Patients in the placebo arms of randomized controlled trials (RCT) often experience positive changes from baseline. While multiple theories concerning such “placebo effects” exist, peculiarly, none has been informed by actual interviews of patients undergoing placebo treatment. Here, we report on a qualitative study (n = 27) embedded within a RCT (n = 262) in patients with irritable bowel syndrome. Besides identical placebo acupuncture treatment in the RCT, the qualitative study patients also received an additional set of interviews at the beginning, midpoint, and end of the trial. Interviews of the 12 qualitative subjects who underwent and completed placebo treatment were transcribed. We found that patients (1) were persistently concerned with whether they were receiving placebo or genuine treatment; (2) almost never endorsed “expectation” of improvement but spoke of “hope” instead and frequently reported despair; (3) almost all reported improvement ranging from dramatic psychosocial changes to unambiguous, progressive symptom improvement to tentative impressions of benefit; and (4) often worried whether their improvement was due to normal fluctuations or placebo effects. The placebo treatment was a problematic perturbation that provided an opportunity to reconstruct the experiences of the fluctuations of their illness and how it disrupted their everyday life. Immersion in this RCT was a co-mingling of enactment, embodiment and interpretation involving ritual performance and evocative symbols, shifts in bodily sensations, symptoms, mood, daily life behaviors, and social interactions, all accompanied by self-scrutiny and re-appraisal. The placebo effect involved a spectrum of factors and any single theory of placebo—e.g. expectancy, hope, conditioning, anxiety reduction, report bias, symbolic work, narrative and embodiment—provides an inadequate model to explain its salubrious benefits.
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<p>Patients in the placebo arms of randomized controlled trials (RCT) often experience positive changes from baseline. While multiple theories concerning such “placebo effects” exist, peculiarly, none has been informed by actual interviews of patients undergoing placebo treatment. Here, we report on a qualitative study (n = 27) embedded within a RCT (n = 262) in patients with irritable bowel syndrome. Besides identical placebo acupuncture treatment in the RCT, the qualitative study patients also received an additional set of interviews at the beginning, midpoint, and end of the trial. Interviews of the 12 qualitative subjects who underwent and completed placebo treatment were transcribed. We found that patients (1) were persistently concerned with whether they were receiving placebo or genuine treatment; (2) almost never endorsed “expectation” of improvement but spoke of “hope” instead and frequently reported despair; (3) almost all reported improvement ranging from dramatic psychosocial changes to unambiguous, progressive symptom improvement to tentative impressions of benefit; and (4) often worried whether their improvement was due to normal fluctuations or placebo effects. The placebo treatment was a problematic perturbation that provided an opportunity to reconstruct the experiences of the fluctuations of their illness and how it disrupted their everyday life. Immersion in this RCT was a co-mingling of enactment, embodiment and interpretation involving ritual performance and evocative symbols, shifts in bodily sensations, symptoms, mood, daily life behaviors, and social interactions, all accompanied by self-scrutiny and re-appraisal. The placebo effect involved a spectrum of factors and any single theory of placebo – e.g. expectancy, hope, conditioning, anxiety reduction, report bias, symbolic work, narrative and embodiment – provides an inadequate model to explain its salubrious benefits.</p>
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<p>Recently, the psychological construct mindfulness has received a great deal of attention. The majority of research has focused on clinical studies to evaluate the efficacy of mindfulness-based interventions. This line of research has led to promising data suggesting mindfulness-based interventions are effective for treatment of both psychological and physical symptoms. However, an equally important direction for future research is to investigate questions concerning mechanisms of action underlying mindfulness-based interventions. This theoretical paper proposes a model of mindfulness, in an effort to elucidate potential mechanisms to explain how mindfulness affects positive change. Potential implications and future directions for the empirical study of mechanisms involved in mindfulness are addressed. © 2005 Wiley Periodicals, Inc. J Clin Psychol 62: 373–386, 2006.</p>
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Those with high baseline stress levels are more likely to develop mild cognitive impairment (MCI) and Alzheimer's Disease (AD). While meditation may reduce stress and alter the hippocampus and default mode network (DMN), little is known about its impact in these populations. Our objective was to conduct a "proof of concept" trial to determine whether Mindfulness Based Stress Reduction (MBSR) would improve DMN connectivity and reduce hippocampal atrophy among adults with MCI. 14 adults with MCI were randomized to MBSR vs. usual care and underwent resting state fMRI at baseline and follow-up. Seed based functional connectivity was applied using posterior cingulate cortex as seed. Brain morphometry analyses were performed using FreeSurfer. The results showed that after the intervention, MBSR participants had increased functional connectivity between the posterior cingulate cortex and bilateral medial prefrontal cortex and left hippocampus compared to controls. In addition, MBSR participants had trends of less bilateral hippocampal volume atrophy than control participants. These preliminary results indicate that in adults with MCI, MBSR may have a positive impact on the regions of the brain most related to MCI and AD. Further research with larger sample sizes and longer-follow-up are needed to further investigate the results from this pilot study.
<p>Objective and Participants: The authors evaluated the effects on stress, rumination, forgiveness, and hope of two 8-week, 90-min/wk training programs for college undergraduates in meditation-based stress-management tools. Methods: After a pretest, the authors randomly allocated college undergraduates to training in mindfulness-based stress reduction (MBSR; n = 15), Easwaran's Eight-Point Program (EPP; n = 14), or wait-list control ( n = 15). The authors gathered pretest, posttest, and 8-week follow-up data on self-report outcome measures. Results: The authors observed no post-treatment differences between MBSR and EPP or between posttest and 8-week follow-up ( p > .10). Compared with controls, treated participants ( n = 29) demonstrated significant benefits for stress ( p < .05, Cohen's d = -.45) and forgiveness ( p < .05, d = .34) and marginal benefits for rumination ( p < .10, d = -.34). Conclusions: Evidence suggests that meditation-based stress-management practices reduce stress and enhance forgiveness among college undergraduates. Such programs merit further study as potential health-promotion tools for college populations.</p>
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This study investigated the link between meditation, self-reported mindfulness and cognitive flexibility as well as other attentional functions. It compared a group of meditators experienced in mindfulness meditation with a meditation-naïve control group on measures of Stroop interference and the “d2-concentration and endurance test”. Overall the results suggest that attentional performance and cognitive flexibility are positively related to meditation practice and levels of mindfulness. Meditators performed significantly better than non-meditators on all measures of attention. Furthermore, self-reported mindfulness was higher in meditators than non-meditators and correlations with all attention measures were of moderate to high strength. This pattern of results suggests that mindfulness is intimately linked to improvements of attentional functions and cognitive flexibility. The relevance of these findings for mental balance and well-being are discussed.
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The capacity to stabilize the content of attention over time varies among individuals, and its impairment is a hallmark of several mental illnesses. Impairments in sustained attention in patients with attention disorders have been associated with increased trial-to-trial variability in reaction time and event-related potential deficits during attention tasks. At present, it is unclear whether the ability to sustain attention and its underlying brain circuitry are transformable through training. Here, we show, with dichotic listening task performance and electroencephalography, that training attention, as cultivated by meditation, can improve the ability to sustain attention. Three months of intensive meditation training reduced variability in attentional processing of target tones, as indicated by both enhanced theta-band phase consistency of oscillatory neural responses over anterior brain areas and reduced reaction time variability. Furthermore, those individuals who showed the greatest increase in neural response consistency showed the largest decrease in behavioral response variability. Notably, we also observed reduced variability in neural processing, in particular in low-frequency bands, regardless of whether the deviant tone was attended or unattended. Focused attention meditation may thus affect both distracter and target processing, perhaps by enhancing entrainment of neuronal oscillations to sensory input rhythms, a mechanism important for controlling the content of attention. These novel findings highlight the mechanisms underlying focused attention meditation and support the notion that mental training can significantly affect attention and brain function.
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This study examined the relationship between the executive control process of inhibition and self-reported dispositional mindfulness, controlling for gender, grade, and cortisol levels in 99 (43% female) fourth- and fifth-graders ( = 10.23 years, SD = 0.53). Students completed a measure of mindful attention awareness and a computerized executive function (EF) task assessing inhibitory control. Morning cortisol levels also were collected and were used as an indicator of neuroendocrine regulation. Hierarchical regression analyses revealed that, after controlling for gender, grade, and cortisol levels, higher scores on the mindfulness attention awareness measure significantly predicted greater accuracy (% correct responses) on the inhibitory control task. This research contributes to understanding the predictors of EF skills in early adolescents’ cognitive development. Specifically, it identifies mindfulness—a skill that can be fostered and trained in intervention programs to promote health and well-being—as significantly related to inhibitory processes in early adolescence.
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Responding to growing interest among psychotherapists of all theoretical orientations, this practical book provides a comprehensive introduction to mindfulness and its clinical applications. The authors, who have been practicing both mindfulness and psychotherapy for decades, present a range of clear-cut procedures for implementing mindfulness techniques and teaching them to patients experiencing depression, anxiety, chronic pain, and other problems. Also addressed are ways that mindfulness practices can increase acceptance and empathy in the therapeutic relationship. The book reviews the philosophical underpinnings of mindfulness and presents compelling empirical findings. User-friendly features include illustrative case examples, practice exercises, and resource listings.
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- Buddhist Contemplation by Applied Subject,
- Contemplation by Applied Subject,
- Contemplation by Tradition,
- Psychiatry and Contemplation,
- Psychotherapy and Buddhist Contemplation,
- Health Care and Buddhist Contemplation,
- Psychotherapy and Contemplation,
- Health Care and Contemplation,
- Psychology and Contemplation,
- Science and Contemplation,
- Buddhist Contemplation
Mindfulness, originally a construct used in Eastern spiritual and philosophical traditions, has found new utility in psychotherapy practice. Mindfulness practice has been recently applied to treatments of several psychological and health related problems, and research is showing successful outcomes in psychological interventions incorporating mindfulness practices. Several schools of psychotherapy have theorized why mindfulness may be an effective intervention. One population which would theoretically be benefited by mindfulness practice in treatment consists of those individuals who have experienced traumatic events and are exhibiting post-traumatic stress disorder and/or related correlates of past trauma. The present paper gives a general review of the application of mindfulness to clinical psychology interventions. Additionally, we explain how mindfulness is applicable to our integrative behavioral approach to treating trauma and its sequelae. Specifically, this paper will (a) give a general overview of the conceptions and applications of mindfulness to psychology and psychotherapy and provide a brief account of the concepts origins in eastern traditions; (b) discuss the theoretical conceptualization of clinical problems that may relate to the long-term correlates of trauma; (c) describe how mindfulness, acceptance and the therapeutic relationship can address trauma symptoms and discuss a modified treatment approach for trauma survivors that incorporates mindfulness and acceptance practices into traditional exposure treatment.
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<p>Objective This study compared changes in bodily pain, health-related quality of life (HRQoL), and psychological symptoms during an 8-week mindfulness-based stress reduction (MBSR) program among groups of participants with different chronic pain conditions. Methods From 1997-2003, a longitudinal investigation of chronic pain patients ( n=133) was nested within a larger prospective cohort study of heterogeneous patients participating in MBSR at a university-based Integrative Medicine center. Measures included the Short-Form 36 Health Survey and Symptom Checklist-90-Revised. Paired t tests were used to compare pre–post changes on outcome measures. Differences in treatment effect sizes were compared as a function of chronic pain condition. Correlations were examined between outcome parameters and home meditation practice. Results Outcomes differed in significance and magnitude across common chronic pain conditions. Diagnostic subgroups of patients with arthritis, back/neck pain, or two or more comorbid pain conditions demonstrated a significant change in pain intensity and functional limitations due to pain following MBSR. Participants with arthritis showed the largest treatment effects for HRQoL and psychological distress. Patients with chronic headache/migraine experienced the smallest improvement in pain and HRQoL. Patients with fibromyalgia had the smallest improvement in psychological distress. Greater home meditation practice was associated with improvement on several outcome measures, including overall psychological distress, somatization symptoms, and self-rated health, but not pain and other quality of life scales. Conclusion MBSR treatment effects on pain, HRQoL and psychological well-being vary as a function of chronic pain condition and compliance with home meditation practice.</p>
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OBJECTIVES: The objectives of this study were to assess the general acceptability and to assess domains of potential effect of a mindfulness-based stress reduction (MBSR) program for human immunodeficiency virus (HIV)-infected and at-risk urban youth.
METHODS: Thirteen-to twenty-one-year-old youth were recruited from the pediatric primary care clinic of an urban tertiary care hospital to participate in 4 MBSR groups. Each MBSR group consisted of nine weekly sessions of MBSR instruction. This mixed-methods evaluation consisted of quantitative data--attendance, psychologic symptoms (Symptom Checklist 90-Revised), and quality of life (Child Health and Illness Profile-Adolescent Edition)--and qualitative data--in-depth individual interviews conducted in a convenience sample of participants until interview themes were saturated. Analysis involved comparison of pre- and postintervention surveys and content analysis of interviews.
RESULTS: Thirty-three (33) youth attended at least one MBSR session. Of the 33 who attended any sessions, 26 youth (79%) attended the majority of the MBSR sessions and were considered "program completers." Among program completers, 11 were HIV-infected, 77% were female, all were African American, and the average age was 16.8 years. Quantitative data show that following the MBSR program, participants had a significant reduction in hostility (p = 0.02), general discomfort (p = 0.01), and emotional discomfort (p = 0.02). Qualitative data (n = 10) show perceived improvements in interpersonal relationships (including less conflict), school achievement, physical health, and reduced stress.
CONCLUSIONS: The data suggest that MBSR instruction for urban youth may have a positive effect in domains related to hostility, interpersonal relationships, school achievement, and physical health. However, because of the small sample size and lack of control group, it cannot be distinguished whether the changes observed are due to MBSR or to nonspecific group effects. Further controlled trials should include assessment of the MBSR program's efficacy in these domains.
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<p>Mindfulness-based approaches are among the most innovative and interesting new approaches to mental health treatment. Mindfulness refers to patients developing an "awareness of present experience with acceptance." Interest in them is widespread, with presentations and workshops drawing large audiences all over the US and many other countries. This book provides a comprehensive introduction to the best-researched mindfulness-based treatments. It emphasizes detailed clinical illustration providing a close-up view of how these treatments are conducted, the skills required of therapists, and how they work. The book also has a solid foundation in theory and research and shows clearly how these treatments can be understood using accepted psychological principles and concepts. The evidence base for these treatments is concisely reviewed.* Comprehensive introduction to the best-researched mindfulness-based treatments* Covers wide range of problems & disorders (anxiety, depression, eating, psychosis, personality disorders, stress, pain, relationship problems, etc)* Discusses a wide range of populations (children, adolescents, older adults, couples)* Includes wide range of settings (outpatient, inpatient, medical, mental health, workplace)* Clinically rich, illustrative case study in every chapter* International perspectives represented (authors from US, Canada, Britain, Sweden)</p>
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Drawing from theories regarding the role of awareness in behavioral self-regulation, this research was designed to examine the role of mindfulness as a moderator between implicit motivation and the motivation for day-to-day behavior. We hypothesized that dispositional mindfulness (Brown and Ryan, J Pers Soc Psychol, 84, 822–848, 2003) would act to modify the expression of implicit autonomy orientation in daily behavioral motivation. Using the Implicit Association Test (Greenwald et al. J Pers Soc Psychol, 74, 1464–1480, 1998), Study 1 provided evidence for the reliability and validity of a new measure of implicit autonomy orientation. Using an experience-sampling strategy, Study 2 showed the hypothesized moderating effect, such that implicit autonomy orientation predicted day-to-day motivation only for those lower in dispositional mindfulness. Those higher in mindfulness showed more autonomously motivated behavior regardless of implicit orientation toward autonomy or heteronomy. It also showed that this moderating effect of awareness was specific to mindfulness and was primarily manifest in spontaneous behavior. Discussion focuses on the implications of these findings for dual process theory and research.
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Mindfulness training has had salutary effects with adult populations and it is seen as a potentially helpful to children’s development. How to implement mindfulness practices with young children is not yet clear; some meditation practices, like sitting still for long periods with internally-self-regulated focused attention, seem developmentally inappropriate. Montessori schooling is a 100-year-old system that naturally incorporates practices that align with mindfulness and are suited to very young children. Here I describe how several aspects of Montessori education, including privileging concentrated attention, attending to sensory experience, and engaging in practical work, parallel mindfulness practices. These aspects might be responsible for some of the socio-emotional and executive function benefits that have been associated with Montessori education, and they could be adapted to conventional classroom methods.
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Meditation refers to a family of complex emotional and attentional regulatory practices, which can be classified into two main styles – focused attention (FA) and open monitoring (OM) – involving different attentional, cognitive monitoring and awareness processes. In a functional magnetic resonance study we originally characterized and contrasted FA and OM meditation forms within the same experiment, by an integrated FA–OM design. Theravada Buddhist monks, expert in both FA and OM meditation forms, and lay novices with 10 days of meditation practice, participated in the experiment. Our evidence suggests that expert meditators control cognitive engagement in conscious processing of sensory-related, thought and emotion contents, by massive self-regulation of fronto-parietal and insular areas in the left hemisphere, in a meditation state-dependent fashion. We also found that anterior cingulate and dorsolateral prefrontal cortices play antagonist roles in the executive control of the attention setting in meditation tasks. Our findings resolve the controversy between the hypothesis that meditative states are associated to transient hypofrontality or deactivation of executive brain areas, and evidence about the activation of executive brain areas in meditation. Finally, our study suggests that a functional reorganization of brain activity patterns for focused attention and cognitive monitoring takes place with mental practice, and that meditation-related neuroplasticity is crucially associated to a functional reorganization of activity patterns in prefrontal cortex and in the insula.
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The scientific interest in meditation and mindfulness practice has recently seen an unprecedented surge. After an initial phase of presenting beneficial effects of mindfulness practice in various domains, research is now seeking to unravel the underlying psychological and neurophysiological mechanisms. Advances in understanding these processes are required for improving and fine-tuning mindfulness-based interventions that target specific conditions such as eating disorders or attention deficit hyperactivity disorders. This review presents a theoretical framework that emphasizes the central role of attentional control mechanisms in the development of mindfulness skills. It discusses the phenomenological level of experience during meditation, the different attentional functions that are involved, and relates these to the brain networks that subserve these functions. On the basis of currently available empirical evidence specific processes as to how attention exerts its positive influence are considered and it is concluded that meditation practice appears to positively impact attentional functions by improving resource allocation processes. As a result, attentional resources are allocated more fully during early processing phases which subsequently enhance further processing. Neural changes resulting from a pure form of mindfulness practice that is central to most mindfulness programs are considered from the perspective that they constitute a useful reference point for future research. Furthermore, possible interrelations between the improvement of attentional control and emotion regulation skills are discussed.
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OBJECTIVE: Positron emission tomography was used to investigate the neural substrates of normal human emotional and their dependence on the types of emotional stimulus.
METHOD: Twelve healthy female subjects underwent 12 measurements of regional brain activity following the intravenous bolus administration of [15O]H2O as they alternated between emotion-generating and control film and recall tasks. Automated image analysis techniques were used to characterize and compare the increases in regional brain activity associated with the emotional response to complex visual (film) and cognitive (recall) stimuli.
RESULTS: Film- and recall-generated emotion were each associated with significantly increased activity in the vicinity of the medial prefrontal cortex and thalamus, suggesting that these regions participate in aspects of emotion that do not depend on the nature of the emotional stimulus. Film-generated emotion was associated with significantly greater increases in activity bilaterally in the occipitotemporparietal cortex, lateral cerebellum, hypothalamus, and a region that includes the anterior temporal cortex, amygdala, and hippocampal formation, suggesting that these regions participate in the emotional response to certain exteroceptive sensory stimuli. Recall-generated sadness was associated with significantly greater increases in activity in the vicinity of the anterior insular cortex, suggesting that this region participates in the emotional response to potentially distressing cognitive or interoceptive sensory stimuli.
CONCLUSIONS: While this study should be considered preliminary, it identified brain regions that participate in externally and internally generated human emotion.
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OBJECTIVE: Happiness, sadness, and disgust are three emotions that differ in their valence (positive or negative) and associated action tendencies (approach or withdrawal). This study was designed to investigate the neuroanatomical correlates of these discrete emotions.
METHOD: Twelve healthy female subjects were studied. Positron emission tomography and [15O]H2O were used to measure regional brain activity. There were 12 conditions per subject: happiness, sadness, and disgust and three control conditions, each induced by film and recall. Emotion and control tasks were alternated throughout. Condition order was pseudo-randomized and counterbalanced across subjects. Analyses focused on brain activity patterns for each emotion when combining film and recall data.
RESULTS: Happiness, sadness, and disgust were each associated with increases in activity in the thalamus and medial prefrontal cortex (Brodmann's area 9). These three emotions were also associated with activation of anterior and posterior temporal structures, primarily when induced by film. Recalled sadness was associated with increased activation in the anterior insula. Happiness was distinguished from sadness by greater activity in the vicinity of ventral mesial frontal cortex.
CONCLUSIONS: While this study should be considered preliminary, it identifies regions of the brain that participate in happiness, sadness, and disgust, regions that distinguish between positive and negative emotions, and regions that depend on both the elicitor and valence of emotion or their interaction.
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<p>Ironically, in spite of the label "affective disorders", research on affective disorders has little to say about just what is disordered about emotion in these illnesses. One major purpose of this Special Issue is to begin to raise this question as a legitimate domain of inquiry in studies of emotion and psychopathology. Historically, the literature on emotion in normal subjects has proceeded almost entirely independently of studies of emotion-related psychopathology. And, studies on psychopathology make virtually no reference to basic research on emotion in normals. Major advances have occurred in our understanding of the neural substrates of these affective processes. Their application to the study of disordered emotion in affective and anxiety disorders is comparatively recent. A goal of this Special Issue is to foster increased integration between research on the neural mechanisms underlying normal emotion and disordered emotion in depression and anxiety-related illnesses. It features exemplars of the best research at many levels, from animal studies of the detailed circuitry subserving fear and anxiety, to human studies of cognitive abnormalities in subjects with affective and anxiety disorders. It also highlights a myriad array of methods for making inferences about affective processes, ranging from the biological to the behavioral, and from the molecular to the molar. A central concept that figures prominently in this collection of articles is the importance of individual differences in different components of affective processes. The study of the brain circuitry that underlies such differences in affective style offers great promise in providing a biologically plausible way of parsing the affect domain and developing a theoretically compelling taxonomy of mechanisms that give rise to vulnerability to affective and anxiety disorders.</p>
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Parenting preschoolers can be a challenging endeavor. Yet anecdotal observations indicate that parents who are more mindful may have greater ease in contending with the emotional demands of parenting than parents who are less mindful. Therefore, we hypothesized that parenting effort, defined as the energy involved in deciding on the most effective way to respond to a preschooler, would be negatively associated with mothers’ mindfulness. In this study, a new parenting effort scale and an established mindfulness scale were distributed to 50 mothers of preschoolers. Using exploratory factor analysis, the factor structure of the new parenting effort scale was examined and the scale was refined. Bivariate correlations were then conducted on this new Parenting Effort—Preschool scale and the established mindfulness scale. Results confirmed the hypothesis that a negative correlation exists between these two variables. Implications are that mindfulness practices may have the potential to alleviate some of the challenges of parenting preschoolers.
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The purpose of this study was to examine pathways in a model which proposed associations among parent mindfulness, parent depressive symptoms, two types of parenting, and child problem behavior. Participants' data were from the baseline assessment of a NIMH-sponsored family-group cognitive-behavioral intervention program for the prevention of child and adolescent depression (Compas et al., 2009). Participants consisted of 145 mothers and 17 fathers (mean age = 41.89 yrs, SD = 7.73) with a history of depression and 211 children (106 males) (mean age = 11.49 yrs, SD = 2.00). Analyses showed that (a) positive parenting appears to play a significant role in helping explain how parent depressive symptoms relate to child externalizing problems and (b) mindfulness is related to child internalizing and externalizing problems; however, the intervening constructs examined did not appear to help explain the mindfulness-child problem behavior associations. Suggestions for future research on parent mindfulness and child problem outcome are described.
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The purpose of the present study was twofold: (1) to obtain information on central mechanisms underlying cardiac self-regulation by comparing changes in cerebral asymmetry during self-control of heart rate with changes observed during the production of affective imagery; and (2) to explore sex differences in hemispheric function during performance of these two tasks. Heart rate (HR) and bilateral parietal EEG filtered for alpha were recorded from 20 right-handed males and females during two discrete experimental phases: cardiac control and image self-generation. HR showed significant effects between up versus down in prefeedback and feedback, and between anger versus relaxing imagery in the image phase. The EEG data indicated similar patterns of hemispheric asymmetry in both sexes during prefeedback. However, with the introduction of feedback, females shifted to greater relative right hemisphere activation comparable to what they show when specifically instructed to think emotional thoughts; males showed little differentiation between conditions. These data indicate that the Self-regulation of HR with biofeedback in males and females may be accomplished by the utilization of strategies involving different underlying patterns of neuropsychological processes.
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