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Commentary: How Fictional Characters Can Help Real-Life Clients

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Two patients wait in the reception area of a busy urban medical clinic. They don’t know each other, but they are about to embark on very similar journeys. In the exam room, Bill receives the diagnosis that he is pre-diabetic and is encouraged to make some lifestyle changes, including reducing his alcohol intake, as his provider has determined that his drinking is at a risky level. Maria meets with her provider and is asked to break a tough habit. Maria is struggling with continuous asthma complications and although she quit smoking cigarettes, she still smokes marijuana every day to cope with stress. Maria’s provider challenges her to quit smoking marijuana for one month to see if it helps improve her condition. Both patients are uncertain if they can break these habits or if they even want to try.

While these patients will sound familiar to medical providers across the spectrum of health care, they are actually the fictional starring characters of a new health education graphic novel being tested by the Treatment Research Institute (TRI). In Keep it Moving: A Guide to Breaking Habits, both Bill and Maria have to resolve their own ambivalence about whether to make an effort to reduce or quit their alcohol and drug use. They model how to deal with stressors, temptations, obstacles and personal triggers that influence their habits.

These relatable characters are part of a greater goal to integrating models of behavioral health care directly into primary care; and to help individuals combat their own personal habits and make the decision to seek further alcohol or substance use treatment. Our clinical research team received a grant from the Pennsylvania Department of Health to conduct a clinical trial of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for the reduction of illicit drug use in three federally qualified health care centers (FQHCs) in Philadelphia. We wanted to be able to provide patients with an educational resource akin to Rethinking Drinking, the excellent patient resource developed and distributed by NIAAA. However, we wanted to be able to address both habitual alcohol and drug use, and we also felt that including more interactive activities and models that were within the grasp of populations with various literacy rates was important.  A community advisory board consisting of medical patients in recovery from substance use issues reviewed numerous health education strategies for alcohol and nicotine cessation, and concluded that our team might best reach our target population by developing our material in a graphic novel format.

The use of graphic novels for health education is not new. SAMHSA’s People Recover about a young couple who enter treatment for addiction is an excellent example. We wanted to equip the behavioral health consultants at the participating FQHCs with a resource that that would help patients begin the process of self-change. Our consultants reminded us that they typically had limited time to meet with patients in a primary care setting, so finding strategies that could help patients remember advice on why and how to make habit change was critical.

The characters model self change using time-tested, habit-breaking strategies. Throughout the narrative, as Bill and Maria exemplify effectively putting change strategies into place, the narrative halts and the reader is invited to complete interactive journaling exercises that allow them to parallel the change process the characters are engaging in.

Our team is currently piloting Keep It Moving in the context of a clinical trial; and while we do not have effectiveness data to share, the early reviews from patients are very positive. Behavioral health consultants have shared with us anecdotal stories of patients returning for second intervention sessions who have completed every exercise in the book, and who have shared content with other family members. So far, more than 70 patients have participated in this the pilot launch of the novel. Our team will monitor results from the pilot through 2014.

Keep it Moving is an example of TRI’s work in counseling tool development, an effort largely intended to encourage counselors to use evidence-based practices. If counselors have the tools necessary to deliver productive and effective interventions that are centered on evidence-based content, they will be more likely to adhere to evidence-based strategies and insist on being properly equipped to do so. Additionally, motivated patients who have been provided with the tools to jump-start self change can surprise providers by moving the change process forward on their own.

Adam C. Brooks, PhD is a Senior Research Scientist working on continuous care and adaptive treatment protocols, along with performance-based contracting strategies at Treatment Research Institute. Dr. Brooks has a PhD in clinical psychology with a specialization in marital and family therapy from St. John’s University.

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