The Language Problem: How Simple Word Changes Make Therapy Work for Aphantasia

In this groundbreaking presentation, Dr. Merlin Monzel delivered surprising news for the estimated 4% of the population who have aphantasia: anxiety treatments that rely on mental imagery can work for them too - but only if therapists change how they communicate.

Dr. Monzel's latest research, published as a stage two registered report titled "Propositional thought is sufficient for imaginal extinction," challenges long-held assumptions about imagery-based therapeutic techniques and opens new doors for treating anxiety disorders in people with aphantasia.

The Problem with Traditional Anxiety Treatment

Exposure therapy is one of the most common and effective treatments for anxiety disorders and phobias. When real-world exposure isn't possible - such as treating fear of flying or war trauma - therapists often turn to "imaginal exposure," asking patients to vividly imagine confronting their fears.

But what happens when a patient literally cannot create mental pictures? This question has puzzled researchers and clinicians working with people who have aphantasia, the inability to generate voluntary mental imagery.

"We had some situations in the lab where aphantasics said to us during the imaginal extinction period: 'What do you mean by imagine the Christmas bauble? I cannot imagine,'" Dr. Monzel explained during his presentation to the Aphantasia Network.

Testing Fear Without Pictures

To investigate whether mental imagery is actually necessary for anxiety treatment, Dr. Monzel's team designed an ingenious experiment using a technique called "imaginal extinction" - a laboratory analog of imaginal exposure therapy.

The study involved three groups:

People with aphantasia

Neurotypical controls

"Simulated aphantasics" (people temporarily unable to visualize due to bright light exposure)

Participants first underwent "fear conditioning," where they learned to associate a Christmas bauble image with painful electric shocks. Then came the crucial test: during the imaginal extinction phase, participants heard audio cues (like "Christmas bauble") and were asked to "imagine" the object in detail - but this time without any shocks.

Throughout the experiment, researchers measured both physiological fear responses (skin conductance, which increases when we sweat from fear) and subjective fear ratings.

The Surprising Results

The findings challenge everything we thought we knew about imagery-based therapy:

Fear extinction worked equally well for all groups. People with aphantasia showed the same physiological pattern as controls - their fear responses decreased just as effectively during the imaginal phase, despite their inability to create mental pictures.

Aphantasics reported feeling less afraid. While their bodies showed the same fear responses, people with aphantasia subjectively experienced less distress during the procedure compared to the control groups.

These results suggest that mental imagery isn't necessary for imaginal exposure therapy to work - a finding with profound implications for clinical practice.

The Key: Changing the Language

The breakthrough came when researchers realized the problem wasn't with the therapy itself, but with how it was communicated. When therapists say "imagine playing with a dog," people with aphantasia may simply disengage because they don't understand what's being asked of them.

Dr. Monzel suggests therapists should use alternative language that aphantasics can work with:

Instead of: "Imagine playing with a dog"

Try: "Describe playing with a dog in as much detail as possible"

Or: "Think about playing with a dog"

Or: "Write down a story with a dog in as much detail as possible"

With these simple language adjustments, imagery-based therapeutic techniques become accessible to people with aphantasia - and may even be equally effective.

A Less Distressing Path to Recovery

Perhaps even more intriguingly, the research suggests that non-imagery-based approaches might actually be superior for everyone, not just people with aphantasia.

"When the effectiveness of non-imagery based strategies and imagery based techniques is the same, you should always use the non-imagery based techniques because they are less distressing," Dr. Monzel noted. This could lead to higher therapy completion rates and better outcomes across the board.

The Aphantasia-Alexithymia Connection

The study also revealed an intriguing pattern: people with aphantasia showed a disconnect between their physiological fear responses and their subjective experience of fear. Their bodies reacted with fear, but they didn't feel as afraid.

Dr. Monzel suggests this might be related to alexithymia - difficulty identifying and describing emotions - which appears to be more common in people with aphantasia. This "decoupling" between physical and emotional responses has been observed in alexithymic individuals before.

What This Means for Treatment

The research has immediate practical implications:

Therapists can confidently use imaginal exposure with aphantasic clients - they just need to adjust their language and instructions

People with aphantasia shouldn't avoid imagery-based therapies - these treatments can work for them when properly adapted

The underlying mechanism may be conceptual rather than visual - thinking about or describing feared situations in detail may be sufficient to achieve therapeutic benefits

Non-imagery approaches might benefit everyone - being less distressing while equally effective

Looking Forward

While promising, Dr. Monzel acknowledges limitations in the current research. The memory consolidation period was shortened to accommodate travelling participants, and the findings need validation in real clinical settings rather than laboratory conditions.

"I would love to do this but we need more contact to practitioners in this case or to patients who have maybe experience with this kind of therapy in the field," he explained.

A New Hope for Diverse Minds

This research represents a significant step forward in making mental health treatment more inclusive and effective for neurodivergent populations. By recognizing that different minds work differently - and that effective treatment doesn't require everyone to think in the same way - we can develop more personalized and successful therapeutic approaches.

For the millions of people with aphantasia who may have struggled with traditional imagery-based treatments, this research offers new hope: effective anxiety treatment is possible, it just requires therapists to speak their language.

The key insight is beautifully simple: when we can't see in our mind's eye, we can still think, describe, and conceptualize our way to healing. Sometimes the most profound discoveries come not from developing entirely new treatments, but from making existing ones accessible to everyone.

For those seeking mental health support, our Aphantasia Specialist Directory connects people with aphantasia to professionals who understand the unique aspects of this neurological difference.