From the very beginning, I realized from Ms. Q's feedback to me that she would respond better if I refrained from an analytic style and instead became more engaged, sharing my opinions and a few relevant experiences, judiciously.

She told me point blank that she did not want to be treated like a "case" but like a "real human being" and complained about the prior therapist who had listened and allowed long periods of silence, without ever offering an opinion.

My style with her was also influenced by her use of metaphors and humor, which I happily integrated into our sessions.

For instance, she used imagery of "valves" to help her integrate her roles of mother and creative artist, she mimicked the voices of other people when she described conversations, and she dramatized the voices of some of her inner parts in a playful, dramatic way.

Consistent with the "common factors" literature, I think that the strength of the relationship was a major therapeutic factor, and I monitored it closely.


I received direct feedback from Ms. Q that the "inner parts" way of viewing inner conflict and my cognitive approach during the first phase of therapy were both effective approaches.

She reported that she had had coped successfully by using these new tools when a very close friend Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] had been unavailable to her.

Whereas previously "it would have put me in bed for days with a breakdown," she was instead able to immerse herself in her creative work.

She used language from our parts work to explain this improvement: "My needy part was not going to take over just because I didn't get the comfort I wanted."


In another session, she described a "breakthrough" and showed that something I had suggested 5 sessions previously had borne fruit.

She was willing to talk about her ex-boyfriend's death and became very tearful.

In this session, as I wrote in my notes "she is letting me see the scared, trembling, overwhelmed kid inside, instead of presenting me with the smiling, articulate, poised, and in-control woman." Her belief that "I've already dealt with it" had yielded to "I need to stay with this in order to get unstuck." She said "I know this will make you happy" in a collaborative, cheerful way, indicating that she was not depriving me of that experience, as she would do with her mother.

In fact, after this session, she paid some visits to her mother and their relationship was more comfortable and equal, and she was able to test reality and learn that her mother was proud of her and thought she was a good parent.

These events gave me feedback regarding her maturation and differentiation from her mother - she no longer was stuck at age 17, when her mother had been an obstacle to her happiness.


In session #22 a bit of unintended psychoeducation had surprising benefit.

She confessed to me something she was very ashamed to have done, and I gave her a technical-sounding definition of the term "acting out": "It must be so hard for you to contain the overwhelming feelings that you're letting yourself experience, you used a common mechanism to deal with or avoid them." I was reframing her impulsive behavior from "something bad and shameful" to "a not-so-effective way of avoiding emotions." At the end of therapy, Ms. Q said that this was one of the most helpful moments because it motivated her to learn to tolerate her feelings and not push them away.

Similarly, my didactic explanations about the "selfobject" concept were beneficial in giving her an explanation for painful feelings as well as a conceptual framework for the weaknesses in both of her relationships.

At the time of my psychoeducational interventions, I had felt embarrassed over switching to the role of teacher and, in fact, had felt guilty about reporting these incidents to my supervisor.

I learned from this experience that the quality of an intervention must be judged by how it impacts the client and whether it produces positive change in her life.

Furthermore, since the client used the intervention in a way that exceeded my expectations, it underlines the importance of therapists listening carefully to our clients to discover the impact of our words.


I was fortunate that Ms. Q was quite direct in telling me her occasional doubts about the benefits of therapy.

For instance, in one session she asked "what's the use of therapy, is this really helping?" I asked her to think about it, and then a couple sessions later asked for her response.

She said "It's my time, I get to focus on myself.

Otherwise I'm fragmented and confused.

I feel confirmed." This feedback confirmed for me that she was experiencing benefits predicted by Kohut's theory, by developing capacities of a more mature self.


On three occasions, she brought in books and read passages related to gender roles and conflicts.

I noticed that the content and tone of her chosen excerpts had progressed from strident feminist male-bashing to an appreciation of the struggles of both men and women to develop Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] their fullest capacities.

These changes corresponded with a more internal focus, less blaming of her husband as an "obstacle," and the ability to tolerate her own painful emotions instead of focusing on externals.


The case formulation is an essential framework for therapy, but rather than being an architectural blueprint it is an ever-evolving itinerary on an unpredictable journey.

It is modified through various influences and obstacles: the client's preferences, the therapist's interpersonal style, the real human relationship that develops between the two, and the impingement of real life events and reactions of other people outside the office.


Instead of being short-term/time-limited, or long-term/open-ended, the course of therapy was actually three separate episodes, with breaks in between resulting from vacations, what Cummings and Sayama (1995) might call "intermittent." The client's outcomes at the time of our last contact included satisfaction with her decision to terminate the marriage, pride in having not neglected her responsibilities as a mother, greater personal confidence and maturity, and success in engaging for longer periods of time in creative writing, her chosen career.

I believe that therapy contributed substantially to these successes.

However, major credit for positive change goes to factors out of our control: her husband found another girlfriend and didn't wait around for her to overcome ambivalence; this led to her mother and sister turning against him and becoming very supportive rather than blaming; and she gained external validation for her writing talents from the acceptance of her stories in magazines and the praise of other writers.


I began working with this client in a psychoanalytic institute that provided instruction and supervision in therapy based on Kohut's self psychology, emphasizing the development of transference.

I initially expected a selfobject (narcissistic) transference to unfold, in which I would be viewed by Ms. Q as someone serving functions to shore up her self, rather than as someone who is a separate individual with a separate point of view.

Some of the markers of that type of transference is the need for "mirroring" (uncritical acceptance), a rejection of ideas from the therapist that offer a new perspective, and an overreaction of rage to minor "empathic failures." Such is the pressure of training settings with a firm orientation that it would be easy for trainees to ignore the data from the client and make assumptions about the client's dynamics from the preferred theory.

Determined to resist that pressure, I attended to the client's reactions to me, and to the development of our relationship, and found that she was open to new ideas, very tolerant of my mistakes, and eager to change her perspective.

The pleasure of working with this client stemmed from the fact that she was intelligent, motivated, and, most important, viewed me as a "real" person and valued my contributions.

Since that time, I have always emphasized the importance of "developmental diagnosis" for understanding the client, creating the best relationship, and making appropriate treatment decisions.


Kohut's theory not only helped me evaluate her level of maturity in relationships, but also was an invaluable lens for understanding her difficulty separating from her husband as well as how her healthy, creative, "grandiose self" had been squelched and now needed support to Guided by "Core Clinical Hypotheses" B.L. Ingram Pragmatic Case Studies in Psychotherapy, http://pcsp.libraries.rutgers.edu Volume 5, Module 1, Article 1, pp.

1-42, 04-06-09 [copyright by author] find its power and voice.

Thus the therapy process was enriched by my integration of Kohut's concepts, without my embracing his treatment methods.

Instead of functioning like an analytic therapist, I engaged in a more equal, collaborative, "real" relationship, often similar to what Kopp (1978) described as a "fellow pilgrim." I also took the expert consultant role when I implemented cognitive strategies, directed experiential inner parts activities, and offered psychoeduation.


I was aware of how my personal values were involved in the process of therapy.

When she talked about leaving her 8-year-old son with her husband, I had judgmental thoughts about her being a bad mother, and, trying not to sound judgmental, confronted her on her rationalizations ("my son doesn't need me any more"), and tried to strengthen the part of her that felt guilty.

For instance, when she said "Being a good mother comes naturally to me, I know there's no danger of my hurting my son." I said "How do you imagine he feels at night when you're not there to tuck him in?" In my view, in these sessions I was the advocate for her child, although I suspect that my approach would be labeled "countertransference" by others at the institute.


It was an enormously valuable experience for me to write this case report and re-evaluate the course of therapy from my current perspective.

At the time, I was trying to learn a psychodynamic orientation and frequently felt embarrassed and annoyed at myself for violating the rules: I spoke too often, I "broke the frame" by giving opinions and validation of the client's strengths, and I destroyed opportunities for transference to develop by being too spontaneous, self-disclosing, and genuine.

In hindsight, I see that I created a positive relationship, showed respect for Ms. Q's autonomy and maturity instead of emphasizing pathology, and exhibited flexibility and creativity.

This case report illustrates how "core clinical hypotheses" influenced my therapeutic decisions, and how diverse ideas can be integrated coherently when the focus is on resolving problems and achieving desired outcomes.

B2: There are MEDICAL INTERVENTIONS (e.g., medication, surgery, or prosthetics) that should be considered.


B3: A holistic understanding of MIND-BODY CONNECTIONS leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind.


CS1: The client's symptoms constitute an EMERGENCY: Immediate action is necessary.


CS2: The client's symptoms result from identifiable recent SITUATIONAL STRESSORS, or from a past traumatic experience.


CS3: The client is at a DEVELOPMENTAL TRANSITION, dealing with issues related to moving to the next stage of life.


CS4: The client has suffered a LOSS AND needs help during BEREAVEMENT or for loss-related problems.


BL1: A behavioral analysis of both problem behaviors and desired behaviors should yield information about ANTECEDENTS (triggers) AND CONSEQUENCES (reinforcers) that will be helpful in constructing an intervention.


BL2: A CONDITIONED EMOTIONAL RESPONSE (e.g., anxiety, fear, anger, or depression) is at the root of excessive emotion, avoidant behaviors, or maladaptive mechanisms for avoiding painful emotions.


BL3: The problem stems from SKILL DEFICITS - the absence of needed skills -- OR the LACK OF COMPETENCE in applying skills, abilities and knowledge to achieve goals.


C1: The client is suffering from the ordinary "miseries of everyday life" and has unrealistic UTOPIAN EXPECTATIONS of what life should be like.


C2: Limiting and outdated elements in the FAULTY COGNITIVE MAP (e.g., maladaptive schemas, assumptions, rules, beliefs, and narratives) are causing the problem or preventing solutions.


C3: The client demonstrates FAULTY INFORMATION PROCESSING (e.g., overgeneralization, all- or-nothing thinking, and mindreading, or is limited by an inflexible cognitive style.


C4: The problem is triggered and/or maintained by DYSFUNCTIONAL SELF-TALK and internal dialogue.


ES1: The client is struggling with EXISTENTIAL ISSUES, including the fundamental philosophical search for the purpose and meaning of life.


ES2: The client is AVOIDING (or needing to utilize) the FREEDOM and autonomy that come with adulthood AND/or does not accept RESPONSIBILITY for present and past choices.


ES3: The core of the problem and/or resources needed for resolving the problem are found in the SPIRITUAL DIMENSION of life, which may or may not include religion.


P1: The problem is explained in terms of INTERNAL PARTS AND SUBPERSONALITIES that need to be heard, understood, and coordinated.


P2: The problem is a REENACTMENT OF EARLY CHILDHOOD EXPERIENCES: Feelings and needs from early childhood are being reactivated and patterns from the family of origin are being repeated.


P3: Difficulties stem from the client's failure to progress beyond the IMMATURE SENSE OF SELF AND CONCEPTION OF OTHERS that is normal for very young children.


P4: The symptom or problem is explained in terms of UNCONSCIOUS DYNAMICS.

Defense mechanisms keep thoughts and emotions out of awareness.


SCE1: The problem must be understood in the context of the entire FAMILY SYSTEM.


SCE2: Knowledge of the CULTURAL CONTEXT is necessary to understand the problem and/or to create a treatment plan that shows sensitivity to the norms, rules, and values of the client's cultural group.


SCE3: The problem is either caused or maintained by deficiencies in SOCIAL SUPPORT.


SCE4: Difficulty meeting demands for SOCIAL ROLE PERFORMANCE contributes to the client's distress and dysfunction.


SCE5: A SOCIAL PROBLEM (e.g., poverty, discrimination, or social oppression) IS A CAUSE of the problem.

Social problems can also exacerbate difficulties stemming from other causes.

You must avoid blaming the victim.


SCE6: The problem is causally related to disadvantages or advantages to the SOCIAL ROLE OF MENTAL PATIENT.


Kohut's concept of "grandiose self" was important for understanding the creative drive; the fact that it was inadequately "mirrored" in childhood contributed to her need to protect it, and her assumption that it would be attacked and stifled by her husband.

As a child in her family she was initially in a very close relationship with her mother, where the normal roles were reversed, and she had to be sensitive to her mother's emotional needs, instead of getting the empathic attunement and calm, loving acceptance for her true self that she needed (Alice Miller's (1981) Drama of the Gifted Child is a good fit with this client's history) Her maturation over the 12 years of her marriage was an important factor in understanding the marital dynamics.

Initially, she had been immature and was satisfied with serving her husband's needs, deriving a sense of safety and worth by being his wife.

However, at the time of therapy she wanted to assert her own needs and fulfill her own talents.

She was having difficulty finding inner sources of self-affirmation, and wanted to separate in the way an adolescent wants to break away.

Her empathy for others was variable.


There is plenty of material in the history for speculation: rage at brother (for being born and stealing her mother) and father (for dying and abandoning her) may have contributed to her feelings towards her husband.

The guilt over her boyfriend's death was talked about, so it seemed conscious, but its persistence despite her awareness that it was irrational suggests that it persisted in limiting her ability to leave another relationship.


As the client matured and became more independent and assertive, it disrupted the marital equilibrium Her husband wanted to assert pressure to return things to the status quo, and did indeed seem to want to sabotage her career development.

Her desired solution of "cut off" was easier than the process of differentiating and standing on her own.


Her mother's hostile disapproval of the client's lifestyle choices stemmed from Latina/Catholic background.

The issue of gender was important to the client: men have an easier time pursuing careers and ignoring the needs of their families and she felt hampered by the traditional female role.


She had a good support system in her friends.

Her mother and siblings sided with her husband and pressured her to put family ahead of "selfish" goals.


Ingram (2009) presents a case study conducted within her model of psychotherapy integration, a systematic approach that takes several factors into account.

Within the integration field, Ingram’s model can be classified within the bounds of “Technical Eclecticism,” and is more encompassing than other similar approaches.

The approach can be improved by greater attention to cyclical factors among her categories, but it remains an important contribution.

Her interesting case study demonstrates how her system can be applied.


Ingram (2009) has described the interesting case of Ms. Q using her particular integrative approach, which I will hereafter refer to as the “Integrative Psychotherapy” model (see Ingram's [2006] detailed book on the model).

I am pleased to be able to comment on this presentation and, in doing so, will divide my remarks into two sections.

The first will place Ingram’s contributions within the general corpus of psychotherapy integration, and the second will be reserved for specific comments about the case.


Within the field of psychotherapy integration, there are four general types of models (e.g., Castonguay et al., 2004; Stricker & Gold, 2006).

These include Theoretical Integration, which strives to encompass previously quite different theoretical perspectives within a single, coordinated theory; Assimilative Integration, which maintains a single orientation but incorporates techniques from other orientations; Common Factors Integration, which strives to find and develop common elements from across different theoretical points of view; and Technical Eclecticism (also referred to as Technical Integration), which focuses on a combination of techniques drawn from different therapeutic systems without regard for any specific theoretical approach.

Ingram’s Integrative Psychotherapy can be classified within this last category.


Ingram’s model is far more specific in its details than a Common Factors approach, and her model’s lack of a guiding theoretical formulation rules out Theoretical or Assimilative Integration.

In Technical Eclecticism, therapeutic procedures are not attached to treatment methods or models, and this is clearly true of Ingram’s Integrative Psychotherapy.

It is comparable in approach to Prescriptive Psychotherapy (Beutler, Consoli, & Lane, 2005) and Multimodal Therapy (Lazarus, 2005a, 2005b).

In comparison to these two, Ingram’s model is much closer in style to that of Lazarus and Multimodal Therapy.


Ingram and Lazarus both begin with a careful assessment of the client and are guided by a comprehensive set of categories.

For Lazarus there are seven modalities of human experience and functioning that include the dimensions of Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drugs/Biological—which as a whole Lazarus refers to with the acronym “BASIC-I.D.” For Ingram it is a combination of four treatment models (Behavioral and Learning; Cognitive, Existential and Spiritual; and Psychodynamic) as well as three other areas that also generate hypotheses about causation (Biological; Crisis, Stressful Situations, and Transitions; and Social, Cultural, and Environmental).

I prefer Ingram’s list to that of Lazarus because of her willingness to acknowledge the potential contribution of Psychodynamic concerns and the explicit attention to Existential and Spiritual issues.


I also note the similarity of her approach to the three-tier approach that Gold and I have developed (Gold & Stricker, 1993; Stricker & Gold, 1988; Stricker & Gold, 2005) within our assimilative psychodynamic integration approach (Gold & Stricker, 2001; Stricker & Gold, 2002; Stricker & Gold, 2005).

In the three-tier approach, we divide our concerns into behavior, conscious experience (perception and cognition), and unconscious dynamic factors.

Ingram has anticipated a clear difficulty in our approach by acknowledging the important role of Social, Cultural, and Environmental factors, and we will include these in future works. I also applaud her explicit concern for Existential and Spiritual issues, which might fit within our tier concerning conscious experience, but deserves the specific attention that she gives to them.


One area with which Ingram (and Lazarus) does less well with is an acknowledgment of the interrelated nature of all of these areas of concern.

It is important to recognize that Ingram’s seven categories are not seven independent areas to be explored, but rather that each one impacts the other.

As a result, we become clear that it is of little concern where our initial intervention occurs because of the synergistic effect that each area has on the other.

Without the concepts of interrelatedness and cyclical impact (Wachtel, Kruk, & McKinney, 2005), a more mechanical pattern of interventions arises.


It is interesting to note Ingram’s experience in choosing her integrative theoretical approach in treating Ms. Q: Prior to this client, I had effectively integrated ideas and treatment methods from cognitive and existential approaches in my work as a staff member and part-time independent contractor for university and community clinics.

After taking a course in the [Self Psychology] work of Heinz Kohut at a psychoanalytic institute, I decided to enroll in a postdoctoral training program to learn more about this theoretical model.

When I started seeing the client, my intention was to put aside my prior methods and techniques, and wholeheartedly embrace the psychoanalytic approach that I was studying.

Instead, I discovered that I was constitutionally incapable of not being integrative.

Fortunately, I had a supervisor for this client who saw me in his private practice office and who accepted that I was seeking to integrate what I was learning rather than to convert to a new orientation.

( pp. 1-2) This description precisely reflects the experience of many people who identify with psychotherapy integration, in that they recognize the value of orientations other than their own, but want to work in a variety of ways that best serve the client rather than to convert to a new set of narrow convictions.

Ingram thus clearly belongs in the tradition of psychotherapy integration, as she recognizes, and it is now time to turn to the application of this imaginative system to the particular case that she presented (Ingram, 2009).


Before beginning a review of the case of Ms. Q (Miscue?), there are several important issues to cover.

First, Ingram notes that she has changed several details to protect the anonymity of Ms. Q, “in the extremely unlikely event that she should read this article.

” The changing of names and of inconsequential details is common practice and raises no concerns.

However, this ordinarily is done to protect the client from being revealed to others who may read it, a less unlikely scenario.

As for protecting the client herself, in my view the much better action is to ask the client, if available, for permission to use her data for a case report, allowing her to read it if she wishes, and abiding by whatever her wishes might be. I have done that several times, have always received permission (a question may be raised about whether there is implicit transferential coercion, although I always try to minimize it), and usually there is a positive benefit from this obviously mutually respectful and collaborative intervention.


The structure of the sessions with Ms. Q varied over time and setting.

Treatment followed the increasingly common pattern of extended sequential therapy rather than a single continuous episode.

As such, this may be viewed as two or three therapy episodes rather than a single one.

There is some value in this emerging pattern, for it allows the client time to consolidate therapeutic gains and focus on new issues.

Usually, as in this case, this pattern is brought about by external factors, such as payment policies and changes in living arrangements, but it rarely is destructive to the flow of treatment.

The point I want to note is that Ingram continued the treatment at the same fee.

I applaud her for this decision.

All too often, I have seen candidates in psychodynamic training settings, such as Ingram in this case, or young therapists moving from clinic settings to private practice, who agree to continue with their patients but only at an increased fee.

Given the powerful nature of the therapeutic relationship, there is the potential for exploitation in this offer, and it is noteworthy that Ingram resisted the temptation to do so. I also have some concern (about typical candidates, not Ingram) when the patients, who are being treated at a reduced fee, are made to feel in a second-class status by the juggling of their appointment times in favor of more privileged full-fee patients.


Ingram notes that her sources of data, besides what the client told her, included external information about Ms. Q’s writing and about her husband.

There are no ethical issues raised by this as long as Ingram did not seek out information from others about the husband (and there is no indication that she did), but there is a very interesting therapeutic point that it raises.

How important is such external confirmation? As long as Ms. Q is committed to a career in writing, must we (can we) judge how talented she is? As long as she sees her husband as stifling her growth, does it matter whether he really is doing so? I certainly can see arguments that claim that such information is important because they would help to introduce reality into the treatment planning, but there also is a point of view that suggests that the only reality that matters is that of the patient.

My position is somewhat intermediate, but it matters less what I think; what is most important is to raise awareness and encourage discussion of this issue within the psychotherapy community.


Finally, at least for these pre-treatment comments, it must be noted that a case study inevitably leaves out data and changes some things that are included to protect anonymity.

As a result, any of my comments may turn out to be incorrect because of a lack of sufficient information, and Ingram may have done exactly what is suggested but failed to record it for reasons of space or privacy.

For Ingram, psychotherapy begins with a thorough assessment and the establishment of outcome goals that are directly related to the identified problems.

No specific mention is made of necessary attention to the establishment of a therapeutic alliance, but the goals and tasks that are mentioned are two of the necessary components of an alliance (Bordin, 1979).

The third component, the bond, although not specifically mentioned, almost surely was established given the description of the case.

It is critical to establish mutually determined goals that can be altered in the course of therapy, as this strengthens the bond, provides the basis for a treatment plan and subsequent interventions, and allows for feedback about progress.


In terms of this monitoring of progress, Ingram notes that “the ineffectiveness of a technique does not invalidate the usefulness of the [case formulation] hypothesis” from which it was deductively derived.

I agree, but it is equally important to note the logically parallel point that the effectiveness of a technique does not necessarily validate the usefulness of the hypothesis from which it was deductively derived, since frequently a particular technique can be effective for a variety of potential reasons.

This is a less frequently noted aspect of treatment, and important to keep in mind.

Ingram indicates that she places a great deal of importance upon an ongoing monitoring process.

Although she doesn’t mention it, this monitoring process is probably the most evidence-based treatment that is available at the present time, especially in actual practice settings.

Rather than a series of highly controlled, experimental studies indicating some limited support for the use of techniques that, themselves, only contribute a relatively small amount of variance to change (Wampold, 2001), the process of feedback has significant demonstrable value (Lambert, 2007).

In addition, it places the clinician within the local clinical scientist model (Stricker & Trierweiler, 1995; Trierweiler & Stricker, 1998), as information learned within the therapy session is used to advance treatment, both with the same patient and with future patients.


In terms of Ms. Q’s treatment goals, it isn’t clear how the attainment of subjective goals such as making good decisions can be evaluated without a judgmental dimension entering into the treatment.

Other problems, such as Ms. Q’s lack of confidence and frustration, are better divided into two so that they can be worked on and evaluated separately.

In regard to the judgmental dimension, this is particularly apparent in the instance when Ingram asked Ms. Q about her child’s feelings when she failed to tuck him in at night.

She appropriately referred to as an example of countertransference.

This occurs again when Ms. Q decided not to enroll in the writing program, but instead to rent an apartment and live on her own while pursuing her writing career.

Ms. Q was very proud of this choice, and it seems as though Ingram agreed as well.

However, was this a good choice? Who can say? I would be inclined to support the patient’s choices whether or not they agreed with my preferences, as long as they weren’t obviously destructive.

However, here again, the threshold for perceived destructiveness will vary as a function of the attitudes of the therapist.

The acceptance of the approach of the client is consistent with Client-Directed Therapy, a new and interesting common factors approach to integration (Duncan, Sparks, & Miller, 2006).


One obstacle to blending cognitive and psychodynamic approaches is that the former is more directive and the latter more expressive.

Providing direction, such as with Ingram’s regard for the welfare of Ms. Q’s son, may serve to compromise a stance that encourages free expression.

This is an inescapable concomitant of an integrative approach, and it is necessary to recognize that techniques that mean one thing within a home approach may mean something entirely different within a different or more integrated approach.

I applaud Ingram’s focus on strengths, as this too is often overlooked.

It is the patient’s strengths that can be the basis of constructive developments within treatment, and also the recognition of strengths is helpful in promoting the therapeutic bond and increasing the patient’s hope of success, which often is integral to therapeutic gains.

The strengths that are listed include both internal strengths, such as Ms. Q’s intelligence, and intra-therapeutic strengths, such as her ability to provide feedback within the treatment.

It is important to keep both in mind, as they both contribute to success in the treatment.


During the first session Ingram asked Ms. Q to consider both individual and couple therapy.

This is an often overlooked aspect of treatment that should be required as part of informing the patient about the risks of treatment.

Ms. Q clearly preferred individual treatment and valued her growth more than her marriage, but that is a choice each patient should be allowed to exercise, and the only correct answer is the one that is consistent with the patient’s goals.

Problems arise when the patient is not alerted to the difference between the two modalities, and to the likely effect of the choice on the patient’s individual growth and relationships.


I do have some concern with what appears to be Ingram’s willingness to accept Ms. Q’s words for her problems without asking for details.

Thus, we have goals concerning Ms. Q’s impulsivity and her inclination to flee situations, but it isn’t clear from the material presented that either of those are present.

For example, I often see patients who are frightened of their anger, but when asked when they acted in an angry way, they are at a loss for examples.

I do not deny that anger is a concern, but it is an impulse rather than an action that is to be feared.

In Ms. Q’s case, I suspect her declared inclination to flee also is more an impulse than an action, and so the solution would rest more in understanding the impulse than in coping with its expression.


Ingram does use the technique of asking for examples when Ms. Q thought her husband would become symptomatic if she were to become more successful.

This was very effective in correcting a misperception of the consequence of success.

Interestingly, Ingram refers to this as cognitive therapy, and it is, but it also is an intervention that would be very comfortable for a psychodynamic therapist.

Similarly, in discussing Ms. Q’s feelings toward her husband, Ingram used techniques that she accurately sees as consistent with Greenberg’s Emotion-Focused Therapy (Elliott & Greenberg, 2007), which, in turn, is a derivative of Rogerian thought.

It is interesting to note that the work of Kohut (1977), which also influenced Ingram, is very similar to that of Rogers (Kahn, 1985).

They agree on the central role of empathy in the therapeutic relationship, a point also emphasized by Ingram in her description of the treatment.

Very often techniques from entirely different theoretical orientations are similar to each other, and this makes the task of integration a good deal easier if one is not caught up in the rigidity of any single system.

However, the previous caution about the changing meaning of similar techniques when placed in different theoretical systems is particularly appropriate here.


The use of chair work, a technique familiar to humanistic therapists and often integrated in the work of therapists with other approaches, was resisted by Ms. Q, but the patient’s idea of accomplishing the goals of chair work without changing seats was accepted by the therapist.

This is a good example of flexibility, as the goal of the technique is more important than the actual execution.

The goals were consistent with Ingram’s “inner parts” hypothesis, and often chair work is used whenever ambivalence is an issue.

Ingram uses a technique of cognitive labeling that I find very useful.

It helps to normalize some behavior, as it did in the case of Ms. Q, and also to help her to develop better skills.

I also have found that labeling serves many other purposes.

By identifying and naming an emotion, it conveys empathy and thereby strengthens the therapeutic alliance.

It also gives the patient a sense of mastery, as a named emotion is also an acknowledged and thus owned one.

Normalization takes the feeling out of the realm of the mysterious, which tends to reduce the helplessness that accompanies the unknown.


During the second phase of treatment, Ms. Q was able to access a sense of never having gotten anything without having to work for it.

I can imagine that this was an important insight and very moving for the patient.

However, I also wonder whether she had been given a good deal without having to work for it before her brother’s birth, and it was the contrast between her rich early years and the subsequent deprivation that was so difficult for her.

This brings up some fascinating questions.

Is this reformulated insight superior in any way to the one that Ms. Q achieved? Does the “historical truth” of the observation matter if the “narrative truth” is meaningful to the patient? ( On this distinction, see Spence, 1984.) In line with the latter, I am inclined to think that the most important thing is to provide the patient with a coherent and credible attribution for feelings and actions, and these can be the vehicle for therapeutic progress even in the absence of historical correlates.


In the last phase of treatment, Ms. Q indicated that her husband’s infidelity made it easy for her, as he had made her decision for her.

This may be, and much might have been untold about this episode, but I would have preferred to see Ms. Q take responsibility for her decision.

However, it doesn’t matter much what I (or any other therapist) would have preferred; if this construction is what enabled Ms. Q to move on with her life, who is to say that she should view it differently? That brings about a very important question, as to the extent to which a patient’s vision should take precedence over that of the therapist.

There is an exciting new approach (Duncan et al., 2006) that suggests that the patient is always right, and so the patient’s theory of change should be placed before the therapist’s.

Although I am not completely sold on this extreme formulation, there is much to recommend it, and it certainly is worth considering in this case.

It also should be noted that Ingram appears to have taken Ms. Q’s formulation into account, and the therapy progressed from that point forward.

Given the apparent success of the treatment, I would have been very interested in asking Ms. Q, at the last session, what she felt were the mutative factors in the process.

I routinely do that with my patients and never fail to be surprised by what they say. They often mention events as being critical that I have long forgotten, and fail to remark about what I saw as turning points.

There is no right or wrong about this at our current state of knowledge, but it does give one cause to pause and to reconsider strongly held beliefs.

Perhaps this disparity is consistent with the notion of client-directed treatment (Duncan et al., 2006) referred to above, and should give us more reason to listen to our patients at least as much as we would like them to listen to us.


I find it fascinating that Ingram wrote the following: At the time, I was trying to learn a psychodynamic orientation and frequently felt embarrassed and annoyed at myself for violating the rules: I spoke too often, I “broke the frame” by giving opinions and validation of her strengths, and I destroyed opportunities for transference to develop by being too spontaneous, self-disclosing, and genuine. ( p. 25) At the initial meetings of the Society for the Exploration of Psychotherapy Integration (SEPI; http://www.cyberpsych.org/sepi/), this sentiment was repeated frequently.

Therapists trained in several different orientations had found themselves doing things that they would have been reluctant to confess to supervisors, yet that were effective for their patients.

The heart of psychotherapy integration, the movement within which Ingram clearly belongs, is that old rigidities hamper rather than aid the treatment process, and there is much that we can learn from each other.

Ingram’s notion of the “ever-evolving itinerary” within treatment captures the sense of psychotherapy as a process, which is the essence of psychotherapy integration.

Ingram has made an important contribution to psychotherapy integration with her clearly presented approach, and some of her embarrassment, although understandable, might better be seen as a point of pride.


Stricker (2009), Grinfeld (2009), and Lampropoulos (2009) provide three types of commentary on my case of Ms. Q (Ingram, 2009): feedback on my handling of psychotherapy with this high-functioning client; critical evaluation of my “28 core clinical hypotheses” model; and discussion of where this model fits within four categories of integrative psychotherapy—common factors integration, theoretical integration, assimilative integration, and technical eclecticism.

In this response I focus on each topic in turn, and conclude with a discussion of the training of clinical graduate students as integrationally-oriented psychotherapists.


Writing the case of Ms. Q (Ingram, 2009) was an absorbing, enlightening experience.

It not only allowed me to describe how I handle choice points in therapy using my 28 core clinical hypotheses model (to be called “28CCHM” throughout this article; Ingram, 2006), but also enabled me to improve my teaching and supervision of clinical psychology graduate students.

Reading the commentaries of people who share my core value of providing the best possible treatment for each unique client—two highly-regarded experts in integrative psychotherapy (Stricker, 2009; Lampropoulos, 2009), and an extremely knowledgeable and articulate graduate student who resonates to my approach (Grinfeld, 2009)—has been what I can only call, in the language of humanistic psychology, a peak experience.

Their feedback rewarded me with the pleasure of being understood, appreciated, and commended for my contribution; challenged me to sharpen my thinking and increase the clarity of my communication; and invited me to address broad issues that affect the theory, practice, and training of integrative psychotherapy.

Throughout this article I will be referring to specific hypotheses by codes, and the charts at the end of Ingram (2009) will provide further explanations.


Writing a case study for public scrutiny, unlike writing an article on theory or research, puts the writer in a vulnerable, exposed position.

So it was with gratitude and relief that I discovered that Stricker (2009), Grinfeld (2009), and Lampropoulos (2009) each made positive comments, providing me with the enjoyment of being both understood and appreciated.

Stricker praised things that I had not even recognized as praiseworthy, such as not raising the fee when I moved from a nonprofit training clinic to private practice, and providing the client the choice between individual and marital therapy, instead of assuming that individual therapy was the treatment of choice.

He recognized my emphasis on empathy and the therapeutic alliance, even though I had not made that explicit in my case report; appreciated my focus on strengths; and described my ongoing monitoring of progress as “probably the most evidence-based treatment that is available at the present time” (p. 46).

Lampropoulos noted “the level of sophistication in assessing, conceptualizing and treating a client integratively via the use of the 28 core hypotheses,” and recognized that tailoring the conceptualizations to the “needs and dynamics of the client at many different levels” increased the chance that “the client would find them meaningful and beneficial in therapy” (p. 53).

Grinfeld approved that I was “monitoring responses to interventions so that those that the client does not find helpful can be abandoned while those that resonate are pursued” (p. 59).

She also commended my approach for incorporating the three components of the APA’s Evidence-Based Practice in Psychology (EBPP; APA Presidential Task Force, 2006): (1) research evidence, (2) clinical expertise, and (3) patient characteristics, culture and preferences.


All three of the commentators gave me credit for the comprehensiveness of the 28 hypotheses, and the fact that the hypotheses incorporate domains that are usually neglected in clinical practice.

Lampropoulus honored me with the statement “she has done an important job in presenting the gist of major theories and concepts that an integrative/eclectic student or clinician ought to know to practice integratively at a basic level” (p. 53).

Both Grinfeld and Stricker appreciate my inclusion of hypotheses from two of the seven domains, Existential and Spiritual, and Social, Cultural, and Environmental; and Grinfeld, additionally, noted the benefit of the Crisis, Stressful Situations and Transitions category.


Delight at reading the commentaries came not only from positive feedback but also from discovering new language to describe my approach.

From Stricker I learned the succinct term “local clinical scientist model” for what I have been describing as “empirical validation through single case design.” I have been using the term “intermittent” to describe therapy with multiple episodes, and henceforth I will prefer to use his term, “extended sequential therapy.

” I was especially gratified by the way Grinfeld grasped and described a level of the process in my treatment of Ms. Q that I was completely unaware of: Ingram’s choice to follow the client’s “orientation preference” … seems … to constitute an empathic attunement to process [my italics] as well as to content, furthering not just the working alliance but also Ms. Q’s sense that her needs can be acknowledged and met (p. 63).


Those words elegantly described my intentions and their impact, and, incidentally, demonstrated unmatched empathic attunement to my content and process.


I greatly valued the criticism and suggestions from the commentators.

For instance, Stricker rightly said that it would have been desirable to get the client’s explicit permission and have her review the document (unfortunately this was impossible given the length of time since the termination of therapy), and Lampropoulus pointed out the disadvantage of not providing standardized quantitative measures as did Clement (2008) in his case study in a prior issue of this journal.

Grinfeld made the excellent point that most clients, unlike Ms. Q, will not directly provide feedback about which hypotheses resonate and which do not, and may in fact prefer straightforward explanations from a therapist who takes a more authoritative role.

For those clients, the most empathically attuned process would be for the therapist to function in the role of confident expert who makes treatment decisions from a single model, as, in fact, would occur when there is a specific empirically-supported treatment that is the best match for the client’s problem.


Stricker posed challenging questions that allowed me to clarify my thinking on issues I had not previously addressed directly: How important is such external confirmation [of her talent for writing]? As long as Ms. Q is committed to a career in writing, must we (can we) judge how talented she is? As long as she sees her husband as stifling her growth, does it matter whether he really is doing so? ( Stricker, 2009, pp.


These were not rhetorical questions but ones that are open for debate, and the answer must be grounded in specific case data.

In the case of Ms. Q, I believed that it was vitally important to determine that her aspirations were realistic rather than being grandiose fantasies or utopian goals.

In a different case—say, a client who talks with pleasure about her beautiful new house—I would not take a drive to her address to see if I agreed with her opinion.

In the latter example, it is a question of values, taste, and personal definitions.

Moreover, it is a fait accompli; the client has already made a choice, and she is satisfied with it.


In Ms. Q’s case, she was faced with making decisions that would have dramatic repercussions for her marriage, her child, and her lifestyle.

Moreover, the issue was one of defining outcome goals, and the importance that goals be realistic and attainable.

( This topic is discussed in detail in Ingram [2006] in Chapter 12).

I believe that an important task of a therapist is to help clients set goals that are not only possible, but also, when attained, will increase their life satisfaction, enhance their self-worth and self-efficacy, and not result in unexpected collateral damage.

For me, failing to challenge a client’s unrealistic goals would be equivalent to failing to mention a banana peel on the person’s path.


Questions about external verification of the clients’ beliefs allow me to elaborate on the importance I place on working jointly with the client to gather data about “reality” so that the client (not just I) can ascertain the fit of her “model of the world” with the evidence of experience (meaning both her sensory, lived experience, and the “reality” that receives consensual validation from outsiders.) In his article, Stricker wondered if I had gathered details about her impulsivity and inclination to flee situations, noting the importance of distinguishing between an internal state that has never been acted on, and a tendency to action that has been demonstrated in the past.

This client told a highly detailed narrative of her life, including specific episodes that she labeled “fleeing,” including leaving home without advance preparation at 18 and leaving her ex-boyfriend without communicating her intentions.


Had she not been so forthcoming, I would have asked questions like, “How do you define ‘fleeing’?” “ Have you ever done that before?” “ Can you give me an example?” “ Please tell me the story of that experience, from beginning to end.” My knowledge about data-gathering questions comes in part from what Bandler and Grinder (1990) called the “metamodel,” defined as a set of linguistic information-gathering tools, and described in my book (Ingram, 2006, pages 40-44) as an essential interviewing skill.

Questions that require the client to check his or her cognitive map against the data of their personal experience are necessary for evaluating the extent to which that map is faulty (C2—Faulty Cognitive Map).

Questions that allow the therapist to evaluate the client’s information processing skills (C3) not only identify weaknesses, but also “hook into” the reality testing part of the client’s mind and reveal strengths in scientific thinking skills.

Answers to those detail-oriented questions allow the client to flesh out and evaluate her personal narratives, as well as modify faulty thinking such as overgeneralization (“Can you think of an example when that didn’t happen?”) and self-imposed limits created by “can’t” and “should” (“What stops you?” “ What would happen if you did?” “ What would happen if you didn’t?”).


Another challenging question from Stricker was this: “Does the ‘historical truth” of the observation [about early childhood experiences] matter if the ‘narrative truth’ is meaningful to the patient?” He proposed that “coherent and credible attribution for feelings and actions … can be the vehicle for therapeutic progress even in the absence of historical correlates” (Stricker, 2009, p. 48).

Reading this, I felt comfortably in the terrain of Jerome Frank (1961) who suggested that the common elements of successful change interventions were a plausible explanation, and a logically-connected ritual.

I believe that while the lack of verifiable historical data is not an impediment to successful therapy outcomes, credibility and plausibility are enhanced when there is confirming evidence from past experience, and the search for evidence is hugely beneficial for building clients’ ability to evaluate and update their cognitive map (C2) and reframe the experiences that led to maladaptive repetitions of past experiences (P2).


This discussion leads me to pose a question to myself: “How do I reconcile my view that the client is the director or collaborator in the direction of therapy with my belief that I have a responsibility to clear up illusions or misconceptions?”


Stricker pointed out my judgmental position when Ms. Q. decided not to leave the state to enroll in a writing program, but instead to rent an apartment near her child, and live on her own while pursuing her writing career.

He comments, “Ms. Q. was very proud of this choice, and it seems as though Ingram agreed as well.

However, was this a good choice? Who can say?” ( Stricker, 2009, p. 47).


While Stricker would be comfortable putting his preferences aside as long as the outcome of the client’s choices were not obviously destructive, I would be integrating several hypotheses to help the client enhance the quality of her decision by correcting faulty information processing (C3), liberating herself from the need for defensive processes (P4), reducing the need for conditioned emotional avoidance (BL2), and realistically appraising the consequences of choices in terms of values and responsibilities (ES2).


Stricker is correct that I did approve of Ms. Q’s choice, and even showed my approval, because it seemed to be a good compromise between fulfilling her need for freedom and embracing her responsibility to consider the emotional impact on her son. I confess that my tendency to judge according to my own values has been my biggest countertransference challenge, and has put at risk the safety and acceptance that clients need in order to express everything they think and feel. ( I have learned that growing up with a mother who believed “I know what is best for you” was not the best preparation for a psychotherapist.)


One of the weaknesses pointed out by Grinfeld was that the list of 28 hypotheses was not as comprehensive as I believed, citing the omission of process variables and treatment approaches.

Grinfeld’s comments give me a chance to clarify the importance of distinguishing core clinical hypotheses and “treatment approaches that have been shown to be effective in therapy.

” The hypotheses are building blocks for the assessment (also referred to as conceptualization, formulation, or explanation), which is (a) consistent with the data of a specific client; and (b) focused on explaining the cause, maintenance, and potential resolution of specific problems.

The treatment plan then (a) follows logically from specific hypotheses, (b) is focused on attaining outcome goals; (c) specifies in detail strategies, techniques, and therapeutic process dimensions; and (d) is a good match for the specific client’s values, preferences, and abilities.


Grinfeld points to omissions in the list of 28, such as: transference and countertransference, attachment theory, and acceptance-based therapy (e.g., Hayes’ [2004] Acceptance and Commitment Therapy and Linehan’s [1993] Dialectical Behavior Therapy).

I believe that my hypotheses, explained in detail in Ingram (2006), incorporate these ideas.


Transference and Countertransference.

Psychodynamic hypotheses (Ingram, 2006, Chapter 8) lead to the use of countertransference and transference as opportunities to discover, in the here-and-now of the therapist-client relationship, the early childhood origins, repetitious patterns (P2), and unconscious feelings and conflicts (P4) that have led to the client’s current difficulties.

When P3 is applied, the transference represents the activation of unmet early childhood needs, rage over failures of empathic attunement, and the mobilization of hope that the client’s needs for mirroring, soothing, and someone to idealize can be met in a close relationship.

Furthermore, the conversation between client and therapist about perceptions and feelings that can be classified as transference and countertransference help build communication skills (BL3) and foster a healthy, authentic relationship (ES1).


Attachment theory.

This topic is addressed in my book (Ingram, 2006, pp. 302-303) in the section on hypothesis P2, Reenactment of Early Childhood Experiences.

The relationship difficulties of adults can be described in terms of different attachment styles, which have their roots in early childhood experiences with caretakers.

Furthermore, attachment theory contributes to an understanding of the dynamics in family systems (SCE1).


Acceptance and Commitment Therapy.

Hayes’s Acceptance and Commitment Therapy (ACT) can be “unpacked” to illustrate that it is an integration of several hypotheses from my list.

Acceptance stems from a set of beliefs (C2) about what can or cannot be changed by the efforts of the client, and is achieved by using mindfulness strategies, which I describe in my discussion of hypothesis B3 (Mind-Body Connections).

When clients are taught to "just notice," in a detached way, their private events, especially the most distressing ones, they are learning a different way of processing information (C3) and are quieting disturbing self-talk (C4).

The instruction to clients to access the part of the self that is observing and experiencing (rather than identified with thoughts, feelings, sensations, and memories) is consistent with the Internal Parts hypothesis (P1), which embraces theories such as Psychosynthesis, Gestalt Therapy, and Transactional Analysis.

If ACT helps clients to clarify their personal values, take action on them, and bring vitality and meaning to their lives, then it clearly incorporates the existential hypotheses (ES1 and ES2).

I assume that once the individual commits to a goal and begins to take action to achieve it, then issues of conditioned emotional avoidance (BL2) and skill deficits (BL3) can be addressed.


Linehan’s Dialectical Behavior Therapy: Linehan’s (1993) approach is described in my book (Ingram, 2006, p. 434) as an excellent model for defining problems in terms of “skill deficits,” which can then be treated with various skill-building approaches (BL3).

The skills of “emotional regulation” (p. 182) are also discussed in the section on hypothesis B3, Mind-Body Connections, as tools for coping with stress and achieving self-management of arousal level (pp. 91-92).


On the other hand, I accept that the list of 28 is a work in progress.

Whenever I discover a new theory, treatment approach, or orientation, I seek to “unpack” the bundled and branded model, to find the component hypotheses.

It is my hope that as people discover and familiarize themselves with my chosen list of hypotheses, there will be fruitful collaborative work to refine, expand, and reorganize the list, as needed.


The analogy of a computer directory system will increase understanding of the structure of the model of clinical hypotheses and its potential to be expanded to embrace all knowledge relevant to planning effective mental health interventions.

The seven domains (Biological, Cognitive, Psychodynamic, etc.) are like directories in a computerized information system; each hypothesis is like a subdirectory; and within each hypothesis subdirectory there are additional subdirectories which contain files with information about the hypothesis, its associated treatments approaches, when it is a good match, and with which other hypotheses it easily integrates.

Some files have only a paragraph, others comprise the content of books or the experiences of extensive training.


Significantly, the same files can be found within the subdirectories of different hypotheses: this is why it is expected for there to be overlap among hypotheses, and the criterion of mutual exclusivity is not met.

Here is an illustration of a small part of one of the domains.


• Biological Domain


o Mind-Body Connections Hypothesis (B3)


• Treatment approaches


• Acceptance and Commitment Therapy
      • Dialectical Behavior Therapy
      • EMDR
      • Relaxation Training


With this framework in mind, we can see that there is room to conceptually incorporate all past, present, and future models of psychotherapy, as long as we are willing to unpack each theory into its component hypotheses, and agree that brand names of theories, and the loyalty they demand, are detrimental to the advancement of effective integrative therapy.

( Note that in addition to the component mechanisms and processes underlying psychotherapy theories, there is also the issue of the empirical evidence for the efficacy and effectiveness of a theory.

For more on evaluating therapy theories on the basis of the empirical evidence that support them, see APA’s Evidence-Based Practice in Psychology web site [EBPP; APA Presidential Task Force, 2006]).


In a related vein, in his commentary, Lampropoulos made an intriguing suggestion—the idea of a group of experts getting together and building a comprehensive framework.

I of course like his idea of perhaps starting this process with my list of hypotheses.


All three authors described the four models of integration: common factors integration, theoretical integration, assimilative integration, and technical eclecticism, citing, among others, Castonguay, Reid, Halperin and Goldfried (2004); Lampropoulos (2001); Stricker and Gold (2006); and Messer (1992, 2001).

In this context, they all offered their view of where the 28CCHM fits.

Stricker and Grinfeld classify it as technical eclecticism, which, in Stricker’s words, “focuses on a combination of techniques drawn from different therapeutic systems without regard for any specific theoretical approach” (Stricker, 2009, p. 43).

I agree that my approach is similar to technical eclecticism because of the pragmatic approach of drawing techniques from multiple models with an emphasis on resolving specific problems.

However, it differs greatly in that it requires intervening hypotheses (theoretical ideas) between a data base and interventions, as well as deep attention to the client’s complex life history, current life situation, and sociocultural context.


Stricker goes on to describe my approach as closer in style to that of Lazarus’s Multimodal Therapy (Lazarus, 2005a, 2005b) than to other examples of technical eclecticism.

In Lazarus’s approach, a specific technique, drawn from a limited range of theories, is paired with a problem within one of the modalities of behavior, affect, sensation, imagery, cognition, interpersonal relations, and biological functioning.

I place high value on this list (along with an additional spiritual modality) as a tool for comprehensive data gathering (cf.

Ingram, 2006, pp. 34-40), but disagree that it is similar to my list of hypotheses.

With Lazarus’s approach, for example, recognition that “depression” is a syndrome would be unnecessary; the therapist could treat sadness, difficulty with sleep, negative thinking, and psychomotor slowness as separate, unrelated problems.

Furthermore, anyone with that list of symptoms might be treated in the same way; there would be no interest in the various routes by which people arrive at depression, such as difficulties coping with illness and disabilities (B1), stress and trauma (CS2), loss and bereavement (CS4), repetitious patterns of unhappy relationships (P2), loss of meaning (ES1), and past and current experiences with discrimination and other forms of social injustice (SCE5).


I felt best understood by Lampropoulos’s assertion that the 28CCHM fits in the category of theoretical integration models.

He states that it “can probably be most accurately categorized as a comprehensive eclectic model, operating within a broad and clearly defined multitheoretical framework” (Lampropoulos, 2009, p. 53).

He describes its difference from technical eclecticism in that it “focuses on the integration of clinical hypotheses (as opposed to interventions),” accurately stating that my intention is the creation of integrative conceptualizations, not the combination of varied techniques.


Stricker notes that my approach lacks “a guiding theoretical formulation” (p 43).

However, in my book (Ingram, 2006), I provide bases for viewing the 28CCHM as a stand-alone integrative theory that is based on a problem-solving metatheory.

The metatheory has requirements for clear problem identification; specification of achievable and verifiable outcome goals; comprehensive data-gathering; conceptualizations that are creative combinations of ideas extracted from established orientations; treatment strategies that are logically related to the conceptualization and that are matched to the unique needs and characteristics of the client; and a commitment to the process of empirical validation of treatment effectiveness.

Furthermore, combinations of hypotheses specifically designed for a single client is a theoretical formulation, an idea captured in the title of Grinfeld’s (2009) commentary, “A New Therapy for Each Patient.” My approach to psychotherapy integration is to allow each licensed practitioner to bring creativity to each unique case, with the requirement that theoretical foundations are necessary to assure coherent treatment plans, and monitoring of client change is necessary to assure evidence-based practice.


Thanks to the commentators, I realize that I need to walk those extra miles to further develop the 28CCHM to meet standards of a good theoretical model.

I agree with Lampropoulos’s recommendation that “some additional guidelines would be helpful in prioritizing and identifying the possible importance of each of the core hypotheses,” and that more guidance is necessary for combining hypotheses to assure that they “are compatible with each other and that the integration is coherent and acceptable to the client” (Lampropoulos, 2009, p. 54).

Stricker’s suggestion that I attend to the interrelatedness of the domains, and to their cyclical impact, will receive my deepest consideration.


My efforts to decide “Where do I fit?” led me to another question: “Why is it important to hold on to that four-category system?” I don’t mean to minimize the wonderful achievement of developing that framework, and the valuable body of literature that it stimulates, but I’m concerned that we may do ourselves a disservice by trying to classify within those categories the new models that are being created.

The assimilation model is defined in such a way that the therapist must start with a commitment to a “home base” theory; thus people who combine ideas from equally-valued theories by default are described as technical eclectics.

I wonder, perhaps from ignorance, whether the need to uphold this classification system springs less from our desire to improve the quality of integrative therapy, and hence benefit our clients, than from a desire to advance our respectability in the eyes of critics of integrative approaches.

Stricker reminds us that “old rigidities hamper rather than aid the treatment process, and there is much we can learn from each other” (Stricker, 2009, p. 49).

We need to be careful that we are not building orientations of integrationism that create new rigidities.


Two of the commentators pointed out the heavy academic and training requirements for competent application of the 28CCHM.

Lampropoulos states “one might expect that learning a complex multitheoretical integrative model at the conceptual and clinical level would require significant time and supervision” (p. 55).

Grinfeld contrasts deductive and inductive ways of using this model, and shows preference (as I do) for an inductive approach: “Once a clinician has a fund of knowledge about various theoretical approaches, the 28 Core Clinical Hypotheses can be used to synthesize the information already known by the clinician” (p. 65).


Both these commentators help me emphasize the importance of a broad and deep education for psychotherapists.

Without it, the use of the list of hypotheses would be a shallow exercise in labeling and categorizing without the competence to plan effective interventions and evaluate their effectiveness.

As a review of the topics in the Social, Cultural, and Environmental domain (Ingram, 2006, Chapter 9) will reveal, the educational foundations must go beyond traditional psychotherapy and include knowledge of systems (family and organizational), intercultural competence, social psychology, community psychology, and environmental psychology.

I further agree with Zeldow (2009) that competent clinicians need to know something about the human condition ….

( t)he kind of knowledge [that] cannot come from psychology textbooks or the scientific literature alone.

It must come from life experience, clinical experience, and at least some immersion in the humanities.

( p. 6)


Only with years of academic education combined with years of hands-on clinical training can a psychotherapist be qualified to engage in creative, integrative, evidence-based practice.. In the graduate program where I teach (Pepperdine University’s Graduate School of Education and Psychology in Los Angeles), there are many prerequisites before I teach about the 28 hypotheses in both a “techniques of psychotherapy” course and the clinical practicum on-campus meetings.


Grinfeld’s commentary provided the graduate student perspective, describing her frustration in educational environments where “reification of theory is the norm” (p. 59).

Her descriptions of her own graduate training attached concrete images to my assertion of the negative consequences of being forced to choose an orientation.

I have taught at Pepperdine for 31 years, and I was happy to note that this semester, when I asked how many students had been told that eclecticism is bad and they would be in trouble unless they chose an orientation, not one hand went up.

About 10 years ago, every student would have raised a hand.

Grinfeld’s story made me realize that my school is not typical of graduate training program.


The assumption that all therapists start by choosing a single orientation is very deeply ingrained.

Sticker explained that people “who identify with psychotherapy integration …recognize the value of orientations other than their own” (my italics; p. 45).

The implication is that we all start with “our” orientation.

That makes sense for perhaps the majority of senior therapists, whose roots were watered in psychoanalytical institutes or cognitive behavioral laboratories.

I believe it may be appropriate to question the necessity of having a “home base” orientation.

The current cohort of clinical graduate students may be likely to have teachers with different orientations (including integrative therapy) and to rotate through practicum and internship placements with exposure to multiple ways of working with clients.

They see something of value in every approach they learn, and in the process of learning different orientations they may be very comfortable developing integrative treatment plans.

I think this is a good thing.


I cannot find better words for closing this article than to quote what Grinfeld said at the end of her article, when she offered the opinion that the 28CCHM “provides graduate students … the opportunity not only to pursue psychotherapy integration within a structured and practiced framework, but also to pursue identities as ‘integrationally-oriented’ therapists” (Grinfeld, 2009, p. 66). If she is representative of her peers, then we can foresee a future where integrative psychotherapy is widely viewed as the treatment of choice.


Baddeley (1986, 1992) has proposed a muiticomponent model of working memory that consists of three func- tionally independent subsystems: a phonological loop, which maintains speech-based information; a visuospatial scratchpad, which maintains nonverbal information; and a central executive, which coordinates cognitive opera- tions.

Much of the research devoted to testing and refining the subcomponents of Baddeley's model has focused on the phonological loop and the manner in which speech- based material is rehearsed (see Baddeley & Hitch, 1994, for a review).

According to Baddeley and his colleagues, speech-based information is stored and refreshed using subvocal (i.e., covert) articulatory rehearsal (see Logie, 1995, for a discussion).

Although the mechanisms in- volved in the rehearsal of visual and spatial information are not well understood, it has been suggested that im- agery or eye movements may playa role in the mainte- nance of visuo spatial information (for recent reviews, see Baddeley, 1992; Logie, 1995).


Experiments using dual-task procedures suggest that the phonological loop and the visuospatial sketchpad are independent subsystems.

Performance on verbal working memory tasks is disrupted to a much greater extent by secondary verbal tasks than by secondary spatial tasks (Baddeley, Lewis, & Vallar, 1984), and performance on visuospatial working memory tasks is more disrupted by secondary visuospatial tasks than by secondary verbal tasks (Baddeley, Grant, Wight, & Thomson, 1975; Bad- deley & Lieberman, 1980; Logie, 1986; Logie, Zucco, & Baddeley, 1990; Quinn & Ralston, 1986).

However, in many studies (e.g., Baddeley, Grant, et aI., 1975; Badde- ley & Lieberman, 1980; Logie, 1986; Logie et aI., 1990; Quinn & Ralston, 1986), it is unclear whether secondary tasks interfered with encoding, maintenance, or both.

Re- cently, Hale, Myerson, Rhee, Weiss, and Abrams (1996) developed procedures for assessing the amount of inter- ference that results from disrupting the maintenance of information after memory items have been successfully encoded.

These procedures revealed completely selec- tive interference by secondary tasks (i.e., secondary ver- bal tasks interfered with verbal working memory but did not interfere at all with spatial working memory, and vice versa; Hale, Myerson, et aI., 1996, Experiment I).


Research in which the effects of age on working mem- ory was examined has revealed consistent age differ- ences in working memory performance (see Craik & Jennings, 1992; Dempster, 1981; and Salthouse, 1994, for recent reviews).

Several studies have demonstrated that children (Chi, 1976; Dempster, 1985; Hale, Bronik, & Fry, 1997; Kail & Park, 1994), adolescents (Dempster, 1985), and older adults (Salthouse, 1994) all have smaller memory spans than do young adults.

Recent research sug- gests that, relative to young adults, both children and older adults show more pronounced age deficits in spatial mem- ory than in verbal memory (Hale et aI., 1997; Myerson, Hale, Rhee, & Jenkins, in press).


One plausible explanation for the observed age differ- ences in working memory stems from research revealing a relationship between processing speed and working memory in children (Fry & Hale, 1996; Kail & Park, 1994) and in older adults (Salthouse, 1991; Salthouse, Kausler, & Saults, 1988).

It is well established that both children (see, e.g., Hale, 1990; Kail, 1988) and older adults (see, e.g., Cerella, 1990, 1991) are generally slower information processors than young adults (see Cerella & Hale, 1994, for a review) and that both children and older adults show smaller working memory spans than do young adults.

Indeed, age differences in working memory are minimal when processing speed is statistically controlled (Fry & Hale, 1996; Kail & Park, 1994; Salthouse, 1994).

Although the mechanisms underlying the relationship be- tween processing speed and working memory are not fully VERBAL AND SPATIAL WORKING MEMORY understood, it has been argued that faster processors may activate and covertly rehearse information more quickly than slower processors (Dempster, 1981; Salthouse, 1994).


Alternatively, Hasher and Zacks (1988) have suggested that age differences in working memory abilities result from deficits in inhibitory function.

They argued that working memory involves not only the storage and ma- nipulation of"information that is along the goal path," but also involves inhibitory mechanisms that prevent the en- trance of "off-goaI-path" information (Hasher & Zacks, 1988, p. 212).

They hypothesized that age differences in working memory result from interference caused by older adults' decreased ability to inhibit irrelevant infor- mation.

A similar suggestion has been offered regarding inhibitory deficits in children (Dempster, 1992; Tipper, Bourque, Anderson, & Brehaut, 1989).


Unfortunately, the interpretation of age differences in susceptibility to interference has been complicated by reliable age differences in baseline performance, as rep- resented by memory span in the absence of interference from secondary tasks (Dempster, 1981; Hale et aI., 1997; Kail & Park, 1994).

These age differences in baseline working memory performance pose an analytical chal- lenge when trying to determine the nature of interference effects across the life span.

The present investigation was motivated, in part, by the idea that an analogous problem exists with respect to interference effects in individuals of the same age.

Such individuals differ in both suscep- tibility to interference and baseline memory performance, and it is possible that examining individual differences in interference with working memory within age groups may shed light on the issue of how to evaluate age differences in interference effects.

Accordingly, we conducted a meta- analysis of data from multiple child, young adult, and older adult samples that was designed to examine the interaction of individual and age differences in suscepti- bility to interference across the life span.'


The present investigation took advantage of the fact that our laboratory has used the same basic procedures, with little or no modification, to assess working memory performance in multiple samples of children and ado- lescents, as well as young and older adults.

Thus, the meta-analysis was able to combine data from seven stud- ies by Hale and her colleagues in which school-age chil- dren (8-year-olds, 10-year-olds, and 12-year-olds), young adults (18- to 22-year-olds), and older adults (65- to 75- year-olds) were administered the digit span and location span working memory tasks first described in Hale, My- erson, et al. ( 1996, Experiment I).

Two of these studies (Hale & Jansen, 1994; Hale, Myerson, Faust, & Fristoe, 1995) were primarily concerned with processing speed and, hence, did not report the working memory data when originally published.

On the basis of the data from the listed in Table 1, both verbal and spatial interfer- ence effects were examined in over 400 subjects.

In both the verbal and the spatial domains, interference effects were measured as the difference between spans with and without secondary tasks.


In all the studies, subjects were exposed to at least four different conditions: digit span, no secondary task; digit span, verbal secondary task; location span, no secondary task; and location span, spatial secondary task.

Exam- ples of the stimuli and procedures are presented in Fig- ure 1.

For the no secondary task conditions, the subjects were shown a series of digits in a box or Xs in a grid, one by one.

The subjects orally recalled the names of the dig- its in the order in which they were presented in the digit span task and marked the locations of the Xs on an empty grid in the location span task.

For the verbal secondary task conditions, in addition to the memory requirements for the no secondary task condition, the subjects were re- quired to indicate the color of each digit or X as it was presented by saying the color name aloud.

For the spatial secondary task conditions, in addition to the memory re- quirements for the no secondary task condition, the sub- jects were required to indicate the color of each digit or X as it was presented by pointing to the matching color in the adjacent palette.


For all seven studies, the subjects initiated the presen- tation of each series of memory items by pressing a but- ton on a response panel.

The presentation of items within a series was computer controlled, and responses were recorded manually by the experimenter.

For all condi- tions, each trial began with the presentation of a fixation square in the center ofthe screen until the subject pressed the ready button.

Following a 250-msec delay, the items in a series were presented for either 1,250 or 1,750 msec, with a 250-msec interitem interval during which the screen was blank.

2 Immediately after all of the items within a series were presented, a recall signal was given.


Testing for all conditions was conducted following the procedure used for the WAIS-R Digit Span subtest (Wechsler, 1981).

That is, the subjects were exposed to two sets of series at an initial length (three items for the digit span and two items for the location span), and if at least one ofthe se- ries was recalled correctly, the length of the series was increased by one.

The experimenter discontinued testing when the subject failed to correctly recall two series of the same length.

The order of presentation of the condi- tions was counterbalanced.


Working memory spans were based on the maximum series length for which at least one series was correctly recalled, without regard to performance on the preceding series.

Ifboth series were correctly recalled at the max- imum length, the span was equal to that length.

If only one series was correctly recalled at the maximum length, the span was equal to that length minus 0.5.

Memory spans for each condition were calculated separately for each subject.


Because the maximum number of digits and locations presented was 9 (in all the studies but Hale et al., 1997), individuals who could remember all 9 items when there was no secondary task might actually have had spans larger than 9.

For such individuals, the resultant underestimation of their span would lead to underesti- mation of their interference effects.

Therefore, individu- als who had digit spans greater than 8.5 were not included in the analyses of verbal working memory.

Similarly, in- dividuals who had location spans greater than 8.5 were not included in the spatial working memory analyses.


None of the subjects from the child samples were ex- cluded for this reason; less than 10% of the young adult subjects and less than 3% of the older adult subjects were excluded.


Mean verbal and spatial working memory spans, with and without secondary tasks for each study, are presented in Table 2.

Mean working memory spans without sec- ondary tasks and interference effects for each age group averaged across all studies are presented in Table 3.

The upper left panel of Figure 2 depicts the mean verbal work- ing memory spans with and without verbal secondary tasks.

As was expected, verbal memory spans when sec- ondary task performance was not required (unshaded bars) increased as the age of the child group increased.

Verbal spans with a secondary task (shaded bars) also in- creased with the age of the child group.

In adults, the older group showed smaller verbal memory spans both with and without a secondary task requirement than did the young adult group.

In all the child and adult groups, verbal memory performance was substantially disrupted when the subjects were required to name the color ofeach letter as it was presented.

When interference effects, were compared across the age groups, 8-year-olds showed the largest interference effects, whereas the l O-year-olds, 12-year-olds, young adults, and older adults all showed


approximately equivalent interference effects (upper right panel of Figure 2).


A similar pattern of results was obtained for the spatial working memory tasks.

That is, spatial memory spans in- creased with the age ofthe child group and decreased with the age ofthe adult group, both when secondary task per- formance was not required and when it was required (lower left panel of Figure 2).

In terms of interference ef- fects, subjects of all ages showed substantial disruption in their memory for spatial locations when they were re- quired to point to the color of each X as it was presented.

As may be seen in the lower right panel of Figure 2, the 8-year-olds, 10-year-olds, 12-year-olds, and young adults all showed similar interference effects, whereas the older adults showed smaller interference effects than all the other age groups.


On the basis of the above results, we would conclude that there is virtually no change in interference from 10 to 20 years of age in either the verbal or the spatial do- mains.

Moreover, there appear to be no consistent age differences (i.e., differences in both domains) in interfer- ence effects across the life span from 8 to 75 years of age.

That is, although the 8-year-olds showed larger in- terference effects than any other age group in the verbal domain, they did not show larger interference effects in the spatial domain.

Similarly,although older adults showed smaller interference effects than all other age groups in the spatial domain, they did not differ from the other groups in the size of their verbal interference effects.


The present results fail to reveal age differences in sus- ceptibility to interference when the absolute size of in- terference effects is compared.

An alternative approach to As was noted in the introduction, when one compares interference in different age groups, one is comparing groups with different baseline levels of memory perfor- mance.

In order to examine the role of age differences in baseline (without transforming the data), we tried com- paring the interference effects of those subjects of dif- ferent ages who had nearly equivalent memory spans when secondary tasks were not required.

This comparison revealed clear age differences in interference between the matched groups: Verbal interference effects decreased systematically with the age of the child subgroup and in- creased with the age of the adult subgroup, and a similar pattern of results was obtained in the spatial domain.


The discrepancy between these results and those of the preceding analysis (which found no systematic age dif- ferences) raises an important new issue.

An analysis that compares subgroups with equal baseline performance is really comparing subgroups of individuals who are sys- tematically unrepresentative of their age groups, and the findings must be interpreted in light of this fact.

For ex-


ample, we matched a subgroup of 8-year-olds with ver- bal spans of 4-5.5 with a subgroup of young adults with the same range of verbal spans.

However, the subgroup of8-year-olds was above average in span, relative to their peers, whereas the matched subgroup of young adults was below average in span, relative to their peers.

Surprisingly, the subgroup of above-average 8-year-olds showed in- terference effects that were not only larger than those of the matched young adults but also larger than their peers.

Also surprisingly, the subgroup of young adults with below-average spans showed interference effects that were not only smaller than those of the matched 8-year-olds, but also smaller than those of their peers.

This may also be seen if one compares the datapoints for subgroups of approximately equal span in the absence of a secondary task in Figure 3.


Taken together, this pattern of results strongly suggests what would otherwise be a counterintuitive idea: Indi- viduals with higher than average spans for their age show larger than average interference effects, and individuals with lower than average spans for their age show smaller than average interference effects.

In order to rigorously evaluate this idea, we next proceeded to examine the pat- tern of individual differences within each group.

In order to do this, subgroups were created within each age group on the basis of verbal and spatial spans in the absence of a secondary task: Subgroups consisted of individuals who had spans of 1-2.5, 3-4.5, 5-6.5, and 7-8.5 items.

These ranges were selected so as to maximize the num- ber of subgroups within each age group, while simulta- neously distributing the total number of subjects in each age group as equally as possible across the subgroups.


We then compared interference effects for all of the different subgroups with ns greater than 5.

The upper and lower panels of Figure 3 show verbal and spatial memory spans with secondary tasks for the different subgroups, plotted as a function of the subgroups' memory spans in the absence of secondary tasks.

As may be seen, when young adults are compared with children and older adults of roughly equivalent span in the absence of a secondary task, the young adults have smaller interference effects.

More importantly, however, interference effects increased with memory ability, as measured by span in the absence of interference in all the age groups.

Within each age group, interference effects were smallest for those with the smallest spans without secondary tasks and largest for those with the largest spans without secondary tasks.

Re- markably similar patterns were observed for both verbal and spatial working memory.


Finally, we analyzed the data from the age group with the largest number of subjects (young adults: verbal n = 153, spatial n = ISO).

The large ns and wide range of spans in this group made it possible to use the techniques of correlational and regression analysis to examine more between age and individual differences in the suscepti- bility of working memory to interference observed in the present analyses is not easily explained on the basis of existing theories of working memory, at least as they are currently formulated.

These theories tend to focus on ei-


precisely the relation between the amount of interference and the size of an individual's memory span in the ab- sence of a secondary task.

The correlation between spans with and without a secondary task was significant for both verbal and spatial working memory tasks (verbal r = .423, spatial r = .333, bothps < .0001).

Importantly, the slope of the regression of span with a secondary task on span without a secondary task was significantly less than 1.0 for both verbal and spatial working memory tasks (verbal slope = 0.501, t = 5.70; spatial slope = 0.421, t = 5.91; both ps < .0001), indicating that the size of the interference effect was an increasing function of span in the absence of a secondary task.


This may be seen clearly in Figure 4, which shows the verbal and spatial regression lines (upper and lower pan- els, respectively) based on all young adult subjects.

In both plots, each point represents the mean and standard error for a subgroup of individuals with exactly the same span in the absence ofa secondary task (e.g., either 5.5, or 6.0, or 6.5, etc.; subgroups with ns < 5 are not shown).

Although, as may be seen, the magnitude of the interfer- ence effect tended to be larger for spatial working memory, the same overall pattern was observed in both domains.

That is, individuals with larger spans in the absence of a secondary task suffered the most interference when per- formance of a secondary task was required.


Collectively, the results of the present meta-analysis re- veal two important findings about developmental and in- dividual differences in susceptibility to interference.

First, verbal and spatial spans measured in the absence of a secondary task increased with age in children and de- creased with age in adults, but interference effects did not change systematically as a function ofage at either end of the life span.

Second, an examination of individual differences within each age group revealed that, in both the verbal and spatial domains, the subjects with larger spans showed larger interference effects than did their peers with smaller spans.


The finding oflarger interference effects in higher span individuals, although counterintuitive, is reminiscent of findings regarding individual differences in the effect of secondary tasks on memory performance reported by Rosen and Engle (1997).

These researchers found that when subjects were required to generate the names of members ofa category (e.g., animals), high-span individ- uals were more affected by a concurrent load on working memory than low-span individuals.

The primary task in- volved retrieval from long-term memory, and it is possi- ble that the concurrent load interfered with the process of retrieval itself or that it interfered with the use of work- ing memory in either the strategic control of retrieval or the evaluation of retrieved information.


In the present case, however, it is clear that the sec- ondary task is interfering with the maintenance of infor- mation in working memory.

The pattern of interaction DISCUSSION ther age or individual differences in working memory and do not deal with the relationship between the two, or they tend to assume that age and individual differences are de- termined by the same mechanisms.


For example, differences in the ability to inhibit irrel- evant information have been used by Dempster (1992) and Hasher and Zacks (1988) to explain age differences in working memory and by Engle (1996) to explain in- dividual differences in working memory.

It is possible that inhibition deficit theories might be able to explain the pattern of age and individual differences in interference effects (i.e., the general lack of age difference in inter- ference effects and the larger interference effects in in- dividuals with larger memory spans) ifthey incorporated additional assumptions.

However, it is not obvious what such assumptions might be.


The difference in interference effects observed between low- and high-span individuals in the present data (as re- flected in the slopes of the regressions in Figure 4) is un- doubtedly exaggerated by measurement error.

Although the reliability ofthe present measures was not determined directly, the digit span task was simply a computerized version of the Digit Span subtest from the WAIS-R (re- liability is equal to or greater than .90 for both young and older adults of ages comparable to those in our sample; Psychological Corporation, 1997), and the location span test followed an analogous procedure.

It is highly unlikely, therefore, that the true slope of the regression between span with a secondary task and span without a secondary task (i.e., the slope corrected for attenuation by measure- ment error) could be greater than 1.0, as is predicted by the inhibition deficit hypothesis.


Alternatively, other researchers have argued that dif- ferences in processing speed are the cause ofdifferences in working memory performance.

Some ofthese research- ers have focused on the relation between age differences in speed and age differences in working memory (e.g., Dempster, 1981; Salthouse, 1996), whereas others have focused on the relation between individual differences in speed and individual differences in working memory (e.g., Miller & Vernon, 1992).

A possible mechanism un- derlying the role of speed in both age and individual dif- ferences in working memory is suggested by the obser- vation that the longer that words take to pronounce, the fewer that can be recalled.

This is known as the word- length effect (Baddeley, Thomson, & Buchanan, 1975).

The word-length effect is often interpreted as implying that the speed with which particular items can be re- hearsed determines how many items can be remembered (e.g., Baddeley, 1986; Baddeley, Thomson, & Buchanan, 1975; but see Brown & Hulme, 1995).

This idea may be extended to imply that any source of difference in rehearsal rate, whether it is attributable to characteristics of indi- vidual items or to age and individual variations, will affect working memory.

Consistent with this idea, developmen- tal differences in children's rehearsal rates are good pre- dictors of developmental differences in memory span (Hulme, Thomson, Muir, & Lawrence, 1984; Kail & Park, 1994; Nicolson, 1981).


Like the inhibition hypothesis, the speed hypothesis may require additional assumptions in order to explain the present findings.

In this case, however, it is more ap- parent what form these assumptions might take.

Most current versions of the speed hypothesis tend to assume that information in working memory will decay in the absence ofrehearsal.

A number ofresearchers (e.g., Bad- deley, 1986; Hulme et aI., 1984; Schweickert & Boruff, 1986) have observed that the number of items that can be recalled in a verbal memory span task is approximately equal to the number of items that can be rehearsed in 2 sec. This is interpreted by Baddeley and others to mean that, in order for an item to be maintained, its trace must be refreshed at approximately 2-sec intervals.

If this is so, when secondary tasks interrupt rehearsal, some items will be lost, and the amount lost will depend on both the rehearsal rate and the speed with which the secondary task is performed (i.e., the length of time that rehearsal is interrupted).


To see this, imagine an individual who can rehearse six items in 2 sec (i.e., three items per second) but cannot rehearse these items while performing a secondary task.

Assume that performance on the secondary task inter- rupts rehearsal for I sec. There is now only 1 sec to re- hearse items before they are lost, and only three items can be rehearsed in that time.

The remaining three items will have gone 2 sec without rehearsal, and their trace strengths may have decayed to the point where the items are unrecoverable.


To see how individual and age differences may affect the amount of interference produced by a secondary task, recall that there are both individual and age differ- ences in processing speed (see, e.g., Cerella & Hale, 1994; Hale & Jansen, 1994) and that there are individual and age differences in rehearsal rate as well (see, e.g., Kail & Park, 1994).

At the group level, both processing speed and rehearsal rate increase with age during child- hood and decrease with age in adulthood.

However, the relationship between processing speed and rehearsal rate in individuals of the same age is not well estab- lished.

Thus, it is unclear to what extent processing speed and rehearsal rate are independent abilities.

Cowan and his colleagues (Cowan et al., 1998) have reported that, although retrieval speed and rehearsal rate both increase with age during childhood, these measures were uncor- related within an age group.

The present findings suggest that the same may be true for processing speed and re- hearsal rate.

If so, this could explain the present pattern of results.


Assume that processing speed governs the amount of time it takes to perform a secondary task.

If the time it takes to perform a secondary task is relatively brief and highly correlated with rehearsal rate, it may be shown that individuals with different rehearsal rates will have more nearly equivalent interference effects.

If, however, the time it takes to perform a secondary task is relatively independent of rehearsal rate, individuals with higher re- hearsal rates will not only have larger spans, they will also show larger interference effects.