JOURNAL OF CHILD PSYCHOTHERAPY

VOL. 32 NO. 1 2006 66 – 84

A slow unfolding – at double speed: reflections

on ways of working with parents and their young
children within the Tavistock Clinic’s Under
Fives Service

LOUISE EMANUEL
London

Abstract This paper describes clinical work carried out as part of the Tavistock Clinic Under Fives
Service, which offers brief focused psychoanalytically based interventions to families with young children, as
well as longer-term work. It elaborates psychoanalyst Annette Watillon’s idea that it is the dramatic way in
which children enact their (and their family’s) predicament in the consulting room which speeds up the
process of change. The author clusters clinical cases into three categories, each cluster representing a different
kind of ‘dramatic’ enactment and leading to a different kind of intervention relating to the therapist’s role,
the structure of the interventions and the ‘ports of entry’ for the work. The categories are defined as: ‘child-
led drama’ with the therapist in the role of ‘therapeutic observer’; ‘internal parental drama’ with the
therapist in the role of ‘therapeutic consultant’; and ‘external parental drama’ with the therapist in the role
of ‘therapeutic modulator’. The author defines these categories, illustrating each category with clinical
examples.

Keywords Dramatic enactment; brief interventions; Under Fives and Perinatal Service; parent
consultation; parent – infant psychotherapy; psychoanalytic approach.

Introduction
This paper is based on work carried out as part of the Under Fives Service at the
Tavistock Clinic, using as a framework aspects of the treatment model which was
pioneered over 20 years ago by members of the Child and Family Department.
The title refers to what may seem to be a paradox, touching on the particular technique
developed in the Under Fives Counselling Service, of working psychoanalytically
(avoiding set interview techniques and questionnaires), but within a brief time frame.
How can there be a slow ‘free associative conversation’ (Watillon, 1993: 1038) with
parents, and a simultaneous exploration of a young child’s communications through
behaviour, play, drawing and interaction with parents and therapist, in what is often a

Journal of Child Psychotherapy

ISSN 0075-417X print/ISSN 1469-9370 online ª 2006 Association of Child Psychotherapists
http://www.tandf.co.uk/journals DOI: 10.1080/00754170600563455
 A SLOW UNFOLDING 67

brief therapeutic intervention? In exploring this paradox, I will be expanding Annette

Watillon’s (1993) suggestion that the dramatic way in which young children ‘enact’ their
predicament (and often the family’s) facilitates this ‘slow unfolding at double speed’.
The Under Fives Service has offered quick response, brief focused psychoanalytically
based interventions to families with babies, toddlers and young children up to five-years-
old for many years, and much thinking has been done around this area in the
corresponding weekly training event, the Infant Mental Health Workshop. In addition
to work undertaken in the Clinic, the multi-disciplinary Under Fives Team offers a
service to families who are more difficult to reach, seeing them in outreach community
settings such as health centres. A peri-natal project, focusing on pregnancy and the early
weeks, offers support to couples with fertility problems, miscarriage, premature babies or
a bereavement. Consultation to nurseries and other day care provision for infants and
pre-school age children is also offered as part of the Service.
Families can self-refer or be referred by their doctor. Referrals include feeding and
sleeping difficulties, crying in infants, failure to thrive, tantrums and aggressive or
disruptive behaviour, sibling relationship difficulties, incontinence, encopresis, eczema
or other psychosomatic difficulties, and developmental delay. Usually the child will
already have had medical checks and the referrer would indicate a concern that the
difficulty might have an emotional basis. This could be rooted in a lack of attunement
or good emotional match between a primary care-giver and the baby or small child, or
between the parental couple. Sometimes separation difficulties or problems around
attachment and bonding lie at the heart of the problem, both for mother and infant. In
many cases the parents bring to the parenting situation their own experience as a child
and may repeat a cycle of neglect or abuse with their own children.
Many families have been, and continue to be, helped by one or two sets of five
sessions, followed by a review meeting, and this method of work with parents and
infants, as well as with ‘older’ (2–4) children under 5 has been well documented
(Barrows, 2003; Daws, 1989; Emanuel, 2002a; Hopkins, 2003; Likierman, 2003;
Pozzi, 2003; Saltzberger Wittenberg, 2001).
However, the service has been going through its own slow transformation over the
past five years. Although a focused psychoanalytic approach remains at its core, the brief
five-session model can no longer be considered applicable in many cases we work with
where problems are more complex and severe, and require a longer time to unfold.
Families whose babies or young children have died, or are seriously ill or disabled, often
require more lengthy interventions around fairly complex cases. The need to link with
other agencies, and the necessity of more distinct multi-disciplinary input around cases
has changed, to some extent, the nature of some of the work. As will become clear, there
are occasions when an initial piece of brief work may bring about change, but may also
function as an assessment for, or result in, long-term family work, individual
psychotherapy treatment for a parent or child or parent/couple work. It is often difficult
to ascertain from the initial referral the level of severity of the problem, and the nature of
the intervention that may be required.
The introduction of the ‘Peri-natal Project’ as part of the Under Fives Service has led
us to focus our thinking about how techniques and skills required when working with
parents and infants may differ from work with toddlers and pre-school age children and
68 L. EMANUEL

their families. As Lieberman (2004: 99) states, ‘toddlers and pre-schoolers are not
infants’, and the approach to treatment will differ in some ways. The Under Fives Team
is therefore constantly re-evaluating this long-established model, adapting it to the
clinical requirements of referred families, whilst endeavouring to maintain the essential
structure of working psychoanalytically within a relatively brief time frame. For the
purposes of this paper I will be exploring the brief model of work with families and their
young children between the ages of 2 and 4. I will be alluding to (but not developing)
ideas about differences in technique used when working with families with ‘older’ under
fives and in parent – infant interventions.

Under Fives model – a framework for thinking

The underlying technique of applying psychoanalytic understanding within a brief time
frame continues to provide an important model for the work offered. The framework
for thinking about clinical material includes an understanding of psychoanalytic theory,
attachment theory, child development research, and observational skills gained through
undertaking an Infant and Young Child Observation.
In practice this involves an ability to be receptive to the powerful projections, via the
mechanism of projective identification, of parents and their children (and co-workers),
as well as an ability to monitor one’s counter-transference responses to the family,
including the ‘total transference’ situation (Jackson, 1998) of the family to the
therapeutic process. The application of observational skills to clinical work with families
with young children (Miller et al., 1989; Miller, 1992; Reid, 1997; Sternberg, 2005) is
of particular relevance to this work, as I hope will emerge through the clinical material.
Recent developments in neurosciences research can also be helpful, particularly an
understanding of the autonomic conditioned fear response (Emanuel, 2004), if working
with children traumatised in infancy who present as hyper-reactive and are prone to
apparently unprovoked outbursts of aggression. This framework, combined with a
flexibility of approach, may allow for a range of decisions to be made about frequency,
duration and the appropriate type of intervention based on clinical judgement. This
may also include some form of practical advice.
Work with parents is a central feature and often the focus is on helping the parents to
gain the insight and strength to function together as a benign parental couple, despite
sometimes conscious or unconscious attempts by the child to split the couple. This may
involve helping a single parent understand her child’s need for her to exercise both
paternal and maternal functions: to maintain in her mind, and to cultivate in the child’s
mind, the notion of a well functioning parental couple. Underlying this approach to
work with parents and children is the idea that each parent embodies within him/herself
both a paternal and a maternal function, a combined internal parental couple. This links
with Bion’s (1962) concept of Container/Contained. Bion’s concept of a ‘container’
incorporates both the maternal receptive and the paternal ‘structuring, penetrative’
role – a new thought, a transformation of what is received. Thus it is essential for the
development of a capacity to think symbolically that a child internalises a parental object
with both paternal and maternal functions. In some situations, the absent father can be
powerfully ‘present’ in the mind of the single parent and child, like a ‘phantom partner’
 A SLOW UNFOLDING 69

in either a benign or an unhelpful way. Excessive preoccupation with an absent parent

can be an obstacle to thinking and interfere with the parent’s capacity to be in touch
with his/her child’s emotional communications (Emanuel, 2002a).

A tale of two camels: dramatic enactment in parent – infant psychotherapy

I recently watched the screening of the film The Story of the Weeping Camel (Davaa and
Falorni, directors; National Geographic World Films and THINKFilm), a moving
documentary set in the windswept Gobi Desert of Mongolia. A family of nomadic
shepherds assists with the births of their camel herd. One of the camels has a protracted
and difficult delivery, rejecting her albino newborn, coldly refusing it her milk and her
motherly love. Despite their strenuous efforts to ‘force’ the mother and baby together,
bonding does not occur and the nomads fear the baby will die. Finally, a traditional
violinist is summoned to the camp and a breathtaking ritual is performed. It involves the
mother of the family stroking the camel’s mane firmly and lovingly while the violinist,
sitting a little way off, plays a repetitive haunting strain. The mother camel appears to
weep as the firm tactile and lilting auditory sensations envelop her and, turning to her
baby, she offers it her teat.
This seemed to me to be a moving account of a successful parent – infant intervention
involving what I see as a strong combined parental couple, with firm paternal and
receptive maternal functions: the violinist sits slightly removed from the dyad as if
taking up Britton’s (1989) ‘third position’, and is able to evoke and transform through
his music the experience of disaffection and then rapprochement between the mother –
infant dyad, while the nomad woman seems to be putting kind but firm pressure on the
mother camel. Together these provide a containing boundary around the mother –
infant dyad, who had been adrift from each other in the vast barren internal and external
landscape. It is a dramatic enactment of the creating of a safe container for this mother
and infant to come together, the watching villagers forming a version of the supportive
‘network’ of the community, drawing in to ensure the couple do not fall through the
‘net’.
I began by mentioning this film in order to highlight the dramatic quality of the
intervention, which formed the climax of the piece. It fits in well with Watillon’s (1993)
suggestion that the ‘speed and spectacular nature of the therapeutic effect’ in work with
Under Fives results from the ‘dramatisation’ of experience in the therapeutic setting. I
have begun increasingly to recognise the dramatic quality of what unfolds in the
consulting room, particularly with 2–5-year-olds as they take centre stage in a child-led
enactment of a crisis within the family. Perhaps this is such a feature of work with this
age group because of the dramatic nature of the Oedipal conflict, which is inherent in so
much of small children’s communications and behaviour inside, as well as outside, the
consulting room.
In thinking about the recent cases I have seen within the Under Fives service, I found
they clustered into three different groups, each group representing a different kind of
‘dramatic’ enactment and leading to a different kind of intervention, relating to my role
as therapist, the structure of the interventions and the ‘ports of entry’ (Stern, 1995) for
the work. These are broadly categorised, using the metaphor of ‘drama’ for these
70 L. EMANUEL

powerful enactments: ‘child-led dramatisations’ with myself in the role of ‘therapeutic

observer/director’, an ‘internal parental drama’ with myself in the role of ‘therapeutic
consultant/supervisor’ and an ‘external parental drama’ with myself in the role of
‘therapeutic modulator’. I will describe what I mean by these, and give clinical examples,
considering the technique involved in these interventions. It goes without saying that
most cases involve a combination of different roles and these are only differentiated for
general purposes of categorisation.
In relation to the theoretical understanding and skills gained through the undertaking
of an Infant Observation (a core part of the pre-clinical training for professionals
working within this model), I would suggest each category highlighted a different aspect
of this experience: in the first category, of ‘child-led dramatisations’, an ability to notice
in detail the non-verbal communications of the child, according them a value and
meaning that the parents may not have recognised, would be foremost; in the second
category, the ‘internal parental drama’, Esther Bick’s ideas about second skin defences,
gleaned from her detailed observation of infants, enabled me to help the parents gain an
understanding of their child’s internal world, and how this linked to her severe biting
behaviour; in the third category, ‘an external parental drama’, the ability to absorb
powerful projections from different family members, to observe without intervening in
the disturbing family drama which is unfolding, and to cope with the temptation to
over-identify with the child (Saltzberger Wittenberg, 2001) – to manage powerful
countertransference feelings. These are all skills gained through Infant Observation.

Child-led dramatisation – therapist’s observer/director role

In these kinds of clinical cases, the child takes centre stage in enacting, through his play,
non-verbal behaviour and conversation, conflicts and concerns within the family, as well
as his own emotional states and mental activity. The role of the therapist as ‘therapeutic
observer/director’ is to try and make sense of these communications, through detailed
observation of the child’s play and monitoring of her countertransference experience,
and to assign meaning to the drama unfolding before her. The therapist takes on the
role of interpreter of the child’s material to the parents. Watillon (1993: 1041) states:
‘The therapeutic effect is due to a ‘staging’ of the conflict by the child himself in the
form of a dramatic performance. By making his presence felt at a precise and meaningful
moment, while the parents are giving their account of the situation, the child makes the
interactional conflict manifest and allows the therapist to decode the message, to
elaborate the emotions projected into him and to interpret the unconscious motivations
of the various members of the ‘cast of the play’. The analyst – as theatre director – can
perform a transforming function.’
This form of dramatisation often involves omnipotent little boys, who are having
difficulties with learning at school because of their inability to tolerate feeling small and
coping with feelings of dependency. This can be the result of an early disappointment in
the maternal object, whereby the infant develops ‘second skin’ (Bick, 1968) defences
against vulnerability by becoming prematurely self-sufficient, hyperactive, thick-
skinned, splitting off and projecting feelings of helplessness and anxiety about ‘not
knowing’ into his parents, who feel increasingly deskilled. Four-year-old Damien was a
 A SLOW UNFOLDING 71

tyrannical and intelligent child, who dominated the sessions with his relentless demands
for my co-worker and me to guess what shapes he was drawing. His parents were
polarised in their parenting styles, mother indulgent and guilty, father bombastic and
fierce. We addressed Damien’s underlying anxiety about not knowing things, feeling
small if he had to rely on others to teach him things. Towards the end of a session
Damien looked up at the clock, which read 16.55, and began saying, ‘It is 10 to 11!’
making various guesses at telling the time (he had been taught this at nursery). Mother
tried patiently to help him by pointing to the big hand and the little hand, but he would
say: ‘5 to 11 . . . 10 to 11’. Eventually I said it seemed as if he couldn’t believe that the
‘little hand’ (which would signify the crucial ‘5 o’clock’) could do anything useful, so he
just wiped it out of his mind. His parents smiled and I felt they understood, through
this dramatic demonstration, what we had previously spoken about regarding his
emotional difficulties interfering with his capacity to make meaningful links important
for learning. The difficulty of the hands coming together linked too to the polarised
styles of parents, which did shift during the course of our work.

Case illustration – child-led intervention

Mario, aged 3½, was referred because he was having difficulty settling into nursery
and was aggressive to other children. Although a lot of the work is done in the
presence of the child, I often invite parents to attend the first session without the
child, unless there is a good reason to include the whole family. I think it is
important to gather in the anxieties of the parents, and provide them with some
containment through beginning to offer them some links to understanding, based
on their description of the situation, before bringing in the children. With a child
such as Mario I often alternate family meetings, and meetings with parents on their
own, particularly if issues to do with limit-setting are to be addressed, as I think it
is important that parents’ areas of difficulty are not further exposed in front of the
child and that they are accorded some privacy to explore these further.
In the initial meeting with this lively and intelligent couple, I heard about their
itinerant lives over the past few years. Mother had gone to Sicily from France as an
au pair, where she had met Mario’s father, an accountant. They left Sicily when
Mario was 9 months old, moving country several times in search of work before
settling in England. They had had difficulty conceiving him, so he was a special
child for them, but mother had had to return to work when he was just 3 months
old – he slept badly and cried a lot. They described him being possessive of
children at school, seeking exclusive relationships and feeling any rejection keenly.
At home, he was similarly preoccupied with his mother and regularly announced
his wish to ‘send daddy away’. I wondered about their ideas for further babies, but
they said sadly that they had not succeeded in conceiving again. Mother told me
that Mario recently announced she has a ‘baby in her tummy’. I wondered whether
the difficulties at school could stem from his shock at finding himself suddenly
amongst so many rival siblings, all in competition for the attention of the teacher
(usually the mummy figure), and they were interested in this. I found myself
72 L. EMANUEL

concerned about his tyrannical control over them, and whether their fear of
incurring his wrath could have a psychological impact on their capacity to conceive
another child.
They returned 2 weeks later with Mario, an intensely expressive child. As they
described their long odyssey from Sicily to Rome, and on to London, Mario built
up brick castles, bringing them crashing down at each mention of another leave-
taking and his world crashing down. They were astonished to see how Mario
played out his anxieties around separation and endings once I drew their attention
to the links between his play and their narrative. As we talked about the family
Mario sellotaped his father’s hand to the sofa, then threw a baby rattle across the
room, saying disparagingly, ‘That is for babies.’ He sellotaped across the vacant
armchair, then smashed through it as if through a finishing line. My comments
about his need to smash his way right inside our conversation or his mummy and
make sure his daddy doesn’t stop him, resulted in further elaborations on the
theme.
He became preoccupied with the door of my cupboard, acknowledging his
desperate curiosity to look inside then sealing it closed with sellotape. His parents
watched in some amazement as I described his curiosity about things inside and
suggested it might be about babies. He took the small popper toy and popped the
four people out of the corresponding coloured holes. He pushed the crocodile’s
tail forcefully into one of the empty holes, removed it and sealed off the hole so
that only three popper figures could fit into their spaces. I talked about
Mario allowing nothing to go in unless he gives his permission. His parents smiled
and I linked this to their current family of three, and to his mixed feelings about
babies and other intruders. I suggested that Mario might experience others as
intrusive or hostile in direct proportion to his own intrusiveness and feelings of
hostility; in his imagination a baby would be as possessive and demanding of his
parents’ exclusive attention as he feels, so he sticks himself firmly to them, to
ensure he won’t be displaced. They felt that this gave them some framework for
thinking about Mario.

In the intervening meeting with the parents on their own, I picked up with them how
much anxiety underlay Mario’s omnipotent defiance; how their own feelings of
disorientation, vulnerability and lack of support arriving in a new country may have
made it more difficult for them to take on a firm parental role, feeling rather helpless
themselves. I suggested that this may have made it difficult for Mario to feel he had a
strong container for his own overwhelming infantile feelings which continued to erupt
at home and school. We discussed how their preoccupation with conceiving another
baby could compound Mario’s anxiety about the destructive effect of his intrusive
attacks on his mother.
I also had the impression that Mario and his parents were particularly wrapped up
together with each other, in their strong Southern Italian identity (despite mother’s
French origins), and that in some way they idealised their son’s fiery ‘Mediterranean’
temperament as they spoke of the coldness and reserve they met here. I thought that at
times Mario’s intellectual brightness, and his tough demeanour might invite them to
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share their more adult concerns with him, give rational explanations and expect an
understanding of issues which were beyond his emotional grasp. They were receptive to
some of these ideas and although we touched on issues relating to their individual
backgrounds, we acknowledged that discovering further links could wait. Helping to
strengthen them as a united parental couple, which could set firm boundaries, took
precedence, and the parent meetings, alternating with family meetings, gave us an
opportunity to address these issues. Lieberman’s (2004) suggestion that the priorities for
addressing aspects of parental functioning when working with parents of ‘older’ under
fives may differ from those with infants, resonates with my view in this case. Lieberman
(2004: 99) points out that although ‘like infant – parent psychotherapy, child-parent
psychotherapy targets the web of mutually constructed meanings between the child and
the parent . . . it differs from infant – parent Psychotherapy in emphasising the growing
child’s autonomous agency during the treatment, with a concomitantly lesser emphasis
on uncovering the parents’ childhood conflicts or helping them reflect on their
individual experience’.

They returned for a family meeting after a long summer break to report that Mario
had moved from nursery to reception class but the children were still visiting the
nursery twice a week to play and see the teachers. Mario was having difficulty
relinquishing his ‘special nursery teacher’ and ‘permitting’ new nursery children to
take his place. The parents mentioned that they had also moved house. As they
talked Mario was waving around a piece of sellotape with four poppers attached
to it, like a small kite. It looked as if the poppers were hanging precariously in
mid-air. I said Mario seemed to be showing that he was in an in-between place,
in-between homes and classes, not quite settled anywhere. Father laughed
incredulously, saying that, in fact, this was accurate, they were in transition, they
hadn’t yet cleaned the house for moving in, it was happening that day.
Mario had sealed a ball in a transparent plastic cylindrical container which he
spun around wildly and I talked about how all these changes could make his head
spin. I talked about the ball, trapped in there, not allowed out until Mario says so.
He laughed with glee and slowly began to unstick the tape, saying, ‘There’s wind
coming’ – then he released the ball with great gusto. I wondered to myself whether
his fantasy was of trapping a baby inside the womb, but didn’t say anything, being
aware of the parents’ painful difficulty conceiving. Mother asked him if he had told
me his news, and he said, ‘I’m having a baby!’ I congratulated them, commenting
on his particular phrasing, wondering to myself whether addressing issues relating
to limit setting and confronting Mario’s omnipotence may have facilitated the
parents conceiving another baby.
Mario was writing a card for his nursery teacher. He had written her name and
wanted to add the word ‘from’. He said he didn’t know how to do an ‘r’ – his
mother suggested a ‘p’ with a tail. He did a perfect ‘R’ but when mum suggested he
write it next to the ‘F, pairing them up to make the word, he did a silly lollipop
shape, saying he couldn’t do it. I suggested that he feels unsure whether he likes to
be a big boy who knows about writing, and has to give up the little baby space; and
that he’s not sure about joining letters up, creating pairs, it seems to lead to babies.
74 L. EMANUEL

Mario had gone sulkily to the cupboard behind dad’s back and was fiddling
with the key and trying to look inside. I said how hard it was not to be able to see
what’s going on inside places he doesn’t belong, and he became increasingly
grumpy.

I think Mario’s mixed feelings about the baby were heightened by the fact that his
parents told him about the pregnancy very early on, so that when subsequently there
were worries about the pregnancy being at risk, his anxiety about his own unconscious
attacks must have been high.

A striking change occurred during the following session two weeks later, which
indicated that the formulations discussed during the parents’ meetings and the
elaborations of Mario’s play may have effected a shift within the family. In this
session, mother who was feeling ill from her pregnancy, came on her own, saying
that father had been away and although things were better at school, Mario was
‘driving her crazy’ at home with his anger and defiance. Mario talked about a
‘volcano’ experiment they had done using household materials, describing the
frothing detergent ‘lava’ with passion and enabling me to talk about his
overwhelming feelings that erupt in a similar way.
He tried to cut up a long piece of string and mother stopped him. Then he
settled down to covering up a toy car in layers of plasticine, so it was completely
shut in and immobilised. He glided the covered car under the table, saying it was a
‘submarine’ and making a hole in the plasticine for a ‘headlamp’. I described how it
has gone deep under there, looking around at what it can see.
As he began drawing a ‘card for the baby’, his mother described her worry that
Mario can be really spiteful; he pushes and hurts other children. She recounted
how Mario and his friend Peter had been riding their trikes in the park, racing to
the gate, when Mario had deliberately crashed his trike forcefully into Peter. The
trike had overturned and Peter had fallen heavily, banged his head on the cement
path and been badly hurt. As we were speaking Mario was gouging the plasticine
off the car, and said, ‘It was an accident.’ ‘No,’ repeated his mother, ‘I don’t think
so.’ At that moment Mario tore the last bit of plasticine from the car, moved over
to the corner of the room, sat face down and murmured, ‘I didn’t want Peter to
win.’ I felt touched, and said Mario seemed to feel it was too hard to be the small
one and to come last, so Peter had to have the hurt, upset little boy, feelings. He
said ‘Yes’ miserably. Mum said, ‘It is the first time he has said that, he has always
insisted it was an accident.’
I commented on the car, now stripped of its outer thick layer, and I said perhaps
when he comes here to the clinic he has a sense that this is a place to show some of
these feelings; the outer layer can be opened up to show what feelings are inside.
Mario sat quietly and listened as I said that sometimes he needs to feel big, wear a
big thick layer like the plasticine, but it’s different when mum and I are here to
understand and we’re firm but not in a shouting mood. When it was time to leave,
he insisted on tying the string from the large armchair to the child’s chair (in
contrast to the impulse to cut up the string earlier). I said he needed to be sure he
 A SLOW UNFOLDING 75

would stay joined up with me until we met next time. We arranged a time when
father could join us.

I felt that mother, by not colluding with his view that this was ‘an accident’, had created a
firm, but understanding, parental couple with me, which provided Mario with the
containment to verbalise his difficulty. Mother’s ability to stand up to him, despite her
exhaustion (managing to embody both maternal and paternal functions), seemed to
relieve his anxiety; at least the adults did not allow the wool to be pulled over their
eyes like the plasticine over the windscreen and wheels of the car. He left clearly feeling
the little boy (chair) was connected to a containing adult (armchair), tied together with
string.
The situation had improved considerably within five sessions. However, bearing in
mind the impending birth of the new baby, I offered further input and the family has so far
been seen for nine sessions. The situation may continue to improve with further alternating
family and parent work. Alternatively, Mario could be considered a possible candidate for
individual child psychotherapy treatment, as he seems to have a desperate need to have his
communications understood and verbalised for him, and is very responsive. His parents
would then be offered regular support. I think this material illustrates Watillon’s
suggestion that ‘the primary function of the therapist is to make a space available to the
family to encourage this dramatic performance, through his listening . . . subsequently by
virtue of his observation and understanding of the processes taking place, he makes it
possible to assign meaning to the drama unfolding before him’ (Watillon, 1993: 1041).
My role as interpreter and therapeutic observer in the drama is clear.

Internal parental drama – therapist’s consultation/supervisory role

The second category of intervention involves a more muted kind of drama, and requires
a different role from the therapist. It involves work with a parental couple who have
brought a serious problem, for example a biting or phobic child, but where the ‘port of
entry’ (Stern, 1995) appears to be work with parents, who are sensitive and available to
thinking about the impact of their child’s communications on them via the mechanism
of projective identification. Such parents are motivated to continue thinking about the
meaning of their child’s behaviour without necessarily bringing the children to
meetings. In some circumstances, they may be reluctant to bring their child to the
clinic, and this requires careful exploration. I would describe my role which is to elicit
and process the parents’ observations and descriptions, thereby illuminating the child’s
internal world for them in the light of their own internal and external experience, as that
of ‘therapeutic consultant/supervisor’.
I found Margaret Rustin’s (1998) paper ‘Observation, understanding and
interpretation: the story of a supervision’, wherein she describes her weekly fax
supervision of a trainee child psychotherapist’s intensive case with a 4-year-old child,
very relevant to thinking about this type of work. Rustin suggests three ways in which
supervisory process can be valuable: first, the therapist needs to be ‘helped to accept
being hated as well as loved’ (p. 437). This applies to parents facing difficulties setting
limits or coping with tantrums, as only when they feel supported by the therapist or
76 L. EMANUEL

helped to support each other, are they able to withstand the barrage of anger and hatred
a small child can level at them.
Second, Rustin notes the ‘therapist’s vulnerability to being encapsulated by the
primitive relational processes of projective identification and thus losing a firm grip on
her own thinking capacities’ (p. 438). Parents of small children often complain of
feeling immobilised, expressing bewilderment at having lost a firm grip of their own
parental capacities. They may display a puzzling paralysis in the consulting room when
faced with a small child’s defiant behaviour, and can be greatly relieved (like the trainee
psychotherapist) by being helped to understand the powerful unconscious processes of
which they are recipients. In fact, Rustin makes the link to parent – infant work herself:

The restorative conversation between parents about a sleepless or anxious baby, in

which meaning can emerge, is I think quite close to the experience of the
supervision of a child patient as the analysis is being established . . . The exhausted
mother/therapist pours out a blow-by-blow account of her breathless day. Intricate
details are noted, but what to make of them? (p. 439)

Rustin’s role was to take the meticulously gathered data (parents often bring superb
observational detail of their children), and to provide the therapist with a gradual
experience of theory in action – the building of a meaningful pattern of understanding.
Parents come to the clinic caught up in the midst of their drama, just as the therapist
had been in relation to her intensive case. One could see this as an Internal drama
involving the parental couple as protagonists as they work out together with me an
understanding of their child’s difficulties (the child’s internal drama). Two sets of
parents suggested that they might come back to me for ‘supervision’ (their words) of
their parenting work, to help them maintain a therapeutic approach to their parenting,
‘recreating room for parents to observe the impact of their children’s powerful
projections’ (Rustin, 1998).

Case illustration: internal parental drama

In the following vignette, one of a number of cases of biting referred to the Under Fives
Service, most of the work of understanding and transformation took place, initially,
through meetings with parents, where I took on the role of ‘therapeutic consultant’.
This was the first stage of a process that eventually led to an assessment for individual
treatment for the child.

Douglas, aged 2, was referred because of the severe nature of the bites he inflicted
on his parents and older sisters Molly (aged 5) and Susan (8). The atmosphere in
the first meeting with the parents was intense (as my notes describe), ‘charged with
passion, feelings of loss, love and hatred at a high voltage’. Mother was petite with
striking auburn hair, father tall and blond with a sensitive face, and they seemed to
have a warm supportive relationship. I heard about how Douglas ‘bites those he
loves’ so hard he draws blood. He pulled their hair, scratched and bit hard. Mother
made a digging movement with her nails like claws in demonstration and grimaced
 A SLOW UNFOLDING 77

as if warding off an intrusive attack. I said it sounded as if Douglas might be

‘holding on’ with his teeth to keep a tight grip on them and mother agreed saying
that she wonders whether biting is Douglas’s way of expressing his feelings. These
seemed to be linked to Douglas having to share his mother’s attention with father
or sisters, or his key worker at nursery with other children.
I said it sounded as if Douglas did not have the mental apparatus to deal with his
feelings – perhaps of exclusion or abandonment – which quickly overwhelmed him,
so he powerfully injected them into his parents with his sharp bites. Their
instinctive response to the pain and shock was to ‘drop’ him, forcefully push him
away, which served to confirm his fears of rejection. Mother described feeling
distraught when a sudden bite on her ankle shocked her with pain. She seemed to
feel punctured, not only her skin but her sense of competence deflated. Their
descriptions gave me a powerful sense of what it might be like to always have to
remain vigilant around Douglas, since his bites came without apparent warning,
when a back was turned – perhaps to talk to someone else – or an arm exposed.
I said Douglas seemed to be making sure his parents always kept him at arm’s
length – at some distance, and that they could never allow themselves to relax into
an intimate cuddle with him, and yet without warning he got right inside them with
his piercing teeth. I wondered to myself whether Douglas was unconsciously
communicating an early infantile experience of being kept at arm’s length, perhaps
by a mother who was depressed or preoccupied in his infancy. I heard that Douglas
had been an anxious baby, he had never allowed mother out of his sight, and his cry,
if left for a moment, was one of utter abandonment and terror.
I wondered aloud why Douglas seemed to be so ‘thin-skinned’ and anxious and
mother said she was surprised by this, as she had stayed at home with Douglas
much longer than she had with the two girls. She mentioned as an aside that she
had had two late miscarriages prior to conceiving Douglas. I explored the impact of
the miscarriages on mother and heard that she had been so anxious about the
subsequent pregnancy (with Douglas) that she hadn’t allowed herself to even
acknowledge it until very late in the pregnancy. I suggested there was a parallel
between the way in which mother had dealt with a fear of unbearable loss by
distancing herself from this pregnancy, and the way in which Douglas seemed to
keep others at a distance. Does Douglas, too, avoid intimacy, as if closeness
followed by separation would feel like a catastrophic loss?
Mother seemed to be brimming with emotion, father too, as they recognised
this link and we were able to talk about the impact of the miscarriages on the
whole family. Douglas’ weaning had been abrupt around the time his teeth came
out, when mother had been suddenly taken ill and hospitalised, but he had already
begun to bite the breast. I wondered whether that dreadful cry of his infancy,
which mother had described, conveyed a deep terror of abandonment, which was
re-evoked around the time of weaning. I said it sounded as if Douglas gave them an
experience of an unpredictable shock each time he bit and wondered whether he
was conveying how he might have experienced sudden shocks and disappearances.
Mother was moved and began to describe her preoccupation and depression during
Douglas’s infancy. I suggested that a baby’s temperament also plays its part, and
78 L. EMANUEL

described my impression from what they had told me, of a child who still required his
parents’ concrete presence, who had not managed to keep alive in his mind a picture
of parents who will return to him after a separation. In addition, the more he bit the
more anxious he became about having damaged them and the harder it was to let
them out of his sight. I suggested to them that what appeared to be aggression could be
defensive if he was feeling persecuted by constant threats of retaliation.

This had been a full and unusual first meeting. I found myself stirred up by the intensity
of feelings expressed, as well as by the quality of exclusive intimacy the parents conveyed
as a couple. Since I thought the parents might value a further opportunity to explore
some of the emotionally charged issues that had been raised. I suggested that they return
for a second meeting without the children.

On their return, they commented on the helpfulness of the meeting saying it had
enabled them to think about Douglas’s experience. They mentioned that Douglas
bites his fingernails off and Father said, ‘There’s nothing we can do to stop him.’ I
wondered whether this could really be true. It became clear that both parents felt
so identified with Douglas, who projected a feeling that any boundary is cruel, that
it made limit-setting difficult for them. I commented that Douglas had always had
an experience of biting at soft things which gave way or punctured, his nails, their
skin, and that perhaps he needed to feel what it was like to bite against a less pliable
object. They took on board the need for a firm, non-collapsible couple who can
resist these attacks and keep the family safe. I spoke about Douglas’s need to attack
and deflate (puncture) the very parental capacities he most needs.
I found myself speaking about the setting within which development can take
place, involving clear boundaries which need to come first (as in a therapy setting).
Mother said she didn’t want to push Douglas away if closeness was what he
needed. I suggested that the fear of a barrage of hatred from a child – for example,
when they have a tantrum or threaten to bite – can intimidate parents and lead
them always to give in. They would need to support each other to cope with the
hatred emanating from Douglas, and this in turn would convey to Douglas that his
parents are separate from him and in charge. In the same way as Rustin (1998)
describes the trainee child psychotherapist needing to be ‘helped to accept being
hated as well as loved’, this is an essential experience for parents, and the reasons
for difficulty some parents experience in this area may be complex.

I thought it was important to have a family meeting, as I had heard much about the
rivalry between the children and had some concerns about the girls who were being
regularly badly bitten by their brother. Despite the parents’ initial reservations about
bringing the children to the clinic, they agreed to the meetings, feeling, perhaps, that
their own anxieties had been contained to some extent.
I met with the whole family on two occasions. The most striking aspect of the
meetings was all the children’s relentless demands for attention from the adults, each
one demanding an exclusive pairing with one parent. Having to wait felt intolerable to
them. I was struck by the way in which physical touching, a need to be concretely
 A SLOW UNFOLDING 79

connected to each other, was evident. Following on from, and alternating with the two
family meetings, I continued to work with the parents on their own. I had a sense that
more was to be gained from exploring with them some aspects of their own internal and
external experience as a couple but also as individuals, and how this linked to the
difficulties they recounted with Douglas (and, to some extent, with the girls).

On the fourth parent meeting, they reported that Douglas’s biting had reduced
considerably although he was pinching a little. Father spoke about Douglas’s
different bites, how they are sometimes passionate, as when Douglas hugs him
intensely and opens his mouth as if to devour him: ‘You never know whether he’s
going to kiss you or bite you.’ Drawing on this discussion, and my own response to
the couple’s evident closeness, I wondered aloud whether the children might feel
painfully aware of being excluded from the marital relationship, and suggested that
perhaps waiting is difficult for them because they fear their parents are so wrapped
up with each other they may forget all about the children! They smiled in
acknowledgement, and father went on to describe how Douglas pushes him away in
the morning when father goes in to his room to get him up, demanding mummy. I
wondered whether Douglas was giving father an experience of what it feels like to be
the least favourite, the one who has been excluded from the parental bedroom all
night long. Father asked me directly whether he should give in and call mother. I
talked about the possibility of a process that gave Douglas the opportunity to
manage his feelings of disappointment and frustration. I suggested that perhaps
father could acknowledge Douglas’s feelings, leave and then return after a short
while, thereby giving a clear message that he has not capitulated to Douglas’s
demands and indicating that despite this, father has remained loving and available
to him. I said Douglas may need to see that his father has not been destroyed by the
power of his rejection.
At this point, we were considering whether the parents had enough
understanding to take things further on their own. After a fairly brief but intense
intervention, where I had taken the role primarily of ‘therapeutic consultant’, some
improvements in the referred symptom had been made. However, mother
expressed concern about a recent incident at nursery, which led her to believe that
Douglas was not coping, despite appearances. When his key worker had been
unexpectedly absent, Douglas had screamed in such terror of abandonment that
his mother had had to take him home. The parents agreed with my suggestion that
this seemed to be an early terror of falling apart, as if he had nothing, internally, to
hold him together.

I think this could be one way of understanding the biting; the holes he makes in other
people’s skin being a vivid communication of his own feeling of having a punctured,
faulty skin container (Bick, 1968). The lack of a symbolic capacity to hold in mind an
absent object, the key worker, or his mother, seemed to be a serious area of concern and
at this point I suggested that we needed to consider an assessment for Douglas to
determine whether he would benefit from long-term individual child psychotherapy
treatment.
80 L. EMANUEL

Discussion
My decision to focus on meetings with the parent couple was based partly on the slight
reluctance they had to bring the children initially, but also my sense that they could
make use of the opportunity to explore areas that they would not necessarily elaborate
on in the presence of their children. Mother’s miscarriages, the parents’ anxiety about
mother’s pregnancy with Douglas, all became possible to think about, in relation to his
immediate symptom of biting. The cumulative effect was an increased understanding of
their functioning as a parental couple. This work may continue to be an elaboration of
an internal drama alongside the individual psychotherapy with the child.
As work with the parents progresses, a further exploration of the parents’ own
childhood experience may be possible. This may clarify whether, and how, a trans-
generational transmission of emotional disturbance may be influencing the couple’s
parenting capacities, particularly relating to separation anxieties. Kate Barrows (cited in
Barrows, 2003: 296), commenting on the experience of traumatic loss in parents,
suggests ‘that when the parent has not been able to come to terms adequately with his or
her bereavements, the child may experience the parent as pre-occupied by a dead
internal object’. She goes on to describe how ‘inadequate mourning could lead to ‘an
identification of the ego with the abandoned object’ (ibid.). Douglas created a symptom,
the biting, which forced his parents to hold him away from their bodies to avoid attack
or to push him away once bitten. This may have been Douglas’s unconscious way of
communicating how he felt kept at a distance from mother during his pregnancy and
then his infancy because mother’s mind was already ‘pre-occupied’ by her previous dead
babies and possible earlier losses in her life. Douglas’s collapse when the object to which
he has been clinging suddenly disappears, has all the force of an infant feeling
abandoned to die. This level of distress may warrant ongoing individual work with
Douglas as well as continuing work with his parents.

External parental drama – therapist’s role as modulator

The third form of intervention focuses on the extreme splitting and polarisation that
sometimes emerges between parents. Here the child does not take centre stage, but
rather has the function of highlighting the main plot, which is to do with the parental
relationship as evidenced in the room. Often the parental couple has become polarised
in its functioning and styles of discipline and the role of the therapist is to help modulate
polarised parental attitudes. In these cases one parent embodies a parody of ‘paternal’
functioning, harsh, inflexible, punitive, and another parent is overindulgent, unable to
set boundaries. Parents of both genders can embody either function. This may be linked
to the ways in which each parent has (unconsciously or consciously) chosen to respond
to their own parental background, if there has been a history of abuse, either identifying
with a harsh punitive paternal figure or reacting against it, resulting in difficulty setting
firm limits. Serious couple/marital difficulties often underlie the parenting problems and
can prove intractable.
A variant of this is where one parent becomes impermeable to the child’s projections,
refusing to ‘receive’ the child’s disturbing communications, putting up a ‘brick wall’
 A SLOW UNFOLDING 81

barrier while conversely the other parent is too permeable and absorbent, becoming
overwhelmed by the child’s powerful projections. Neither state is of much use to the
child. The more the child feels that his projections of distress or rage are refused by one
parent and appear to flatten and overwhelm the other, the more his tantrums will
increase in ferocity until he feels his communications have been received without
completely destroying the container. Work with a parental couple to help them bring
together these extreme polarisations and integrate the paternal and maternal functions,
supporting each other in understanding the meaning of the child’s communications,
and thereby providing containment for him, can be successful in reducing children’s
behaviour difficulties (Emanuel, 2002b).
My role in this drama is as modulator attempting to help parents to begin to function
as a containing parental couple, and to integrate the extreme positions which they have
taken up or into which they may have been pushed by their child’s splitting and
projection. I do not agree with Lieberman (2004), who implies that it would only be
‘clinically indicated’ for both parents to attend if ‘both parents are experiencing
difficulties in their relationship with the child’. I think that if one parent claims to be
having difficulty with a child, there is a lot to understand about the parental functioning
of the couple and increasingly I try to work with both parents in the room.
I will give a brief vignette of the kind of drama where the extreme splits between the
parents are brought in dramatic relief, for work within family and parent sessions.

Case illustration: external parental drama

Two-year-old Gareth was referred for severe tantrums, head-banging and concerns
because of speech delay. I was alerted to the extreme split between these parents in
the waiting room, as they were seated so far apart I could not identify them as a
couple. Gareth ran out and set off on his own in the opposite direction. Father
grabbed him forcibly and brought him to the room. In the room, Gareth sat next
to father on the couch, but mother showed him to the little chair at the table. I felt
as if the parents were pulling in opposite directions from the start. Gareth was
unsettled and restless, and did not once ask for help to lift toys or take lids off pens.
He struck me as prematurely self-sufficient, avoiding interaction with any of us.
Mother spoke loudly and constantly, father sat surly and quiet, just repeating
‘head-banging’ when I asked about his concerns.
It became apparent that their styles of discipline were extremely different. Father
appeared to be much stricter, and his voice exuded a quiet controlled threat of
violence: ‘I just raise my finger and he listens.’ Mother seemed much ‘softer’ on
Gareth, allowing him to rummage in her bag and tip its entire contents onto the
floor of my room. She told me she doesn’t believe in routine – ‘(Gareth) will have
routines for the rest of his life, so he has no fixed bed time and falls asleep on the
sofa’. Gareth demonstrated a tantrum when I stopped him using my computer,
banging his head violently against mother’s legs and on the floor, becoming very
distressed. To comfort him mother produced a half empty tube of ‘cream’, which
he held and squeezed like a soft comforting breast. Mother told me he takes it to
82 L. EMANUEL

bed and wakes up grasping for it, loves soft fabrics and comforters and takes them
everywhere, and makes baby sounds in public and hardly speaks. Father was
concerned about Gareth wearing mother’s shoes and handbags around the house. I
said it was unlikely to be a gender identity issue but rather Gareth’s way of
‘becoming’ mummy, having total access to her. In the split between the self-
sufficient boy and the tiny baby, Gareth paralleled the split between the parents.
As well as attending nursery, Gareth was cared for by both sets of grandparents,
mother and father, all in shifts, each one imposing their own very different sets of
expectations on him. I suspected that he was being driven ‘crazy’ with worry about
how he had to behave at any one time, the stress of adapting from one kind of care
to another being too great for him to cope with. He was becoming hyper-vigilant,
and ‘disorganised’ in his behaviour, unable to predict from hour to hour what
behaviour was expected of him. I thought his frustration and anxiety might be
calmed by his parents getting together to think about how they could unite in their
approach to his care. In subsequent meetings, mother and father found it
difficult to accept the ways in which each other disciplined Gareth. This was clearly
linked to their own troubled histories of abuse and abandonment – each had
chosen a different response, mother with determination not to do the same, and a
sense that any separation or boundary would be harmful (her own history had been
of sudden loss) and father by identifying with the rather menacing figures in his
early life.
The parents’ own internal difficulties manifested themselves in this external
drama, the dysfunctional polarised parenting – the extreme lack of boundaries in
mother, which allowed Gareth to ‘merge’ totally with her, where language would
be perceived to be unnecessary, and the over-punitive father – which was
impacting negatively on Gareth’s life. Over time things shifted slightly, with father
becoming a little more receptive towards Gareth and mother becoming a little
more boundaried with him. Gareth’s head banging diminished although it was
clear that his problems and the family’s were complex and more help would be
required.

In his paper, Paul Barrows (2003), having discussed the ‘ghosts’ that haunt the nursery
(Fraiberg, 1975), argues that work with the parent/couple on the ‘intimacy of the
marital relationship’ is an important and valid part of work with families with children
under 5, ‘given the importance of the nature of the couple’s relationship for the infant’s
psychological development’ (p. 297). He argues that, having established the existence of
‘unprocessed trauma in the parent’s background’, work with the parental couple needs
to take place in the ‘here and now’, because ‘what matters from the infant’s point of
view is not so much whose ghost it is, father’s or mother’s, but the nature of the
interaction that then ensues between the parents’ (p. 297). If longer term work were to
be undertaken with this family, assuming their availability and willingness, work on
aspects of the couple relationship would be an important part of the work of the Under
Fives Service clinician.
The paternal and maternal functions can manifest themselves equally in parents
of both genders. In a case similar to the one above, mother was dominating and
 A SLOW UNFOLDING 83

forceful, berating her husband during family sessions for his weakness and indulgence
of the children, while he mildly protested that her regimes were too strict for a 4-year-
old child. In this case, the parents were able to make some dramatic changes in
their couple/parenting relationship; they were motivated by concerns not only about
their 4-year-old son, but also about their 18-month-old baby who showed signs of
speech delay.

Conclusion
In this paper, I have described the range of approaches and techniques that may be
employed in an Under Fives Service. Work with parents forms a central part of the
Service and this can take many different forms. I have expanded on Watillon’s
description of this work involving a ‘dramatisation’ of conflicts, and have noted three
different clusters of cases, each cluster inviting a particular kind of intervention either
with families and/or with the parental couple. I have suggested that each type of
intervention also draws on different aspects of the discipline of Infant Observation,
which forms the core of much of our clinical work. Invariably most of the interventions
will involve a combination of roles and approaches, but the fundamental framework of
observational skills, psychoanalytic understanding and knowledge of child development
remains constant.
Child and Family Department
Tavistock Clinic
120 Belsize Lane
London NW3 5BA
UK

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