Clinical Environments
For many patients, clinical environments induce anxiety, stress, uncertainty, and sometimes fear (Newman 1984; Pride 1968; Dijkstra, Pieterse, and Pruyn 2006). Studies have shown that high anxiety levels can cause a breakdown in communication between patients and doctors (Lerman et al 2006). Since most of the diagnostic information is derived from the doctor-patient interview, the miscommunication can impede positive health outcomes (Simpson et al 1991; Stewart 1995). Although there have been attempts made to improve the atmosphere of facilities, there has been little exploration of ways to improve the mental state of patients while they wait to see the doctor. Furthermore, doctors and other healthcare providers are aware of this problem, and implementing a system that is easy, affordable, and non-disruptive to the pattern of healthcare can be very challenging (Grol and Grimshaw 2003). In addition, designing a system that is user-friendly and provides affordance to patients who vary in age, medical symptoms and exposure to technology can be extremely challenging.
Acoustic Communication
In Truax’s Acoustic Communication Model (Truax 2000), rather than focusing on the physical properties of sound, the importance of the greater exchange of information between the listener and the sounds of the environment is emphasized. The importance of implementing Truax’s model is that it shifts our focus from prioritizing the physical properties of sound towards the manner in which sound mediates the relationship between the individual and environment. Additionally, the human experience within the context of an environment can be extended to include attitudes, memories, and the visceral sense of awareness (Southworth 1969). For example, what we might consider to be delightful sounds, such as the sound of birds, is not only based on the physical properties of the sound, such as sound intensity or frequency levels. Rather, it also depends on the type of receptive information that we ascribe meaning to – the memories that we might associate it with or its novelty – that makes a difference to the listener (Grimshaw, Lindley and Lennart 2008). The sonic events occurring in the environment help the listener understand the functionality of sound. Although Truax primarily speaks of the functionality of sounds and exchange of information, there is an experience created at a subconscious level that is unique to the individual listening to the sonic environment. This particular sound experience and aesthetic can provoke our senses and change the way we experience objects, people, and our surrounding environment (Steel 2004). The environments themselves, emitting and captured through field recordings, have a particular sensorial quality, or an atmosphere. The particular type of atmosphere that is experienced is based on the physical perception of the individual, which is influenced by her or his feelings and emotions. The affective quality of an atmosphere, in turn, triggers subjective states and particular feelings and emotions (Boehme 2005). Therefore, by taking into account these human experiences, we are able to gain insight into the functionality of sound and psychological behaviors of listeners, which we may apply to other fields of research such as healthcare.
Presence & Immersion
In this particular study, I am interested to find out the types of experiences patients can have while listening to soundwalk recordings. Presence and immersion will play an important role in creating an environment that promotes relaxation and such environmental recordings may act as a mechanism for distraction from the physical clinical environment. Auditory spatial awareness may be considered as our internal experience of an external environment (Blesser and Salter 2007). Therefore, applying the proper spatialization of sound may help reinforce the feeling of presence in the space. It is difficult to separate the link between our conscious perception, the internal space, and the physical environment, the external space, because the experience of the physical space exists in the listener’s consciousness. Presence becomes an important factor in the experience of immersion in a virtual space created by recordings of soundwalks. Presence can be defined as “the sense of being immersed in a simulation or virtual environment” (Shilling and Shinn-Cunningham 2002: 800). From a different perspective, presence can be thought of as a “state of consciousness” (Blesser and Salter 2007: 13). Although presence can be a subjective concept, which is difficult to quantify, it can be enhanced through various mediums such as auditory, visual and tactile cues (Slater and Wilbur 1995). As the participants become more aware of their presence in the environment, the level of immersion is increased. Augoyard and Torgue describe immersion in the context of sound as the “dominance of a sonic micro-milieu that takes precedence over a distant or secondary perceptive field” (Augoyard and Torgue 2005: 64). We may consider immersion as being variable and dependent on the individual’s perception and reaction to a virtual environment. Besides immersion, there are other factors that affect the sense of presence, and these include sensory fidelity, task, distraction, quality of the interface, cognitive style, and the involvement of the participant (Singer and Witmer 1999). Blesser and Salter suggest that “a simulated spatial reality can be understood as a surrogate implementation: real spaces use sound waves, whereas virtual spaces use signal-processing algorithm. If the virtual space closely mimics a real space, a listener will, in effect, perceive the real space” (Blesser and Salter 2007: 132). Therefore, if great consideration is taken into account with the creative and design process of environmental sounds and recording methodology, we can create a greater sense of presence and create an immersive simulated environment using audio playback.
Soundwalk Recording - Initial Attempt
It was the summer of 2012 when I initially collaborated with fellow musicologist Tyler Kinnear and interaction designer Maryam Mobini to develop a series of soundwalk recordings for this research. My gut feeling regarding the use of soundwalks as a resource to help improve the patient’s experience in clinical settings was set in motion. The goal of the soundwalk was to prioritize the act of listening in order to help the patient become receptive to the sonic milieu. Soundwalks consist of three diverging parameters: time, space, and event. These become the parameters for deriving meaning from the sonic environment. During a soundwalk, the environment can be experienced as a performative event, wherein the listener becomes an active participant listening and attentively moving through the space. The sounds emitted are not limited to the environment and include the sounds produced by the participant, such as footsteps or breathing. This, in turn, leads to a real-time soundscape composition that is unique to the individual participating in the soundwalk.
For the purpose of this research, since the patients we focus on experience chronic pain and typically suffer from mobility issues, we decided to use recordings of soundwalks as the basis for this particular study. The soundwalk recordings were created in a process similar to how music is composed. The question might arise as to why a soundwalk is considered more appropriate than music and headphones rather than speakers in this context. It may be argued that sonic environments are subjective. However, it is easier to categorize (i.e., urban vs. rural) and test which environment may be more appropriate for anxiety management. We can also further refine the process by identifying particular sounds that may be more appropriate for therapeutic practices. There are several issues that arise with using music. First, music is subjective, and considering the appropriate genre that might be suitable for the wide array of patients who visit clinics in terms of age, ethnicity, medical condition, and gender, to name a few, is extremely difficult. Secondly, music is usually in stereo and lacks the immersive quality binaural recordings produce. Stereo sound is often a poor choice for enhancing the immersive experience in an audio playback due to a number of limitations: it is limited to frontal positioning only, and the sound image is positioned in the center with a separation of no more than 60 degrees between a pair of speakers. This limits phantom imaging, especially if the participant is positioned further away from the speakers. The localization of sounds is disrupted once the listener moves off-axis, and this effect may be deprecated further under head rotation (Malham 1998). In the case of headphones, a binaural approach would produce a full three-dimensional sound. Using headphones separates the listener from the external environment, “cocooning” them from intrusion, and the space becomes “both auratic and intimate” (Bull 2000: 32). The binaural processing is an effective way of reproducing and replicating what the ear would hear in a natural situation. This type of playback may promote active listening and improve non-verbal medial communication when representing an environment in a virtual context. One limitation of binaural sound, which should be mentioned, is the individual head-related transfer function (HRTF). The mismatch between these subtle angular changes of the ear can limit the receptive response to front and rear sound cues (Shinn-Cunningham 2000). This can cause the person listening to make a perceptual error in recognizing the location of a sound.
Lastly, in a recent study we conducted, patients were asked about their preference regarding sounds that they find calming or relaxing. The majority of the patients preferred nature sounds to music (Nazemi et al 2013a). In addition, patients experiencing severe pain, which has developed into chronic pain, exhibit a higher sensitivity to audio frequencies in comparison to healthy people, especially in the frequencies between 1000 Hz – 3500 Hz. Interestingly, female patients are significantly more sensitive to audio frequencies and everyday sounds than male patients (Nazemi et al 2013b).
With insight into how frequencies can impact patients, we have the ability to use this frequency sensitivity data and apply it to our recordings of original soundwalks during the recording phase and audio processing in post-production. The soundwalks are structured and separated into three sections: an introduction to establish context, the journey of walking through a predefined path, and finally the return to home. To create a sense of three-dimensionality, binaural microphones are used to record the sounds of the environment. The recordings for this study were all captured using Korg MR1000 and MR2 field recorders at 24bit 96kHz. Using such a method is an effective way of reproducing and replicating what the ear would hear in a natural situation. In addition, we controlled the immersive quality of the binaural effect by modifying parameters such as HRTF strength, ear size, distance, control of high frequency content with an equalizer, and reverb timing in post-production. Such control allows us to create a custom-designed soundscape that is appropriate for the patients waiting in clinics, without inducing anxiety, pain, fatigue, or cluster phobia. The soundwalks for this first iteration of the study were recorded in the Metro Vancouver area.
The challenge we faced, which we did not account for at first, was that the soundwalk recordings are intended for a specific audience, patients who might be experiencing anxiety and/or pain. Additional challenges had to do with finding appropriate locations. We wanted to compose a calming and naturalistic sound environment, devoid of noises created by machines and minimizing human sounds. The biggest culprit was the sound of jet planes passing by and traffic noise. Even though we had selected remote locations, it was very difficult to avoid these sounds entering into the recordings.
Soundwalk Recording - Final Result
Listening back to the initial recordings, we finally realized the changes we needed to make to our process in order to capture recordings that fit the context of this research.
The goal was to focus on creating a sensorial journey that would, for the majority of users, promote relaxation. The first improvement was made through maintaining a walking speed that did not induce anxiety during playback. We also did not want the walking to sound “rushed”. In addition, head movement needed to be kept to a minimum to reduce the feeling of nausea when listening to the recordings.
Specific environmental sounds such as ocean waves are captured as part of the soundscape composition.
Recordings from several locations were needed to create the appropriate journey for the patient. The concept ofmediated spaces plays an important role in developing such recordings. Mediated spaces are exploratory spaces that employ the principles of soundwalks and soundscapes to create an experience that evokes a sense of immersion. In such a mediated space, the participant physically moves through a real environment, but is simultaneously immersed in a virtual space, which is created through the use of binaural recordings played back through headphones. The use of binaural recordings helps to recreate a convincing three-dimensional sound sensation. Janet Cardiff and Christina Kubisch are sound installation artists known for their seminal soundwalks focusing on mediated spaces. During the 1970’s, Kubisch was using electromagnetic induction to explore the sonic responses of magnetic fields in the environment. Electromagnetic pickups were embedded in headphones that picked up these synthetic sounds. Her sound-related works were meant to enhance aural and visual explorations of spaces, such as gardens, castles, cellars, parks, buildings, and galleries (Kubisch 2012). In The Walk Book, Miriam Schaub describes Cardiff’s interactive audio performance, titled Her Long Black Hair, as “the overwhelming physical immersion in an apparently boundless soundtrack that begins to dominate our shared experience” (Schaub 2005: 14). In creating this walk, Cardiff placed miniature microphones in the ears of a dummy head and using this head, captured binaural recordings of the sounds in Central Park in New York City. The sounds that were recorded were then layered with Cardiff’s voice, which guides the participant through an immersive soundwalk in Central Park. As a result, the boundaries are blurred between a participant’s physical presence and a mimetic journey. The participants are encouraged to synchronize their movement by breathing and walking according to Cardiff’s pace. Directive instructions are given to guide a participant’s walk through the park. Schaub discusses how the walks created by Cardiff heighten the senses and deviates the attention of the participants from their own body image, transforming them into the environment imagined and experienced through Cardiff’s own subjective experience. Schaub explains that, “you can smell what she is describing and you can taste the salt from the sea air. Cardiff expands our sense of self-awareness by drawing our attention to the process of perceiving the immediate environment and talking candidly about our bodies as instruments of perception and their reactions to the world around us” (Schaub 2005: 132). The soundwalks produce a distinct quality which helps focus the attention of the participant toward three intertwined levels: a micro-narrated experience, thereby heightening a visceral sensation as they engage with the voice of the narrator; the soundscape composed from the binaural recording; and the participant’s immediate, real-time physical presence in the environment. Cardiff explains that when she first discovered the binaural recording technique, she quickly became attracted “to the closeness of the sound and the audio bridge between the visual, physical work and [her] body” (Egoyan 2002: 66).
Building Soundscape Compositions from the Soundwalks
The underlying premise of a soundscape composition is to re-contextualize or re-embody the environment. It produces an imaginative space that the listener can associate with and that can evoke memories. For this particular research, three types of environments were constructed, based on Schafer’s categorization of Hi-Fi to Lo-Fi sounds. The first, a Hi-Fi location consisting of a natural environment, was composed based on soundwalk recordings from Kitsilano Park, Stanley Park, and Lighthouse Park.
A control group recording was composed based on sounds edited from recordings of clinics and hospitals. Due to privacy and ethical reasons, the recording of sounds from the location of the study was prohibited. Due to time constraints, I made the decision to use recordings from the Park and Market instead of the downtown recording since the recording of the Market was also Lo-Fi and, most importantly, it includes a transition from indoor to an outdoor environment, which may be experientially more interesting for the patients.
Experiment
For this study, 30 patients from the Vancouver Arthritis Research Centre (ARC) were recruited to participate in this study. Consent forms from patients, doctors, and (ARC) were obtained for completing this study. The experiment consists of three phases of testing: (1) a background anxiety-screening questionnaire phase, (2) a testing phase, and (3) a feedback phase.
Prior to the listening phase, 41% of the patients reported experiencing anxiety, which included feelings like irritability and worries, and 47% felt tension. Furthermore, 23% of the patients had prescriptions for anxiety medication. Post listening phase, patients experienced a decrease in anxiety levels. In addition, patients who listened to soundscape recordings of the park revealed the most significant reduction in anxiety levels when compared to the patients who listened to recordings of the market or the control group. Based on the feedback from the doctor, the patients seemed to clearly communicate their symptoms, and 68% of the patients felt completely relaxed during the consultation. Comments from the patients also provided insights into how they felt listening back to the different soundscape recordings.
Comments based on Location A: Park
“Foot-steps walking behind me, like someone was coming up on me”
“Felt like I was down by the beach enjoying it”
“Walking on the stones, a little annoying”
“Calm, waves always are relaxing to me”
“Pleasant, relaxation being close to nature”
“Like I am out for a walk”
“Walking along a beach with the water slapping at the shore wild birds calling”
Comments based on Location C: Market
“People sounds, I do not like being around places where people congregate. All I want to do is go home. I live in the country”
“It seemed to be difficult to comprehend”
“Mad. Noise made me mad”
Comments based from Control Group
“Baby crying, loud noises”
“Agitated”
“The sound of a loud ventilation system was annoying. Also conversations I couldn't quite hear were uncomfortable”
Comments based on experiences of physical sensation while listening to the recordings
Location A: Park
“Relaxed and sleepy”
“Relaxation of muscle”
“A little anxiety (maybe) when it felt like someone walking behind me.”
Location C: Market
“Heart beat faster”
“It seemed to be useless sounds that urges to shut it off may have been more or better use of my time!”
“Tension in the neck and shoulders”
Conclusion
The responses from the recordings varied drastically. It was clear that the soundscape recording of the Park had the most positive psychological impact on the patients, while the recording of the Market and the control group recording agitated the patients. Despite our careful composing of the soundscapes, we discovered some factors that can help improve the experience for patients. The most surprising element was that the sound of walking itself brought about fear and anxiety in some patients. The duration of the compositions was optimal, at 5 minutes per recording. Editing more dynamic changes in location might also serve to keep the listeners more attentive to the composition. Despite some of the challenges faced during the development of this study, the experiment shows the potential for using soundscapes as a distraction mechanism to help patients manage anxiety during their visit at clinics.
Future Work
Based on the results from this first iteration of the study, I plan to record new soundwalks which I hope will increase the level of immersion experienced by the patients. One approach that I plan to experiment with is recording transitions of spaces. For example, moving from indoors to outdoors, or from a busy urban area to a quiet park. The recordings will then be edited into soundscape compositions. Participants will be recruited to randomly listen to each recording and rate its affective capacities, such as in evoking emotional responses, imagery, physical sensation, as well as the level of immersion experienced.
Three types of soundscapes will be investigated:
- A soundwalk recording based on movement through a single location.
- A transitional soundscape recording in which two recordings of soundwalks from various locations will follow one another.
- A soundwalk based on an unfamiliar environment recorded in a foreign country.
The second part of the study is a quantitative assessment, which will be conducted at two locations: a chronic pain clinic and St. Paul’s Hospital, both located in Vancouver. The most appropriate, based on data captured from the first phase of this study, soundscape composition will be used to assess if a change in anxiety occurs in patients waiting in the clinical environment. Participants will be randomly assigned to three groups: (Group A) listening to soundwalk through headphones, (Group B) listening to a live audio feed of the clinic through headphones, and (Group C) waiting with no headphones. The reason for two control groups is to look for any changes in anxiety that may be caused by simply wearing headphones.
Acknowledgments
I would like to thank Tyler Kinnear and Maryam Mobini for their early contributions to my research. A thank you, also, to Barry Truax for an inspiring course that brought focus to my research.
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