Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP) and Clinical Geropsychology

Synonyms

Case conceptualization; Formulation

Definition

The Contextual Adult Lifespan Theory for Adapting Psychotherapy (CALTAP) model is a transtheoretical model developed to assist in increasing the understanding of both who the older adult client is and the broad context within which he or she presents for therapy.

Introduction

The Contextual Adult Lifespan Theory for Adapting Psychotherapy (CALTAP) (Knight and Lee 2008) is a model that has been developed with an older adult population in mind. Fundamentally, the model provides a framework within which a holistic and in-depth understanding of older adult clients can be developed. In order to achieve this, the CALTAP model draws on lifespan developmental principles and social contexts (both current and historical and at a cultural and cohort level). The model has also been designed to be transtheoretical in nature rather than being wedded to any one particular type of therapy (e.g., cognitive behavioral therapy, interpersonal psychotherapy, etc.). The CALTAP model therefore offers the opportunity for the clinician to explore the case history of the client at a broad level and then determine the best therapeutic approach to meet the goals of therapy.

Drawing on Knight’s (1996) contextual, cohort-based, maturity-specific challenge (CCMSC) model of psychotherapy, the CALTAP model elaborates on the CCMSC model by outlining a more integrated approach to psychotherapy with older adults and adding consideration of the importance and relevance of culture (Knight and Lee 2008). CALTAP identifies the following factors for consideration in psychotherapy with older adults: context, culture, and cohort. The CALTAP model (like the CCMSC model) is designed to be transtheoretical; that is, the model is not linked to any one particular approach to therapy and as such may be used across approaches to psychotherapy. Regardless of therapeutic focus, the model has the goal of increasing the therapists understanding of the client, outside the context of any one particular type of therapy, by encouraging the importance of understanding and incorporating the depth and breadth of contextual influences (Knight and Poon 2008). Having such an understanding not only guides case conceptualization but provides a frame for selecting and adapting therapeutic modalities, the use of clients’ idiosyncratic strengths and challenges, and choice of therapeutic method which avoids reliance on stereotypical beliefs which can be subtle in nature and insidious in effect. For example, while older adults are more likely to experience chronic illness, some cope better with chronic illness than others. The CALTAP model therefore encourages the clinician to explore the client’s experience of chronic illness both with respect to their current circumstances and to current and historical contextual factors that may be contributing to their ability to cope. A stereotypical mind-set without guidance from a model such as CALTAP, on the other hand, might assume that all older adults have difficulty coping with chronic illness, resulting in treatment missing the most appropriate therapeutic goal(s).

The CALTAP model also encourages consideration of both strengths and challenges within individual (e.g., maturation, presenting problem), environmental (e.g., context), and social contexts (e.g., culture, cohort). The focus of this model is on exploration and adaptation, encouraging the psychologist to adapt to the needs of the client (based on the information they gather) rather than having the client adapt to the psychotherapy or the underlying beliefs of the therapist. At its broadest level, the model considers both intra- and interindividual factors as they relate to the client. The model also encourages consideration of interpersonal, intergenerational, and intercultural elements. Therefore, the CALTAP model is a tool that encourages a structured approach to gathering information about the client, which is multi-factorial in nature and considers the client from a number of different perspectives (e.g., interpersonal, intergenerational, and intercultural). Such a comprehensive method of collecting data guides therapy goals and offers both the therapist and the client a means of understanding who the client is and what they bring to therapy.

The Elements of the CALTAP Model

The Element of Context

The inner circle of the model (see Fig. 1) focuses on the individual and immediate context. The central diagram (i.e., “positive maturation,” “negative maturation,” “specific challenges,” “presenting problem,” “therapeutic relationship”) encapsulates intraindividual factors, while the domain of “context” within which this central diagram sits considers both interindividual and interpersonal factors. This portion of the model therefore highlights the importance of consideration of the elements that might be broadly framed as the everyday context in which the client lives, including personal, environmental, and social factors. With regard to personal factors, consideration is given to what the clients themselves bring to therapy and the therapeutic relationship, as well as the interactions between those elements, which are captured via the central diagram within the center circle. In considering environmental and social factors, the focus is on the context in which the individual currently lives and socially engages, including such things as housing and living arrangements, the medical environments in which they engage, recreational settings, interpersonal environments, and family and social settings, for example.

Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP) and Clinical Geropsychology, Fig. 1

Contextual Adult Lifespan Theory for Adapting Psychotherapy (CALTAP) model

The maturation elements capture lifespan developmental processes, those positive and negative changes that are posited to occur naturally as people age. Positive maturation reflects gains with increasing age, and negative maturation includes decrements in functioning with age, along with those things that people are more at risk of with increasing age (e.g., reduced processing speed, increased risk of illness, etc.). The broad and generic nature of the model also allows for consideration of variations in developmental processes, acknowledging the fact that while the lifespan developmental literature offers insight into normative developmental processes, individual differences in development can and do occur.

“Positive maturation” refers to the elements of cognitive and emotional complexity (Knight and Poon 2008). Cognitive complexity encompasses the accumulation of knowledge and skills across a lifetime, as a result of both structured and unstructured learning, that result in what can be summarized as maturation in cognition. Emotional complexity refers to the notion that as people age, they become better able to regulate their emotions (Mather and Carstensen 2005) and also experience more complex, as well as less intense, emotions than those perceived to be experienced by younger adults (Ong and Bergeman 2004). “Negative maturation,” on the other hand, encompasses the broad areas of both physical decline and cognitive decline. Physical decline encompasses the idea that as people age, their body and bodily functions tend to become less efficient and less effective, and the risk of illness increases. Variability in decline is influenced by lifestyle choices of the individual as well as the normative changes associated with aging. Cognitive decline refers to the normative changes in cognition as the individual ages. Such changes include decrements in processing speed, attention, and memory (e.g., Kemper et al. 2003; Light 2000; Salthouse and Ferrer-Caja 2003). As with physical decline, and all elements of maturation, the level of decline and/or development (i.e., “negative maturation” and “positive maturation”) will, in part at least, depend on the life that the individual has led and the genetic hand they have been dealt. The CALTAP model structures a holistic approach, neglecting neither the positive nor the negative aspects of developmental processes – at an individual level – in order to build understanding of the client within a therapeutic context.

“Specific challenges” refer to life circumstances that challenge the individual and therefore can impact on the sense of self and the sense of well-being. Examples of such challenges can include chronic illness, disability, and changes in interpersonal functioning (e.g., dealing with grief, caregiving, role changes, etc.). To illustrate, with regard to chronic illness and disability, not all older adults will develop such conditions, and how much of a challenge such factors are to the individual will depend on a number of elements, not the least of which being the severity of the illness or disability, the coping ability of the individual, and the support available. Grief is another example of a “specific challenge,” which may not only cause the person to think about his or her own existence but can also impact on psychosocial functioning. Length and intensity of relationship, manner of death, coping skills, and support all play a role in how well the individual might cope with the challenge of grief. “Specific challenges” also include role changes such as caregiving. Older adult caregivers can be frail and ill themselves; they may lack support or experience emotional distress as a result of the changes in their partner and themselves. With regard to the challenges that role changes may create, traditional partner roles can be challenged when the person who always saw themselves as the caregiver becomes the care receiver. Like the elements of maturation, there is no clear formula or template here, which is considered a strength of the CALTAP model as it encourages consideration of the individual, in his or her own context and specific circumstances.

As illustrated in the central portion of the diagram via the arrow configurations, the CALTAP model also highlights that the elements of “positive maturation,” “negative maturation,” and “specific challenges” each play a role in shaping the “therapeutic relationship” as well as the “presenting problem.” An individual’s context will necessarily impact on his or her ability to form relationships, including with a therapist, and will shape the therapist’s ability to form a good rapport with the older client. The direction of the arrows and links they create among the elements within the center circle make intuitive and clinical sense, although such relationships have not been established via research specifically focused on the CALTAP model. One might need to consider at the very least, for example, whether bidirectional arrows should exist between “specific challenges” and “therapeutic relationship” and between “specific challenges” and “presenting problem.” The bidirectional arrow between “positive maturation” and “negative maturation” highlights the interrelationship between these elements as coexisting within lifespan development.

As a group (i.e., the central portion of the diagram), the aforementioned elements are located within the center circle labeled “context.” The construct of “context” itself looks to capture details of the settings within which older adults currently engage, including the environments in which they live, work, and play. It therefore looks to emphasize consideration of what elements of the individual’s living arrangements, work or volunteer commitments, and socializing (at professional and personal levels) might be relevant to the presenting problem and therapeutic intervention choices.

“Context” is an apt name for this central portion of the model given that exploration of such elements provides the psychotherapist with an appreciation of the immediate context within which the client both exists and presents. One of the key strengths of this portion of the model then is to discourage stereotypical beliefs about the older adult and call attention to both environmental and intraindividual influences as a firm basis upon which to begin effectively meeting the therapeutic needs of the individual client. However, the positioning of the central portion of the diagram (which focuses on intraindividual factors) specifically within “context” (which focuses on interindividual factors) can be confusing since intuitively it makes sense to look at each of those factors separately outside the realms of such a model. It may therefore be beneficial for the clinician to think of the central diagram and “context” as two separate elements, rather than as one embedded within the other.

The Elements of Cohort and Culture

Moving out from the center circle, “cohort” and “culture” form the outer ring of the model and represent consideration of interindividual factors. This is a change from the first iteration of the CALTAP model (Knight and Lee 2008), where the two elements were initially presented as separate rings. The significance of the two elements now being encapsulated within the one ring represents a recognition by the authors that, realistically, cohort and culture are inseparable, with each having an effect on the other, and so now present them together (Knight and Poon 2008). While the illustration of the model does not highlight this point, consideration of both historical and current contextual factors for “cohort” and “culture” is encouraged.

Cohort

At a population level, cohort refers to portions (sometimes arbitrarily determined) of the population thought to share common characteristics as a result of what might be termed shared world experiences. Knight and Lee define cohort, specifically in relation to the CALTAP model, as a group of people, often determined based on when a person was born, who are therefore assumed to have been “…socialized into certain abilities, beliefs, attitudes, and personality dimensions, which remains relatively stable with age and distinguishes the group from other cohorts” (Knight and Lee 2008, p. 61). For example, an individual born between the years of 1946 and 1965 is defined as belonging to the baby boomer cohort, a group of people born in the Western world after World War II, when conception rates were high with the arrival of peace. Slight variations in definition can occur depending on, for example, in which country the individual was born. Further, Knight and Lee’s definition implies that to think of someone as belonging to a larger cohort such as baby boomers may risk stereotyping the individual by characterizing the client in terms of the overarching qualities assumed to be characteristic of a particular population rather than seeing clearly the qualities of the individual. Clinicians are encouraged to avoid pigeonholing their clients within one “popularized” cohort by using information about one fact in the context. Consideration should also be given, therefore, to the potential areas of influence within the cohort portion of the model, which may include such things as intellectual abilities, education level, personality development, historical experiences, norms, and values. As such, the cohort influences are based primarily on life experiences and the impact those experiences have on the development of the individual.

More specifically, cohort encourages the psychologist to explore and gain an understanding of the older adult’s sense of self, which has been developing over a lifetime. As previously mentioned, consideration should be given to both the historical context and the current context in order to understand where the older adult has “come from” and where she or he is now. Cohort influences are historical in nature, which act to build the individual into who they are today and how they interpret their world. A key implication of the cohort portion of the model is that many of the distinctions that can be made between young people and older people at any point in time may be due to cohort influences and the sociohistorical context in which the individual became an adult rather than developmental changes due to aging or of being at different points in the lifespan. Recent discussions regarding the CALTAP model have made it clear that the model is also seen as useful in terms of helping clients understand their own aging processes and the meaning of variations between themselves and younger family members as caused at least partially by differences in cohort rather than age (Knight and Pachana 2015).

Culture

The final element of the CALTAP model is “culture,” which Knight and Poon (2008) describe as twofold, with variations in both cultural values and beliefs, as well as ethnic and racial considerations, being important considerations. These factors contribute to not only who the clients are but also how others treat them, how the clients interpret psychological distress, and their willingness to seek assistance.

Knight and Lee (2008) offer a definition of culture that encompasses the idea of the individual taking on group characteristics via the process of socialization, expressed as customs, language, beliefs, and behaviors. The element of culture highlights the importance of interpreting each client in the context of her or his own cultural existence, thus refraining from relying on ill-informed or stereotypical beliefs when it comes to exploring the element of culture with the client. Assumptions about culture from such concrete factors as skin color and general appearance miss important factual information with regard to how the client actually interprets themselves under the banner of culture.

Also encouraged is the exploration of the cultural beliefs toward older adults within the client’s own environment. The model therefore also encourages consideration of culture from two perspectives, that of the client and that of those around them. The importance of this consideration is that it helps to determine the client’s place within her or his environment, potentially highlighting such things as the availability of support and the degree of respect (or place they hold) within the particular environment. As with all the elements of the CALTAP model, such in-depth considerations highlight the need to have an understanding of the individual beyond stereotypical beliefs, one that specifies the individual within the heterogeneous older adult population as a guide toward appropriate and effective treatment decisions.

Summary

As a transtheoretical model, CALTAP offers the psychotherapist the ability to develop an understanding of the individual that can assist in guiding therapeutic approach by focusing the clinician’s attention on both intra- and interindividual factors of relevance. The importance of this is that formulation models (i.e., models for conceptualizing a client’s case in order to guide treatment focus) for specific types of therapy often neglect such factors, providing instead only a snapshot of the client as applicable to the needs of the therapeutic approach being used. Contextual factors, however, are an important addition in understanding how to best apply therapy to the case of the individual client. The CALTAP model therefore encourages consideration of both the forest and the trees.

The breadth of scope of the model, however, is also one of its limitations. There is comfort in having small, targeted goals as can be established from formulation models associated with specific types of therapy. The CALTAP model, on the other hand, looks to incorporate much more data, which can lead to lack of clarity with regard to establishing the goals of therapy. However, by exploring the elements of the CALTAP model with the client, the clinician has the opportunity to assist the client in broadening their understanding of their own context, which may in fact help provide for the development of more nuanced goals.

The CALTAP model recently was explored as a useful tool for consideration within the cognitive assessment context as well (Knight and Pachana 2015). Knight and Pachana (2015) expand on the model’s utility by highlighting its relevance within the cognitive assessment domain. The authors encourage clinicians to become similarly aware of the depth and breadth of the client’s individual context given that such knowledge contributes detail and richness to the data available in the assessment arena, as well as influencing assessment decisions, thereby improving validity overall and allowing for more targeted assessment choices and more individualized recommendation strategies.

The CALTAP model encourages psychologists to consider the range of contexts within which the older adult client presents at the level of the individual, offering a transtheoretical tool to assist in individualizing therapy and to help both the client and the psychotherapist understand the intra- and interindividual factors of relevance to the presenting problem. Authors of the model primarily leave the decision of how to use the model in practice up to the individual clinician although the model is intended to guide more than the intake interview. CALTAP was designed as a tool to guide case conceptualization and as a broader framework that can guide assessment, selection, and adaptation of therapeutic approaches and identify relevant factors for assessing outcomes.

Cross-References

• Interpersonal Psychotherapy