times’ Business section about the Obama administration’s push for a transition to digital record systems in hospitals and clinics. Merwin, W.S. “Fear.” The Carrier of Ladders. New York: Atheneum: 1971. Collection of poems by the American poet W.S. Merwin, which includes the poem “Fear.” Parker-Pope, Tara. “You’re Sick. Now What? Knowledge Is Power.” New York Times. 29 Sept. 2008. http://www.nytimes.com/2008/09/30/ health/30pati.html?ref=healthspecial. Article in the Times’ Science section by regular columnist Tara Parker-Pope about the growing importance of self-education and information-gathering by patients in the search for a doctor, diagnosis and treatment. Picone, Mary. “The Ghost in the Machine: Religious Healing and Representations of the Body in Japan.” Zone 4: Fragments for a History of the Human Body, Part 2. ed. Michel Fehrer. Brooklyn, New York: Zone Books, 1989. 466-489. Essay by anthropologist Mary Picone about the relationship between healing and the physical body in traditional and contemporary Japanese medicine. Ramachandran, V.S. “Tales of the ‘Tell-Tale Brain’.” Interview with Terry Gross. Fresh Air. NPR, New York. 14 Feb. 2011. Interview with the neurologist and author of The Tell-Tale Brain in which he describes neurological cases that demonstrate how people understand themselves and their bodies in three-dimensional space, including the example of Phantom Limb Syndrome. Rheinfrank, John J. and Katherine A. Welker. “Meaning.” Looking Closer: Critical Writings on Graphic Design. ed. Michael Beirut, William Drenttel, Steven Heller, DK Holland. New York: Allworth Press, 1994. 165-169. Essay on the importance of imbuing design with multiple layers of meaning for the user in order to make a design more useful and appealing. Scarry, Elaine. The Body in Pain. New York: Oxford University Press, Inc., 1987. A broad, ambitious and widely-referenced book by scholar Elaine Scarry that addresses in part physical pain’s ability to disempower by inhibiting expression.
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ANNOTATED BIBLIOGRAPHY
Sontag, Susan. Illness as Metaphor and AIDS and Its Metaphors. Picador, 1989. A collection of two essays by Sontag on the subject of metaphor and illness. In the first essay, she outlines the metaphorical significance tuberculosis and cancer took on during the 19th and 20th centuries respectively. In the second, she discusses AIDS in similiar terms. St. Clair, Robert N. “Visual Metaphor, Cultural Knowledge, and the New Rhetoric.” Learn in Beautfy: Indigenous Education for a New Century. ed. Jon Reyhner, Joseph Martin, Louise Lockard, and W. Sakiestewa Gilbert. Flagstaff, Arizona: Northern Arizona University, 2000. Essay by communications scholar Robert N. St. Clair on the distinctions between visual language in Native American cultures and verbal language in traditional Western cultures, focusing on the role of visual metaphor in Navajo storytelling. Tierney, Hanne. “Hannah Wilke: The Intra-Venus Photographs.” Performing Arts Journal. Vol. 18, No.1, Jan 1996. http://www.jstor.org/ stable/3245813?seq=6. A contemporary review of Wilke’s posthumous photo series, The Intra-Venus Photographs, a collection of self-portraits of the artist during her last years of life fighting cancer. Treib, Marc. “Pictures, Phonemes, and Typography.” Looking Closer: Critical Writings on Graphic Design. ed. Michael Beirut, William Drenttel, Steven Heller, DK Holland. New York: Allworth Press, 1994. 81-83. Essay about the translation between spoken and written language. “Where Am I?” Radiolab. NPR. WNYC, New York. 2 March 2011. Episode in which hosts Jad Abumrad and Robert Krulwich feature stories around how the mind and the body communicate to help us understand our immediate surroundings, including a segment with neurologist Oliver Sacks describing a case study in proprioception. Whitney, Hunter. “Beyond the Medical Chart: Information Visualization for Improving Personal and Public Health.” UX Magazine. 14 Oct. 2010. http://www.uxmag.com/design/beyond-the-medical-chart. Web article about the ability of data visualization to change how doctors, patients and companies understand health and health systems. Wood, Denis. The Power of Maps. New York: The Guilford Press, 1992. Book by cartographer Denis Wood describing in words and images the role of mapping in framing, understanding and remaking the world. 87
Thank you to Edvin Yegir, Mark Sanders, David Frisco, Warren Bernard, Jeff Bellantoni and all of the friends, family and teachers who participated in and contributed to this thesis. Special thanks to Sandie Maxa for being my steadfast thesis advisor for a record two years.
This book was set in Helvetica Neue and Chronicle and printed at Rolling Press in Brooklyn, New York.