Five things I’ve learned about aphantasia as a therapist

IMPORTANT: This blog is not a substitute for therapy, but provides evidenced-based education for the purposes of self-help, or to compliment the therapeutic process. ​ ​This blog is non-monetized.

“It’s what you learn, after you think you know it all, that counts.”

~ John Wooden
(the greatest NCAA basketball head coach of all time)

I’m a neurodivergent psychotherapist and have been treating and supporting folks with ADHD for almost a decade. Accidentally learning about aphantasia, a lesser known neurodivergence, has been one of the more fascinating things I’ve encountered as a psychotherapist. I say ‘accidentally’, because until the moment arose when I realized someone I’d known for a very long time had a completely different inner experience of things we’d regularly discussed, (but never discussed what they saw in their mind), I had no idea they didn’t see what I could see.

A few months later, I was talking to one of my best friends of 26 years, and we realized she had aphantasia too. How could this have never come up? Then my other best friend realized she had it. Turns out, a third of the people I work with have it too! … (another thing we didn’t learn about in grad school!).

Aphantasia is the absence of the brain’s ability to automatically or willfully generate visual images, and purposefully do things with the images (in your mind). While aphantasia is not a mental health diagnosis (in fact early research has shown aphantasia to be protective against PTSD), it can have a profound impact on how folks who struggle with anxiety for example, move past it in traditional psychotherapy.

Every day decisions about the future include not being able to reasonably predict the outcome of any choice, or to be reassured by one’s own imagination of possibilities, or to be intrinsically motivated toward an imagined goal in the future. While these invisible differences seem bound to have an impact on a person living in a world that has little time for the invisible, there are also a few distinct advantages I have learned over the years, from a mental health perspective, including the different experience of grief.

Do we ‘get’ each other?

As a neurodivergent therapist, when I share the same neurotype as my client, our immediate ease of connection – we get each other – is very powerful. If therapists aren’t careful, it can also sometimes extend too easily to the hasty conclusion they already know what their client’s experience of the world is.

That is, until the day comes, when your client says that one thing that suddenly stands out, like a surprise line drive, in a sleepy summer baseball game, that sends the crowds roaring to their feet.

As you read that last sentence, did you ‘see’ anything in your mind’s eye? An image? Or a movie perhaps? – did it automatically appear in your mind? Can you picture it now? Or did you simply read the sentence?

Understanding Aphantasia

Aphantasia and hypophantasia, its milder counterpart, present intriguing challenges in psychotherapy. Simply defined, aphantasia refers to the complete absence of mental visualization, (or the absence of the minds automatic conjuring of imagery), while hypophantasia refers to reduced visual imagery. The extent to which someone visualizes affects each person differently, shaping their cognitive processes and emotional landscapes. You might liken it to being left-handed, in a righty world.

The opposite end of that spectrum is where I sit – with hyperphantasia. When I think of anything, it’s in a movie format. Automatically and instantaneously. (When I dream at night, my partner and I both experience what we have always called ‘adventure dreams’, never knowing this didn’t happen to everyone else.)

The interesting thing I have noticed as a therapist is I’m generally more excited to unpack what’s happening in any aphantasia moment, because it changes the course of the therapeutic conversation. The difference between understanding a painful moment driven by aphantasia, versus a moment our therapy culture would likely blame the client for, is ultimately transformational.

Let’s break it down a little further

A substantial percentage of psychotherapy interventions, particularly for anxiety and trauma-related disorders, rely overwhelmingly on visual imagery techniques. Being told to imagine, picture this, describe what you ‘see’, can most certainly leave one with a familiar neurodivergent feeling – there’s clearly something I’m not getting that the therapist seems to find intuitive. It’s a subtle disconnection that the unaware therapist might experience over and over again, never quite knowing why the intervention isn’t working the way it’s supposed to. In the end, when the client doesn’t do the homework or pushes back in the session, the therapist has been trained to consider their patient ‘resistant’.

Visual imagery, or ‘seeing’ things in your mind, plays a big role in how we remember past events, imagine the future, hold images in our mind temporarily, and even dream. It helps us relive memories and imagine what might happen in the future, which in turn helps us make sense of the world around us and make smart decisions. When visual imagery goes really wrong, it can be a sign of mental health problems, especially in disorders where people see or imagine things that aren’t really there.

Research shows that people with aphantasia may struggle with remembering personal experiences, seeing themselves in their mind’s eye, and therefore struggle with forming a strong sense of self-identity, in the same automatic way a visualizer does.

A few things we do know from the research, and those with lived experience include:

  • Folks with aphantasia often have severely deficient autobiographical memory, meaning they can’t vividly recall past events from their own perspective.
  • Because people with aphantasia don’t instantly visualize things, they may find it tough to remember personal experiences and then connect with their emotions attached to them.
  • The inability to create mental images seems to limit access to past memories and emotions, possibly impacting a person’s sense of who they are.
  • While it’s not fully understood how aphantasia affects identity development, there’s evidence that difficulty in imagining and recalling personal experiences might hinder the formation of a strong sense of self. In essence, the inability to visualize mentally might affect how people remember their past and construct their sense of identity, but more research is needed to grasp this connection fully.

Exploring Connections with Anxiety and ADHD

Nothing forces a novice therapist into a person-centred approach faster than working with a neurodivergent client. Therapists today are increasingly learning what it means to be ‘neurodivergent-affirming’, which is a professional competency, just as important as affirming gender, race, body size, culture and so forth.  As a therapist who works with adults with ADHD, in particular adults ‘late-diagnosed’ in adulthood (either missed as a child, or misdiagnosed with something else), I have a good number of clients who have both ADHD and aphantasia (it’s not as rare as early literature suggested). (Of note, while discussing ‘neurodivergence’ broadly, I won’t specifically cover the experience of aphantasia for autistic folks).

In general, we steer clear of generalizations as psychotherapists … so when a ‘trend’ becomes unavoidable, it gets our attention. One thing all of my clients with ADHD and aphantasia have in common (other than me), is their self-described experience of anxiety. (One could actually argue it’s not really anxiety – it’s less about an irrational fear, and more about the completely reasonable (intense) discomfort of not being able to reasonably predict what/how to do the thing. For the sake of this post, I’ll refer to it as anxiety, because that’s what it will be mistaken for). Despite differences in gender, education, socioeconomic status, sexuality, in almost identical language, my clients with varying degrees of aphantasia each describe the situations that set off a debilitating amount of anxiety, and their responses to my initial explorations of how they think or feel their way through these moments, are astoundingly the same.

The 5 things we’ve figured out

1. The most severe anxiety/discomfort is around new experiences.

While anxiety itself is future based (a worry about something that might happen) and the triggers are present day, for people with aphantasia, there is a specific future-based anxiety specific to new experiences, like the first day on a new job, or driving to a place they’ve never driven before. I’d like to note – the experience of this isn’t universal, and seems to be a bit less intense for those with hypophantasia. But our friends and loved ones with aphantasia will generally have a lot of questions about what to expect, and feel increasingly frustrated and unsettled, not really being able to get the specificity in answers they hear. In contrast, for those of us who are visualizers, we have the ease of being provided an automatic array of possibilities, generated by our brain’s imagination.

Even though they have successfully overcome the situation in the past, or been successful at say, starting a new job, my clients tend to attribute the success factors to the past situation, rather than themselves. Is this just a cognitive error? No – the reason they don’t apply it to the future scenario isn’t because they have low self-esteem; it’s because they can’t see it. How could they? It simply hasn’t happened yet. While it’s true it hasn’t happened yet for the rest of us, the difference is the non-aphantasic brains’ ability to automatically conjure or imagine a reassuring scene where everything turns out fine is not automatically available to the person with aphantasia.

TIPS: If you are in therapy and recognize yourself here, ensure you share this information with your therapist to talk through together. I find therapists who have aphantasia, (whether they know it or not), automatically adapt around it; its the rest of us who need to know what you ‘see’ in your mind when we’re exploring things in the session room. Therapists, if you must use worksheets, ensure they are in first person, rather than second person tense (“My problem”, versus “your problem”).

2. New romantic relationships and dating

In new relationships, or potential relationships and dating situations, instead of being that person who on the first date, imagines their wedding or imaginary children and needs to be told by friends to cool their jets, my clients with aphantasia are bombarded with memories of the past.  

My hypothesis is that because their brain isn’t future imagining, the next best thing from your brain’s perspective (as far as our own self-context), is to pull up memories from the past when we were in the same circumstance (which may not be happy ones). When I go to my favourite restaurant with someone new, one I’ve been too with my ex, the date ends, and now I’m flooded with memories of my ex! I’m left wondering why? Why are these memories of suddenly coming up? Does it mean I’m not over them? Does it mean I shouldn’t be dating? Maybe. Or maybe it’s just aphantasia-driven anxiety running the only loop it’s got.

Even in an existing relationship, if someone doesn’t see what you see, like being able to picture yourselves on a planned trip, or in your first home, or your upcoming wedding, you might erroneously conclude they aren’t on the same page, or don’t want the same things.

What happens a lot in non-neurodivergent-aware therapy is emotional meaning – usually negative – is applied to something that is simply a neurodivergence.

TIP: The solution isn’t more CBT – it’s to release those old assumptions and go make new experiences for your brain to reference.

3. Folks with aphantasia can seem a lot more negative than they really are.

There is a particular quality to an aphantasic brains’ insistence on the worst-case scenario that is frankly, quite compelling.  Even in trying to mind-map or brainstorm, people with aphantasia have no problem immediately coming up with the worst-case scenario. Reluctantly, they might agree with me on a maybe sorta possible best-case scenario (which usually is some version of the thing gets cancelled). It makes perfect sense that if your brain cannot conjure imaginary scenario’s, it seems like a ridiculous activity. To even come up with a middle of the road scenario, even with prompting draws blank looks. As their therapist, if I suggest possible options based on what I know about them, their values, their past experiences and their strengths, it still doesn’t resonate.

The negative inclination stands out, and indicates an easy initial strategy to your unknowing therapist. CBT therapists might pull out their negative automatic thought (NAT) worksheets. However, those worksheets ask the client to imagine how much this problem will matter in 5 days, 5 months or 5 years, asking them to picture the future. The exercise is frustratingly over before it could even begin.

TIP: It’s so important to validate the logic that it would be incredibly uncomfortable to move forward in a scenario where none of the variables can be reasonably predicted. Then try to put that experience into context – being in the world with other people who automatically or wilfully have multiple scenarios generate in an instant, that those are going to be very different experiences of the world.

4. People with hypophantasia have worse nightmares than the rest of us.

While the research seems to confirm people with aphantasia are saved from visual reminders of whatever they dreamt the night before, people with only a little bit of the image seem to have a worse experience. My clients with aphantasia also have in common a much stronger sensory experience – sound, movement, voices and smell even – their recall of nightmares sound more like PTSD flashbacks, a total re-experience of a past lived experience or pieced together memory. I referenced having hyperphantasia earlier – my nightmare or bad dream experience is like a full colour movie (any kind of dream, every time), but interestingly, they rarely have sound or smell.

TIP: It’s good practice to include ongoing care coordination with your clients other healthcare practitioners. If your client does have PTSD or their nightmares are preventing them from sleeping consistently and regularly, their physical health is absolutely going to be impacted (which impacts mental health). There are specific medication’s for nightmares associated with PTSD and your clients’ family doctor may be able to help.

5. The ADHD complication.

One of the biggest challenges in ADHD life is tracking intrinsic motivation – the internal desire to move toward the thing we want. We know ADHD brains have a situationship with a consistent dopamine supply (in addition to other neurotransmitter, structural and functional brain differences), and we also know intrinsic motivation is fuelled by dopamine transmission. Researchers look for more definitive answers, and those of us with ADHD are forever looking for hacks.

One such ‘hack’ or technique (for help with remembering and motivation) is visualization.

That is, picture Tomorrow You remembering to do the thing you need to do tomorrow, when you need to do it (like stopping for milk on the way home). Those of you who are athletes, or parents of athletes, will be familiar with visualizing in sports – goalies imagine stopping pucks or batters imagine hitting that home run.

For folks with ADHD brains, we rely on the fact that anticipation of a future reward releases a trickle of dopamine, which is what move us toward that reward.  If people with ADHD can leverage the brains’ ability to trigger a pre-dopamine release in anticipation of a future reward, what happens if the brain on your therapy couch doesn’t visualize, or very much struggles to visualize?

Does that mean that someone with ADHD and aphantasia will be forever stuck when it comes to intrinsic motivation fuelled by imagining success? Of course not.

We all know ADHD brains love a good challenge. Even if you can’t imagine it visually, you still have the ability to move towards the good thing, remembering that time when you could do the thing. We do have muscle memory. We can experiment. Narrowing in on past positive experiences or memories, we can tap into how it felt physiologically, what scent we remember, what kinds of things did we hear, what did we see, who was there?

Further, there are neurodivergent-friendly therapeutic approaches that do not rely solely on visual imagery, such as somatic and embodied techniques, Acceptance and Commitment Therapy (ACT), Interpersonal Psychotherapy (IPT), mindfulness-based approaches and memory strategies. And despite the imagery based early phases of EMDR, those phases can be adapted. It does require the therapist directly ask a client whether they see images or can manipulate images in their mind, and potentially consider the VVIQ screen for aphantasia.

TIP: In my experience as a therapist who doesn’t have aphantasia, my adult clients with aphantasia are less inclined to initially think we have hit on something significant. It makes sense – their brains aren’t seeing what mine sees. One thing I have learned as an ADHD specialized therapist is we must slow it down. What happens over time as my clients generously engage in these explorations, is things do start to improve (sometimes suddenly), with evident improvements in self-insight, ongoing self-awareness, relational openness, openness to new experiences and willingness to try new things. The therapeutic goal of knowing yourself better in this case, has absolutely been achieved.

Embracing Complexity and Diversity

The inability to conjure mental images does pose distinct challenges in the process of traditional, imagery based therapy. Deficient autobiographical memory and difficulties in emotional recall may hinder identity formation (so it’s not all trauma!). Strategies like focusing on sensory experiences (mindfulness meditation would be more gratifying than guided), exploring personal values, and engaging in creative outlets offer pathways to resilience and self-discovery.

Thankfully, there are many facets of identity beyond just visual self-image, and finding personalized and affirming ways to access, reflect on, and express your authentic self might become your new therapeutic goal.  With creativity and self-compassion, people with aphantasia or hypophantasia, who have struggled with ‘seeing’ themselves, or having a strong sense of self, can absolutely cultivate a very strong and meaningful sense of identity, and start to leave some of that anxiety behind them.

Understanding the nuances of aphantasia opens doors to self-acceptance, self-compassion and insight-based growth.  When therapists affirm all neurotypes, we embrace our client’s brains complexity and diversity, and we pave the way for inclusive mental health practices that honour the richness of the human experience. Careful and curious listeners will continue to explore and deepen their understanding of their clients’ inner worlds with probes that help us explore whether we really get it.

Ask your clients if they see pictures when they close their eyes. If they say, “what to you mean?” and you say, “what do you mean what do I mean?” then you know it’s time to dig a little deeper.


More Resources

Who to follow on twitter/X on Aphantasia:

Find a Neurodivergent-Affirming therapist on our team: Find A Therapist


References

Dawes, A.J., Keogh, R., Andrillon, T. et al. A cognitive profile of multi-sensory imagery, memory and dreaming in aphantasia. Sci Rep 10, 10022 (2020)

Lou, R. (2020, October 26). Creating in the dark – aphantasia & art. Aphantasia Network. https://aphantasia.com/article/stories/creating-in-the-dark/

Pearson, D. G., Deeprose, C., Wallace-Hadrill, S. M., Burnett Heyes, S., & Holmes, E. A. (2013). Assessing mental imagery in clinical psychology: a review of imagery measures and a guiding framework. Clinical psychology review33(1), 1–23. https://doi.org/10.1016/j.cpr.2012.09.001

University of Exeter (Ed.). (2024, March 27). A Decade of Aphantasia Research: What we’ve learned about people who can’t visualize. Medical Xpress – medical research advances and health news. https://medicalxpress.com/news/2024-03-decade-aphantasia-weve-people-visualize.html#google_vignette

Takahashi, J., Saito, G., Omura, K., Yasunaga, D., Sugimura, S., Sakamoto, S., Horikawa, T., & Gyoba, J. (2023). Diversity of aphantasia revealed by multiple assessments of visual imagery, multisensory imagery, and cognitive style. Frontiers in psychology14, 1174873. https://doi.org/10.3389/fpsyg.2023.1174873

Voznaya, A. (2023, August 7). Unlocking the inner world: A journey into Aphantasia and the power of the mind. MentorCruise. https://mentorcruise.com/blog/unlocking-the-inner-world-a-journey-into-aphantasia-and-the-power-of-the-mind/ 

Wilson, M. (2002). Six views of embodied cognition. Psychonomic Bulletin & Review, 9(4), 625–636. Zeman A. (2024). Aphantasia and hyperphantasia: exploring imagery vividness extremes. Trends in cognitive sciences, S1364-6613(24)00034-2. Advance online publication. https://doi.org/10.1016/j.tics.2024.02.007


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Picture of ​Christina Crowe, H.BSc. MACP, RP, (S-Cert) OAMHP (she, her)

​Christina Crowe, H.BSc. MACP, RP, (S-Cert) OAMHP (she, her)

Registered Psychotherapist, Validated Clinical Supervisor, ADHD Therapist & Coach Podcast Host The Christina Crowe Podcast Christina is a Canadian Registered Psychotherapist, a member of CADDRA's Advocacy Committee and relentless mental health advocate. Christina believes great mental health information should be available to everyone, loves creating content that makes invisible things VISIBLE and finding new ways to bring healing experiences to as many people as possible.

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