Uplift: Cultivating Happiness and Communication in the Context of Cancer by Salih Berk İlhan

Uplift: Cultivating Happiness and Communication in the Context of Cancer. Berk İlhan

This publication accompanies the MFA thesis project of Salih Berk İlhan, conducted in School of Visual Arts in New York. Editors: Chelsey Larsen and Jennifer Schifano Author: Salih Berk İlhan Book design: Salih Berk İlhan Copy editor: Chelsey Larsen Project manager/Art Director/Designer: Salih Berk İlhan Typeset in Graphik © 2015 by Salih Berk İlhan All rights reserved. No part of this publication may be reproduced in any manner without permission.

TABLE OF CONTENTS

Preface............................................................................................................................................. 8 Introduction.................................................................................................................................... 10 About Uplift....................................................................................................................... 10 About Framework............................................................................................................ 10 Why I care & Background............................................................................................. 12 Goals and Objectives.................................................................................................................. 17 Revealing Design Opportunities within Complementary Medicine............. 20 Opportunity: Productizing Laughter Therapy....................................................... 24 Raising Awareness about Communication Problems........................................ 26 Re-imagining an Integrated Healthcare System.................................................. 27 Improving Health-Related Quality of Life............................................................... 28 Envisioning and Creating Futuristic Scenarios..................................................... 30 Audience & Ecosystem............................................................................................................... 33 Audience of the Uplift.................................................................................................... 34 Differences between Stakeholders.......................................................................... 35 What Are the Similarities of Stakeholders?............................................................. 36 Why I Should Consider All the Stakeholders......................................................... 37 The Ecosystem of Uplift................................................................................................ 38 Gesundheit Institute: a Health Care Bliss................................................................ 40 Gildaâ&#x20AC;&#x2122;s Club Movement................................................................................................. 42 Laughter Yoga Movement............................................................................................ 44 That Dragon, Cancer...................................................................................................... 46 Monyay Project by IDEO................................................................................................ 48 Quantified Self and Self-Tracking Trend.................................................................. 50 Research.......................................................................................................................................... 52 The Purpose of the Research...................................................................................... 54 Methodology.................................................................................................................... 55 Primary Research............................................................................................................. 56 Conversational Interviews............................................................................................ 58 Field Research.................................................................................................................. 68 Method Acting as Design Research......................................................................... 74 Mapping the User Journey........................................................................................... 76 Happiness and Communication Survey................................................................. 78 Diary Studies..................................................................................................................... 80 Co-Creative Workshop.................................................................................................. 86 Literature Research......................................................................................................... 90 Interventions.................................................................................................................................. 93

Speculative Objects....................................................................................................... 94 Syringe-Ball........................................................................................................................ 100 Emotion Necklace........................................................................................................... 102 Dare...................................................................................................................................... 104 The New Your Times....................................................................................................... 106 Speculative Press Release: Laughter Device......................................................... 108 Branding Lens................................................................................................................... 112 Smile Mirror....................................................................................................................... 114 Talk to Me........................................................................................................................... 122 Laughter Box..................................................................................................................... 124 View Changer for Chemotherapy Rooms.............................................................. 128 Futuring and Speculative Design: Smart Smile.................................................... 132 Experience Design: Giggle Up.................................................................................... 136 Service Design: All Together....................................................................................... 144 Information Architecture 164 Looking Forward........................................................................................................................... 174 Lexicon............................................................................................................................................. 176 Acknowledgments ...................................................................................................................... 178 Bibliography................................................................................................................................... 180

PREFACE

Design is a superpower that has been used by humankind to shape the life: Sometimes with good intentions and bad consequences; Sometimes with evil and selfish intentions and bad consequences; and rarely with good intentions and good consequences.

“There are few professions more harmful than industrial design.” Victor Papanek

Charles Chaplin told the story of industrial revolution and its tragic impacts on human life with his movies. He used caricaturized industrial designer figures in his movies “Modern Times”[1] and “The Great Dictator”[2] which clearly illustrated how capitalism used designers as pawns. In the movie The Great Dictator, the industrial designer figure works for the dictator, “Hynkel”, who represents Adolf Hitler. Throughout the movie, this character constantly develops war machines for Hynkel which is the reason for his existence. In another Chaplin movie, Modern Times, there is a designer who works for the owner of the factory by designing practical mechanisms to feed workers while they screw the nuts on the production band. The automatic feeding machine removes the necessity of lunch breaks by boosting the efficiency of production made per work shift in exhausting and sometimes brutal environments. Although Chaplin uses a whimsical language to

illustrate these characters, it reflects the sad reality very well. Decades later, in today’s modern capitalism, people suffer just as portrayed in Chaplin’s movies. There are life threatening consequences of this “revolution”, indeed. According to a scientific research conducted by Rosalie David and Michael Zimmerman of the Manchester University, cancer is the second cause of death in industrialized societies, whereas cancer was very rare in ancient times according to the historical investigation they conducted. David and Zimmerman claim “There is nothing in the natural environment [in ancient times] that can cause cancer. So it has to be a manmade disease, down to pollution and changes to our diet and lifestyle”. [3] On the other hand, there are promising design movements such as Positive Design. The goal of Positive Design is to increase people’s subjective well-being by considering three main elements: design for pleasure, design for personal significance, and design for virtue.[4] That said, there is always hope for a better future and present time.

Zimmerman, Michael R., and A. Rosalie David. “Cancer: An Old Disease,

a New Disease or Something in Between?” Nature Reviews Cancer 10 (2010): 728-33. The University of Manchester. Web. 16 Apr. 2015. <http:// 1

Modern Times. Dir. Charlie Chaplin. Perf. Chaplin and Paulette Goddard.

United Artists, 1936. 2

Chaplin, Charlie, Charlie Chaplin, and Paulette Goddard. The Great

Dictator. United States: Charles Chaplin Film Corp, 1940.

www.manchester.ac.uk/discover/news/article/?id=6243>. 4

Desmet, Pieter M. A., and Anna E. Pohlmeyer. “Positive Design: An

Introduction to Design for Subjective Well-Being.” International Journal of Design. 1 Jan. 2013. Web. 9 Apr. 2015. <http://bit.ly/1HWhXnq>.

INTRODUCTION

ABOUT UPLIFT

ABOUT FRAMEWORK

Uplift is my MFA thesis project, which I conducted in School of Visual Arts in the MFA Products of Design program. It is a journey of investigation and exploration through different lenses of design to identify opportunities that cultivate joy and happiness and strengthen the support group to improve the quality of life for cancer patients.

MFA Products of Design program emphasizes the importance of having a perspective and encourages students to cultivate their unique point of views. The program has a unique framework for thesis projects. The framework includes different lenses to look at the investigation areas. These lenses are: speculative design, social enterprise, service design, design research, co-creative design, experience design, business modeling and branding practices. The challenge is to explore and investigate the theses topics by making. Creating physical and digital assets leads to constructive discussion, hence, new insights and learnings could be gained. In this book you will see a body of work that addresses issues that have not been addressed by the healthcare industry in the way I did. You will see a design approach beyond the conventional attitudes in traditional industrial design.

INTRODUCTION

“People crave for laughter as if it were an essential amino acid.” Patch Adams

WHY I CARE & BACKGROUND

Some movies change the way we think. For me Patch Adams is one of those movies. Starring Robin Williams, the movie Patch Adams portrays the early life of revolutionary doctor Patch Adams (Hunter Doherty). Many people do not know that Patch Adams is a real person. He is the founder of the Gesundheit Institute, a hospital where patients are cared by a friendly, compassionate and humorous approach. It is a hospital where patients are not charged, where no health insurance is required. Patch is an advocate of meaningful and joyful life. According to Patch’s point of view, health is everything that touches a person in a positive way; the key ingredients of a healthy life are humor, fun and love. (Adams, Mylander, 1998). Patch travels around the world to clown in hospitals and to teach clowning to all kinds of people, doctors, medicine students, hospital staff, and so on. At Gesundheit Institute, Patch and his team host events to pass on their knowledge to others. Although they use props like red rubber noses and other funny objects, their services are human based as opposed to technology. Patch states that “in medicine, technology has transformed turn-of-thecentury humility into modern arrogance.” I couldn’t agree more. When we look at the modern healthcare products designed by pioneer design companies, what we see is a celebration of technology, materiality and advanced functionality. When I was studying industrial design in undergrad, I admired the products

which were designed with a humancentered design approach, meaning that they are designed for human needs through the lens of empathy. However, compared to the Patch Adams’ vision of ideal health care, these human-centered design objects were still missing some sort of spirit, “humor”. Therefore, I investigated around the question of how could design touch people at an emotional level, especially in the conditions where they feel the most vulnerable? How could these products change the dialog between patients and doctors? This topic is also important to me because I am a diagnosed patient with Asthma and have spent a lot of time in hospitals. Doctor appointments are something I dread especially after having several pulmonary functioning tests done. My first intervention in healthcare as an asthmatic designer was to change the pulmonary functioning testing experience. During a pulmonary functioning test, doctors examine the patient’s lung capacity and inhalation/exhalation power in order to diagnose any potential illness such as asthma or chronic obstructive pulmonary disease (COPD). A spirometer is the device that measures breath inhale and exhale. However, the current and commonly used spirometers were failing due to the patient’s cooperation. According to the The American Thoracic Society, the regulations require the operator of the test to guide the patients and inform them when to inhale, exhale

and push all the air out of their lungs. After observing the test for a couple of days in the room, I realized that it was extremely terrible. Patients were failing to cooperate and they were usually afraid of exhaling for a long period of time. The simple reason being you canâ&#x20AC;&#x2122;t ask a person with a respiratory illness to empty his/ her lungs. Because, he/she is someone who canâ&#x20AC;&#x2122;t even respire adequately. With feelings of emotion like rejection, I decided to take on this challenge to re-design this test for my graduation project in Middle East Technical University, Ankara. The magic of design is in its power to shift the perspective. I believed, this daunting robotic device could be approached in a very different way. Then I tried to think of times when people exhale quickly and with intensity. Birthday candles! The rule is simple, blow out all of the

candles and your wish will come true. Using this playful element I designed Spiro-Plus: a fun and friendly spirometer that not only gives feedback to operators but also to patients. Instead of asking patients to empty their lungs, Spiro-Plus gives patients the challenge of blowing out candles to motivate them and to give them a very simple and understandable feedback. Another reason behind my interest in the topic is the mere fact that joyâ&#x20AC;? and happiness is the understated fact to simple living. I have often heard that I should consider kids rather than adults for my playful spirometer concept, Spiro-Plus, but I resisted this biased point of view. I believe that adults need just as much playfulness and humor as kids do. In his TED talk, Dr. Stuart Brown -the founder of the National Institute for Playsays that we human beings are designed

to play throughout our whole lives but we forget the value of play as we get older.[5] Because of the biases, we can’t really talk about playfulness and games in adult contexts without considering pragmatic benefits and goals. The term “gamification” is a good example for this issue. The denotative meaning of the term “gamification” is “the application of typical elements of game playing to other areas of activity, typically as an online marketing technique to encourage engagement with a product or service.”[6] Therefore, the connotation of gamification centers on murky marketing strategies created by companies to deceive their customers. Although the term was developed and first used in software contexts in the last decade, I believe that gamifying is much bigger than a marketing strategy, and much older than the computer age.

Brown, S. “Why Play is Vital - No Matter Your Age”, 2008, http://www.ted.

com/talks/view/lang/en//id/483 6

“Definition of Gamification in English:.” Gamification: Definition of

Gamification in Oxford Dictionary (American English) (US). Web. 16 Apr. 2015.

<http://www.oxforddictionaries.com/us/definition/american_

english/gamification>.

Being someone who requires medical attention on a regular basis to regulate my asthma symptoms, I have a true understanding for the need to keep happiness and joy within the healthcare system as I, too, often feel down upon arrival at a hospital. For cancer patients who spend much of their time at a hospital clinic for treatment most likely experience constant feelings of depression they are “forced” to give their time where they don’t want it. In other words, cancer patients need positive influences to help them through a difficult time in their lives. In the rest of my thesis my emphasis is on cancer patients and striving to lead them to a better treatment process through my investigation/intervention of Uplift. That being said, most of these concepts, which you will learn about later on, could not only help cancer patients but, also, other people who need more joy and happiness in their lives.

GOALS AND OBJECTIVES

Uplift has multiple goals and numerous objectives under one main idea: uplifting people who deal with cancer, including cancer patients and their caregivers. Uplift addresses two areas in the journey of coping with cancer: morale and communication. Uplift evaluates and approaches patients’ and caregivers’ experiences through the lens of the Health-Related Quality of Life (HRQL) concept. HRQL is defined as people’s happiness or their subjective well-being in consider to the aspects of life as they are affected by an illness.[7] In other words, the purpose of this investigation is not about curing cancer, but to help cancer patients and caregivers to improve their morale by using exercise methods to encourage them to smile and laugh more. To identify service concepts that connect cancer patients and caregivers to effectively communicate with each other.

Preedy, Victor R., and Ronald R. Watson, eds. Handbook of Disease

Burdens and Quality of Life Measures. Springer New York, 2010. 4304. Print.

In order to achieve this greater goal of uplifting, there are five sub-goals, which address different stakeholders’ roles from a general standpoint: 1. To reveal design opportunities within complementary medicine (particularly laughter therapy) 2. To raise awareness about the communication problems that cancer patients face 3. To imagine an integrative healthcare system that approaches general health by considering the body and mind as one 4. To improve the Health-Related Quality of Life of the patients and their relatives 5. To envision and create futuristic scenarios that lead to constructive discussions about the future of cancer and the potential solutions to improve coping experiences.

GOALS AND OBJECTIVES

REVEALING DESIGN OPPORTUNITIES WITHIN COMPLEMENTARY MEDICINE

Uplift aims to reveal design opportunities in order to re-think and re-imagine the experience of going through cancer. Thus, the objective to accomplishing this goal is to explore potential applications of the complementary medicine in the field of healthcare design. Before moving forward to revealing other opportunities in this field, it is important to understand these four concepts: • conventional medicine • alternative medicine • complementary medicine • integrative medicine Conventional treatment is medicine that is practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by health professionals who work with them.[8] Conventional medicine is defined by the health care authority of each country’s health care systems. For instance, radiation therapy, chemotherapy and surgery are forms of conventional treatment in Western Medicine, whereas acupuncture is a form of conventional therapy in China. Alternative medicine is medical therapies that are not regarded as orthodox by the medical profession. Alternative medicine is used in place of conventional medicine. For instance, electromagnetic therapy claims to treat some diseases by applying electromagnetic radiation to the body. Another example of

alternative medicine in the context of western medicine is acupuncture. Acupuncture is the stimulation of specific acupuncture points along the skin of the body using thin needles.[9] Complementary medicine is a group of different medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine.[10] Complementary medicine is a term which should be grasped comprehensively so that its potential can be understood clearly. It is also considered a blurry topic because many physicians have different— often opposing—views. A cause of this conflict is that complementary medicine (or therapy) is often confused with alternative medicine (or therapy). I came to this conclusion after talking with several oncologists, reading scholarly articles on complementary and alternative medicine (CAMs), and articles on mainstream health blogs. It may help patients feel better and improve their coping skills while they are dealing with a disease such as cancer. There are different viewpoints on CAMS, scientific research, and trials that are still in progress to prove alternative methods. However, there are many 9 Adams, D; Cheng, F; Jou, H; Aung, S; Yasui, Y; Vohra, S “The safety of pediatric acupuncture: a systematic review.” Dec 2011. Pediatrics 128 (6): e1575–e1587. 10 National Center for Complementary and Alternative Medicine

National Center for Complementary and Alternative Medicine (NCCAM)

(NCCAM)

health professionals who are in favor of using complementary therapies.[11] Examples of complementary medicine in western cultures for cancer patients are aromatherapy, acupuncture, herbal medicine, massage therapy, visualization, laughter therapy, and yoga[12] and, also, laughter yoga. Some of the most common conventional treatments used in western medicine for cancer patients are chemotherapy, surgery, radiotherapy, biological therapies, and hormone therapy. Integrative medicine, which is also called integrated medicine and integrative health, merges both the complementary and conventional treatments. Advocates of integrative medicine claim that integrative medicine treats the “whole person,” rather than focusing on treating disease, it focuses on wellness and health.[13] The connotations around the terms alternative and complementary medicine are generally negative. Many physicians whom I talked to about the topic were highly skeptical of alternative and complementary medicine. In an interview with oncologist, Murat Baş explains, “As a physician, who is an advocate of complementary and alternative medicines,

11-12 “The

Difference

between

Complementary

and

I think it is a very murky area. There are many spiteful people who want to deceive patients with fake treatment. On the other hand, when practiced properly, there are many useful methods in complementary and alternative medicines.” Murat Baş, M.D was also concerned about the term “complementary”, he added that the term “complementary” indicates that conventional medicine is not complete and needs to be supported. Doctor Patch Adams thinks differently, as expected. He is in favor of peace between conventional medicine and complementary and alternative medicines, because he believes that no one is perfect and there is always room for everyone to collaborate each other.[14]

Alternative

Therapies.” Cancer Research UK. Web. 10 Feb. 2015. <http://www. cancerresearchuk.org/about-cancer/cancers-in-general/treatment/ c o m p l e m e n t a r y - a l t e r n a t i v e /a b o u t / t h e - d i f f e r e n c e - b e t w e e n complementary-and-alternative-therapies>.

13 Snyderman R, “Integrative medicine: bringing medicine back to its

14 Adams, Patch, and Maureen Mylander. Gesundheit! Rochester,

roots”. Arch. Intern. Med. 162 (4): 395–7. February, 2002

Vermont: Healing Art, 1998; 54-55 Print.

GOALS AND OBJECTIVES

“Laughter yoga “is based upon the scienti�ic fact that, even if you laugh for the sake of laughing, even if you are pretend laughing, your body cannot tell the difference.” Madan Kataria ‘Guru of Giggling’, founder of Laughter Yoga Clubs movement

OPPORTUNITY: PRODUCTIZING LAUGHTER THERAPY

Laughter therapy is a type of complementary therapy which has been around for decades. Humor and laughter have been investigated and promoted by scientists in the context of healthcare from Hippocrates, the father of western medicine, to innovative physician Madan Kataria, who made the laughter yoga popular in the last decade. One of my objectives was to explore opportunities to productize laughter therapy; to design products and services that provoke laughter, so that people can try and exercise laughter practices in their home by themselves, with their families or in hospital waiting rooms. Recent scientific studies point out very interesting health benefits of laughter on human health. According to the researchers Lee S. Berk, DrPH, MPH, and Stanley Tan, MD, PhD, laughter can cause the same reactions as a workout which result in increased morale and decreased stress levels. There are also other physiological benefits of laughter such as lowering blood pressure and fostering the immune system by increasing natural killer cell activity, which is known to be a strong fighter against cancer.[15]

However, in a broader perspective, laughter is a very powerful and magical coping 15

tool that helps relieve us by lifting up our spirits. Medicalization of laughter could be risky and tricky. When we expect laughter to cure us, we might miss the opportunity to be lifted up. Medicalization refers to treating human conditions and problems as a medical condition. In his TED talk titled “Are we over-medicalized?” Ivan Oransky, the vice president and global editorial director of MedPage Today, exemplifies medicalization with conditions related to a woman’s body: menstruation, pregnancy and menopause. Although these conditions are very natural that every woman goes through, they are medicalized and, therefore, re-contextualized[16] in a way that they are unnatural medical conditions. On the other hand if we look at wearable smart fitness trends from a cognitive and behavioral psychology perspective, we can see the impact medicalization has on people to change their lifestyles. For instance, we already know the health benefits of exercising, but when our doctor recommends us to run for a certain amount of time we tend to take it more seriously. Moreover, when we invest in a product that enables us to set goals for ourselves to exercise more and eat properly, we tend to obey the directions better. Thus, medicalization and productization are very popular trends that benefit from cognitive and behavioral psychology.

Christie, Nancy. “The Humor Prescription.” Cancer Fighters Thrive: 21-

24. Cancer Treatment Centers of America. Cancer Treatment Centers of

America. Web. 10 Feb. 2015. <http://www.cancercenter.com/community/

thrive/the-humor-prescription/>.

talks/ivan_oransky_are_we_over_medicalized/transcript?language=en

Oransky, I. “Are we over-medicalized?”, 2012, http://www.ted.com/

My investigation around productizing laughter therapy aimed to understand how people could benefit from this helpful tool –laughter- by using a carefully designed product to stimulate a laughing response from its users.

“I made the joyous discovery that ten minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep.” Norman Cousins American writer, professor, and world peace advocate

GOALS AND OBJECTIVES

RAISING AWARENESS ABOUT COMMUNICATION PROBLEMS

One of the biggest insights gathered after interviewing cancer patients, caregivers, and oncologists is that conventional communication tools, which is our daily language, became useless in very tough situations: People struggle to communicate their emotions and feelings to the people they love. One interviewee, Fikret, stated that she felt alone and abandoned when her friends and relatives didn’t call her frequently. In order to raise awareness on communication issues, I shot a short movie as part of this Uplift project that captures some problematic conversations between cancer patients and their friends and family. Lori Hope’s book Help Me Live points out common communication mistakes that friends and family make while talking to cancer patients, including: listening to patients inattentively, giving advice and directions, or talking about other people who have had cancer but unfortunately did not survive.[17] The purpose of the short movie is not only to raise awareness of potential communication issues but, also, to find some potential places to intervene. Thus, I designed two different service concepts in the form of mobile apps. These concepts are “I Am Thinking Of You” and “Say This Instead.” “I Am Thinking Of You” mobile app aims to eliminate all the dangerous phrases (“my uncle died from the same type of cancer”) but leave the

17 Hope, Lori. Help Me Live, Revised: 20 Things People with Cancer Want You to Know. New York: Celestial Arts, 2005. Print.

most impactful and loving phrases (“I love you” and “I am thinking of you”) or phrases that express honest and sincere feelings (“I don’t know what to say”). Although these are the most common phrases that have been considered as appropriate and powerful by many different perspectives, the fact that it’s a pre-written message given by the app to users did not serve very well for the objective. Then, I decided to design another mobile app concept that automatically detects some offensive words and suggest corrections to users. In this way, when someone sends a text to a friend who has cancer, the sender won’t hurt the friend by using inappropriate words.

RE-IMAGINING AN INTEGRATED HEALTHCARE SYSTEM

Another objective of Uplift is to reimagine an integrated healthcare system that approaches health holistically by considering the body and mind as one concept. Since cancer is a chronic disease with exhausting treatments for patients not only in terms of physical stamina but also psychological well-being, it is important to consider and treat the psychological part of the human as well. Given the fact that modern psychiatry tends to prescribe more and more antidepressant drugs[18] for patients who suffer from depression, there are numerous adverse effects of feeling “happy” with medications. Uplift’s goal is to point out this unfortunate situation and to use “medicalization” in an ironic way: since patients and doctors have an implicit conversation channel which is called “prescription,” I wanted to design prescribable products which aim to heal the mind as well as the body. Laughter device concepts that I designed through Uplift doctors not only “to suggest” laughter therapy but, also, to prescribe it by providing patients with laughter devices.

18 More patients are being prescribed antidepressants by nonpsychiatrists and without a psychiatric diagnosis: Research Activities, March 2012, No. 379. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/newsletters/researchactivities/mar12/0312RA34.html

GOALS AND OBJECTIVES

IMPROVING HEALTHRELATED QUALITY OF LIFE

Another goal of Uplift is to improve the Health-Related Quality of Life (HRQL) of patients and their relatives. Health-Related Quality of Life is an important value system that focuses on the subjective well-being of patients and the effects of the disease on patients’ lives. In order to improve Health-Related Quality of Life, my objective is to design products, services and platforms to enrich the social interaction between patients and their relatives because relatives play an important role in the HRQL of patients. Cancer not only affects the patients but, also, their loved ones; relatives usually go through this challenging journey with their loved ones together, and those suffering loved ones often need their emotional and physical support while coping with the side effects (including minor and major effects) of cancer. However, due to some constraints caused by treatment, relatives can’t always be in the reach of their sick family member. Uplift aims to help patients and relatives by placing some design interventions using scenarios in the hospital and in daily life. During initial conversational research that I conducted with a cancer survivor and an oncologist, I learned about a scary hospital room called the “Isolation Ward”. After certain types of radiotherapy some patients are put in these isolated rooms to rest and get rid of the effects of radiation. No one is allowed in these rooms, not even hospital staff. Patients’ meals are put in front of the door, and patients open the door only to take

their food inside. Besides the exhausting physiological influence of the treatment, this extraordinary level of feeling alone is extremely harmful for patients. Fikret, one of the patients that I interviewed, expressed the feeling of staying in isolation wards as being in a casket. Another area to consider is hospital inpatient rooms. Patients who stay in hospitals, which is also referred to as “inpatient,” develop a different relationship with the room they stay inside of. It seems these hospital rooms become like a new home for inpatients where they are not always accompanied by relatives, and there are many times when patients are alone. Considering the social communication needs in both isolation rooms and inpatient rooms, I designed a voice message recording device. The purpose of the device is capturing heartwarming messages of visitors, relatives and friends into a small colorful box; patients can listen to messages over and over again whenever they feel lonely in their room. Apart from the hospital scenarios, communication needs also exist in cancer patients’ daily lives. For instance, patients who receive chemotherapy feel exhausted at home; therefore, they might need a friend’s help with necessary tasks like going to the grocery store. In interviews some patients declared that they find it difficult to ask someone for help. Due to embarrassment and feeling too tired to text or call. A friend of a cancer patient might not feel comfortable with calling the cancer patient friend frequently in fear of

being a disturbance or not knowing what to say. Indeed, in Lori Hope’s book Help Me Live, the interviewees, who are also cancer patients, often state that there are times that they want to get socialized with friends and family but sometimes they just want to be by themselves. However, the timing is not always as they would want in an ideal world. In reality, people come over to cancer patients’ homes when patients don’t want to see anyone or vice versa. Therefore, Uplift’s objective is to help patients and relatives to communicate their needs in a platform which would benefit both the patients and relatives. This platform, All Together, would ease the ways of expressing the needs for patients and make it understandable for relatives to act on. For instance, cancer patient can post a task like “picking up kids from school, next week” and friends could see this task on the online platform, so that they could act on it. Thus, relatives and even the support system would constantly be in touch with the cancer patient.

GOALS AND OBJECTIVES

ENVISIONING AND CREATING FUTURISTIC SCENARIOS

Finally, my last goal with Uplift is to envision and create futuristic scenarios that will lead to constructive discussions on the health care that we all want and deserve. We all want to dream big about our futures so my objectives are to use speculative design tools with a participatory design method where we, as designers, patients, caregivers and oncologists, can develop inspiring and affirming ideas all together. The most significant objective is to conduct co-creative workshops in collaboration with cancer patients and caregivers. â&#x20AC;&#x192;

AUDIENCE & ECOSYSTEM

AUDIENCE OF THE UPLIFT

As I considered designing for cancer patients, I struggled with the concept of focusing on such a difficult life condition and the complication of the various different types of cancer. Most subject matter experts suggested that I focus on a concise area, such as one type of persona or illness (e.g. primary caregivers of people with advanced stage breast cancer), so that my offerings would be sharp and to the point. However, I wanted to investigate a wide range of personas (i.e. cancer patients, caregivers and doctors). My purpose with this direction of keeping the range of target audience wide was to understand the different stakeholders’ point of view and reveal general insights. 1. Cancer patients 2. Family caregivers 3. Support system 4. Physicians While choosing an area of focus for this project, I weighed the emotional needs of patients in order to find the most needy demographic. Since the core of the emotional problems in life threatening diseases are related to the fear of death, spiritual beliefs have an important role in the diagnosis of behaviors and psychological reactions of patients. People who don’t have religious involvement or strong spirituality fall into the audience field of this thesis relatively more than those who are spiritually saturated because non-religious patients are more emotionally at-risk. Mayo Clinic conducted a very comprehensive research

that suggests religious involvement and spirituality have a strong positive impact on health outcomes.[19] According to the analysis of a variety of academic studies, it is revealed that religious involvement and spirituality help cancer patients to cope with cancer more effectively.[20] So far, what we realize is that religious people have less difficulties with dealing with cancer compared to people who don’t have religious involvement, and we understand that depression is a big problem that affects a patient’s healthrelated quality of life. Although religious people also face tremendous problems with the existing healthcare systems even in economically developed countries due to failure in meeting spiritual needs during illness,[21] this thesis rather focuses on the personal journey of cancer patients and their relationship with their social circle instead of hospital regulations and bureaucracy. The design concepts and offerings of Uplift aim to cultivate happiness by provoking smile and laughter for all kind of patients and caregivers regardless of their religious beliefs, because smiling is universal and a big part of the human nature. I would talk a little bit about patients who do not have spiritual beliefs.

Paul S. Mueller, MD; David J. Plevak, MD; Teresa A. Rummans, MD.

“Religious Involvement, Spirituality, and Medicine: Implications for Clinical Practice”. Mayo Clinic. 27 Jan. 2015. 20 Jenkins RA, Pargament KI. Religion and spirituality as resources for coping with cancer. J Psychosoc Oncol. 1995;13:51-74. Print. 21 Paul S. Mueller, MD; David J. Plevak, MD; Teresa A. Rummans, MD. “Religious Involvement, Spirituality, and Medicine: Implications for Clinical Practice”. Mayo Clinic. 27 Jan. 2015.

DIFFERENCES BETWEEN STAKEHOLDERS

All these stakeholders go through different experiences while standing under the same umbrella. Here are some of the key questions and aspects to understand stakeholders’ differences: 1. Their distance to the core and dense problem: how are they affected differently by the problem? 2. Their interaction with the problem: how much are they affected by the problem? 3. Their point of view: how do they see the problem and each other? 4. Their influence on each other: how much and in which ways do they affect each other? 5. Their roles in the ecosystem: what is the result when one of them behaves differently? In the very center of the map is the patient. If all the problems would distill into one sentence, he or she would be the subject of that sentence. Although the immediate family such as partners, parents, children or siblings experience a very tough emotional process, it is the patient who experiences the most difficult part of it. Doctors stand in a very different place, expectedly. They are very familiar with the process, although they can’t cure most of the cancer types yet but, because they are used to this process, they behave differently than patients and caregivers. They do not feel surprised, panicked or shocked. Therefore, some doctors start to lose the concept of human value. Because they treat so many cancer patients and see so many of them not survive they

start to look at them as just subjects and not humans to keep the emotions out of their work. However, by doing so, some doctors start to lose their bedside manner. Another reason why doctors lose empathy towards patients is the harsh trainings they undergo in medical school. According to a study conducted at the University of Arkansas, medical students’ vicarious empathy declined over time. After freshman year, there was a drop in students’ vicarious empathy scores by around 6%. Scores dropped again following junior year after students began their first clinical experience. Researchers have found that on average students empathy scores were around 50%.[22] On the other hand, a patient struggles, suffers, denies and changes with this new thing’s arrival into their lives. Other than the “doctors vs patients” comparison, there is also “patient vs acquaintances” difference that plays a big role in understanding stakeholders. At first glance, acquaintances do not seem that important when assessing the experience of coping with cancer. However, their role has an important effect on the patient. According to the findings of my primary research conducted with the conversational research method—through intense in-person or on-phone interviews— and secondary research conducted with literature research, it was revealed that

a support system is very influential for patients. However, due to unfamiliarity and not having prior experience, acquaintances might unintentionally show some harmful behaviors to patients. Although they do share similar socioeconomic and educational backgrounds, patients and their acquaintances cannot empathize with each other. Therefore, acquaintances might become dangerous with their words, expressions and behaviors for patients who suffer from life threatening diseases like cancer. On the other hand, acquaintances are important for patients to have in order to socialize and hold on to life.

22 Newton, PhD, Bruce W., Laurie Barber, MD, James, Clardy, MD, Elton Cleveland, MD,, and Patricia O’Sullivan, EdD. “Is There Hardening of the Heart during Medical School?” Academic Medicine 83 (2008). Web. <http://casemed.case.edu/caml/pages/journalclub08/march-dwolpaw. pdf>.

AUDIENCE & ECOSYSTEM

WHAT ARE THE SIMILARITIES OF STAKEHOLDERS?

Although they have very different roles, affiliations and behavioral patterns, stakeholders also show some similarities. The biggest similarity is that they all dislike the issue, they all want to overcome it and to get rid of it. Another similarity is that they all, except for the support system, become experts on their type of cancer. Relatives, friends and acquaintances—the parts of the support system—learn about cancer to an extent as they go through the process with the patient. However, only the members of the support system who are especially close to the patient become real experts because they witness the patient’s care first hand. They too are emotionally and physically affected as they watch their friend or family member go through treatment. Acquaintances are usually full of secondhand knowledge, most of which are myths.

One significant common point for all these stakeholders is that communication tools are not all that helpful. In interviews, doctors claimed that they have a difficult time sharing the bad news with patients. Patients stated that they struggled with communicating their situations with their social network. Caregivers mentioned that although they hold the hands of their loved ones during his/her struggle to survive, they are not sure how to react and respond to him/her. Family and friends, on the other hand, are the ones who usually fail in communication by using inappropriate expressions, such as sharing failure stories of other cancer patients they know, or superficially giving suggestions that cancer patients are tired of hearing.

WHY I SHOULD CONSIDER ALL THE STAKEHOLDERS

Any problem that one of the stakeholders experiences usually results from the acts of another stakeholder, this is the reason why I considered all these different groups of people as my audience. For instance, doctors are struggling with the effects of the government’s decisions, such as salaries, work shifts, etc., on their work life, which results in anxiety and nervousness at work, which then reflects on their attitudes towards their patients. Patients are emotionally attacked by some doctors’ negative behaviors, which causes them to go through some psychological disorders. Patients are full of sadness and anger, which might result in some aggressive behaviors against caregivers. However, caregivers know that they can’t lose their temper against patients because it’s their responsibility to absorb the anger of patients. At times, the chain might turn backwards: caregivers might get angry with patients. In conclusion, all stakeholders have an important role in the patient’s emotional journey. Therefore, it is necessary to observe each person in the scenario to understand his or her role and impact in order to create a positive atmosphere for the patient.

AUDIENCE & ECOSYSTEM

THE ECOSYSTEM OF UPLIFT

In the observation of the emotional and psychological journeys of cancer patients through their battle with cancer, Uplift stands on the positive design side of the ecosystem. Positive design includes designing for happiness, subjective well-being and joy. Putting the stakeholders in the centerâ&#x20AC;&#x201D;in most cases the patientâ&#x20AC;&#x201D; Uplift offers tools for communicating with each other and with the self. These communication tools aim to nurture positive feelings and healthy social interactions between stakeholders such as cancer patients, caregivers, support systems and physicians. To understand what kind of ecosystem

Uplift belongs to, it is essential to observe other positive design initiatives including: 1. Educational platforms (websites, apps, organizations) that aim to increase awareness about cancer 2. Social platforms that works on a voluntary-based structure in order to help patients 3. Storytelling platforms that meet social needs of patients and caregivers. 4. Design companies and projects that aim to increase subjective well-being.

AUDIENCE & ECOSYSTEM

GESUNDHEIT INSTITUTE: A HEALTH CARE BLISS

Founded by Patch Adams, MD, and run by him and many passionate health care volunteers, Gesundheit Institute is an extraordinary hospital example. It is a hospital where patients are not charged for health care nor is health care insurance accepted. Hunter Doherty, however, better known as Patch Adams, and his team of volunteer clown doctors, travel the world to share and teach their ideology. They believe that health care and medical practice must include compassion, love, joy and humor. Patch Adams always wears entertaining costumes to break the cold walls between people, and he says costumes never fail him.[23] It is not only a different point of view about health care but, also, a different way of approaching the problems with a more holistic, positive and humorous way of thinking that points out the deficiencies in social life, the economic system and personal relationships.

23 Adams, Patch, and Maureen Mylander. Gesundheit! Rochester, Vermont: Healing Art, 1998. Print.

In an ecosystem where “big data” is the most hot topic, where tech start-ups raise millions of dollars by promising investors more money, where insurance companies collaborate with self-tracking gadgets to find an ideal business plan to offer to their customers, Patch Adams’ radical position is highly interesting and very promising.

AUDIENCE & ECOSYSTEM

GILDA’S CLUB MOVEMENT

Named as the famous American comedian Gilda Radner, died from ovarian cancer in 1989. Gilda Radner’s husband and oncopsychotherapist started a movement known as Gilda’s Club. The purpose of Gilda’s Club is to help people with cancer and their families and friends to build a support system that provides social and emotional support to each other. This growing community aims to prevent cancer patients from facing cancer alone.[24] The club is open to everyone to walk in and to be a part of a special community. Focusing on emotional and social support Gilda’s Club movement is a potential collaborator for Uplift, and a potential early adopter for the services and offerings of Uplift. In our conversational interview with Jordan Patinkin, who is a volunteer as the Internal Events Coordinator at Gilda’s Club New York City, she explained to me the mission and objectives of the club, and she explained the variety of events they hold in the club to support patients and their families emotionally and socially. Laughter yoga is amongst one of the many activities offered at the club and according to what Jordan said, some people love laughter yoga and some don’t, because they find it silly. There is an opportunity to re-contextualize laughter yoga so that biases around it could be removed and more people could benefit from it.

24 “History.” Gilda’s Club New York City. Web. 16 Apr. 2015. <http://www. gildasclubnyc.org/About/history.html>.

AUDIENCE & ECOSYSTEM

LAUGHTER YOGA MOVEMENT

Laughter yoga (also known as Hasya Yoga) is a framework that was popularized by the Indian physician, Madan Kataria, and now there are more than 5,000 laughter yoga clubs. Laughter yoga consists of a series of breath and voluntary laughter exercises in aiming towards physiological and psychological health benefits. Laughter yoga helps people to reduce their stress level, strengthen their immune systems, increases the amount of oxygen input, and gives more energy.[25] Laughter yoga exercises are offered to patients in some non-profit cancer society clubs and hospitals. Beth Bongar, also known as the Laughing Diva, is a laughter yoga instructor based in New York City. I interviewed her to get more information and perspective about this health craze and the methodology behind it. I, also, participated in one of her laughter yoga classes to experience it first hand. It was an intense session full of laughter and at the end we, as the participants, were all full of joy and happiness. Of course not everyone needs laughter yoga, since laughter is a natural behavior we already inherit. However, in some challenging conditions, such as dealing with cancer, or high levels of stress laughter yoga could be a tool that significantly helps people to lift up their spirits. Many times it helps one to forget

25 “What Is Laughter Yoga & How Can It Help You?” Laughter Yoga. Web. 16 Apr. 2015. <http://www.laughteryoga.org/english/laughteryoga>.

everything he or she has to endure when facing disease for just a split second to enjoy a little bit of life again. This class serves as a reminder that even in our darkest moments we still deserve to be happy and gives us strength to carry on.

AUDIENCE & ECOSYSTEM

THAT DRAGON, CANCER

Cancer is a life-threatening disease that affects millions of people throughout the world. Not everyone affected by the life-changing impacts of cancer are able to tell their feelings and share with others. However, while Ryan and Amy Green, parents of five kids, were dealing with their son’s (Joel) brain cancer, they decided to share this process with other people by making it into a video game. Joel was diagnosed with a type of tumor in January of 2010 when he was just one year old. After going through surgery to remove the tumors in his brain, Joel received chemotherapy and radiation. Over the course of four years he battled against cancer and stayed alive even though there were numerous times doctors insisted that Joel only had a few weeks to live. On their online blog[26], Amy and Ryan shared all the phases of their journey. At one point, they realized that this story was way too difficult to tell on their blog on a daily basis. At the Electronic Entertainment Expo E3-a trade show for computer and video games- Ryan said, “To me, this is something you can’t do with film… You can observe the action happening, but you aren’t in the character’s head. I hope with this game, people connect in a more personal way.”[27] Their desire to put people inside of a patient’s head influenced their

decision to use a video game as a narration to share their feelings with others and to make others talk more comfortably about cancer. In the beginning, players listen to Ryan’s words that describe his emotions. Later, they are thrown into the story and become a part of the family. This example shows that gamification is a brilliant tool to cultivate empathy and communication regarding difficult topics. Starting as a fundraising project, the video game That Dragon, Cancer received significant attention in a short amount of time. Later, the Greens signed an agreement with the company OUYA to continue the production.[28]

26 Green, Amy, and Ryan Green. “Joel Evan Green.” Joelevangreencom. Web. 27 Jan. 2015. <http://joelevangreen.com/>. 27 Stark, Chelsea. “Cancer, the Video Game: A Story of Hope.” Mashable.

21 June 2013. Web. 27 Jan. 2015. <http://mashable.com/2013/06/21/that-

28 Green, Ryan. “Support the Project.” That Dragon, Cancer. Web. 27 Jan.

dragon-cancer/>.

2015. <http://thatdragoncancer.com/support>.

AUDIENCE & ECOSYSTEM

MONYAY PROJECT BY IDEO

IDEO is a world-renowned design consultancy firm, that serves as one of the advocates for design thinking and human-centered design approaches. Monyay is a project that IDEO New York developed in collaboration with Studio 360 with the purpose of bringing joy to Mondays. Directed by Ingrid Fetell, Monyay is a humorous project. One of the product ideas is a ticklish alarm clock called Lolzzz that wakes up people with child laughter and rocks back and forth to mimic the physical human behavior of laughing.

Joy, humor and happiness have been keywords for my thesis from the beginning. Thus, IDEOâ&#x20AC;&#x2122;s Monyay project and Uplift belong to a similar ecosystem, that embraces humor and joy.

â&#x20AC;&#x192;

AUDIENCE & ECOSYSTEM

QUANTIFIED SELF AND SELF-TRACKING TREND

Self-tracking devices are becoming more and more popular every day. There are numerous products in the market that track usersâ&#x20AC;&#x2122; physical activity, give them feedback, and help them to set goals or track their health related data with various sensors interacting with the body. Quantified Self is a platform for makers and users of self-tracking tools from all over the world. Founded by Gary Wolf and Kevin Kelly, Quantified Self organizes international meetings, expositions, forums, and conferences to help the self-tracking enthusiasts. It is important to have a comprehensive understanding of the Quantified Self concept, because this trend is gradually shaping the future of our current health care market system. On the other hand, this thesis explores the possibilities to foster and cultivate ideas such as Qualified Self, subjective wellbeing, and pleasure therapy. Although subjective well-being and pleasure therapy do not necessarily oppose Quantified Self all the time, the purpose is to point out the importance of feelings, emotions, and spirituality in changing the experience of coping with life-threatening conditions. â&#x20AC;&#x192;

RESEARCH

THE PURPOSE OF THE RESEARCH

To address valid problems and identify fruitful opportunities that will help to achieve my goals within this study, it was essential to conduct a comprehensive research that reveals the invisible reasons behind the complex problems that cancer survivors, family caregivers and doctors face. As a designer, I needed to get rid of OR validate my biases. With invalid and biased assumptions in pocket, it is impossible to design for real world problems. Therefore, I conducted a variety of research methods to gather useful and groundbreaking insights that will take me to the next steps in my study.

METHODOLOGY

For conducting this research I used a variety of research methodologies under the main categories titled primary research and secondary research. Primary research stands for the research methodology which is conducted first hand by the researcher to collect original research data. Secondary research means that the researcher gathered the data by reading and analyzing other researchersâ&#x20AC;&#x2122; findings. Under these two main categories there are some particular research methodology that I used; which are: Primary Research Conversational Interviews Field Research Method Acting as Design Research User Journey Happiness and Communication Survey Co-Creative Design Secondary Research Literature Research

RESEARCH

PRIMARY RESEARCH / CONVERSATIONAL INTERVIEWS

Conversational interviewing is an alternative kind of survey interviewing that enables alteration from the criterion of standardized interviewing. Within the conversational interviewing research, researchers can ask participants whether they understand the question or not and provide spontaneous feedback to clarify the meaning of questions as necessary.[29] Conversational interview is an informal type of interview that is like a normal conversation. This method was one of the very first types of research that I conducted in the early phases of the thesis research. It helped me to get a grasp on the topic in a very short period of time thanks to the level of expertise that the interviewees had. I not only used this research method in the first part of my thesis research but I, also, applied it during the advanced phases. The people I interviewed are from a wide range of subjects. They are as follows: Cancer survivors: Fatma Ulutan Fikret Tasbek Prens Canan Perdahlı Stacey Gutman Family caregivers: Seda Evis Yunus Emre Prens Oncologists: Prof. Dr. Deniz Yamaç, Oncologist Assoc. Prof. Dr. Murat Baş, Oncologist

29 Currivan, Douglas B. “Conversational Interviewing.” (2008). SAGE Research Methods. Web. 24 Feb. 2015. <http://srmo.sagepub.com/view/ encyclopedia-of-survey-research-methods/n107.xml>.

Experts: Ajay Revels, Design Researcher, Principal at Polite Machines Alex Tan, Creative Director at Philips Healthcare Assist. Prof. Dr. Fatma Korkut, Faculty Member at METU ID Ayşe Birsel, Co-founder at Birsel+Seck Beth Bongar, Laughter Yoga Teacher Cenk Aytekin, Industrial Designer Dr. Figen Işık, Faculty Member at METU ID Prof. Dr. Ferit Taneri, General Surgeon Jason Severs, Creative Director at Frog Design NY Jeffrey Kapec, Principal at Tanaka Kapec Design Jen Van Der Meer, Founder of Reason Street LLC John Maeda, Partner at Kleiner P. Caufield & Byers John Thackara, writer, speaker and design producer, and director of Doors of Perception Jordan Patinkin, Internal Events Coordinator at Gilda’s Club New York City Marcel Botha, Founder of 10xBeta and Spuni Rob Walker, author and freelance journalist, contributing writer to The New York Times Magazine and blogger for Design Observer. Interviewing with cancer patients, family caregivers, and oncologists helped me to understand the audience better, to get rid of the biases I had and to identify problems and opportunities much better. Interviewing with designers, researchers, scholars, authors and thinkers enabled me to observe different perspectives. Here are some significant observations from the interviews with cancer patients:

Yunus Prens Family caregiver

Seda Evis McPhee Family caregiver

Jeffrey Kapec Principal Tanaka Kapec Design Group, Inc.

Stacey Gutman Cancer Conqueror

Prof. Dr. Halil İbrahim Güllü Medical Oncologist

John Maeda Partner at Kleiner P. Caufield & Byers

Jason Severs Executive Creative Director at Frog Design

Ayşe Birsel Co-founder & Creative Director at Birsel + Seck

Canan Perdahlı Stage 4 Metastatic Breast Cancer Survivor

Prof. Dr. Deniz Yamaç Medical Oncologist

Beth Bongar Laughter Yoga Teacher

Dr. Fatma Korkut Faculty Member at METU ID

Dr. Figen Işık Faculty Member at METU ID

Fikret Taşbek Prens Cancer Survivor

Dr. Murat Baş Medical Oncologist Integrative Medicine Specialist

Alex Tan Creative Director at Philips Healthcare

Cenk Aytekin Industrial Designer at Laerdal Medical

Jen Van Der Meer Founder of Reason Street

Prof. Dr. Fatma Ulutan Cancer Survivor

Dr. Orkun Tan Obstetrician-gynecologist

Ajay Revels Principal at Polite Machines

John Thackara Writer, speaker and design producer, and director of Doors of Perception

Rob Walker Writer at Yahoo Tech, The New York Times Magazine and Design Observer

Cathy McPhee Cancer Survivor

Dr. İsmail Dölen Obstetrician-gynecologist

Marcel Botha Founder of 10xBeta and CEO at Spuni

Şiyar Bahadır Medical Intern

Randy Lehrer Psychotherapist

Prof. Dr. Ferit Taneri General Surgeon

Jordan Patinkin Internal Events Coordinator at Gilda’s Club New York City

RESEARCH

PRIMARY RESEARCH / CONVERSATIONAL INTERVIEWS / FATMA ULUTAN

Fatma Ulutan is a professor of medicine at Gazi University Faculty of Medicine in Ankara, Turkey. Years ago she was diagnosed with Leukemia, which is a type of cancer of the body’s blood-forming tissues. She went to a hospital in the U.S. to receive treatment and fortunately was able to overcome her first battle against cancer. After coming back to Turkey and re-adapting to the life, her cancer returned required her to go back to the U.S. again. Doctors were hopeless but, still, she won the battle again. In our conversation we talked about the factors that had a supporting role in conquering her battle, the factors that affected her morale in a negative “My friends gave me this way and the unforgettable snow globe and told memories from those days. me to play its music As a doctor herself, her whenever I miss them, diagnosis process was different and it really helped me.” than a non-doctor cancer patient. Her colleague and friend who is a very successful oncologist, diagnosed her symptoms and gave her the news of her cancer in a very sensitive, caring way. She said “my oncologist was like a coach of a soccer team, he made me feel like I am ready to play.” While preparing for her move to the U.S. for treatment, her colleagues at the faculty and the president of the university gathered around and threw a party to support her. While telling her stories eagerly and remembering all the details, Fatma brought a box full of memories from those days, gifts, postcards, letters and everything

that supported her morale in the hospital. One of the most supporting thing was the snow globe that was gifted by her friends. She also shared some of the letters with me. Her friends’ letters helped her to believe that she will win the battle against cancer, and will accomplish all of her goals and dreams afterwards. One of her friends wrote “Spring only comes to those who are waiting for it.” Fatma knew that her battle was more than for herself, she had bigger goals than just lengthening her life, she wanted to continue teaching students to become future doctors. “A friend from The Atatürkist Thought Association told me that I have responsibilities to the young generations as a professor and must overcome this illness to share my knowledge with these young doctor candidates to train them.” Hope and future goals really motivate cancer patients not to give up on their fight. Her friends used to ask Fatma about her future plans after the illness, and she would carefully think and reply to them. Imagining a future full of plans and no illness helped her to focus on the post-illness period rather than focusing on the illness. Fatma also considered the illness itself as an assignment. “This illness was given to me so that I can be an example to others.” When we talked about the things that had negative effects on her

motivation, she mentioned the song, Love Story. “Whenever they played Love Story on the radio, I cried and turned the radio off because the girl in the movie, Love Story had the same illness as me and however she dies at the end.” We, also, talked about how often she thought about cancer when she was ill. I asked “Were there times when you put the cancer aside and thought about something else?” she replied “There is no such thing in dealing with cancer. Cancer is consistently on your mind.” Fatma left all those difficult days behind, considering it as a perspective changing milestone in her life. Although she is grateful for being restored to better health, she doesn’t regret the life changing experience and challenges she often faced. She is happy that she is more sensible about the meaning of life.. She still teaches at Gazi University Faculty of Medicine as a professor for infectious diseases. She is waiting for her retirement day to give the speech that she prepared during her stay at the hospital in the U.S.

“Spring only comes to those who are waiting for it.”

RESEARCH

PRIMARY RESEARCH / CONVERSATIONAL INTERVIEWS / FİKRET TAŞBEK PRENS

Fikret is a family member of mine, who is a creative entrepreneur in the advertising industry and a mother. Since she was diagnosed with cancer a few years ago, as part of the family we were deeply affected and underwent the process of coping with cancer along with her. Her struggle and fight made me especially want to focus on the topic of cancer. Over the course of one year, she shared her experiences with me and provided me with a great understanding of cancer and the problems in coping with it. Fikret mostly talked about her friends’ neglecting her. She said that her friends did not really show her any support. At times, Fikret felt antisocial, so she did not really want to talk to people. However, she did not want her friends to forget about her either.. A simple text to say hi or a quick phone call just to catch up was all Fikret ever wanted to feel like people cared. In many cases, though, when someone is confronted with disease it puts other people in uncomfortable situations. I like to think of the term confrontation in a general sense. It’s occurred to me that most people usually back down and tend to cower when confronted for any reason due to the simple fact that no one enjoys to be confronted. Usually, confrontation is associated with negative context. My “Some of my friends call me understanding of in a rush and ask if I need Fikret’s situation anything from the grocery is that once her store, but I can’t answer that friends were

quickly, so I say no, then they never ask again.”

confronted with the knowledge of Fikret’s cancer they withdrew themselves, for the most part, from the situation altogether. Listening to her feelings, reactions and other challenges she had to often face were not something her friends were able to communicate with her.. Fikret needed attention, care and support. Her friends did not know how to move out of their comfort zones and reach out to be a shoulder to cry on when Fikret needed her friends the most. Unfortunately, like Fikret, many patients often find that their friends and sometimes family members remain distant to them. They simply just don’t know how to handle the situation. “My husband has been the biggest supporter. His efforts and energy kept me alive.” Fikret mentioned how her husband, Yunus,played a big role in her battle against cancer. Yunus has been taking care of her while his parents have been helping them with the care of their three year old son, Çağan. Spending time with her son has truly been an enormous help. She found great strength to fight for life because of her son.

Fikret, also, mentioned many hospital experiences that had a negative impact in her journey. She talked about radiation therapy wards where she was alone receiving radiation treatment. She continued to tell about the frightening procedures she had to go through where the technicians placed her head in the radiation machine using bulky nuts to keep her head still.

â&#x20AC;&#x153;These are really fancy hospitals that I am talking about; however, you would think that their machines are for torture.â&#x20AC;? She also remembered a scary experience of going into the radiation ward. The darkness, loneliness and coldness of the room added more terror to the discomfort she already felt.

“In radiation therapy wards, I tried to dream about my son, growing tomatoes and good things but the room was so dark and scary that I couldn’t dream…”

RESEARCH

PRIMARY RESEARCH / CONVERSATIONAL INTERVIEWS / STACEY GUTMAN

Stacey Gutman is a Business Development Executive, Product Innovator and Technology Strategist, a mother and wife who won her battle against cancer. She generously accepted to share her cancer journey, challenges and motivations with me. For Stacey it was a big undertaking to communicate the news of her illness and give updates about her progress to her close friends “I needed to and family. After the initial phone spend my time calls made to her immediate and energy family, she created an email trying to get well list consisting of her family vs. managing and friends so that she could communications.” manage communications to them throughout her diagnostic and treatment journey. “In the first days after my diagnosis, it was weird to look at myself in the mirror and acknowledge that I have cancer in my body.” Stacey mentioned the difficulty of grasping the fact that she had cancer in her body. She said that she would look at herself in disbelief trying to absorb the new reality. “I then found a way to be myself amidst it all.”She explained that she had to change her mindset.

PRIMARY RESEARCH / CONVERSATIONAL INTERVIEWS / CANAN PERDAHLI

Canan, a spirited social worker, works with cancer patients and their families hand in hand to help them cope with cancer better. She, herself, has advanced stages of metastatic breast cancer that has recurred after some years. She told me the story of her life, the story of her cancer, how she became a social worker and other patients’ stories whom she helped. Canan explained how cancer changed her whole perspective on life. She said that she used to stress about unnecessary things before her diagnosis of cancer. After learning that she had contracted breast cancer, and had accepted this fact, she experienced a heavy depression. She says “I died that day and then the rest of the days were all mine, I started enjoying life.” When I asked about the things that caused stress and disturbance for her, she said “Some people just don’t know what to say or what not to say to a cancer patient.” She heard things like “…she had the same cancer, but she lived for 5 years, don’t worry.” It drove her crazy. Canan works with an oncologist in Ankara. Since she is a social worker she is very sensitive about doctor-patient relationships and says that she cannot tolerate doctors who neglect, are overly insensitive and have distasteful attitudes. Once she was brought to a doctor’s room after surgery, the doctor would not give any eye contact to Canan at all, instead he always appeared to be reading something on his desk. After asking irrelevant questions, the doctor wanted the nurse to turn Canan on the bed. Canan was so frustrated by the doctor’s

actions that she couldn’t help herself but yell at him for not considering the fact that she was unable to roll over due to her post-surgery condition. Had he taken the time to thoroughly understand Canan’s condition or taken a simple look at her, he would have seen that she was not in any condition to do as was asked of her. As a result of Canan’s experience, we see that even doctors sometimes do not conduct themselves in a professional manner which is vital for good “Fighting against common medical practice cancer takes in providing care to patients. teamwork.” “Cancer is a romantic way of dying, you as the cancer patient have the privilege to say goodbye to your loved ones” Although we talked about many negative aspects, we had a chance to talk about the positive things as well. Throughout her cancer experience she was able to meet many wonderful people.. She is very happy to have been treated by a great team of oncologists, Prof. Dr. Deniz Yamaç and Prof. Dr. Ercüment Tekin. She says that cancer takes teamwork and without the support of family, friends and oncologists it is quite difficult to overcome. One of the most insightful research

RESEARCH

FIELD RESEARCH

methods is observing the problems in their own context. In order to understand the relationships, interactions and communication issues, investigating an environment provides very constructive perspective on the topic. Therefore, I carried out an extensive field research in two different oncology departments of two hospitals in Ankara, one of which is a state hospital and the other a private hospital. I observed waiting rooms, radiation wards, chemotherapy rooms, and doctor rooms both in the pediatric and adult clinics. The first hospital I observed was Hacettepe University Hospital. This hospital is known nation-wide where people come from all around the country to receive treatment. Patients who come to this hospital are usually from mid-low socioeconomic classes. Each day, approximately 100 cancer patients come to the oncology clinic to receive chemotherapy treatment for approximately one hour. Chemotherapy rooms varied from rooms containing two beds to those with six beds. I assumed that because there were so many patients receiving the same treatment they would conversing amongst other patients; however, what I found was quite the opposite. In fact, many patients did not even talk to their companions. The silence was almost deafening as the depressing emotions filled the room. As I observed the experience of receiving chemotherapy first hand –which I will explain in detail in the “Method Acting as Design Research” section - it is a tough

process filled with emotional breakdowns and internal reflections. The chemotherapy rooms in Hacettepe University Hospital –state hospital- are much more crowded and chaotic compared to those in Güven Hospital –private hospital. Several rooms at Hacettepe have six beds whereas, each individual chemotherapy room at Güven Hospital has its own bed. It seems though that no matter the number of patients that can receive treatment in a room (whether it’s just one or six) there is always a level of loneliness. Another thing that affects patients’ experience is the sunlight. According to research,[30] sunlight exposure has a positive impact on patients’ perceived stress and pain level. Furthermore, patients who get more sunlight typically require less painkillers. However, the chemotherapy rooms in Hacettepe had very poor quality of sunlight compared to Güven Hospital. The medical oncology department of Güven Hospital is located near the top floor of a tall building. Thus, patients at Güven Hospital have a great view of the city while receiving chemotherapy. One intervention idea of mine was to provide patients with viewfinders that show calming, inspirational and relaxing landscape photographs or videos. This would prevent them from seeing the other anxious patients and all the

30 Walch, JM, BS Rabin, Williams JN, Choi K, and Kang JD. “The Effect of Sunlight on Postoperative Analgesic Medication Use: A Prospective Study of Patients Undergoing Spinal Surgery.” (2005). Web. <http://www.ncbi. nlm.nih.gov/pubmed/15673638>.

RESEARCH

FIELD RESEARCH / HACETTEPE UNIVERSITY HOSPITAL

FIELD RESEARCH / GÜVEN HOSPITAL

RESEARCH

crazy commotion happening around them. Inviting them to a beautiful calming view could help them to cope with the process better and, also, help to relieve nerves. Waiting rooms were another important topic area that has a significant impact on patients’ experience. Patients and family caregivers are often expected to wait long hours in these rooms.. Both hospitals did, however, have big spacious waiting rooms. As predictable, the private hospital –Güven Hospital- offers more comfortable seating to its patients and the setting is just like a luxurious hotel lounge; whereas, the state hospital – Hacettepe University Hospital- had cold metal benches and were positioned in a way that all patients were able to see each other. This setting is certainly not ideal l for an oncology department because, patients are vulnerable both physiologically and psychologically. It might be difficult for cancer patients to tolerate or ignore the pitying looks of other patients and caregivers. In conversational interviews, cancer patients stated that it was very traumatizing them when someone approached them and said things like “Oh dear, you are so young!”, “How much time do you have?”, or “Oh honey, my aunt recently died from the same type of cancer.” Based on these observations, I think a better waiting room experience should be distracting, entertaining, and of course, uplifting. Patients and family caregivers should be distracted by enjoyable activities such as: watching fun

videos, reading entertaining comic books, listening to calming music. As seen in the “Diary Study 3: Testing the Laughter Device in Sports Medicine at Chelsea” patients’ and family caregivers’ experience could easily be shifted from negative to positive with small interventions. A calm and smiling patient will not only have a better experience but, also, a brighter outlook on life and will likely have better communication with the doctors and hospital staff. Waiting rooms should be considered as one of the first touch points designated to uplift patients.

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METHOD ACTING AS DESIGN RESEARCH

Method acting, is a system developed by Lee Strassberg, who is an actor, director, acting teacher and the founder of the Actors Studio,. Method acting is a set of techniques that help actors to understand the realities of the characters and find similar realities in their own personal memories in order to create the same feelings and the same relationships on stage. For instance, if you are to play the part as the best friends on stage, and in reality you barely know your actor friend, how can would you truly act out a scene with your “best friend” and make it meaningful? feel like you are talking with your best friend? Method acting offers a set of solutions to actors to overcome these kinds of difficulties. There are numerous exercises and techniques to that help you see the world through the eyes of the character you are trying to give life to on the stage or in front of the camera. These techniques enable actors to feel similar emotional feelings as the characters would feel depending on the conditions given in the script. While carrying out research methodologies that are widely used in the design research processes of user experience design projects, I, also, tested a novel research method by carrying out method acting practice during my field research. The purpose of trying method acting was to stimulate the emotional sensory to create similar feelings to the ones that patients feel while undergoing difficult procedures in hospitals.

Role play in design research is not a new research method. It is being used by designers to understand the user needs in a complex scenario especially, when users have different conditions that are not similar to the designers’. However, method acting is very different than role-playing. Having studied method acting practice at the BOVA Actors Workshop, directed by Anthony Vincent Bova in New York, I am very impressed by the power of this method in terms of empathizing with others –the character in the context of theater-. My aim was to use method acting techniques to empathize with patients and doctors, to understand what kind of experience they go through and what kind of relationship they have with their surroundings, such as the environment, people, interiors, objects, and etc. I believe that this study will open a door for the design world by helping designers to put themselves in the users’ shoes. During my field trip at an oncology center in Ankara, I asked a nurse if we could act out a situation where she explains the chemotherapy procedure to me as if I were the patient who is on his first chemotherapy session after recent diagnosis. After she excitedly accepted, I sat in the patient seat in the chemotherapy room. For her, it was a very common situation, because she is used to giving that speech to each new patient in the beginning of his/her chemotherapy sessions. However, it was quite a difficult conversation for me to have even in just

the very first moment. When she put that “cheering” and “optimistic” tone in her voice, I immediately sensed that something was wrong. As she went on to explain the procedure very carefully with the purpose of acknowledging me about the entire process and her responsibilities in the process itself, I felt extremely terrified. I started to experience tunnel vision. I stared at my surroundings, escaping her eyes and trying to understand how the room felt around me. It was a very luxurious private hospital room with an amazing view of Ankara. The furniture was brand new and beautiful. However, I hated that place from the sea of distressed faces that loomed the waiting rooms and hallways.. I happily dropped off my burden in the oncologist’s office, quitting the role, when I went to interview her. However, what I took away from the whole experience was invaluable. I found it extremely frustrating to learn about all the terrifying steps one will face on their journey back to better health. When I shared these feelings with the nurse, she explained that there are many patients who react in the same way that I did but, she added that there are also patients who want to be informed about everything from the very beginning. This finding revealed that health care should be targeting each person’s needs by building empathy bridges and understanding their personalities to offer the most suitable care for them.

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MAPPING THE USER JOURNEY

During my conversational interview with Canan Perdahlı, I wanted her to draw a diagram to take me through each process which equated to her entire cancer journey. She carefully thought about and remembered all the phases. As she started drawing the curve with zigzags from pre-diagnosis, to diagnosis, to treatment, to check-ups, and then from her relapse to the state of remission. Visualizing the journey on a 2D map helped both me and her to understand the important shifts in a better way.

As seen in the picture [Canan’s map], Canan expresses her treatment process as an inclination in her mood. Her zigzags decline when the treatments are over on the map. I asked her about the reasons behind the decline in her mood, she said that adaptation was a problem after going through that dense treatment process, because it is a totally different mindset where she didn’t really care about little things. However, when she went back to work after the treatment was over, she had difficulty in adapting to that superficial life where people worry about unnecessary things.

After conducting in-depth conversational interviews with cancer patients, caregivers, oncologists and other experts, I wanted to conduct a survey to understand if the pain points that I have identified were real problems that also many others struggle with or is just specific to my interviewees. 205 people participated in the online survey I created. Cancer patients and family caregivers were asked questions regarding their experience of dealing with cancer. Questions addressed topics like communication, psychological supports, knowledge and attitudes about laughter therapy. In order to understand the communication patterns, I asked “What was the first reaction of your friends and family when you shared the news about your cancer diagnosis?” 75% of respondents said “My friends and family said I will overcome the cancer.” 40% of the respondents stated their friends and family told them that they will pray for them. My second question was “What did your friends and family members tell you to make you feel better?” Most cancer patients stated that hearing motivating phrases such as, “You will overcome it!” and “We are with you” helped them to feel better. On the other hand, most patients stated that hearing pitying expressions made them feel worse. Question three asked, “Among which of the following listed below was the most difficult for you to handle during your illness?” The three choices were “sharing the bad news

RESEARCH

HAPPINESS AND COMMUNICATION SURVEY

with my friends and family”, “performing activities of daily living”, and “asking for help from family and friends.” The responses stated the most difficult experience for cancer patients was performing activities of daily living (48%); whereas, 27% of participants stated that sharing the news was the most difficult and 24% of the participants stated that asking for help was the most difficult experience for them. In the psychological support section, when participants were asked about whether they received professional psychological support or not, 60% of them said they did not receive it. 29% of participants, also, stated they used antidepressant medicines. To understand the participants’ knowledge about laughter therapy, they were asked if they had ever heard the terms “laughter therapy” or “laughter yoga”. 51% stated they had never heard of it before. In the following conditional question when they were asked if they would like to try laughter therapy in case their doctor would suggest it, 84% of the participants said they would like to try it. Among those who want to try laughter therapy, 73% stated that they would prefer trying the laughter therapy in a group therapy setting rather than doing it at home by themselves. When patients were asked what kind of activities they received help for,cooking”(62%) and “going to hospital”(%67) were the among the top answers. Another question focused on the problem

with asking for help from others to perform daily activities. Patients were then asked about the reasons behind their hesitation when asking their family and friends for help. 47% said that “I don’t know when they are available.” 36% said that “I am not sure if they are willing to help me.” 30% stated the reason as “asking for help would make me look weak.” 20% said that “I did not know what kind of help I would need.” Lastly 6% stated that they did not want to talk on the phone for a long time to ask for help. Besides cancer patients, caregivers were, also, asked some questions. Their results, too, showed that there is a need for a guidance for a better communication in the context of cancer. Caregivers were asked what kind of experiences they had in communicating with their loved ones who must deal with cancer. 43% stated they wanted to help more; 31% stated they did not know how to react when they first heard the news about the cancer diagnosis; 14% said they hesitated to call and talk; and 11% stated that they did not know how to help. 82% of the caregiver participants, also, stated that they would like to use a product/service that would help them to know how and when to offer help to their loved ones who deal with cancer. To conclude, I have realized that there is definitely a need for a service that would help people to communicate better during their fight against cancer.

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DIARY STUDIES

Diary studies are very helpful research tools that helps to gather extensive information about the userâ&#x20AC;&#x2122;s journey by using a service, product or testing over a period of time. The participants are often given a set of directions and encouraged to fill out a diary-like form to reflect their feelings, thoughts, feedbacks and reactions. Some diary studies are conducted through digital platforms such as SMS texting or e-mail correspondence. Based on the requirements of the research, different mediums could be used to be in touch with the participants to ask them questions as they begin experiencing new products, services, exercises, and etc. Diary studies provide the kind of information that a design researcher could not easily gather from a one-session-survey, interview or field research. Therefore, I conducted three different diary studies with different user groups, to investigate the factors that cultivates happiness.

DIARY STUDY 1: FIKRET’S HAPPINESS DIARY ABOUT LAUGHTER EXERCISES

The healing power of laughter has been one of the significant topics that my thesis focuses on. I have been very excited about the idea of prescribing laughter to the cancer patients who do not laugh often. The best part is that this prescription doesn’t come in a pill bottle and only has to be found within you. So, to find the best ways of implementing laughter exercises into the cancer patient’s daily routine, Fikret and I, who is currently undergoing a type of recurred cancer case, conducted a diary study. In one of our routine talks about her cancer journey, I asked her how often she laughs a day. I was not expecting to hear that - she said she almost never laughs nowadays. We talked about the laughter yoga phenomenon and said she had heard about it and seemed very interested in the idea of improving her spirits with laughter and boosting her immune system (laughter strengthens the immune system in the human body). Thus, we decided to try the forced laughter to see how it improved her evaluation of her happiness level. In this diary study, we investigated the changes in Fikret’s happiness level and its relation to the forced laughter exercises she did. These forced laughter exercises did not include watching, reading or listening to any funny content. Fikret forced herself to laugh out loud for four minutes and four times over the course of eight days. Before starting the forced laughter exercises, Fikret recorded her feelings for four days, so that we had an idea of what her average feelings were

before applying the laughter exercises. During these four days of no laughter, she had some highs and lows between the rankings of 4 and 6 out of 10 being high. She noted physical problems like the common cold had a negative impact on her happiness and seeing a friend from the university made her feel younger and better, but, still, the highest ranking was only 6 out of 10. Starting the laughter exercises on the fifth day, Fikret’s rankings of her happiness gradually improved and reached from 5 to 7 throughout the next 12 days. More importantly, she stated in her diary that she laughed by herself for the first time on the 11th day. In the end she reported that there are benefits of increasing laughter in her life. Cultivating an infectious positive energy influenced her son and her husband, who later laughed with her as a response. She did find it, on the other hand, fairly difficult to laugh by herself. According to her realization, it is not always possible to generate laughter alone, because the patient’s psychology is variable. Sometimes it is just difficult to laugh, but having another person could solve this problem, as she experienced with her son and her husband.

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DIARY STUDY 2: PROMPTING PEOPLE TO LAUGH AND EXPRESS THEIR GRATITUDE

I conducted the second user diary research with eight of my classmates. The purpose of this diary research was to investigate the influence of forced laughter and gratitude on subjective well-being. I used texting as a medium to ask participants how they rank their happiness level each day. Keeping some of the participants as a control group, I experimented different exercises with the other participants. These experiments included asking them to smile for a certain amount of time, to express their gratitude to someone whom they feel really grateful for, and to watch an online laughter yoga class to practice the exercises shown in the videos. I collected the answers in a spreadsheet to analyze the changes in happiness levels through the different exercises. According the outcomes: Prompting participants to smile for 15 seconds and 30 seconds, improved their happiness ranking by approximately %10. Prompting participants to express their gratitude to someone, improved their happiness ranking by approximately %15. Prompting participants to perform belly laughter by providing or not providing helpful content did not work out. Participants hesitated to laugh by themselves for no reason. Some conclusions I reached are: Smiling helps people to improve their mood, no matter how they are really feeling. At times, some participants stated that their previous happiness ranking were very low. Due to some personal incidents, they were

feeling stressed, sad or anxious. Prompting them to smile improved their mood very quickly. After performing the smiling task, they reported that they felt much better. Obviously, we are seeing that there is an opportunity and a need to create a service that helps people to smile more often by using a time based reminder algorithm. Belly laughter, on the other hand, is relatively a more difficult task. People needed a some kind of gesture or prompt to be able to start laughing. Also, it is important to be willing to laugh. For instance, Fikret, who participated in diary study #1, was fully committed to the laughter exercises although she did not have any any objects to help in the process of laughing. One of the reasons behind her motivation was her believing that laughter will cheer her up and help her to cope with cancer better. However, other participants expressed their struggle of trying to start laughing for no reason, especially when their mind is focused on something else and the stress keeps them from thinking about funny things.

Showing gratitude is one of the most effective mood boosters. Especially participants who ranked their happiness levels with low numbers showed tremendous progress in their happiness ranking. Sending a thank you note to someone who had a positive impact in our lives, who helped us with something we were struggling or just made us feel happy with their existence is an amazing tool to increase our mood. There is a huge opportunity to embrace and nurture this behavior in the practices of coping with cancer.

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DIARY STUDY 3: TESTING THE LAUGHTER DEVICE IN SPORTS MEDICINE AT CHELSEA

Another user testing was conducted in Sports Medicine at Chelsea in collaboration with physiotherapist, Dr. Meghan Dowdle. Sports Medicine at Chelsea is a medical practice that combines primary care with sports medicine. The patients with sport related injuries experience high level of pain due to their injuries. On a scale of 0 (no pain) to 10 (emergency room pain) patients often express their pains between 5 and 7. After observing my goals, objectives, and concept ideas, Dr. Meghan Dowdle very generously accepted to collaborate with me and allowed me to offer the patients to demo the laughter device prototype while waiting for their appointment. The purpose of this user test was to understand how watching funny baby laughter videos could improve the patient’s experience while waiting. Thus, patients were provided with a modified Google cardboard headset, a smartphone that loops various funny baby laughter videos, and headphones that are connected to the smartphone. Over the course of three weeks, more than 30 patients used the prototype. They watched and listened to the laughing baby videos in the cardboard box. At the end they were asked to share their mood by marking one of the five different mood faces. According to 25 of the patients’ ranking report, on a scale of 0 to 10, the average level of happiness these patients experienced were 9.92.

Some patients reported their feelings on the report. Some made interesting comments and used words like, “Made me smile, laughed out loud, warm, happy, joy.” “Delighted, cheerful, jolly smiley”, “My goodness those babies are cute!”, “Made me smile, laugh and smile, uplifting.” “Laughter was initial, subsided a bit and re-appeared again.” Seeing these delightful reactions was enough proof. This conclusion reveals an opportunity to re-think the experience of waiting in a hospital’s waiting room. This intervention could easily be applied to any kind of hospital or clinic. By handing these lowcost cardboard mini movie theaters to patients to watch baby laughter and other funny videos, hospitals and clinics could uplift their anxious patients. Another way could be playing these videos on big screens so that all patients in the waiting area could watch the content together and share the laughter. However, there is a different positive impact of using the cardboard box, it isolates the patients from the environment, which helps them to forget where they are, and engage with the entertaining content at a high level.

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CO-CREATIVE WORKSHOP

Bringing stakeholders into the design process and brainstorming collaboratively in a structured framework is helpful to expand the perspective. In order to learn from the stakeholders, such as cancer patients and family caregivers, I conducted a co-creative workshop with the participation of two cancer patients and two family caregivers. In the workshop, participants were provided with 2D modular geometric design elements, various future forecast information, and a problem hierarchy map provided on the Google Slideshow platform. After identifying the biggest problems they struggled with during their process of dealing with cancer, they chose one of the paragraphs,

which contained information about the future forecast to build on their product ideas by using the geometrical shapes. All participants developed ideas that addressed emotional and communicational problems. Some of these ideas are as follows: A smart wristband that detects emotions and physical fatigue of the patient and transmits the data to the medicine manufacturing device so that the cancer patient- could receive a personal, targeted treatment. This device works so that it connects cancer patients and their family and friends by transmitting the emotional status of the patient to them.

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LITERATURE RESEARCH

In collecting comprehensive information and reviewing insightful point of views of the experts who have spent a lot of time thinking, researching, and writing about the topic for a long time, it was very helpful to read and review their research results, books and articles. Some books have been enormously inspirational and insightful such as Patch Adam’s Gesundheit!, Lori Hope’s Help Me Live, Robert R. Provine’s Laughter: A Scientific Investigation and Allen Klein’s The Healing Power of Humor and a huge help in writing and understanding the topic of this thesis.

INTERVENTIONS

SPECULATIVE OBJECTS

With the purpose of initializing ideas, I designed a set of speculative objects that addresses the problems and needs in the existing healthcare systems. Thanks to the helpful method I followed, I came up with many speculative object ideas; some of which I prototyped. By using lateral thinking methodology, which is an important and helpful method for generating as many ideas as one can, exploring different territories and different opportunities in healthcare became much more convenient. Lateral thinking is a method invented by Edward de Bono, who is the author of the “Lateral Thinking” book which teaches how to be open minded, which explains how to be more creative and playful to generate more ideas easily. In his book he talks about looking at things differently and opening all of our senses up to see as many opportunities as possible. As stated by Bono, it is essential to unleash the mind and play with numerous “irrelevant” concepts irreverently. By having no limitations and no fear, one can easily come up with tons of ideas, most of which will probably sound silly and nonsense. However, as the journey goes on, magic happens and unthinkable ideas occur one by one. It is very surprising to see how the human brain loves being creative and playful and doesn’t prefer judgmental comments. This could also be observed in kids’ behaviors. They don’t have the fear of making mistakes. They play, they run, they do silly things but at the end of the day they never fail to surprise

adults with their magical creativity. Using this method was very enjoyable and delightful to think about the healthcare topic and try to come up with interesting ideas. The outputs of the exercise were sketches and prototypes. Starting questions with “what if…” clauses I started to dream about the ideal healthcare experiences. What if the tools were less scary? What if the doctors were friendlier? What if the needle was not sharp? What if hospitals looked like lovely coffees? What if the newspapers only had good news? The lateral thinking method and personal questions helped me to put my thoughts and insights on the paper. I was able to see my initial ideas and opinions much more clearly. By doing so, I realized that I was mainly playing around with three main categories. First the interaction between the patients and the medical devices, secondly the interaction between patients and doctors and lastly the relationship between patients and their long term diseases. There are certainly many other elements in this area but these three were the areas I took the most interest in. Medical tools and devices, or any product and artifact that get in touch with patients in hospitals have an impact on their psychology and on their experience. Designers design new products that aim to eliminate those bad impacts for sure, but, unfortunately, hospitals lack medical instruments that are less frightening to better serve their clientele during their visits. The IV drips, needles, multi-functional

patient beds, surgery tools, examination tools, knives, scissors and many other necessary tools have not changed for a long time. There may be a rational reason behind it but it doesn’t mean that interventions are impossible. It seems as though the medical industry strives to make instruments for precision but do not take into consideration the people that have to be worked on by these tools. I started with what in my opinion is the scariest tool. The syringe is most commonly used. A syringe has a long cylindrical body with level marks on it, and a long needle at the bottom. Some children and adults have small fears of needles but some have irrational phobias of needles making shots a real chore and a lot of anxiety to undergo. Regardless,

most if not all people typically do not enjoy getting poked with needles. One of the initial concepts on my speculative objects work is a syringe that hides its needle like a bee. The idea was that it might be less intimidating if the patient doesn’t see the long needle but only a big balloonlike smooth ball approaches his arm. The interaction between patients and doctors was the second issue in my speculative objects work. Doctors are the core of the hospital experience for patients who see them to receive treatment for their illness. The experience of visiting a hospital might be awful or wonderful depending on the attitude of the doctors. A friendly doctor who approaches his/ her patients with respect and care will

definitely lead a healing and calming experience; whereas, a tired and angry doctor who has poor bedside manner and doesn’t respond to their needs will probably cause a terrible experience. Empathy is an essential tool in order to build bridges. Because of long and tiring days that doctors often endure throughout the week, patients sometimes have to suffer their resentment. It is unfair to expect patients not to depend on doctor’s behaviors since doctors are the most important source of information that they are wanting to learn about. The concept I’ve developed to address this issue is a necklace that makes emotions visible through color coding. By using this necklace both doctors and patients can constantly

communicate their emotions to each other. Finally, the third issue is the relationship between patients and their long term illnesses. Some diseases are acute, some are chronic and some are fatal. There are many people in the world who have to live with debilitating diseases for the life time. Mental wellness and emotional support have become much more essential factors in these scenarios. For instance, a cancer patient who is dealing with tiring and exhausting treatments crave love and support. Communicating with family and close friends become key. On the other hand, seeing bad things, bad news, and hearing tactless comments might affect them terribly. Third concept focuses on this issue, re-thinking a newspaper for mentioned type of users. The concept is a special newspaper called “The New Your Times” which is curated by the New York Times. The purpose of the New Your Times is to filter the bad news and deliver the good news to patients. Good news might be from all around the world and from patient’s social environment such as his/her friends, family, partners, co-workers, etc. By creating a platform that only delivers the good news, the intention of the concept is to celebrate life and to keep the morale high.

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SPECULATIVE OBJECTS / SYRINGE-BALL

Smooth Syringe is one of the speculative object concepts developed to question and re-think the existing experience of going through frustrating healthcare experiences. Asking the question of “What if the syringe was not that scary?”, Smooth syringe concept was developed to change the perception of syringes. It hides the needle by showing a smooth and harmless shield to patients.

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SPECULATIVE OBJECTS / EMOTION NECKLACE

Emotion necklace helps patients, doctors, and hospital staff to visually express how they feel in order to understand each other and have better communication. Using a color code system provides a quiet language design without embarrassing the users. Each color translates to a certain feeling such as anxious, angry, grateful, tired, and confused. The concept emphasizes the importance of empathy in the context of healthcare. â&#x20AC;&#x192;

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SPECULATIVE OBJECTS / DARE

Dare is a provocative blood drawing concept that questions the hierarchy between patients and doctors. By turning the blood drawing setting into a double sided action, where patients draws doctor’s blood as the doctor draws patient’s blood, dare aims to empower patients.

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SPECULATIVE OBJECTS / THE NEW YOUR TIMES

The New Your Times is a positive newspaper concept. It is curated by the New York Times to serve cancer patients. The New Your Times only gathers the happy news about loved ones and filters out the bad news. Therefore, it aims to support the cancer patient emotionally. â&#x20AC;&#x192;

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SPECULATIVE OBJECTS / SPECULATIVE PRESS RELEASE: LAUGHTER DEVICE

Another lens of this thesis was to write a press release and design a product that reflects it; then showing the product in an advertisement format. Here is the press release:

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For Immediate Press Release Laughing is the best medicine. Philips Healthcare introduces the world’s first laughter machine to be used in hospitals and hospice centers. The collaborators of the project are Jimmy Kimmel and Memorial Sloan Kettering Cancer Center. New York, November 3, 2014 –Laughter is known to be one of the oldest and best medicines in history. It was used by surgeons to distract patients from pain in the 13th century and in the 20th century. A scientific study showed that humor has a strong impact on physical wellness. It is proven that laughter helps to reduce pain, decrease hormones that cause stress and boost the immune system in people. Some hospitals, cancer centers, and clinics have been offering laughter therapy for their patients. However, it was not until Philips Healthcare introduced the laughter machine called Haha™ that it was a standard and required health care service in hospitals. Haha™ is a product of joy and optimism

that makes its users giggle first and then laugh out loud until they are physically and mentally relaxed. In order to achieve that, an animated film is presented to patients on a small display inside of the helmet-like product. After patients are provided with step by step laugh exercising techniques, they see interactive videos of various people who laugh as they laugh. Since laughter is contagious, patients immediately start laughing and interacting with the people’s laughing videos. By productizing the laughter therapy as Haha™, Philips Healthcare achieves two things at once. First, they change the standards of healthcare services by stating that emotional needs are as much as important as physical needs and a good healthcare service should respond to the emotional needs of the patients in order to improve the quality of their lives. The federal agency of the United States Department of Health and Human Services had a meeting to review the FDA certification procedures after the announcement of Haha™, it is more likely that in the near future healthcare products will be required to fulfill

patients’ emotional needs at a certain level regarding their role in patient’s experience. Secondly, Haha™ makes it possible to transform the isolation room experience into something more fun and enjoyable. Patients will be able to relieve themselves with the laughter machine, Haha™ after receiving exhausting radiation therapy and then being placed in an isolation room. The designer of the concept, Berk Ilhan says that, “laughing is the best medicine and everyone should celebrate this natural gift that we were all born with.” Haha™ was exhibited at an event show at MoMA last fall. Memorial Sloan Kettering Cancer Center is since one of the early adopters of the product. They are planning to add the new Haha™ product to all of their isolation rooms.

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BRANDING LENS

Approaching the thesis through the branding lens helped me to understand the essence of it and what kind of purpose, positioning and promise that Uplift offers to its audience. I built the brand pyramid and decided on the hierarchy of the visual, sentimental, logical and spiritual aspects of the objects that I designed within this framework. â&#x20AC;&#x192;

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BRANDING LENS / SMILE MIRROR

A magical mirror that lets users see themselves only when they smile. It aims to remind and provoke people to smile more, and see themselves smiling, because making a facial expression, such as a smile, can produce effects on the body that are similar to those that result from the actual emotion, such as happiness. (Kleinke, C.L., Peterson, T.R, 1998). Moreover, smiling is a contagious act; because, of the mirror neurons in our brain we naturally smile when we see a smiling person even if weâ&#x20AC;&#x2122;re only seeing ourselves. Smile Mirror provides the user with a delightful and meaningful experience. It consists of three elements: a smart switchable film that becomes transparent or opaque according to its electrical status, a smile detecting software and Arduino open source circuit prototyping board. â&#x20AC;&#x192;

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BRANDING LENS / TALK TO ME

“Love and attention are critical tools for helping patients get better. If it were a form of medication, we would prescribe it.” says Ronnie Nathan, Chief Barker of the Variety Club. Hospital visitations are very important for in-patients. Seeing a friend or a family member helps them to recover faster. Talk to Me is a voice recorder device that enables patients to capture the joyful moments from guest visitations and relisten to them. By picking one of the colorful interactive sticks and plugging it into the base, the user starts recording a personal voice message to his/her loved one who is sick. Thereafter, the patient could tap on each stick and listen to those heart-warming messages when they are feeling lonesome.

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LAUGHTER BOX

Laughter Box encourages people to take a short break from their daily routine and to enjoy funny videos which promotes laughter. Depending on the user’s taste, Laughter box delivers different types of humorous content (i.e giggling babies, outrageous accidents, and scrambling cats, etc.) thanks to the accompanying YouTube channel which users can access the videos by using their own smartphones. After imagining a device that would provoke its users to laugh, I decided to prototype this idea very quickly in order to try it with real people. With the original rendering that I made (in Speculative Press Release: Laughter Device), my aim was to dream a collaboration between Philips Healthcare, Jimmy Kimmel and Memorial Sloan Kettering Cancer Center. The purpose of this collaboration is to provide patients with a magical headset that makes them laugh as they use it. Emphasizing the important health benefits of laughter, the idea is to bring laughter as a therapy to the cancer patients, most of whom suffer from depression. In order to test the concept, I downloaded Google Cardboard layout from Google, then changed the size and shape to create a different experience. Afterwards, I chose several entertaining and funny videos such as cats and laughing baby videos. I opened these videos on my phone and placed my phone into the cardboard prototype. I tested the prototype with approximately ten people from different ages ranging between 24-32. Similar initial

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reactions were, excitement to engage with the product, dropping chins in awe, disassociating self from the physical environment, and engaging the stimuli at a high level. Some of them expressed their feeling as “being in a movie theater” and “forgetting where actually I am.” I also tested this concept at Sports Medicine at Chelsea and at the Integrated Family Medicine center. As seen in the diary studies section of the research, it increased patients happiness levels while they waited for their appointment.

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VIEW CHANGER FOR CHEMOTHERAPY ROOMS

In previous weeks I made a continuum diagram to show my intentions with the direction of this thesis. My directions were: from “fixing” to “starting a conversation” from “assumption based” to “proven”, and from “general healthcare” to “focused on life threatening diseases”. Articulating the directions helped me to think strategically for the decisions I’m about to make for the following steps of the thesis. After the continuum diagramming, I was challenged to represent my goals by making “something.” Since I have been thinking about the chemotherapy experience and how to change it in a positive way, I wanted to visualize an idea of my own, which would also give a sense about where I want to direct my journey. Having observed oncology clinics and interviewed with patients who were receiving chemotherapy, I realized that there are some factors that causes stress and sadness. These factors are:

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Having no distractions: Chemotherapy sessions take hours. If the patient doesn’t have a distraction, it becomes very stressful to wait until the end of the session, because it is too much time alone focusing on the possibilities of cancer. Based on conversational interviews that I conducted with patients, self-reflection often evokes depressing thoughts. Depressing views: What most patients see during chemotherapy is other patients. At first I thought this could be good for them because they could talk to each other and share their feelings, but according to my observations they don’t talk to each other, they usually behave like introverts and keep quiet. Therefore, the view they have (figure B) is fairly depressing. Learning from the observations I wanted to create a headset that provides relaxing nature views during the chemo. Using this headset would help patients to leave their existing thoughts related to their fears.

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FUTURING AND SPECULATIVE DESIGN / SMART SMILE

Smart smile is a smart switch that could be attached to electrical appliances. Communicating with the smart wall plug, Smile Switch could turn any kind of appliance into a smiletriggered system. For instance, you can make a cappuccino by smiling. It provokes users to smile more often. According to the facial feedback hypothesis facial expression could change how we feel. Smiling is a powerful tool to reduce the stress caused by an upsetting situation. Therefore, I designed the smart smile switch as a spirit lifting tool for cancer patients. â&#x20AC;&#x192;

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EXPERIENCE DESIGN / GIGGLE UP

Giggle Up is a design performance and interactive experience to investigate the idea of spreading contagious laughter. The event took place on March 28th, 2015 in the Flatiron District. Three actors, including me, dressed in white Tyvek suits carried wooden frames that have on/off toggle switches and LED indicators on them. The experience is designed to have three main parts: 1. Attraction: The noticeably large toggle switches and actors who were dressed funny, attracted people. Many people stopped and watched the show curiously. 2. Engagement: When the audience became engaged with the actors to turn on the switches, actors started to laugh loud, which also caused the audience to laugh. 3. Takeaway: In the end, people who were engaged in the activity were given stickers, which allowed them to have a “giggle up” button, too. Then they started to play the game with each other by pushing each other’s button and laughing.

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SERVICE DESIGN / ALL TOGETHER

All-Together is a service that enables cancer patients to share and manage their daily tasks with their family members and friends. Having conducted an extensive user research with cancer patients and their families and friends, I realized there are usually a few people who help cancer patients to accomplish their daily tasks, such as cooking, grocery shopping, transportation to and from the hospital, and picking up kids from school, etc. Therefore, these tasks become a big burden for cancer patients and their family caregivers. The problem is that patients and their family caregivers hesitate to ask help from their relatives and friends, because they donâ&#x20AC;&#x2122;t know if they are available or if they would be willing to help. On the other hand, relatives and friends donâ&#x20AC;&#x2122;t really know how and when to offer help to cancer patients either.

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The service All-Together creates a new social contract between cancer patients, family caregivers, relatives, and friends. It works like this: Patients and family caregivers download the app, register and create a team name and invite selected friends/relatives either through social media or from their contact list. When patients post new tasks to the team, team members could assign themselves to the tasks that they can help with. Thus, All-Together changes the social contract of asking/ offering help by providing this simple and straightforward communication platform for patients and their social network.

According to the result of the survey which was participated by 208 cancer patients and family caregivers; this is a big pain point that affects the cancer patients’ quality of life (and also caregivers’ quality of life).

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SERVICE DESIGN / ALL TOGETHER / CONVERSATION MODELS

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SERVICE DESIGN / ALL TOGETHER / INSPIRATION: WEDDING REGISTRY

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SERVICE DESIGN / ALL TOGETHER / SECOND ORDER FEEDBACK LOOPS

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SERVICE DESIGN / ALL TOGETHER / SITEMAP U0.0 Home

U1.0

U2.0

Share a Task

See Active Tasks

U2.1 Accept Help Offer U1.1

U1.2

Create a New Task

Choose from the List

U2.2 Contact Helper

U1.1.1

U1.2.1

Explain the task manually

Choose a task

U2.3 Share Appreciation on Social Media

U1.1.2

U1.2.2

Set Deadline

U2.1 Accept Help Offer

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U1.1.3

U1.2.3

Assign a person

U1.1.4

U1.2.4

Define required skill sets

U1.1.5

U1.2.5

Define required facilities

U1.2.6

Share on Uplift

U1.2.7

Share on Social Media

U3.0

S0.1.1

Learn about your Disease

Profile Settings

S0.1

S0.4

My Account

S0.1.2 Change my Role

S0.1.2.1

U3.1 Search Topics

I am Patient

U3.2

S0.1.2

Contact Physician

I am Helper

U3.2.1 Choose the topic

U3.2.2 Ask a Question

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SERVICE DESIGN / ALL TOGETHER / WIREFRAME

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SERVICE DESIGN / ALL TOGETHER / INITIAL DESIGN

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SERVICE DESIGN / ALL TOGETHER / FINAL DESIGN

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SERVICE DESIGN / ALL TOGETHER / APPLEWATCH APPLICATION

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INFORMATION ARCHITECTURE / DRAWING THE MESS

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INFORMATION ARCHITECTURE / DRAWING THE MESS

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INFORMATION ARCHITECTURE / PERFORMANCE CONTINUUM

INFORMATION ARCHITECTURE / CONTEXT, CHANNELS & FACTORS

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LOOKING FORWARD

Uplift aims to help cancer patients and caregivers to improve their life quality by providing tools and services to support them both emotionally and socially. Most of the concepts could be scaled up to a wide range of conditions including other life threatening illnesses or health care contexts, such as hospital experiences. â&#x20AC;&#x192;

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LEXICON

Activities of daily living (ADLs): Activities of daily living (ADLs) are basic self-care tasks, related to the kinds of skills that people usually learn in early childhood. They include the following: feeding, toileting, selecting proper attire, grooming, maintaining continence, putting on clothes, bathing, walking and transferring (such as moving from bed to wheelchair) Alternative Medicine: Alternative medicine is used in place of conventional medicine. A health or medical practice is called “alternative” if it is based on untested, untraditional, or unscientific principles, methods, treatments, or knowledge. Cancer recurrence: Cancer recurrence is defined as the return of cancer after treatment and after a period of time during which the cancer cannot be detected. Cancer survivor: Someone who is “living with or beyond cancer” (Source: Macmillan Cancer Support) Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to destroy cancer cells. It is also called “chemo.” (Source: National Cancer Institute) Complementary medicine: A group of different medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

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Complementary medicine is used together with conventional medicine. [Source: National Center for Complementary and Alternative Medicine (NCCAM)] Conventional medicine: Conventional medicine is practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by health professionals who work with them. [Source: National Center for Complementary and Alternative Medicine (NCCAM)] Family Caregiver: A “family caregiver” is anyone who provides any type of physical and/or emotional care for an ill or disabled loved one at home. Loved ones in need of care, may be suffering from a physical or mental illness, disability, substance misuse, or other conditions. There are different types of family caregivers: Parents, Adult children, Spouses, Family members, Neighbors, Friends Health-Related Quality of Life (HRQOL): HRQOL refers to an individual’s satisfaction or happiness with domains of life insofar as they affect or are affected by “health” as defined above. (Source: American Thoracic Society) Instrumental activities of daily living (IADLs): Instrumental activities of daily living (IADLs) are the complex skills needed to successfully live independently. These skills are usually learned during the teenage years and include the following: managing

finances, handling transportation (driving or navigating public transit), shopping, preparing meals, using the telephone and other communication devices, managing medications, housework and basic home maintenance Integrative Medicine: Treatment that combines conventional medicine with CAM therapies that have been reported to be safe and effective after being studied in patients. [Source: National Center for Complementary and Alternative Medicine (NCCAM)]

negative aspects of life (Source: Centers for Disease Control and Prevention) Radiation therapy: Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells (1). X-rays, gamma rays, and charged particles are types of radiation used for cancer treatment. (Source: National Cancer Institute) Support System: Friends, family members and community members who help patients secondarily after primary caregivers. â&#x20AC;&#x192;

Lexicon: The vocabulary of a person, language, or branch of knowledge. Metastatic Cancer: Metastatic cancer is cancer that has spread from the place where it first started to another place in the body. (Source: National Cancer Institute) Palliative care: Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (Source: World Health Organization) Quality of Life (QOL): Broad multidimensional concept that usually includes subjective evaluations of both positive and

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ACKNOWLEDGMENTS

There are some people whom I must acknowledge, because without their help and support I would not have been able to complete this thesis. I am very lucky to have them and am very grateful for all their help and support. Here is the list in which I will forget to mention lots and lots of amazing people who helped me a lot: My family for their limitless support and love. My classmates for being such a caring, smart and supportive group; I consider you to be my ensemble. Allan Chochinov, for always encouraging me to take bigger, never giving up on me and teaching me how to be fearless. Andrew Schloss for believing in me more than I did. Abby Covert for enlightening me when I struggled making sense of the mess. Chelsey Larsen for pulling all-nighters with me to edit the book. Sinclair Smith for helping me to tell the story. Emilie Baltz for having a contagious unlimited energy and her invaluable mentorship in experience design. Steven Dean for teaching me how to handle even the most complicated systems like childâ&#x20AC;&#x2122;s play. Brent Arnold for his patience and mentorship in designing for screens. Elliott Montgomery for bringing different perspectives. Rob Walker for pointing out interesting opportunities. Janna Gilbert for guiding me on the path of entrepreneurship. Marcel Botha for his support and guidance.

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Ajay Revels for always being there and sharing my excitement. Beth Bongar (Laughing Diva) for teaching me the dynamics of laughter and joy. Fikret Taşbek Prens for inspiring me with her fight. Canan Perdahlı for sharing knowledge of years and experience with me. Ayşe Birsel for being an incredibly inspiring design hero and teaching me how to design the life I love (I am still working on it.) Marianna Mezhibovskaya and Souvik Paul for helping me tinker with Arduino and sharing their invaluable know-how. Gabrielle Kellner for patiently listening our presentation rehearsals and giving amazing feedback. Marko Manriquez for managing all the technical issues even after his pinky became veteran. Alisha Wessler for bringing the most joyous laughter to the program, her laughter calmed us down when we were most stressed. Leif Mangelsen, John Heida, Boris Klompus and Tak Cheung for their technical support in Visible Futures Lab Jeffrey Kapec, John Thackara, John Maeda and Jason Severs for their wise suggestions. Adam Fujita, Roya Ramezani, Marianna Mezhibovskaya, Chelsea Stewart and Vidhi Goel for spending their day with me at Madison Square Park to perform the Giggle Up event. Jane Fujita for teaching how to present something effectively and well articulated. First years for their inspiring work, and third years for their sincere help and support all the time. The list goes on and on, thank you to everyone that helped me conduct this joyful project.

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