Winnicott's therapeutic consultations and squiggle game

1. Introduction

Version followed: D. W. Winnicott, Therapeutic Consultations in Child Psychiatry (1971), with "The Squiggle Game" (1964/1968; reprinted in Psycho-Analytic Explorations, 1989, and Collected Works vol. 8) for the game itself, The Piggle (1977) as the model for on-demand follow-up, and "The Observation of Infants in a Set Situation" (1941) for infants. Later adaptations (Claman 1980; Berger 1980; Stefana 2014; Brafman 2001; Brazilian family-consultation studies) are marked as adaptations wherever they appear.

What it is. A therapeutic consultation is a full, open first interview, or a small number of them, with a child (sometimes a parent alone). Winnicott used it at Paddington Green Children's Hospital for children who did not need analysis or could not get it. He called it applied psychoanalysis, not psychoanalysis proper. The squiggle game is his usual way in: the therapist and child take turns making a quick line that the other turns into something. [source: Winnicott 1971 as summarised in Diniz & Amparo 2025; Johns, Int. Dict. of Psychoanalysis]

This is a clinical stance with one signature technique, not a manual. Winnicott deliberately gave no rules for the game and no protocol for the interview. Everything below is either a technique he describes, a pattern visible in his published cases, or marked [synthesis]. [source: focusing.org (Interactional squiggle drawings) and psyciencia.com, both noting he gave no prescriptive rules]

How change happens. Children often come to a first meeting already hopeful, having imagined the doctor in advance. Winnicott found that many had dreamed of him the night before, so he was a "subjective object". This hope makes early material less defended. If the therapist is reliable, identifies with the child and does not retaliate, the child can put "the current problem or the emotional conflict" on paper in play. The aim is a moment of self-discovery that the child reaches personally. The family must then be able to use the shift (Winnicott's "average expectable environment"). Without that, a single interview does not hold. [source: Winnicott 1971 pp. 2, 7, 14–15 as cited in focusing.org and Diniz & Amparo 2025; "average expectable environment" as cited in the IJP commentary on Ithier] The phrase "sacred moment" for this first-interview opportunity, which can be used or wasted, is widely attributed to the 1971 Introduction. The exact passage is [uncertain].

2. Framework

The stages are reconstructed from Winnicott's case reports and commentators. He did not number them. [synthesis on the ordering; content per sources cited]

Stage	Goal	Format and typical length	Move on when
0. Referral and case selection	Decide whether one or a few consultations could help	Referral letter, phone or brief contact with a parent or referrer	The child appears able to communicate and the family seems able to support change. If the environment is too fragile, offer management, longer therapy or environmental work instead [source: Diniz & Amparo 2025; IJP commentary]
1. Contact with parent(s)	Gather enough history and set a frame. Sometimes the parent is the patient (Mrs X, a single interview with a mother)	Before or after the child's interview; Winnicott varied the order case by case [uncertain about any fixed order]	The child can be seen. Do not over-load yourself with history that would replace what the child brings [synthesis]
2. The child's consultation	Reach the child's central problem through play and drawing, aiming at a moment of self-discovery	Usually one long session; squiggles, talk, often questions about dreams. Length was flexible, often longer than 50 min [uncertain on duration]	The child has said or drawn what they needed to, and anxiety settles. Interpretation, if any, comes late [source: Diniz & Amparo 2025]
3. Feedback and management	Help parents and professionals use what emerged	Talk or letter to parents and referrer; practical management advice	The family can carry on, or a referral for ongoing treatment is made [synthesis built on the "average expectable environment" criterion]
4. Follow-up and "potential presence"	Keep the therapist available as a reliable figure	Letters, phone calls, occasional further consultations over years	The child keeps going. If difficulties return, offer a consultation "on demand" [source: Diniz & Amparo 2025]
4a. On-demand treatment (The Piggle)	Ongoing analytic work paced by the child's own requests	16 consultations with Gabrielle between ages 2 and 5, arranged when she asked to come, with parents writing to Winnicott between visits. He called it "psychoanalysis partagé" (shared with the parents) [source: Penguin description; Luepnitz 2017 abstract]	The child no longer asks, or symptoms resolve
Infants (set situation)	Observe and help an infant's relation to an object in the mother's presence	Infant on mother's lap at a table with a shiny spatula; one or several visits [source: Johns; Diniz & Amparo 2025]	The infant moves through hesitation, use and dropping of the spatula

Session count. One to three consultations is the norm. 1971 presents about 21 cases, some with follow-up meetings. [uncertain: case count; the publisher blurb says seventeen case histories]

3. Guiding principles

Make the first interview count. The child's hope peaks at first contact. Treat the first session as possibly the only one and give it full attention. [source: Diniz & Amparo 2025 on the subjective object; Winnicott 1971 blurb on the rewarding first interview]
Use the subjective object; don't spoil it. The child may have pre-imagined you. Be reliable and receptive so the hope finds a real person, without rushing to correct their picture. [source: Winnicott 1971 pp. 14–15 via Diniz & Amparo]
Identify with the patient. Winnicott names the "capacity to identify with the patient" as a requirement. In practice, follow the child's line of thought and stay with it. [source: 1971 p. 2 via focusing.org]
Do not retaliate. He requires "an absence of the tendency to retaliate". Meet rude, odd or hostile drawings with interest, not correction. [source: 1971 p. 2 via focusing.org]
Reliability is being tested. The child is "unconsciously weighing up the reliability" of the relationship. Keep time, keep promises, and make your stance predictable. [source: 1971 via focusing.org]
Play is the medium, not a warm-up. The game itself is "one way of getting in contact" and communicating. Don't treat it as an icebreaker before the real talk. [source: 1971 pp. 3, 8 via focusing.org; Playing and Reality 1971]
No rules, no technique to copy. The game has no fixed rules, so it stays spontaneous. The therapist's personal suitability matters as much as training. [source: psyciencia.com; Winnicott 1971 publisher blurb]
Equality and reciprocity. Both sides draw, both may fail, and either may decline. Stefana's commentators summarise this as "me a little and you a little". [source: Johns; Stefana 2014 abstract]
Let the child find it. Self-discovery the child arrives at counts more than a correct interpretation. Of one patient he stressed it was "important to get this from Ruth herself". [source: 1971 p. 328 via focusing.org]
Interpret sparingly and late. Interpret only when the child can use it, usually toward the end, and never as the main event. [source: Diniz & Amparo 2025]
The environment decides what lasts. Choose cases where the family can use the consultation. Otherwise work on the environment (management, social work, school) or refer for longer therapy. [source: Diniz & Amparo 2025; IJP commentary]
Keep the drawings and order them. The series of drawings is the record and the communication. Keep them in sequence. [source: Johns; 1971 cases reproduce numbered drawings]
Work with the family as partner. Parents are informants, co-workers and sometimes the patient (Mrs X; "psychoanalysis partagé" in The Piggle). [source: Diniz & Amparo 2025; Luepnitz 2017]
Remain a potential presence. Availability after the meeting through letters, calls and on-demand visits is part of the treatment. [source: Diniz & Amparo 2025]
Applied, not full, analysis. Use analytic understanding to guide what you notice. Don't set up a transference analysis inside a one-off consultation. [source: Diniz & Amparo 2025]
Safeguarding overrides the game. Modern child-protection duties (consent, the limits of confidentiality, acting on disclosure) apply in full. Winnicott's texts predate them. [synthesis]

4. Intervention inventory

These are in order of use. Items 1–16 are Winnicott's own practice. Items 17–22 are later adaptations by other authors, labelled as such. Item 23 (safeguarding) is my synthesis. All example wording is illustrative unless it is quoted and cited.

1. Case selection: assessing the environment

Purpose: Decide whether a one-off or brief consultation can help. Winnicott's method relies on an "average expectable environment" that can use the change. [source: IJP commentary on Ithier; Diniz & Amparo 2025]
Steps: (1) Read the referral and speak briefly with the parent or referrer. (2) Ask who looks after the child day to day, what has already been tried, and how the adults react to the symptom. (3) Rough screen [synthesis]: is there at least one adult who is reasonably stable, interested and able to adapt? Is the child safe? Is the problem new or reactive, rather than long-entrenched with chaotic care? (4) If yes, offer a consultation. If not, offer environmental work (social care, school, parent support) or longer therapy, and treat any consultation as assessment only.
Example language (illustrative): "I'd like to meet [child] once, properly, and then see how things settle at home before we decide on anything more."
Watch for: Ongoing abuse, severe parental mental illness, or a family in acute crisis. These mean safeguarding and management come first. [synthesis]

2. Parent contact and history

Purpose: Get enough context and form an alliance with the parents. Winnicott worked with families and took history, but his order varied between cases. [source: Diniz & Amparo 2025] [uncertain: no fixed sequence documented]
Steps: (1) Meet the parent(s) briefly, before or after the child depending on age and anxiety. (2) Cover the presenting worry, its onset and any precipitants (births, losses, moves), development, family history, and what each parent thinks is going on. (3) Explain the plan: you will see the child, you will draw and talk, and you will tell the parents in general terms what you have understood. You will not repeat everything the child says. (4) Explain the limits of confidentiality and safeguarding duties. [synthesis] (5) Keep history-taking short so the child's own communication isn't pre-empted. [synthesis]
Example language (illustrative): "Tell me when this started and what else was happening in the family around then." "I'll see [child] on their own, and afterwards we'll talk about what I make of it. If I'm ever worried about safety, I'll tell you."
Watch for: A parent who is the real patient. Mrs X's single interview, about her own childhood, changed how she treated her daughter. [source: Winnicott 1971 pp. 316–327 via Diniz & Amparo]

3. Consultation with a parent alone (Mrs X model)

Purpose: When a parent's own history drives the child's difficulty, the consultation can be with the parent. [source: Winnicott 1971 Case Mrs X via Diniz & Amparo 2025]
Steps: (1) Invite the parent to describe the relationship with the child. (2) Follow associations into their own childhood (separations, care, losses). (3) Ask about dreams if they come up, and stay with them. (4) Hold back interpretation until near the end. Mrs X's dream was interpreted only at the close and linked to her early deprivation. (5) Then turn to practical arrangements for the child. No squiggle game is needed.
Example language (illustrative): "When you describe her clinging, what does it remind you of from when you were small?"
Watch for: The parent recovering a good memory, or seeing the child as a separate person rather than as their own past. In Mrs X's case the daughter stopped being treated only as sick. [source: Diniz & Amparo 2025]

4. Setting and materials

Purpose: Offer a simple, uncluttered setting that holds the child and gives room to play. [source: Abram 1998 on the facilitating environment]
Steps: (1) Use a small table with chairs side by side or at a corner, not across a desk. [synthesis] (2) Put out plain paper and pencils. Winnicott mostly used pencil. Coloured crayons are an adaptation. [source: focusing.org (adaptation with markers and crayons)] [uncertain on Winnicott's exact materials] (3) Allow time, and avoid a 50-minute cut-off if you can. (4) Have a way to number and keep drawings in order.
Example language: None needed.
Watch for: Too many toys or materials, which dilute the exchange. [synthesis]

5. Introducing the game

Purpose: Lower anxiety and invite play as an equal. The child is free to decline. [source: Johns]
Steps: (1) After a little free chat, suggest a game casually. One account describes Winnicott tearing a sheet in a relaxed way to signal informality. [source: psyciencia.com] [uncertain on primary wording] (2) Explain the rule in one sentence. (3) Make it clear that either of you can say "I can't make anything of it". (4) Offer an alternative (talk, other play) if the child declines.
Example language (illustrative): "Shall we play a game? I'll do a squiggle and you turn it into something. Then you do one and I'll turn it into something. If you can't make it into anything, that's fine too."
Watch for: The child taking over the rules or inventing their own version. That is often good: the child is making the game theirs. [synthesis]

6. Making the therapist's squiggle

Purpose: Offer an ambiguous, non-directive stimulus that carries no meaning of your own.
Steps: (1) Draw a quick wiggly line. Winnicott sometimes did this with closed eyes. [source: Abram 1998] (2) Keep it simple and open; don't draw a recognisable shape. (3) Hand it over and wait.
Example language (illustrative): "Here's mine. What could it be?"
Watch for: Squiggles that unconsciously steer the child (a face, a weapon). If you see this in your own drawing, note it and keep the next one more neutral. [synthesis]

7. Transforming the child's squiggle

Purpose: Show reciprocity, accept the child's offering, and sometimes offer a gentle response to the theme.
Steps: (1) Invite the child to make a squiggle for you. (2) Turn it into something, keeping close to what is there. (3) Say what you made. (4) Your choice can carry a light echo of what has emerged (identification), but avoid heavy symbolism. [source: focusing.org on empathic, non-leading responses]
Example language (illustrative): "I've made yours into a little boat, a long way from the shore."
Watch for: You performing or showing off. The child should lead. Your drawings should contain and reflect the child's material, not express yours. [source: focusing.org]

8. Following and commenting on drawings

Purpose: Let meaning build across the series. Winnicott saw the drawings as "putting down" the current problem. [source: 1971 p. 7 via focusing.org]
Steps: (1) After each drawing, ask what it is and what is happening. (2) Use the child's words and add little. (3) Track themes across drawings, such as repeated objects, sudden changes, breaks in rhythm, or refusals. Changes in rhythm and pattern can signal basic anxieties. [source: Diniz & Amparo 2025] (4) Number the drawings in order.
Example language (illustrative): "What's happening to him?" "That one again: the thing with the big mouth."
Watch for: A drawing that surprises the child, a sudden quiet, or a burst of energy. These often mark the approach to the central theme.

9. Asking about dreams

Purpose: Winnicott often moved from drawings to dreams to reach unconscious material. Dreams appear throughout his consultations, including Mrs X's. [source: Diniz & Amparo 2025 on Mrs X] [uncertain: frequency across child cases is from my reading of the 1971 cases, not re-checked this session]
Steps: (1) When drawings reach something emotionally charged, ask whether the child has dreams. (2) Invite them to draw the dream. (3) Follow the dream's details without interpreting straight away.
Example language (illustrative): "Do you ever have dreams? Could you draw one for me?"
Watch for: A bad dream that links to the presenting symptom. This is often the doorway to the central problem.

10. Recognising the significant ("sacred") moment

Purpose: This is where change happens: the child discovers something about themselves in the play. [source: Playing and Reality p. 51 and Winnicott & Khan via focusing.org] [uncertain on "sacred moment" wording in 1971]
Steps: (1) Notice when the child surprises themselves, makes an exclamation, or links a drawing to their life. Ruth: "O look, I'm further and further away from my mother". [source: 1971 pp. 326–7 via focusing.org] (2) Stop adding material. (3) Reflect it back simply, or just stay with it. (4) Don't explain it away.
Example language (illustrative): "Yes. Further and further away." (then pause)
Watch for: Relief, calm, deeper play, or spontaneous talk about the real situation. These indicate it landed. Flatness or a change of subject means it was too early or came from you, not the child.

11. Interpretation (sparing and late)

Purpose: Put into words something the child is nearly ready to know, but only when they can use it. Interpretation is not the main event. [source: Diniz & Amparo 2025]
Steps: (1) Wait until the child has said what they need to say, usually near the end. (2) Interpret only what the material has already shown, and keep it short and concrete, linked to the child's own drawing and words. (3) Offer it tentatively. (4) If the child rejects it, drop it and don't argue.
Example language (illustrative): "I wonder if the boat being far from the shore is a bit like how it's been since the baby came, being further from Mummy."
Watch for: Over-interpreting early, which shuts play down. Some of the best outcomes involve no interpretation, just the child's own discovery. [source: Ruth p. 328 via focusing.org]

12. Ending the consultation

Purpose: Close in a way that leaves the experience intact and the therapist available. [source: Diniz & Amparo 2025, comparing the ending to the spatula game's final phase of losing interest and readiness to finish]
Steps: (1) Notice when the child loses interest or relaxes. That usually means the work is done. (2) Say the session is ending, and say what happens next. (3) The drawings stay with you as the record. [synthesis on the rule; Winnicott's published drawings imply he kept them] (4) Say whether you will see them again or can be asked for.
Example language (illustrative): "We've done a lot of drawings today. I'll keep them safe. If you want to come and see me again, you can tell Mum and Dad."
Watch for: A child who can't end. That may point to greater need, or to a home that can't hold them, and calls for an ongoing offer.

13. Feedback to parents and referrer

Purpose: Hand the work back to the family. The environment carries the change. [source: Diniz & Amparo 2025]
Steps: (1) See the parents after the child, or soon after, in person or by phone or letter. (2) Share your understanding in general, usable terms, not the child's private words. (3) Give specific management advice where relevant, for example about a recent loss, a new baby, or a separation. (4) Write to the referrer. (5) Agree a follow-up route. [synthesis on steps 1–5, following Winnicott's hospital practice]
Example language (illustrative): "I think the night fears are tied up with feeling pushed away since the baby. She doesn't need you to do anything elaborate. She needs some time that is only hers, and for you to let her be cross."
Watch for: Parents who seem relieved and freed up rather than blamed. Defensive parents need more of an alliance before any formulation is shared.

14. Follow-up as "potential presence"

Purpose: Keep the therapist available as a reliable figure without regular sessions. [source: Diniz & Amparo 2025]
Steps: (1) Invite letters or calls from parents. (2) Reply. (3) Offer further consultations when asked. (4) Review after a set interval, such as 1–3 months. [synthesis on the interval]
Example language (illustrative): "Write and let me know how things are in a few weeks. If you'd like me to see her again, I can."
Watch for: Reports that the symptom has eased and that the child is "more herself". Repeated relapses show a need for ongoing treatment.

15. On-demand treatment (The Piggle model)

Purpose: A series of analytic consultations timed by the child's requests rather than a fixed schedule, with parents as partners. [source: Penguin description; Luepnitz 2017 abstract]
Steps: (1) Agree with the parents that the child can ask to see you and that they will arrange it. (2) Ask the parents to write between sessions about the child's state, dreams and play. Parents' letters form part of The Piggle. (3) In each session, follow the child's play and interpret as in analysis. (4) Keep notes and reply to parents. (5) End when the child stops asking and development has resumed. Gabrielle had 16 consultations between ages 2 and 5. Winnicott called it "psychoanalysis partagé". [source as above] Whether the father was sometimes in the room is [uncertain] (not verified this session).
Example language (illustrative), to parents: "If she asks to come, ring me and we'll find a time. Do write and tell me what she says and dreams in between."
Watch for: Parents interpreting at home or over-reporting. Later critics, including Luepnitz and Gold, ask whether more direct work with the parents would have helped. [source: Cleveland Psychoanalytic Center 2018; Luepnitz 2017]

16. Spatula game (infant set situation, 1941)

Purpose: Observe and help an infant's relation to an object in the mother's presence. It predates the squiggle game and is Winnicott's consultation tool for babies. [source: Johns; Diniz & Amparo 2025]
Steps: (1) Seat the mother with the infant on her lap at a table. (2) Place a shiny spatula in reach. (3) Don't encourage; just observe. (4) Note three phases: hesitation; reaching, taking, mouthing and playing; dropping or losing interest. (5) Note the mother's responses. (6) Talk with the mother about what you saw.
Example language (illustrative), to mother: "Let's just see what he does. You don't need to help him."
Watch for: Prolonged hesitation or an inability to drop the object. Diniz & Amparo map the three phases onto the consultation as testing the setting, communicating, and readiness to end.

17. Squiggle-drawing storytelling (adaptation: Claman 1980)

Purpose: Extend the game for school-age (latency) children who resist direct questions. Squiggles are combined with Gardner and Kritzberg-style storytelling. [source: Claman 1980 abstract]
Steps: (1) Play the squiggle game as usual. (2) Ask the child to tell a story about a picture. (3) Respond with a story of your own based on the same picture, with a healthier resolution. [uncertain: steps 2–3 inferred from Gardner's mutual storytelling; Claman's full text]
Example language (illustrative): "Tell me a story about this creature. What happens next?"
Watch for: The child taking up alternative endings in later stories.

18. Squiggle with adolescents (adaptation: Stefana 2014)

Purpose: A way into relationship for adolescents who find talking hard. [source: Stefana 2014 abstract; psyciencia.com]
Steps: (1) Offer the game lightly. Some adolescents first start with tic-tac-toe or noughts and crosses. Accept that, then move into squiggles. (2) Emphasise reciprocity. (3) Talk about the drawings at their pace.
Example language (illustrative): "This is a bit of a daft drawing game, but it sometimes helps. Want to try?"
Watch for: Embarrassment. Respect a refusal and offer talk instead.

19. Squiggle with adults (adaptation)

Purpose: Create a shared space where images can reach the page. It is not used as a test. [source: psyciencia.com, citing Winnicott as saying it is the same with adults] [uncertain on the original wording]
Steps: (1) Offer it as an option, not a requirement. (2) Exchange squiggles. (3) Explore associations.
Example language (illustrative): "Sometimes drawing gets at things words miss. Would you try a quick exchange of scribbles with me?"
Watch for: Feeling infantilised. Frame it as adult exploration.

20. Joint parent-child consultations (adaptation: Brafman 2001; Gold; Brazilian studies)

Purpose: Address child-parent interaction patterns directly. Parents witness and understand what the child communicates. [source: Brafman 2001 description; Cleveland 2018; Diniz & Amparo 2025]
Steps: (1) See the parent(s) and child together for at least part of the time. (2) Let the child draw or play while the parents watch. (3) Help the parents understand what they see, and link it to family patterns.
Example language (illustrative): "Let's look at this drawing together. What do you notice?"
Watch for: The child censoring themselves in front of the parents. Add time alone with the child.

21. Showing drawings to parents and using squiggles at turning points (adaptation)

Purpose: Help parents understand the child's difficulty, and mark transitions in ongoing therapy. [source: focusing.org author's practice]
Steps: (1) With the child's consent, show selected drawings to parents. (2) Use the game again at turning points and at termination, not as routine play therapy.
Example language (illustrative), to the child: "Is it OK if I show your mum this one? Which ones would you rather keep just between us?"
Watch for: Breaches of trust. Always ask first.

22. Group and paediatric applications (adaptations)

Purpose: Brief consultations in group or medical settings. [source: Diniz & Amparo 2025 on group consultations with mother-baby pairs (Almeida 2023); Berger 1980 on squiggles in paediatric practice] [uncertain: Berger abstract]
Steps: Adapt the same stance: brief, reciprocal, aimed at communication.
Example language (illustrative): "While we're waiting, shall we do some drawing together?"
Watch for: Limited privacy in group or medical settings.

23. Safeguarding procedure within the consultation [synthesis]

Purpose: Meet modern child-protection duties that Winnicott's texts predate.
Steps: (1) Before you start, explain the limits of confidentiality to parents and child in age-appropriate terms. (2) If drawings or talk suggest harm, ask open, non-leading questions. (3) Don't promise secrecy. (4) Record the child's words verbatim and keep the drawings as part of the record. (5) Follow local safeguarding procedures, such as consulting the designated lead. (6) Don't share concerns with a parent who may be a risk until you have taken advice.
Example language (illustrative): "Thank you for telling me. I need to make sure you're safe, so I'll talk to someone whose job is to help with that."
Watch for: Your interpretations becoming leading questions. Don't suggest abuse scenarios through your squiggles.

5. Handling problems

Winnicott gives principles, not troubleshooting. Most responses below are [synthesis] built on his stance. Source-backed points are tagged.

Child won't draw or play. The child may decline. [source: Johns] Accept it without pressure, chat about anything, and offer other play or simply talk. If you have time, re-offer the game later in a lighter way. You can also draw alone and comment aloud so the child can join without committing. [synthesis] Mrs X shows that a consultation can work without the game. [source: Diniz & Amparo 2025]
Stereotyped or "clever" drawings (compliance, false self). The child turns every squiggle into a safe object such as a house or a car. Go on playing without hurrying. Respond with your own playful, slightly surprising transformations to model freedom. Comment on the sameness only if it persists. [synthesis]
Stuck: nothing meaningful emerges. Ask about dreams, or about best and worst things. Accept that this time may be assessment only, and offer another consultation. [synthesis, building on item 9]
Overwhelm: anxiety rises sharply, or the child regresses or becomes disorganised. Slow the pace, stop interpreting, and return to neutral squiggles or simple talk. Name the end of the session clearly and help the child settle before handover. Tell the parents what to expect that evening. [synthesis] In psychotic-level anxiety (such as Gabrielle's night terrors), a single consultation may not be enough. Offer on-demand or ongoing treatment. [source: Luepnitz 2017 abstract on "psychotic night terrors"]
Child resists or opposes (aggression, mocking, scribbling over). Don't retaliate. [source: 1971 p. 2 via focusing.org] Treat scribbling over a drawing as communication. Set limits only for safety. [synthesis]
Rupture with parents (they feel blamed or disagree with your view). Share your understanding as tentative, and frame it around the child's needs rather than parental failure. Invite their view. If needed, offer a consultation for the parent alone (item 3). [synthesis]
Non-adherence to management advice. Explore what makes it hard. The parent's own history may be involved, as with Mrs X. Simplify the advice to one doable change. [synthesis]
Environment can't use the consultation (not an "average expectable environment"). Stop treating the consultation as treatment. Move to environmental work (social care, school, wider family) or refer for ongoing therapy. [source: Diniz & Amparo 2025; IJP commentary]
Safeguarding disclosure mid-game. Follow item 23. Stop the game if continuing would trivialise the disclosure. Follow local procedures and standard child-protection practice. [synthesis]
Suicidal or self-harm content (older children, adolescents). Do a standard risk assessment using your service's protocol. Inform the parents or guardians in line with safeguarding policy, and arrange appropriate urgent follow-up. A consultation does not replace risk management. [synthesis]
Therapist over-interprets or performs. Supervise or self-review your drawings in sequence: who led? Return to the principles of reciprocity and of letting the child find it. [source: focusing.org; Ruth p. 328] [synthesis on the review method]
Parent expects a report or diagnosis after one meeting. Explain the purpose (understanding and a nudge to development). Give a written summary of your understanding and recommendations if the service requires it. [synthesis]
Child wants more sessions, or seems dependent. Offer the on-demand route (item 15) with clear arrangements, or refer for regular therapy. Don't end abruptly. [synthesis]
On-demand arrangement misused (parents booking too often, or for their own anxiety). Clarify that the child's requests set the pace. Offer the parents a separate consultation. [synthesis]
Adult or adolescent feels infantilised. Frame the game as optional and exploratory. Offer talk instead. [source: Stefana 2014; psyciencia.com]
Online or remote delivery (not in the sources). Squiggles can be exchanged by holding drawings up to the camera or using a shared whiteboard. Expect less spontaneity. Keep a record of the drawings. [synthesis] [uncertain]
Cultural or language differences. Drawing reduces reliance on language, but check what images mean in the family's culture before interpreting. Consider transcultural consultation models. [source: Diniz & Amparo 2025 on Oliveira et al. 2023] [synthesis on application]

Sources

Sources:

Further reading (primary texts not drawn on in full):

Winnicott, D. W. (1941). The observation of infants in a set situation. IJP, 22.
Winnicott, D. W. (1953/1958). Symptom tolerance in paediatrics. In Through Paediatrics to Psycho-Analysis.
Winnicott, D. W. (1964/1968). The squiggle game. Voices, 4(1); in Psycho-Analytic Explorations (1989).
Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry. Hogarth Press.
Winnicott, D. W. (1971). Playing and Reality. Tavistock.
Winnicott, D. W. (1977). The Piggle. Hogarth Press.
Berger, L. R. (1980). The Winnicott squiggle game: a vehicle for communicating with the school-aged child. Pediatrics [uncertain].
Claman, L. (1980). The squiggle-drawing game in child psychotherapy. Am. J. Psychotherapy, 34.
Brafman, A. H. (2001). Untying the Knot: Working with Children and Parents. Karnac.
Luepnitz, D. A. (2017). The name of the Piggle. IJP.
Not located: a "Farhi" commentary on the squiggle game [uncertain].

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