What aphantasia does to therapy, in numbers

Most of what is publicly understood about how aphantasia interacts with therapy comes from forum posts, anecdotal reports, and the lived testimony scattered across r/Aphantasia and r/SDAM. Useful, but not the kind of evidence base a clinical service can budget against. Mawtus, Renwick, Thomas, and Reeder’s 2024 paper in Collabra: Psychology is the first peer-reviewed study to put numbers on what the lived testimony has been describing for years.

What the paper did

A mixed-methods design: a structured questionnaire on mental-health diagnosis and treatment experiences delivered to adults with and without aphantasia, followed by qualitative interviews with a subset. The questionnaire side gives the population-level numbers; the interviews give the texture. Together they cover the same ground from two angles, which is the right shape of evidence for a phenomenon this under-studied.

What the paper found

• Imagery-shaped symptoms are missing in the aphantasic presentation of almost every disorder. Across virtually all psychiatric conditions covered by the questionnaire, aphantasic respondents reported the disorder without the imagery-related features that typify the textbook description: PTSD without sensory flashbacks, eating disorders without imagery-driven body image, intrusive thoughts without intrusive images. The condition is real; the imagery is not the route by which it expresses itself.
• Missed and misdiagnosis: same prevalence, different attribution. Aphantasic respondents were no more likely to report a missed or misdiagnosis than typical-imagery controls. But when missed or misdiagnosis did occur, aphantasic respondents specifically attributed it to "lack of awareness or understanding of aphantasia" in the professional. The headline number is reassuring; the texture beneath it is not.
• Imagery-based therapies are reported as ineffective. Aphantasic respondents were significantly more likely than controls to rate therapies involving mental imagery — visual imagery in CBT in particular — as not working for them. This is the empirical backbone for the technique-mismatch concern that comes up repeatedly in lived testimony.
• Two qualitative arcs. The interviews surfaced two recurring narratives: a Quest for Identity (feelings of being different, memory challenges, coming to the language for one’s own cognition late) and a Mental Health Journey that broke into three sub-paths. Aphants with anxiety or depression reported variable but generally workable experiences; those with neurodivergence reported similar; those with trauma or complex mental-health conditions reported outcomes that depended critically on whether the practitioner offered empathy and was willing to adapt the work.

Why it matters

Two reasons. First, it is the first time the lived-experience pattern — that aphantasic patients fall through the cracks of imagery-shaped diagnostic criteria, and find imagery-based therapy ineffective — has been documented at the level of evidence a service commissioner or clinical-training body will take seriously. The vocabulary of forum posts is now the vocabulary of a peer-reviewed paper.

Second, the missed/misdiagnosis finding is more nuanced than it sounds. Aphants are not being misdiagnosed at higher rates overall, but when things go wrong, the gap is specifically about professional unfamiliarity with the condition. This points training resources at the right intervention: not a separate diagnostic pathway, but an awareness add-on to existing ones. The therapist briefing on this site is one small attempt at that add-on.