Managing stress through the Stress Free app: Practices of self-care in digitally mediated spaces

Technological practices of care

Telecare has come to represent a range of technological solutions that are designed to reduce healthcare spending, while also aiming to increase feelings of independence for the healthcare user. Telecare is praised for improving access to care in rural and urban locations for people with chronic physical health problems ¹ and the rapid advances in digital tools means that many forms of psychological distress are now being met with technological innovations (e.g. dementia). The shift to developing tools for psychological distress is premised on the same idea as earlier movements in the telecare field – that increased involvement in one’s care will lead to a sense of independence and empowerment, all of which can be managed at a distance. However, critical analysis of the telecare movement (for examples see Cartwright ² and Pols³⁾ instils a need to explore the realities of using these technologies and the broader implications of how care works via these technologies, particularly in the shift to developing tools to address psychological issues. Furthermore, it reminds us of the possibilities for new technologies to coerce people into using the technology in ways that reproduce normative forms of independence and actually reduce the chances of a real sense of independence. ⁴ Following this critical perspective, a recent special issue of Science and Technology Studies utilised the term ‘Patient 2.0’ as a way of conceptually and empirically interrogating the use of technologies in healthcare. ⁵ Patient 2.0 explores what kind of relationships between agency, technologies and bodies are made possible, restricted and encouraged through current healthcare technologies. This shows that critical examination of technology requires looking at how we manage our bodies in relation to technology and what forms of bodily knowing are made possible in and through the technology. This paper will focus on how people manage and organise the body in the use of a new app that is designed to deal with stress.

Technologies work to bring forth a form of cultural information that provides a particular way of knowing the body. Technology is constantly producing new resources through which the body can be known. For example, Lopez and Domenech ⁶ identify that autonomy in one particular telecare service was governed by the decision to wear a pendant that includes an alarm that can be used to signal the need for help at any time. The decision to engage with the pendant raises a question of the autonomous body, as it is clear that the pendant displaces the body and impacts on the ability to feel autonomous. The authors conclude that ‘the use and implementation of these technologies enacts a fragile and constantly-at-risk body that requires monitoring care and self-surveillance (p.191). The body is ‘constantly-at-risk’ as the presence of the pendant means that the wearer must continue to evaluate if they need medical attention. The body is locked in a constant state of awareness where there is an ongoing need to reflect on whether they need to activate the device. The introduction of a new technology provides a good opportunity to assess the kinds of ways that the body is brought forward.

In this paper we examine how the body is made relevant in the use of a particular technology that is designed to manage, organise and potentially improve psychological wellbeing by reducing stress. The app is called Stress Free (Virtually Free, 15 Warwick Road, Stratford Upon Avon, Warks CV37 6YW) and is one of a number of technologies that focuses on dealing with a psychological form of wellbeing. For instance, computerised cognitive behavioural therapy (cCBT) builds on traditional self-help tools in a way that utilises relational features of an online space. ⁷ Other clinical interventions include mood tracking apps, remote access to health services and GPS-based location services (see Luxton et al. ⁸ for a useful summary). The shift has led to a new field being designated ‘mobile health’ (mHealth). ⁹ Commercial technology companies are also producing digital media tools that target psychological forms of distress, e.g. stress, phobias and mood disorders. The current paper investigates one of these technologies. These interventions are premised on the idea that technologies have the power to intervene in people’s psychological activity. This poses an interesting question in relation to the nature of the relationship between psychology and technology. Are the latter just passive tools to be used by people through pre-planned activity to manage wellbeing or do they have power and agency in and of themselves to affect the human condition?

In this paper we use stress as a condition, and experience – through which we explore questions of agency, bodies and ontology – it as something that can be felt in and through practices that are psycho-physiological, and consequently of value in addressing questions of distress, embodiment, agency and technologies. These kinds of questions centre on a concern with understanding how what comes to be seen as actualised experience and activity is contingent on practices that are simultaneously human and technological,^10,11 and therefore making a theoretical distinction between the two does not help in understanding the reality of social activity emerging in and through embodied-technological assemblages.

Adrian MacKenzie ¹² prefers the term ‘technicity’ to technology as it facilitates a different signification; one that emphasises the relationality of body–technology connections, rather than conceptualise them as fundamentally distinct. Furthermore, the concept of technicity shifts the analytic perspective somewhat, as it defies us to consider the context of an object’s concrete individualisation, which should not be taken as being determined by some form of internal essence or defined set of properties. For MacKenzie, ¹² ‘the technicity of an element is heightened or diminished according to the relative independence it displays in relation to variations in context’ (p.13). As such, technicity directs us towards considering how it is that a given technology (e.g. mobile app) comes to produce a specific actualised effect. In this sense, the whole notion of a stress reducing app can be framed as technicity, in terms of it being designed to have a particular effect on those that use it (i.e. reduce stress). Social scientific analysis of the impacts of such technical elements involve identifying the forms of technicity that specific technologies co-constitute by conceptually mapping the process of technology to technicity.

The shift towards a notion of technicity is useful when thinking about forms of technological care emerging through digital tools to improve psychological wellbeing. For such an intervention to be able to have an effect we have to think of it as intrinsically linked to psychological processes; as interacting directly with the felt aspects of experience. We know people are increasingly living with technologies, and whilst a lot of this has been in terms of maintaining relationships through social media as well as a variety of leisure activities (e.g. shopping, listening to music etc.), accessing health services and consequently engaging in practices of ‘digital self-care’ are becoming increasingly prominent. ¹³ In this sense we have to invent new ways of managing our bodies in and through digital technologies. It is not so much that we are extending our bodies through technologies, but that we are working in patterns of activity that are as much technological as biological.

This paper aims to look at the ways that people use the app Stress Free in terms of how the body can become known within a particular cultural space. In this instance the cultural space is the Stress Free app and the focus is on how the app commands a certain way of feeling about the body as a potentially stressful object. It is important that this form of bodily knowing is shaped in terms of a non-dualistic relationship between the individual and the collective.

The individual and the collective

With the emergence of psychologically focused digital media we see that such technologies are coming to ‘regulate the existence’ of different forms of psychological distress (e.g. stress and anxiety). For the 20th century philosopher of individuation and technology Gilbert Simondon, there is a tension in the realisation of how individual experience is formed in concert with technologies, in ways that are not entirely pre-figured. Here Simondon draws out a point regarding the way that the event of individualisation (biological and physical) is always produced amidst a broader sphere of potential activity (what he calls the pre-individual), and as such, occurs as simultaneously collective and individual:

The subject can be conceived of as the unity of being as an individuated living being, and as a being that represents its actions through the world to itself as an element and as a dimension of the world (Simondon, ¹⁴ p.8).

This sits within Simondon’s broader philosophy that frames the ‘human’ as always-already collective, and given that technologies are agents in the production of collective life, they are by definition, constituents of ‘humanity’. The crucial point for Simondon is to prioritise analysis of individuation over individuality, so that we need ‘to understand the individual from the perspective of the process of individuation rather than the process of individuation by means of the individual’ (Simondon, ¹⁵ p.301, original emphasis). Simondon argues that to focus only on individuality as a concept does not incorporate the broader context of the process of individual experience; ‘individuation, moreover, not only brings the individual to light but also the individual-milieu dyad’ (Simondon, ¹⁵ p.301). Consequently, we can think of technologies as engendering processes of individuation, which form as embodied patterns of everyday life. Technologies, although individual in one sense, are also heavily collective in terms of being accessible and offering potentialised activity to societies and culture as a whole. This captures the interest in the current paper about what practices of individuation emerge when using Stress Free.

Technological affect

Hansen ¹⁶ argues that the issue of experiencing oneself as a body between individualism and preindividualism is felt in moments of affectivity. Here, Hansen draws on Simondon’s account of affectivity being the mode in which individual bodies are experienced as somehow incomplete, as needing to be resolved. For Simondon this is a continuous feeling that does not diminish through some form of completion of embodied experience. In this sense the body cannot become ‘whole’, as it is always in a state of ‘making future’. That is, bodies are continuously trying to find the means by which to enter forms of fixity, and yet such endeavours will always fail. The point, for Hansen, is that it is the collective (Simondon’s ‘pre-individual’) that individual bodies have to engage with in their search for completion. This connecting with collectivity, which is a necessary compulsion, is felt as a form of anxiety. Accordingly, bodies can never quite feel at total ease with themselves as a result of this continual need to work with the collective, which of course cannot be known in the same way as one’s individual body (as Bergson ¹⁷ noted so well). In this sense we are reliant on the non-human technics that co-constitute the material environments within which everyday life unfolds. This means that concepts that are commonly taken to be uniquely human (e.g. feelings, thought etc.) actually need to be conceptualised as products of the relationships that come to be between bodies and technics. Hansen captures this well when stating, ‘the body’s capacity to act is never simply a property it possesses in isolation; it is always a recursive and constantly modulated function of its embeddedness within a rich texture of sensation’ (Hansen, ¹⁶ p.186). Accordingly, we are encouraged not to reduce concepts of feeling (i.e. emotion and affect) to a purely physiological level, as this directs attention away from the other parts of the nexus that constitute their emergence. Instead we are encouraged to follow Bergson’s notion of bodies as ‘centres of indetermination’ (Bergson, ¹⁷ p.35); namely, bodies are always-already incomplete, and are tasked to organise and manage their activities in relation to the ‘excessive realm’ of the technical environments that surround us.

Hansen ¹⁶ invites us to think about the ways that contemporary forms of media allow people to be taken outside of their immediate habitual experience in order to be able to experience something new and engage with ‘something that would not otherwise be experientiable’ (p.223). The use of apps allow people to get a sense of their body in a different way, perhaps as a ‘stressed body’ or a ‘digital body’ or as a ‘relaxed body’, where each of these different versions of the body is embodied in the way that people organise their image of their bodies in the app. Hansen ¹⁸ describes how the ‘digital image’ involves the reappraisal of the relationship between the user’s body and the ‘image’ of the body, where the ‘image’ of the body encompasses ‘the entire process by which information is made perceivable through embodied experience’ (p.9). Here the world is composed of an aggregate of images where the person perceives a subset of this aggregation by isolating certain images that form a ‘centre of indetermination’.

Hansen explains how the body is continually being created anew in the process of filtering information and in new digital media. Digital images of the body have an extended margin of indetermination that give rise to experimentation with different ways of giving life to digital information. Following Bergson, Hansen accepts that the body is a special kind of image that is used to organise all other images and one that is prioritised above all others. So we must accept that when thinking about the role of digital images that these still must be ordered in relation to the ‘privileged’ position of our bodies. Our body is the ‘central organising site’ of our experience and it is through these digitised bodily trials that we are able to get a sense of how our bodies act and feel, resulting in the concept of building an affectual understanding of our own body through the ability to engage and develop our digital image of the body. In this paper we trace a specific example of how the body filters information in one app in order to create an image of the body that gives rise to an affective experience. The booming digital culture of mobile health apps, ranging from those concerned with general wellbeing to specific forms of mental distress, are one part of an individual’s system of apps on a mobile device and are consequently ready-to-hand at any moment.

Stress Free

In this paper we focus specifically on an app designed to reduce stress. The app is based on a model that utilises a series of behavioural exercises to help users reduce or avoid stress (i.e. calm breathing, deep muscle relaxation, self-hypnosis, meditation). The app is of interest because it is a good example of a first wave of digital media that focuses on psychological issues. Another reason the app is of interest is because we can frame these technologies as networked activities of movement that induce sensations, whether they are directly designed to or not. Furthermore, this app allows for a timely exploration of the wider cultural dynamics that are embedded in this new form of technical care and how these technologies enact reductions in psychological and/or physiological distress.

Figure 1 shows how the app appears on an iPad, with the main menu on the left-hand side of the screen. Users can move their way around the entire app, with each of the icons representing a different activity within the app. On choosing to complete one of the relaxation sessions the user is taken to a similar screen in which each of the icons represents one of the different forms of relaxation. Users are required to work through each of the sessions in turn and in doing so ‘unlock’ future sessions, beginning with calm breathing and developing to deep muscle relaxation. Figure 1 also shows Dr Freeman on the right-hand side of the screen. In each session Dr Freeman explains how to complete each of the relaxation techniques and gives the user time to complete each of the exercises (which is often accompanied by soothing music). OPEN IN VIEWER

The app also includes an anxiety rating scale that people can use to self-register before and after taking part in an exercise. Users rate their anxiety in the app by selecting a point on a scale between a happy face and a sad face. These ratings are then transformed into a percentage and collected together in a separate part of the app called ‘anxiety statistics’. The app states that users are able to see all of their anxiety ratings across the different exercises and they are able to monitor their stress and anxiety levels. The anxiety statistics function is linked to a journal feature in which users can add content regarding their experiences of taking part in a session or anything else that they may wish to document. There are also auto-entries associated with each session so that users are encouraged to record their feelings after every exercise.

In the next section we will draw upon some empirical research into people’s experiences of using the app Stress Free. At the time of collecting the data for this project Stress Free was relatively new (three months old), and we asked 10 undergraduate students from a London university to use the app for one month and then attend a semi-structured interview to discuss their experience of using the app. Eight females and two males took part. All names have been changed to make them anonymous. The participants were asked to try and use the app once a day but not to feel any commitment to have to use the app, the idea being that it was more likely that they would give an honest appreciation of the app if they had not been specifically told to use the app for a certain number of hours per day. They were also told to work through the app and use as much of it or as little as they wanted. Fortunately, the app is designed in such a way that it is necessary to work through each of the exercises in order to open the new ones. All of the participants worked through the entirety of the content in order to experience all of the exercises.

The analysis focused on the way/s that participants talked about their experiences of Stress Free in a general sense, as well as having a specific focus on the role of bodies and affect in the Stress Free experience. We utilised a discourse analytic approach, in which the interview transcripts were initially coded according to participants’ experiences of Stress Free. This initial stage of coding was followed by a ‘cyclical process’, ¹⁹ which involves shifting between stages of coding and analysis. During this process, coding and analysis are connected processes, with early themes fed back into existing codes, which then inform subsequent analysis. This approach is iterative, and designed to ensure a rigorous and sophisticated analytic approach.

Analysis

Direct and indirect technogenesis

What we have seen in the analysis are some of the potential issues that can arise when people engage with digital technologies that are designed to intervene in psychological issues where the object of attention is specifically modelled as interior and individual (i.e. personal stress). Apps such as Stress Free are premised on the idea that stress is psycho-physiologically based, and that intervening at the level of the individual is a potentially valuable strategy. At an ontogenetic level technologies can produce an affective response in the form of awareness of recognising that one’s body is always-already organised and managed in a relational nexus with technologies (and other people). This means the actual relation with technologies is affectively registered, and consequently has to be managed as such. This can become a first hurdle (and hence obstacle) to people’s anticipation of any potential benefits of working with digital apps designed to improve psychological health. This level of ontogenetic configuration is not usually factored into the design and implementation of digital apps, which tend to work on the premise that increased digital media use means people are primed to use such technologies in any aspect of their life (e.g. managing health as well as work, social relationships etc.). In a sense, then, the relationship people have with technologies works on several levels. There is an anticipatory relationship at a more general level through which people relate certain technologies as a whole as holding the potential to increase stress. This initial phase can be followed by a more specific relationship with a digital app that can be more stress reducing.

An increasing proportion of our everyday lives is unfolding in close relationships with technologies, and as such we are coming to feel closer to a virtual realm of potentialised activity (which is exactly what Simondon¹⁵ was focused on with his concept of preindividuality). This relationship, though, is far from straightforward. On the one hand it comes from a desire for the high frequency and multiple connections that digital media make possible. On the other hand, with awareness of an ‘always on’ culture comes increased pressure and awareness of ever-ready catalysts and compulsions for new action. The psychological impact of this is yet to be fully understood, and yet we saw with Louise that it can be stress inducing. Here the stress is not some internal element of Louise’s life, but is fundamentally contingent on the relationship with the app. Whilst the app is designed to lower stress (or avoid its increase) at an individual physiological level, it needs to be understood as residing in pre-existing relationships with technologies that have affective impact. The strategies digital media develop as aids for psychological health need to recognise they are operating within a nexus of pre-existing relationships, which all have affective components.

Hence, understanding and empirically studying the impact of digital media on psychological health and wellbeing is not solely a task of identifying the specific effects of a given technical tool (e.g. Stress Free). What is required is a conceptual approach to identifying how the use of a given tool is situated within a broader set of relations between bodies and technologies, through which individual experience is produced and is played out against. We find of particular use the work of Mark Hansen and Gilbert Simondon, as they offer an understanding of how bodies are ever subject to having to reconfigure in light of new demands from technologies (and yet they remain the primary site of action), as well as a broader body–technology ontogenesis that frames individual activity as always the product of processes of individuation emerging from collective sets of techno-biological activity. In this paper this approach informed analysis of participants’ use of Stress Free and the challenges and benefits experienced. Approaching their use of the app solely in terms of its effects on stress in an individual psycho-physiological way (e.g. by evaluation impact of the app’s relaxation techniques) would miss the broader contextual factors that actually shape the everyday use of the app.

In this sense, adopting a ‘social’ approach to understanding digital media tools designed to aid with psychological issues is valuable. As Simondon¹⁵ taught us, the very notion of ‘individuation’ needs to be understood as a ‘product’ of wider sets of relations, of which technologies play an indelible role. The ‘digital age’ we are currently living through provides a new theoretical and empirical target for Simondon’s thinking (most of which was focused on pre-digital technologies). The individualistic medical model approaches of the mHealth field are recruiting digital media at an increasingly fast rate. Their internalistic approach to psychological distress fails to incorporate the broader contexts of the experience of distress (such as stress and anxiety). To gain analytic insight into the impacts of digital apps such as Stress Free on psychological distress we argue for a social scientific approach that gives equal weighting to bodies and technologies in the production of stress. Moreover, doing so facilitates an important focus on the existing relationships people have with technologies that can be disrupted by apps such as Stress Free, and consequently affect what new patterns emerge.

We have seen that the ways that bodies interact and co-create with technologies is affective. So the affective elements at play in mobile app use take place at multiple intersecting levels. This includes the general level of impact of living with technologies such as mobile phones (as we saw with Louise), as well as the effects of using specific apps. The experience of using Stress Free is bound up in a broader affective nexus of pre-existing relations with technologies that are (re)configured through using the app. Consequently, any change to the stress experience brought about by use of the app cannot be entirely reduced to the app itself. What it can do, though, is shift existing patterns of action, and create new body–technology relations through which affective novelty can arise (e.g. the structure Stress Free provided to Robert’s anxiety experience that worked to manage its reduction). Mapping this novelty and (re)configuration of bodies in the ongoing organisation and management of psychological health is an increasingly important task for social scientific analysis.