Ten people with PTSD on the metaphors they hid behind and the ones they built with a therapist

"And they'll just run with it." That is how one participant, listed in the paper as 29M, described what follows when he answers a therapist with a metaphor that does not match what he feels.

Jeremy Cooper of Regent University in Texas and Ingo Tophoven of Gordon-Conwell Theological Seminary in North Carolina, both licensed psychotherapists, interviewed ten adults with PTSD, the diagnosis taken from self-report. Five men and five women aged 29 to 53, referred by clinicians from their caseloads, talked for 40–55 minutes each between October 2022 and January 2023. The questions were about how metaphor felt in therapy; nobody was asked for the metaphors themselves or whether treatment helped.

The authors call the first theme power, and chose the word on purpose. Masking and misleading come from people whose agency trauma took away, and the authors ask clinicians not to read it as resistance.

Mutuality, the second theme, is the turn. Participants invested in a metaphor when they saw the therapist working to find one that fitted, what they called "more than a story". They then changed its elements, and a shared language formed. One participant's therapist returns to "the ditches", their shared metaphor: "it feels like, Oh, I've been exposed. But then it-he provides a safety in that exposure."

The third theme is experiential change: more vivid emotion, hope, a firmer sense of control. Participant 35MA described the indirect route. Talking about "the candles on the cake", he knows he is working through something "without actually talking about it"; the same material, taken head-on, burns him out. With metaphor, "the pain isn't so sharp. The sadness isn't so deep. Until it needs to be."

Banks and ditches

The authors call one point in their discussion the most significant. Participants were wary of prescribed metaphors meant to help them engage their emotions, and several spoke of misleading therapists who used them. What mattered was a metaphor that started from the themes of their own sessions and that the therapist kept coming back to.

This is my comment, not the paper's. Prolonged exposure and ACT arrive with ready-made images: the Center for Deployment Psychology keeps a PE Metaphor Bank, and ACT has books of them. The study names no protocol and says nothing about banks. A bank metaphor, though, enters from the therapist's side of the room, the side these participants had learned to manage. A patient who nods at the passengers on the bus may be running with it exactly as 29M described.

A bank metaphor can still be a first draft. Offer it, then ask the patient to change something in it – who else is on the bus, where the ditch runs – and use their version from then on. When an image is accepted at once and never altered, ask what it leaves out. When a patient brings an image of their own, write it down and bring it back next session.