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Dr. Nemiroff's approach to working with adopted children utilizes a theoretical integration of Kohut's theories of the development of the Self, Winnicott's theories about containment and "the space between," and the work of the Object Relations theorists focusing on attachment and separation. The concepts of mirroring, containment, the existential experience of loss, and the possibilities of re-attachment to an "other" are emphasized. Mirroring and containment are woven throughout treatment and are essential elements in the establishment and sustaining of the therapeutic alliance. Issues of loss, rejection, and the establishment of hope are best saved for later stages of treatment, although they are gently touched on in the course of the taped interview for teaching purposes. Mirroring refers to helping a child understand that he or she has a Self (or can build a Self) by "seeing" him- or herself and his or her affect accurately mirrored by the therapist. Containment refers to the capacity of the therapist to contain (i.e., hold as if a vessel, the child's unwanted and unbearable feelings until the youngster has developed sufficient self to be able to "reclaim" the once-contained affects from the therapist-receptacle). Loss is an inherent part of living, and the object relations theorists posit that separations and terminations are the primary reiterated life experience that must be understood and re-understood in the course of life. Adopted children have had a rupture in their attachments, by virtue of having been adopted, and this has happened prematurely (i.e., not at the child's developmental pace). This issue weaves itself in and out of the fabric of the treatment of an adopted child. Adoption issues are not consistently present in the treatment of a child (and of course not all adopted children develop pathology requiring treatment; adoption itself is not a form of pathology), but recur at various stages. They become reexpressed throughout treatment at a level commensurate with the child's development. Nonverbal communication and body language are often important in work with adopted children as they may be hypervigilant to their interpersonal environment. Treatment of adopted children, therefore, requires ongoing microanalysis of nonverbal communication occurring between both therapist and patient. Nonverbal communication is particularly notable in the taped interview in the stillness of the therapist, the timing of attempts at animation and humor, and the amount of emotional room the little girl is given. Attachment disorders are often, but not always, associated with adopted youngsters who require treatment. However, in the course of this interview, Dr. Nemiroff tries to help this suffering little girl teach us about adoption itself and what it feels like to her. The interview requires intense attention and microanalysis, and the youngster is very inhibited. It should be added that this is a brave and generous child who consented to be interviewed ("to make a movie") by a stranger so that it might help other doctors help adopted children. Dr. Nemiroff uses this individual therapy approach with adopted children who are willing to be engaged in the therapeutic endeavor. Adoption concerns are usually interwoven with other psychotherapeutically required problems. The child's consent might be covert and considerably subtle and symbolic, but he or she will usually give some sign that he wants to be helped. Dr. Nemiroff's approach uses an integration of several mainstream psychoanalytic concepts and techniques, and the patient must have sufficient ego (inner strength) to be able to work in this manner. That is, he or she needs to be willing to play and interact and understand that he or she is being scrutinized even while joined in play with the therapist. Parental involvement in the child's treatment is critical and is something Dr. Nemiroff requires of all parents. He meets with the parents regularly (at least once monthly and sometimes more frequently) and requests that they call when there are noteworthy occurrences in the youngster's daily life. He will only work with a child in individual play therapy if both parents (in an intact family) consent to attend parent meetings regularly. Dr. Nemiroff believes that this approach is contraindicated when a child's severe acting-out behaviors spill over into his or her treatment sessions such that they cannot be contained. In addition, sometimes this psychoanalytically-oriented type of play therapy is too agitating to a child (this is relatively rare) and leads to worsened behavior at home and an exacerbation of parent–child difficulties that is intolerable to the family and the child. In such cases, sometimes a form of benignly administered behavior therapy may be more appropriate, at least for a while. |
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