5 Design study I: How to create an ambulatory app for patients with BPP 175 data should be manually operated and remain under control of the patient. But then again, therapists desire supervisory control over the e-coach. One solution in which both needs are met is to leave control over data-sharing with the patient and to implement a function for therapists to activate and deactivate the account of a patient. Both groups suggested to let the e-coach adopt terminology and metaphors used in therapy when communicating (emotional) arousal. This was perceived as a need to be able to intuitively understand how to work with the e-coach. For the patients and therapists in our design study, which were all in treatment or working in the same treatment center, the shared terminology addresses emotional arousal in terms of a five-stage process in which ‘water in a saucepan on a stove’ gradually starts to boil and eventually boils over. This terminology stems from a specific training called the ‘Systems Training for Emotional Predictability and Problem Solving’ (STEPPS; in Dutch: VERS, or ‘Vaardigheidstraining Emotie-Regulatie Stoornis’) [9]. Both target groups suggested to implement the ‘saucepans’ in the e-coach to report on the current level of arousal. Although this suggestion seemed sensible at first, it was decided not to turn it into a design element: the future e-coaching application does not display a direct measure of emotional arousal but a processed physiological measure that serves as a proxy of emotional arousal. Adopting the metaphor of the saucepans in the e-coach could cause patients to mistake these physiological measures for their psychological emotional arousal. Also, incorporating the terminology from the STEPPS into the e-coach would limit its compatibility with other theoretic frameworks and thus employability in the field. To meet the requirement of the terminology used in therapy, the physiological data on arousal is to be presented neutral, but still compatible with the theoretical framework(s) used. As other centers, mental health professionals and/or patients may use other methods and terminology to address emotional arousal, we think an easy-to-interpret ordinal rating scale (such as a 5-point or 10-point scale or a scale using percentages) rating scale to visualize the arousal level of emotions is suitable: it is not only compatible with the specific theoretical framework of the contacted user groups, but it is actually also very common in cognitive behavior therapy (CBT), which is the most common form of psychotherapy nowadays. Patients also expressed a desire for the e-coach to have a function that enables users to insert personal emotion regulation strategies, next to a function that enables them to enable predetermined strategies used in therapy. These strategies should be presented at certain levels of identified emotional arousal set by the patient user. The system should offer a set of potential emotion regulating strategies but let the user decide what to do or not do. Low levels of automation are desirable for a system
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