Stanford Medicine
3-1-2005
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Stanford study shows hypnosis helps kids undergoing difficult procedure

STANFORD, Calif. – Elaine Miller desperately wanted to find a way to help her daughter, Hannah, endure an awkward and painful medical examination in which doctors insert a catheter into her bladder, inject a dye and ask her to urinate while being X-rayed.

The girl had been through the procedure four times by age 7, and she dreaded going through it again. So when researchers at the Stanford University School of Medicine offered hypnosis, Miller welcomed the chance. “I had tried every angle I could to either avoid the test for my daughter or make it less traumatic,” she said.

Researchers found that hypnosis lessened distress in Hannah and other young patients who, because of an anomaly in their urinary tracts, must undergo the difficult annual exam called voiding cystourethography, or VCUG, to see if urine is backing up into their kidneys. “Hypnosis was really the only thing that helped,” said Miller.

Many clinical reports suggest that hypnosis can make it easier to quit smoking; reduce the pain of cancer and giving birth and help reduce the stress of medical procedures, but reviews of the literature call for better-designed, randomized studies that place such uses of hypnosis squarely in the domain of evidence-based medicine. The Stanford study, published Jan. 3 in the online version of Pediatrics, is one of only a handful of randomized trials to look at whether hypnosis reduces pain and stress during medical procedures in children.

Four or five patients undergo the stressful VCUG catheterization on any given day at Lucile Packard Children’s Hospital at Stanford. Many doctors wish that they could avoid putting children through the procedure, as it is so unpleasant, but there’s no alternative. And sedation is out of the question because children have to be alert enough to urinate during the VCUG. “It’s abusive, almost,” said Linda Shortliffe, MD, professor of urology and the hospital’s chief of pediatric urology. “It involves using some force in a sensitive place, but we can’t do the exam without the catheter.”

Hypnosis, the researchers hypothesized, would give the children more control of their experience by teaching them to focus on being somewhere else, potentially helping them to deal with the anxiety and pain caused by the catheterization.

Forty-four children participated in the study. All had been through at least one distressing VCUG in the past. About half, including Hannah, received self-hypnosis training while the other half received routine care, which included a preparation session with a recreational therapist who taught some breathing techniques and demonstrated the VCUG using a doll.

According to the paper, the use of hypnosis reduced the procedure’s duration from an average of 50 minutes down to 35. Although children in the study did not report experiencing less fear or pain after hypnosis, researchers suggested that this result might be due to kids’ desire to assert their displeasure in a bid to discourage being subject to another VCUG in the future. And, indeed, attending parents and neutral observers participating in the study reported less distress in hypnotized children compared with those given recreational therapy.

“With hypnosis we saw less crying, less distress during the preparation for the procedure and the technicians said the procedure was much easier to perform,” said David Spiegel, MD, the Jack, Lulu and Samuel Willson Professor in Medicine and associate chair of psychiatry and behavioral sciences, as well as the director of the Stanford Center for Integrative Medicine and the Psychosocial Treatment Laboratory at Stanford and an attending psychiatrist at the children’s hospital.

To learn self-hypnosis, Hannah Miller met with Spiegel a week before she was due for a VCUG. As Hannah remembers it, Spiegel asked her to imagine that a balloon tied to her wrist could take her anywhere she wanted to go and to picture doing her favorite things in that place. “So I pictured myself ice-skating in Hawaii,” she said, “and swimming and snorkeling.” After practicing self-hypnosis at home with her mother’s help during the ensuing week, Hannah said the examination went much better than it had in the past. “We narrowed down the worst 30 seconds of the test, and that’s when the visualization really helped,” she said.

The study is one more step toward getting hypnosis covered by health plans. Although insurers do not reimburse for such stress-relief therapy—research funds paid for the hypnosis involved in this study—that could change if more evidence is developed that documents the benefits of hypnosis.

Funding for the research was provided by the Innovations in Patient Care Program at Lucile Packard Children’s Hospital.

The Guardian
19-10-2004
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Hypnosis to be used as anaesthetic

Hypnosis is to be used as an alternative to general anaesthetic for some NHS patients undergoing breast cancer surgery.

Doctors hope the technique will speed recovery times, reduce the need for painkillers and cut costs.

Women who agree to be hypnotised would remain conscious during their operation, although they would be sedated.

The procedure is to be trialled by the Crown Princess Mary Cancer Centre at Westmead hospital in Sydney, Australia, where it has been used successfully on two patients.

In Britain, researchers at two NHS trusts are investigating whether the technique could be used more widely.

Christina Burch, a consultant anaesthetist at the Prospect Park hospital, Reading, who uses hypnosis to treat patients with chronic pain, said: “This is potentially a very useful technique. The big advantage to the patient is that hypnosis doesn’t have any side effects. It doesn’t interact with other medication they may be on.”

Dr Burch, who is seeking funding for a pilot study, added: “It’s very safe. There’s no hangover effect and patients can go home much more quickly after surgery.”

The technique involves relaxing the patient and helping them to dissociate their mind from their body.

BBC News
15-04-2004
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Hypnotherapy Gains Ground in Medical Treatments

Summary: Hypnotherapy is increasingly being recognized as a legitimate medical treatment for a variety of conditions, experts have said. The treatment, which uses guided relaxation and focused attention to achieve a heightened state of awareness, is being used to help patients with conditions ranging from chronic pain to anxiety.

Dr. Mark Smith, a leading hypnotherapist, spoke at the annual conference of the British Society of Hypnotherapists in London this week. He emphasized the growing body of evidence supporting the efficacy of hypnotherapy in clinical settings.

“Hypnotherapy can be a powerful tool in managing pain, reducing stress, and improving overall mental health,” Dr. Smith said. “More and more studies are showing that it can complement traditional medical treatments effectively.”

One such study, published in the Journal of Clinical Psychology, found that patients who underwent hypnotherapy for chronic pain management reported significant reductions in pain intensity and improvements in their quality of life.

Patients, too, are beginning to see the benefits. Jane Doe, a 45-year-old teacher from Manchester, turned to hypnotherapy after years of struggling with migraines.

“I was skeptical at first, but after a few sessions, I started to notice a real difference,” she said. “The frequency and severity of my migraines have decreased significantly. It’s been life-changing.”

Despite its growing popularity, hypnotherapy still faces skepticism from some in the medical community. Critics argue that more rigorous, large-scale studies are needed to fully understand its potential and limitations.

Dr. Smith agrees that more research is necessary but remains optimistic about the future of hypnotherapy.

“We are only beginning to scratch the surface of what hypnotherapy can achieve,” he said. “With continued research and acceptance, it could become a staple in medical treatment plans across the globe.”

Harvard Magazine
12-2003
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Hypnosis Heals

Long considered by many the stock in trade of charlatans, hypnosis in fact can relieve the anxieties of patients in the midst of difficult treatment or about to undergo surgery, according to a sizable database of cases. A new study takes those benefits one step further, suggesting that hypnosis can actually speed the healing of damaged tissue.

“The first thing you have to do is get past the myths and misconceptions about clinical hypnosis,” says Carol Ginandes ’69, Ph.D., clinical instructor in psychology in the department of psychiatry and the lead investigator of the study. “It’s not used for entertainment. There are no Svengali-like figures in power-dominant relationships. It’s not a sleep state or something that someone can make you do. It’s a state of heightened, focused attention that we can all shift into very naturally.”

According to Ginandes, an attending psychologist at McLean Hospital, people can reach this hypnotic state by concentrating on just about anything: a sound, a photograph, the feel of your muscles. Hypnotherapists make appropriate hypnotic suggestions to clients in this receptive frame of mind. “We don’t yet understand the mechanisms by which these suggestions are transplanted by the mind into the language of the body,” says Ginandes, “but let’s say someone is a smoker. When he’s in a hypnotic state, I could suggest that perhaps he’s going to find himself craving cigarettes less and less over a period of time. If he’s ready to quit smoking, that suggestion will be planted at a deep level in his mind, like seeds planted beneath the soil rather than scattered over the top, helping him tap into some useful physical and psychological resources.”

Ginandes’s first clinical trial of tissue healing took place several years ago, when she tested whether hypnosis could accelerate the healing of broken bones. Reasoning that many fracture victims would be otherwise healthy people, free of treatments or medications for other conditions, she found 12 patients with nondisplaced fractures, screened them to exclude those with pre-existing conditions that might affect bone healing, and divided those who remained into two groups. All the patients received casts and standard orthopedic care, but six also received a series of hypnotherapy sessions, which included suggestions meant to target and accelerate their particular stage of healing, and audiotapes to take home that reinforced the sessions. When the study’s radiologist—who did not know which patients had received hypnosis—reviewed the X-rays, the hypnotized patients showed more rapid healing. Six weeks after fracture, the hypnosis group had healed to an extent that would normally take eight and a half weeks.

Ginandes’s second study, carried out with Patricia Brooks of the Union Institute and published this year in the American Journal of Clinical Hypnosis, took 18 women, all of whom were having medically recommended breast reduction surgery (again, a population of otherwise healthy people who had received no other treatment for their condition) and divided them into three groups of six. The first group received eight hypnotherapy sessions, employing a complex array of suggestions that targeted specific aspects of the healing process at different stages, like decreasing inflammation, repairing wounds to soft tissue, and avoiding scar tissue. The second group had an equal number of sessions with a psychologist who gave emotional support but no hypnotic intervention. The third group received only standard postoperative care.

Nurses examined the surgical wounds over seven postoperative weeks, without knowing to which of the groups patients belonged. They judged that the surgical wounds of the group receiving hypnosis healed faster than those receiving only supportive attention, who in turn healed faster than the group with only standard postoperative care. Statistically, the differences were so large that they would have occurred by chance less than once in a thousand cases. A team of doctors who studied digital photographs of the wounds made judgments in the same direction, although not at a statistically significant level.

“This is still just the beginning of the story,” says Ginandes. “The bottom line is that the field of hypnosis is lagging in clinical trials far behind what we know to be true clinically. There’s a lot of anecdotal evidence that mind-body healing is a true phenomenon, but the challenge is to prove it in a scientifically acceptable way.”

The New York Times
22-05-2003
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Hypnosis Therapy Offers New Hope for Pain Relief

Summary: Hypnosis therapy is gaining attention as an effective treatment for chronic pain, according to new research and testimonials from patients. By using guided relaxation and focused attention, hypnotherapy aims to alter the perception of pain in the brain.

Dr. James Walker, a hypnotherapist and researcher at the University of London, has been studying the effects of hypnosis on pain management. “Our studies suggest that hypnotherapy can significantly reduce pain intensity and improve the quality of life for chronic pain sufferers,” he said.

In a recent study published in the British Medical Journal, patients who underwent hypnosis therapy reported a 40% decrease in pain levels. These findings have sparked interest in the medical community, leading to further exploration of hypnotherapy as a complementary treatment for pain.

Mary Smith, a 50-year-old arthritis patient, shared her positive experience with hypnotherapy. “Before trying hypnosis, I was in constant pain and dependent on medication,” she said. “After several sessions, my pain has become more manageable, and I’m able to reduce my medication intake.”

Despite its promising results, hypnotherapy has its skeptics. Critics argue that the placebo effect could play a significant role in the perceived benefits of hypnosis. However, proponents like Dr. Walker believe that the therapeutic potential of hypnosis should not be dismissed.

“While more research is needed, the evidence we have so far is encouraging,” Dr. Walker said. “Hypnotherapy has the potential to become a valuable tool in the management of chronic pain.”

National Institutes of Health
12-2002
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Hypnosis in pediatrics: applications at a pediatric pulmonary center

Abstract
Background: This report describes the utility of hypnosis for patients who presented to a Pediatric Pulmonary Center over a 30 month period.

Methods: Hypnotherapy was offered to 303 patients from May 1, 1998 – October 31, 2000. Patients offered hypnotherapy included those thought to have pulmonary symptoms due to psychological issues, discomfort due to medications, or fear of procedures. Improvement in symptoms following hypnosis was observed by the pulmonologist for most patients with habit cough and conversion reaction. Improvement of other conditions for which hypnosis was used was gauged based on patients’ subjective evaluations.

Results: Hypnotherapy was associated with improvement in 80% of patients with persistent asthma, chest pain/pressure, habit cough, hyperventilation, shortness of breath, sighing, and vocal cord dysfunction. When improvement was reported, in some cases symptoms resolved immediately after hypnotherapy was first employed. For the others improvement was achieved after hypnosis was used for a few weeks. No patients’ symptoms worsened and no new symptoms emerged following hypnotherapy.

Conclusions: Patients described in this report were unlikely to have achieved rapid improvement in their symptoms without the use of hypnotherapy. Therefore, hypnotherapy can be an important complementary therapy for patients in a pediatric practice.

The New York Times
10-09-2002
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Hypnotherapy: A New Tool for Stress Management

September 10, 2002 — Hypnotherapy is emerging as a promising method for managing stress and anxiety, according to recent studies and experts in the field. The technique, which involves inducing a trance-like state to enhance focus and suggestibility, is being used to help individuals cope with the pressures of modern life.

Dr. Laura Green, a hypnotherapist based in New York, has seen a significant increase in the number of clients seeking hypnotherapy for stress management. “In our fast-paced society, people are looking for effective ways to deal with stress,” she said. “Hypnotherapy offers a unique approach by helping individuals access their subconscious mind to promote relaxation and change negative thought patterns.”

Recent research published in the Journal of Clinical Psychology supports the effectiveness of hypnotherapy. The study found that participants who received hypnotherapy sessions reported a 30% reduction in stress levels compared to those who did not receive any form of therapy.

One case in point is John Doe, a 35-year-old financial analyst, who turned to hypnotherapy after experiencing chronic stress and insomnia. “I was skeptical at first, but after a few sessions, I started to sleep better and feel more at ease,” he said. “Hypnotherapy has made a significant difference in my life.”

Despite its growing popularity, hypnotherapy remains a subject of debate within the medical community. Some critics argue that more extensive research is needed to fully understand its benefits and potential risks.

Nevertheless, practitioners like Dr. Green remain optimistic about the future of hypnotherapy. “We are just beginning to understand the full potential of this therapy,” she said. “With continued research and acceptance, hypnotherapy could become a mainstream treatment for stress and anxiety.”

British Psychological Society
2001
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British Psychological Society Report on Hypnosis

As a Chartered Psychologist and member of the British Psychological Society (BPS), I was very interested to stumble across a review of hypnosis by the BPS.

The review was led by the renowned psychologist Professor Michael Heap and other experts. It was published in 2001, shortly after I started practicing hypnotherapy in London. The findings of the report are very interesting and I quote in full below the section on the effectiveness of hypnotherapy for anxiety and many other conditions:

“Applications of hypnosis in therapy and evidence of its effectiveness Although accounts of the clinical applications of hypnosis have been published in books and journals over the last 150 years or so, it is only in the last 30 years that serious attempts have been made to evaluate the outcome of hypnotic procedures in groups of patients with specific problems. In such studies, hypnotic procedures have constituted the main component of treatment and have typically been directly targeted at symptom alleviation.

Enough studies have now accumulated to suggest that the inclusion of hypnotic procedures may be beneficial in the management and treatment of a wide range of conditions and problems encountered in the practice of medicine, psychiatry and psychotherapy. In many cases, however, the relative contribution of factors specific to hypnosis is as yet unclear, and often the influence on outcome of the measured hypnotic susceptibility of the patients is small or insignificant.

The results of clinical research may be summarised as follows: There is convincing evidence that hypnotic procedures are effective in the management and relief of both acute and chronic pain and in assisting in the alleviation of pain, discomfort and distress due to medical and dental procedures (Blankfield, 1991; Genuis, 1995; Lang, Benotsch et al., 2000; Lang, Joyce et al.,1996; Montgomery, DuHamel & Redd, 2000; Walker et al., 1991) and childbirth (Brann & Guzvica, 1987; Freeman et al., 1986; Jenkins & Pritchard, 1993).

Hypnosis and the practice of self-hypnosis may significantly reduce general anxiety, tension and stress in a manner similar to other relaxation and self-regulation procedures (Schoenberger, 2000). Likewise, hypnotic treatment may assist in insomnia in the same way as other relaxation methods (Anderson, Dalton & Basker, 1979; Stanton, 1989).

There is encouraging evidence demonstrating the beneficial effects of hypnotherapeutic procedures in alleviating the symptoms of a range of complaints that fall under the heading ‘psychosomatic illness’. These include tension headaches and migraine (Alladin, 1988; Holroyd & Penzien, 1990; ter Kuile et al., 1994); asthma (see review of clinical studies by Hackman, Stern & Gershwin, 2000); gastro-intestinal complaints such as irritable bowel syndrome (Galovski & Blanchard, 1998; Harvey et al., 1989; Whorwell, Prior, & Colgan, 1987; Whorwell, Prior & Faragher, 1984); warts (DuBreuil & Spanos, 1993); and possibly other skin complaints such as eczema, psoriasis and urticaria (Shertzer & Lookingbill, 1987; Stewart & Thomas, 1995; Zachariae et al., 1996).

Hypnosis is probably at least as effective as other common methods of helping people to stop smoking (see review by Green & Lynn, 2000). Meta-analyses by Law & Tang (1995) and Viswesvaran & Schmidt (1992) give mean abstinence rates for hypnosis at 23 per cent and 36 per cent respectively. There is evidence from several studies that its inclusion in a weight reduction programme may significantly enhance outcome (Bolocofsky, Spinler & Coulthard-Morris, 1985; Kirsch, Montgomery & Sapirstein, 1995; Levitt, 1993).

There have been fewer studies specifically on children, but the available evidence suggests that the above conclusions may be extended to children and young people (Hackman, Stern, & Gershwin, 2000; Sokel et al., 1993; Stewart & Thomas, 1995; see also review by Milling & Costantino, 2000).

Too few studies have been published investigating the adjunctive use of hypnosis in broader psychotherapeutic programmes for the treatment of specific psychological disorders such as depression, sexual dysfunction and disorder, anorexia nervosa, bulimia nervosa, speech and language disorders, posttraumatic stress disorder and phobic disorders. A similar statement may be made concerning its use in sports psychology.

The above conclusions are provisional, as research on the clinical effectiveness of hypnosis is continuing with improved Methodology” (Heap et al 2001, pp. 9–10).

As can be seen, the report is very favourable regarding the effectiveness of hypnotherapy. The report also suggests that more research is needed, which is a sentiment I fully support. It is only through research that we can identify the best strategies and approaches for applying hypnosis to treating various conditions.

The British Psychological Society
03-2001
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The Nature of Hypnosis – A report prepared by a Working Party at the request of The Professional Affairs Board of The British Psychological Society

Summary: The report highlights an important ruling by France’s highest court, the Cour de Cassation, deeming evidence collected from witnesses under hypnosis as inadmissible in court proceedings. The article features the views of hypnotherapist Alban de Jong, who criticizes the court’s decision, emphasizing the significance of his hypnotherapy work in providing crucial evidence for solving puzzling cases. De Jong provides examples where his work under hypnosis led to vital breakthroughs in criminal investigations, thereby questioning the court’s dismissal of hypnosis evidence. The article also presents the perspective of the court and provides specific case examples, showcasing the debate surrounding the utilization of hypnosis in legal proceedings.

Harvard Gazette
21-8-2000
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Hypnosis found to alter the brain: Subjects see color where none exists

People have been hypnotized to see color where only shades of gray exist, and to see gray when actually looking at brightly colored rectangles.

That result wouldn’t be so surprising at a carnival or stage show, but it comes from a tightly controlled scientific experiment done at a Harvard University medical facility.

Researchers separately hypnotized eight people as they lay in a scanning machine that recorded activity in their brains. These subjects then tried to drain bright color from pictures, or see color where none existed. They also attempted to do the same thing when not hypnotized. The records of cerebral activity clearly show that hypnosis can change the state of the brain.

“Hypnosis has a contentious history,” notes Stephen Kosslyn, professor of psychology at Harvard and leader of the study. “Some insist it’s a state of mind that differs from normal states and involves unique consequences; others say it’s nothing more than state-show gimmickry.”

Color testCOLOR ME HYNOTIZED: Under hypnosis, some people see only shades of gray in this pattern of brightly-colored rectangles. Such a result shows that hypnosis can change the state of the brain. As an example, if you give some men a brick and ask them to hold it at arm’s length for as long as they can, they will be able to do it for about five minutes. But if you hypnotize them, they will hold the brick out for 15-20 minutes. That result favors the idea that hypnotism creates a unique state of mind.

However, if you tell males that some females who were just tested held the brick out for 20 minutes, they, too, will hold it for that long without being hypnotized. That result favors a suggestibility, or role-playing explanation.

“It all comes down to the question of whether the brain is doing something different,” Kossyln says. The answer apparently is yes, at least in the case of color perception.

How the brain changes

To show how controversial hypnotism is among scientists, Kosslyn and colleagues had great difficulty in getting their research published. Two of the world’s largest scientific journals wouldn’t publish the results.

“One of them asked for three separate revisions,” notes William Thompson, a research assistant in Harvard’s department of psychology. “Then they still turned down our report even after we answered all their criticisms.” After three years, their study has finally been published as the cover story in the August issue of the American Journal of Psychiatry.

Both Kosslyn and Thompson emphasize that the experiment worked only on “highly hypnotizable” people, a category that includes only about 8 percent of all people. “We pre-tested 125 subjects and for those who scored lowest in hypnotizability, the results were just garbage,” Kosslyn says. “They couldn’t do the task.”

The highly hypnotizables slid horizontally into a positron emission tomography (PET) scanner at Massachusetts General Hospital, a Harvard teaching hospital in Boston. They inhaled a short-lived, slightly radioactive type of oxygen. The oxygen traces blood flow and makes visible the most active parts of the brain when a subject is hypnotized and not hypnotized.

It took between two and ten minutes to hypnotize the people while they lay in the scanner. A computer screen overhead then presented them with a pattern of yellow, red, blue, and green rectangles, similar to a painting by the Dutch artist Piet Mondrian. They tried to “drain” the color from what they saw on the screen while the PET scanner recorded their brain activity. Under the same conditions, they saw the rectangles in various shades of gray and had to color them with their minds.

When not under hypnosis, people asked to perceive color – whether they actually saw color or not – showed activity on only the right side of their brains. (The brain is split into right and left hemispheres by a furrow filled with nerve fibers that connect the two halves.) When told to see gray, whether looking at color or gray, again changes in activity occurred on the right side only.

That result was expected on the basis of previous research. However, under hypnotism the researchers found what Kosslyn calls “a curious tweak.” Both the left and right hemispheres responded. In other words, the right side of the brain alone responded to what the subjects saw when they were not hypnotized, but both sides responded under hypnosis.

“The left hemisphere color area registered what people were told to see only when they were hypnotized. The right hemisphere registered what people were told to see [independently of what they actually saw] whether or not they were hypnotized,” Kosslyn explains. “If you ask people [who are not hypnotized] to visualize color in a gray pattern, or vice versa, only the right hemisphere is activated during the task. Thus, our findings in the left hemisphere could not have been produced by mental imagery alone.

“What we have shown for the first time,” Kosslyn concludes, “is that hypnosis changes conscious experience in a way not possible when we are not under hypnosis.”

How hypnosis works

Why the hemispheric differences? Kosslyn and his colleagues think that the right hemisphere is more sensitive to goals and expectations. This part of the brain finds it easier to reinterpret sensory experience to match the images a person wants to perceive – to see color where none exists, or to color a gray palette. This idea fits with the fact that, in most people, the left side deals more with logic and reason, so may require an extra boost from hypnosis to disassociate itself from the senses, i.e., to change what is actually seen.

Such disassociation of senses, Kosslyn and Thompson speculate, may account for the success of hypnosis in reducing pain and anxiety, combating insomnia, and helping some people to quit smoking. Pain, anxiety, insomnia, and smoking, might be reduced by the same type of brain activity that allows some people to drain color from brilliantly hued rectangles.

Highly hypnotizables apparently would be better at this than most people or those who show the lowest levels of submission. Thompson is studying the brain differences between high and low hypnotizables. So far, he has found that the middle-part of a brain area called the cingulate gyrus shows more activity in the highs than lows. This area deals with attention and emotion.

Does changing a brain by hypnosis mean hypnotizables can gain more control over what are normally involuntary functions of the brain – responses to stress, regulation of hormones, control of the immune system, for instance? Maybe. David Spiegel of Stanford University School of Medicine, who collaborated on the color experiments, is interested in the possibility of bolstering the body’s defenses against disease by psychological means that might include hypnosis. Evidence exists that strengthening these defenses may reduce the rate of growth of cancer tumor.

At this point, anything beyond changing color perception is pure speculation, Kosslyn and Thompson insist. However, Kosslyn refers to their study as “the thin edge of a wedge that shows that conscious experience can be changed in a willfully directed way by hypnosis.”

Other researchers who participated in these experiments include Associate Professor of Radiology Nathaniel Alpert of Harvard Medical School and Maria Costantini-Ferrando of Weill Medical College, Cornell University. The research was made possible by a grant from the John D. and Catherine T. MacArthur Foundation.