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Social Science & Medicine 58 (2004) 1647–1657

Understanding breast cancer stories via Frank’s narrative types
Roanne Thomas-MacLean*
Dalhousie University Family, Medicine Teaching Unit, Dr. Everett Chalmers Hospital, P.O. Box 9000,
Priestman St. Fredericton, NB Canada E3B 5N5

Abstract
While breast cancer narratives have become prevalent in Western culture, few researchers have explored the structure of such narratives, relying instead on some form of thematic analysis based upon content. Although such analyses are valuable, Arthur Frank (The Wounded Storyteller, The University of Chicago Press, Chicago, 1995) provides researchers with an additional means of studying stories of illness, through the examination of their structures. In this article, the author applies Frank’s work to a phenomenological study of embodiment after breast cancer. Frank’s three narrative types are used to enhance understanding of the ways in which stories are culturally constructed, using data collected through one focus group discussion and two in-depth interviews with each of 12 women who had experienced breast cancer. The author then conveys the significance of this form of analysis for future research. r 2003 Elsevier Ltd. All rights reserved.
Keywords: Breast cancer; Qualitative and narrative

Introduction
Frank (1995) writes that those who are ill ‘‘need to become storytellers in order to recover the voices that illness and its treatment often take away’’. (p. xii)
Frank’s ideas are supported by the fact that stories of breast cancer have become ubiquitous in Western culture (Couser, 1997), while Bury (2001) provides compelling illustration of the historical failure of biomedical narratives to address illness experiences and the subsequent ‘‘expansion of information about illnessyvia media coverage, the internet and alternative forms of health care’’ (p. 268). For instance, a recent search of a major internet bookseller returned 1054 texts related to breast cancer, including numerous autobiographies, while comparative searches of ‘‘prostate cancer’’ and ‘‘colorectal cancer’’ returned only 300 and
71 hits, respectively. Nonetheless, while published accounts of breast cancer and thematic analyses of illness experiences are prevalent (e.g., Bury, 1982; Cope,
1994; Couser, 1997; Kleinman, 1988; Langellier &
*Tel.: +1-506-452-5706; fax: +1-506-452-5710.
E-mail address: rtmaclean@health.nb.ca
(R. Thomas-MacLean).

Sullivan, 1998; Williams, 1984), it remains that few have questioned the structure of such stories in relation to the meaning of illness.
In contrast to thematic approaches, Frank’s (1995) exploration of various sub-genres of illness narratives in
The Wounded Storyteller is extremely useful in understanding how stories are created and presented, following specific plot sequences or ‘‘emplotments’’
(Sandelowski, 1991, p. 164). As such, Frank’s (2001) ideas about illness narratives are reflective of both form and content, with form assuming a key role in this particular work, thus creating a means of ‘‘thinking with the story’’ (p. 361). Rather than providing an analytical prescription, Frank’s work suggests ways in which stories might be reflected upon, in order to be better understood by those who have experienced illness, as well as those who live with them.
In this article, I explore Frank’s (1995) work in relation to stories of breast cancer. I begin this article with a description of the significance of stories or narratives, situating stories in their social context and provide an overview of Frank’s narrative types. Next, I briefly summarize my research approach. Then, I relate
Frank’s conceptualizations of illness narratives to the stories of breast cancer that were shared with me as I

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completed in-depth interviews with 12 women who had experienced breast cancer. Finally, I conclude with a review of the implications of this application for future research. of illness narratives direct attention to both the content and structure of stories in order to illuminate both experience and context (Sandelowski, 1991). For, as
McLellan (1994) shows, illness stories will become even more pervasive because of electronic publishing.

Significance of stories
‘‘Narrative types’’ and stories of breast cancer
Stories provide a means of making sense of one’s life and experiences, and coherent stories are connected to coherence of life and understanding (Josselson, 1995;
Kerby, 1991; Linde, 1993; Ricoeur, 1986; Rosenwald &
Ochberg, 1992). In other words, narratives make life meaningful (Langellier, 1989) and they are currently regarded as a valuable source of experiential knowledge
(Atkinson, 1997; Charmaz, 1999; Cope, 1994; Couser,
1997; Denzin, 1989; Frank, 1994, 1995, 1998; Kerby,
1991; Polkinghorne, 1988; Sandelowski, 1991). The study of narratives has evolved as a vital branch of qualitative inquiry, explored through a variety of forms such as autoethnography (Langellier, 1989; see also
Atkinson, 1998; Denzin, 1989; Ellis, 1999; Gubrium &
Holstein, 1995; Josselson, 1995; Sandelowski, 1991).
More specifically, illness narratives represent a means of understanding what body experiences through illness and a way of recuperating what may be considered lost
(Frank, 1995). As Schweizer (1995) argues, one may not be able to explain suffering, but one can learn to comprehend this phenomenon (see also Charmaz, 1999).
Stories may then enhance understanding of illness and may also facilitate positive relationships between health care practitioners and patients as Coulehan (1995) asserts, as well as those who live alongside people who have experienced illness. Critical exploration of both the content and structure of stories is therefore vital to qualitative health research.
Stories in context
Part of the critical exploration of stories is understanding the social context in which they occur.
Rosenwald and Ochberg argue that ‘‘all narratives are told within the paradigms deemed intelligible by their specific culture’’ (Rosenwald & Ochberg, 1992, p. 7; see also Bruner, 1987; Gergen, 1992; Josselson, 1995;
Langellier, 1989; Linde, 1993). Rosenwald and Ochberg imply that one must search within audible stories for those that may be rendered inaudible by cultural influences. It may be argued then that stories and culture share a symbiotic relationship.
Thus, Riessman (1993) argues, it is important to question the structure of stories. What shapes a story?
How might various stories be compared? What knowledge is created through the comparison of various structures of stories? What other ways could a particular story be told (Bruner, 1987)? It is imperative that studies

Using the concept ‘‘narrative type,’’ Frank describes three types of illness narratives in The Wounded Storyteller (1995; see also Frank, 1994). A narrative type is
‘‘the most general storyline that can be recognized underlying the plot and tensions of particular stories’’
(Frank, 1995, p. 75). While stories are individual, people
‘‘compose these stories by adapting and combining narrative types that cultures make available’’ (Frank,
1995, p. 75). Classifying illness stories in this way is not meant to simplify their complexity, or to contribute to a view of stories as static and as readily classified into particular types. Rather, searching for and illuminating types of stories enhances understanding, as such excavation is an exercise in listening and understanding
(Frank, 1995). Given their inherently complex nature however, all three of Frank’s narrative types will find themselves in any story of illness ‘‘alternatively and repeatedlyylike patterns in a kaleidoscope: for a moment the different colours are given one specific form, then the tube shifts and another form emerges’’.
(1995, p. 76) Stories are always fluid and continually unfold. Nonetheless, the types provide accessible entry points to narrative analysis without being cumbersome.
Frank begins with the ‘‘restitution narrative’’ (1995,
p. 77) arguing that this is the most common form of narrative type. This type moves through three themes, beginning with health, followed by sickness and looking to a return to health in the future. This narrative type is about movement away from and back toward health, exploring experiences of tests, treatments and results. As
Frank shows, the restitution storyline can be both helpful and harmful to people who have experienced cancer. It may be helpful to hear of others and their return to health. Alternatively, a restitution narrative may be thought of as medicalized (Frank, 1995). Viewed in this way, restitution narratives may be seen as a form of social control. They are reflective of Western medicine’s emphasis upon diagnosis, treatment and cure. As such, restitution narratives may function as a social imperative to return to health, thereby losing some of the more subtle nuances of the meaning of illness and its lasting effects.
In contrast to restitution, Frank posits the chaos narrative and its storyline which ‘‘imagines life never getting better’’. (1995, p. 97) These stories ‘‘reveal vulnerability, futility, and impotence’’ and may be considered ‘‘anti-narrative’’ (Frank, 1995, pp. 97, 98).

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Because they lack a specific sequence of timing and experience, stories of chaos are difficult to discern.
Williams concurs, stating that within some illness narratives, ‘‘the ‘orderly sequence of facts’ gets broken up. It cannot be sustained against the chaos’’. (1984,
p. 178) There is however, a strong imperative for us to hear these stories of ‘‘wreckage’’ (Frank, 1995, p. 110).
To ignore or push people through these stories toward restitution narratives, means denying certain experiences and ‘‘people who are being denied cannot be cared for’’
(Frank, 1995, p. 109). Although most people would likely prefer to avoid stories of chaos, they must be uncovered in order to enhance understanding of the meaning of illness and caring for those who experience illness. In summary, chaos narratives depict people
‘‘sucked into the undertow of illness’’ while restitution narratives depict illness as ‘‘transitory’’ (Frank, 1995,
p. 115).
The third type of narrative, the quest, shows how illness may be considered useful (Frank, 1995). Quest narratives are as familiar to our culture as restitution narratives in that most published accounts of illness follow the format of illness as ‘‘challenge’’ and document illness as impetus for change (Frank, 1995, pp. 116, 128). There are three sub-types of quest narratives: (1) memoir in which events are related simply; (2) manifesto in which illness becomes a motivator for social action or change; and (3) automythology in which illness is universally expanded to reveal fate or destiny (Frank, 1995). Similarly, Couser
(1997) argues that published breast cancer narratives constitute their own distinct sub-genre of illness narratives because of the emphasis on illness as a transformative force.
While quest narratives may be considered therapeutic, these narratives may also be considered limited (Couser,
1997). The danger inherent to such stories is that they may show movement through illness ‘‘as too clean and the transformation too complete, and they implicitly deprecate those who fail to rise out of their own ashes’’
(Frank, 1995, p. 135). Couser states: ‘‘The desire of the breast cancer patient as a mortal individual may be to wrap up the story, encapsulating the malignancy and preventing it from infiltrating the entire life’’ (1995, p.
41). Such tidy, or ‘‘wrapped up,’’ narratives may form the basis for cultural imperatives or social prescriptions for living with illness, creating an assumption that once treatments have ended, narratives have also concluded and illness is no longer worthy of discussion. Yet, those who survive breast cancer show that the meaning of illness lasts far beyond the conclusion of treatments. The tendency toward the tidy or conclusive narrative may then become manifest in academic writing as well. For example, in one study, ‘‘the preferred participants were women who never gave in when suffering from breast cancer’’ (Jensen & Back-Petters-

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son, 2000, p. 7). No mention is made of women who, for various reasons, might find it impossible to remain positive, not giving in, while experiencing breast cancer. The lack of attention to the difficulties inherent to a concept such as ‘‘not giving in’’ is alarming. Hence, as Frank (1995) shows, chaos narratives serve as reminders to be cautious about accepting quest narratives uncritically. Thus, chaos narratives, along with the restitution and quest narrative types, provide researchers with a means of exploring the links between culture, individuals and their experiences of illnesses, such as breast cancer.

Method
After obtaining ethical approval from a university’s ethics review board, I collected data for this study via discussions (one focus group and in-depth interviews) with women who had experienced breast cancer. Five women participated in the focus group discussion, the purpose of which was to facilitate the creation of interview guides. Subsequently, 12 women were interviewed on two occasions each.
I began the first interviews with questions that were not related to breast cancer, in order to learn information about the women that extended beyond their experiences of illness. Following these first questions, my use of only a few open ended questions in the initial interview allowed me to follow each woman’s interests and concerns—an unfolding dialogue. These types of questions also gave the women the opportunity to start at the beginning of their breast cancer stories. From previous research, I sensed that it would be difficult for women to speak to me about changes to their bodies without first framing their experiences as stories. This then permitted analysis of both the content and structure of the stories that they shared. It is the material from the first interviews that I refer to here.
The ages of participants ranged from 42 to 77. Only two of the participants were working outside of the home at the time of our interviews. Five of the women described themselves as being retired, while one woman stated that she had been a teacher and did not categorize leaving the profession as retirement. Ten of the 12 women were married and two were widowed. The number of years that had passed since their diagnoses ranged from 1 to 24. Breast cancer treatments included mastectomy, radiation and chemotherapy as well as combinations of these three modalities. Seven women were also prescribed tamoxifen following the conclusion of acute treatments. Using a five year marker, seven of the women could be categorized as long term breast cancer survivors at the time of the interviews. ARTICLE IN PRESS
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Narrative analysis

Findings

Following established guidelines for phenomenological and narrative inquiry, (e.g., Bentz, 1995; Bentz &
Shapiro, 1998; Munhall, 1994; Olesen, 1998; van
Manen, 1990, 1997) transcripts were analyzed both holistically and line by line. A holistic reading provided, for example, an understanding of the women’s stories of breast cancer, while reading line by line facilitated understanding of ongoing issues surrounding the women’s everyday lives—another area of research interest.
Narrative analysis supplemented thematic analyses in that it allowed for examination of the structure and context of women’s stories, grounded in feminist and interpretive theoretical frameworks. Both narrative and thematic analyses are essential to understanding experiences of life after breast cancer, but I focus here upon narrative analysis.
Riessman (1993) describes the following as components of narrative analysis that allow for movement between social context and experience: (1) attending, (2) telling, (3) transcribing, (4) analyzing, and (5) reading.
Similarly, DeVault (1990) writes of talking, listening, editing and writing as understood from a feminist perspective. Attending to experience means reflecting upon the context in which the narrative is taking place.
Within this project, I took note of the location and circumstances surrounding the interviews. In telling experiences, people create selves and decide what information they will share and how to share it.
Transcription may be summative or it may include
‘‘silences, false starts, emphases, nonlexical like ‘uhm,’ discourse markers’’ and soon (Riessman, 1993, p. 12; see also Atkinson, 1998). My transcripts include these elements as well as notations of various emotions that were expressed through tone of voice. Riessman states that analysis ‘‘creates a metastory,’’ (p. 13) as the researcher describes what is signified by the stories, what might be included or excluded and the ways in which the stories might be compared.
Because I prepared a summary of each initial interview for participants to review at the beginning of our second interviews, analysis of the transcripts began as soon as the first interviews were completed. Aware of the tendency of people who have had cancer to attempt to neatly summarize their experiences in ways similar to the restitution and quest narrative types, I asked participants to start the first of two interviews with their diagnoses of breast cancer. While the women’s stories do begin with their diagnoses and move through treatments to the present day, analysis shows that the format of the narratives is complex and does indeed shift between the various types as Frank suggests. In doing so, the narratives reveal much about breast cancer experiences. Restitution
Within the breast cancer narratives, this story form appears to be the one that is most desired by participants. One participant, diagnosed with breast cancer one year prior to our interview, talks of her conversation with a breast cancer survivor and says,
‘‘She had a really normal life. She went back to nursing’’
(Marie). Restitution narratives reflect the desire to return to a time when life was ‘‘normal.’’ Initially, seven of 12 participants begin their interviews with narratives following a restitution form. The women move quickly through diagnosis and treatment, the past, and reintroduce themselves as healthy in the present. Ultimately however, restitution narratives may be the most difficult type of narrative for women who have had breast cancer to sustain, given the altered nature of their bodies as a result of treatments. Is it possible to fully return to a state of health one knew before breast cancer? Even though the response to this question may be negative, there are still many elements of restitution stories to be found within the breast cancer narratives which reflect the desirability of this narrative type.
Moving toward restitution, one woman, a former teacher 16 yr past her diagnosis, describes her discovery of a lump, her medical diagnosis and surgery in one long paragraph and concludes, ‘‘It was all done in a two week period of time, which was very good’’ (Martha).
Without further questioning, she might tend to view her narrative as complete at this point. In a similar vein, another participant, who had been diagnosed 6 yr earlier, says that her appearance changed, but her way of life had not because she is able to do now what she did then. ‘‘Then’’ referring a period of time before she had breast cancer: ‘‘My life hasn’t changed because I have had cancer. It’s the same, what’s changed is the weight, the looks, but not an actual day in my life. I do now what I did before I had cancer. I can’t say there’s been a change. Appearance?
Yes. Way of life? No’’ (Beth). Further, when asked about the change in the appearance of her chest, she says: ‘‘Well, at first I thought it was grossyNow I almost tend to forget. Really, it’s nothing on my mind all the time anymore.’’
While not fully restored to the state of health and wholeness she experienced prior to breast cancer, this participant’s statements convey the idea of restitution.
She is able to forget her body or take it for granted, an aspect of everyday life assumed by those who are healthy and presumably, by this woman before she had breast cancer. Likewise, Marie provides a succinct restitution narrative when she says, ‘‘I’m just thankful that we have the diagnostic equipment, that it was caught early and I had skilled surgeons, that I’m well.’’

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Although this woman tells a story of a return to health, wearing a prosthesis, as she does, is not an unconscious return to health as it requires the conscious action of dressing in a certain way each and every day. A woman who has lost a breast cannot experience a complete return, or restitution, to a previously known state, but she may feel partially reconstructed to that state through the use of a prosthesis. Although wearing a prosthesis enables one woman to say, ‘‘Now I’m the same as everyone else,’’ (Diane) in reality, she is the same as everyone else only when clothed. Thus, despite their reliance upon restitution, participants show that their experiences also lie outside of the domain of restitution. Perhaps then, aspects of the narrative which deal with breast prostheses and the appearance of the chest, would be more aptly classed as reconstruction narratives. However, as Frank shows, restitution narratives can move smoothly and chronologically through past experiences, and then components of other narrative types can intrude. For example, Susan, diagnosed in
1996, moves through the events leading up to her biopsy, including specific days of the week. The story is easy to follow, until she begins to describe her reaction to the diagnosis of breast cancer:
And it was cancer (pauses) so (pauses) that was aah
(pauses) um (pauses) that was quite an experience
(pauses) and, but, you know, I mean, I didn’t mind losing the breast, that wasn’t the thing. I think the thing was, um (pauses) the worry. Knowing that I had had cancer and then, I like, it’s always on your mind, any little thing that goes wrong (pauses). And, um (pauses) now this is my, I had a biopsy yesterday and that’s my third biopsy. Luckily two of them were fine, this one is 99 per cent okay (pauses) and, uh
(pauses) so I won’t know until next week, and then,
(voice becomes inaudible).
The pauses, the sudden introduction of ‘‘ah’s’’ and
‘‘um’s,’’ and the way in which this woman’s voice finally disappears, dramatically illustrate the impact of the possibility of recurrence without the use of an extensive vocabulary or descriptors. Her story becomes difficult to follow, or chaotic, and she leaps from her diagnosis which occurred 4 yr ago to the day prior to our interview. It is evident that recurrence signifies a return to chaos, both within a narrative format and within this woman’s life itself.
It is also interesting to note the times in which restitution narratives are presented and then contradicted, so that what is revealed is the message, ‘‘I am fine. I am still the person I was before breast cancer, but
I have changed.’’ One woman says, ‘‘It [the mastectomy] was like another surgery. Like, I’d gotten rid of the bad, now everything is going to be fineyI have one breast

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less and I’m different, but as far as the cancer goes, it’s gone’’ (Beth). Unlike her earlier statement in which this woman says her body has changed, but she has not, here she does say that she is different thereby contradicting the earlier restitution statements.
Nowhere is the contradiction more pronounced than in the narrative I present next. This participant suffers from the most debilitating side-effects of treatment as compared to any of the other participants, yet her language very much reflects the vocabulary and storyline of restitution narratives. When talking of acute diarrhea associated with chemotherapy, this woman concludes,
‘‘But it went away’’ (Catherine). When talking of a low white blood cell count and being closely monitored for infection because of the low count, she says, ‘‘After a few years, it came back.’’ When she speaks of lymphedema, she says, ‘‘I kept golfing and curling! I could still use my arm.yThings worked out.’’ Finally, she concludes, ‘‘You gradually get better, but all of a sudden, I think I woke up after that third year and I said, ‘You know, I think I feel human again.’’’ Despite ongoing and current physical difficulties, Catherine employs a restitution narrative type to summarize her experiences and asserts that she has returned to a state of health that she experienced before breast cancer.
Perhaps restitution narratives are so powerful because they are most similar to what life might have been like if breast cancer had not intervened. While some might read participants’ words as being indicative of the denial of illness, the women do acknowledge that they have been ill. This suggests that the concept of denial either requires expansion, or, as I would argue, that it is a clinical concept that is not based in my participants’ experience. One woman states, ‘‘If I had a choice, I would have certainly liked to stay how I was’’
(Beth). While this might seem the most obvious response to breast cancer, preferring never to have had the illness at all, it is not the only response I encountered, nor is it a denial that illness has occurred.
For some women, breast cancer is valued as it contributes to their sense of illness as a quest that provides order in the midst of chaos.
Chaos
Within the breast cancer narratives, the chaos narrative figures most prominently in certain situations.
As Frank (1995) states, chaos narratives are often contained within the other two forms. For example, the breast cancer stories told by five participants begin with a state of health and move through diagnosis and treatment. In between are segments of text where the story does not flow well and participants interrupt themselves. Chaos narratives occur most often when participants speak of bodily difficulties and the involvement of other people in their lives.

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One participant’s story flows smoothly when she talks of her decision to have a mammogram, but once she begins to describe the details of receiving a diagnosis of breast cancer, her speech is dominated by sentences that each jump from one sub-topic to another, from a description of a poster in the clinic to the inconvenience of scheduling her mammogram and back to a message her doctor left on her answering machine:
I got called for a recall, but even at that, the recall, you know, there’s all kinds of posters that say you don’t have to be afraid if you get a recall. A lot of people are called and it’s nothing. I got a call saying
I should go for a recall, and it wasn’t convenient, so I postponed it, and again, it wasn’t convenient, so I postponed it. Eventually, I got there and I had the second diagnostic mammogram, and the very next day there was a call on my answering machine when I came home that my family doctor wanted to see me today or tomorrow. (Marie)
As if recognizing some elements of chaos in her speech, this participant asks, ‘‘So is that clear enough?’’
While the events described, or the content, remain somewhat unclear, what is clearly conveyed is that even the passage of time and reflection do not always result in an ordered story, particularly when one returns to those moments that are most traumatic. This is also evident in another participant’s narrative. Her story unfolds with great attention to detail and order until she describes a severe reaction to a medication (Diane). Likewise, when
I asked Fran, who was treated for breast cancer in 1996, about her decision to have a mastectomy rather than a lumpectomy, the past, present and future become somewhat jumbled:
Well, I had a choice and then it’s much easier just to go through a lumpectomy than to have everything taken out, but with the fear of this recurring and the way my breasts were developed with all the little bumps and lumps that are in them, it was better to do the whole thing. That worry was eliminated. Now, I wouldn’t know whether it was a new lump or whether it was a little grape seed that’s in there all the time, so it was best.
The chaos narrative type then manifests itself at several times within each participant’s narrative. It may be evident upon learning the diagnosis of breast cancer, sharing it or experiencing traumatic aspects of treatments. As with Fran’s narrative, Beth, Lynn and
Catherine’s stories also progress until they speak of having to choose between treatments, when their narratives exhibit evidence of discord. Speech deteriorates into sentence fragments, or into run on sentences, with sentences jumping from past to present, doctors’

opinions, to the fear of recurrence, to being unprepared to assume responsibility for such a decision.
Moreover, one woman’s story flows remarkably well as both quest and restitution narrative types, almost as if her story has been regularly rehearsed, until she begins to speak of the impact of breast cancer upon her family’s life: My mother lived with us at the time and she did what she could, but the bulk of it was my husband. If I were to go through it again, I would insist on a parttime nurse/housekeeper combination. I would never put my family through what I didyBut at that time,
I didn’t realize, and they didn’t want anyone in the house to interrupt the pattern that they, and they didn’t want to lose that control, because they were both controlling what they could do and they wanted to do, but if I were to go through it again, I would insist on certain changes. (Arlene)
Although it is not difficult to understand this woman’s speech and her sentences remain relatively intact, the concern with control implies its very opposite, that her family experienced chaos, the opposite of control. In this sense, the narrative becomes chaotic because of its emphasis upon control, an antonym of chaos, and this participant’s insistence that things could be different than they were. This woman’s world, and that of her family, was very much out of control. Her son and her husband controlled what they could—housekeeping—in response to an illness over which people have very little control. Lynn’s narrative also shifts into chaos when she describes her family’s reaction to her diagnosis:
I was in a really, I was just very upset. I couldn’t handle it, I guess. And they were trying, my husband and daughter, walking on eggshells, because they didn’t want to get me upset, and they wouldn’t mention it and they wouldn’t cry because I guess they thought if they cried, I’d get upset. But when I went in, I had to go in to see a counsellor and they came with me, and she’s really, she just sits there and she doesn’t say anything, and it was like, you’re almost uncomfortable at first. But then, she says, ‘‘What is your problem?’’ And I started to talk and she just lets you talk, and as I’m talking, I’m bawling and I said,
‘‘I just feel like I’m crying alone, like there’s nobody to cry with because they’re trying to hold back, so they don’t get me upset, so I end up crying by myself.’’ Lynn’s repeated use of the word ‘‘and’’ demonstrates the sort of wreckage and verbal stockpiling that Frank describes as characteristic of chaos narratives. Lynn’s phrases are strung together and spill out quickly, possibly in the same emotional way that she may have sobbed in the counsellor’s office.

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Another story hops from various medical professionals and various illnesses and symptoms, past and continuing, as the participant describes doctors’ involvement with her body and her life (Susan). This corroborates Frank’s assertions that when one is in the midst of illness, coherent storytelling may be virtually impossible. It is only after one has achieved some distance from illness that storytelling becomes increasingly possible. It is interesting to note however, that even though all of these participants have had time to reflect upon the meaning of illness and had time to frame stories, that elements of incoherence or chaos still emerge. Once treatments have ended, chaos does not automatically disappear and stories may never become ordered, the past haunts the present (Frank, 1995,
p. 60).
The possibility of recurrence also introduces chaotic elements to the breast cancer narratives. Frank shows how chaos may be marked by a stacking of events rapidly in a section of conversation and while this type of verbal stockpiling is present within the breast cancer narratives, more typically, chaos is marked by sentence fragments and questions. For example, when talking about recurrence a participant says:
If there is unusual things that happen, and there has been, because I have had a couple of surgeries since then, they had to take my gallbladder out because it had collapsed. And I didn’t know if I had gotten cancer in that area, if it had spread. Then you wonder, is it cancer? Or what is it? Because you had it before. But so far, it was gallbladder, hernia. It was different things like that. But I don’t dwell on it. But then I have been lucky because I’ve been tested a lot too.yI’ve had bone scans because I have a bad back and there are places you can’t touch. (Beth)
Another participant’s description of the possibility of recurrence also results in sentence fragments and several ideas are presented as a disorderly mass similar to the chaos depicted in the quotation above:
It’s [breast cancer] always on your mind, the back of your mind, any little thing that goes wrong. And um, now this is my, I had a biopsy yesterday and that’s my third biopsy. Luckily, two of them were fine. This one is 99 per cent okay. And, uh, so I won’t know until next week. I am thinking more about it today and this last couple of weeks because of this biopsy I just had. You know I think this has worried me a bit because I got so I could relax and not think about it and all of a sudden this came up. I thought I could go the whole summer without having to have an appointment for a change with a doctor and this came up. So, you know, I’m sure I will be all right— we’ll hope it’s just the inflammation. (Susan)

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While elements of chaos may prevent the development of a coherent story, both participants just mentioned also show how hearing about disruption in the lives of others may be therapeutic, while another woman shows that the desire to express chaos is often outweighed by the family’s desire for restitution, ‘‘I wish there had been someone there.yI could never express some of my feelings because if I expressed negative feelings to my family, it was only going to bring them down’’ (Arlene).
Similarly, she talks of ‘‘having a bit of a pity party’’ and crying over the loss of her breast, yet she did not tell anybody. Would the telling of such chaotic moments be more beneficial than denying they exist? Both telling and hearing chaotic narrative types may provide opportunities for healing. A participant observes, ‘‘People are hurting and need to talk’’ (Lynn).
Adding still another dimension to ways in which chaos might be valued, Beth describes a desire for the acknowledgement of chaos when speaking of her dissatisfaction with a support group. Like three other participants, Beth appears to wish for the opportunity to talk about experiences in their entirety, and also, like another participant, to hear about them:
I went to the group and I thought, ‘‘Well, they’ll talk about it and I’ll find out what the other ladies had went through,’’ like sick, and the treatments, and all that. But nobody talked about it muchyit didn’t seem to be brought up muchyI understand they are going to bring it up moreyBut a lot of it may be too that, maybe a lot of people aren’t comfortable.
Beth was most interested in hearing about feelings and experiences that might be considered negative, ‘‘If you get to feeling sorry for yourself, you listen to someone else and you wonder, ‘Well why do I have to feel sorry for myself? Look at that poor woman, she’s got a little bit more to worry about’ythey will take you out of your doldrums.’’ A second participant says, ‘‘I want to know it all and see it all and talk about it’’ (Fran).
It is significant that two women are able to recognize our culture’s discomfort with chaotic stories, even in the midst of an environment in which they might be most accepted. Support groups are viewed as an appropriate context for the telling of stories, yet even in this setting, some stories are not welcome. Perhaps, members of the support group share the perspective of one participant’s mother, ‘‘If she didn’t talk about it, it wasn’t really there’’ (Catherine). Another woman’s reactions to a support group contradict other participants’ experiences with support groups to some extent, but she does recognize some value in sharing stories:
It can be quite depressing sometimes because you go around the circle and all you’re hearing about is, I shouldn’t say people bitching because that’s not the right word, but people talking about their problems I

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guess. It’s not uplifting in that sense. It’s not necessarily all good news you’re hearingyBut I think there is a benefit from forming at least even loose connections with people in similar circumstances. (Diane)
Chaos narratives then powerfully illustrate the impact that stories may have upon those who are ill. Their absence is strongly felt and noted. Though their absence may be desirable at some points in time by some participants, chaos narratives are also recognized as opportunities for healing. In contrast to the sometimes invisible nature of chaos narratives, stands the final narrative type, the quest.
Quest
Couser argues that all published breast cancer narratives ‘‘may be viewed as doing important cultural workyin the act of writing [the writers] seek to enhance others’ chances of survival and to support them by sharing their experiences’’. (1997, p. 37) But, of the 12 narratives shared with me, only three of them are truly representative of the quest narrative type. Four other stories are partially framed as quest narratives, but they occupy a more tenuous place in this analysis when compared to the more powerful examples provided by the first three.
One woman’s story begins with her life and her work before she had breast cancer. She then moves into her a description of her diagnosis and then briefly summarizes her experiences with treatments. The transitions are seamless throughout her narrative and she concludes her summary with the following statements, ‘‘And, as a result, I’ve done some things I never would have done. I took my first hot air balloon ride last Sunday. It was just simply beautifulyAnd I’ve learned to swim’’ (Arlene).
This aspect of the quest narrative is representative of a memoir. This woman has changed—her diet, exercise, priorities—her life, but talks of this change rather matter of factly.
Another memoir also begins rather subtly as a participant states, ‘‘I found I learned to live one day at a time and try to enjoy it because you just never know’’
(Lynn). Her subtle quest narrative is conveyed as a lesson she has learned. She does not experience restitution, but change. Framing one’s quest narrative as a lesson may be a means of acknowledging that the experience of illness is involuntary, but that the meaning one creates from illness experiences is somewhat voluntary. The implication of framing one’s narrative as a lesson is indicative of a blurring of the boundaries between illness and meaning, as lessons do not imply active choice to change, but a response to external force.
Though both involve change, a memoir is very different from a manifesto.

Arlene’s narrative is representative of both the memoir and manifesto quest narrative type. While the memoir emphasizes simple or ‘‘stoic’’ attention to change, a manifesto carries ‘‘demands for social change’’
(Frank, 1995, p. 120). For example, Arlene has published a pamphlet, distributed through her church, that provides guidelines for conversation with those who are ill. She is also starting a support group in her hometown for women who have had breast cancer.
Lynn is also creating change as she speaks of her future role as the facilitator of a support group.
In contrast, Diane’s story departs from format when she questions the quest, whether or not she is a better person today. Stating that she did not wish to experience dramatic change and describing her reassessment of her life as ‘‘little’’ establishes Diane’s ambivalence about framing her experiences as a quest narrative: It was a decision I think I made that I wasn’t prepared to change my lifestyle dramatically and that’s the right decision for me, but other people do things differentlyySome things I’m not prepared to change at this point. I’m not prepared to give up everythingyIt [breast cancer] gives you the opportunity to reassess a little bit about life.
Further, given her uncertainty about framing her narrative as a quest, and that only three women fully share quest narrative types, one must then question how useful published accounts of breast cancer really are, as they tend to follow this format. Published breast cancer narratives do contribute to a social environment in which breast cancer may be openly discussed, but, at the same time, participants found them lacking. One participant offers a critique of the published narratives when asked about images of women with breast cancer in the media: ‘‘Some women are really gung ho about ityI don’t know, it’s no big thing to advertise. Like why make a big deal? But I suppose it had to be done for other people’’ (Beth).
Even more significant is another participant’s critique of published narratives, despite the ways in which her own story echoes those that are published: ‘‘Celebrities, if they’ve had breast cancer, it’s a big dealyI think they’re making a big dealyyes, it is devastating, but if they would get on and tell someone’s really terrible story and how they have dealt with it, I think people might have more respect’’ (Arlene). This woman begins with a critique of the quest narrative, or at least, those stories that appear to be too neat, too tidy. She wants to hear the ‘‘terrible story’’ which implies that she wants to hear about chaos and turmoil. Yet, she concludes the passage with a reassertion of her belief in cancer stories as quests, saying that one must get on with life. There is no restitution, or return to one’s life before cancer, because

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‘‘yesterday is gone.’’ There is then a tension between chaos and quest.
The two participants just cited had similar reactions to quest narratives. For instance, Beth believes these breast cancer survivors are just ‘‘living their lives’’ and that while stories of exceptional women who climb mountains after breast cancer are ‘‘kind of an upbeat thing’’ one must also acknowledge the ‘‘mental breakdowns and things like that.’’ For Beth and Arlene, published quest narratives then miss elements of chaos that, if included, would result in clearer, or more comprehensive, stories of breast cancer. Hearing, recognizing, and acknowledging all three of the narrative forms are essential to understanding breast cancer narratives. Critical reflections
Frank introduces his text stating that narrative
‘‘[f]rameworks can disentangle types of narratives’’ and help us to envision the ways in which ‘‘the story proclaims a certain relation of the body to the world’’.
(1995, p. 24) Frank’s conceptualizations of narratives types are uncommon in that they are accessible to social and cultural theorists, as well as clinicians and those who have experienced illness. The types offer a means to enhance understanding of the intersection of culture, meaning and experience. Each of the three narrative types, or ‘‘listening devices’’ also point to different paths of understanding that could be explored further (Frank,
1995).
There may be moments when it is difficult to articulate experience. The characteristics of cancer treatments and their long-term effects, such as lymphedema, make it difficult to form a cohesive story about illness and treatment, even when the diagnosis is several years past. Adding complexity to experiences of breast cancer is the uncertainty of treatment outcomes. One must question the effects of biomedical dimensions of illness and treatment and how they might affect one’s ability to shape one’s story. When speaking of the time when her radiation treatments occurred, Diane observes,
‘‘I think what you need to have is support, but the problem is, I’m not so sure I would have been ready to talk to anyone at that point anywayyI wasn’t ready to go to the support group for quite a long time.’’ While some may feel the need to share chaos while in the midst of chaos, perhaps others need time to reflect upon their experiences before discussing them. Susan says she was too groggy just after her mastectomy to appreciate the visit from a breast cancer volunteer. At some point, a restitution narrative may have been inspiring for this participant, but in the midst of treatment, it was not possible for her to receive such a story.

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One might also explore how a quest narrative may be disrupted by a recurrence of breast cancer. Frank states that quest narratives may be ‘‘too heroic,’’ and writes that he has been recalled to ‘‘the pain of having cancer,’’
(1995, p. 136; see also Frank, 2001). Quest narratives emphasize positive change via difficult and trying circumstances. What might happen amidst the chaos of recurrence? The quest narrative could contribute to feelings of loss and betrayal as the empowering nature of the quest is dissolved by a recurrence. Memoir and manifesto may no longer provide comfort in this instance. What type of narrative might then emerge from these circumstances? It is important to recognize that stories continually unfold, and it is up to those who are listening to discern when narratives are being abandoned, reworked or when new forms are emerging.
There may also be situations in which no narrative emerges. Within the specific analytic context of this article, one of my participant’s story is missing, in that her discussion of breast cancer lacks any kind of discernible plot line, whether coherent or chaotic. The absence of narrative is striking when compared to the other interviews as this woman responds negatively to most of my questions. For her, there are no lasting effects and her mastectomy is no different from her seven other operations. She indicated that relatives who had died as a result of cancer made her experiences seem relatively insignificant. This may account for her reluctance to construct a breast cancer story.
Future inquiries may also further explore the concept of restitution, or the idea of a return to a life similar to one experienced before breast cancer. While I indicated that restitution may not be possible, it also may not be desired. Some participants talk of feeling ‘‘let down’’ after treatments are completed. Thus, while active treatments involve both wreckage of body and of narrative as Frank notes, leaving that chaotic context may also be experienced as problematic. A fear of recurrence may mean that full restitution is not possible.
More positively, restitution narratives may be anticipated by people who are ill. Batt writes that it is a medical myth that women with breast cancer can be transformed ‘‘back into ‘perfect people’’’ (Batt, 1998, p.
146), but restitution narratives may also act as positive opportunities for healing. When one participant speaks of her hair loss, she says she thought, ‘‘When I get mine back, I’ll appreciate it more’’ (Martha), and Fran says that she is going to celebrate when she is 5 yr past her diagnosis. Their words could be read as the anticipation of a welcome return to health and well-being, thereby instilling hope and some possibility of a form of restitution. Earlier, I suggested that reconstruction, rather than restitution, might be more readily understood as the underlying structure of breast cancer stories. Such a plot line would involve similar elements of diagnosis and

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treatment, but rather than returning to health, only some semblance of this prior state is both achieved and recognized. For as much as restitution might be desired, participants must also recognize that it is impossible.
While my sample is limited to women who did not elect to have reconstructive surgery, the question remains, if full restitution were a paramount concern, is it possible then that more women would have opted for cosmetic surgery? Instead, they wear prostheses, perhaps a stronger reminder of a body that was, than the scars of reconstruction. Thus, Frank’s narrative types provide a point of departure for uncovering new and emerging narrative forms.
More compellingly perhaps, Frank also provides a way of understanding stories that is accessible to a number of listeners, including those who are not researchers. Honouring narratives may enhance care within a clinical context, if clinicians are provided with a means of understanding stories, such as Frank’s narrative types. Further, without ‘‘deep listening’’
(Frank, 1998), stories which illuminate the chaos and wreckage of illness may be lost, thereby contributing to an oversimplification of the complexity of illness through an emphasis on stories which are culturally preferred. In this respect, restitution narratives may be both helpful and harmful to women who have had breast cancer. Likewise, unquestioningly accepting quest narratives as the sum of an illness experience may contribute to individualistic prescriptions for life after breast cancer. Frank’s work provides a means of engaging with stories and a way of understanding experiences that may otherwise be inaudible. While it is important to recognize that ‘‘all texts stand on moving ground’’ (Riessman, 1993, p. 15), understanding the structure of stories and unpacking their relationship to culture is an essential task for both clinicians and qualitative researchers.

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