Cheryl overdosed on heroin — or so she’d hoped — the night before. But that’s not the reason she’s in the emergency department late the next day with me sitting at her gurney, confused.

She woke up this morning so upset to be alive she kicked a wall at the homeless shelter and broke her toe. But that’s not why she’s in the ED, either.

Something came up a few weeks ago that made her miss her appointment at the methadone clinic. That absence got her kicked out of the clinic for 30 days, or so she said. The withdrawal symptoms made her want to die, and returning to heroin was the easiest solution. But wanting to stop using heroin isn’t the reason she’s in the emergency department.

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And then her boyfriend died unexpectedly. It wasn’t related to their drug use, or so she said. He was in his 30s, an age when hearts don’t just give out. He was her love, her reason for getting clean, but he was also the one who found her veins. So when she needed heroin after he died, she skin popped.

Angry-looking abscesses now pock her arms. She extends them to me and looks away, but neither shame nor infection drove her to the emergency department late at night.

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The police had been called for a disturbance in the shelter that involved Cheryl. She wouldn’t shut up, and her mouth earned her a ride to the emergency department. She didn’t want to be here — she made that point loud and painfully clear — yet she complained about the wait to see a doctor.

The lines in Cheryl’s cheeks and jaw were sharp and striking. Her eyes, I noticed, were sea blue, the sadness as troubling as any ocean. She was anxious, jumping out of her skin, and too thin: symptoms of narcotic withdrawal, or so she said.

But these symptoms could be a separation from, and the need for, a more potent substance: hope.

When I asked Cheryl if she wanted to kill herself, whether she still possessed the desire to die, she turned away from me and didn’t answer. I didn’t fill the silence but just sat there. After taking a deep breath, she said: “I’m stuck in a tornado of life.”

What do you say to someone caught up in the tornado of life, whose problems are so woven into other problems that you’re almost afraid to tug at a single thread for fear of everything unraveling?

The plot of Cheryl’s story was hard to listen to. I was afraid to ask more questions. There was no bottom to her troubles. Pitted against the “tornado of life,” I felt utterly powerless.

Luckily, I recognized that she was telling me a “chaos narrative.” The sociologist Arthur Frank framed the pivotal idea of the chaos narrative. It refers to patients’ stories that smack of a complete loss of control. If a narrative describes a sequence of connected events, then a chaos narrative defies such ordering. Frank points out that putting language to these experiences can be difficult for patients. They can possess a hurried quality, as if the person is trying to “catch the suffering in words.”

Medicine, however, prides itself on the pretense of control, the romance where problems are managed and remedies offered. Chaos narratives threaten the safety of this paradigm and cut through clinicians’ psychic defenses. These unmoored storylines may not only provoke clinicians to interrupt, but also stir their anxieties. Everyone is vulnerable to the tornado of life.

The fundamental challenge in listening to a chaos narrative is the ability to sit with the chaos and not to steer the patient away from her feelings. “To deny a chaos story is to deny the person telling the story,” wrote Frank, “and people who are being denied cannot be cared for.”

Understanding that Cheryl was telling me a chaos narrative gave me some comfort. My responsibilities became clearer. I didn’t offer balmy optimism, suggest that everything would be OK, you’re just going through a tough stretch. I avoided the reflex to take the wreckage and make a bouquet. Resisting that impulse was hard, but I took my cue from Frank and his idea of the chaos narrative.

“I can’t imagine what you’re going through,” I said. The response to a chaos narrative isn’t simplifying what isn’t simple or solving what isn’t solvable, but to sit with the complications and acknowledge that life can be hellish and even hateful. “And I’m not going to pretend that I do.”

Cheryl cried and tried to laugh the tears away.

“So what’s next?” I asked.

A long silence followed.

“Look at me,” she said, lifting her arms as if the bruising and abscesses said everything she couldn’t.

“I can see that,” I said. “What’s next,” I asked again. “What happens when you wake up tomorrow? Can you write that line?”

Her hands groped the air, her mouth searching for words. In these situations, it’s easy for frustration to creep in. One possible reaction by the listener to this uncomfortable feeling is to feel nothing. There are claims that medical providers suffer from a lack of empathy. But instead of a diminishing or hardening of hearts, I wonder if the problem relates to caring for patients whose needs are overwhelming, ungraspable, and even intimidating, and being at a loss about how to respond.

“Can you write that line?” That question surprised me. Behind it, I think, wasn’t the impression that tomorrow will be better, but the recognition that tomorrow has weight, that every tomorrow is an achievement.

Cheryl’s medical issues were complicated but familiar. My next steps were clear. X-ray her toe. Consult psychiatry for her suicide attempt. Take a multi-dimensional approach to her substance use disorder — aimed toward treatment, overdose prevention, and harm reduction — which would include offering medication-assisted treatment for her withdrawal, counseling with a peer recovery coach, and naloxone training.

But first I sat there. Cheryl sat there, too. The silence grew between us and I desperately wanted to fill it, to move things along. There were other patients to see, other chaos narratives to sit with. This type of listening is hard. Cheryl wasn’t yelling anymore, but what I heard in her efforts to disturb the quiet was chilling.

Jay Baruch, M.D., is associate professor of emergency medicine and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University. The patient’s name and identifying details have been altered to protect the patient’s privacy.

  • I welcome and really appreciate this article. It was the next piece I needed in my own counseling work, esp. the reference to Frank’s book. Thanks so much.

  • Doctor have our own Chaos Narrative. For a long time I have taught that the fundamental experience of being a doctor (or other front line caregiver) is chaos. I have called it “the whirlwind”. The challenge is patient care and the episode you describe above is only a portion of the madness that is your daily whirlwind.
    The challenge is simple: from the inside of the whirlwind all you can see is the inside of the whirlwind … things coming at you from all directions, including the patient’s overwhelm and struggles.

    This is why team huddles and mindfulness are so important. To give you a break from the whirlwind and a method of recentering to be the eye of the storm.

    Much more to teach/say/practice.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • The implication here by a condescending doctor, is that this person brought it on herself, because he describes the drug use as central to the story. These kinds of narratives can be heard from people without substance issues, but they are not as riveting and have no room for judgemental, feel good observations.
    There are plenty of seniors living on the streets homeless and in similar situations without drug use. All it takes is an injury, illnesses, job loss or a rent increase. This doctor conflates all of these “Trauma Narratives’ with drug use. Children are born into these “chaos narratives” and no help or understanding is available as they get exploited and abused by the system. Of course that would not be interesting reading here, because many of the readers are complicit.

    So sick of these adversity porn, “look how woke or compassionate I am, shameless self promotion.

  • Such BS, physician contributed to the “Chaos Narrative” when they ruined so many lives and covered it up. They are still in denial as is illustrated here, demeaning and shaming patients and then portraying themselves as if they have a clue about any of these issues, is still killing more patients

    No one should get the idea that any of them even treat patients they consider their “lessers” as if they are human. These are the kinds of lies and false narratives they have been running for 20 years, as the rates of suicide, overdoses, alcohol deaths and deaths of despair climbed. None of this adversity porn, relates the economic disparities. Disgusting false narratives are killing even more people.

    • It sounds like you may be in the middle of your own chaos narrative that makes you write such a harsh comment on a narrative of compassionate care. I hope you can find compassion in your own life, and peace.

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