Integrating Empathy and Lived Experience through Co-Creation in Service Design

Abstract

While empathy is often hailed as a central aspect of service design, there is a growing acknowledgement of the risks associated with an over-reliance on empathy in design processes. As such, there is increasing recognition of the need to integrate lived experience-the direct, first-hand perception of a relevant situation, condition, or identity in an everyday context. This paper reviews existing literature related to empathy and lived experience in co-creation, with particular attention to the associated risks of amplifying one over the other. From this literature, we highlight two different manifestations of the relationship between empathy and lived experience: "I-It" and "I-Thou". We build an understanding of the interdependence of empathy and lived experience and argue for an integration of both to enable reciprocal co-creation. To advance the existing discussion, we highlight a number of important directions for future research in this area.

Full text

ServDes2018 - Service Design Proof of Concept
Politecnico di Milano
18th-19th-20th, June 2018
Integrating empathy and lived experience
through co-creation in service design
Josina Vink, CTF - Service Research Center, Karlstad University, Karlstad, Sweden and
Experio Lab, County Council of Värmland, Karlstad, Sweden
josina.vink@kau.se
Anna-Sophie Oertzen, Department of Marketing and Supply Chain Management, Maastricht
University, the Netherlands and KISD, Technical University of Applied Sciences Cologne,
Cologne, Germany
Abstract
While empathy is often hailed as a central aspect of service design, there is a growing
acknowledgement of the risks associated with an over-reliance on empathy in design
processes. As such, there is increasing recognition of the need to integrate lived experience—
the direct, first-hand perception of a relevant situation, condition, or identity in an everyday
context. This paper reviews existing literature related to empathy and lived experience in co-
creation, with particular attention to the associated risks of amplifying one over the other.
From this literature, we highlight two different manifestations of the relationship between
empathy and lived experience: “I—It” and “I—Thou”. We build an understanding of the
interdependence of empathy and lived experience and argue for an integration of both to
enable reciprocal co-creation. To advance the existing discussion, we highlight a number of
important directions for future research in this area.
KEYWORDS: empathy, lived experience, co-creation, service design
Introduction
Empathy is repeatedly stressed as a central and distinguishing factor in design, especially in
service design (Koskinen et al., 2003; New & Kimbell, 2013). It is typically described as
understanding what it feels like to be another person or to walk in someone else’s shoes
(Kouprie & Sleeswijk Visser, 2009; Wright & McCarthy, 2008). Over the years, a variety of
design methods have been developed and employed to elicit empathy including:
bodystorming (Burns et al., 1994), observation (Leonard & Rayport, 1997), experience
prototyping (Buchenau & Suri, 2000), design probes (Mattelmäki, 2006), role playing games
(Kaario et al., 2009), and service walkthroughs (Blomkvist & Bode, 2012). While empathy in
the service design process has commonly been perceived as having positive effects, such as

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
472
supporting a creative understanding (Postma et al., 2012), critics have recently highlighted its
dark side by suggesting that an over-reliance on empathy can promote single-mindedness, a
present-day orientation, reinforce otherness, enhance exclusion, and ironically support
designers to design for people like themselves (Abbott, 2017; Holt, 2011; Meill, 2015; Staffer,
2015; Wendt, 2017). As such, too much emphasis on empathy can contribute to controlling
and disciplining the interpretation of human experiences, further reinforcing the practices of
colonization in design (Tlostanova, 2017).
One response to the over-emphasis on empathy is to leverage lived experience in service
design processes through co-design, participatory design, or user-led design (Couvreur et al.,
2013; Holmlid, 2009; Sanders & Stappers, 2008; Steen et al., 2011; Trischler & Scott, 2014;
Trischler et al., 2017). We define lived experience as direct, first-hand perception of a
relevant situation, condition, or identity in an everyday context. While there has been
significant attention paid to empathy within design literature, there has been little research on
the nuances of lived experience or how to effectively integrate empathy and lived experience
in co-creation (Cipolla & Bartholo, 2014). As highlighted by Smeenk and colleagues (2016,
p.31): “the specific utility, and legitimacy, validity of this first-person perspective in design is
currently not sufficiently understood and recognized […] a better understanding of the
relative value of the first-person perspective compared to—and combined with—other
fundamental perspectives […] can contribute to enrich and develop design methodologies.”
This paper focuses on integrating empathy and lived experience for co-creation in service
design. For the purpose of this paper, we define co-creation as collaborative activities
between two or more actors. Traditionally, most research in service design has accentuated
the beneficial nature of co-creation: it fosters the fit between services and its users (Holliday
et al., 2014; Hussain et al., 2012); leverages a mutual understanding between involved actors
(Akama, 2014; Fjuk et al., 2016; Følstad et al., 2014); and supports the development of new
and existing services (Aro et al., 2012; Holliday et al., 2014; Kronqvist and Korhonen, 2009).
However, a growing body of literature suggests that co-creation can actually be a ‘double-
edged sword’ (Chan et al., 2010; Dong et al., 2015, Piller et al., 2011; Xu et al., 2014) due to
several associated risks, such as participants not having an equal voice in co-creation efforts
(Näkki, 2012) and concerns about the sustainability of ideas (Akama, 2014). Extant research
insinuates that a pressing risk in many co-creation efforts is that the scope and value of
innovations may be biased towards the designer, as the designer often takes on the dominant
role in the co-creation process (Takeyama et al., 2012). Although there is some
acknowledgement of the risks inherent in co-creation, more research is needed on these
pitfalls as current literature predominantly focuses only on the positive aspects (Dong et al.,
2015; Mustak et al., 2013, 2016).
In this vein, the current paper specifically reviews existing literature related to empathy and
lived experience for co-creation in service design, with particular attention to the associated
risks of amplifying one over the other. A focused literature review was conducted by
manually scanning abstracts for relevance to empathy, lived experience, and co-creation in
previous ServDes proceedings and the International Journal of Design as well as through a general
search of design and service research outlets. In addition, opinion pieces from popular
discourse, such as blog posts, were added to capture the evolving public sentiment regarding
empathy and lived experience. To illustrate issues brought forward through the literature, we
draw on short examples of activities within service design processes supported by Experio
Lab, a group that uses a service design approach to foster co-creation within the healthcare
system in Sweden. The examples presented here were gathered through ethnographic
research, which involved observation, interviews, and a review of archival data related to
Experio Lab’s work. In doing so, this paper contributes to service design literature by: 1)
synthesizing the documented risks of co-creation caused by a dominant focus on empathy or
lived experience; 2) detailing the different manifestations of the relationship between
empathy and lived experience in service design; and 3) highlighting the interdependence of
these processes for reciprocal co-creation.

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
473
The Over-Emphasis on Empathy
Within design literature, and more specifically service design studies, there has been a
growing body of research on empathic design focusing on how designers attempt to get
closer to the lives and experiences of users (Koskinen et al., 2003; Leonard & Rayport, 1997;
Mattelmäki et al., 2014; Postma et al., 2012). Empathic design aims to move beyond a
consideration of rational and practical issues to the experiences and contexts of users,
typically to inform new product and service development (Mattelmäki & Battarbee, 2002;
Postma et al., 2012). The conceptualization of empathy in design has been informed by a
variety of perspectives. Drawing on social theory, Wright and McCarthy (2008) highlight that
empathy involves both perceiving the emotion of another as well as articulating the other’s
context within one’s own. Similarly, inspired by psychology, Kouprie and Sleeswijk Visser
(2009) highlight two common dimensions of empathy: 1) the affective dimension associated
with emotions and feelings and 2) the cognitive dimension focused on understanding and
perspective.
In service design, a variety of methods have been introduced to help facilitate empathic
engagement with a user’s experience of a service (Stickdorn & Schneider, 2011). One such
example are service walkthroughs, which aid actors in understanding service in a holistic way,
focused on the experience of customers and other stakeholders, by enacting and walking
through the process of a service (Blomkvist & Bode, 2012). Other common approaches
include the use of empathy tools (Hoss & Roopani, n.d.), which involve working with
physical objects or social techniques to get a sense of what users feel in their everyday life,
and empathy maps, which help to visualize the multi-sensual experience of actors (Gray et
al., 2010). However, when actors simulate the experience of others, without having lived
experience themselves, their experience remains one of novelty and they cannot fully
understand what it feels like for someone who lives this experience (Abbott, 2017). Through
the use of these empathic methods, actors can end up projecting their own assumptions on
to the experiences of others and falsely rationalizing design directions (Meill, 2015; Staffer,
2015; Wendt, 2017).
To put this in context, Figure 1 illustrates examples of the use of empathy tools and empathy
maps at Experio Lab. Within the context of Experio Lab’s work, empathy tools are often
used to help healthcare staff take on the role of the patient and build their understanding of
different perspectives. In the photograph on the left, a healthcare leader is putting on an
‘aging suit’ to simulate what it feels like being 30 years older while moving around the
hospital. Here the actor wearing the suit makes assumptions based a short-term simulated
experience about what it might feel like to move through the hospital for seniors.
Furthermore, empathy maps are often used to detail the experience of patients and stimulate
a dialogue about their underlying emotions and motivations. In the photo on the right,
designers are working with healthcare staff to brainstorm about what their patients might be
thinking, feeling, saying, and doing in relation to their service. However, completing empathy
maps without intentional interaction and input from patients may simply reflect staff’s own
interpretations of the patient experience, clouded by their own role, identity, and
experiences.

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
474
Figure 1: The use of empathy tools and empathy maps at Experio Lab
When these empathic methods are employed without the participation of those with lived
experience or a critical dialogue with them to unpack the limitations, these methods can
contribute to replicating colonial practices in service design. By colonial, we refer to the
process of European political domination that involves ‘othering’ and undermining the self-
definition of people (Tunstall, 2013). Decolonizing service design practice and research
requires an understanding of the locations and bodies related amid complex power dynamics
(Schultz et al., 2018). As such, we must acknowledge that empathic methods can often create
a semblance of participation and end up becoming tools for the coloniality of design
(Tlostanova, 2017). When actors objectify those that they are designing for by assuming that
they know them and can understand them through their own actions, they engage in what
Cipolla and Bartholo (2014, drawing on Buber, 1921/1996) refer to as “I—It” relationships.
The authors highlight the need to move toward reciprocity in co-creation for more socially
responsible service design practices. One way to do this is by leveraging lived experiences in
co-creation.
Leveraging Lived Experience
Although there has been some recognition of the need to engage users to cross-validate
insights (Buchenau & Suri, 2000) or provide expertise throughout the design process
(Wetter-Edman, 2012), the role of lived experience in co-creation has not received much
attention within the service design literature to date. There are, however, some methods
associated with engaging actors with lived experience, such as: auto-ethnography (Curedale,
2013), co-creation workshops (Stickdorn & Schneider, 2011; Westerlund et al., 2003), and
prototyping with users (Sanders & Stappers, 2014). While the body of knowledge on lived
experience remains in its infancy, there has been a growing movement in service design to
appreciate users as partners in the design process through co-design (Sanders & Stappers,
2008). This movement is peripherally connected with the maturing field of participatory
design, which was built on the premise that users should be involved in the process of
designing systems that affect them (Halskov & Hansen, 2015; Holmlid, 2009; Kensing &
Blomberg, 1998). This evolving ecosystem of collaborative design processes also shares
certain links with discussions on user innovation, where users with lived experience actively
take on the role of designers in the development of specific products and services (Essén
and Östlund, 2011; Oliveira et al., 2015; Trischler and Scott, 2014).

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
475
Within these converging bodies of literature, a variety of benefits of user involvement have
been discussed, such as: service providers gaining a better understanding of users’ needs
(Steen et al., 2011), supporting user empowerment (Holmlid, 2009; Hussain et al., 2012;
Taffe, 2015; Wetter-Edman, 2012), and combining different knowledge sources for
enhanced novelty (Trischler et al., 2017). However, there is also some evidence suggesting
that user-generated ideas are less feasible, producible, and sustainable (Akama, 2014;
Magnusson et al., 2003; Trischler et al., 2017). Additionally, there is discussion that a more
user-driven approach can cause a greater reliance on users’ own knowledge (Oliveira and von
Hippel, 2011) and may create difficulty in integrating traditional forms of expertise (Carr et
al., 2009). On most occasions, the user is still entering the designer’s sphere and the designer
takes on a dominant and guiding role (Takeyama et al., 2012), which results in participants
often not having an equal voice in the process (Näkki, 2012). As such, there is recognition of
the need for role renegotiation (Donetto et al., 2014). Further research suggests that the
involvement of end-users in the design process may actually shift their role away from
designing for their own needs toward designing for a hypothetic ‘other’ (Taffe, 2015).
While the potential negative outcomes or risks associated with these collaborative design
approaches remain under-researched (Vink et al., 2016), early work suggests that the
integration of lived experience in co-creation on its own is not a panacea. While lived
experience has immense value in deepening the understanding of needs and context, it is also
critical to integrate different knowledge sources (Trischler et al., 2017) and work with
multiple ‘truth regimes’ (Sellen, 2017) to enable the full benefits of co-creation. As such,
both empathy and lived experience are required to bring together the relevant skills and
knowledge within a service design process. Furthermore, research suggests the importance of
designers leveraging their own lived experience in local contexts to connect with other actors
in a more reciprocal exchange (Cipolla & Bartholo, 2014). In this way, lived experience is not
necessarily only held by end users, but designers and other participating actors may also have
direct and first-hand perceptions that are relevant within a design process. However, little is
said within service design literature to date about how diverse actors can tap into their own
lived, not just simulated, experience. Based on this notion, it is important to discuss empathy
and lived experience among diverse constellations of actors, not simply the designer-user
dyad that has been the dominant focus of existing literature in this area.
To contextualize this discussion, an example of the involvement of actors with lived
experience in the service design process is shown in Figure 2. The image captures a co-
creation workshop with youth in the development of a digital mental health service for
young people supported by Experio Lab. During this project, one youth was hired as an
advisor for this two-year project. While the designers and staff members supporting the
project were once youth themselves, they acknowledged the value of having youth who are
living and breathing this experience every day to contribute to moving the project forward.
Throughout the entire service design process, the voices and experiences of youth
themselves drove design decisions and influenced the perspectives of the healthcare staff and
designers supporting the project. Driven by youth’s own experiences, a new digital service
was developed to support youth with monitoring their own mental health and to connect
them with support more easily. Within this interactive service design process, staff built
empathy for the youth by hearing their stories and visions for the future, which sparked
them to make shifts in their own clinical roles in a way that recognized youth as the experts
of their own experiences. This example from Experio Lab moves closer to what Cipolla and
Bartholo (2014) call “I—Thou” relationships where an actor relates to another actor by
recognizing that they do not know them entirely and can only know more by engaging with
them in reciprocal dialogue.

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
476
Figure 2: A co-creation workshop during the design of a digital mental health
service supported by Experio Lab
Integrating Empathy and Lived Experience
As highlighted in the literature review above, there are different manifestations of the
relationship between empathy and lived experience in co-creation. We draw on existing
literature, particularly the work of Cipolla and Bartholo (2014), to highlight two critical
manifestations as show in Figure 3. The first manifestation is co-creation based on “I—It”
relationships, where there is an over-reliance on actors’ empathy. Here actors use methods to
project their own assumptions, negating the value of others’ lived experiences and
undermining their self-determination. The “I—It” relationship reflects a situation where
actors objectify the ‘other’, assuming they know and understand them. The second
manifestation is co-creation based on “I—Thou” relationships, where actors’ empathy is not
recognized as sufficient on its own, but must draw on and be seen in service to others’ lived
experience to enable reciprocal benefit. Co-creation based on “I—Thou” relationships
acknowledges that all actors can tap into their own lived experience while recognizing others’
unique experiences within a dialogic process, rather than constructing a false ‘us vs. them’
divide within service design.

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
477
Figure 3: The spectrum of different manifestations of empathy and lived
experience in co-creation
From the literature review on empathy and lived experience in co-creation, it may seem that
empathy and lived experience in design are somewhat opposing forces: empathic design
approaches are about designing for others, while the use of lived experience in design is
more about designing for one’s self. However, when viewed systemically, it becomes clear
that empathy relies heavily on lived experience and that lived experience can benefit
significantly from empathy within reciprocal co-creation. In this way, we can see the mutual
benefits of integrating both empathy and lived experience in service design. While designers,
for example, are able to develop valuable offerings through their technical expertise and
empathizing with other actors, they often cannot experience certain situations first-hand and
thus, lack contextual and situated knowledge. On the other hand, actors with lived
experience embody this situated knowledge, yet in some cases they may miss the particular
technical knowledge to fully develop valuable innovations for themselves and others. In this
way, co-creation based on “I—Thou” relationships through integrating empathy and lived
experience can offer reciprocal benefits.
Figure 4 highlights the complementary nature of some of the risks and benefits of empathy
and lived experience. For example, while one risk of empathy is that designers or other
actors only gain a superficial understanding of a person’s needs and experiences, the benefit
of leveraging lived experience is that actors offer specific, situated understanding informed
by their inherent contexts. Similarly, while the integration of lived experience in co-creation
has sparked the need for role renegotiation between actors, it is through empathy that others
experience disruption and conflict, which can facilitate role shifts. The application of either
empathy or lived experience within co-creation relies on the existence of the other. One
cannot truly have empathy unless it is informed by lived experience, and the use of lived
experience in co-creation requires the integration of particular skills and knowledge from an
empathic other to realize valuable innovations that are of mutual benefit.

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
478
Figure 4: Illustrations of the complementary nature of empathy and lived
experience in co-creation
Moving Toward Reciprocal Co-Creation
Through an examination of the literature, supported by empirical examples from Experio
Lab, we have highlighted the pressing issues related to the over-emphasis on empathy in
service design. We argue that while empathy is a key building block for an actor’s ability to
design valuable offerings for others, lived experience is just as important and functions as a
necessary complement to empathy in co-creation. Yet, while there is increasing recognition
of the value of integrating actors with lived experience into service design processes, there is
little discussion within this discourse about how actors can and do leverage their own lived
experience while co-creating with other actors. Existing research details a one-sided process
of empathy in co-creation that, we argue, has the possibility to manifest itself as an “I—It”
relationship. To move beyond “I—It” relationships, we, aligned with the work of Cipolla
and Bartholo (2014), suggest the need for reciprocal co-creation. The foundational work of
Bohm (1996) on the principles of dialogue may offer further insights for reciprocal co-
creation, including working with no pre-set agenda, nurturing sensitivity, and suspending
assumptions.
While the principles of dialogue offer a starting place, in-depth empirical research on the
practices of lived experience and the inter-related processes of empathy and lived experience
amid reciprocal co-creation is necessary. To continue the journey towards “I—Thou”
relationships in service design, there is a need to deepen the understanding of the potential
risks associated with empathy that have been touched upon in popular discourse (Abbott,
2017; Meill, 2015; Staffer, 2015; Wendt, 2017) and to better understand the important and
intertwined role of lived experience in service design. More work needs to be done to
apprehend how actors can leverage their lived experience to support reciprocal co-creation;
for instance, how do actors become aware of and interpret their own experiences and
contribute to envisioning desirable alternatives to their own situation? Furthermore, more
research is needed to understand if and how the open-ended process of dialogue and
leveraging lived experience may support the process of decolonizing service design practices.
How can we move from “I—It” to “I—Thou” relationships in co-creation? What are the

Josina Vink, Anna-Sophie Oertzen
Integrating empathy and lived experience through co-creation in service design
Linköping University Electronic Press
479
practices of lived experience and how do these practices relate to the practices of empathy in
“I—Thou” relationships? What are the enablers and barriers of integrating the lived
experiences of actors in service design?
While this research highlights connections between empathy and lived experience, it is
important to reinforce that these two processes are not mutually exclusive. More work is
needed to better understand how we can move from seeing these as separate processes by
distinct people, to eliciting empathy and leveraging lived experience from all actors. For
example, at this intersection we see the role of caregivers in healthcare service design
processes that have a particular lived experience and often deep empathy for those they are
caring for. We also believe it is important to better understand how designers themselves can
be encouraged to tap into, rather than ignore, their own lived experience in service design. In
this vein, there is a need for examining the representation among actors in service design
processes, including designers, end-users, and other actors. Are the actors involved reflective
of the spectrum of lived experiences of the populations they are designing with and for?
Healthcare is an interesting context in which to investigate this phenomenon because of the
difficulty in fully understanding the experiences of actors who have conditions that can never
be experienced by others. In addition to the investigation of co-creation activities with actors
with lived experience in healthcare, user-led design activities, such as activities of the “Patient
Innovation” platform in Portugal, could also be fruitful settings for advancing the
understanding of the role of lived experience in the design process. Here patients with rare
diseases who are often underserved by pharmaceutical firms and other medical suppliers, due
to the small market size, innovate themselves and with some support from others to develop
valuable and novel offerings (Oliveira et al., 2015). By examining the processes of these
patients, insights may be gathered on how actors perceive their own situations and leverage
their insider knowledge to develop solutions that are beneficial for themselves and others.
Conclusion
This research highlights several issues following an over-emphasis on empathy in service
design, including that it can result in actors projecting their assumptions onto the
experiences of others. We argue that while empathy is a key building block for actors’ ability
to design valuable offerings for others, lived experience is just as important and functions as
a necessary complement in co-creation. By building on the work of Cipolla and Bartholo
(2014), we have highlighted two different manifestations of the relationship between
empathy and lived experience: “I—It” and “I—Thou”. Furthermore, we have shown the
interdependent nature of empathy and lived experience within co-creation, and the
importance of working toward “I—Thou” relationships by integrating both in reciprocal co-
creation. In calling for more research on lived experience and reciprocal co-creation, we have
highlighted a number of lingering questions that will be important for service design research
and practice to address moving forward.
Acknowledgements
This project has received funding from the European Union’s Horizon 2020 research and
innovation programme under the Marie Sklodowska-Curie grant agreement No. 642116. The
authors would like to thank Gaby Odekerken-Schröder & Birgit Mager for their helpful
reviews of this manuscript and all the folks at Experio Lab for their openness, critical
reflections, and inspiration.

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Linköping University Electronic Press
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