A briefing for therapists working with aphantasic and SDAM clients.

Why this page exists

A meaningful proportion of any therapist’s caseload — somewhere between two and five percent for aphantasia, less well-characterised but non-trivial for SDAM, with notable overlap — cannot do something most therapy modalities quietly assume they can do. Standard scripts ("close your eyes and picture yourself back in that room"; "imagine your safe place"; "visualise the calm version of you talking to the anxious version") fail silently with these clients. The session does not visibly break. The client may say nothing. But the technique has not done what the therapist thinks it has done, and over weeks or months the therapy stalls without an obvious diagnosis.

The point of this page is to make the failure mode legible early, and to offer adaptations that keep the underlying clinical work intact while removing the imagery dependency.

The four ways aphantasia and SDAM affect therapy

1. Disbelief

The first failure mode is the therapist not believing the client. A client who reports they genuinely cannot picture their grandmother’s face, or genuinely cannot replay last Christmas, is often met with reassurance that "everyone struggles with that sometimes" or with prompts to try harder. Both are well-meant; both are wrong. Aphantasia and SDAM are stable neurocognitive variations, not effort problems and not avoidance. A client who has worked out the term has usually already had the experience of being told they must be doing it wrong, and the therapy room is not the place to repeat it.

The corrective is plain belief, followed by curiosity about what the client’s cognition does instead.

2. Misdiagnosis when criteria assume imagery

Several diagnostic frameworks and screening instruments embed the assumption that imagery is intact. PTSD criteria reference intrusive images and flashbacks; depression scales ask about brooding on past events; anxiety inventories assume catastrophic mental simulation. A client with aphantasia or SDAM may genuinely not have intrusive images, may not brood in the expected sense, and may not simulate catastrophes as imagery — yet have the underlying condition the instrument is trying to detect. The instrument returns a low score; the clinical picture is real.

The corrective is to ask about the underlying experience in modality-neutral terms. Instead of "do you get unwanted images," ask "do unwanted reminders of the event come up — in any form, including thoughts, sensations, emotional surges, or words?" The phenomenon is the intrusion, not the modality.

A worked example. The Autism Quotient (AQ), the most widely used screening instrument for autistic traits in adults, contains items that reference imagery. Dance and colleagues (2021) reported that aphantasic adults scored higher on the AQ than typical-imagery controls, even after the most obviously imagery-related items were removed. A 2025 study by Bouyer and colleagues, which removed a wider set of imagery-laden items, found the correlation weakened substantially — suggesting the AQ effect is at least partly an artefact of how the instrument is built. The empirical literature on this is small and the resolution is open; what is settled is that the assumption built into a diagnostic instrument matters, and that scoring needs the same scrutiny as the criteria themselves.

3. Technique mismatch

Once the client is correctly identified, a second failure mode appears: techniques built around imagery do not, in their default form, work. EMDR’s installation phase has historically used a calm-place image — though community reports and emerging research suggest the underlying mechanism (connection to a calmed bodily or emotional state) can be reached through non-visual routes, so EMDR is not necessarily a write-off for an aphantasic client. CBT’s behavioural-experiment phase often asks the client to mentally rehearse an alternative. Compassion-focused therapy uses the compassionate-self imagery exercise. Trauma-focused CBT reconstructs the traumatic memory in detail before processing it. Each of these has an imagery dependency in the form most therapists were trained on; each can fail for a fully aphantasic client unless adapted.

The corrective is not to abandon the underlying mechanism — exposure, behavioural rehearsal, self-compassion, narrative integration — but to deliver it through a modality the client has. For most aphantasic and SDAM clients, that modality is verbal, propositional, or somatic. Worked examples follow.

A direct empirical test of this principle has now landed. Monzel and colleagues (2025) ran fear-conditioning followed by imaginal exposure across aphantasic adults, simulated-aphantasia controls (eyes-open in bright light to disrupt imagery), and standard controls. Imaginal extinction succeeded in all three groups, demonstrating that propositional thought — thinking about a feared stimulus rather than seeing it in the mind’s eye — is sufficient. The exposure mechanism does not, in fact, require imagery. Aphantasic participants additionally showed less subjective fear during conditioning, an exploratory finding worth more work.

4. Relational damage from repeatedly asking the impossible

The most insidious failure mode is cumulative. A client who is asked, session after session, to do something they cannot do — picture, imagine, go back to, see in their mind’s eye — without their inability being recognised, learns that therapy is a place they fail. Some leave; some stay and quietly disengage; a few internalise the failure as further evidence that something is wrong with them. None of these outcomes are the therapist’s intention, and all of them are avoidable with a single intake question.

Worked adaptation: CBT without imagery

The standard CBT trigger-thought-feeling-behaviour chain is not imagery-dependent and works as written. The places imagery enters are usually: behavioural experiments ("imagine doing X — what would happen?"), exposure planning ("picture the worst-case version"), and relapse-prevention rehearsal ("imagine yourself in that situation handling it well").

A modified protocol that holds across these:

The replacement is the therapeutic substance; visualisation was the delivery mechanism. Removing it changes the texture of sessions but not the mechanism of change.

Worked adaptation: bodywork and "go back to" without revisiting

Trauma modalities frequently ask the client to "go back to" the incident. For an SDAM client this is not a refusal or an avoidance — the re-experiencing apparatus is genuinely not available. The client knows the event happened, knows roughly when, knows what is recorded about it, but cannot re-enter it.

A modification that preserves the clinical work:

This adaptation generally feels less raw than imagery-based revisiting in early sessions, and clinicians used to working with abreaction should expect a different rhythm. It does not generally feel less useful by the end.

A short intake question

The single change that prevents most of the above is asking, at intake, whether the client has voluntary mental imagery and whether they can mentally re-experience past events. A non-leading version:

Most clients answer in the expected range. Clients who do not — who report no imagery at all, or no re-living capacity — should have that recorded in the assessment notes alongside the standard cognitive and mood items. It is not a diagnosis and does not require one. It is a parameter the rest of the work needs to take into account.

Where to go next

For deeper engagement with the literature and the practitioner community:

• The cornerstone guide on this site — /guide — covers what aphantasia and SDAM are, what they are not, prevalence, and the lived texture, fully cited.
• Aphantasia Coach (aphantasiacoach.com) — UK CPD-accredited training for mental-health professionals on adapting therapy for aphantasia, SDAM, and anendophasia. The companion book Unseen Minds: A Therapist’s Guide to Multisensory Aphantasia and Invisible Cognitive Differences (Smith, 2024) covers the territory of this page in book length. The practitioner-focused training programme this page does not duplicate.
• The published literature — Zeman 2025’s decade review in Neuropsychologia is the single best entry point; Palombo et al. 2015 is the foundational SDAM paper. See the research tracker for plain-English walk-throughs of newer findings.

A note on the limits of this page

This is a working brief, not a training programme. It is written by someone with both conditions, drawing on lived-experience accounts and on the literature, with one round of review from an aphantasic early reader before publication. It is not a substitute for proper supervised training in trauma-focused modalities, nor for the structured CPD that Aphantasia Coach and the academic groups offer. Therapist review and corrections are actively welcomed.

If you adapt your practice based on this page and find a refinement, a correction, or a missing impact category, the contact details are on the /about page. Corrections welcomed; experience reports welcomed; complaints welcomed.