Strong Mindfulness: Integrating Mindfulness and Character Strengths

Strong Mindfulness: Integrating Mindfulness and Character Strengths

Ryan M. Niemiec, Tayyab Rashid, Marcello Spinella (2012). Strong mindfulness: Integrating mindfulness and character strengths. Journal of Mental Health Counseling, 34(3), 240-253. Reprinted With Permission.

This article explores the integration of mindfulness meditation and character strengths. Beyond simply focusing attention, mindfulness involves the cultivation of attention infused by an unconditional friendliness and interest. Universally valued character strengths (Peterson & Seligman, 2004) are useful constructs for such an infusion. Most mindfulness approaches and programs deal with managing a problem or psychological disorder; far less discussion, empirical work, and scholarly papers have addressed mindfulness from a positive psychology perspective that explicitly attempts to increase what is good. We review research and practice considerations for such an integration and discuss how character strengths enhance mindfulness (i.e., Strong Mindfulness) by dealing with barriers to mindfulness practice and augmenting mindful living in walking, driving, consuming, speaking, and listening.

Mindfulness and character strengths, which have often been discussed in the literature of positive psychology, have much in common. Each is a universal quality, something that taps into what it means to be human. Each has been viewed as transient, as well as more enduring. Each can be seen as a “process” or higher-order procedure that can be layered onto a counselor’s current orientation in working with people; and both mindfulness and character strengths can be heightened deliberately (Borghans, Duckworth, Heckman, & ter Weel, 2008; Kabat-Zinn, 1990; Peterson, 2006).

Considering these parallels and the positive benefits of mindfulness and character strengths individually, it is surprising how little has been published about their explicit integration and mutual impact. One exception is a chapter by Baer & Lykins (2011), who explored the connections between mindfulness and domains of positive psychology, such as character strengths and virtues, well-being, and optimal functioning. Another exception is Niemiec (2012b), who suggested ways that character strengths can serve as intervention pathways of mindful living through the five mindfulness trainings conceptualized by Thich Nhat Hanh (Nhat Hanh, 1993; Nhat Hanh & Cheung, 2010). Niemiec (2012a) has also created Mindfulness-Based Strengths Practice (MBSP), an eight-week program that integrates mindfulness and character strengths. MBSP merges the best practices of each field; through meditations, exercises, and dis­cussions, participants discover synergies to improve their engagement with life, life meaning, relationships, coping, and well-being.

This paper primarily discusses the conceptual overlap between mindfulness practices and character strengths. Although further research is needed to confirm our ideas, we suggest that the integration of mindfulness and character strengths offers distinct and promising benefits for those who practice mindfulness and those who work with character strengths by

  • Offering individuals who practice mindfulness a way to confront, man­ age, or overcome obstacles that naturally emerge during mindfulness practices (e.g., mind wandering, painful body sensations).
  • Giving mindfulness practitioners concrete tools to widen perspective and deepen practice by employing particular strengths (e.g., persever­ance) as needed during mindfulness
  • Giving mindfulness practitioners a language to capture positive states and traits that can often be outcomes of
  • Facilitating increased self-awareness and potential for change by bring­ing one’s character strengths more clearly into view.
  • Creating a synergy of mutual benefit that can foster a virtuous circle and upward positive spirals; as mindfulness increases, so does awareness of personal strengths and the potential for continued interaction between the two.

BACKGROUND AND RESEARCH

Character strengths are viewed as capacities of cognition, conation, affect, and behavior— the psychological ingredients for displaying virtues or human goodness. Character strengths influence each other; they do not occur in iso­ lation (Peterson, 2006). They are dimensional-considered in degrees— and vary in relevance depending on the context (McGrath, Rashid, Park, & Peterson, 2010). Though they are viewed as stable over the lifespan, deliberate intervention is one of many ways they can be impacted (Borghans et al., 2008).

One of the most substantial and impactful projects in positive psychology has been the VIA Classification of 24 character strengths and 6 virtues (see Table 1), which was developed as a common language for describing one’s best qualities (Peterson & Seligman, 2004). This work emerged from collaboration between 55 scientists and review of over 200 works from the last 2,500 years by the greatest philosophers, theologians, educators, and scholars. From historical review, application of various criteria for strengths, and other analyses, the VIA Classification was established; it was followed by the VIA  Inventory of Strengths, a scientifically valid instrument that assesses the 24  character strengths (Park & Peterson, 2009; Peterson & Seligman, 2004).

Recently, scholars proposed a two-part operational definition of mindful­ness. Bishop and colleagues (2004) suggested that one core element is the self-

Table I. The VIA Classification of Character Strengths: Six Virtues and 24 Character Strengths, Universal Across Cultures, Nations, and Religions Spanning 2,500 Years.


Wisdom and Knowledge – cognitive strengths that entail the acquisition and use of knowledge

  • Creativity [originality, ingenuity]
  • Curiosity [interest, novelty-seeking, openness to experience]
  • Judgment [critical thinking, open-mindedness]
  • Love of Learning
  • Perspective [wisdom]

Courage – emotional strengths that involve the exercise of will to accomplish goals in the face of opposition, external or internal

  • Bravery [valor]
  • Perseverance [persistence, industriousness]
  • Honesty [authenticity, integrity]
  • Zest [vitality, enthusiasm, vigor, energy]

Humanity – interpersonal strengths that involve tending and befriending others

  • Love [capacity to love and be loved]
  • Kindness [generosity, nurturance, care, compassion, altruistic love, “niceness”]
  • Social Intelligence [emotional intelligence, personal intelligence]

Justice – civic strengths that underlie healthy community life

  • Teamwork [citizenship, social responsibility, loyalty]
  • Fairness
  • Leadership

Temperance – strengths that protect against excess

  • Forgiveness [mercy]
  • Humility [modesty]
  • Prudence
  • Self-Regulation [self control]

Transcendence – strengths that forge connections to the universe and provide meaning

  • Appreciation of Beauty and Excellence [awe, wonder, elevation]
  • Gratitude
  • Hope [optimism, future-mindedness, future orientation]
  • Humor [playfulness]
  • Spirituality [religiousness, faith, purpose]

Source: Peterson & Seligman, 2004. Copyright VIA Institute on Character, 2012. Reprinted with permission; www.viacharacter.org.

regulation of attention toward the present moment, whether to internal experience (e.g. thoughts, memories, emotions) or external (e.g. sights, sounds, touch, etc.). Another core element is curiosity, openness, and acceptance  of the experience in the present moment (Bishop et al., 2004). These two elements are essentially character strengths: self-regulation and curiosity. They are common  to nearly every definition of mindfulness and may represent a maxi­mally parsimonious definition of it (Coffey, Hartman, & Fredrickson, 2010).

Taking the connection further, mindfulness could be described as an overarching human strength closely linked with human well-being (Masicampo & Baumeister, 2007; Wallace & Shapiro, 2006) and the ability to adaptively self-regulate feelings and actions (Baliki, Geha, Apkarian, & Chialvo, 2008; Eisenberg & Spinrad, 2004). Rather than perceiving psycholog­ ical phenomena as fixed, a mindful disposition encourages us to treat them as transitory and impermanent (Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002). Such a disposition, however, requires repeated effort — usually through regular meditation (self-regulation) practice ー which allows individuals to move toward healthier regulation of feelings and actions (Kabat-Zinn, 1990). Baumeister and colleagues likened self-regulation to a muscle in that it is a lim­ited resource whose strength can be depleted or built up with practice (Baumeister, Matthew, DeWall, & Oaten, 2006; Muraven & Baumeister, 2000). In flexing the self-regulation muscle, a mindful disposition offers new insights by enhancing cognitive flexibility, which decreases the need to control or alter environment and experiences; the individual then moves toward more acceptance and genuine appreciation (Chambers, Gullone, & Allen, 2009).

The study of mindfulness meditation and mindfulness-based practices has been burgeoning (Brown, Ryan, & Creswell, 2007). No doubt this is in part due to the work of Jon Kabat-Zinn and his Mindfulness-Based Stress Reduction (MBSR) program (Kabat-Zinn, 1990). Mindfulness training has relieved many psychological and medical conditions, among them chronic pain (Kabat-Zinn, 1990); anxiety disorders (Hayes, Strosahl, & Wilson, 1999); depression (Segal et al.,2002); substance abuse (Bowen et al., 2009); binge eating (Kristeller & Wolever, 2011); and borderline personality disorder (Linehan, 1993).

Most of these programs have focused on decreasing problematic (e.g., stress, pain, marital conflict) or psychopathological behavior (e.g., depressive episodes, anxiety, substance use, binge eating). Such a problem area sets a framework of “decreasing” or “getting rid” of something that is wrong or dys­functional. But although this aspect is not assessed routinely, mindfulness nat­urally engenders positive emotions that have seldom been a subject of systematic inquiry. For example, a recent randomized trial of Mindfulness­ Based Cognitive Therapy (MBCT) found an increase in positive affect and pleasure in daily life experiences compared with a control group (Geschwind, Peeters, Drukker, Van Os, & Wichers, 2011). While many mindfulness programs do measure positive outcomes (e.g., mood, vitality, physical health), we are not aware of any that focus explicitly on using awareness, exploration, and enhancement of positive phenomena as the main approach and intention, and certainly none that focus directly on core, positive personality traits — char­acter strengths. It is fair to say, however, that at some point most mindfulness programs focus on the positive, as in the “pleasant events calendar” used in MBCT, values clarification in Acceptance and Commitment Therapy, and healthy communication practice in Mindfulness-Based Relationship Enhancement. Moreover, the tone and atmosphere of most mindfulness pro­grams is positive and accepting, as witnessed in the debriefing of exercises and sharing of personal experiences in standard MBSR groups.

The last decade has produced a number of effective mindfulness and mindfulness-based psychological interventions (Allen, Bromley, Kuyken, & Sonnenberg, 2006; Baer, 2003). Table 2 presents several for which we inferred character strengths that may directly or implicitly moderate effectiveness.

Mindfulness seems to be a core feature of many cognitive-oriented strengths (the virtue of wisdom and knowledge) and self-control-oriented strengths (the virtue of temperance). Ellen Langer (1989, 2005) took a cogni­tive view when she defined mindfulness as the continuous creation of new cat­egories, openness to new information and novelty, and implicit awareness of more than one perspective. Similarly, in character strengths language, curios­ity (pursuing novelty) and judgment (being open to new information) might be seen as acts of creativity and learning. The temperance strength of self-regula­tion has been viewed as central to mindfulness because all self-regulation strategies are based on feedback loops that can be enhanced through attention (Shapiro & Schwartz, 2000).

The other-oriented, interpersonal strengths related to the virtues of humanity and justice may often be the fruits of solid mindfulness practice, as has been discussed for leadership (Boyatzis & McKee, 2005) and love (Carson, Carson, Gil, & Baucom, 2004). However, some interpersonal strengths (e.g., kindness) are particularly important to the process of mindfulness and to main­taining a regular practice (Salzberg, 1997). The transcendence strengths seem to be a way to make mindfulness practice more meaningful, as can be seen in the connection between mindfulness and spirituality and meaning (Carmody, Reed, Merriam, & Kristeller, 2008) and in the light-hearted approach sug­gested by Gunaratana (2002), which is like the humor strength. The courage strengths might be called forth to deal with internal and external obstacles con­sistent with a genuine, deep mindfulness practice. Evans, Baer, & Segerstrom (2009) found that mindfulness predicted persistence during a difficult labora­tory test. Mindfulness has also correlated positively with authenticity, a dimen­sion of the strength of honesty (Lakey, Kernis, Heppner, & Lance, 2008).

Table 2. A Sample of Mindfulness Studies and the Potential Character Strengths in Use

Presenting Problem or Outcome Potential Character Strengths Utilized Researchers
Clinical
Effective prevention of depression

relapse

 Perspective, Curiosity, Judgment,

Spirituality

 Ma & Teasdale, 2004; Segal,

Williams, & Teasdale, 2002
Residual depressive symptoms Curiosity, Perseverance Kingston, Dooley, Bates, Lawlor, &

Malone, 2007
Anxiety Self-Regulation, Bravery, Fairness,

Curiosity

 Evans et al., 2008; Kabat-Zinn, 1990
Body-image issues Gratitude, Kindness Stewart, 2004
Drug abuse Self-Regulation, Bravery Gifford et al., 2004; Hayes, Strosahl,

&Wilson, 1999
Trauma Perseverance, Bravery, Hope Follette, Palm, & Pearson, 2006
Nonclinical
Improved attention and working

memory

 Self-Regulation, Love of Learning Chambers et al., 2008; Tang et al., 2007
Reduced anxiety; adaptive dealing with threat Self-Regulation, Curiosity, Perspective Brown, Ryan, Creswell, & Niemiec, 2008; Shapiro, Schwartz, & Bonner, 1998
Adaptive stress response Self-Regulation Davidson et al., 2003
Improved romantic relationships Love, Kindness, Social Intelligence Cordova & Jacobson, 1993
Decreased negative self-focused

attention

 Zest, Humor Murphy, 1995
Decreased negative affect Zest, Hope Brown & Ryan, 2003; Chambers, Lo, & Allen, 2008

CHARACTER  STRENGTHS  AND MINDFULNESS PRACTICES

Some character strengths are part of the core process  of  mindfulness, some may enhance mindfulness practice, and others are outcomes of that prac­tice. We next describe some mindfulness practices and identify character strengths that both promote and are enhanced by mindfulness practice.

Practices often found in mindfulness-based programs are the body scan, sitting meditation, three-minute breathing space, eating meditation, mindful walking, mindfulness with emotions, loving-kindness meditation, and mindful yoga (Carson et al., 2004; Kabat-Zinn, 1990; Segal et al., 2002). Each requires such character strengths as perseverance, self-kindness, and perspective.

Raisin Exercise: A well-known formal practice is the raisin exercise, in which participants practice using curiosity and an open “beginner’s mind” by taking several minutes to explore and eat a single raisin. With this exercise, the core of mindfulness practice emerges: Participants practice regulating their attention by returning their wandering minds back to exploring the object of their attention, the raisin, with curiosity and interest.

Body Scan and Mindful Yoga: Exercises directly involving the body, such as the body scan and mindful yoga, invite participants not only to be curi­ous and accepting of their body and its wonders, beauties, and limitations, but also to be kind and compassionate toward it during the practice. Kindness directed to the self is a core part of meditation practice (Brahm, 2006).

Breathing Space Exercise: Another common meditation practice is the three-minute breathing space, used in MBCT (Segal, et al., 2002). This prac­tice of tuning in to the present moment, focusing on the breath, and then expanding the awareness to sense the whole body can be approximated to the practice of three separate strengths, one for each minute of the breathing space: curiosity in the awareness phase, self-regulation in the concentration phase, and perspective in the expanded awareness phase.

Mindful Speech and Listening: Mindful speech and deep, mindful lis­tening involve speaking with the honesty strength and listening with the kind­ness/compassion strength. Interpersonal communication, one application of increased mindfulness, is critical to relationship satisfaction (e.g., Meeks, Hendrick, & Hendrick, 1998). Increased mindfulness allows for more attention to verbal communications and nonverbal cues and to one’s reactions to these cues. It also increases the ability to listen non-judgmentally and tune in to one’s own patterns during conflict. Indeed, a longitudinal study found that trait mindfulness predicts higher relationship satisfaction and more constructive responses to relationship stress (Barnes, Brown, Krusemark, Campbell, & Rogge, 2007). Trait mindfulness also predicted lower emotional stress responses during discussion of conflicts and post conflict perception of the rela­tionship, and state mindfulness related to better communication during the dis­cussion. In MBRE interventions, couples reported greater relationship satisfaction, closeness, autonomy, and acceptance of each other, and less rela­tionship distress (Carson et al., 2004). Benefits were maintained at a three­ month follow-up, and those who practiced mindfulness more had better outcomes; diary entries showed that greater mindfulness practice on a given day was associated with better relationships and ability to cope with stress on consecutive days.

Mindful Walking: Mindful walking is a key MBSR practice (Kabat-Zinn, 1990). While there is little research on the specific practice, movement-based therapies such as tai chi have been found to positively affect mindfulness (Caldwell, Harrison, Adams, Quin, & Greeson, 2010). Walking and other forms of behavioral activation have been linked with increased energy and well-being (Mazzucchelli, Kane, & Rees, 2010; Ryan & Frederick, 1997).

Thus we suggest that the character strength of zest (enthusiasm, energy, and vitality) is mobilized as individuals become more active and consciously aware of their movement. As is the case with behavioral activation interventions, improvement in energy and mood becomes reinforcing, leading to more  energy and zest for further activity. We have observed that as individuals practice mindful walking- observing external and internal environments while taking slow, deliberate  steps — many of them  begin  to be  more aware  of what is around them and notice beauty in places they had previously overlooked. It will be interesting to see if future research uncovers a causal link between mindfulness and appreciation of beauty and excellence.

Mindful Driving: Mindful driving requires individuals to bring a curious and open approach to their internal  and external  experiences  when operating a vehicle. This practice is far less common in formal mindfulness-based pro­grams because of the associated pragmatic challenges, but some scholars have discussed its importance (Honore, 2005; Nhat Hanh, 1992). Individuals can be encouraged to consider the character strengths that accompany mindful dri­ving. We suggest that the strength of prudence is important generally in bring­ing individuals to attend to short-term effects of their actions; making wise, practical decisions; and exercising the core element of prudence, “wise cau­tion.” This can counterbalance those who overuse bravery behind the wheel. Anecdotal reports have noted the importance of social/emotional intelligence in tuning into the potential role of the emotions of others (e.g., being mindful that how others drive may be a reaction to a poignant stressor or an impending emergency) as well as within oneself (e.g., preventing road rage by self-regulat­ing emotions and impulses).

Mindful Consuming: Mindful eating, drinking, and otherwise consum­ing probably involves a number of strengths, such as gratitude, appreciation of beauty, kindness, self-regulation, and perspective. While consuming is normal, the excesses of materialism and consumerism have consistently been found to relate inversely to numerous aspects of well-being (see, e.g., Sirgy, 1998). There are indications that mindfulness relates to less materialism and more emphasis on personal values. Brown and Kasser (2005) found that adolescents and adults who reported more subjective well-being also reported more ecologically responsible behavior, which might be seen as citizenship (a dimension of the teamwork strength). These two factors in turn related to higher trait mindful­ness and value orientation. Thus, mindfulness and a values orientation are conducive to greater collective as well as personal well-being.

Improving self-regulation in one area improves the general capacity to self­ regulate, thus impacting other areas of functioning (Baumeister et al., 2006). For example, more self-regulated, mindful eating would improve the capacity for self-regulation and likely lead to gains in relation to exercise, shopping, and other areas that require self-control. Thi ch Nhat Hanh (1993; Nhat Hanh & Cheung, 2010) has emphasized mindful consumption in terms of anything that is taken into the body and mind, not only food and drink but mass media, such as video games, Internet sites, magazines, books, television programs, and movies. Niemiec and Wedding (2008) discussed mindful consumption in terms of selecting movies that portray character strengths and elevating themes, and those that can be used to inspire character strengths, positivity, and meaning in viewers. The use of specific character strength exercises to promote healthy, mindful consuming is discussed elsewhere (Niemiec, 2012b).

Dealing with Obstacles
One of the biggest challenges of mindfulness practice, and not just in sit­ting meditation, is dealing with obstacles (Segal et al., 2002). We hypothesize that deployment of certain character strengths will help individuals address barriers. Some researchers explain that many mindfulness programs do not explicitly teach behavioral  changes other than those  necessary to maintaining a mindfulness practice (Baer & Lykins, 2011). We propose that a number of strengths are related to handling obstacles and maintaining  a strong  practice. As individuals practice mindfulness, they naturally encounter such obstacles as a wandering mind, boredom, physical discomfort, distraction with sounds, and difficulty committing to a practice schedule. Mind wandering can be particu­larly vexing to new meditators because it is so pervasive. People have been found to be less happy when their mind wanders (Killingsworth & Gilbert, 2010), and linking mindfulness with mind wandering can precipitate a nega­tive reinforcement cycle that discourages people from practicing. One of the most important character strengths in dealing with obstacles is perseverance, which  is closely  related  to pushing  onward  in  mindfulness  practice  — repeat­edly moving beyond the obstacles that emerge.

Bravery, like several other strengths, seems to have a mutual relationship with mindfulness. A client who works through unpleasant mental, emotional, or physical content during mindfulness practice is demonstrating bravery (also referred to as psychological courage [Putnam, 1997]). Thus, character strengths promote mindfulness, and the converse also appears to be true: in practicing mindfulness one has more opportunities to deploy and build bravery.

Zest corresponds closely to the Buddhist concept of viriya, which might be translated as enthusiasm or energy (Kuan, 2008). Mindfulness meditation involves a careful balance of effort to avoid the extremes of either lethargy or agitation. Excessive lethargy calls for more enthusiasm. In the Christian con­templative tradition zest is applied to avoid the state of lethargy and apathy called acedia (Norris, 2008).

Another  strength   important   in  dealing  with  obstacles is perspective, which in part requires self-knowledge, realizing larger patterns of meaning, and taking a wider view. This relates to the “de-centering” aspect of mindfulness, where one learns to avoid identifying with thoughts, emotions, and sensations and to experience them simply as cognitive events. This metacognitive perspec­tive (Teasdale, 1999) makes it possible to see these as temporary phenomena rather than creating an identity from them. Perspective in turn suggests the relevance of humility/modesty and humor, which can strip some seriousness away from meditation and bring the focus back to what is important.

Finally, any of the other-oriented character strengths-love, kindness, fairness, and forgiveness— can be shifted toward oneself in establishing a mind­ fulness practice where the individual manages and overcomes obstacles. Being fair with oneself in terms of the amount of time available to practice medita­tion, expressing forgiveness or letting go of limitations and struggles, and direct ing loving kindness inward can be healthy ways to promote practice.

BUILDING A STRONG MINDFULNESS PRACTICE

Be Guided by Signature Strengths
Each of the mindfulness practices discussed can probably be enhanced by using signature strengths — those particular strengths that are most natural and energizing to the individual and that family and friends readily recognize (Peterson & Seligman, 2004; Seligman, 2002). To identify signature strengths, individuals can take the VIA Inventory of Strengths (Peterson & Park, 2009; Peterson & Seligman, 2004) at www.viasurvey.org and examine the results, which rank the 24 character strengths. They are encouraged to  confirm whether the highest strengths are indeed those that are most natural, authen­tic, and uplifting, and then explore how they have used these strengths when they were at their best and how they might now use them in new and unique ways (Seligman, Steen, Park, & Peterson, 2005). Individuals who have a signa­ture strength of curiosity, for instance, can apply interest and novelty-seeking in their approach to mindful sitting, driving, eating, etc. Individuals for whom kindness is a signature strength can apply self-kindness to their mindful yoga; compassion as they mindfully listen to someone’s pain; and kindness in their attitude to their body as they walk or practice the body scan exercise.

Identify Strengths that Emerge During Mindfulness Practice
Mindfulness practitioners focus on whatever thoughts, feelings, and actions are arising in the present moment. This material is often character strengths —related because character strengths are capacities for thinking, feel­ing, and behaving. Practitioners can therefore take notice when they are having a “brave thought,” “a kindness-related emotion,” or an idea for “prudent behavior” and file it away in their mind as an insight for the future.

Use Character Strengths to Combat Obstacles
Because they inevitably encounter obstacles, mindfulness practitioners will likely have to call upon bravery, whether it is a signature strength or not, if they want to directly confront the emotional and physical pain that emerges during mindfulness practices; and similarly rally their zest when they are feeling lethargic as they engage in mindful walking.

Set Up Environmental Cues
To combat the tendency to shift away from mindfulness, practitioners might set up external reminders (sticky notes, strength words, etc.) to remind them to use their strengths, and then find ways to use their strengths to foster awareness in their daily life.

FUTURE DIRECTIONS

Character strengths are one path to a strong mindfulness practice, and in turn mindfulness offers an opportunity to express strengths and work with the contextual nuances that emerge. However, empirical researchers today are grappling with questions for which as yet there are no answers. For example, does focusing on character strengths in counseling that uses mindfulness tech­niques improve those strengths? Might mindfulness help individuals enhance strengths, spot them, and express how they value the strengths of others? Might it assist in assessing situations for optimal strength deployment? These empiri­cal questions warrant attention. Integration may well be a recipe for flourish­ ing, deeper engagement in work, a higher sense of meaning and purpose, higher physical and psychological well-being, and improved relationships.

Empirical evidence is needed to flesh out the connections between these two constructs and evaluate the practical implications of their integration. Meanwhile, practitioners can build off the synergies we have proposed.

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Ryan M. Niemiec is affiliated with the VIA Institute on Character, Tayyab Rashid with the Via Institute and the University of Toronto, and Marcello Spinella with Richard Stockton College of New Jersey.

Acknowledgment: The authors are grateful to Jeremy Clyman, who helped with the review of the literature for this paper.