© 2015 Intellect Ltd Miscellaneous. English language. doi: 10.1386/jaah.6.3.247_1
Research into the power of literature to enhance empathy supports the inclusion
of reflective reading and writing in medical humanities programmes around the
world. Building on additional research into perspective-taking, investigators piloted
an intervention using guided fiction writing to focus participant attention on risky
health behaviours and the social determinants of health. A mix of clinical and non-
clinical participants at a medical humanities workshop were asked to develop a
fictional character engaging in a negative health behaviour and write about that
individual in two prescribed scenes. The exercises were found to be valuable and
feasible by participants and highlighted themes in effective practice, including
cultural competence. Analysis of the participants’ writing and the session transcript
JAAH_6.3_Saffran_247-255.indd 247 3/15/16 9:06:03 AM
indicated increases in awareness of the social and economic determinants of health
and suggested that examining modifiable risk behaviours in non-clinical settings
through fiction writing may be an important tool in enhancing provider empathy.
The 2008 World Health Organization Report, Closing the Gap in a Generation,
accelerated the shift worldwide towards adapting health systems to address
social and economic determinants of health (Commission on Social
Determinants of Health 2008). In the United States, where non-communicable
diseases make up an estimated 50 per cent of premature morbidity and mortal-
ity, evidence persists of a strong social and economic gradient (Chokshi 2010),
even among conditions with behavioural risk factors, such as obesity and lung
disease (Bodenheimer et al. 2009). Access to care and the quality of care are
unequally distributed as well, particularly as it concerns under-represented
minorities (Institute of Medicine 2002). Current guidelines in medical education
reflect the need for physicians to incorporate social determinants and popula-
tion health knowledge into practice, particularly in light of growing emphasis
on preventive interventions (Bodenheimer et al. 2009). Yet, even as curricula
change, the National Research Council (2004: 16) notes that ‘Although the
scientific evidence linking biological, behavioural, psychological, and social
variables to health, illness, and disease is impressive, the translation and incor-
poration of this knowledge into standard medical practice appear to have been
less than successful’.
Medical humanities programmes that focus provider empathy on non-
clinical settings may offer a valuable alternative when ‘traditional educa-
tional frameworks are not well-suited to demonstrate the mechanisms by
which living conditions cause disease’ (Institute of Medicine 2002: S182).
For instance, literary fiction may provide an opportunity to educate provid-
ers about the worlds of their patients. Reading fiction has been shown to
disrupt stereotypes and assumptions (Kidd and Castano 2013) and solicit an
empathetic response towards ‘individuals whose inner lives are rarely easily
discerned but warrant exploration’ (Kidd and Castano 2013: 378). The crea-
tion of original work may further offer the potential to move students ‘from
reflection towards transformation’ (Kumagai 2012: 1142).
Creative writing interventions have been widely employed to promote
self-reflection among providers and humane care-giving (Reisman et al. 2006;
Hatem and Ferrara 2001). In medical humanities programmes, writing is most
often focused on exploring experiences of care-giving and in making sense of
and challenging assumptions through narrative (DasGupta and Charon 2004)
or on improving listening and communications skills among providers (Pallai
and Armijo 2013). Research into perspective-taking (Blatt et al. 2010) combined
with studies tying exposure to literary texts with enhanced empathy, in particu-
lar those that ‘engage their readers creatively as writers’ (Kidd and Castano
2013: 377), suggests that fiction writing may offer a unique strategy for promot-
ing reflection on the social determinants of health.
seTTing and parTicipanTs
The one-hour Building Character workshop was open to the participants of
the Examined Life Conference held annually at the Roy J. and Lucille A. Carver
College of Medicine at the University of Iowa. The conference encourages
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health care professionals, medical educators, patients and their family members
to incorporate humanities and writing into all aspects of health and patient care.
Fifteen participants attended the workshop and constituted our convenience
sample for analysis. They included six physicians, two nurses, one midwife, a
biomedical researcher, a medical librarian, a writer, an undergraduate and two
who did not identify a category. The majority (approximately two-thirds) of
participants were female, and participants ranged in age from university-aged
to mid-50s. The majority of participants appeared to be European American,
although participants were not asked to record their race or ethnicity. All fifteen
participants voluntarily submitted their worksheets with no identifiers other
than professional category to protect participants’ confidentiality and support
an open and unrestricted creative process. The project was approved by the
Health Sciences Institutional Review Board at the University of Missouri.
The workshop was moderated by Lise Saffran and Michelle Teti, who together
have expertise in fiction writing, narratives and public health, and qualitative
In this innovation we explored whether fiction-writing prompts that placed
characters who had engaged in unsympathetic health behaviours in non-
clinical settings would help participants develop a more concrete aware-
ness of how living conditions influence health behaviour. Secondarily,
we explored the acceptance and feasibility of guided fiction writing with
The workshop began with the discussion question How is health affected
by the circumstances in which a person lives and works? Responses constituted a
baseline from which to gauge general familiarity with the concepts of health-
related behaviour and social determinants of health. Following a short clari-
fication about what is meant by ‘health-related behaviour’, participants were
asked to think of a health-related behaviour for which it was difficult to gener-
ate empathy (i.e. smoking while pregnant).
Participants were asked to take a mental snapshot of an imaginary indi-
vidual engaging in the chosen health behaviour. This individual was to consti-
tute their ‘character’ for the rest of the session. Participants then recorded
demographic data about their character, including age, race, and other
socio-economic factors. See Table 1 for examples of unsympathetic health
Health behaviours Socio-economic status
Smoking while pregnant Eleven of fifteen had a high school education or below
Taking quick result diet pills Eight of fifteen were described as working poor or poor
Having Cheetos and soda for breakfast Four described as middle class
Female circumcision One (character who refused to vaccinate) described as
Risky driving Fourteen of the fifteen characters described as Caucasian;
one as Hispanic
Table 1: Examples of written work.
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behaviours that participants chose for their characters, along with demo-
graphic indicators chosen to correspond with those characters.
Following a brief explanation of ‘round’ characters in literature, partici-
pants were given writing prompts that encouraged them to imagine their
character’s inner life. These prompts included questions about their charac-
ter’s childhood memories, as well as prompts that encouraged participants
to reach beyond stereotypes that might be associated with their character,
such as asking them to complete the sentence ‘No one might ever guess that
[character] can […]’.
A brief explanation of the term ‘scene’ in creative writing and tips for
creating scenes was followed by the prompt to write a scene in which the
character was on his or her way to work. A second scene involved the char-
acter engaged in a difficult task (cooking a meal, fixing a car) with another
person, in which something goes wrong. In a final instruction, participants
were asked to make the character ‘as smart as you are’, which was designed
to discourage reductive explanations of behaviour. Each phase was followed
by a moderated discussion. See Table 2 for themes that emerged during the
discussions following each phase of the exercise.
Data from the workshop included a recording of the session and participant
worksheets on which they recorded the behaviour, demographic characteris-
tics of the character and scenes involving their fictional character. Our anal-
ysis was exploratory in nature and included reviewing a transcribed record
of the workshop session and participant worksheets to identify key themes
in the data. All of the authors reviewed the data multiple times to become
familiar with overall concepts and patterns in the transcripts and worksheets.
We created a codebook that contained the most salient themes related to
our research questions about empathy, feasibility and social determinants of
health (including economic and cultural factors). A new theme emerged during
analysis: importance of imaginative work. Importance of imaginative work relates
to participants’ recognition of imagination as a tool in understanding health-
We coded the data with the codebook, matching text to themes, and
wrote memos to compare and contrast codes and ideas throughout the analy-
sis. We noted which data followed the intervention phases and which data
were baseline comments. Then we printed out a code report and used that
to construct the text and examples in the results section based on grounded
theory (Charmaz 2006). We used qualitative methods of theme analysis that
were neither novel nor created for this project in particular. The trustworthi-
ness and quality of our analysis was maintained by meeting to discuss data
codes and resolve discrepancies, by using triangulation methods – two forms
of data, group transcripts and worksheets – to corroborate ideas, and by clearly
outlining our methods and procedures.
Most of the providers’ comments regarding social determinants before
intervention focused on clinical encounters, such as hospital admissions.
This is unsurprising, given that for the baseline discussion participants were
asked to draw on their own experience of observed behaviour, as opposed
to the later phases, which asked them to imagine patients’ life circum-
stances in non-clinical settings. A few pre-intervention comments implied
a baseline lack of familiarity with the concept of health behaviour and/or
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social determinants of health (i.e. identifying fame and/or affluence as a
general determinant of substandard care). In writing their scenes, however,
participants often did include determinants such as social support, which is
described from a fictional character’s point of view in the following excerpt:
‘With the children, a single mom only had so much control over time.
Already tense, anticipating the demeaning tone of her boss, the sight of
grandma’s driveway brought a wave of relief, of strength’.
In neither of the two scenes were participants asked to write about the
health behaviour itself, and yet, alongside increased empathy with the charac-
ter, many participants also directly linked health behaviour to the circumstances
in which the character lived, worked or played. A character whose problematic
behaviour was identified as ‘eating Cheetos [cheese-flavoured snacks] and
orange soda for breakfast’ was later portrayed in a scene in which he was
rushing to complete shift work for which he had been working overtime
because of financial difficulties. In at least a few instances, the fiction writing
exercises prompted participants to reflect on past experiences interacting with
diverse populations in health care settings.
For example, the comment included in Table 2 under the Cultural compe-
tence theme was made by a man in late middle-age who appeared to be
Caucasian. In response to the instruction to ‘make the character at least as
smart as you are’ he shared a memory of encountering an individual whom he
identified both as a ‘working man’ and as a ‘Hispanic’ in a pharmacy setting
and noted ‘the problem that we interpret as not being that smart is that people
are not speaking the same language’. In the discussion, he went further to
clarify that the language to which he referred was not the English language so
much as an issue of health literacy, noting ‘[his] English was perfect but he
just couldn’t get the instructions to his medicine’.
Participant comments also addressed the value of fiction writing as a tool
for developing insight into health behaviour (categorized as the importance of
imaginative works). At each phase of the intervention, participants commented
on the feasibility of the exercise. Some focused on the writing task itself and
others pointed to the specific difficulty of empathizing with someone in differ-
ent circumstances. The direction to participants, given along with the scene-
writing prompts, to ‘make the character you are writing about at least as smart
Discussion themes Participant responses
Effect of social determinants
on health behaviour
‘So people who don’t have the resources to get their kids to the clinic
visits; that would be a huge stress’.
Value of imaginative work
in understanding health
‘I think that choosing a behaviour we don’t understand forces us to feel
sympathy for the character, and as we develop the story we understand
more why the character does what he does’.
Cultural competence ‘He just couldn’t get the instructions to his medicine […] the problem
that we interpret as not being that smart is that people are not speaking
the same language. That’s the biggest thing in medicine; people just do
not speak our language’.
Feasibility of exercise ‘I found it interesting that once you come up with one thing, other
things sort of follow in a logical order and you just come with all these
ideas to put down and it kind of makes sense’.
Table 2: Four themes.
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as you are’ was designed to avoid reductive explanations for the problematic
behaviour and to encourage a more nuanced exploration of motives. One
participant summed up succinctly in the following comment the emotional
and intellectual challenge presented by this aspect of the intervention:
[…] I’m smart enough to not do that behaviour so how do I set up a
character that is as smart as me but still doesn’t get why the behaviour
is so bad?
Examples of participant writing indicated evidence of an understanding of and
ability to apply creative writing concepts such as scene construction, dialogue
and point of view. Writing samples also displayed a coherent thread connect-
ing the disparate components of the exercise (e.g., the two scenes amplified
characteristics and conflicts present in the snapshot and rounding questions).
Participant comments following each prompt indicated that the exercise
was effective in eliciting self-reflection and identification with ‘characters’.
Comments also indicated a growing awareness of the social context of health-
related behaviour and increased empathy with behaviour previously identi-
fied as unsympathetic. Interestingly, the intervention also prompted some
participants to relate principles explored in this intervention – for example, the
idea that smart people in challenging circumstances may engage in damaging
health behaviours, to past experiences with diverse populations. This find-
ing resonates with the research of Batson et al. demonstrating how increasing
empathy towards individual members of stigmatized groups can impact atti-
tudes towards the groups as a whole (1997).
Although some described the exercise as ‘challenging’, many found it to
be interesting and feasible and expressed the belief that imaginative work had
a role in improving clinical care.
This was a humanities in medicine conference, and consequently the
sample represented a high proportion of participants who had an existing
interest in literature and the arts; yet many were inexperienced with fiction
writing. As the exercises progressed, participant comments revealed an
increased understanding of how fiction writing actually works, insights that
further illuminate the mechanisms through which perspective-taking encour-
The process fiction writers employ to create rounded characters takes
participants a step beyond many perspective-taking exercises in which
students picture themselves in a patient’s shoes. Instead, it requires them
to invent fictional people with pasts and futures, hopes, dreams and regrets.
In their research into the cognitive process associated with perspective
taking, Galinsky et al. (2005) note that interventions that offer simple direc-
tion to participants to take another’s perspective without detailed instruc-
tions achieved, at best, superficial results. The very fact that fiction writing is
perceived as difficult and is often unfamiliar to health professionals required
the facilitators to use a guided approach, which appears to have engaged
participants in deep acts of imagination.
Participant reactions to this challenge further suggest accordance with the
conceptual model of ‘self-other overlap’ that Galinsky et al. (2005) propose
to be at the heart of perspective-taking’s power to reduce prejudice. For
example, one participant observed that it was ‘hard to stay true to fiction’
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and that the lines between what the writer thought and remembered and the
character thought had become ‘blurred’. The subsequent discussion touched
on the extent to which fiction writers do incorporate elements of real life, often
autobiographical details, in imaginary scenes and stories in order to enhance
verisimilitude and engage emotion. The ability of participants to draw on
their own memories and emotions, particularly during the phase where they
answered ‘rounding’ questions about their characters’ inner lives, appeared to
increase their ability to understand the problematic behaviour.
One participant wrote, ‘Once I wrote down the behaviour, absolutely
every question in here answered why that person behaved the way she did’.
Upon analysis, the demographic data describing each fictional charac-
ter raise some questions regarding instructions to participants during that
phase of the intervention. Specifically, was there any effort by participants to
self-correct for socially acceptable responses before recording demographic
details to describe the character in their mental snapshot? Most study partici-
pants appeared to be of European American descent, but as they were not
asked to report their race or ethnicity that information may be inaccurate or
incomplete. Notably, none of the fictional characters created by the partic-
ipants were under-represented minorities, except for one Hispanic. It may
well be that participants hesitated to choose a character of a different race or
ethnicity, or having imagined such a character in their initial scenario hesi-
tated to describe that character as such, in order to avoid seeming biased. In
future iterations, the moderators would recommend including an instruction
to participants to record the data without deviating from their initial mental
picture, as well as instructions asking them to record their own age, gender
Our research was limited by the relatively small number of participants
in the workshop, as well as the inclusion of participants other than medical
professionals and no participants in the medical training stage. A larger and
more uniform group of participants could increase the external validity of the
results, and piloting the programme with medical students or residents would
be useful in determining its relevance for medical curricula. It is unknown
whether or not any insights gained through the intervention will be translated
into clinical practice and/or might result in measurable increases in cultural
competency or empathy using an externally validated instrument.
While efforts are being made to reduce disparities in health outcomes and
increase access to quality care, medical education is still developing strate-
gies to train physicians to address these issues in daily practice. Previous
research has found medical humanities useful in encouraging self-reflection
and creative thinking and increasing students’ tolerance for ambiguity. In
at least one study, the ability of medical students to tolerate ambiguity was
associated with positive attitudes towards underserved populations (Wayne
et al. 2011). Building further on research that associates perspective-taking
with increased patient satisfaction and reduced stereotyping among provid-
ers in clinical encounters (Blatt et al. 2010), the intervention described here
focuses participants’ attention on non-clinical settings and risk behaviour.
This innovation may offer further useful insights as medical educators seek
to employ humanities interventions to encourage a focus on social context,
population health and cultural competence, recognized as increasingly
important to the modern practice of medicine (Institute of Medicine Health
Care Quality Initiative 2001). Subsequent research might illuminate the
extent to which similar interventions might assist public health professionals
JAAH_6.3_Saffran_247-255.indd 253 3/16/16 11:41:16 AM
Lise Saffran | Michelle Teti | Michelle Long
in developing prevention programmes that are attuned to cultural and social
With a few notable exceptions (Reisman et al. 2006; Pallai and Armijo 2013)
most reflective writing interventions in the health professions focus on non-
fiction and encourage participants to ‘write clearly about their experiences,
describe their observations and distinguish between observations and conclu-
sions’ (Hatem and Ferrara 2001: 14) or ‘create original work addressing diffi-
cult or meaningful experiences with patients, colleagues or teachers’ (Shapiro
et al. 2006: 232). The intervention described in this article prioritizes imagina-
tion over experience, however; it asks participants to invent fictional characters
and scenarios rather than reflect on past events. In its phased approach to
writing, the intervention may offer some strategies for increasing the effec-
tiveness of perspective-taking exercises by demonstrating the ‘vivid, process-
oriented and descriptive’ instructions called for by Galinsky et al. (2005: 120).
Based on the results of this pilot workshop, we believe that guided fiction
writing may have something unique to contribute to strategies for improv-
ing provider self-reflection and understanding of the social and cultural influ-
ences on health-related behaviour.
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Saffran, L., Teti, M. and Long, M. (2015), ‘Building character: A creative
writing intervention to encourage clinician reflection on the social deter-
minants of health’, Journal of Applied Arts & Health, 6: 3, pp. 247–255, doi:
Lise Saffran (MPH, MFA) is the Director of the Master of Public Health
Programme at the University of Missouri.
Contact: MU MPH Program, 802 Lewis Hall, Columbia, Missouri 65211,
Dr Michelle Teti is Assistant Professor of Health Sciences at the University of
Missouri, School of Health Professions.
Contact: Department of Health Sciences, 512 Clark Hall, Columbia, Missouri,
Michelle Long (MPH) is a former Programme Fellow for the Master of Public
Health Programme, and an Adjunct Instructor for the Department of Health
Sciences at the University of Missouri.
Contact: Kaiser Family Foundation, 1330 G St. NW, Washington, DC, 20001,
Lise Saffran, Michelle Teti and Michelle Long have asserted their right under
the Copyright, Designs and Patents Act, 1988, to be identified as the authors
of this work in the format that was submitted to Intellect Ltd.
JAAH_6.3_Saffran_247-255.indd 255 3/17/16 9:10:40 PM
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Applied Theatre Research
ISSN 20493010 | Online 20493029
2 issues per volume | Volume 1, 2013
Applied Theatre Research is the worldwide journal for theatre and drama in non-tradi-
tional contexts. It focuses on drama, theatre and performance with specific audiences
or participants in a range of social contexts and locations. Contexts include education,
developing countries, business and industry, political debate and social action, with
children and young people, and in the past, present or future; locations include thea-
tre which happens in places such as streets, conferences, war zones, refugee camps,
prisons, hospitals and village squares as well as on purpose-built stages.
The primary audience consists of practitioners and scholars of drama, theatre and
allied arts, as well as educationists, teachers, social workers and community leaders
with an awareness of the significance of theatre and drama, and an interest in inno-
vative and holistic approaches to theatrical and dramatic production, learning and
community development. Contributors include eminent and experienced workers and
scholars in the field, but cutting-edge contemporary and experimental work from new
or little-known practitioners is also encouraged.
The journal has a global focus and representation, with an explicit policy of ensuring
that the best and most exciting work in all continents and as many countries as pos-
sible is represented and featured. Cultural, geographical, gender and socio-economic
equity are recognised where possible, including in the Review Board.
JAAH_6.3_Saffran_247-255.indd 256 3/15/16 9:05:46 AM