Clinical Case Studies 2009 Shepherd 99 112

Clinical
Case Studies
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The Use of Emotive Imagery and Behavioral Techniques for a 10-Year-Old Boy's
Nocturnal Fear of Ghosts and Zombies
Laura Shepherd and Adam Kuczynski
Clinical Case Studies 2009 8: 99
DOI: 10.1177/1534650108329664
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The Use of Emotive Imagery

and Behavioral Techniques for
a 10-Year-Old Boys Nocturnal
Fear of Ghosts and Zombies
Clinical Case Studies

Volume 8 Number 2
April 2009 99-112
2009 SAGE Publications
10.1177/1534650108329664
http://ccs.sagepub.com
hosted at
http://online.sagepub.com
Laura Shepherd
Kings College London
Adam Kuczynski
Great Ormond Street Hospital, London
This case describes the use of emotive imagery and behavioral techniques in treating a
10-year-old boys nocturnal fear of ghosts and zombies. His anxiety had led to nightmares and
avoidance of sleeping in his bedroom. To a significant degree, the intervention was led by the
child. With the therapists support, the child developed and deployed a number of imaginary
characters during and between sessions to reduce his sense of threat about ghosts and zombies.
Relaxation, boundary setting, and an incentive program were also implemented to target residual avoidant behavior. Self-reported anxiety measured by a diary and on the Spence Childrens
Anxiety Scale reduced during the course of treatment. Furthermore, the frequency of his nightmares decreased and the number of nights that he spent in his bedroom increased. The case
highlights the effectiveness of emotive imagery in treating anxiety surrounding imaginary
creatures in children. It also suggests that behavioral techniques may also be required to
effectively promote behavior change.
Keywords:
anxiety; imagery; nightmares; ghosts; child
Theoretical and Research Basis

Fear is a natural and adaptive response to threatening stimuli. It has cognitive, affective,
physiological, and behavioral components (Herbert, 1994). The types of stimuli which
elicit fear change as children grow older in tandem with developments in the childs cognitive and social competencies and concerns. Toddlers typically fear imaginary or supernatural creatures. In early childhood (5 to 7 years), fear of natural disasters and diseases is
common. During middle childhood (8 to 11 years), fear of failing in academic or athletic
domains emerges (Klein, 1994; Ollendick, King, & Yule, 1994).
A distinction can be made between normal (adaptive) fears based on accurate appraisals
of the potential threats posed by stimuli or situations and maladaptive anxiety based on
inaccurate appraisals (Ollendick et al., 1994). Clinically, children are typically referred for
Authors Note: Please address correspondence to Dr. Laura Shepherd, Institute of Psychiatry, Kings College
London, Addiction Sciences Building, 3rd floor, 4 Windsor Walk, London, SE5 8AF, United Kingdom; phone:
+442078480223; e-mail: laura.shepherd@iop.kcl.ac.uk.
99
100
treatment of anxiety if it prevents them from completing developmentally appropriate tasks,

such as going to school or socializing with friends (Carr, 1999).
Phobic anxiety is defined by DSM-IV-TR as an intense and persistent fear which is provoked by an object or situation from a circumscribed class of stimuli (American Psychiatric
Association, 2000). Furthermore, the fear is disproportionate to typical adult appraisals of
the stimulus threat, and leads to persistent avoidance, emotional distress, and functional
impairment. DSM-IV-TR reported current prevalence rates of between 4% and 8.8%, with
lifetime prevalence rates between 7.2% and 11.3% in community samples.
There is evidence that a significant proportion of phobias presenting in adulthood dates
back to childhood (Hugdahl & st, 1985; Marks & Gelder, 1966), suggesting the importance of early and effective intervention. Antony and Barlow (2002) proposed a model
explaining the etiology of specific phobias. They argued that a nonspecific genetic predisposition to experience anxiety and a linked psychological vulnerability interact with life
experiences. These experiences follow the three pathways to fear identified by Rachman
(1976, 1977): direct conditioning, vicarious (observational) learning, and information.
Antony and Barlow exemplified the three pathways in terms of being involved in a car accident, witnessing someone else experience a car accident, and reading or being told about
the dangers of driving, respectively. Substantial support for both direct and indirect forms
of phobia acquisition has been reported (Di Nardo et al., 1988; st, 1985, 1991; st &
Hugdahl, 1985). Interestingly, Davey (1992) has argued that the pathways of phobia acquisition may be different in adults and children, with indirect (i.e., vicarious or information
learning) being more important in the development of phobias in children.
Behavioral therapy directly addresses the avoidance that characterizes phobias. This
involves exposing the person to the phobic object, either gradually (systematic desensitization) or in a nongraduated manner (flooding) until anxiety subsides. These can be in
vivo or imagined. Exposure is widely considered to be both necessary and sufficient for
treating a wide range of specific phobias in adults (Antony & Barlow, 2002), including
fear of spiders (st, Salkovskis, & Hellstrm, 1991), snakes (Gauthier & Marshall, 1977),
thunder and lightning (st, 1978), and heights (Baker, Cohen, & Saunders, 1973). Further
evidence suggests that exposure techniques, particularly in vivo, are effective for treating
specific phobias in children (Kendall & Treadwell, 1996). The child can be helped during
exposure through techniques such as relaxation, positive imagery, and coping statements.
Cognitive theory offers a complementary approach to understanding phobic anxiety (Beck,
Emery, & Greenberg, 1985). This highlights the significance of threatening thoughts or
beliefs about an object or situation in causing anxiety and avoidance. Cognitive therapies
involve cognitive restructuring, in which individuals monitor situations where anxiety-related
cognitions occur and engage in activities that challenge their validity. Research shows that
anxiety is associated with a threat-sensitive cognitive style, and that cognitive strategies have
been usefully combined with behavioral exposure in the treatment of phobias (Antony &
Barlow, 2002; Craske & Rowe, 1997; Kendall & Treadwell, 1996). This includes childrens
fears of medical procedures, darkness, and school (Heard, Dadds, & Conrad, 1992).
Nightmares and a fear of sleeping alone are common in children but may become developmentally inappropriate and more problematic, warranting clinical intervention. Again,
behavioral approaches such as the operant reinforcement of appropriate nighttime behavior
Shepherd, Kuczynski / Emotive Imagery and Behavioral Techniques
101
and nonreinforcement of anxiety or avoidant behavior have been shown to be effective in

such cases (Cellucci & Lawrence, 1978; Kellerman, 1980). Nocturnal anxiety has also been
reduced through cognitive-behavioral programs that combine exposure, cognitive restructuring, relaxation, and incentive programs (Graziano, Mooney, Huber, & Ignasiak, 1979).
Another technique that has been used in the treatment of childhood phobias is emotive
imagery. This was pioneered by Lazarus and Abramovitz (1962) and refers to imagery that
produces positive feelings (e.g., self-assertion, pride, or affection) and other similar anxietyinhibiting responses. It is considered to be a form of systematic desensitization because the
child engages in emotive imagery while anxiety-provoking items are gradually introduced.
This typically involves the therapist helping the child to develop a story about the childs
favorite heroes helping them to be brave or fight back when the feared object is presented
(King, Heyne, Gullone, & Molloy, 2001). The child can also pretend to become the hero and
take on their characteristics (e.g., courage or special powers). Jackson and King (1981)
reported the successful treatment of a child with darkness phobia by imagining that Batman
was with the child and keeping the child safe. Similarly, emotive imagery has been found to
be effective in reducing nighttime fears and worries about nighttime creatures (Cornwall,
Spence, & Schotte, 1996; King, Cranstoun, & Josephs, 1989) as well as other phobias (CritsChristoph & Singer, 1983).
It seems that emotive imagery may be particularly useful in treating anxiety where the
phobic object is imaginary, such as monsters or ghosts, and conventional in vivo exposure
is not possible. In this context, the present case study describes the use of emotive imagery
to treat a 10-year-old boys nocturnal fear of ghosts and zombies, with associated nightmares and avoidance. The case also highlights the utility of additional behavioral
techniques in further reducing avoidant behavior.
Case Introduction
Marco (name changed) was a 10-year-old Portuguese boy living in the United Kingdom.
He was referred to his local child and adolescent mental health service by his family doctor, concerning nightmares about ghosts and zombies at nighttime. This had developed into
a fear of being alone at nighttime and a refusal to sleep in his bedroom. At the time of referral,
Marco would only sleep in his parents bedroom.
Presenting Complaints
The presenting problems were closely concerned with the nocturnal fear of ghosts and
zombies. No concerns about mood, other anxiety disorders, or other symptomatology were
expressed by Marco or his family.
Marco reported increasing anxiety and worry during the course of each evening as bedtime approached. This included one physiological sign (increased heart rate) and cognitive
symptoms (i.e., rumination and beliefs about the existence of ghosts and zombies and their
potential to harm him). Marco also experienced distressing nightmares on approximately 2
102
nights a week, each time involving ghosts and zombies chasing, attacking, and hurting him.
However, he denied ever seeing or hearing any ghosts or zombies.
Marcos mother reported that the nightmares had occurred for more than 1 year. During
this time, Marco had become progressively more afraid of being alone at nighttime and
more avoidant of his bedroom. Instead, Marco typically got into bed with his mother until
his father went to bed, whereon he slept on their bedroom floor in a sleeping bag. At assessment, this had occurred every night for approximately 1 year. This made him feel safer
and less scared. His parents had tried to persuade Marco to return to his own room (e.g., by
saying his room was nice and safe and that he was too old to sleep with them), but this had
only distressed him further. Their other attempts to reduce his anxiety (e.g., leaving the bedroom light and television on and leaving the door open) were also unsuccessful.
History
His mother described Marcos birth and early and subsequent development as normal,
apart from his current phobia. Marco lived in a flat with his married parents and an older
brother (aged 16 years). He also had two other older brothers who lived away from the family home. Marco appeared to have good relationships with his parents and the two oldest
brothers, although there had been some recent stressful events. These included his father
being diagnosed with cancer the year before (in remission at the time of treatment) and a
preferred brother moving abroad (although they maintained telephone contact). Also Marco
was aware that his parents had argued more than usual recently.
In contrast to his relationships with other family members, Marco seemed less close to his
16-year-old brother. Marco said that they argued every other day and that his brother frequently teased and scared him (e.g., telling him that their house was haunted, jumping out
from behind Marcos bedroom door, and waving his arms around and making spooky wailing noises). Marco interpreted this as meaningful and threatening. That said, his mother perceived it as playful and thought that her sons did not argue any more than most other siblings.
Marco was considered to have normal cognitive abilities. For example, his teacher had
no concerns about his development and described his school attainment as within the average range. He presented as socially interested and communicative. Both he and his mother
confirmed that he had friends at school. As noted above, he had no concerns about home,
school, or other areas of daily life. Marco said that he did not enjoy school but liked art. In
particular, he enjoyed drawing cartoons. There was no family history of sleep or other psychological difficulties nor had there been any previous involvement with child and adolescent mental health services.
Specifically regarding sleep, Marco had slept in his parents bedroom until he was 2 years
old. He had then shared a room with the older brother who remained in the household, but
occasionally went into his parents room at nighttime. This arrangement continued until 2
years before the referral. At that time, the two oldest siblings left home and Marco moved
into a bedroom by himself. He then started to experience nightmares. These were occasional
at first but gradually became more frequent until the time of the referral and assessment.
103
Assessment
The initial assessment comprised an unstructured interview with both Marco and his mother,
conducted by the first author, who was undergoing doctoral training in clinical psychology, and
a qualified and experienced child clinical psychologist. The interview was increasingly guided
by DSM-IV-TR criteria for specific phobia (American Psychiatric Association, 2000).
Considered against these criteria, it was clear that Marco displayed a marked and persistent fear
that was excessive and cued by the anticipation of a specific class of object (i.e., ghosts and
zombies). Exposure to the phobic stimulus (i.e., being alone in his bedroom at nighttime)
almost invariably provoked an immediate anxiety response and was avoided, which significantly interfered with Marcos life. The problem had persisted for more than 6 months and
could not be better accounted for by another mental disorder. Therefore, Marco received the
diagnosis of a specific phobia (300.29) of the other type. No other diagnoses were made on
Axes II to IV. In keeping with the specificity of the difficulty in the context of generally good
functioning, the Axis V Childrens Global Assessment Scale rating was 65.
Marco was able to reflect on and verbalize his thoughts and feelings, including his
beliefs about ghosts and zombies. At first, Marco said that he was 80% sure that The
ghosts want to scare me. He also believed that They lived in my house before, then they
died, and now they want their house back and me to move out, The ghost can have my
body to live again and They are going to get me if I fall to sleep.
Interestingly, Marco described overcoming a previous fear of The Addams Family (a comically macabre fictional film family) by imagining their imprisonment. However, he said that
this strategy had not been successful against ghosts and zombies as they were Too strong.
The Spence Childrens Anxiety Scale (SCAS; Spence, 1998) was administered as a standardized self-report measure of anxiety. At assessment, Marcos total score on the SCAS
was 70 (z = 2.58), consistent with unusually elevated anxiety.
Case Conceptualization
Arguably, the present problem could be simply formulated in terms of basic learning theory. For example, according to classical conditioning models, the brothers play frights
(i.e., jumping out from behind the bedroom door) and viewing scary movies may have led
to a conditioned fear of his bedroom. However, following Staatss (1981, 1996) theory of
psychological behaviorism, the formulation can be substantially enhanced by the inclusion
of other human factors at different levels. This is depicted in Figure 1 below.
The formulation proposed that Marco may have been predisposed to anxiety and
associated behaviors by his experience of previous and current anxiety-provoking events
within the family system. This may have included his fathers illness, his older brothers
emigration, and arguments between his parents. The specific nature of Marcos phobia may
have been determined not only directly by the brothers playacting but also through the
transmission of generational and cultural learning. This included the familys shared beliefs
about the existence of ghosts and watching scary movies. In fact, Staats (YEAR) stressed
104
Figure 1
Formulation of Marcos Difficulties
Anxiety in the family
system (e.g. illness,
emigration, arguments)
Brothers play-frights
Conditioned anxiety
response to being in
his bedroom
Watching scary
films in his bedroom
Developmental
readiness
Avoidance of
bedroom a
night
Fear
Own beliefs and
imagery about
harmfulness of ghosts
Nightmares
Familys beliefs about

the existence of ghosts
the importance of vicarious learning, primarily language mediated, in the learning of a wide
range of emotional responses. This is similar to Rachmans (1977) position that vicarious
and informational learning can be pathways to phobias.
Marcos learning from these experiences would have been in keeping with his developmental level, which may have been characterized by the relative accessibility of images
compared with complex language, and an ambiguity regarding the distinction between
imaginary and real events.
It was formulated that gradual learning over time gave rise to basic behavioral repertoires
that were concerned with fear of ghosts and zombies. These involved both the language-cognitive system, linking words, images and emotions, and the emotional-motivational system,
whereby the emotions affected his behavior, notably leading to avoidance. The preponderance of imagery in these systems may have contributed to his nightmares.
Returning to basic learning theory, Staats (YEAR) reasoned that because stimuli elicited
emotions, they were reinforcers in the sense of operant conditioning. In this case, because
the bedroom came to elicit fear and anxiety, the alleviation of that anxiety reinforced the
avoidance. Furthermore, Marcos avoidance may also have been reinforced by his parents
allowing him to sleep in their bedroom. Thus, ongoing experiences continued to maintain
the existing behavioral repertoires. In terms of protective factors, Marco and his family
recognized that his fear and avoidance had become maladaptive and there was a need for
emotional and behavioral change.
105
Course of Treatment and Assessment of Progress

Marco was offered seven intervention sessions, each lasting approximately 1 hour, at
his local child and adolescent mental health center. Six of the sessions were at weekly
intervals with the final session occurring 2 weeks after the sixth. The intervention sessions
were administered by the first author, under the supervision of a qualified child clinical
psychologist. Most of each session was spent with Marco alone. Importantly, Marco
engaged well and appeared comfortable with the therapeutic relationship. He always tried
out the strategies discussed in sessions and gave feedback on how useful they had been.
His mother joined him at the beginning and end of each session to give an independent
report of behavioral change and hear a summary of the work to date. This enabled her to
support her son throughout the intervention, including praising his attempts to complete his
therapy homework between sessions.
The first session focused on goal setting, but cognitive restructuring and emotive
imagery were also introduced. Sessions 2 to 5 emphasized the development of emotive
imagery techniques, although one also incorporated advice on boundary setting. The sixth
session was allocated to developing an incentive program and relaxation techniques. The
final session was to review the incentive program and end treatment.
Marcos self-reported anxiety during the course of the sessions was measured in two
ways. The SCAS (Spence, 1998) was administered at assessment and at the final session.
Second, Marco was asked to complete a simple diary every morning based on his experience of the previous night. This had been developed collaboratively with Marco so that he
understood how to use it. The diary recorded subjective nocturnal anxiety ratings (0 to 10;
0 representing no fear and 10 representing the most scared he could be), incidence of
nightmares, and where he had slept (yes or no according to whether he had slept in his
own bedroom or not).
The different components of the intervention are described in more detail below, in approximately
chronological order.
A. Goal setting: Marco identified three goals: (a) to decrease his nocturnal fears of ghosts
and zombies, (b) to decrease the frequency of his nightmares, and (c) to increase the frequency of nights he slept in his own bedroom alone. His mother shared these goals.
B. Cognitive restructuring: This involved attempting to alter Marcos beliefs about the ghosts
and zombies (e.g., their existence and intent to frighten and harm him) so they became less
threatening to him. However, Marco seemed convinced that they existed and could not generate any positive or less threatening reasons for their existence. Furthermore, he would not
entertain suggestions made by the therapist. As a consequence, emotive imagery techniques became the main focus of treatment.
C. Emotive imagery: When discussing coping strategies, Marco suggested that thinking of
good things might stop bad thoughts. As mentioned above, he had previously used
imagery independently to decrease his anxiety regarding some fictional characters.
Further questioning revealed that Marco believed that the Tasmanian Devil or Taz,
one of his favorite cartoon characters, definitely wouldnt be scared of ghosts or zombies and would scare them away by beating them up because he is strong. Moreover,
Taz could probably imprison zombies but not the ghosts because they can escape from
prisons by walking through the walls. He was encouraged to imagine Taz imprisoning
106
the zombies during the session and prompted to describe what he imagined vividly in different modalities (e.g., what he saw, heard, smelt, and touched). Marco was then asked to
repeat this at home during the subsequent week. This strategy proved partially effective
almost immediately. At the second treatment session, he stated, Im safe from them
[zombies] now and reported no further anxiety about zombies.
Given this change, emotive imagery played a significant role in further treatment. He
was very much involved in generating the emotive imagery described above and appeared
engaged in this process. For example, he regularly drew pictures of the characters without
being prompted. However, Marcos fear of ghosts was more resistant than his fear of zombies. During sessions 3 to 5, Marco introduced more characters, who chased the ghosts
away and acted bravely, into his emotive imagery and practiced using emotive imagery
between sessions. His efforts were consistently praised to reinforce this behavior. Marco
was 99% sure that a giant robot would be able to chase the ghosts away. When this proved
partially effective, Marco recruited extra help to deal with the harder ghosts, such as
some older boys with an army of cars to chase ghosts away and tricks to tie ghosts up.
Meanwhile, he drew pictures of Taz and other characters to put in his bedroom as
reminders of his coping strategies and to chase ghosts away.
Marco said he was 80% confident that this would make the more difficult ghosts go away.
However, despite steady decreases in self-reported anxiety during sessions, his avoidance of sleeping in his own bedroom persisted.
D. Boundary setting and behavioral techniques: At session 5, Marcos mother reported that
Marco often delayed going to his bedroom at night even if he would eventually sleep
there. She was advised to set a regular bedtime routine supported by firm boundaries.
By session 6, Marco was sleeping in his own bedroom more often, but with his mother
sharing the bed all night to ease his anxiety. This time, she was advised to spend only 10 to
15 minutes with Marco in his room at bedtime, before leaving and not returning despite any
protest by Marco. It was hoped Marco would learn that his mother would not return once she
had left, despite any protesting. Furthermore, they agreed on an incentive program whereby
Marco would earn a computer game if he successfully slept alone in his bedroom for 2 weeks.
E. Relaxation: In session 6, Marco was also taught relaxation techniques. He completed the
My Relaxing Place exercise, outlined by Stallard (2002). This involved him imagining
the sights, sounds, smells, tastes, and tactile sensations of a waterfall in a forest. He drew
a picture of this scene to place near his bed as a reminder to visualize it. Marco added his
own suggestions of relaxing activities (e.g., having a bath, listening to relaxing music, and
watching boring television before bedtime) and wrote them down to remind himself.
F. Further emotive imagery work: During the 2-week period of the incentive program after
Session 6, Marco had developed his emotive imagery independently and described this in
Session 7, the final session. It involved two kung-fu cartoon characters who locked ghosts
away in Demon World from where they were unable to escape. By this time, he had
spent 2 weeks sleeping alone in his bedroom without feeling much anxiety.
It is clear from this account that Marco had made significant progress during the course
of seven treatment sessions, notably with reference to his goals of decreased nocturnal
107
Figure 2
Self-Reported Anxiety at Assessment
(Session A) and on Treatment Sessions 1 to 7
10
80
6
40
4
Diary rating
SCAS total
60
20
2
SCAS total
Mean weekly
diary rating
0
A
Session
anxiety, an increased frequency of sleeping in his bedroom alone, and decreased nightmares (Figures 2 to 4, respectively).
His progress appeared to be clinically significant, including a shift in SCAS scores from
the clinical to the normal range and a decrease in self-reported anxiety (indicated in
Figure 2 by the use of anchors). He also exhibited consistent positive changes on all other
measures. Perhaps most significantly, Marco had slept alone in his bedroom for the 2 weeks
preceding the final session. Also he had experienced only one nightmare in that period,
which had not been about ghosts or zombies. Importantly, he got up to tell his parents about
the nightmare but then went straight back to his own room. Both Marco and his parents
reported being pleased about these changes.
It was also interesting to observe apparent cognitive changes despite the setting aside of
formal cognitive restructuring early on in the intervention. At assessment, Marco believed
that ghosts and zombies were real creatures that could physically harm him. However,
toward the end of treatment, he began to think that ghosts and zombies were in [his] imagination, not real and therefore harmless. This was supported by evidence such as If they
were real, thousands of people would have seen them and they havent. Marco attributed
this shift to the effectiveness of emotive imagery.
That said, the change seemed incomplete, preserving the possibility of the reality of the
supernatural creatures. For example, Marco was only 90% sure that ghosts could not hurt
him. When asked about emotive imagery, Marco explained that it had worked in two ways:
by really beating the ghosts up and by simply imagining that this was happening. When
questioned about the prison and Demon World, he said, The places are real inside my
head, but not outside my head. They are places all monsters can go if you want to get rid
of them. You imagine putting them there. Theyre not real but in my imagination. Finally,
108
Figure 3
Frequency of Nightmares at Assessment
(Session A) and on Treatment Sessions 1 to 7
Nightmares
0
A
Session
when asked about the 10% uncertainty regarding the danger posed by ghosts, he replied
They might get out of Demon World.
Complicating Factors
One complicating factor concerned the possibility of partial avoidance of sleeping in his
bedroom alone at night. It transpired that Marco kept a television or light on at nighttime
throughout treatment. This behavior was not targeted because of time limits on the treatment. Instead, Marco was encouraged to use coping strategies to deal with any behaviors
that might constitute residual or recurrent avoidance of sleeping alone in his room. At the
final session, it was encouraging that Marco and his family agreed he could achieve the
goals of turning off the television and light without professional support.
Despite the apparent significance of cognitions in Marcos initial presentation, formal
cognitive restructuring was of limited utility. This appeared to be because of the strength
of his belief in the reality of supernatural beings, which only wavered after substantial
behavioral change. It would have been informative to track cognitive change even
though this was not the focus of the intervention. It may also have been timely to reintroduce cognitive strategies to address the persistence of the weakened belief if still
maladaptive.
Evaluating the outcome of treatment was complicated by Marcos irregular completion
of the anxiety diary, either through forgetfulness or temporarily losing the diary, such that
only 50% of the maximum possible number of ratings was available. This was in contrast
to 100% maternal report of nights spent in his room and nightmare frequency. It might have
been helpful to incorporate the diary more directly into the appealing aspects of treatment
(e.g., including pictures of Taz or other imagined characters chasing ghosts away).
109
Figure 4
Frequency of Night Spent in His Own Bedroom in the Weeks
Preceding the Assessment (Session A) and on Treatment Sessions 1 to 7
7
Nights in own room
6
5
4
3
2
1
0
A
3
4
Session
Follow-Up
A follow-up appointment could not be offered to Marco because of service restrictions.
Treatment Implications of the Case

The present case illustrates the contribution of emotive imagery to the treatment of nocturnal anxiety in a boy with a phobia of imaginary creatures, in conjunction with conventional behavioral techniques. The rationale for using emotive imagery in this case included
previous evidence of its effectiveness in the treatment of childhood phobias (Jackson &
King, 1981; King et al., 2001) and nocturnal fears and worries about nighttime creatures
(Cornwall et al., 1996; King et al., 1989). However, at least as important was its apparent
fit with the childs abilities and aptitudes. That was, his artistic skills and imagination.
Aspects of the formulation were in agreement with theoretical accounts of the etiology
of phobias (Antony & Barlow, 2002), notably the information pathway to fear proposed by
Rachman (1976, 1977). In this case, sources of information included the familys cultural
beliefs and an older brothers attempts to frighten the child appeared to be linked to strong
beliefs about the reality and threat posed by supernatural creatures. The presence of such
anxiety-provoking beliefs is, of course, also consistent with cognitive theories of anxiety
(Beck et al., 1985).
The intervention did not directly address these threatening beliefs because the child did
not engage in initial cognitive restructuring attempts. Rather, it used the childs aptitudes
and existing strategies (e.g., drawing and the use of imagery). This approach seemed to
facilitate his obvious engagement, including examples of adherence to homework and his
spontaneous development of new and more powerful emotive imagery. The good outcome
110
is at least consistent with the currently modest evidence base supporting the application of
emotive imagery in the treatment of childhood anxieties and fears.
Arguably, the imagery was a relatively safe and acceptable means of imaginal exposure
to ghosts and zombies (rather than, say, imagining and overcoming his worst fears of being
harmed by them), in keeping with behavioral therapies. However, one may also consider
emotive imagery as a cognitive technique in the sense of having an indirect effect on
beliefs. Indeed, this work coincided with a significant cognitive shift regarding not just the
danger posed by ghosts (which one might predict from exposure alone) but in their existence (which one would not necessarily otherwise expect). Indeed, Marco attributed this
shift in his belief to the emotive imagery. It was as if he had reasoned that because he could
beat his fear of ghosts using his imagination, the ghosts could only exist in his imagination.
This in turn enabled him to appraise other relevant evidence (e.g., If they were real, thousands of people would have seen them and they havent). As described above, his beliefs
remained somewhat contradictory in this respect. However, Marco anticipated that he
would be able to think of other reasons why such creatures were not real as he got older,
suggesting a grasp of the significance of cognitions in his fear.
That said, the intervention also involved more conventional behavioral techniques and
the good outcome might be attributed to their established effectiveness in the treatment of
avoidance in specific phobias (Antony & Barlow, 2002; Baker et al., 1973; Gauthier &
Marshall, 1977; st, 1978; st et al., 1991) and child nocturnal anxiety (Cellucci &
Lawrence, 1978; Kellerman, 1980). Therefore, it remains an open question whether emotive imagery was an effective means of change or whether it may be better understood as a
useful adjunct to standard exposure-based treatments.
Recommendations to Clinicians and Students

One of the most interesting aspects of the case for us was the way in which the course
of treatment was substantially determined by the child himself, including the choice of
emotive imagery as a technique. To a large extent, the child treated himself, supported by
his family and the psychologist. Letting the child lead the way may give rise to uncertainty on the part of professionals. However, it may also facilitate the childs motivation and
ability to engage in the treatment.
Emotive imagery seems to have considerable potential as a technique in working with
children. It allows children to exercise their imagination with favorite characters and engage
in enjoyable activities such as drawing, while limiting the role of language. The possibility
that it also brings about significant cognitive change merits more systematic investigation.
Of course, letting the child take the lead may mean that significant factors in the formulation are overlooked in treatment. For example, relatively little attention was given to
parental beliefs and emotions about the feared stimuli or their sons anxiety. It is important
to be aware that certain parental characteristics are implicated in child anxiety, including overcontrol, a reluctance to promote autonomy, and reinforcement of avoidance (Barrett, Rapee,
Dadds, & Ryan, 1996; Dadds, Barrett, Rapee, & Ryan, 1996; Rapee, 1997; Siqueland,
Kendall, & Steinberg, 1996). There were signs of this in the present case, such as the mother
sharing her sons bed when he first returned to sleeping in his own room. The significance
111
of examples such as this may need to be considered by clinicians working with anxious
children, particularly if the problem seems intractable.
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Laura Shepherd, at the time of submission, was a clinical psychologist in training at the Institute of Psychiatry,
Kings College London, United Kingdom. She worked with this case while undertaking her core child and adolescent mental health placement, as part of her doctoral training. Her interests include anxiety, trauma, and pediatric and adult clinical health psychology.
Adam Kuczynski is a clinical psychologist at Great Ormond Street Hospital, London, United Kingdom. He
was the clinical supervisor for the case. His interests include pediatric neuropsychology.

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The Use of Emotive Imagery