Narrative medicine: a non-violent alternative in medical settings communication

The word Oxford English Dictionary’s definition of Violence is: 

The exercise of physical force to inflict injury on, or cause damage to, persons or property; action or conduct characterized by this; treatment or usage tending to cause bodily injury or forcibly interfering with personal freedom. 

The etymon of the word violence comes from a composition of two Latin words “Vis” and “Opulentus” the former means strength and violence, and latter – opulentus –  as exaggerated, powerful, or virulent. Therefore, Strength if joined with the word Power can sum up to violence. Curious is the etymon of Violence in ancient Greek; she is a Minor Goddess “Bia”, and she is the Sister of Nike, meaning victory (as the Nike brand) and of Cratos, from which every kind of word which ends in – cracy; demo-cracy, plutocracy, technocracy.

The World Health Organization defines violence as 

the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.

In this case, the WHO insists in the human behaviour: violence is just caused by good or wrongs deeds of human being, nature is totally neglected and even unconsidered for using the world violence. 

Johan Christian Clausen Dahl, Stormclouds over the Castle Tower in Dresden, 1820–1830, Alte Nationalgalerie, Staatliche Museen zu Berlin

Using the Natural Semantic Metalanguage (NSM), a theory that attempts to reduce the semantics of all lexicons down to a restricted set of 65 universal semantic primitives, we could try to get to the core of the word violence using a grammar and words drawn from the NSM. Violence is when: 

  • I want you (and the others) to do this; 
  • Maybe you don’t want it; 
  • Maybe the thing I want you to do make you feel bad; 
  • Maybe I want to do something bad on (your) body 
  • Maybe I want to say you bad words which make you feel bad 
  • Maybe I do not know that all these things are bad for you (and the others) 
  • Maybe I know that all these things are bad for you and good for me. 
  • When we use the NSM we see the polarization between the subject and the otherness. 

But we can broad our horizon, Violence is not just a result of a single human deeds but it is present almost everywhere, even in natural events and laws. It is, for example, in the change of a health status. And what about the possible violence of delivery? And the difficult age of adolescence? And the getting older? And death? 

A sudden outbreak, a slower cognitive impairment, are at the edges of the possible violence spectrum when we experience a loss in health, according the biological, psychological, social, and existential model: the “quiddity” in the middle of the line, can be mastered, coped with, but they are generally undesired events. Therefore, it is so important that in the “Violence” of nature with its biological rules, we move towards a safe space, which is made of trust and keeps violence out of the door. 

But violence lies in communication as well and in medicine many times it is given by the ritual words, by the gestures, by the bureaucratic action, by the organizational culture. Regarding this last one, which is the reference frame, violence is the continuous shortage of resources in health care practice, it is the fast discharge for economic reason when a patient has not recovered yet, it is the abolishment of convalescent, it is short term contract and low salaries to doctors and nurses, too long shifts for the providers, too long waiting lists, too short time at a visit. These are the main organization features of something that went wrong in many different national health service. 

Violent communication is in patients’ narrative who write about the doctor’s side, they mention the ritual “take off your clothes”, “now give me your arm”, “don’t be scared, it’s only a little needle”.  As a matter of fact the jargon in medical field either is technical or is hierarchic, since the organizational culture is that one of having two possible “chiefs”- The former is the “old style patronizing” doctor who decides for you what to do, not even with e gentle nudge, but commanding you exactly which drugs to take, without maybe not getting a clear picture of the life context of the patient. 

Nonviolent Communication (NVC) is an approach to communication based on principles of nonviolence. It is not a technique to end disagreements, but rather a method designed to increase empathy and improve the quality of life of those who utilize the method and the people around them. It is on old technique, developed by Marshall Roserberg, an American psychologist, in the seventy’s eighty of last century; quite resembling the Rogers point of view of person-centred program, it became more popular under the name of compassion communication or empathetic communication, with the word “Violence” possibly often upgrade new semantic formulas. The NVC found many applications in health care, in education, in diplomacy, in family therapy, n working organization, but broader in self-development. 

Here the steps for a nonviolent communication for a patient centred approach; 

  1. observations, it means a deep reality check, according not only to the biomedical model but broader to the biological psychological social and existential model. HO to do this fact checking? Asking questions, willing to be informed before expressing any possible evaluation about the deeds. 
  2. feelings, it means cognitive empathy to catch those emotions and to create a safe space. How to do this? By acknowledging the feeling of the others and about oneself in the relationship.  But first come the others; and here, asking the questions about, “How do you feel because of…?” Not simply “How do you feel, since it’s a too vague question”. WE are not used to give the nuances to our emotions, and we could try to not use only the five primary emotions as sadness, anger, shame, joy and fear, but being a bit more accurate about this, for instance fear ;  Is it anxiety,? Is it panic? Is it terror? Is it something that this has not found a name, but it can be well be expressed through a metaphor?  
  3. needs, it means to create the environment so that the person can express his /her own needs without fearing judgment, and without being submitted to rules that maybe in the future will be not followed. The needs are of course related to the analysis of emotions:  according to Marshall it is impossible to separate the emotions of the human beings from the needs.  
  4. and requests; it means the possibility to open and express oneself, independently by the asymmetric knowledge position of the doctor and the patient: the doctor is competent but the patient is worth to express his opinion. The request shall be expressed with the words “ I want to…” and not, “I don’t want to…” according to Rosemberg. This is because we are mor focused to avoid risks and malevolence experiences than to wish to enjoy life as we could despite this is “a wild world”. 

Nonviolent communication helps also in maintaining a good quality of life, and a civil way of professional life within the organization and to express oneself, also in a spiritual way: focusing more on the needs than to the “obsolete” idea to be right or wrong brings peace and harmony even in frantic working environment: it helps concentrations, affiliation, trust, it preserves from abuse of power and brutalities.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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