Approximately 2% of people have difficulty picturing things in their mind. This can become an issue when psychotherapeutic help is needed, as many common therapeutic approaches rely on the patient’s visual imagination to be effective. This blog article by the Institute for Modern Psychotherapy in Berlin explains which therapies are still suitable to help people with aphantasia, for example, with depression or anxiety disorders.
Overview of All Topics
What is aphantasia?
The phenomenon of lacking mental imagery was first described in 1880 by Francis Galton, a British naturalist. He interviewed 100 men, asking them to describe their breakfast table in vivid detail. To his surprise, 10 of them struggled with this question and could only form faint or no images in their minds. After interviewing more subjects, Galton concluded that this phenomenon was widespread. His observation faded into obscurity until, 130 years later, British neurologist Adam Zeman encountered a patient who had lost his ability to visualize after surgery. This patient, who had previously enjoyed reading novels and immersing himself in vivid imaginary worlds, suddenly couldn’t see anything in his mind’s eye; everything remained black. Even family members were no longer visualizeable. Zeman began researching the topic and, in 2015, published a study on this phenomenon of lacking visual imagination, which he termed aphantasia—the absence of imagination. He discovered that some people are born with aphantasia, while others develop it later in life due to incidents like accidents or strokes. Interestingly, people with aphantasia may be unable to count sheep before falling asleep, but they can still dream. This suggests that only conscious mental imagery is missing. Zeman, who continues to study the phenomenon, observed through brain scans that individuals with aphantasia process information in different brain regions than those without it. For this reason, aphantasia is considered a deviation from the norm rather than an illness. Interestingly, many individuals who participated in Zeman’s study worked in creative fields.
Zeman found that people with aphantasia develop their own strategies to compensate for the lack of imagery. This also explains why people with congenital aphantasia often don’t realize they lack mental imagery.
Many affected people don’t realize they have autism.
This was the case for one of my patients who came to my practice. The young man suffered from social phobia. It started when he had to give a presentation at school as a teenager. He was never comfortable being in the spotlight, and the topic didn’t resonate with him, so it turned into a disaster. He couldn’t think clearly, and he eventually stood speechless in front of his classmates, who whispered and giggled. His teacher quickly and empathetically intervened, excusing him from continuing the presentation. He went to the restroom, sweating and with a racing heart, trying to calm down. But in the years that followed, he couldn’t shake off the anxiety. The haunting whispers and giggles from his classmates lingered in his mind. The fear of embarrassing himself in public grew stronger, taking a toll on him physically. He experienced nausea and shortness of breath. He began avoiding parties and gatherings with friends and even stopped dining out. His career choice reflected this—he became an accountant at a company with no client interaction. Yet deep down, his passionate career aspiration remained: he wanted to study architecture. He worked on a portfolio of drawings at home in preparation for an entrance exam at the university. But part of the application process involved a personal interview where candidates would discuss their motivation for the profession. His goal seemed increasingly out of reach.
When he sat in front of me, he complained that he had tried everything to rid himself of his anxiety. The well-intentioned advice to imagine people he was speaking to as being naked was completely useless to him—everything remained black before his eyes. Hearing this, I had a suspicion. I asked him what he had drawn in his portfolio. “A design for a conference center,” he replied. When I asked him to describe it, he shrugged. It turned out that he couldn’t visualize the conference center he himself had designed. I asked how he came up with the design. “Simple,” he replied. He found a picture of a building in Tokyo online that he liked, and he drew his design as his own variation of it. That’s when I realized my patient didn’t know he had aphantasia. But he had unknowingly developed a strategy: using the reference image, he was able to complete his drawing since he lacked the mental imagery to visualize his design in his head.
Since visual imagery also plays a significant role in psychotherapeutic treatments, the crucial question now was: which form of therapy is suitable to optimally support people with aphantasia in overcoming anxiety disorders or depression?
Aphantasia and mental disorders: Which Treatments Help?
For people with autism, it’s not easy to engage in psychotherapy. This is primarily because many psychotherapeutic treatment methods require good visual imagination as a basic prerequisite for successful therapy. As a result, some individuals with aphantasia resist seeking this type of help. Even if they are not yet aware that they have aphantasia, they subconsciously sense that they lack access to therapeutic benefits.
An exception to this is the Bernhardt Method, which addresses all five sensory channels equally, not just visual imagination. In this case, people with aphantasia can also be treated successfully, and there’s even the option of self-therapy using an online therapy.
This approach is certainly better and healthier than attempting to manage life through psychotropic medications. The risks often outweigh the benefits, even though many are unaware of this.
Why Mental Health Issues Should NOT Be Treated Medically in Cases of Aphantasia
Many doctors recommend a combination of antidepressants and psychotherapy for depression and anxiety disorders. However, since conventional psychotherapeutic methods often don’t work for people with aphantasia, medication often seems like the only remaining option. When this doesn’t produce the desired results, the dosage is typically increased in hopes that the treatment will finally provide relief.
Aphantasia and Mental Disorders: Which Treatment Helps?
For people with aphantasia, engaging in psychotherapy is not always straightforward. This is because many psychotherapeutic methods require strong visual imagination for effective treatment, which makes some affected individuals reluctant to seek such help. Even if they’re unaware that they have aphantasia, they may subconsciously feel they are unable to access the full therapeutic benefit.
An exception is the Bernhardt Method, which engages all five sensory channels equally, not just visual imagery. This means people with aphantasia can also be treated successfully, with the option for self-therapy via an online online therapy. This approach is far better and healthier than attempting to manage life through psychotropic medications, as the risks often outweigh the benefits, though many people may not realize this.
Why Mental Health Issues Should NOT Be Treated Medically in Cases of Aphantasia
Many doctors recommend a combination of antidepressants and psychotherapy for depression and anxiety disorders. However, since conventional psychotherapeutic methods often don’t work for people with aphantasia, medication often appears to be the only option. When this doesn’t bring the desired results, the dosage is typically increased, hoping it will finally have the intended effect.
It’s now proven that antidepressants don’t even work well for depression, the condition for which they were named. A positive effect was observed in only about 14% of patients, while 86% experienced no improvement or suffered a range of sometimes severe side effects. A look at the package insert for any antidepressant reveals that common side effects are significant: nausea, headaches, dizziness, drowsiness, insomnia, sweating, dry mouth, and constipation. It’s now also known that three-quarters of all psychotropic medications lead to sleep disturbances. Less common but still impactful side effects such as heart rhythm disorders, loss of libido, or weight gain add to the burden on patients.
Antidepressants should therefore be used, if at all, only for severe depression and only for a few weeks until a basic ability to engage in therapy is restored. For mild to moderate depression and all types of anxiety disorders, alternative treatments should be chosen. But which alternatives are suitable for people with aphantasia?
Why Psychotherapy Can Sometimes Be Problematic for People with Aphantasia
So how effective are these therapies for people with aphantasia? For my patient with social phobia, cognitive behavioral therapy, for example, would likely be frustrating. He lacks the ability to visualize anxious thought patterns. He would also encounter limitations with talk therapy, as he would need to discuss his problems using his visual imagination, which he doesn’t possess—even unable to visualize his own designs.
If you’re thinking that exposure therapy might be suitable, I have to disappoint you. As Klaus Bernhardt, director of the Institute for Modern Psychotherapy, explains in his bestseller “Overcoming Panic Attacks and Other Anxiety Disorders,” this form of therapy often helps only in the early stages of anxiety development. When an anxiety disorder has been present for a long time, exposure therapy may even worsen it. In my patient’s case, repeated exposure to a simulated oral exam might provide temporary relief, but it would only desensitize him to the anxiety without eliminating it.
Since each thought forms neuronal connections in the brain, strengthened by accompanying emotions, each exposure forms not only a few hundred positive synapses but also thousands of negative neural connections. In my patient’s case, he might realize that he can “survive” the exam scenario, but at the same time, his neural pathways would continue to fuel his fear of being judged poorly by others.
He might constantly fear, or even hear, giggling or whispering from others. And here, especially in the auditory realm, lies an effective treatment option to break the vicious cycle of fear.
Highly Suitable for People with Aphantasia: The Bernhardt Method
The Bernhardt Method has been successfully used for several years to treat anxiety disorders and has also proven effective for depressive moods. It doesn’t involve medication and is highly suitable for people with aphantasia. This is because the method incorporates not only the visual channel but also other channels, such as hearing, feeling, smell, and taste, into the therapeutic process.
People with aphantasia tend to rely heavily on the auditory channel when dealing with anxiety. This means that inner dialogues play a crucial role in their mental health. They often talk to themselves, activating both panic and happiness.
The Bernhardt Method allows people with aphantasia to retrain their brains using simple exercises and techniques based on the latest neuroscience findings. You can learn exactly how this method works in a video linked HERE. It’s the first of 53 episodes in a new online online therapy we developed specifically for people with anxiety disorders.
Incidentally, my patient not only found the courage to register for the entrance exam for architecture school but also passed successfully. Using the 10-sentence method and the 5-channel technique, he was able to build so many positive connections in his brain within a few weeks that he could confidently and calmly stand before the admissions committee.
To make optimal use of the visual channel during therapy, we used a small trick: the young man downloaded images from the internet showing confident, successful men speaking in front of large groups. Using photo editing software, he replaced the speakers’ heads with his own and used these images while practicing the 10-Sentence Method.
Troy A.
Tampa, Florida