As her interview with Bill Nye drew to a close, Alie, of the Ologies with Alie Ward podcast asked, "What do you love the most about what you do?" In short, Bill responded, "The essence of the scientific enterprise is the joy of discovery, or the J.O.D. as I call it. And that is what gets me. Celebrate it, my friends!" These wise words have inspired me to approach this article under the guidance of my own J.O.D.
I hope you, too, will keep this joy of discovery in mind as you discover
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Harrison is pursuing his doctoral degree in counseling psychology. He has a wide range of interests including, exploring the impact of aphantasia and mental imagery in the counseling field and anything mental health related.
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Therapy And Aphantasia
Perhaps, you’ve recently discovered your inability to voluntarily visualize mental imagery, known as aphantasia. Understandably, you might feel various emotions in your discovery. Your emotions are valid. In your discovery, you might decide to seek therapy or perhaps you are already in therapy and wondering how to talk to your therapist about aphantasia. My hope here is to provide validation in your experiences and insight around how to potentially have a conversation about aphantasia with your therapist.
Aphantasia was first coined in 2015 (Zeman et al.) and the field of imagination research and academic understanding of “extreme imagination” are still in their infancy. Hence, your therapist may or may not be aware of the term, it’s validity, or the need to evaluate how mental imagery plays a role in your experiences.
Thus, you might find yourself having to introduce this term and your experiences to your therapist – and that is okay. Your therapist is there to provide you an empathetic, authentic space.
While most therapists do a wonderful job, it is important to note that historically psychotherapy and broadly psychology has not been perfect when discussing people’s differences. And when it comes to discussions with therapists about invisible differences, such as aphantasia, these conversations are anything but perfect. Most people and therapists may not have even heard the term before, let alone understand its implications in our lives. It's worth remembering, we're still in the early days of discovery.
So, What Exactly is Psychotherapy?
Before moving forward, let’s discuss what psychotherapy is. According to Tschacher et al. (2015), psychotherapy “is a learning process, which relies on general mechanisms of action that are implemented using psychological techniques and interventions” (p.2). Easy enough to understand, right?!... Right?!... Okay, maybe not!
Despite psychotherapy being a space for people to process their emotions, cognitions and experiences, the concept of psychotherapy is steeped in rigid, pedantic language and ideas. Hopefully, our discussion begins to demystify what psychotherapy can be.
When looking for a therapist, you will typically find each therapist orients themselves under a specific type of psychotherapy, typically referred to as the theoretical orientation. The theoretical orientation is useful in the sense that it helps the therapist contextualize and implement specific techniques within a framework. Various studies have compared the effectiveness of one type of orientation to the other. Debates about which type of therapy is more effective given a particular presenting concern or diagnosis continues and there is no shortage of the types of therapies provided (e.g. psychodynamic, cognitive behavioral, interpersonal, eye movement desensitization and reprocessing, multicultural therapy, etc.).
Through using randomized controlled trials and meta-analyses, we know psychotherapies are effective. However, research has struggled to find the exact mechanisms that lead to change in psychotherapy and the majority of change can only be discussed through correlations, not causation (Cuijpers, et al., 2019). In other words, therapy works, but we aren’t quite sure how.
While some who seek therapy may keenly enjoy a specific therapist’s theoretical orientation, some research points towards the idea that the specific lens of therapy is only one component and may not be as effective as a predictor of therapy outcomes when compared to other components like empathy, the relationship, collaboration and expectations (Wampold, 2015). These components are typically referred to as the common factors. In 1936, Saul Rosenzweig first introduced the concept of common factors. Observing that the array of various therapies each had comparable outcomes, he made the conclusion there must exist something common to all. In the 1960s, Jerome Frank cemented the common factors as being influential and needing serious consideration in research (Cuijpers, et al., 2019). Since then, psychotherapy research has developed various models to enhance our understanding of common factors.
I highlight these common factors for a couple reasons. The first being that while aphantasia research is growing in its body, the extent of its implications is not yet fully studied. As mentioned earlier, this lack of research might mean that you, as the client, have to introduce aphantasia and your experiences to your therapist. How your therapist responds is important. How they adjust their clinical interventions to meet your experiences and needs is important. Thus, I focus on a few common factors as key areas you can look for as the client to check in with yourself about your therapeutic experiences and if the therapist and therapeutic environment is working for you.
Common Factors
Let’s focus on three of the common factors: alliance, empathy, and expectation. I highlight these three common factors specifically for their significance in the research, as well as their significance for you as the client in therapy.
Before exploring the theoretical underpinnings of the common factors, I want to explore what these common factors might look like in a session when navigating therapy and aphantasia, I have included a hypothetical conversation between a therapist and a client. Following the conversation, I will make a few remarks and discuss the three common factors in more detail.
How to talk to your therapist about aphantasia (example)
Therapist: When you discuss your concerns around your future, do any images come to mind?
Client: Like in my mind?
Therapist: Yes
Client: Well… actually this is something I’ve been wanting to bring up. That’s difficult for me to answer ‘cause I can’t mentally imagine something.
Therapist: So, there’s no imagery with your thoughts about your future?
Client: Correct. But it’s not just my future. There is no mental imagery at all.
Therapist: Could you tell me a little more about this?
Client: Umm… sure. I mean I will try my best. It’s actually called aphantasia. So, I can’t just bring up images in my mind. It’s just blank. For instance, if I were to say think of an image of a dog, what do you see?
Therapist: Well, what immediately comes to mind is my dog at home. I can see her clearly sitting on the couch before I started work today.
Client: Okay! So, for me, the best way I can describe it is as just like black space. I know what a dog is. I know they have four legs, fur, eyes, a nose, like to sniff. I even have a dog who I love. But there is no image that comes to mind for me. Like just associations of things.
Therapist: Huh… so, if I am understanding you correctly, and please do correct me if I am wrong, your aphantasia - did I get that right?
Client: Yes, aphantasia, which makes me aphantasic!
Therapist: Great. Your aphantasia affects your ability to mentally visualize things and you can’t just willingly call up images.
Client: Yeah, pretty much!
Therapist: Do you feel like it impacts our work together?
Client: I do.
Therapist: Truthfully, I have not heard about this before, so I appreciate you bringing this up in our session. If you are comfortable with this, I am curious to talk about how this more broadly affects your life, what that’s like for you and how it is impacting our time together?
Client: Yeah, I would appreciate discussing it further. It’s only been more recently that I even came to this realization about it myself. I have wanted to bring it up in session. I just wasn’t sure how.
Despite the therapist being unfamiliar with aphantasia, they did not make snap judgments. Through open-ended questions, the therapist further asked the client to explain their experiences. The therapist showed empathy through restatements of what the client was discussing and engaging in the client’s exercise of mental imagery about the dog. Additionally, by asking at the end to discuss how the client’s aphantasia might be impacting their work together, the therapist created a collaborative opportunity (alliance) to renegotiate what their expectations look like.
I want to emphasize this hypothetical therapy and aphantasia situation is just that, hypothetical. Not all conversations, whether with your therapist or not, will always progress in a linear way. What I hope this exercise does is help you identify what some of these common factors could look like in the room. The common factors are often the subtle ways the therapist interacts with you to build your relationship together. To better understand the common factors, let’s explore each in more detail.
Alliance
Research is finding one of the best predictors of outcomes in psychotherapy is the relationship between the therapist and client, typically called the therapeutic alliance (Horvath et al., 2011). Additionally, the alliance is one of the most researched components of the common factors. Wompold (2015) discusses three primary components of alliances: “the bond, the agreement about the goals of therapy, and the agreement about the task of therapy” (p. 272). The alliance does not happen by chance. If you are beginning therapy for the first time, the early phases of building rapport are important and vital for success.
Alliance is inseparable from everything else a therapist does in session. As Horvath et al. (2011) states, “the therapist does not ‘build alliance’ but rather he or she [or they] does the work of treatment in such a way that the process forges an alliance with the client” (p. 15). The focus on alliance is to build the collaborative commitment to therapy by all involved.
Be mindful of the fact, alliance is not a static condition. The strength of alliance might often fluctuate due to various factors (e.g. if the therapist and client is grappling with a difficult experience). That is okay if it does fluctuate and you, as the client, feel good, bad, indifferent towards the alliance in specific moments. That can be an informative part of therapy. However, overarching, you should have a therapeutic alliance where you feel you are able to express these changes. Where you feel heard, understood, and validated. Like in the example above on how to talk to your therapist about aphantasia. Simply, you and your therapist’s alliance should be flexible, mutual and collaborative in nature.
Empathy
To define empathy, I quote Wampold (2015) who states, “empathy [is], a complex process by which an individual can be affected by and share the emotional state of another, assess the reasons for another’s state, and identify with the other by adopting his or her [or their] perspective,” (p. 273). Empathy is fundamental in the therapeutic process. In part, because the therapeutic relationship is a unique social relationship, wherein the interaction is confidential and disclosure of difficult experiences, ideas, and/or thoughts do not disrupt or damage the social bond of the therapist and client. The therapist will not terminate the relationship because of the difficult information shared.
Therapy can and should provide a unique human connection, one in which you feel connected to a therapist who is empathic, caring, and promoting your healing. Levitt et al. (2016) highlights this by naming one of their themes as, “caring, understanding, and accepting therapists allow clients to internalize positive messages and enter the change process of developing self-awareness” (p. 819). Clients’ often report that being understood and respected, which I consider to be an aspect of empathy, leads to self-reflection.
Empathy from your therapist ideally leads to feeling validated, and this authentic care is critical to the work of therapy. When discussing different experiences with your therapist, like your experiences with aphantasia, you should feel empathized with, validated by, and heard.
Collaborative Expectations
Expectations are another important factor to the therapeutic process. Therapeutic expectations should be collaborative in nature. Expectations are used to understand and explain your experiences, present the rationale for a specific treatment and provide the client participation in the therapeutic process (Wampold, 2015).
Discussing expectations are key in negotiating client-therapist roles, otherwise power imbalances can develop. Remember, therapy is your space. You know intimately your lived experiences, because they are yours; you live it daily. Thus, expectations about the process of therapy or how therapy may look in this space is key. Levitt et al. (2016) found that explicitly discussing and negotiating the client-therapist roles can lessen the sense of problematic power imbalance.
Further, Levitt et al. (2016) found when therapists are aware of and have discussed therapist-client differences, “it improved the therapy relationship and was felt to be empowering and validating” (p.820). Discussing and negotiating differences in the therapeutic space with your therapist and how that might impact the process is part of expectation setting.
You should be able to explicitly discuss your expectations with your therapist. All of this is part of the collaborative nature of therapy. Like in the therapy and aphantasia situation above where both the client and therapist discuss how aphantasia may be impacting the therapeutic process.
Concluding Thoughts on Aphantasia and Therapy
Realizing you have aphantasia is a discovery. It is a process of understanding yourself in a more intimate way. It helps you contextualize your experiences of the world. You are in the midst of a discovery, and discoveries can be challenging and maybe even anxiety-inducing. That is okay.
In many ways, therapy is also a process of discovery. Your therapist should want to know the joy of discovering you and your experiences. If you decide to share your experiences of aphantasia (or any other parts of your experiences) with your therapist, your therapist should respond with empathy, curiosity and care. They should want to understand you better and be willing to renegotiate expectations of therapy and aphantasia with this new knowledge. And when you share this with them, your therapist should also do their own work to understand aphantasia. Therapy should be working for you.
If you are worried or uncertain how to talk to your therapist about aphantasia or that maybe they will not understand, hopefully these core common factors can help you negotiate if this feels like a space you can share and be heard. Consider asking yourself these questions to check in:
How is my working relationship with my therapist? Do I feel heard and understood? Can I negotiate or renegotiate my expectations of therapy?
Hopefully, these questions will help you determine whether this environment and this therapist is the right fit for you. If it does not feel like it is the right fit for you, it is okay to acknowledge that and to assess if a different provider or therapist would be better suited for you. While the process can be difficult, it is within your power to lean into the “J.O.D., the joy of discovery.” Remember that therapy is your space; your space to discover you.
For those seeking support, our Aphantasia Specialist Directory connects people with aphantasia to therapists, counsellors and coaches who understand the unique aspects of this neurological difference.
References
Cuijpers, P., Reijnders, M., & Huibers, M. J. (2019). The Role of Common Factors in Psychotherapy Outcomes. Annual Review of Clinical Psychology, 15(1), 207-231. doi:10.1146/annurev-clinpsy-050718-095424
Horvath, A. O., Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-16. doi:10.1037/a0022186
Levitt, H. M., Pomerville, A., & Surace, F. I. (2016). A qualitative meta-analysis examining clients’ experiences of psychotherapy: A new agenda. Psychological Bulletin, 142(8), 801-830. doi:10.1037/bul0000057
Tschacher, W., Haken, H., & Kyselo, M. (2015). Alliance: A common factor of psychotherapy modeled by structural theory. Frontiers in Psychology, 6. doi:10.3389/fpsyg.2015.0042
Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277. doi:10.1002/wps.20238
Ward, Alie (Host) (2017-Present) Ologies: Pedagogology (science communication) with Bill Nye [Audio podcast]. Ologies. https://www.alieward.com/ologies/billnye
Zeman, A., Dewar, M., & Sala, S. D. (2015). Lives without imagery – Congenital aphantasia. Cortex, 73, 378-380. doi:10.1016/j.cortex.2015.05.019
As her interview with Bill Nye drew to a close, Alie, of the Ologies with Alie Ward podcast
I hope you, too, will keep this joy of discovery in mind as you discover aphantasia
Therapy And Aphantasia
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