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J Rat-Emo Cognitive-Behav Ther (2008) 26:232–249

DOI 10.1007/s10942-008-0084-7


Contextual Adult Life Span Theory for Adapting

Psychotherapy with Older Adults

Bob G. Knight Æ Cecilia Y. M. Poon

Published online: 13 November 2008

Ó Springer Science+Business Media, LLC 2008

Abstract Our aging population is growing in size and diversity. To integrate

different views on aging and make explicit the role of culture as a contextual factor,
we modified Knight’s (Psychotherapy with older adults, 2004) Contextual, Cohort-
based, Maturity, Specific Challenge (CCMSC) model of psychotherapy with older
adults into the Contextual Adult Lifespan Theory for Adapting Psychotherapy
(CALTAP). This article describes various components of the CALTAP, which
serves as a meta-theoretical framework in guiding an integrated psychotherapy
approach for the aging population. The interaction between environmental factors
like cohort differences and socio-cultural contexts and individual factors such as
maturation and age-related specific challenges not only shapes the experience and
presentation of older adults in clinical settings, but also highlights special consid-
erations in adapting psychotherapy for older adults.

Keywords Older adults  Elderly  Psychotherapy  Cognitive behavioral therapy


The 21st century is marked by a continuous growth in size and diversity of the
world’s aging population. The proportion of older individuals aged 60 or above is
projected to rise from 10% to 21% between 2000 and 2050 (United Nations 2003).
In the U.S., ethnic minority elderly are expected to take up nearly 40% of the older
population by 2050 (Federal Interagency Forum on Aging-Related Statistics 2006).
Along with growing interests in the all-encompassing influence of culture in the
field of clinical neuropsychology, these trends in demographic changes have

B. G. Knight (&)  C. Y. M. Poon

University of Southern California, Los Angeles, CA, USA
e-mail: bknight@usc.edu

Psychotherapy with Older Adults 233

provided an impetus for theories and research that can meet the needs of our older
and culturally more diverse population.
Integrating different views on aging, Knight’s (2004) Contextual, Cohort-based,
Maturity, Specific Challenge (CCMSC) model of psychotherapy with older adults
served as a meta-theoretical framework in guiding an integrated psychotherapy
approach for the aging population. With the culmination of findings on cultural
beliefs and practices on psychological issues and treatments of older adults in recent
years (e.g. Aranda and Knight 1997; Knight and Kim 2005; Knight et al. 2002; Lau
and Kinoshita 2006), we believe there is a need to modify the CCMSC to capture
cultural contexts explicitly in the model, so as to illustrate more clearly the
interrelationship among components in the model. We also wanted to clarify the
interrelationship of the components of the model in the visual presentation of it,
such that maturation effects primarily affect the ways that specific challenges and
other personal issues are presented to the therapist and also the nature of the
therapeutic relationship, with these effects occurring within the general background
of cohort, culture, and social context. With that in mind, we propose the Contextual
Adult Lifespan Theory for Adapting Psychotherapy (CALTAP), which highlights
how contextual factors, especially culture, intersect with other components in the
original CCMSC model in shaping the experience and behavioral repertoire of older
adults in clinical settings. This article describes the CALTAP and special
considerations in adapting psychotherapy for older adults.
Like the CCMSC model, CALTAP (See Fig. 1) emphasizes that adaptations to
psychotherapy come not only as a result of developmental aging processes, but also

Fig. 1 Components of the Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP)

234 B. G. Knight, C. Y. M. Poon

the unique social-cultural environment, cohort membership, and challenges

common in late life. At the macro level, contextual and cohort components in the
CCMSC model pinpoint the impact of different birth cohorts, socio-historical
experiences, and the immediate social environment in which older individuals live.
CALTAP extends this conceptualization of contextual influence by making explicit
the interactions of culture with one’s cohort membership and immediate context. At
the individual level, both the CCMSC model and the CALTAP conceptualize many
cognitive and emotional changes associated with aging as an indication of
maturation rather than deficit. Instead of treating disability and frailty as a form of
inevitable loss in late life, common presenting problems such as chronic illness,
grief, and caregiving responsibilities are framed as specific challenges to older
individuals where adjustments can be made. Knowledge about the impact of
maturation is crucial to the understanding of how older adults function in their
environment and the range of social contexts they can function in.
Taken together, contextual and individual factors all contribute to the nature of the
presenting problem, older clients’ expectations and level of engagement in therapy, as
well as available options for change. As was the CCMSC model, CALTAP is trans-
theoretical in nature and does not seek to introduce new intervention strategies in
psychotherapy with older adults. Instead, a broad conceptualization and understanding
of age and context specific influences on older clients is emphasized. We now discuss
each component of the CALTAP in relation to psychotherapy with older adults.

Cohort-based Influences

Cohort membership shapes one’s developmental trajectories in late life. Defined as

a birth-year dependent group, individuals born within a 7 to 10 year period belong
to the same birth cohort. Older adults growing up in different historical time periods
represent different generational groups, such as the Depression-era Generation, the
GI Generation, the Baby Boomers Generation, and Generation X. In Fig. 1, the
outermost of the three concentric circles represents cohort effects. Depending on the
cohort they belong to, people are placed in different socio-historical and cultural
contexts, resulting in a wide range of functional abilities, personality dimensions, as
well as attitudes and beliefs that remain relatively stable with age (Knight 2004).

Cognitive Abilities and Personality

Different socio-historical environments and opportunities available may have

contributed to differences in cognitive abilities of different cohorts, although earlier-
born cohorts are not always at a disadvantage. The Seattle Longitudinal Study
illustrates that among 13 consecutive cohorts with mean birth years from 1889 to
1973, earlier-born cohorts perform less well on tasks that require reasoning ability
and spatial orientation skills (Schaie 2005). Thus, the use of hypothetical scenarios
and visual imagery in therapy may require more thorough explanation and practice
with earlier-born older adults. Some earlier-born older adults also have less motor-
cognitive and attitudinal flexibility than later-born cohorts (Schaie 2005), making it

Psychotherapy with Older Adults 235

important to attend to the pace of therapy when attempting to change dysfunctional

beliefs. In addition, in most developed nations earlier-born cohorts received fewer
years of formal education. To effectively communicate with these older clients,
abstract psychological concepts and complex terminology may need to be explained
in simpler terms.
Cohort differences are noted in the personality domain (Mroczek and Spiro
2003). A fall in community involvement, conservatism, and political concern has
been observed in later born cohorts in the Seattle Longitudinal Study (Schaie 2005).
While there is a decline in extraversion and neuroticism with age in earlier born
cohorts, there is a rise in extraversion with age in younger cohorts (Mroczek and
Spiro 2003). Later born cohorts are also more prone to depression. Bearing in mind
that observed differences in personality styles between younger and older adults are
often cohort effects, therapists are encouraged to regard older adults’ personality
styles in handling people and things as residing not only in the person but also in the
cohort-based environmental context. Instead of seeing these individual character-
istics as unalterable developmental patterns resulting from the aging process, one
then remains hopeful that therapy may induce change and promote more adaptive
behaviors, even in old age.

Historical Experience

Older adults from different cohorts have distinct generational experiences (e.g.
Great Depression, the two World Wars). Not only do such unique experiences have
an impact on how older adults view themselves and people around them, but they
also affect how older adults interact with other members of society and their family
in current relationships. For example, one client spoke very critically about her
grandson who threw away her left-over food without asking. Some knowledge about
her experience of starvation during the war era made it easier to show empathy to
her anger. A basic understanding about things that happened to different cohorts and
the ability to explain younger generations’ beliefs to earlier born cohorts are helpful
tools in working with older adults. One way to explore a client’s significant
historical context is to add 20 years to the client’s birth year (Knight 2004). Having
a client born in 1940, for example, may lead us to wonder if his worldview has been
shaped by the civil rights movement and the Vietnam War.

Norms and Practices

Depending on their personal experience and socio-historical context, older adults

from different cohorts are bounded by different norms and beliefs, which may be
dissimilar and unfamiliar to the therapist. For example, earlier born older adults tend
to be less willing to discuss their sexuality and related difficulties with others
(Deacon et al. 1995). They may therefore find it less comfortable using words and
phrases commonly employed by younger generations. Less explicit expressions
such as ‘‘being intimate’’ may be preferred to more overt expressions, such as
‘‘having sex’’. Although information on a particular cohort may not be readily
accessible to younger therapists, they can be gathered through an open interaction

236 B. G. Knight, C. Y. M. Poon

with older clients. Our clinical experience shows that when there is a client-therapist
discrepancy in socio-cultural experience, constructive use of therapists’ ignorance
can facilitate rapport building and greater openness.
Cohort-based effects are also illustrated by differences in normative life
trajectories and role expectations. While it is now normal for women in developed
countries to delay or give up marriage for career pursuit, such behavior was less
socially desirable a few decades ago (Knight 2004). Changes in gender role
expectations also influence how women are treated in society and within the family.
For example, one older client had a hard time reconciling with her adult son for
marrying a woman who was divorced and had a child before marriage, considering
that as a shame to the family. Notwithstanding the impossibility of knowing and
endorsing all specific norms of every cohort and locale, it is important not to jump to
conclusions and apply standards of current times to scrutinize older clients’ thoughts
and behaviors.
Particularly important to psychological intervention is the recognition of cohort
beliefs about mental distress and psychological services. One powerful cohort effect
is the familiarity with psychology and psychotherapy among later born cohorts.
Earlier born older adults may not have as much knowledge about mental illness as
younger generations do. Earlier born cohorts are more likely to perceive mental
illness as something embarrassing and indicative of poor social skills, personal
failure and spiritual deficiency (Segal et al. 2005). Perceived stigma attached to
mental illness and psychotherapy does not only reduce older adults’ inclination to
seek psychological treatment, but also increases the likelihood that they downplay
the seriousness of affective symptoms, as they regard self-sufficiency to be a virtue
in handling mood disturbances such as depression, anxiety, and bereavement (Robb
et al. 2003). An understanding of these beliefs is crucial for treatment planning;
detailed explanation of current practices in psychotherapy may strengthen the
therapeutic relationship.
In therapy, older adults from different birth cohorts may use words, anecdotes,
and references to public or fictional figures in the media that are unfamiliar to the
therapist. For example, a therapist who knew about legendary movie stars had
greater ease in visualizing an older client’s disappointment and grief over losing her
long-time spouse to dementia when she compared their relationship to the dancing
duo Fred and Ginger. Knight (2004) suggests that working with older adults in
therapy frequently involves learning something of the folkways of people born years
ago. Some appreciation of old movies and music may help strengthen rapport with
older clients. At the same time, it is important not to blindly assume every older
client has experienced the same events in a similar fashion. Acknowledgement of
older adults’ unique cohort experience in specific historical context may foster a
sense of trust and understanding.


Represented by the middle circle in Fig. 1, the role of culture in fostering diverse
developmental trajectories and experience of older generations is two-fold:

Psychotherapy with Older Adults 237

Differences in cultural values and beliefs are as influential as ethnic and racial
differences in socioeconomic resources and opportunities.

Values and Beliefs

Older adults’ help-seeking behavior, presentation in treatment, and behaviors in

broader social and familial contexts may be colored by their cultural values and

Illness Interpretation

Ethnic minority older adults tend to interpret symptoms and illnesses using a model
different from their counterparts who grew up in the West. For example, ethnic
minorities from Southeast Asia do not view a person in mind-body duality, but as
part of a larger social context. Research on South Asian depressed patients shows
that the most effective treatment involves an approach that incorporates both
traditional healing resources and standard Western treatment (Sembhi and Dein
1998). The process of treatment planning may benefit from an understanding of how
cultural heritage and beliefs influence older clients’ illness attribution.


Structurally, many cultural groups have their own support networks and remedies
for medical and psychological problems through their reliance on family and
relatives, shaman or folk medicines (Braun and Browne 1998; Harris 1998). Ethnic
minorities also have more actual barriers to receive psychological services because
of limited mobility and English proficiency (Pang et al. 2003). Psychologically,
ethnic minority older adults may be less inclined to seek help for fear of shame and
stigma. For example, the term for dementia is translated into ‘‘crazy’’, ‘‘catatonic’’,
or ‘‘stupid’’ in the Chinese language (Elliot et al. 1996). Similarly, older Japanese
regard the onset of dementia as a personal failure to minimize burden on their
family and society (Traphagan 2000). Therapists need to be aware of these culture
specific attitudes about aging and cognitive or psychological difficulties, which may
affect problem presentation in clinical settings.
Knowledge of how older adults are treated in different cultural groups also
promotes therapists’ ability to adapt intervention to match different help-seeking
beliefs and coping strategies. Previous studies in our research group show that stress
and coping processes of caregivers are influenced by different cultural values such
as familism and filial piety (e.g. Knight et al. 2002; Knight and Kim 2005). Although
both ideas emphasize mutual support within the family, filial piety places greater
emphasis on care and respect for older members of the family. Younger members
are reminded to recognize the care they receive from the older generation and fulfill
filial obligation to respect and care for them in return, both as a form of debt
repayment and affection toward their parents (Chee and Levkoff 2001). Ethnic
minority families are more receptive to using formal care and outside assistance for
older family members when familial participation is encouraged (Knight and Kim

238 B. G. Knight, C. Y. M. Poon

2005). A non-pathologizing attitude in explaining psychological distress and

therapy to ethnic minority older adults may also help alleviate their fear of shaming
their family when seeking outside help.

Presentation in Therapy

Symptom presentation may differ across cultural groups because of values ascribed
to emotional distress and its expression. Ethnic minority older adults are more likely
to express psychological distress in culturally accepted somatic forms, such as pain
and insomnia (Sue and Sue 2003). Somatization may be more acceptable in Asian
cultures because of their unitary concept of mind and body. There are also ethnic
differences in display rules. Even when controlling for language spoken, cultural
conceptions of emotion influence how people talk about emotion. Less acculturated
Chinese Americans are more likely to use somatic and social words to describe their
emotions than European Americans (Tsai et al. 2004). Therapists are encouraged to
incorporate older clients’ cultural beliefs and vocabulary when discussing feelings
and emotions. To foster a trusting relationship with older clients, therapists need to
acknowledge their cultural beliefs with openness and empathy.

Culture and Cohort Interaction

While research on cultural influence often regards ethnicity as synonymous with

culture (Aranda and Knight 1997), there is as much variation within as there is
between each ethnic group. Within group differences are often a result of different
levels of acculturation across different cohorts and classes. On top of cohort
differences, certain cultural groups are more likely to face poverty, limited
educational opportunities, abuse or catastrophic losses that limit their ability to age
well. Although earlier born cohorts tend to have less formal schooling than the later
born in most developed countries, ethnic minority older adults often possess even
less formal education than their White counterparts because of limited social and
economic resources stemming from segregation and racism in earlier eras.
Immigrants of earlier cohorts who came from less developed countries in mid-life
to pursue a better future also tend to have lower literacy in English and their native
tongue (Lau and Kinoshita 2006). Given the impact of educational aptitude on
cognitive abilities in old age (Schaie 2005), racial disparities in educational
attainment may partly explain the range of cognitive changes among older adults
from diverse cultural backgrounds.
Cultural differences among older adults also work in the opposite direction.
Cohort differences provide unique cultural experiences for various racial and ethnic
groups. Older adults from earlier cohorts in the West may have grown up at a time
when public expression of unfavorable attitudes towards ethnic minorities was
socially sanctioned (Hinrichsen 2006). Therapists have to be sensitive to how client-
therapist differences in racial and ethnic backgrounds may influence the therapeutic
relationship and accept that it may really be ‘‘nothing personal’’. While keeping an
open mind on how racial differences are addressed by different cohorts, therapists
will also benefit from having the ability to place prejudiced remarks about other

Psychotherapy with Older Adults 239

racial or ethnic groups in current social context, and explain in a non-judgmental

manner why they may cause damage to interpersonal relationships.


Cohort and cultural differences interact with one’s immediate socio-environmental

context, represented by the innermost circle in Fig. 1. Both the CCMSC model and
the CALTAP emphasize how the immediate context affects older adults, but the
CALTAP draws additional attention to how culture shapes the immediate social
environment. Therapists are reminded not to attribute older adults’ behavior to
developmental changes alone but to be aware of changing environmental demands.

Specific Environments

Services for older adults are typically multidisciplinary in nature, requiring mental
health professionals to have sufficient knowledge of systems and environments that
directly affect older adults’ behaviors and beliefs.

Residential Settings

While many older adults continue to live independently in neighborhoods that are
not age specific, a significant proportion of older adults live in more specialized
settings, such as age segregated housing, retirement homes, and nursing homes.
Realistic understandings of what can and cannot be changed in these settings are
important to treatment planning and implementation, especially ones that require the
use of behavioral and social learning treatment models (Satre et al. 2006). Accurate
and client-centered views of home environments are also necessary in cognitive
intervention that aims at changing maladaptive thoughts. For example, one older
client was constantly worried about being robbed. A visit to her apartment in a less
desirable neighborhood prompted the therapist to reframe the situation and promote
problem-solving strategies, rather than labeling her concern as being irrational.

Healthcare Settings

Hospitals and other care facilities are key environments where older adults spend a
lot of time whether it is because of their own physical illness or their caregiving
responsibilities. Awareness of general interaction styles of medical professionals
may help therapists prepare older clients for future encounters with their physicians.
For example, older adults may need more time to explain things while their doctors
only have a few minutes to spare. Helping older clients come up with a list of key
points to bring to their medical appointments may facilitate doctor-patient
interaction and reduce their feeling of not being understood. Not having witnessed
the experience of older clients as patients in medical settings, therapists may find it
hard to perceive older clients’ accounts as honest and realistic appraisals of these
settings. Knowledge about current healthcare plans and policies may also fuel

240 B. G. Knight, C. Y. M. Poon

therapists’ empathy for the frustration and helplessness expressed by older clients
who are struggling with the medical system.

Recreational Settings

Each senior center and recreational group has its specific clientele. Our experience
suggests that the need of older clients who are eager to participate in various
committees and classes differ from those who go to a senior center because there is
nowhere else to go during the day. The ability to serve culturally diverse clients also
varies by settings. For example, one Chinese client was eager to join a computer
class but had to settle for an exercise class because the computer class was only
available in English. Given that older adults may engage in group activities at senior
centers due to logistical barriers rather than real interest and compatibility,
therapists have to guard against giving generic recommendation to older adults to
make new friends at community and senior centers.

Interpersonal Context

Personal experience of older adults is largely dependent on their interpersonal

encounters. Two important settings where these encounters take place are their
immediate family and society at large.

Family Context

Increased longevity and changes in social and family practices have created more
opportunities for intergenerational interaction. Moderated by birth cohorts, inter-
generational relationships can be a potential source of tension and discord when
deeply held cohort beliefs about family and marriage come into conflict (Bengtson
et al. 2000). Culture also moderates the family context of older adults. Intergen-
erational conflicts stemming from differences in cohort beliefs may be even more
intense in households where less acculturated ethnic minority older adults interact
with younger generations that have adopted the Western values (Lau and Kinoshita
2006). For example, older adults who value filial piety may be disappointed or angry
with adult children who fail to obey the elderly family member’s command to give
harsh punishment to their grandchildren when they misbehave.
On the other hand, ethnic minority older adults who endorse the cultural value of
interpersonal harmony may be reluctant to voice their distress within the current
family context, fearing they may disrupt family coherence. Coupled with the fact
that younger generations may not be able to communicate with older family
members in their native language, these older adults may experience a heightened
level of perceived loss of authority (Lau and Kinoshita 2006). In dealing with
emotional distress derived from these situations, therapists need to consider both the
cohort differences in beliefs and varying degrees of acculturation of family
members from different cohorts.

Psychotherapy with Older Adults 241

Social Context

Another significant interpersonal context that shapes the self-concept and day-to-
day encounters of an older person is the society in which he or she lives. Our society
is infiltrated with stereotypes of aging in the media (Donlon et al. 2005). The
prevalence of stereotypes of aging influences how older adults are treated by other
individuals in society. Cuddy et al. (2005) show that older adults are perceived and
treated differently than younger adults by people of different backgrounds within
our society, including health professionals, with whom older adults spend a good
amount of time. Medical professionals often follow existing beliefs about aging and
old age in society. Older adults who endorse ageist beliefs also tend to treat their
older counterparts less favorably. Therapists have to be aware that the intensity and
frequency of ageist attitudes in society will affect the experience of an older person
in various settings.
Equally important is the internalization of negative stereotypes about growing
old, which prompts older adults to conform to the notion that suffering and loss are
inevitable aspects of old age and cannot be changed (Levy 2003). Older adults’
perceptions about aging may affect how they approach their physical and emotional
distress. Older people who hold negative expectations about old age are more likely
to think that being unhappy or depressed is a part of normal aging, thus delaying
treatment seeking (Sarkisian et al. 2003). Compared to younger adults, older adults
tend to view depression as a less severe problem, therefore feeling less likely to
consider having a consultation with mental health professionals (Robb et al. 2003).
An assessment of older adults’ beliefs about aging may provide therapists with a
sense of how best to alter certain maladaptive thoughts and attributions. This also
underpins the importance of fighting therapists’ own ageism in order to effectively
combat self-directed ageism among older clients.
An understanding of specific social and interpersonal environments may enhance
the level of comfort and expertise of mental health professionals in working within
these settings to introduce effective interventions to older clients. Each setting is
governed by a unique sub-culture. However, generalizing the understanding of one
setting to another may contaminate accurate and comprehensive understanding of
old age, overlooking the influence of individual difference in physical and cognitive


Developmental processes of maturation influence where older adults situate

themselves in society. Informed by research in scientific gerontology and life span
developmental psychology, the image of later life is moving from the loss-deficit
model of aging (Gitelson 1948) towards a more optimistic perspective. Instead of
focusing on pathological aging, recent research seeks to examine mechanisms that
may compensate for cognitive decline or enhance emotional well-being in old age
(Carstensen et al. 2006; Willis and Schaie 2006). An appreciation of both the
positive and negative aspects of maturation challenges the belief that all older adults

242 B. G. Knight, C. Y. M. Poon

are frail and encourages timely detection of age-related changes that are revisable
through therapy.

Positive Aspects of Maturation

Two positive aspects of maturation that are most relevant to psychological

interventions with older adults are cognitive and emotional complexity. Both can
enhance older adults’ ability to deal with negative consequences of aging and specific
challenges in late life.

Cognitive Complexity

Cognitive maturation occurs throughout adulthood and into old age. Observed
changes after age 70 in average level of intellectual abilities are neither global nor
universal, and may be indicative of early stages of dementia or to illness-related
declines. Conceptualized as one’s store of general knowledge, vocabulary, and
arithmetic skills, crystallized intelligence typically improves from young adulthood
to around age 60 and only demonstrates mild decline as a result of aging after age 70
(Salthouse 2004). Accumulation of life experience and knowledge about how things
are and how they function may have fostered the development of expert systems
(Rybash et al. 1986). This may explain the expansion and preservation of
crystallized intelligence, as well as continuous development of wisdom, which
represents a rich fund of factual and procedural knowledge, life span contextualism,
relativism of values and priorities, as well as the ability to recognize and handle
uncertainties (Baltes and Staudinger 2000).
Accumulation of crystallized knowledge also buffers against deterioration in
fluid abilities in old age. Although older adults may experience a fall in cognitively
flexibility, their ability to draw upon their wealth of life experiences and expertise
can help them adapt to life’s challenging situations. Therapists can capitalize on
older clients’ expertise in their professional, familial and interpersonal roles.
Cognitive complexity is also an asset in bolstering the ability to embrace changes in
life; examine life events from others’ perspectives; and appreciate diverse
viewpoints arising from differences in cultural, religious, and family backgrounds.
Such cognitive sophistication may facilitate the process of coaching older clients to
come up with alternatives to minimize dysfunctional thoughts and behaviors.

Emotional Complexity

Research on personality and emotional development across the lifespan highlights

the slow decline of neuroticism over age and a slight upturn for the old-old (e.g.
Terraciano et al. 2005; Mroczek and Spiro 2003). While extraversion and openness
tend to decline with age, agreeableness increases and conscientiousness remains
stable beginning in early old age (Terraciano et al. 2005; Schaie 2005). Continuous
development of personality structures in late life may be affected by actual physical
deterioration, as well as adjustments in coping styles when dealing with challenges
brought by biological and social changes. In particular, emotional development of

Psychotherapy with Older Adults 243

older adults is marked by a shift toward more positive emotion and better emotion
regulation (Carstensen et al. 2006). According to the socioemotional selectivity
theory, changes in emotional development in old age may have resulted from a shift
in motivational focus and an active attempt to manage one’s social environment to
minimize negative emotions (Carstensen et al. 2003). Although older adults may
experience psychological distress because of their physical and cognitive decline,
regulation of their social environment and interaction may serve as a buffer against
negative emotions.
Older adults also report greater emotional complexity and emotions that are less
pure and intense than younger adults (Ong and Bergeman 2004). Older adults are
more likely to experience both pleasant and unpleasant emotions at the same time. For
example, an older client who lost her adult child to cancer might experience a mixture
of sadness and grief over the premature loss of life, yet feel a sense of relief from her
caregiving responsibilities, as well as the fact that her son no longer had to suffer from
agonizing pain. Satre et al. (2006) recommend that rather than replacing negative
emotions with positive ones, cognitive therapy may help older clients reconcile the
co-existence of positive and negative emotions through reframing. In turn, greater
emotional complexity is associated with lower levels of neuroticism and psycholog-
ical stress, as well as greater psychological resilience (Ong and Bergeman 2004).

Negative Aspects of Maturation

Although there is a growing emphasis on positive aspects of maturation, the aging

process is still associated with less desirable changes for most people, including
deterioration in physical and cognitive abilities.

Physical Decline

Various models have been applied to describe the phenomenon of biological aging.
The ‘‘wear and repair’’ model (Ricklefs and Finch 1995) highlights the accumulation
of exposure to environmental stresses, toxins, and injuries across the lifespan and how
the human body’s ability to repair and replace the wear and tear caused by these
damages gradually diminishes. For example, the immune response becomes less
efficient in old age (Lesourd 1999). Compared to younger adults, more time may be
needed for older adults to recover from a cold. Older adults are also more likely to
experience medical complications after undergoing a surgical procedure. Nonethe-
less, therapists must bear in mind the huge variability in health status among older
people of the same age. Social and psychological factors affect the pace of aging.
Older adults growing up in a cohort with less economic resources and greater stress
may experience higher rates of disease and physical frailty compared to those from
later born cohorts that enjoy more economic benefits (Seeman et al. 2004).

Micro-level Cognitive Changes

Compromised cognitive capacity in the domains of processing speed, working

memory and attention is evident in normal aging (Schaie 2005). The most pervasive

244 B. G. Knight, C. Y. M. Poon

change is reduced performance on tasks that depend on processing speed (Salthouse

2004). Age effects on reaction time are seldom eliminated even when practice,
physical exercise, and other interventions are available. Working memory, the
limited capacity resource through which information is processed before it is
registered in long term memory, also declines with age (Salthouse 2004). A related
phenomenon observed is reduction in attention, especially selective attention to
screen out distracting or irrelevant stimuli or information (Kemper et al. 2003). As
such, older adults tend to have greater difficulties in screening out background noise
or engaging in multiple conversations that overload their attentional capacity.

Changes in Memory and Intelligence

Studies of memory change in older adults over time generally confirm that free
recall declines with age, while performance in cued recall and recognition remains
relatively intact (Smith 1996). Emotionally salient information, particularly those
with positive valence, is also favored and better retained than neutral information
(Carstensen et al. 2006). In addition, fluid intelligence that involves abstract
reasoning follows a downward trend in old age (Salthouse 2004; Schaie 2005).
More explicit guidance and concrete examples that are relevant and emotionally
salient to older clients may be necessary to complement tasks that require older
clients to make abstract inferences on their own.

Cultural Influence on Cognitive Compromise

Apart from having fewer years of formal schooling, cognitive changes in ethnic
minority elderly may also be moderated by other cultural effects. Although aging
generally has a much bigger impact on cognition than culture, age and culture affect
different aspects of cognitive abilities (Park and Gutchess 2006). Specifically, the
most prominent impact of the aging process on cognition involves resource-
demanding tasks that depend on reaction speed and working memory. On the other
hand, culture plays a bigger part in tasks that demand the use of knowledge-based
structures, such as categorical clustering and picture naming, which often mobilize
culturally-implicated knowledge. Therapists working with ethnic minority older
clients have to be ready to make additional effort in educating clients about various
components of psychotherapy, which in itself is derived from a Western
conceptualization of emotional and somatic distress.

Therapeutic Adaptations

What maturation does to older adults’ physical and cognitive abilities calls for
several therapeutic adaptations. Generally, therapeutic progress is slower with older
clients in terms of number of sessions needed to achieve therapeutic goals. Pinquart
and Sörensen (2001) reported in their meta-analysis that interventions with more
than nine sessions yielded significantly better outcome than shorter interventions
with older clients. To combat the impact of slower processing speed in old age and
avoid confusion stemming from attention overload, therapists may increase the

Psychotherapy with Older Adults 245

latency between clients’ and therapists’ speech, reduce background noise and
distractions in clinical settings, and adopt a more directive stance with shorter and
simpler phrasing. To compensate for decline in memory, therapists may repeat
and summarize key points throughout the session, ask clients to take notes on key
points, provide handouts, and use mnemonic aids (Satre et al. 2006).

Age-related Specific Challenges

Older clients seeking psychological intervention often face problems that disrupt
psychological homeostasis and produce emotional distress. Although these prob-
lems are not unique to older adults, they are more likely to occur in later life.

Chronic Illness and Disability

Increasing age is a major risk factor for the development of chronic illness and
disability (Seeman et al. 2004). While the impossibility to completely reverse
physical impairment may create discomfort for some therapists, it is important to
keep in mind that improvement in emotional and functional well-being through
psychotherapy is an attainable goal. An assessment of relative contribution of
physical disabilities and emotional distress to functional impairment is crucial in
goal setting. For example, before suggesting a physical exercise plan to improve a
depressed old client’s mood, therapists may have to consult with the primary care
physician to see whether the nature and prognosis of specific illness and disability
will interfere with plan implementation and adherence. This also provides helpful
information for gauging clients’ optimal level of functioning, especially when older
clients with chronic illness and disability over- or underestimate their ability to
perform certain tasks.
Depending on the level of illness and impairment, there may be profound social
impact on older adults. An older person who has reduced mobility after a stroke may
have to begin taking the bus, a social context previously foreign to her. Older clients
who can no longer prepare their own meals may begin attending congregate meal
sites and dealing with meal delivery personnel. Treatment of older adults with
chronic illness and disabilities also depends on available social capital. While
functional loss resides in the individual, disability depends on conditions external to
the person (Crimmins 2004). Chronic illness may produce less functional limitations
in regions where services are available to people with physical disabilities. At some
point, therapeutic work may involve preparing older clients with disability to steer
through the healthcare system and novel social settings without losing their sense of

Grief and Bereavement

Loss of loved ones to death is more commonly experienced as older adults move
towards the later phase of life. For older adults who live alone or have less social
support, the experience of loss may be more strongly felt (Stroebe et al. 2001).

246 B. G. Knight, C. Y. M. Poon

When working with older adults on bereavement, it is prudent to examine their

immediate social environment and whether a life without the deceased is sustainable
in that specific surrounding. Death of a close family member is often coupled with a
new social identity, such as widowhood. Changes in social contexts and networks
may take place when the surviving partner no longer attends activities, such as
social dances, that were enjoyed by the couple as a unit. Living arrangements may
also change if adult children intend to have the surviving parent live with them. For
example, after the death of her husband, one older client with chronic disability
moved in with her adult son who recently experienced divorce and unemployment.
Clearly, individual, interpersonal, and contextual factors all became potential targets
when working through her depressed mood.


Given the high prevalence of illness and disability in late life, older adults often
engage in prolonged caregiving for family members with severe cognitive
impairment or physical frailty. Caring for an older family member with dementia
produces more stress than caring for a physically frail older person (Ory et al. 2000).
While there is a variation in degree and duration of care provision, as well as personal
reactions to caregiving, it is physically and emotionally draining to care for an ailing
individual when the caregiver is also facing some limitations imposed by advanced
age. Studies show that caregivers are more prone to physical and emotional distress
(Pinquart and Sörensen 2003). Because caregiving work normally takes place in
specific environments, such as within an extended family, therapists may need to
adopt a family systems perspective when working with older caregivers.
In addition to contextual influence, the experience as a care provider to an older
member in the family may be moderated by the family’s cultural background.
Because of limited social and economic resources, as well as cultural beliefs about
family obligations, ethnic minority older adults are more likely to become family
caregivers to their frail spouse or adult children. However, their greater reluctance
to seek help compared to their White counterparts may exacerbate the stress and
burden associated with caregiving. Studies on culturally diverse family caregivers of
older adults with dementia pinpoint the role of culture on coping styles and
availability of social support (Knight et al. 2002). An exploration of different
cultural beliefs and obligations may guide the adaptation of psychotherapy for older
caregivers of different ethnic backgrounds.


As a model, CALTAP is transtheoretical with regard to theories of psychological

therapy. In many ways, cognitive behavioral approaches provide a good fit to the
needs of older adults as conceptualized by the CALTAP model. The understanding
of client’s problems in CBT is always highly individualized and placed in
environmental context. CALTAP provides some guidance in comprehending the
often specific nature of that context for older adults, including specific social

Psychotherapy with Older Adults 247

environments and the more macro-level influences of culture and cohort. Of these,
the placement of clients within different socio-historical contexts by birth cohort is
likely to be the most novel for CBT therapists.
In principle, CBT provides a good basis for intervention with the specific
challenges often faced by older adults. The rational-emotive thread within cognitive
therapy theories is particularly well adapted to the common theme in working with
older adults facing specific challenges of late life that their lives have in fact taken a
turn for the worse, but that there is hope for improvement of quality of life and of
one’s emotional response to the challenges (i.e., it is not a total catastrophe).
The chronic nature of many problems faced by older adults can be a challenge for
the traditional short-term focus of CBT. Unlike work with younger adults which
often involves working out responses to acute stressors that occurred prior to the
beginning of the therapy, the problems faced by older adults are often chronic,
ongoing, and progressive. Faced with chronic problems that go on for months and
years, CBT work with older adults may also go on for months and even years. On
the other hand, the CBT focus on setting goals and monitoring progress toward their
attainment is an important check on the tendency of some therapists to keep older
adults in therapy indefinitely, assuming that they need the support forever. We find
that older clients are generally quite pleased to ‘‘graduate’’ from therapy, having
accomplished their goals.
The simple fact that older clients have several decades of life history, and the
pleasure that many take in reminiscing about their histories, pose challenges for the
present-oriented focus of CBT when working with older adults. With so much more
history, there is also a drive toward a more complex and abstract level of thinking
about current problems. Older clients have decades of experience with their
problems and with their ways of solving such problems. Good assessment of
difficulties and strengths often involves some ability to abstract the common
elements of multiple stories and situations covering decades of life history. Finding
the balance between doing this level of assessment as related to therapy goals and
getting lost in the digressive reminiscence of the client is an important skill in
learning to do CBT with older adults.
Rather than introducing new therapeutic techniques, the CALTAP endeavors to
bring attention to contextual considerations when adapting psychotherapy for older
clients. To understand older clients’ presentation in psychotherapy, their develop-
mental changes have to be placed in specific historical, social, and cultural context.
The willingness and readiness to appreciate the intricate interaction between the
older individual and his or her environment will not only strengthen therapeutic
alliance, but also provide guidance to therapists in treatment planning, implemen-
tation, and evaluation.


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