Diversity, equity, and inclusivity in observational ambulatory assessment: Recommendations from two decades of Electronically Activated Recorder (EAR) research.

Ambient audio sampling methods such as the Electronically Activated Recorder (EAR) have become increasingly prominent in clinical and social sciences research. These methods record snippets of naturalistically assessed audio from participants' daily lives, enabling novel observational research about the daily social interactions, identities, environments, behaviors, and speech of populations of interest. In practice, these scientific opportunities are equaled by methodological challenges: researchers' own cultural backgrounds and identities can easily and unknowingly permeate the collection, coding, analysis, and interpretation of social data from daily life. Ambient audio sampling poses unique and significant challenges to cultural humility, diversity, equity, and inclusivity (DEI) in scientific research that require systematized attention. Motivated by this observation, an international consortium of 21 researchers who have used ambient audio sampling methodologies created a workgroup with the aim of improving upon existing published guidelines. We pooled formally and informally documented challenges pertaining to DEI in ambient audio sampling from our collective experience on 40+ studies (most of which used the EAR app) in clinical and healthy populations ranging from children to older adults. This article presents our resultant recommendations and argues for the incorporation of community-engaged research methods in observational ambulatory assessment designs looking forward. We provide concrete recommendations across each stage typical of an ambient audio sampling study (recruiting and enrolling participants, developing coding systems, training coders, handling multi-linguistic participants, data analysis and interpretation, and dissemination of results) as well as guiding questions that can be used to adapt these recommendations to project-specific constraints and needs.

Personalizing interventions using real-world interactions: Improving symptoms and social functioning in schizophrenia with tailored metacognitive therapy.

OBJECTIVE: When clients' lives are not reflected in therapy, they struggle to apply the skills learned in treatment to everyday situations. In this pilot study, we determined if using clients' real-world interactions in therapy could effectively target metacognitive capacity-yielding improved symptoms and social functioning-by tailoring treatment to focus on issues faced by clients in daily life. METHOD: Using a randomized controlled trial design, schizophrenia subjects with metacognitive deficits completed 24 sessions of: (a) Standard Metacognitive Reflection and Insight Therapy (MERIT); or (b) Tailored MERIT. Real-world interactions were captured via the Electronically Activated Recorder (EAR), a smartphone application that passively records audio in daily life. All subjects wore the EAR; however, real-world interactions were only used to personalize sessions in Tailored MERIT. RESULTS: Feasibility and acceptability were shown; those in Tailored MERIT wore the EAR 84% of their waking hours and reported minimal burden. When compared to Standard MERIT, Tailored MERIT participants showed large pre-post reductions in negative metacognitive beliefs and disorganized symptoms. Small, but nonsignificant, improvements in social functioning were also observed. CONCLUSIONS: Compared to an evidence-based benchmark, we observed that real-world interactions can be used to tailor metacognitive therapy and improve outcomes in schizophrenia. Tailored MERIT has the potential to impact practice by personalizing treatment to account for individual variations in environment and lifestyle-aligning with the Precision Medicine Initiative-in a way that is not possible with current therapy. This is particularly salient in schizophrenia, where limited insight and cognitive deficits often make subjective reporting unreliable. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A new approach to capturing pain disclosure in daily life in-person and online.

This feasibility study employed a new approach to capturing pain disclosure in face-to-face and online interactions, using a newly developed tool. In Study 1, 13 rheumatoid arthritis and 52 breast cancer patients wore the Electronically Activated Recorder to acoustically sample participants' natural conversations. Study 2 obtained data from two publicly available online social networks: fibromyalgia (343,439 posts) and rheumatoid arthritis (12,430 posts). Pain disclosure, versus non-pain disclosure, posts had a greater number of replies, and greater engagement indexed by language style matching. These studies yielded novel, multimethod evidence of how pain disclosure unfolds in naturally occurring social contexts in everyday life.

Social functioning in schizotypy: How affect influences social behavior in daily life.

OBJECTIVE: Social deficits are already exhibited by people at risk for schizophrenia-spectrum disorders. Technological advances have made passive detection of social deficits possible at granular levels. METHOD: In this real-world study, we tested if schizotypy status (high/low) predicted two types of social behavior: (1) being around other people; and (2) actively socializing with others. We also examined if schizotypy influences relationships between social behavior and affect using subjective and objective instruments. RESULTS: Our findings revealed that socializing with others was significantly decreased in the high schizotypy group. Positive affect increased in social situations and predicted later social behavior in those low, but not high, in schizotypy. CONCLUSION: Decreased social behavior in schizotypy may be explained, in part, by these individuals being less incentivized than their peers to pursue social situations. Future studies should test this explanation in larger samples exhibiting elevated positive, negative, and disorganized schizotypy traits.

Real-Life Language Use Across Different Interlocutors: A Naturalistic Observation Study of Adults Varying in Age.

Amid the growing interest in studying language use in real life, this study, for the first time, examined age effects on real-life language use, as well as within-person variations across different interlocutors. We examined speech samples collected via the Electronically Activated Recorder (i.e., portable audio recorder that periodically records ambient sounds) for a larger project. This existing dataset included more than 18,000 sound snippets (50-s long) from 53 American couples (breast cancer patients and their spouses; aged 24 to 94 years) in their natural environments. Sound snippets that included participant speech were coded for different interlocutors and given scores on three linguistic measures that are associated with age-related cognitive changes: usage of unique words, usage of uncommon words, and grammatical complexity. Multilevel models showed that there were no age effects on the three linguistic measures when interlocutors were not taken into account. We found that interlocutors influenced usage of unique words and grammatical complexity. More specifically, compared to talking with their spouse, participants used fewer unique words with children and friends; and used simpler grammatical structures with children, strangers, and in multiparty conversations. Next, we found that interlocutors influenced the associations between age and language use. More specifically, young adults used more unique words and more uncommon words with children than older adults. They used more uncommon words with friends and uttered more complex grammatical structures with strangers than older adults. Our results offer preliminary evidence for a new perspective to understand real-life language use: focusing not only on individual characteristics (i.e., age), but also context (i.e., interlocutors). This perspective should be useful to researchers who are interested in collecting "big data" and understanding cognitive activities in real life.

Interpersonal positive reframing in the daily lives of couples coping with breast cancer.

OBJECTIVES: This study examined word use as an indicator of interpersonal positive reframing in daily conversations of couples coping with breast cancer and as a predictor of stress. DESIGN: The Electronically Activated Recorder (EAR) and Linguistic Inquiry and Word Count (LIWC) were used to examine naturally occurring word use conceptually linked to positive reframing (positive emotion, negative emotion, and cognitive processing words). SAMPLE: Fifty-two couples coping with breast cancer. METHODS: Couples wore the EAR, a device participants wear, that audio-recorded over one weekend (>16,000 sound files), and completed self-reports of positive reframing (COPE) and stress (Perceived Stress Scale). LIWC, a software program, measured word use. FINDINGS: Both partners' word use (i.e., positive emotion and cognitive processing words) was associated with their own reported positive reframing, and spouses' word use was also indicative of patients' positive reframing. Results also revealed that, in general, words indicating positive reframing predicted lower levels of stress. CONCLUSIONS: Findings supported the hypothesis that partners-and particularly spouses of breast cancer patients-may assist each other's coping by positively reframing the cancer experience and other negative experiences in conversation.

Too (Psychologically) Close for Comfort? Comparing Verbal Immediacy among Adult Children of Alcoholics (ACOAs) and Non-ACOAs.

BACKGROUND: Adult Children of Alcoholics (ACOAs) have shown poorer psychosocial outcomes compared to their counterparts (non-ACOAs). These poorer outcomes, however, are not consistently present between groups. Investigating psychological markers of such functioning can help to highlight nuances between ACOAs and non-ACOAs even when mean differences of psychosocial outcomes are not present. This is pertinent to the study of ACOAs to understand predictors of positive well-being trajectories. OBJECTIVE: The aim of the present study was to compare the linguistic content of ACOAs and non-ACOAs in relation to psychological functioning. METHOD: A quasi-experimental design was employed; ACOAs (n = 53) and non-ACOAs (n = 80) were asked to write a significant memory in which they went through a change of some kind (i.e., turning point) regarding a parent. Participants were then asked to complete measures of psychological functioning. Using a word counting software, we identified verbal immediacy, a combination of words signifying psychological closeness, within participants' memories. RESULTS: Results indicated no mean differences in the amount of verbal immediacy amid ACOAs and non-ACOAs, but there were differences in its predictive ability between groups. Among ACOAs, verbal immediacy predicted better psychological functioning. Yet, there was no association found among non-ACOAs. Conclusions/Importance: These results show that psychological closeness, among ACOAs, is indicative of better psychological functioning, even though it is typically associated with worse outcomes. This suggests that vulnerable individuals may have nontraditional correlates between psychological markers, like verbal immediacy, and such functioning and should be assessed when comparing these populations.

Naturalistically observing noncancer conversations among couples coping with breast cancer.

OBJECTIVE: This study revealed the landscape of noncancer conversations, identifying topics and types of everyday conversation, and examined links to psychological adjustment among couples coping with breast cancer. METHODS: Fifty-two couples wore the Electronically Activated Recorder (EAR) over 1 weekend and self-reported psychological adjustment while patients were on treatment. The EAR sampled 50 s of ambient sound every 9 minutes to estimate the frequency of noncancer conversation and reveal topics and types of conversation. RESULTS: Analyses revealed noncancer conversations comprised over 93% of conversations. The most common topic discussed was people. Substantive conversation was associated with better, while emotional disclosure was associated with worse, well-being for patients, but not spouses. CONCLUSIONS: Results revealed that ordinary conversations are frequent among couples who face breast cancer, and they are associated with patients' psychological adjustment, providing a foundation for potential interventions for coping with cancer that do not focus on illness.

Words matter: Implementing the electronically activated recorder in schizotypy.

In schizophrenia-spectrum populations, analyzing the words people use has offered promise for unlocking information about affective states and social behaviors. The electronically activated recorder (EAR) is an application-based program that is combined with widely used smartphone technology to capture a person's real-world interactions via audio recordings. It improves on the ecological validity of current methodologies by providing objective and naturalistic samples of behavior. This study is the first to implement the EAR in people endorsing elevated traits of schizophrenia-spectrum personality disorders (i.e., schizotypy), and we expected the EAR to (a) differentiate high and low schizotypy groups on affective disturbances and social engagement and (b) show that high schizotypy status moderates links between affect and social behavior using a multimethod approach. Lexical analysis of EAR recordings revealed greater negative affect and decreased social engagement in those high in schizotypy. When assessing specific traits, EAR and ecological momentary assessment (EMA) converged to show that positive schizotypy predicted negative affect. Finally, high schizotypy status moderated links between negative affect and social engagement when the EAR was combined with EMA. Adherence did not influence results, as both groups wore the EAR more than 90% of their waking hours. Findings supported using the EAR to assess real-world expressions of personality and functioning in schizotypy. Evidence also showed that the EAR can be used alongside EMA to provide a mixed-method, real-world assessment that is high in ecological validity and offers a window into the daily lives of those with elevated traits of schizophrenia-spectrum personality disorders. (PsycINFO Database Record

New Evaluation of the Electronically Activated Recorder (EAR): Obtrusiveness, Compliance, and Participant Self-selection Effects.

The Electronically Activated Recorder (EAR) is a method for collecting periodic brief audio snippets of participants' daily lives using a portable recording device. The EAR can potentially intrude into people's privacy, alter their natural behavior, and introduce self-selection biases greater than in other types of social science methods. Previous research (Mehl and Holleran, 2007, hereafter M&H) has shown that participant non-compliance with, and perceived obtrusiveness of, an EAR protocol are both low. However, these questions have not been addressed in jurisdictions that require the consent of all parties to recording conversations. This EAR study required participants to wear a button bearing a microphone icon and the words "This conversation may be recorded" to comply with California's all-party consent law. Results revealed self-reported obtrusiveness and non-compliance were actually lower in the present study than in the M&H study. Behaviorally assessed non-compliance did not differ between the two studies. Participants in the present study talked more about being in the study than participants in the M&H study, but such talk still comprised <2% of sampled conversations. Another potential problem with the EAR, participant self-selection bias, was addressed by comparing the EAR volunteers' HEXACO personality dimensions to a non-volunteer sample drawn from the same student population. EAR volunteers were significantly and moderately higher in Conscientiousness, and lower in Emotionality, than non-volunteers. In conclusion, the EAR method can be successfully implemented in at least one all-party consent state (California). Interested researchers are encouraged to review this procedure with their own legal counsel.

Whole-Body Hyperthermia for the Treatment of Major Depressive Disorder: A Randomized Clinical Trial.

IMPORTANCE: Limitations of current antidepressants highlight the need to identify novel treatments for major depressive disorder. A prior open trial found that a single session of whole-body hyperthermia (WBH) reduced depressive symptoms; however, the lack of a placebo control raises the possibility that the observed antidepressant effects resulted not from hyperthermia per se, but from nonspecific aspects of the intervention. OBJECTIVE: To test whether WBH has specific antidepressant effects when compared with a sham condition and to evaluate the persistence of the antidepressant effects of a single treatment. DESIGN, SETTING, AND PARTICIPANTS: A 6-week, randomized, double-blind study conducted between February 2013 and May 2015 at a university-based medical center comparing WBH with a sham condition. All research staff conducting screening and outcome procedures were blinded to randomization status. Of 338 individuals screened, 34 were randomized, 30 received a study intervention, and 29 provided at least 1 postintervention assessment and were included in a modified intent-to-treat efficacy analysis. Participants were medically healthy, aged 18 to 65 years, met criteria for major depressive disorder, were free of psychotropic medication use, and had a baseline 17-item Hamilton Depression Rating Scale score of 16 or greater. INTERVENTIONS: A single session of active WBH vs a sham condition matched for length of WBH that mimicked all aspects of WBH except intense heat. MAIN OUTCOMES AND MEASURES: Between-group differences in postintervention Hamilton Depression Rating Scale scores. RESULTS: The mean (SD) age was 36.7 (15.2) years in the WBH group and 41.47 (12.54) years in the sham group. Immediately following the intervention, 10 participants (71.4%) randomized to sham treatment believed they had received WBH compared with 15 (93.8%) randomized to WBH. When compared with the sham group, the active WBH group showed significantly reduced Hamilton Depression Rating Scale scores across the 6-week postintervention study period (WBH vs sham; week 1: -6.53, 95% CI, -9.90 to -3.16, P < .001; week 2: -6.35, 95% CI, -9.95 to -2.74, P = .001; week 4: -4.50, 95% CI, -8.17 to -0.84, P = .02; and week 6: -4.27, 95% CI, -7.94 to -0.61, P = .02). These outcomes remained significant after evaluating potential moderating effects of between-group differences in baseline expectancy scores. Adverse events in both groups were generally mild. CONCLUSIONS AND RELEVANCE: Whole-body hyperthermia holds promise as a safe, rapid-acting, antidepressant modality with a prolonged therapeutic benefit. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01625546.

Waiting for a baby: Navigating uncertainty in recollections of trying to conceive.

OBJECTIVE: Guided by the uncertainty navigation model, this study examined experiences of uncertainty associated with trying to conceive and identified predictors of this experience using a multi-method approach. METHOD: 429 American adults from Amazon's Mechanical Turk who had a child under age three completed online questionnaires regarding their experiences trying to conceive, including recollections of psychological adjustment, use of coping strategies, and individual and situational variability. Then they provided open-ended reflections of their experience trying to conceive. Participants' descriptions were analyzed for word use using LIWC, a text-analysis software program, to obtain an unobtrusive and pseudo-observational measure of coping resources. RESULTS: Consistent with the uncertainty navigation model, recollections of distress as individuals tried to conceive were associated with lower levels of dispositional optimism; intolerance of uncertainty; fewer social, emotional, and cognitive resources (reflected in word use); placing greater importance on conception; lower risk for infertility; and less searching for meaning in life. CONCLUSIONS: This study revealed many novel insights regarding the experience of trying to conceive, including protective factors and vulnerabilities that may buffer or heighten the distress associated with this experience.

Cancer conversations in context: naturalistic observation of couples coping with breast cancer.

This study explored the feasibility and potentials of a naturalistic observation approach to studying dyadic coping in everyday life. Specifically, it examined the natural context and content of the spontaneous cancer conversations of couples coping with cancer, and how they relate to patients' and spouses' psychological adjustment. Women with breast cancer (N = 56) and their spouses wore the electronically activated recorder (EAR), an unobtrusive observation method that periodically records snippets of ambient sounds, over one weekend to observe the couples' cancer conversations in their natural context. Both patients and spouses completed self-reported measures of psychological adjustment at baseline and at a 2-month follow-up. Cancer was a topic of approximately 5% of couples' conversations. Cancer conversations occurred more often within the couple than with friends and family, and they were more often informational than emotional or supportive. Consistent with research on the social cognitive processing model (Lepore & Revenson, 2007), spouses' engagement in emotional disclosure and informational conversation with patients predicted better patient adjustment. This first naturalistic observation study of dyadic coping revealed that the EAR method can be implemented with high compliance and relatively low obtrusiveness within the sensitive context of couples coping with cancer, and having a spouse who discussed cancer in an emotional or informational way predicted better patient adjustment. As a complement to in-lab and other momentary assessment methods, a naturalistic observation approach with a method such as the EAR can contribute to a more comprehensive understanding of the role that communication processes play in coping with cancer.

Linguistic indicators of patient, couple, and family adjustment following breast cancer.

BACKGROUND: This study examined how language reflective of emotional and social processes during a cancer-related discussion relates to patient, couple, and family adjustment after breast cancer. It investigated whether emotional expression or relational focus, manifested in language use, indicates healthy family coping following breast cancer. METHODS: Family members each completed measures of adjustment (Family Environment Scale, Dyadic Adjustment Scale, and patient Profile of Mood States) and engaged in a 15-min family discussion about how they have coped with breast cancer. Transcripts from the discussion were submitted to a text-analysis software program to obtain frequency of positive and negative emotion words, and personal pronouns spoken by each family member. The relationship between self-reports of adjustment and frequency of language use during the family discussion was analyzed with regression models. RESULTS: Partners' positive emotion words were indicative of better family adjustment, patients' negative emotion words indicated greater family conflict, and sons' and daughters' anger words indicated poorer adjustment, whereas their anxiety words indicated better family adjustment. Partner we-talk was related to better dyadic adjustment, and couples' 'you' was somewhat related to worse adjustment at all levels. CONCLUSIONS: Important information about how a family copes with breast cancer can be obtained by attending to families' emotional and relational language. This study suggests that clinicians and members of families' support networks can gauge how well a family has adapted after the breast cancer experience by attending to the type of words that each family member uses to describe how they coped with breast cancer.

Naturalistic observation of health-relevant social processes: the electronically activated recorder methodology in psychosomatics.

This article introduces a novel observational ambulatory monitoring method called the electronically activated recorder (EAR). The EAR is a digital audio recorder that runs on a handheld computer and periodically and unobtrusively records snippets of ambient sounds from participants' momentary environments. In tracking moment-to-moment ambient sounds, it yields acoustic logs of people's days as they naturally unfold. In sampling only a fraction of the time, it protects participants' privacy and makes large observational studies feasible. As a naturalistic observation method, it provides an observer's account of daily life and is optimized for the objective assessment of audible aspects of social environments, behaviors, and interactions (e.g., habitual preferences for social settings, idiosyncratic interaction styles, subtle emotional expressions). This article discusses the EAR method conceptually and methodologically, reviews prior research with it, and identifies three concrete ways in which it can enrich psychosomatic research. Specifically, it can (a) calibrate psychosocial effects on health against frequencies of real-world behavior; (b) provide ecological observational measures of health-related social processes that are independent of self-report; and (c) help with the assessment of subtle and habitual social behaviors that evade self-report but have important health implications. An important avenue for future research lies in merging traditional self-report-based ambulatory monitoring methods with observational approaches such as the EAR to allow for the simultaneous yet methodologically independent assessment of inner, experiential aspects (e.g., loneliness) and outer, observable aspects (e.g., social isolation) of real-world social processes to reveal their unique effects on health.

Naturalistically observed swearing, emotional support, and depressive symptoms in women coping with illness.

OBJECTIVE: The goal of this study was to explore the intra- and interpersonal consequences of swearing. Specifically, it investigated what implications swearing has for coping with and adjustment to illness. METHODS: The present project combined data from two pilot studies of 13 women with rheumatoid arthritis and 21 women with breast cancer. Participants wore the Electronically Activated Recorder, an unobtrusive observation sampling method that periodically records snippets of ambient sounds, on weekends to track spontaneous swearing in their daily interactions, and completed self-reported measures of depressive symptoms and emotional support. RESULTS: Naturalistically observed swearing in the presence of others, but not alone, was related to decreases in reported emotional support and increases in depressive symptoms over the study period. Further, decreases in emotional support mediated the effect of swearing on disease-severity adjusted changes in depressive symptoms. CONCLUSION: These exploratory results are consistent with the notion that swearing can sometimes repel emotional support at the expense of psychological adjustment. This is one of the first studies to examine the role of swearing, a ubiquitous but understudied psychological phenomenon, in a medical context.

Naturalistically observed sighing and depression in rheumatoid arthritis patients: a preliminary study.

OBJECTIVE: This study tested the degree to which naturalistically observed sighing in daily life is a behavioral indicator of depression and reported physical symptoms (i.e., experienced pain and flare days) in rheumatoid arthritis (RA) patients. DESIGN: Thirteen RA patients wore the Electronically Activated Recorder (EAR), an observational ambulatory assessment tool, for two weekends (Friday through Sunday) approximately one month apart. The EAR periodically recorded snippets of ambient sounds from participants' momentary environments (50 s every 18 min). Sighs were coded from the sampled ambient sounds. MAIN OUTCOME MEASURES: Depression was assessed with the Center for Epidemiological Studies Depression Scale and the Beck Depression Inventory. Pain during the past month was assessed with a 10-cm visual-analog scale, and number of flare days during the prior 6 months was reported. RESULTS: Sighing was significantly and strongly related to patients' levels of depression and nonsignificantly and less strongly related to their reported pain and number of flare days. CONCLUSION: The findings suggest that sighing can serve as an observable marker of depression in RA patients. Because the sample size was small, the findings should be considered preliminary.