Neil Vickers reviews Non-violent Communication and Narrative Medicine for Promoting Sustainable Health by Maria Guilia Marini (Springer, 2024).
Maria Giulia Marini will be known to readers of The Polyphony as one of the most prolific and original European writers on narrative practices in healthcare. Her first book in English, Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities (2015) argued, somewhat in the spirit of Iain McGilchrist, that medicine is neither an art nor a science, but a strange hybrid with elements of both. We live in an age when the power of science has never been more prized. Demonstrating an interest in scientific methods is the surest route to resources of all kinds. But some things cannot be investigated exhaustively by conventional scientific methods and the human imagination is one of these. If you think the imagination has nothing to do with healthcare, think of the placebo effect or health research describing the differential impacts of good care.
Her second, book, Languages of Care in Narrative Medicine: Words, Space and Time in the Healthcare Ecosystem (2018) introduced Natural Semantic Metalanguage as a way of bridging the interests of patients, professionals and carers. As Marta Arnaldi has observed in The Polyphony, Marini’s work, like that of many Italian medical humanities scholars, is heavily literary. Literature and mythology have a vital status in her books as sources of wisdom about everyday struggles.
Non-violent Origins
Non-violent Communication and Narrative Medicine for Promoting Sustainable Health, draws inspiration from ideas developed by clinical psychologist Marshall Rosenberg in the 1960s and 1970s, which culminated in his bestselling book, Nonviolent Communication: A Language of Life (2003). As Marini points out, Rosenberg’s method resembles Carl Rogers’ person-centred therapy in demonstrating ‘unconditional positive regard’ for the other as the basis of non-violent action. But community settings rather than psychotherapists’ consulting rooms were the original focus of nonviolent communication (NVC). Rosenberg had begun his career working in newly integrated schools in California and Virginia. His technique emphasises four kinds of openness as a key to constructive communication: openness to observations, openness to feelings (especially feelings that the other finds it difficult to name), openness to needs, openness to requests – all of which implied awareness of our intentions when we communicate with others.
It is worth recalling that intuitions like Rosenberg’s lay at the origins of the narrative medicine movement. Social psychologist Elliot Mishler’s book, The Discourse of Medicine: Dialectics of Medical Interviews (1984) – to my mind, the first major contribution to narrative medicine – argued that routine medical consultations should be seen as a struggle for dominance between ‘two different domains of meaning’: ‘the voice of medicine’ and ‘the voice of the lifeworld’ (121). Medical students are taught to ignore the voice of the lifeworld by turning their patients into biomedical ‘projects.’ The narrative methods Mishler proposed were intended to mitigate an underlying violence in the medical encounter, itself a reflection of underlying violence in the social world. Mishler’s thinking was influenced by Habermas’s work on communicative rationality, Harvey Sacks’s work on conversation analysis, and Schutz’s phenomenology of the social world. Rita Charon, the doyenne of narrative medicine, studied under Mishler and has called him her most influential teacher (Charon, 2002: 636).
Chapter 1 of Marini’s book lays out Rosenberg’s model through a reading of The Tempest in which Prospero and Caliban are violent communicators, until Prospero renounces his ‘rough magic’. Chapter 2 asks why medicine needs to involve itself with narrative methods at all. Her answer can be briefly stated: because the human imagination plays a powerful role in shaping health outcomes. Chapter 3 is concerned with science as an ideology. Chapter 4 deals with the violence of medical care during the pandemic. Patients and their loved ones were robbed of what might be called the ‘ceremonial’ side of illness – everything from home and hospital visits to a proper funeral. Marini counters this by noting the rise of new rituals, observing a practice that apparently became commonplace in the US during the pandemic of surgeons writing condolence letters to their deceased patients’ families. This was an instance of nonviolent communication at its best.
Hikikomori: Pulling Inward
Chapter 5 starts off with a discussion of Emily Dickinson, whom Marini hails as ‘the first Hikikomori poet in modern literature.’ I had to look up Hikikomori, a mental illness first described in Japan, and ‘characterized by a “pulling inward,” or wilful social isolation.’ It is more extreme than Jung’s category of ‘introversion’ or the psychoanalytic concept of the ‘schizoid’ personality (where the inner world becomes so engrossing that it substitutes for the outer world). It always involves severe social withdrawal. Marini offers us two types of Western Hikikomori: Emily Dickinson, who took to her bed in the 1860s, probably because of Bright’s Disease (chronic nephritis), and spent her days writing her poetry, almost none of which she published; and the millions of young people today who seldom go out to meet their peers face to face but who have countless interactions online, with long periods of solitude spent on video games, sustained by an unhealthy diet’.
Marini sees the Hikikomori syndrome as a rational response to the values prevailing in Western societies today, ‘in which one must be famous, rich, and beautiful’. I think there is the beginnings of a Jungian argument here: Hikikomori are doing something on behalf of the rest of us, compensating for the deficiencies of society; they are in touch with the Collective Unconscious. Marini reports the results of a qualitative survey study carried out by her university comparing young people’s habits before and after the pandemic. Although the sample size was small (n=41), the most striking finding to my mind was how pessimistic the respondents were about the future. COVID had made them more pessimistic about climate change, their employment prospects, and interpersonal relationships. Many described themselves as ‘Doomers’, a coinage designed to contrast with ‘Boomers’ (their parents’ generation). Marini speculates that the surge in the incidence of eating disorders since the pandemic – which has also been recorded in the UK – is a further sign of the advance of the Hikikomori syndrome.
(Slow) Violence & Scale
One of the pleasures of this book is the multiple scales on which it pursues its argument. The later chapters deal with the phenomenon of ‘slow violence’ which finds its most sinister expression in environmental degradation, and slow violence of a different kind which is shown in long-term epidemiological studies examining the impact on health of social oppression of all kinds. But Marini is true to the original narrative-medical focus on the constructive role that can be played by physicians in giving understanding to their patients. She cites a study published in JAMA Health Forum in 2023 showing that physician consultations with Black and Hispanic patients were on average shorter than consultations with White patients (Neprash et al, 2023). Black and Hispanic patients also were more likely to be given antibiotics inappropriately and to be co-prescribed opioids with benzodiazepines, which can cause fatal respiratory depression. Another study she cites showed that physicians were likely to cut short consultations with patients presenting with mood disorders (Tai-Seale et al, 2007).
It should be obvious that I think this book should be required reading for anyone interested in the question of how to extend the paradigm of narrative medicine into new areas. If I have a criticism of it, it is that it doesn’t devote enough space to the violence to which healthcare professionals are subject today. There hasn’t been enough reflection in our field on the meaning of assaults on paramedics and staff in emergency care settings. But what Marini has given us here is rich indeed and she deserves our congratulations and thanks.
About the Author
Neil Vickers is Professor of English Literature and the Health Humanities and co-director of the Centre for the Humanities and Health at King’s College London. His latest book (co-authored with Derek Bolton), Being Ill: On Sickness, Care and Abandonment, was published in 2024 by Reaktion Books. He can be found on X/Twitter @NeilVickers2 and on Bluesky @neilcvickers.bsky.social.
References
Arnaldi, M. 2023. ‘Medical Humanities in the Italosphere.’ The Polyphony. 28 July 2023. https://thepolyphony.org/2023/07/28/medical-humanities-italosphere/
Charon, R. 2002. ‘Lifeline’. The Lancet. 359: 636.
Marini, M. 2015. Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities.Cham, Switzerland: Springer.
Marini, M. 2018. Languages of Care in Narrative Medicine: Words, Space and Time in the Healthcare Ecosystem. Cham, Switzerland: Springer.
Mishler, E. 1984. The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, New Jersey: Ablex.
Neprash HT, et al. 2023. ‘Association of primary care visit length with potentially inappropriate prescribing’. JAMA Health Forum. 4(3):e230052.
Rosenberg, M. 2003. Nonviolent Communication: A Language of Life. Lancaster: Gazelle.
Tai-Seale M, et al. 2007. ‘Time allocation in primary care office visits.’ Health Services Research. 42(5):1871–94.
