Encouraging perspective taking: Using narrative writing to induce empathy for others engaging in negative health behaviors.

Societal expectations of self-care and responsible actions toward others may produce bias against those who engage in perceived self-harming behavior. This is especially true for health professionals, who have dedicated themselves to helping reduce the burden of illness and suffering. Research has shown that writing narratives can increase perspective taking and empathy toward other people, which may engender more positive attitudes. Two studies examined whether creating a fictional narrative about a woman who smokes cigarettes while pregnant could increase positive attitudes toward the woman who smokes and reduce the internal attributions made for her behavior. Across both experiments, the narrative writing intervention increased participants' empathy and perspective taking, evoked more positive attitudes toward a woman who smokes cigarettes while pregnant, and increased external attributions for her behavior. This work supports our hypothesis that narrative writing would be an efficacious intervention promoting attitude change toward patients who engage in unhealthy, and often contentious, behaviors. This work also suggests that narrative writing could be a useful intervention for medical professionals and policy makers leading to more informed policy or treatment recommendations, encouraging empathy for patients, and engendering a stronger consideration of how external forces can play a role in someone's seemingly irresponsible behavior.

Introduction

Imagine witnessing someone you know who struggles with alcoholism order a drink at a bar. Imagine a parent using drugs in front of their child or a pregnant woman who smokes. Witnessing these behaviors may make observers uncomfortable and lead to negative attitudes toward the individual engaging in them [1]. The development of these negative attitudes may be particularly problematic when they occur in the context of helping professions (e.g. psychology, medicine, social work). Previous research has indicated that health professionals can form negative attitudes towards patients who engage in negative health behaviors, such as drug use and substance misuse [2, 3] and toward those that are obese [4]. To the extent that unhealthy behavior, along with other health-related outcomes, conforms to the social and economic gradient in health—with less educated and less wealthy populations being more at risk—the negative attitudes of providers may be disproportionally attached to marginalized populations, especially in cases where providers have received only superficial training in the social determinants of health [5, 6]. There is great concern that the attitudes and beliefs of providers will influence the practice of health care and contribute to the documented health disparities [7-9]. Therefore, it is imperative to understand both the reason that providers form these negative attitudes toward their patients and methods for preventing or reversing the process.

Research has shown that one effective way to influence health professionals’ relationships with their patients and improve the care they provide is by increasing empathy [10]. Empathy can be defined as the ability to identify another’s emotional state and feel what the person is feeling. Thus, it includes elements of perspective-taking such as imagining yourself in someone else’s situation, acknowledging their point of view, seeing things through their eyes, and trying to understand their emotional state and behavior [11]. Research has shown that a practitioner’s ability to empathize is a trait preferred by some patients [12] and that the ability to take the perspective of patients is associated with greater patient satisfaction [13]. Further, physicians who score highly on a measure of empathy have patients with more positive clinical outcomes for diabetes [14]—however, there also exist discordant data [15]—and patient ratings of provider empathy are associated with better health outcomes, including a shorter and less severe experience with the common cold [16, 17].

Although higher levels of physician empathy are related to better outcomes for patients, and patients report empathy as an important aspect of their care, research has indicated that not all physicians are able to empathize with their patients [18, 19], and empathy tends to surprisingly decrease across medical school and residency [20]. Further, even when a physician may show empathy toward one patient, they may not do so consistently across patients [21].

One method of increasing empathy is to share in a common experience. Research has demonstrated that when physicians experience a serious illness and become patients themselves, they develop increased empathy, place a greater emphasis on the patient’s preferences, and demonstrate a willingness to work with the patient through the decision-making process [22, 23]. Further, reflective writing, which seeks to draw out personal experience with illness, has also been a useful method of inducing this type of empathic personal reflection [24].

In addition to the use of reflective writing on personal experience, a number of interventions have been designed to build empathy in health professionals [10, 20], including the use of creative writing exercises [25-27]. While reflective writing typically asks the writer to reflect on their own personal experiences, the purpose of creative writing is to shift the focus from the writer to an external character, often a patient, allowing the writer to develop an empathic affiliation [28, 29]. For example, medical students who engaged with elderly patients diagnosed with dementia in the context of a creative storytelling task felt more empathy and had more positive attitudes towards these patients, as well as dementia patients more generally [29]. Additionally, Shapiro and colleagues compared essays written by two groups of medical students, those trained in creative writing and those trained in clinical reasoning [30]. Stories written by both groups were analyzed with both thematic coding and the Linguistic Inquiry and Word Count program [31] and demonstrated that students trained in creative writing wrote stories with more emotion, empathy, insight, and religious and spiritual references than the students in the clinical reasoning group.

In addition to increasing empathy, creative writing exercises also promote perspective taking, or taking the perspective of another. There are a number of benefits associated with perspective taking, including: 1) reducing reliance on stereotypes to judge members of an outgroup [32] and 2) creating a stronger link between the self and the outgroup (termed self-outgroup merging), which can result in more positive attitudes toward the outgroup [33]. Additionally, perspective taking can help debias the fundamental attribution error, which describes our tendency to view the negative behaviors of others as a function of stable, internal attributes or personal traits (e.g., they are a bad person), while we view our own negative behaviors as a reflection of external factors (e.g., I had very little sleep last night). Taking the perspective of an outgroup member results in fewer internal attributions for their situations or behaviors [34] compared to those who do not engage in perspective taking. Further, studies have found that some of the positive effects of perspective-taking can last for hours [35], days [36], weeks [37], and even months [38].

Importantly, increasing empathy and perspective-taking not only shifts our attitudes and attributions towards others but also has the potential to reduce health disparities and change the care that marginalized groups may receive. In a compelling study examining disparities in pain management, Drwecki and colleagues demonstrated that both undergraduate and registered nurse participants exhibited a bias favoring White patients over African-American patients in the (fictional) pain management treatment they would assign when simply told to make their “best, most accurate treatment decisions for each patient” [39]. However, participants assigned to a perspective-taking condition, who were given several additional prompts including “try to imagine how your patient feels about his or her pain and how this pain is affecting his or her life”, did not exhibit a pain treatment bias against the African-American patients. Instead, participants in the perspective taking condition assigned similar pain treatments to both White and African-American patients.

Because a lack of empathy, limited perspective taking, and biased attribution of causes to behaviors is likely to impact the care a patient receives and their subsequent health outcomes, it is important to develop strategies for the creation of more empathic, and less biased, health care providers. To date, there has been no research targeting these three psychological constructs (empathy, perspective taking, and the fundamental attribution error) in the context of health behavior. To address this gap in the literature, we propose the use of a creative narrative writing intervention designed to encourage writers to reflect on the social determinants of health behaviors [40, 41]. The target of this writing exercise is a fictional character that engages in a negative, and controversial, health behavior: smoking while pregnant. Because of the detrimental effects on fetal development [42], this is a behavior that may not only harm a woman herself, but potentially her unborn baby.

Drawing upon the narrative and creative writing literatures, we hypothesized that writing a fictional narrative about a person who engages in an unhealthy behavior would increase empathy and perspective taking (H1) and make attitudes towards the person engaging in a negative health behavior more positive (H2). Further, we hypothesized that creative narrative writing would debias the fundamental attribution error (H3), whereby participants would be less likely to make internal attributions about the person’s behavior and more likely to recognize the influence of external factors.

To test these three hypotheses, we conducted two studies in which participants constructed a fictional narrative about a woman who smokes cigarettes while pregnant and examined its effect on participants’ empathy/perspective taking, attitudes towards the woman who smokes while pregnant, and internal vs. external blame. The purpose of this research was to provide “proof of concept”—that this creative narrative writing intervention can produce the hypothesized change in these psychological constructs. Therefore, the samples of our two studies are comprised of undergraduate college students. However, if this creative narrative writing exercise is efficacious, it could form the basis of an intervention for healthcare providers that is designed to increase empathy, promote perspective taking, and debias the fundamental attribution error.

Study 1 used a within-subjects design, measuring participant responses before and after the narrative writing intervention. Study 2 was designed to replicate the findings of Study 1 as well as to test the hypothesis that the observed changes from before to after the narrative writing intervention were the result of the narrative intervention itself and not an artifact of repeated measurement. To do so, Study 2 employed a mixed design where we compared pre-post responses on empathy/perspective taking, attitudes, and internal vs. external attributions for both the narrative writing condition that employed the narrative writing intervention from Study 1 and a control condition that wrote about a neutral stimulus.

Study 1 method

Participants

Thirty female undergraduate students 18 years of age or older at the University of Missouri participated in this study in exchange for partial course credit in a psychology course. We restricted our sample to females in Study 1 because we wanted to minimize the variability in narrative writing due to gender in order to maximize our effect size for the intervention. The mean age of the sample was 18.93 (SD = 1.10), and the majority of participants were White (83.3%). 6.7% of participants indicated that they were smokers, while 36.7% participants said one or both of their parents were smokers at any point in their childhood. 20% of participants indicated that their mother smoked.

Materials and procedure

The study procedures and materials were reviewed and approved by the Institutional Review Board at the University of Missouri. The Institutional Review Board approved a waiver of written consent for this study. Participants instead read a cover letter describing the purpose of the study, the length of time the study would take, and additional information about privacy, confidentiality, and alternative assignments. Participants indicated consent by clicking a button at the bottom of the cover letter in the survey software that read, “If you choose to participate in this study, please click the arrow in the lower right-hand corner to begin.”

Narrative writing intervention

To construct a fictional narrative, participants were first asked to imagine a character that would be the protagonist in their story. In this exercise, they were asked to imagine a scene in which they are leaving a grocery store, and they witness a woman who is pregnant smoking a cigarette. After imagining this initial scene, participants were asked to respond to several items evaluating their attitudes toward the pregnant woman (measures described below). After the pre-writing assessment, participants were instructed to further develop the main character for their fictional writing task (e.g., the woman who smoked while pregnant) by imagining her age, race, economic status, educational status, etc.; see S1 Appendix for complete instructions for the narrative writing intervention. Participants also received instruction on creative writing more broadly and strategies for developing complex scenes with vivid detail and rich dialogue. The instructions were written by a member of the research team (L.S.) who has extensive experience with creative writing.

Participants then created two scenes in this fictional writing exercise that included their main character. In the first, they were instructed to draft a scene in which their character is on her way to work; in the second, they were asked to create a scene in which their character is attempting to do something difficult with another person. In addition, all participants were told to adhere to one rule while writing their narrative: they must assume that their character is at least as smart as they are. Smart was clarified to not mean “educated” but intelligent even if a certain educational level had not been reached. Participants were reminded of this rule for both prompts. We included this stipulation because we wanted to go beyond the simple justification that the character made this choice (i.e., smoked while pregnant) because they did not understand the consequences. Rather, we wanted to nudge participants toward construction of some theory of mind that depicted their main character as capable of having a complicated inner life. Participants were also encouraged to write for a least five minutes for each of the two scenes. The next portion of the study was not accessible to participants until 5 minutes had passed.

Measures

After imagining this scene but before engaging in the narrative writing task, participants were asked to rate their own emotional state on ten dimensions (sadness, excitement, anger, pity, disgust, happiness, hopelessness, surprise, disappointment, concern) from not at all (0) to very much (100). Following this, participants were asked about their attitudes toward the woman by rating their agreement from not at all (0) to very much (100) with the following statements: “The woman is a bad mother”, “The woman is selfish”, “The woman is doing the best she can” (reverse coded), “the woman does not have her future child’s best interest at heart”, and “I can never imagine a situation where I would smoke cigarettes while pregnant”. To measure empathy and perspective taking, we adapted the Perspective Taking subscale of the Interpersonal Reactivity Index [43] so that the items reflected the main character in the narrative (e.g., “I put myself in her shoes”) and used the same 0 (not at all) -100 (very much) scale to indicate their agreement with these statements. There were 14 total items measuring empathy and perspective taking. Participants were then presented with items intended to measure their attributions for the imagined woman’s behavior, including: “To what extent is this person to blame for her action of smoking cigarettes while pregnant?”, “To what extent are external factors, such as life circumstances, responsible for this person smoking cigarettes while pregnant?” and “To what extent does this person have freedom to make better choices?” After completing the narrative writing intervention, participants responded to the same items measuring emotions, attitudes, empathy/perspective taking, and attributions for the woman’s behavior. The specific wording of all items can be found in S1 Appendix. All study materials, data, and R Markdown documents associated with this manuscript can be viewed at: https://osf.io/8fhrn/

Following the post-narrative assessment, participants were asked to complete a series of demographic questions.

We conducted a series of within-subjects analysis of variance (ANOVA) models comparing ratings before and after the narrative writing intervention to test our three hypotheses. Specifically, we predicted that the narrative writing exercise would increase empathy and perspective taking (H1), make attitudes towards the pregnant woman who smoked more positive (H2), and debias the fundamental attribution error (H3), whereby participants would be less likely to endorse internal attributions for the person’s behavior.

To test H1, we reverse coded selected items so that higher values represented greater empathy and created a composite measure of empathy and perspective taking by summing the items we adapted from the Perspective Taking subscale of the Interpersonal Reactivity Index.

We had no a priori hypotheses about the effect of imagining a woman who smoked while pregnant on ratings of participants’ current affective state. We conducted a series of within-subjects ANOVA models employing a Bonferroni correction for multiple comparisons to explore pre-post differences in ratings of mood state. The alpha level for these analyses was .005.

Study 1 results

Attitude, empathy/perspective taking, and attribution items

In support of H1, there were significant pre-post differences on empathy/perspective taking, F (1, 29) = 54.46, p < .001, n2 = .65. Mean scores at Time 1 were 531.2 (SD = 150.98), while mean scores at Time 2 were 790.80 (SD = 133.54), indicating that participants exhibited significantly more empathy and perspective taking after the narrative writing intervention than before.

In support of H2, there were significant pre-post differences on four of the five items measuring attitudes towards the character. Our planned analyses revealed that participants were less likely to rate the woman as: 1) a bad mother—M(SD)pre = 70.47 (24.14), M(SD)post = 50.46 (24.72); F (1, 29) = 21.16, p < .001, n2 = .42; 2) selfish—M(SD)pre = 77.83 (23.40), M(SD)post = 56.90 (25.53); F (1, 29) = 15.28, p < .001, n2 = .35; and 3) not having her child’s best interests at heart—M(SD)pre = 83.90 (17.79), M(SD)post = 57.30 (25.44); F (1, 29) = 30.34, p < .001, n2 = .51. Participants were also more likely to rate her as “doing the best she could do” after the narrative writing intervention—M (SD)pre = 25.47 (20.98), M(SD)post = 60.47 (27.71); F (1, 29) = 42.66, p < .001, n2 = .60. However, there were no pre-post significant differences in participants’ willingness to endorse the item, “I can never imagine a situation where I would smoke while pregnant”—M(SD)pre = 93.90 (13.37), M(SD)post = 90.87 (15.37); F (1, 29) = 2.90, p = .10., n2 = .09.

Additionally, we found support for H3; we observed significant pre-post differences on all of the items measuring internal vs. external attribution. Our planned analyses showed that participants were: 1) less likely to believe that the woman is to blame for smoking cigarettes while pregnant—M(SD)pre = 91.77 (31.15), M(SD)post = 68.63 (26.22); F (1, 29) = 27.23, p < .001, n2 = .48; 2) less likely to believe that she has freedom to make better decisions—M(SD)pre = 95.17 (10.07), M(SD)post = 85.23 (18.43); F (1, 29) = 10.99, p = .001, n2 = .27; and 3) more likely to believe that external factors such as life circumstances are responsible for her behavior—M(SD)pre = 51.40 (30.57), M(SD)post = 72.73 (24.28); F (1, 29) = 14.51, p < .001, n2 = .33, after the narrative writing intervention as compared to before.

Participant emotion

While employing the Bonferroni corrected alpha level (p < .005), participants still reported less negative affect after the narrative writing intervention than before. Specifically, participants felt less anger, F (1, 29) = 27.52, p < .001, n2 = .49, less disgust F (1, 28) = 44.07, p < .001, n2 = .61, less surprise, F (1, 28) = 14.54, p = .001, n2 = .34, and less disappointment, F (1, 29) = 10.51, p = .003, n2 = .27, as well as increased feelings of pity, F (1, 29) = 17.56, p < .001, n2 = 0.38. There were no significant pre-post differences in reported hopelessness, sadness, excitement, happiness, or concern, p > .005.

Study 2 method

One hundred and sixty-eight undergraduate students 18 years of age or older at the University of Missouri participated in this study in exchange for partial course credit in a psychology course. The mean age of the sample was 18.70 (SD = 0.95). The majority of participants were female (58.3%) and White (83.3%). 5.3% of participants indicated at they were smokers, while 63.2% participants said one or both of their parents were smokers at any point in their childhood. 15.5% of participants indicated that their mother smoked.

The study procedures and materials were reviewed and approved by the Institutional Review Board at the University of Missouri. The Institutional Review Board approved a waiver of written consent for this study. Participants instead read a cover letter describing the purpose of the study, the length of time the study would take, and additional information about privacy, confidentiality, and alternative assignments. Participants indicated consent by clicking a button at the bottom of the cover letter in the survey software that read, “If you choose to participate in this study, please click the arrow in the lower right-hand corner to begin.”

The design for Study 2 was the same as Study 1 with one exception. After imagining a scene in which they witness a pregnant woman smoking a cigarette and answering questions related to this scenario (e.g. current emotional state, attitudes towards the main character of the narrative, empathy/perspective taking, and internal vs. external attributions for the woman’s behavior), participants were randomly assigned to either the narrative writing condition, which was comprised of the narrative intervention used in Study 1, or the control condition, in which participants were instructed to write about the room that they are sitting in. Like the narrative intervention, participants in the control condition were asked to create two scenes in their writing exercise. In the first scene, they were instructed to write about the room in which they were currently sitting; in the second, they were asked to create a scene that described what they saw as they first entered the building and walked to the room where the experiment was being held. Participants were also encouraged to write for a least five minutes for each of the two scenes. The next portion of the study was not accessible to participants until 5 minutes had passed.

As in Study 1, after completing either the narrative or control writing exercise, all participants were then asked to re-imagine the scenario in which they observe a woman a smoking a cigarette while pregnant, and to answer the same questions about their emotional state, their attitudes, empathy/ perspective taking, and their attributions for her behavior that they completed at the beginning of the study. These items were assessed at two time periods, before and after the writing exercises.

To examine the effectiveness of the narrative writing intervention in Study 2, we conducted a series of mixed-design ANOVAs on these measures examining interactions between time (pre-post difference) and condition (narrative intervention vs. control). We again hypothesized that the narrative writing intervention would increase empathy and perspective taking toward the main character of the narrative (i.e., woman who smoked while pregnant) (H1), result in a more positive attitude towards the character (H2), and induce greater external attribution for her behavior (H3), while the control condition would not change significantly on these measures. Hence, we predicted significant time x condition interactions on attitudes, empathy/perspective taking, and behavioral attributions.

We also measured participants’ emotional responses to the scenario and conducted a series of mixed ANOVA models to look for time x condition interactions. As in Study 1, we had no a priori hypotheses about the effect of the interventions on the items measuring participant emotion. Therefore, we employed a Bonferroni correction to control for family-wise error with multiple comparisons. The critical value of alpha for these analyses was .005.

To test H1, we reverse coded selected items so that higher values represented greater empathy and created a composite measure of empathy and perspective taking by summing the items we adapted from the Perspective Taking subscale of the Interpersonal Reactivity Index.

In addition to comparing participant responses on the above items, we examined the content of the writing in both the narrative writing and control conditions using Linguistic Inquiry and Word Count, LIWC [44]. LIWC 2017 is a text analysis application designed to examine the emotional, cognitive, and structural components of written and verbal speech. LIWC output includes word count, summary language variables (e.g., analytical thinking), general descriptors (e.g., words per sentence), linguistic dimensions (e.g., % of words in text that are pronouns), psychological constructs (e.g., affective processes), personal concern categories (e.g., work), and punctuation (e.g., periods). Our analyses will focus on the summary language variables and a subset of the psychological constructs including affective, social, and cognitive processes.

Study 2 results

Replicating Study 1, we found support for all three hypotheses. We observed a significant time x condition interaction for the empathy/perspective taking items; we report the results from the individual items and the composite measure in Table 1. Change in empathy and perspective taking from before the writing exercise to after was significantly greater for participants in the narrative writing condition than participants in the control conditions (H1).

Table 1

Attitude, empathy/perspective taking, and attribution items—Study 2, M (SD).

Perspective Taking Scale0–100 Scale‘Strongly Disagree’ to ‘Strongly Agree’	Control	Narrative	Statistic	p	n2p
Composite measure (sum of 14 items)
Pre    Post	640.51 (161.60)661.95 (161.26)	646.65 (189.68)752.01 (202.17)	F (2, 166) = 23.95	< .001	.22
I put myself “in her shoes”.
Pre    Post	43.01 (3.16)45.81 (2.80)	46.45 (3.14)59.62 (2.79)	F (2, 166) = 12.71	< .001	.13
I felt very sorry for her when I was thinking about her problems.
Pre    Post	41.44 (3.23)42.46 (3.05)	46.27 (3.21)56.77 (3.03)	F (2, 166) = 6.10	.002	.07
I tried to take her side of the problem.
Pre    Post	32.02 (2.64)40.72 (2.72)	35.78 (2.62)52.22 (2.71)	F (2, 166) = 22.26	< .001	.21
I felt kind of protective towards her.
Pre    Post	22.15 (2.32)27.18 (2.72)	26.38 (2.30)38.50 (2.70)	F (2, 166) = 15.89	< .001	.16
I imagined what it was like to be her.
Pre    Post	46.74 (3.02)44.79 (2.69)	43.09 (3.00)58.52 (2.67)	F (1, 166) = 20.56	< .001	.20
Her misfortunes disturbed me a great deal
Pre    Post	55.06 (3.01)54.88 (2.94)	51.15 (2.99)58.12 (2.92)	F (2, 166) = 4.31	.01	.05
I tried to look at her side of the situation in addition to my own.
Pre    Post	47.38 (2.88)46.92 (2.53)	47.99 (2.89)57.50 (2.51)	F (2, 166) = 7.62	< .001	.08
I found it difficult to see things from her point of view.
Pre    Post	63.06 (2.70)61.28 (2.77)	61.41 (2.69)50.70 (2.76)	F (2, 166) = 17.53	< .001	.17
I was sure I was right about her, so I didn’t waste much time considering her side of the situation
Pre    Post	47.12 (2.86)48.93 (2.85)	43.58 (2.85)37.77 (2.84)	F (2, 166) = 1.96	.15	.02
I tried to imagine how things look from her perspective.
Pre    Post	44.81 (2.79)47.64 (2.56)	48.71 (2.77)59.73 (2.55)	F (2, 166) = 12.42	< .001	.13
Based on my feelings while considering this scene, I would describe myself as a pretty soft-hearted person
Pre    Post	50.95 (2.62)51.02 (2.70)	53.04 (2.61)54.23 (2.68)	F (2, 166) = 0.45	.63	.01
Before criticizing her, I tried to imagine how I would feel if I were in her place.
Pre    Post	41.79 (2.91)47.40 (2.62)	44.77 (2.89)57.23 (2.60)	F (2, 166) = 12.08	< .001	.13
I felt pity for her when I was thinking about her experience.
Pre    Post	48.72 (3.13)48.75 (3.04)	47.86 (3.11)54.59 (3.03)	F (2, 166) = 2.99	.05	.03
I didn’t spend lots of time trying to get her point of view.
Pre    Post	56.26 (2.95)52.39 (2.72)	53.58 (2.93)44.72 (2.70)	F (2, 166) = 5.40	.005	.06
Attitude Items0–100 Scale‘Strongly Disagree’ to ‘Strongly Agree’	Control	Narrative	Statistic	p	n2p
This woman is a bad mother.
Pre    Post	67.69 (2.75)64.31 (2.74)	67.84 (2.73)57.13 (2.72)	F (2, 166) = 10.55	< .001	.11
This woman is selfish.
Pre    Post	75.69 (2.50)72.17 (2.58)	76.97 (2.49)65.45 (2.57)	F (2, 166) = 11.55	< .001	.12
This woman is doing the best she can.
Pre    Post	19.79 (2.12)23.57 (2.57)	23.08 (2.20)38.36 (2.56)	F (2, 166) = 21.07	< .001	.20
This woman does not have her future child’s best interest at heart.
Pre    Post	83.97 (2.35)74.72 (2.85)	81.37 (2.34)69.02 (2.83)	F (2, 166) = 14.28	< .001	.15
I can never imagine a situation where I would smoke cigarettes while pregnant.
Pre    Post	90.37 (1.82)88.20 (2.50)	94.01 (1.81)87.86 (2.49)	F (2, 166) = 3.16	.04	.04
External Attribution Items0–100 Scale‘Not at all’ to ‘A great deal’	Control	Narrative	Statistic	p	n2p
To what extent is this person to blame for her action of smoking cigarettes while pregnant?
Pre    Post	86.06 (1.72)83.32 (2.09)	86.65 (1.71)77.50 (2.08)	F (2, 166) = 12.76	< .001	.13
To what extent are external factors, such as life circumstances, responsible for this person smoking cigarettes while pregnant?
Pre    Post	56.42 (3.17)58.74 (3.15)	52.72 (3.15)62.38 (3.13)	F (2, 166) = 6.33	.002	.07
To what extent does this person have freedom to make better choices?
Pre    Post	86.44 (1.85)85.41 (2.09)	89.15 (1.84)85.58 (2.08)	F (2, 166) = 2.35	.10	.03

In support of H2, we observed significant time x condition interactions for all of the items measuring attitudes towards the woman who smoked while pregnant; see Table 1. For participants in the narrative writing condition, agreement with the statements “this woman is a bad mother”, “she does not have her child’s best interest at heart”, and “this woman is selfish” decreased more after the intervention than participants in the control condition. Ratings of agreement with the statements “this woman is doing the best that she can” and “I can never imagine a situation where I would smoke cigarettes while pregnant” increased more after the intervention for participants in the narrative condition than for participants in the control condition.

In support of H3, there were significant time x condition interaction for two of these items measuring external attribution. Participants in the narrative condition were less likely to believe that the woman was to blame for her actions and more likely to believe that external factors were responsible for her behavior after their narrative writing exercise than before compared to participants in the control condition. There was no significant time x condition interaction for the item measuring her perceived freedom to make better decisions.

With the Bonferroni corrected alpha, we observed a time x condition interaction for anger—F (2, 166) = 14.77, p < .001, n2 = .15, disgust—F (2, 166) = 5.92, p = .003, n2 = .07, surprise—F (2, 166) = 9.68, p < .001, n2 = .10, disappointment—F (2, 166) = 11.39, p < .001, n2 = .12, and pity—F (2, 166) = 12.15, p < .001, n2 = .13. Participants in the narrative writing condition reported significantly less anger, disgust, surprise, and disappointment and more pity after the intervention than before compared to participants in the control group. There were no significant time by condition interactions observed for sadness, excitement, happiness, concern, and hopelessness, p > .005.

LIWC analyses

There were a number of qualitative differences between the writing produced by the narrative and control conditions. First, participants in the narrative writing condition wrote almost two hundred more words on average than the control condition; see Table 2 for means, standard deviations, and statistics associated with all of the LIWC summary measures. Writing in the narrative condition was also characterized by significantly less analytical thinking, which measures the extent to which the writers’ used words suggesting formal, logical, or hierarchical thinking patterns [45].

Table 2

LIWC Summary variables.

	Control Writing Exercise	Narrative Writing Exercise	F (1, 170)	p	n2p
Word Count	431.23 (147.27)	627.47 (269.39)	35.13	< .001	.17
Analytical Thinking	79.26 (17.39)	67.28 (18.78)	18.87	< .001	.10
Clout	28.66 (11.86)	78.11 (22.31)	329.40	< .001	.66
Authenticity	88.14 (14.28)	21.98 (29.04)	369.50	< .001	.68
Emotional Tone	38.60 (17.38)	27.35 (18.24)	17.14	< .001	.09

The texts written within the two conditions also differed significantly in their emotional tone. The algorithm for this summary variable was constructed such that larger numbers indicate a more positive emotional tone and smaller numbers indicate a more negative emotional tone [46]. Writing in the narrative condition was significantly more negative than writing in the control condition. And was also described by significantly greater clout, which reflects verbal representation of social status, confidence or leadership [47]. However, writing in the control group had greater authenticity, which measures the extent to which people are personal and vulnerable in their writing.

Focusing on the LIWC psychological constructs, the narrative writing texts were more affect rich and slightly, but significantly, more positive than the control writing texts; see Table 3. However, the overall difference in affect between the two groups was largely driven by the sizable difference in negative emotion between the two texts, with the narrative texts exhibiting much greater amounts of negative emotion than the control texts. More specifically, the narrative writing had significantly more anxiety, anger, and sadness than the control writing.

Table 3

LIWC Affective process measures.

	Control Writing Exercise	Narrative Writing Exercise	F(1, 170)	p	n2p
Affect	2.07 (1.27)	3.79 (1.48)	66.61	< .001	.28
Positive emotions	1.35 (0.96)	1.79 (0.97)	8.27	.005	.05
Negative emotions	0.66 (0.58)	1.97 (1.07)	98.85	< .001	.37
Anxiety	0.08 (0.16)	0.45 (0.47)	48.70	< .001	.22
Anger	0.11 (0.22)	0.42 (0.42)	37.13	< .001	.18
Sadness	0.22 (0.27)	0.46 (0.42)	19.25	< .001	.10

The narrative writing texts also include more content related to social processes, F (1,170) = 619.62, p < .001, n2 = .78, than the control writing texts. Specifically, the narratives passages were much more likely to include discussion about family, F (1,170) = 84.08, p < .001, n2 = .33, and friends, F (1,170) = 27.95, p < .001, n2 = .14, than the control writing. The narrative writing texts also include slightly more content describing cognitive processes than the control writing, F (1,170) = 4.63, p = .03, n2 = .03, although this difference is much smaller than the other differences in affect and social processes.

Discussion

Across two studies, we examined the impact of a creative narrative writing intervention on empathy/perspective taking, attitudes towards a target character, and attribution of blame (internal vs. external). Study 1 found that after writing the narrative intervention, participants held more positive attitudes towards the woman who smoked while she was pregnant. Specifically, they were less likely to endorse statements that the character was a bad mother, selfish, and did not having her child’s best interest at heart. Participants were also more likely to agree that the character was “doing the best she could”, and they increased the amount of reported empathy and perspective taking after the narrative writing intervention as compared to before. Finally, participants were less likely to endorse internal attributions for the negative health behavior (e.g. “the woman is to blame”) after the narrative writing exercise and more likely to endorse external attributions for her behavior.

Study 2 was designed to replicate and extend the results of Study 1 by including a control condition that wrote about the room they were sitting in and the use of text analysis to describe the differences in writing content between the control and narrative conditions. We observed significant condition by time interactions, demonstrating greater changes before and after the writing intervention in the narrative group than the control group. The narrative writing group reported larger increases in empathy and perspective taking, more positive attitudes toward the target character, and a greater endorsement of external attributions for behavior.

We gained additional insight into the mechanism through which those changes occurred by conducting a text analysis of the writing produced by each group in Study 2. Writing in the narrative condition was characterized by less analytical thinking, a more negative emotional tone, and more content related to social processes. These findings are consistent with other differences observed between in studies employing LIWC. Writing that is narratively-styled typically exhibits lower levels of analytical thinking, focusing on “the here-and-now” and other personal experiences [45]. In contrast, the increased negative emotional tone and social interactions observed in the narrative writing texts are likely due to task differences. In the narrative writing task, one of the two writing prompts asked participants to specifically write about their character engaging in a difficult situation, which likely contributed to a greater use of negatively valanced words. Additionally, the narratives included social interactions at a much greater rate than the texts written by the control group. Again, this is largely because the control group was more likely to refer to themselves and their experiences, while the narrative group wrote about a fictional character.

Strengths and limitations

Perhaps one of the most important strengths of the present research is its potential to address disparities in the health care that marginalized and vulnerable populations may receive. The patients who are most at risk for engaging in negative health behaviors also tend to be less educated and less wealthy, thus complicating their access to care and potentially increasing the negative biases that their providers may hold, restricting the care that their providers may assign to them. However, when health professionals are able to empathize with their patients, experience similar situations as patients themselves, or are asked to imagine how their decisions may affect those patients, they tend to provide better care [22–24, 39]. Engaging in a creative narrative writing intervention such as one presented here may be a relatively quick, economically viable way to improve patient relations and care in these most vulnerable populations.

Yet, there are also some limitations of this research that reduce its immediate generalizability. Study 1 used only female undergraduate students as participants to decrease variability in written responses. However, women are known to be more empathic and demonstrate greater perspective taking than males [48]. To address this limitation, we replicated the results in a sample containing both male and female undergraduate students. However, the reliance on an undergraduate sample still limits our ability to generalize these results to our desired population of health professionals.

Future research

The results of the present studies significantly contribute to our understanding of empathy-based interventions for health-related behaviors, yet this work also raises important questions. For example, whereas the present study asked participants to create a fictional story about an individual engaging in a negative health behavior, would it be as beneficial for health professionals to create stories about nonfictional characters, such as their patients? Or, alternatively, if health professionals were provided with short, nonfiction biographies of their own patients, would this impact the care that they provide to those patients? Indeed, a similar practice known as “My Life, My Story” was developed at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, and was implemented in 2013 [49]. Short,1,000-word biographies of patients’ lives are created in a collaboration between a writer and the patient and are then added to the patient’s medical records. Patients and health professionals have responded extremely positively to the program, believing that it helps foster better relationships between patients and their health care teams.

With any of these kinds of real-world applications, it is critical to know how–and in what ways, and for how long–the interventions may affect health professionals’ behavior. For example, it would be useful to know whether the effects of such an intervention could transfer to other patients in similar health situations, or if the intervention would only work for the one patient into whose shoes the provider will step (or whose biography they will read). And of course, research should examine whether engaging in this type of creative narrative writing intervention more generally (and positively) impacts long-term skills in perspective-taking, empathy, and attribution allocation such that a health professional might be able to transfer these changes to other patients, other distinct health behaviors, or to the varying circumstances in the lives of their patients.

Together, these two studies demonstrate that the creative narrative writing intervention is an effective perspective taking exercise that can engender more positive attitudes toward characters engaging in negative behaviors and reduce blame and internal attributions for the behavior. These results are consistent with past research demonstrating the effectiveness of interventions based on creative writing and other creative outlets on empathy and attitudes [29, 50, 51] as well as attributions [30], and underscore the importance of delineating the mechanisms that cause these shifts in thinking. Future research will focus on understanding whether this type of intervention can impact the care that patients receive, with members of vulnerable populations who engage in negative health behaviors perhaps benefitting most of all.

Study materials.

(PDF)

Click here for additional data file.

7 Aug 2019

PONE-D-19-16962

Encouraging Perspective Taking: Using Narrative Writing to Induce Empathy for Others Engaging in Negative Health Behaviors

PLOS ONE

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Reviewer #1: Dr. Frans Derksen

Researcher Primary Health Care/ Gender & Women's Health

Frans.Derksen@radboudumc.nl

Radboud university medical center

Dept. of Primary and Community Care

P.O. Box 9101

6500 HB Nijmegen

The Netherlands

Review manuscript: Encouraging Perspective Taking: Using Narrative Writing to Induce Empathy for Others Engaging in Negative Health Behaviors

Reviewer: Frans Derksen

Comments to the authors:

Dear authors,

Prior Comments: This is a very helpful paper on an important topic. Because too little research has been performed about the interaction of narrative writing with empathy and how this improves the efficiency in patient-GP communication.

Reading the manuscript I realized that it describes two studies, which causes, in my opinion, a hybrid situation (see my remarks). That’s why my remarks mostly are structurally characterized and less about the content of the manuscript.

Abstract: presents the central themes sufficiently but can be more clear when it is presented in a structure such as: goal, method, results, discussion, conclusion.

Introduction: describes important topics, however it is too much and too long. Many topics belong, in my opinion, to the discussion. For instance in a paragraph as “comparison with other research”. Furthermore dated references are used (1993, 1997).

At the end of the discussion a description of a precise gap in research is lacking and the goal of the study has been described ambiguously. In my opinion due to the hybrid situation as described above.

After the general introduction a new introduction starts of study 1, that is confusing.

Method: is a very long paragraph. In my opinion it is useful to summarize. Moreover sometimes the method is mixed up with items from the results paragraph.

Results: after the results the description of the second study starts and after this description a discussion starts. And the discussion lacks a clear arrangement (summary of the study, strengths and limitations, comparison with existing literature) .

Sorry, but at that moment my interest in the manuscript has been disappeared because of the overload of information.

I surely hope it can be published after major improvement. I strongly recommend to separate both studies.

Reviewer #2: • Overall Impression: This study has value for interventions that may help mitigate bias, promote perspective-taking and empathy, and foster considerations for the impact of social determinants of health on patient decision-making and health outcomes.

• Recommendations for writing style/grammar:

o It may be slightly awkward to start the first sentence of the abstract with “People,”. Perhaps something like, “It is very common for people, including health professionals….” OR “Societal expectations of self-care and responsible actions toward others may produce bias against those who engage in perceived self-harming behavior. This is especially true for health professionals, who have dedicated themselves to helping reduce the burden of illness and suffering.”

o In the last sentence of the abstract, the definition of the adjective “dubious” with regard to behavior does not seem to align with the authors’ intended use. Perhaps “irresponsible,” “self-harming” or “adverse” would be clearer to readers?

o Typo, top of page 16, “. There were no prepost differences in reported hopelessness, sadness, excitement, happiness, or concern, p > ,05.” – comma should be replaced with a period to read “p> 0.05.”

o Page 20, for the sentence, “There were no significant time by condition interactions observed for sadness, excitement, happiness, concern, and hopelessness, p > .005.” – did you mean to say “p> 0.05.” rather than 0.005? My understanding is that you were stating that the results in these domains were not significant (eg, p not equal to or less than 0.05), correct?

o Statements in the Results section, such as, “This is unsurprising given that one of the two writing prompts asked participants to specifically write about their character engaging in a difficult situation.” would likely be better placed into the Discussion Section. Results should be stated as such, with any interpretation thereof held until the discussion.

• Study Materials & Study Design

o In future iterations of the study, consider adding “Other/Non-binary” to gender options

o Consider collecting demographic data that includes intended career pathway (helping professions vs other) and past experiences with smoking that might bias a participant (eg, does the study participant has a family member who smokes, or is the participant a current or past smoker? These are variables that may influence perspective-taking.

• Discussion

o I did not see any discussion of limitations to the study. This should be added to the Discussion section.

� Examples:

• Limiting participants to females (study 1) significantly limits generalizability of results, as females have been shown in numerous studies to statistically significantly test at higher empathy levels than males.

• Limiting the study to undergraduate students also limits generalizability to health professionals.

**********

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Reviewer #1: Yes: Frans Derksen

Reviewer #2: No

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20 Sep 2019

Paula Pérez-Sobrino, PhD

Academic Editor, PLOS ONE

Dear Dr. Pérez-Sobrino,

Thank you for the feedback on the revised version of our manuscript. We used the comments from the two reviewers to further refine the paper. In this letter, I will detail the changes that we have made to the manuscript in response to these comments. As requested, we have uploaded both a copy of the revised manuscript with the changes tracked and an unmarked copy.

Editor Comments:

Comment: Please ensure that your manuscript meets PLOS ONE’s style requirements.

Response: We updated our manuscript and file names accordingly.

Comment: Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Response: Neither study included minor participants. This is clarified in the Participants section of both studies (see pages 10 and 16). We provided additional details about the consent process for both studies in the Materials and Procedure subsections (see pages 10-11 and page 16).

Reviewer 1:

Comment: Abstract: presents the central themes sufficiently but can be more clear when it is presented in a structure such as: goal, method, results, discussion, conclusion.

Response: It is our understanding that the PLOS One journal style requires unstructured abstracts, so we did not modify the abstract as suggested.

Comment: Introduction: describes important topics, however it is too much and too long. Many topics belong, in my opinion, to the discussion. For instance in a paragraph as “comparison with other research”. Furthermore dated references are used (1993, 1997).

Response: We streamlined the Introduction and reduced the text by approximately 1,000 words. However, we disagree that the date of publication should be a reason to exclude citations from the manuscript. While we cite a handful of classic references, the majority of the research cited in the manuscript are much more recent publications.

Comment: At the end of the discussion a description of a precise gap in research is lacking and the goal of the study has been described ambiguously.

Response: We revised the Introduction to include a precise description of the gap in the literature and described the goals of the two studies more explicitly (pages 6-7)

Comment: After the general introduction a new introduction starts of study 1, that is confusing.

Response: We removed the separate introductions to the two studies.

Comment: Method: is a very long paragraph. In my opinion it is useful to summarize. Moreover sometimes the method is mixed up with items from the results paragraph.

Response: We improved the efficiency of our Method section by removing material that was redundant with the Introduction. However, we prefer to err on the side of greater transparency and retain many of the methodological details. We moved the details about our analytical methods from the Results section to the Method section.

Comment: Results: after the results the description of the second study starts and after this description a discussion starts. And the discussion lacks a clear arrangement (summary of the study, strengths and limitations, comparison with existing literature).

Response: We added a section on the Strengths and Limitations of the research and included headers to emphasize the structure of the Discussion section (pages 22-25)

Reviewer 2:

Comment: Overall Impression: This study has value for interventions that may help mitigate bias, promote perspective-taking and empathy, and foster considerations for the impact of social determinants of health on patient decision-making and health outcomes.

Response: Thank you!

Comment: It may be slightly awkward to start the first sentence of the abstract with “People,”. Perhaps something like, “It is very common for people, including health professionals….” OR “Societal expectations of self-care and responsible actions toward others may produce bias against those who engage in perceived self-harming behavior. This is especially true for health professionals, who have dedicated themselves to helping reduce the burden of illness and suffering.”

Response: We appreciate the suggestion and have modified the first two sentences of the Abstract to include your suggested wording.

Comment: In the last sentence of the abstract, the definition of the adjective “dubious” with regard to behavior does not seem to align with the authors’ intended use. Perhaps “irresponsible,” “self-harming” or “adverse” would be clearer to readers?

Response: We replaced ‘dubious’ with ‘irresponsible’.

Comment: Typo, top of page 16, “. There were no prepost differences in reported hopelessness, sadness, excitement, happiness, or concern, p > ,05.” – comma should be replaced with a period to read “p> 0.05.”

Response: We corrected the punctuation.

Comment: Page 20, for the sentence, “There were no significant time by condition interactions observed for sadness, excitement, happiness, concern, and hopelessness, p > .005.” – did you mean to say “p> 0.05.” rather than 0.005? My understanding is that you were stating that the results in these domains were not significant (eg, p not equal to or less than 0.05), correct?

Response: Because we had no a priori predictions regarding emotions, we employed a Bonferroni correction for multiple comparisons, which resulted in a critical alpha value of .005. However, we reminded the reader about the use of the Bonferroni procedure in that paragraph to eliminate confusion.

Comment: Statements in the Results section, such as, “This is unsurprising given that one of the two writing prompts asked participants to specifically write about their character engaging in a difficult situation.” would likely be better placed into the Discussion Section. Results should be stated as such, with any interpretation thereof held until the discussion.

Response: As suggested, we moved the interpretive statements about the LIWC analyses to the Discussion section.

Comment: In future iterations of the study, consider adding “Other/Non-binary” to gender options

Response: Thank you for this suggestion. We will be sure to do so in our future work.

Comment: Consider collecting demographic data that includes intended career pathway (helping professions vs other) and past experiences with smoking that might bias a participant (eg, does the study participant has a family member who smokes, or is the participant a current or past smoker? These are variables that may influence perspective-taking.

Response: Thank you for the suggestions about future demographic information to include. We did actually measure a few of the suggested items, but forgot to include them in the Participant section. As indicated in our experimental materials available on OSF, we collected the following three items about smoking: 1) Do you smoke cigarettes? (y/n); 2) At any point in your childhood, did one or both of your parents smoke cigarettes? (y/n/don’t know); 3) At any point in your childhood did your mother smoke? (y/n/don’t know). All of the demographic items are now summarized in the respective participant sections for both studies.

Comment: I did not see any discussion of limitations to the study. This should be added to the Discussion section. Examples: 1) Limiting participants to females (study 1) significantly limits generalizability of results, as females have been shown in numerous studies to statistically significantly test at higher empathy levels than males. 2)Limiting the study to undergraduate students also limits generalizability to health professionals.

Response: We added a discussion about the strengths and limitations of the work on pages 23-24.

Thank you for the opportunity to submit a revision of the manuscript. We appreciate the helpful comments, and we believe they have led to an improved version of the manuscript. We look forward to hearing your decision.

Sincerely,

Victoria A. Shaffer, PhD

Department of Psychological Sciences

University of Missouri

208 McAlester Hall

Columbia, MO 65211

Email: shafferv@missouri.edu

Submitted filename: Narrative Writing Manuscript Response to Reviewers.docx

Click here for additional data file.

4 Oct 2019

Encouraging Perspective Taking: Using Narrative Writing to Induce Empathy for Others Engaging in Negative Health Behaviors

PONE-D-19-16962R1

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear authors, I am pleased to inform you that both reviewers agree that their suggestions and comments have been appropriately addressed, and that the manuscript is entirely improved. Many thanks for your hard work and the great spirit with which you have incorporated the suggestions. Congratulations!

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Every part of the manuscript is corrected. The manuscript is entirely improved and allows much more insight into the subject.

Reviewer #2: The authors have incorporated recommended edits. The revised manuscript is substantially stronger, clearer, more transparently and thoughtfully discussed. Well done!!

**********

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Reviewer #1: Yes: Frans Derksen

Reviewer #2: Yes: Jennifer R. Hartmark-Hill, MD, FAAFP

8 Oct 2019

PONE-D-19-16962R1

Encouraging Perspective Taking: Using Narrative Writing to Induce Empathy for Others Engaging in Negative Health Behaviors

Dear Dr. Shaffer:

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