DELHI PSYCHIATRY JOURNAL Vol. 15 No.

APRIL 2012

Case Report

Psychotherapeutic Management of
Night-time Fears
S. Malhotra1, G. Rajender2, M.S. Bhatia3
Department of Clinical Psychology, CNBC Hospital & MAMC, Delhi,
2
Department of Psychiatry, Mahatma Gandhi Medical College, Jaipur,
3
Department of Psychiatry, UCMS & GTB Hospital, Delhi
1

Introduction
Nightmares and fear of sleeping alone are
common in children but may become developmentally inappropriate and more problematic,
warranting clinical intervention. Behavioural
approaches such as the operant reinforcement of
appropriate nighttime behaviour and not reinforcing
anxious/ avoidant behaviours have been shown to
be effective in such cases1. Nocturnal anxiety in
children has also been managed through cognitive
behavioural programmes that combine exposure,
cognitive restructuring, relaxation and incentive
programmes2. Yet another technique that has been
reported to be effective in the treatment of childhood
phobias is emotive imagery3 and refers to imagery
that produces positive feelings (for example, selfassertion, pride, affection) and other similar anxiety
inhibiting 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 favourite heroes
helping them to be brave or fight back when the
feared object is presented 4 . The child may be
encouraged to pretend to be some hero and take on
their characteristics (for example, courage or special
powers). Emotive imagery has been specifically
recommended for managing nighttime fears.5,6 It has
been assumed that emotive imagery may be
particularly useful in treating anxiety where the
phobic object is imaginary, such as monsters and
ghosts and conventional invivo exposure is not
possible7 .
The present case study highlights the process
of psychotherapy for a six year old boy reporting
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with fear of ghosts.

Case Report
T, a six year old boy studying in Grade 2 from
urban background, was brought by his mother for
complaints of nightmares about ghosts, not going
to sleep with lights off as he feared ghosts may come
since last one year. The child also reported fear of
being left alone at nighttime and refusal to sleep
alone owing to this fear of ghosts. There were no
complaints regarding childs affect, other anxiety
disorders or any other psychiatric/ neurological
illness. T reported high levels of anxiety (increased
heart rate) and cognitions (that is, ruminations that
ghosts do exist; they will come and harm him/ his
family). He also reportedly experienced frequent
nightmares involving ghosts chasing, attacking,
hurting him/ his family members. However, he
denied ever seeing any ghosts.
Baseline Assessments
The initial assessment comprised of psychiatric
interviewing and detail work up. Visual Analogue
Scale (VAS) was used as an outcome measure,
which is a ten point equidistant scale ranging from
0 to 9 where 0 stands for no problem and 9 stands
for maximum problem. Patient himself and his
parents reported the severity of the problem on VAS
every alternate day during the course of treatment.
Based on the parental reporting and interview
sessions the goal of the present intervention
programme was outlined so to enable the patient to
overcome his presenting problems and deal with
the underlying cognitive factors associated with his
symptoms. The three goals that were set included
(a) to decrease his nocturnal fear of ghosts, (b) to
decrease the frequency of nightmares and (c) to be

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DELHI PSYCHIATRY JOURNAL Vol. 15 No.1

able to sleep with lights off.

Since the child himself requested his mother
to help him get rid of his fear of ghosts and had
good cognitive abilities, cognitive restructuring was
used along with emotive imagery.
Since the fearful stimuli elicited emotions in
the child, they were reinforcers in terms of operant
conditioning. Since being alone in the dark triggered
fear and anxiety, the alleviation of that anxiety
reinforced avoidance behaviour. His avoidance
behaviour may have also been reinforced by his
parents always accompanying him whenever he
wanted them to be with him and not being left alone.
Thus, ongoing experiences were the maintaining
factors for continuing behavioural problems.
Management
Psychotherapeutic intervention was given
during a total of eight sessions, each lasting for
approximately one hour spread over a period of
three weeks. After the initial session which focused
on assessment and diagnosis of the patient, all other
sessions were so planned that after every session
the child and his family members were given a few
assignments involving therapeutic techniques that
were to be followed and monitored at home.
The first intervention session focussed on goal
setting, but cognitive restructuring and emotive
imagery were also introduced. Next few sessions
focussed on the development of emotive imagery
techniques. Appropriate reinforcements and
relaxation were also introduced. The cognitive
restructuring sessions, focussed on altering Ts
beliefs about existence of ghosts so that they
become less threatening to him. In this process of
cognitive restructuring, T himself came up with the
supposed origin of his fear- watching of horror
shows on television. This made the process of
cognitive restructuring easier as the child himself
had come up with this supposed origin. Emotive
imagery was also used along side and the child was
encouraged to pretend himself to be like his
favourite cartoon character (that was supposed to
have special powers to fight with and defeat ghosts).
However, care was taken to ensure that the child
did not over pretend this cartoon role as this would
have led to further behavioural problems. All his
efforts were consistently reinforced.

the course of treatment revealed marked decrease

in childs fear (Pre-intervention score of 8 and post
intervention the score was 2). He made significant
progress during the course of intervention sessions.
The present case study illustrates the effective use
of emotive imagery and cognitive restricting in the
treatment of nocturnal anxiety and fear of ghosts in
a child as young as six years of age. The rationale
for using emotive imagery in this case included
previous evidence of its effectiveness in treatment
of childhood phobias3 and nocturnal anxieties4. The
most remarkable aspect about this case study was
the way the child himself wanted treatment of his
ghost fear and his active participation throughout
the treatment. Emotive imager y along with
cognitive techniques seems to have considerable
potential as an effective technique in working with
children in managing their anxieties and fears.
References
1. Cellucci AJ, Lawrence P S. The efficacy of
systematic desensitization in reducing
nightmares. J Beh Ther Exper Psychiat 1978;
9 : 109-144.
2. Lazarus AA, Abramovitz A. The use of emotive
imagery in the treatment of childrens phobias.
J Ment Sci 1962; 198 : 191-195.
3. Graziano AM, Mooney KC, Huber C, Ignasiak
D. Self-control instructions for childrens fear
reduction. J Beh Ther Exper Psychia 1979; 10
: 221-227.
4. King NJ, Heyne D, Gullone E, Molloy G N.
Usefulness of emotive imagery in the treatment
of childhood phobias: Clinical guidelines, case
examples and issues. Counseling Psychol Quart
2001; 14 : 95-101.
5. Cornwall E, Spence E, Schotte D. The effectiveness of emotive imagery in the treatment of
darkness phobia in children. Behav Change
1996; 13 : 223-229.
6. King NJ, Cranstoun F, Josephs A. Emotive
imagery and childrens nighttime fears: A
multiple baseline design evaluation. J Beh Ther
Exper Psychia 1989; 20 : 125-135.
7. Shepherd L, Kuczynski A. The use of emotive
imagery and behavioural techniques for a 10
year old boys nocturnal fear of ghosts and
zombies. Clin Case Studies 2009; 8 : 99-111.

Outcome and Discussion

Both childs and parents ratings on VAS during
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