Metaphorical Cards in Psychotherapy: Why Images Can Help Us Say What Words Cannot
Sometimes psychotherapy reaches a very sophisticated clinical impasse known as:
“I don’t know.”
What do you feel??????
“I don’t know.”
What happens inside when you think about it?
“No idea.”
What is this relationship like for you?
Long silence. Mild existential collapse.
This does not necessarily mean that the person is resistant, emotionally unavailable, secretly plotting against therapy, or in urgent need of seventeen interpretations about their mother.
Sometimes experience exists before language catches up with it.
And this is exactly where an image can become interesting.
Not because the picture magically reveals a hidden truth.
Not because the therapist has been issued special infrared glasses for detecting the unconscious.
But because an image can offer another route into meaning.
A picture does not tell us what is inside a person
This distinction matters.
Metaphorical or associative cards are sometimes described as projective tools. Historically, projective techniques included instruments such as the Rorschach and the Thematic Apperception Test.
The scientific record of classical projective testing, however, is mixed and often controversial. Reviews have found that while some specific indices may have empirical support, many broader interpretive claims do not. In other words, looking at an ambiguous picture does not give a therapist scientific permission to announce:
“Interesting. You chose the abandoned lighthouse. Clearly your father was emotionally unavailable.”
No.
Please return the lighthouse to the table.
The useful question is usually not:
“What does this image objectively reveal about you?”
It is:
“What happens in you when you look at this image?”
That is an entirely different therapeutic position.
Metaphor is already everywhere in psychotherapy
Psychotherapy has always been full of metaphors.
People say:
“I’m drowning.”
“I’ve hit a wall.”
“I’m carrying everyone.”
“There is a knot in my chest.”
“I feel trapped.”
“My life is going nowhere.”
These are not decorative literary flourishes. They are ways of organizing experience.
A research review published in Psychotherapy in 2023 concluded that metaphor is common in therapeutic work and that collaboratively developing metaphors with clients appears to be associated with useful in-session processes, particularly cognitive engagement. At the same time, the authors emphasize that the empirical literature is still relatively limited.
That word collaboratively is important.
A metaphor becomes therapeutically interesting when therapist and client explore it together, rather than when the therapist declares its meaning from above like an unusually confident oracle.
Older psychotherapy research found something similar: clients tended to remember therapist metaphors particularly when those metaphors were developed together and revisited. Sessions containing remembered therapeutic metaphors were also rated by clients as more helpful in that small study.
So metaphor is not merely pretty language.
Sometimes it becomes a temporary architecture for thinking.
Images can give metaphor a body
Now imagine that instead of asking:
“What is your anxiety like?”
I place several images on the table.
One shows an empty railway platform at night.
Another shows a child hiding under an enormous red blanket.
Another is almost abstract: grey, violet and black bleeding slowly into one another.
Another shows a ridiculous little bear standing in a dark corridor while something enormous casts a shadow behind him.
Nothing about those images has one correct psychological meaning.
For one person, the railway platform may mean abandonment.
For another, freedom.
For someone else:
“Oh God, finally. Nobody is talking to me.”
Same platform.
Very different nervous systems.
That is precisely the point.
What does research on metaphorical cards actually show?
Research specifically on illustrated metaphorical or associative cards is much smaller than the literature on psychotherapy as a whole, so extravagant claims would be inappropriate.
But there are interesting findings.
A qualitative study by Karnieli-Miller, Nissim and Goldberg used illustrated metaphor cards while interviewing people with severe mental illness and staff working in rehabilitation settings.
In most cases, the cards appeared to help participants express themselves and produce richer, more detailed personal narratives. The researchers described the cards as an additional channel through which participants could communicate experiences, emotions and their own unique voice.
Notice what this does not mean.
It does not mean:
“Cards scientifically expose hidden personality structures.”
It means something much more modest and, clinically, much more interesting:
sometimes an image helps a person tell a story that was difficult to tell before.
And images can genuinely evoke emotion
There is also evidence that associative therapeutic images are not emotionally neutral objects.
Research on COPE associative cards has examined whether different images evoke distinguishable affective responses. Experimental work has found that exposure to different categories of such cards can be associated with changes in emotional arousal, including physiological measures related to autonomic nervous system activity.
This should not be overinterpreted.
A racing heart does not mean a picture has uncovered a repressed childhood trauma involving a staircase.
But it does remind us of something very basic:
looking is an embodied act.
Images can attract attention, disturb us, soothe us, confuse us, disgust us, delight us or produce that peculiar psychological response known technically as:
“Why the hell do I keep looking at this one?”
And that can be clinically useful material.
Mental imagery already has an important place in psychotherapy
There is another reason not to dismiss visual work as merely decorative.
Mental imagery is already used in several established therapeutic approaches.
One example is imagery rescripting, in which distressing memories or mental images are deliberately revisited and transformed within a structured therapeutic process.
A 2023 systematic review and meta-analysis examining imagery rescripting across several disorders found promising effects, although results varied depending on the comparison condition and the number of studies remains limited.
A more recent randomized trial published in 2026 also found imagery rescripting to be a promising adjunct within CBT for depression, while appropriately cautioning that larger studies are still needed.
None of this proves that metaphorical cards themselves are a treatment.
It tells us something broader:
human beings do not process psychological experience through words alone.
Imagery matters.
Why might a picture help when a question does not?
There are several plausible clinical reasons.
An image can create a little distance.
Instead of:
“Tell me exactly what is wrong with you.”
—which, frankly, is not always an invitation to spontaneous poetry—
a therapist can ask:
“Which image feels closest to what this week has been like?”
Now the person is not forced immediately into explanation.
They can begin with perception.
“This one.”
What caught your attention?
“The door.”
What about it?
“It is open, but I don’t want to go through it.”
And suddenly we are somewhere.
Not because the card knew.
Because the person began to speak.
Images are especially interesting when experience is difficult to organize
Some experiences arrive in beautifully edited paragraphs.
Many do not.
Traumatic experience, bodily states, diffuse anxiety, contradictory feelings, relational patterns and early memories may be experienced as fragments, sensations, scenes or emotional atmospheres rather than tidy propositions.
Research on metaphor in areas such as psychosis has similarly emphasized its potential role in helping people articulate subjective experiences that can otherwise be difficult to communicate.
A picture can therefore become a kind of temporary external surface.
Something can be placed there, between therapist and client.
We can both look at it.
We do not have to immediately decide what it means.
That shared third object can sometimes make difficult material more tolerable to approach.
But the therapist can also ruin everything beautifully
There is, of course, a trap.
Images are seductive.
Humans are pattern-making animals, and therapists are humans with additional vocabulary.
Give us an ambiguous picture and five minutes, and somebody will eventually say:
“Notice that you placed the wolf on the left side. Perhaps this represents the paternal line.”
Please do not arrest the wolf.
Good work with metaphorical images requires restraint.
The client's association matters more than the therapist's cleverness.
If someone looks at an image of a storm and says,
“This feels peaceful,”
then peaceful is the interesting part.
Not:
“But storms are usually anxiety.”
No international committee assigns psychological meanings to clouds.
So what are metaphorical cards actually good for?
Their strength is not diagnosis.
Their strength is conversation.
They may help a person:
notice something,
choose something,
reject something,
tell a story,
find a metaphor,
locate an emotion,
recognize a contradiction,
or suddenly say:
“I don’t know why, but this picture makes me angry.”
Excellent.
Now we have something alive in the room.
The image is not the answer
Perhaps the most useful way to think about metaphorical cards is this:
the card does not contain the meaning.
The meaning happens in the encounter between the person and the image.
Another person might choose the same card and construct an entirely different story.
The same person might choose it again six months later and see something they could not see before.
That is not a flaw.
That is the interesting part.
A metaphor is not a laboratory result.
It is a provisional way of seeing.
Sometimes we need words.
Sometimes we need silence.
And sometimes, apparently, we need a tiny cardboard bear standing terrified in a badly lit corridor.
Psychotherapy is a serious business.
Fortunately, the psyche has never shown much respect for seriousness.
References and further reading
McMullen, L. M., & Tay, D. (2023). Research review of psychotherapists’ use of metaphors. Psychotherapy, 60(3), 255–265.
Karnieli-Miller, O., Nissim, G., & Goldberg, M. (2017). “It’s in the Cards”: The Contribution of Illustrated Metaphor Cards to Exploring Values Within Narratives. Qualitative Health Research, 27(1), 138–151.
Martin, J., Cummings, A. L., & Hallberg, E. T. (1992). Therapists' intentional use of metaphor: memorability, clinical impact, and possible epistemic/motivational functions. Journal of Consulting and Clinical Psychology, 60(1), 143–145.
Kip, A., Schoppe, L., Arntz, A., & Morina, N. (2023). Efficacy of imagery rescripting in treating mental disorders associated with aversive memories: An updated meta-analysis. Journal of Anxiety Disorders.