Psychotherapy with older adults addresses the specific characteristics of patients aged 65 plus years (old) and 80/85 plus years (very old); however, chronological age per se is a weak indicator of objective resources, inner experiences and behavior of patients. It is important for the therapist to overcome old age stereotypes and to develop a realistic, differentiated understanding of the physical, psychological and social resources and deficits of older patients. In order to describe the special challenges and characteristics, a four-dimensional conceptual framework for a contextualized approach towards psychotherapy with old and very old patients (PIA-CONTEXT) is presented. Significant progress has been made in evidence-based development and evaluation of psychotherapeutic approaches, which in light of the good evidence for the effectiveness calls for implementation in the healthcare system. Despite guideline recommendations, older people with mental disorders are still heavily psychotherapeutically underserved.