Vol. 43 No. 2 February 2012 Journal of Pain and Symptom Management 293

Humanities: Art, Language, and Spirituality in Health CareSeries Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD

Turning Toward Dissonance: LessonsFrom Art, Music, and LiteratureSuzana K.E. Makowski, MD, and Ronald M. Epstein, MDLois Green Learning Community (S.K.E.M.) and Palliative Care Program (S.K.E.M.), Cancer Center

of Excellence, Department of Medicine, University of Massachusetts Medical School, Worcester,

Massachusetts and Departments of Family Medicine, Psychiatry, Oncology and Nursing (R.M.E.) and

Center for Communication and Disparities Research (R.M.E.), Family Medicine Research Programs,

University of Rochester Medical Center, Rochester, New York, USA

Abstract

Conflict and chaos are prevalent in health care, and perhaps especially in palliative care.Typically, our point of entry into our patients’ lives is often at the moment of conflict, discord,or intense suffering. Despite this, little in our formal training as clinicians teaches us how tobe present for this suffering. Much has been written about the process of communication withregard to giving bad news, handling family meeting conflicts, and negotiating shifting goalsof care, but little has been addressed about how to train the clinician to be present with thedissonance and suffering. In this paper, we explore how music, art, and literature teach ushow to stay in moments of tension. In turn, lessons on how to learn to lean into thedissonance of many palliative care encounters are extrapolated. J Pain SymptomManage 2012;43:293e298. � 2012 U.S. Cancer Pain Relief Committee. Published byElsevier Inc. All rights reserved.

Key Words

Palliative care, dissonance, humanities, communication, mindfulness

Clashing discords, loss of equilibrium, ‘prin-

ciples’ overthrown, unexpected drumbeats,great questionings, apparently purposelessstrivings, stress and longing [.] This is ourharmony.dVasily Kandinsky1

Fig. 1. Vasily Kandinsky (Composition 8 [Komposition8], July 1923; Oil on canvas; 55 1/8� 79 1/8 inches[140� 201 cm]; Solomon R. Guggenheim Museum,New York; Solomon R. Guggenheim FoundingCollection, By gift; 37.262).

Address correspondence to: Suzana K.E. Makowski, MD,Palliative Care Program, Cancer Center of Excellence,Department of Medicine, University of MassachusettsMedical School, 55 Lake Avenue North, Worcester,MA 01655, USA. E-mail: Suzana.Makowski@gmail.com

Accepted for publication: June 24, 2011.

� 2012 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2011.06.014

294 Vol. 43 No. 2 February 2012Makowski and Epstein

Those of us who practice and appreciatemusic find solace in the resolution of disso-nance. As an apprentice student of musiclearns, the dissonance before the resolutionis often accentuated, played longer and loud-er, allowing the performer to appreciate theexquisite tension before the (often softer)resolution. In simpler music, these resolu-tions end on a consonant harmony; in morecomplex music, whether it be medieval or21st century, the dissonances resolve into con-sonance tinged with new dissonances, whichthen provide the imperative to resolve onceagain. Music would not speak if it were devoidof dissonance.

Like dissonance in music and the dis-jointed lines and shapes that defy gravity inKandinsky’s watercolors, conflict and chaosare prevalent in health care. We often grapplewith the tensions of cure vs. comfort, develop-ing a problem list vs. finding existentialmeaning, reductionistic diagnosis vs. knowingthe person, the want to live with the accep-tance of dying. As palliative care clinicians,we often anticipate discord and discomfortas we prepare to walk into family meetings(our ‘‘procedure’’). In our day-to-day work,we often find ourselves in these spaces of cog-nitive, emotional, and spiritual dissonance.We need to be prepared for discorddthat isour workdmuch as we seek acceptance, com-fort, and harmony.

Consider the situation faced by Mr. JamesMcKnight (a pseudonym), a 62-year-oldretired electrician. He was admitted to thecritical care unit after being found unre-sponsive and requiring intubation for respi-ratory support. He was known to haveend-stage alcoholic cardiomyopathy andliver failure. Now he was hypotensive andin renal failure.

Mr. McKnight had a large family, the mem-bers of which alternated spending time at hisbedside and in the waiting room. He was di-vorced and had adult children whom hehad not seen in months. His alcoholism hadisolated him from his family during themonths and years leading up to his hospitali-zation. Some children had not spoken withhim for years. His ex-wife and sister hadbeen in touch, though. It was his sister whohad called 911 when he did not answer thephone.

Mr. McKnight had no advance directives.Given his clinical status, he was unable toparticipate in medical decision making. Theintern on the case, Dr. Jean Kreisler, vividlydescribed walking into the family conferenceroom and meeting a cacophony of emotions:the quietly praying sister, the regretful andtearful son who did not want to let go, theangry daughter who suggested he neededto fight on despite the suffering, and thedaughter and ex-wife who held each otherwhile crying out how he never wanted tolive this way. She was struck with the intensityand range of emotions and opinions in oneplace.Dr. Kreisler realized that the ability to stay

present with this level of turmoil and emotionis core to the practice of medicine and yet sherealized that she had few landmarks about howto evince this skill. She asked where she couldturn to further develop her ability to stay pres-ent and lend strength in the face of this levelof suffering and conflict.Anticipating the upcoming family meeting,

when conflict emerges, or when we are in, asKandinsky shares, the ‘‘clashing discords[that often lead to a sense of] loss of equilib-rium,’’ we can face, as Rumi describes in hispoem, The Guest House,2 a ‘‘crowd of sorrows,who violently sweeps your house empty of itsfurniture.’’ The drama of these situations is of-ten the compelling elements of literature; theyboth captivate the attention and evoke fear,tension, and confusion.

Vol. 43 No. 2 February 2012 295Turning Toward Dissonance

Dissonance, Drama, and Conflict‘‘All dramatic stories always involve conflict,’’

writes Professor Ian Johnston in his introductorylecture on Shakespeare. ‘‘Typically, the dramaticnarrative opens with some sense of normal soci-ety[.] Then something unusual and often un-expected happens to upset that normality. [.]Creates confusion and conflict. [.] Attemptsto understand what is going on or to deal withit simply compound the conflict, accelerating itand intensifying it. Finally, the conflict is re-solved.’’3But, the resolution isnotalwaysprettydresulting in forgiveness and reintegration of soci-ety andpersonhood; in fact, themost famousandcompelling plays end in alienation, death, andsorrow. Literature has the advantage of creatingcoherence, even in the presence of unspeakabletragedy; after the hero’s demise, there is often la-ment and ‘‘a reflection of the significance of thelife which has now ended.’’3

Contemporary storytellers continue to useconflict and discomfort to pull in the audi-ence. Storytellers Loren Neimi and ElizabethEllis address the concern writers and cliniciansoften share about confronting or telling un-comfortable stories. They write: ‘‘To assumethat listeners cannot understand the meaningof a story or will not be prepared to deal withdifficult material is to deny the richness andcomplexity of people’s real lives.’’4 The willing-ness to allow these difficult stories to unfoldsometimes asks us to be courageous, curious,and to care about what might happen next.

On the one hand, many clinicians attemptto protect patients from their own stories outof concern that they are unable to either un-derstand the complexity or deal with the diffi-culty of their situation. On the other hand, inpalliative care, we are asked to ‘‘lend strength’’in the face of suffering. This allows the spacefor the story to unfold, to move from disso-nance to whatever might follow. Although res-olution may occur on its own, as palliative careclinicians, our role, when possible, is to facili-tate the opportunity for this form of healing.

From Resolving Dissonance to BeingWith Dissonance

It would seem that our natural inclination,our survival instinct, would be to turn away

from these experiences, to try to escape fromdissonance, tension, and conflict. And, clearlywe do turn away when horrors are too pervasive,intrusive, and meaningless. But, part of whatmakes music beautiful and stories and dramaticnarratives compelling is that they invite us intothe dissonance. In our view, dissonance canteach us two lessons. The first lesson is themore straightforwarddthe potential for resolu-tion if we are willing to stay. This narrative ofhope and redemption is what many of us seek.As palliative care clinicians, when we remainwith a patient and his or her family as they strug-gle from tension to tension, we create room forthe possibility of catharsis. In doing so, we lendour strength, our curiosity about the possibilitythat their narrative will discover meaning, pur-pose, and harmony. By staying we don’t writethe ending but rather facilitate the potentialfor the protagonist to finish their ownstorydpreferably with less pain, distress, andloneliness. This we might call the harmony ofresolution, the narrative of hope, and the resto-ration of proportion and meaning.5

There is a second lesson to be learned fromdissonance, howeverdone more difficult toexpress and explain. By developing a senseof curiosity toward dissonance we may discovera sense of wonder about the rich complexity ofthe human experience and develop mentalstability and courage.6 We all know thatmany of the situations in which we find our-selves clinically have no neat resolution, no lit-erary denouement, no da capo recapitulationof a familiar theme, and no sudden transitionfrom a lament in a melancholy minor key toa major and joyous (if quiet) cadence. Rumireminds us, in his poem, The Guest House,that many of our ‘‘visitors’’ or houseguestscome unexpected, carrying jarring messagesthat might not be what we want to see orhear. Many centuries later, the romanticpoet, Rilke, evokes a similar spirit, exploringwith us his experiences of ‘‘the rest betweentwo notes, which somehow are always in dis-cord.’’7 Neither poet tries to fix the tension,but each creates the opportunity for us to dis-cover the beauty that lives within the disso-nance. Perhaps this discovery of how to ‘‘bewith dissonance’’ without the attempt to re-solve the tension teaches us to welcome theunexpected visitors described by Rumi, ratherthan to fear them.

296 Vol. 43 No. 2 February 2012Makowski and Epstein

Practicing Attention, Practicing BeautyHow do we discover the curiosity and cour-

age to ‘‘meet [these guests] at the door laugh-ing, and invite them in’’ or to experience this‘‘rest between two notes which are somehowalways in discord’’ as beautifuldtremblinglybeautiful? Unfortunately, here medical train-ing has had little to offer its practitionersdtothe detriment of the well-being of its work-force. As clinicians, researchers, and educa-tors, we have had to rely on other traditionsthat focus on the person of the practitionerto learn to stay present, to practice nonaban-donment, to lend strength, and to engage inthe practice and discipline of approaching dis-sonance with willing eyes open.

Practicing to pay attention or to stay presentwhen situations are uncomfortable is taughtin many meditative traditions. Recent researchon experienced meditators suggests that they(as compared with novice meditators) havea greater capacity for self-regulation of whatmany consider to be ‘‘automatic’’ reactions tostressful events. Whereas popular lore wouldhave it that meditators would have a sense ofequanimity and personal distance fromdistress-ing events, Lutz and other researchers havefound exactly the opposite. Experienced medi-tators showed signs of increased cardiovascularresponse and enhanced brain activity in theareas associated with emotions and physicalsensation, suggesting that they have more in-tense responses to the suffering of others. Inter-estingly though, they simultaneously seem toshow increased activation of the areas of thebrain linked to discernment between self andother as well as compassion. Their immediate

response to stress was more robust than thatof novices, but their recovery from the initialcardiovascular stress response was also quicker.8

Although preliminary, this line of research sug-gests that it is possible to be both present andmaintain good boundaries and that as Kearneysuggests, the opposite of burnout is not avoid-ance but engagement with suffering.9 Thisline of research challenges the notion that toavoid burnout, we must disengage.The discovery that more meditation leads to

increased intensity of the response to sufferingmay be surprising to many readers. On furtherconsideration, the practice of meditation trainsus to explore uncomfortable moments, andevenmoments of suffering, with curiosity, allow-ing us to dig deeper and stay with them longer.The first step, one might say, is to know one-selfdto learn how to stay when we are uncom-fortable with our own silence, with a busymind, or perhaps with the itch on the nose; tolearn how to stay, or to come back to being pres-ent and attentive, when our inclination is tomake a phone call, write a list, or scratch ournose. It is much like learning and practicingthe scales for a musician or stretching for anathlete. Our minds and bodies learn how tostay, how to stretch, and how to lean into the ex-perience and explore it instead of moving ontoanother task. While we learn to explore the ex-perience before us, we gain a curiosity, an in-creased compassion, and simultaneously, wedevelop the ability to distinguish the sufferingof the person before us from our own.

There’s only one way to come to understandthe other person’s story and that’s by beingcurious. Instead of asking yourself, ‘‘Howcan they think that?!’’ ask yourself, ‘‘I wonderwhat information they have that I don’t?’’.Certainty locks us out of their story, curiosityleads us in.dStone et al.10 (p. 37)

The ability to stay present in moments of ten-sion is not limited to meditative practice butalsomay be learned from the arts and literature.The development of curiosity toward episodesof dissonance and their potential for resolutionare taught to children through music, litera-ture, children’s tales, and even Disney movies.A good storyteller builds the narrative to a disso-nant crescendo before taking the listener to itsclimax, to its resolution. Rarely have I heard ofpeople standing up and leaving the story or

Vol. 43 No. 2 February 2012 297Turning Toward Dissonance

a movie at its most tense moment. Even chil-dren sit on the edge of their seats, grippingthe chair, eager to know if Peter Rabbit willescape Mr. McGregor in the gooseberry net orwhat will happen after Snow White accepts theapple from the witch.

Music and Awareness

An unstable tone combination is a disso-nance; its tension demands an onward mo-tion to a stable chord. Thus dissonantchords are ‘‘active’’; traditionally they havebeen considered harsh and have expressedpain, grief, and conflict.dRoger Kamien11

Music has the potential to expand the capac-ity to find beauty in dissonance. As a complexand mature piece, Brahms’s A German Requiemgoes from dissonance to dissonancedelementswithin each dissonance leading to resolutionsthat are only partial and that carry the listenerthrough a range of emotions. Mourners don’tleave the concert hall during the second move-ment of the Requiem; they stay, drawn in by theintroduction of exquisitely sculpted melodieswhose beauty brings those dissonances intoeven sharper relief.

Music teaches a similar lesson to narrative butwithout words. Musical dissonance is consideredto be a combination of notes creating an un-stable chord whose ‘‘tension demands anonward motion to a stable chord.’’7 Often con-sidered un- or less harmonious, these musicalintervals are associated with ‘‘pain, grief andconflict.’’11 Dissonance in music is not merelya property of harmony (the simultaneoussound of several pitches at the same time) ormelody (a sequence of pitches in time) butalso can emerge in the rhythm and cadenceof a piece.

Learning to play music is in some ways‘‘practicing dissonance.’’ The beginningmusician is consciously aware of each noteand each step and only later becomes awareof the overall coherence of his or heractions. Similarly, a novice clinician learnshow to verbalize and be present with suffer-ing by starting to think carefully of eachword selection, the steps of conducting a fam-ily meeting, or responding to emotion. Withpractice, the clinician is able to move beyond

these cognitive steps and lean into narrative,noting and navigating from dissonance todissonance.

In a recent Technology, Entertainment,Design (TED) lecture, ‘‘Benjamin Zander onMusic and Passion,’’12 the conductor of theBoston Philharmonic, demonstrates how,through intense practice, the musician cancreate the illusion of regularity of pulse, evenwhen it is immensely irregular. PlayingChopin’s Prelude in E-minor, he reveals thatthe sense of regularity, coherence, and flow isa carefully constructed illusion. The rhythmsounds regular, yet, on careful listening, onerealizes that he creates an illusion of steadymotion by exaggerating the length of somebeats and shortening others. This distortionof beat-to-beat variability draws the listenerin. The performance, thus, is artdit is not‘‘natural’’ in the sense of a heartbeat or bird-song but rather beautifully and intentionallycrafted. In the face of discord, horror, and suf-fering, empathic responding is, in a certainway, not a ‘‘natural’’ response either. Naturalresponses are to withdraw from pain andugliness and seek calm, peace, and comfort.Artdand medicinedteach us that beautydoes not emerge from mindless tranquilitybut rather can be discovered when we delveinto the very dissonance that we instinctuallytry to avoid.

Slowing Down

So I think healing has to do with slowingdown, coming into the present, listening,accepting, forgiving, entering into commu-nity with, and healing is prevented by theopposites of those things.dBalfour Mount,MD13

Benjamin Zander tells the TED audiencethat too often young pianists stop playing justbefore they learn how to transform a series ofnotes into the coherent melody. Too often,he explains, the young musician gets stuck inthe tasks of hitting the notes, misses thebeauty, and then walks away from the instru-ment. Clinicians learn the steps to conductingfamily meetings, to respond to emotion butoftendlike young musicians frustrateddstop

298 Vol. 43 No. 2 February 2012Makowski and Epstein

when the emotions are too intense and fever-ish. Overwhelmed, the inclination is to endthe meeting, plan a follow-up, or answera page. In the case presented, Dr. Kreisleridentified another possibility, one where shewould know how to respond, stay, slow down,and potentially heal.

By entering into this moment of disso-nance, the full clash of symbols, the narrativecatharsis, Dr. Kreisler had a choice to followher initial instinct to withdraw or respond inthe manner that she had learned from art,music, and literature: to practice beauty. Dr.Kreisler returned to the family and acknowl-edged the emotions and their source: thetragic condition of Mr. McKnight. The com-plexity of the family dynamics had developedover decades and would not be fixed or re-versed, nor could Mr. McKnight’s impendingdeath be denied. The intern watched and lis-tened, not knowing what else she could do.Her steady presence allowed a quiet transfor-mation: the family took their turns visitingMr. McKnight and without discourse allowedeach person to experience their singulargrief. Once each had taken their turn tellingthe patient what they needed to say, togetherthey looked to Dr. Kreisler and told her it wastime to let him go. Nothing had been fixed.No lives had been saved. No sense of redemp-tion provided.

By exploring the possibility of being pres-ent in conflict without the need to assure res-olution but rather with a curiosity for andwillingness to ‘‘show up,’’ she created the op-portunity for healing. This practice is notmerely a cognitive or behavioral act but an ar-tistic mastery that demands patience, atten-tion, and curiosity. It asks the clinician tochallenge the natural instinct of turningaway from suffering, discord, and tensionand instead to explore its nuances, its possi-bilities, and how it may unfold. In this man-ner, by practicing beauty, the novice cangrow into an experienced, compassionate,and effective clinician.

Disclosures and AcknowledgmentsNo funding was received for this work and

the authors declare no conflicts of interest.

References1. Lindsay KC, Verge P, eds. Kandinsky: Completewritings on art. Cambridge, MA: Da Capo Press,1994:193.

2. Rumi J. The essential Rumi. In: Barks C, MoyneJ, trans. San Francisco, CA: Harper, 1995:109.

3. Johnston I. Studies in Shakespeare [Video] 1999.Nanaimo, British Columbia: Malaspina UniversityCollege. Available from http://records.viu.ca/wjohnstoi/eng366/lectures/lecture1.htm. AccessedJune 6, 2011.

4. Niemi L, Ellis E. Inviting the wolf in. Atlanta,GA: August House, Inc, 2006:24.

5. Frank AW. The wounded storyteller: Body, ill-ness, and ethics. Chicago, IL: University of ChicagoPress, 1997.

6. Dyche L, Epstein RM. Curiosity and medical ed-ucation. Med Educ 2011;45:663e668.

7. Rilke RM. Selected poems of Rainer MariaRilke. In: Bly R, ed. New York: Harper Perennial,1981:31.

8. Lutz A, Greischar LL, Perlman DM,Davidson RJ. BOLD signal in insula is differentiallyrelated to cardiac function during compassion med-itation in experts vs. novices. Neuroimage 2009;47:1038e1046.

9. Kearney MK, Weininger RB, Vachon MLS,Harrison RL, Mount BM. Self-care of physicians car-ing for patients at the end of life. JAMA 2009;301:1155e1164.

10. Stone D, Patton B, Heen S. Difficult conversa-tions: How to discuss what matters most. NewYork: Penguin Books, 1999:37.

11. Kamien R. Music: An appreciation, 6th brief ed.Columbus, OH: McGraw-Hill Humanities/SocialSciences/Languages, 2007.

12. Zander B. Benjamin Zander on music and pas-sion [Video]. 2008. Available from http://www.ted.com/talks/lang/eng/benjamin_zander_on_music_and_passion.html. Accessed June 6, 2011.

13. A wayfarer’s journey: Listening to Mahler. Dir.R.Y. Drazen. 2007. PBS Home Video. DVD.