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Section 13
Client-Centered Therapy for Childhood Traumatic Grief

Question 13 | Answer Booklet | Table of Contents

Use of Client-Centered Treatment as an Active Intervention
Among the many and diverse orientations to mental health treatment, empathy has been shown to be a common variable for successful outcome, regardless of orientation. Client-centered therapy (CCT) is based on the belief that empathy is one of the most essential aspects of treatment. CCT is a nondirective approach founded primarily on the principles of Carl Rogers and his techniques for providing empathic understanding, therapeutic genuineness, and unconditional positive regard. Each of these elements is expressed in various ways in the context of a therapeutic relationship. The therapist provides assistance via a belief in the person as valuable, worthwhile, and fully equipped to understand her life. The dynamic interpersonal aspects of the approach are essential for change and aided through the therapist’s active use of listening, clarifying, accurately reflecting, and, most importantly, accepting. The challenge for the CCT therapist is to remain actively engaged with the client in the moment, making deliberate choices about when to make clarifying, summarizing, and supportive statements.

In CCT, the therapist does not actively direct themes and elicit feelings; instead, the setting is offered as a form of
external structure and "container" for feelings and their expression in behavior as they naturally evolve. The therapist models how another person can bear to listen to the patient’s pain and experiences in a nonjudgmental way. The therapist does not provide solutions to presented problems. The work stems from an understanding that the client knows herself best and that, as a consequence, applicable solutions can come only from her. Giving advice would reinforce the idea that the solutions lie outside. The client is aided in understanding how, due to her worth and value as a whole person, she can make her own decisions and cope with their consequences. The therapist does not function to protect the client, for such "rescuing" efforts reinforce the notion that the therapist believes the client to be not a fully capable and resourceful person.

Although practitioners have used concepts and interventions similar to CCT with adults in brief dynamic therapy with PTSD that resulted from a single trauma, studies examining the efficacy of CCT for a given diagnosis or for individuals at different ages are limited and hindered by design problems. In a study of adolescents suffering from depression, CCT was used as a control for the nonspecific aspects of treatment in a comparison of family therapy and cognitive-behavioral therapy (CBT). CBT was shown to have a greater effect on symptom recovery and at a faster rate than either family therapy or CCT. There were no differences, however, among CBT, CCT, and family therapy in reducing suicidal ideation or in improving the adolescents’ functioning. Other studies showing superior treatment response from CBT as compared to CCT have questionable treatment integrity. Such studies have utilized a form of CCT in which interpretations are offered, topics are suggested, and, in some cases, token prizes are awarded. The use of such techniques violates CCT’s fundamental principle of unconditional positive regard, suggesting that treatment delivery was not monitored.

Although used in practice for many years, CCT has been criticized because it had received insufficient scientific scrutiny and also because existing studies were methodologically deficient. Hill and Nakayama have recently attempted to address this problem by encouraging the use of manualized treatments that allow for standardized treatment, improved treatment integrity, more objective assessment and comparison of changes in response to treatment changes, and ultimately better research on CCT’s efficacy. A CCT approach has shown promise in various areas—for example, as potentially beneficial in addressing psychological issues that could compound medical problems or ones relating to surgery—and the benefits and costs of using CCT to treat depression appear to be similar to those of CBT.

Additional Treatment Issues
It remains uncertain how best to help children with CTG who are burdened by PTSD symptoms and unable to engage in what are considered normal bereavement tasks. The few studies that have been published highlight treatment goals based on divergent theoretical approaches to treating children who are bereaved or have experienced trauma. The different interventions focus on alleviating distress from specific PTSD symptoms on the change in a child’s self-concept that has resulted from being traumatized, or on tasks specifically related to grief, such as accepting the reality of the death and developing new relationships. What remains to be done is to use CCT as a treatment for children with CTG, looking at its effect on both alleviation of symptoms and mastery of bereavement tasks.

It is also important to recognize how parents affect children. Parents’ psychological functioning can interfere with
their parenting ability, their understanding of the child’s symptoms, and their ability to support their children as they learn to cope with the trauma. Based on intervention research with children who have been sexually abused, inclusion of a parent or guardian in treatment is recommended for the resolution of the parent’s own PTSD symptoms, regardless
of the treatment approach used for children who have experienced trauma. Burman and Allen-Meares suggest that the goals for parental treatment focus both on the parent’s resolution of her own emotional distress related to the trauma and on helping the parent assist in monitoring the child’s symptoms. It has been suggested, moreover, that in conducting family therapy or parent training, CCT focused treatment be included for the child.

Traumagenic Model
The use of CCT is especially compatible with Finkelhor and Browne’s traumagenic model, which posits that specific PTSD symptoms following the trauma of abuse are related to dynamic changes that children experience in their self and world-views. According to this theory, the abused, traumatized child feels betrayed by adults—the very people who were to be protectors—and develops a sense of being unprotected. Stigmatization follows from an abused child’s shame and the culture of blame still surrounding abuse situations. A sense of powerlessness can result from any number of factors—for example, manipulation by a perpetrator, lack of a sense of self-efficacy, or even intrusion of images in the form of nightmares. Finkelhor and Browne suggest that sexually abused children also may exhibit inappropriate sexual behavior or act out in other angry or manipulative ways indicative of behavioral deregulation. Cohen and Mannarino have extended the traumagenic model to understand the presentation of symptoms and behaviors of children with CTG. Not only may the child with CTG feel betrayed by the deceased and her own ideas of the world as fair or good, but she may be disappointed by the failure of other family members, friends, or society to protect her and her family. These feelings may be manifested as anger or confusion. The child may feel ashamed, guilty, or isolated from others who are not grieving. Experiencing a change in relationships with others damages the child’s sense of identity and contributes to the sense of being stigmatized. Responses to this experience may range from social withdrawal to social conformity.

The child may have a profound sense of powerlessness in that she was unable to prevent untoward events or to rescue her loved one from danger. Following the trauma, the feeling of powerlessness may be exacerbated by an inability to control either the means by which authorities handle the trauma or the ways in which others express their grief or memorialize the deceased. Since a traumatic event affects the structure of a child’s life, it is not uncommon for her to experience behavioral deregulation and to act in ways that are uncharacteristic or that serve either as distractions from her own feelings or to distract others from observing those feelings.

CCT, based on supporting and encouraging the construction and repair of a positive sense of self, may be especially well suited for helping traumatized children whose trust in themselves and in others has been damaged. This form of therapy is also especially well suited to adolescents. Teens often benefit from exposure to nonjudgmental, accepting adults outside the family, who can provide guidance as the teens develop their identity and establish a secure sense of self and self-efficacy.
- Morgan, A., Juriga, S., & Brown, E. (Jul/Aug 2004). Letting the Story Unfold: A Case Study of Client-Centered Therapy for Childhood Traumatic Grief. Harvard Review of Psychiatry, 12(4).

Update
Assessing DSM-5-TR and ICD-11
Prolonged Grief Disorder in Children
and Adolescents: Development
of the Traumatic Grief Inventory
- Kids - Clinician-Administered

- Van Dijk, I., Boelen, P. A., de Keijser, J., & Lenferink, L. I. M. (2023). Assessing DSM-5-TR and ICD-11 prolonged grief disorder in children and adolescents: development of the Traumatic Grief Inventory - Kids - Clinician-Administered. European journal of psychotraumatology, 14(2), 2197697.

Peer-Reviewed Journal Article References:
Bellet, B. W., LeBlanc, N. J., Nizzi, M.-C., Carter, M. L., van der Does, F. H. S., Peters, J., Robinaugh, D. J., & McNally, R. J. (2020). Identity confusion in complicated grief: A closer look. Journal of Abnormal Psychology, 129(4), 397–407.

Boerner, M., Joseph, S., & Murphy, D. (2020). Is the association between posttraumatic stress and posttraumatic growth moderated by defense styles? Traumatology. Advance online publication. 

Colasante, T., Zuffianò, A., Haley, D. W., & Malti, T. (2018). Children’s autonomic nervous system activity while transgressing: Relations to guilt feelings and aggression. Developmental Psychology, 54(9), 1621–1633.

QUESTION 13
What is the main challenge for a CCT therapist? To select and enter your answer go to Answer Booklet.

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