The Picture Book as a Clinical Device: A Bridge Between the Adult Mind and Pre-Verbal Experience

Article written in collaboration with  @dott.ssaantonellatroccoli

Abstract

This article explores the clinical potential of the picture book as a psychotherapeutic mediator in work with adult populations. Drawing on Winnicott's (1971) theoretical contributions on transitional space, Bion's (1962) concept of the alpha function, and Stern's (1985) work on implicit memory, an integrated reading of the illustrated page is proposed as a device capable of bypassing the adult's rational defences and reactivating pre-verbal affective traces. Panksepp's (1998) neuroscientific construct of primary emotional systems and van der Kolk's (2014) elaborations on somatic trauma provide further grounding for the clinical observations presented.

Introduction

Clinical psychology with adults confronts a structural paradox on a daily basis: the patient who seeks help is often also the patient who, through sophisticated defence mechanisms, obstructs access to their own inner life. Intellectualisation, rationalisation, and isolation of affect — secondary defences that Kernberg (1975) systematically described in the organisation of the adult personality — ensure adaptive functioning in the world, but at the cost of a progressive distance from deeper emotional life.

Against this backdrop, the present article proposes the picture book as a clinical device capable of enacting a silent subversion of this defensive system, opening pathways where verbal language alone encounters resistance.

The Adult's Rational Armour

The adult organises experience predominantly within the boundaries of rationality. This cognitive-defensive structure represents a fundamental evolutionary acquisition: it enables mentalisation, impulse regulation, and long-term planning. However, as Fonagy et al. (2002) observed, mentalising capacity — though a crucial resource — can become an obstacle when it turns into the only available mode of remaining in contact with inner experience.

The so-called mature defences, such as intellectualisation and rationalisation (Vaillant, 1993), constitute what might be termed an "armour of competence": they guarantee control and predictability, yet leave the individual efficient and simultaneously distant from their primary emotional core. In Bionian terms, they prevent the transformation of beta elements — raw fragments of sensory and affective experience — into thinkable alpha elements (Bion, 1962).

The Illustrated Page as Primordial Code

Something shifts in the adult mind when faced with a picture book. Semantic complexity diminishes. Words give way to images. Images, in turn, communicate through symbols, archetypes, and silences — what Jung (1964) described as the language of the collective unconscious, which precedes and outlasts the rational constructions of the subject.

It is precisely this apparent simplicity that constitutes the clinical power of the picture book. Lacking the conceptual density that alerts cognitive resistances, the visual text reaches layers of experience that verbal language, by its very nature, rarely touches. As Ogden (1989) argued, there exist modes of experience that precede the depressive position and that remain organised according to logics of spatial and sensory contiguity rather than narrative causality. The illustrated image naturally inhabits this territory.

Transitional Space and the Containing Function

Winnicott's (1971) concept of transitional space offers the most illuminating theoretical framework for understanding what occurs during the shared reading of a picture book. Winnicott describes an intermediate area of experience — neither purely internal nor purely external — that emerges within early caregiving relationships and persists, in adulthood, in cultural, creative, and playful experiences.

Shared reading of a picture book creates precisely this territory. It is a safe, non-threatening place in which the adult patient can dwell alongside their implicit resonances without being overwhelmed by them. Archaic emotions find here a distance sufficient to be observed, yet a proximity sufficient to be felt — what Fonagy et al. (2002) would describe as the optimal window of affective processing.

From a Bionian perspective, the function of the clinician who reads alongside the patient — or who proposes reading as an between-session task — is analogous to the primary caregiver's alpha function: receiving unprocessed contents, tolerating them, and returning them in a more thinkable form (Bion, 1962). The picture book thus becomes an auxiliary container that supports and enhances the therapist's capacity for reverie.

Implicit Memory and the Awakening of Affective Traces

One of the most significant theoretical contributions to understanding the clinical potential of the picture book comes from Stern's (1985) conceptualisation of implicit memory. Stern distinguishes between explicit memory — declarative, narrative, conscious — and implicit procedural memory, which stores schemas of subjective experience learned before language could organise them: emotional postures, relational patterns, affective imprints that Stern calls "ways of being with."

When an adult encounters an archetypal image — the child weeping in the shadows, the hand reaching toward something beyond grasp, the monster sleeping in the same room as the child — this pre-verbal deposit activates without passing through the rational filter. Ancient sensations surface, bodily recognitions, emotional resonances that precede thought. These are the "affective traces" Stern describes, finally brought to light.

At the neuroscientific level, Panksepp (1998) identified primary subcortical emotional systems — SEEKING, CARE, PLAY, FEAR, RAGE, GRIEF, LUST — that operate relatively independently from the prefrontal cortex. These evolutionarily ancient circuits respond to symbolic and archetypal stimulation in an immediate, somatic, pre-reflective manner. Van der Kolk (2014) has shown how traumatic experiences remain encoded at the somatic and implicit level, frequently resisting purely verbal processing. Non-verbal pathways — among them visual images — therefore represent privileged routes for reaching and transforming such affective encapsulations.

The Picture Book as a Transgenerational Bridge

The transgenerational dimension becomes particularly salient when picture book reading takes place within the parent-child relationship, and that relationship is itself the object of clinical work. In this context, the picture book is not only a mediator between the adult patient and their own childhood experience: it is also a space of encounter between generations, in which affective — and at times traumatic — transmissions between caregiver and child are played out.

Research within the field of attachment has shown that the manner in which a parent reads aloud reflects their own attachment organisation (Fonagy et al., 2002): the capacity to enter into the emotional world of the character, to tolerate scenes of fear or loss without deflecting, to allow an open ending to resonate — these are meaningful indicators of the caregiver's reflective functioning. The picture book thus becomes both an observational tool and a vehicle for clinical intervention within the relationship.

Clinical Implications

From the theoretical considerations outlined above, several operational implications emerge. The use of the picture book within the adult psychotherapeutic setting — whether individual or group — may take different forms: shared reading within the session, its proposal as a reflective task between sessions, or its use as an anchor point for narrative exploration.

In each case, the choice of text is not clinically neutral. Picture books that thematise fear, loss, difference, waiting, and repair — such as those by Sendak (1963), Erlbruch (1993), or Tan (2006) — activate distinct affective registers and lend themselves to specific clinical uses. The clinician who chooses to introduce this tool into their practice is called to prior reflection on their own response to the text, in a spirit of supervision and conscious use of self.

Conclusion

The picture book is not merely a tool for children. It is, in its own right, a clinical device capable of reaching what words alone cannot touch. Where the adult's defences guard the threshold of feeling, the image opens a door. In the suspended space between the visible and the unsayable — that territory which Winnicott (1971) would have recognised as the domain of play, cultural experience, and authentic living — affective experience finally finds a voice. And with it, the possibility of transformation.

References

Bion, W. R. (1962). Learning from experience. Heinemann.

Erlbruch, W. (1993). The big question. Europa Editions.

Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. Other Press.

Jung, C. G. (1964). Man and his symbols. Doubleday.

Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Jason Aronson.

Ogden, T. H. (1989). The primitive edge of experience. Jason Aronson.

Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. Oxford University Press.

Sendak, M. (1963). Where the wild things are. Harper & Row.

Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. Basic Books.

Tan, S. (2006). The arrival. Lothian Books.

Vaillant, G. E. (1993). The wisdom of the ego. Harvard University Press.

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

Winnicott, D. W. (1971). Playing and reality. Tavistock Publications.