From the detailed notes of interviews with the included 10 participants, 6 themes were identified; 1) psychoeducation versus misinterpretation, 2) balancing depth with accessibility, 3) aesthetic appeal, 4) contextual relevance and realism, 5) daily stressors, and 6) parental and social relationships. In addition, the reflections of the research team after interviews was amalgamated and presented under interviewer reflections.
Theme 1: Psychoeducation versus misinterpretation
Adolescents and their caregivers consistently highlighted that the book was helpful in providing ways to manage anxiety, especially in a context of uncertainty and disadvantage. They also felt it connected with the need to share with family and friends, and seek support from others. This was particularly favored by parents, who reported feeling their children do not share much with them.
Adolescent 1, 13 years old: ‘Breathing slowly helps you calm down’
Mother 1; ‘I liked how the book emphasized communication. The parents and the doctor helped the child get over the problem. Kids don’t tell parents about their fear, or about school. It’s really important to sit with your child and understand their fears.’
Mother 1: ‘The nightmare part was good; learning to understand what caused it and what happened before it.’
Adolescent 3, 15 years old: ‘It gives an idea about fear.’
Mother 3: ‘The idea is to face your fear to get rid of it.’
Mother 1: ‘I liked the fact that the book mentioned a series of problems in the girl’s life. It showed that life problems never stop, you have to keep dealing with them.’
However, both adolescents and parents struggled to extrapolate meaning from some of the metaphors and images used in the book, with children in particular taking messages literally. For example, the clinically commonly used analogy of doing laundry as a metaphor for trauma processing, was often understood by children as the need to keep up with chores. The analogy of the impossibility of not thinking about ‘an elephant on roller-skates’ (amended from the commonly used ‘don’t think about a pink elephant’) as an analogy for the negative consequences of thought suppression, was understood by some families as the need to not think about difficult memories, which is the opposite of the intended meaning.
Mother 3: ‘I like the idea of laundry, there’s a lot of work. I relate to it [laughter in the room]’
Interviewer: ‘What did you understand from the elephant on the wheels?’
Adolescent 3, 15 years old: ‘Think of something funny.’
Mother 3: ‘It’s rhetorical. Don’t make a big deal out of the dream. Even big worries or difficulties go away. They will get resolved… Humor can help in tense situations, I do that with my husband when we fight.’
Interviewer: ‘What did you get out of the laundry part?’
Adolescent 3, 13 years old: ‘The laundry: do it and fold it.’
Mother 3: ‘The laundry stands for something else: I do my work step by step, I become organized.’
Adolescent 3, 15 years old: ‘There’s an idea but it’s unclear.’
Interviewer: ‘What did you understand of the part about the elephant on wheels?’
Adolescent 4, 15 years old: ‘You can avoid thinking about the shark or the nightmare.’
Theme 2: Balancing depth with accessibility
The comic book format was liked by families, and kept adolescents engaged in the story. Most families were literate enough to follow the story as it was being read to them, but reported that children would struggle to read and understand the book without help from an adult. There were divided opinions about how to remedy this, with some parents suggesting more explanations and that the book can then be explained by the parent to the child, with others suggesting that the book should keep its format to remain accessible to children.
Father 1: ‘We can help her understand it [the laundry analogy], and later discuss it.’
Mother 1: ‘It’s more beneficial to read it together and discuss it aloud together. Discussing the story after will clarify some ideas.’
Mother 3: ‘Maybe reduce the photos.’
Adolescent 3, 13 years old: ‘No.’
Mother 3: ‘I want more words.’
Father 1: ‘I also think the book should be more simplified.’
Theme 3: Aesthetic appeal
Families also commented on the appeal of the pictures and language in the book. They suggested splitting and organizing content differently, and reframing the text, for example to avoid repeatedly using the word ‘fear.’ Families indicated that the aesthetic appeal was important for engagement in the story.
Mother 3: ‘There was a section where “fear” was repeated; it made the story weaker. You can put it like this: عندما تواجهي مخاوفك يقل الخوف في المرة القادمة التي يثار فيها شعورك [when you face your fear, it will diminish the next time you feel it]’
Adolescent 3, 15 years old: ‘You can split the second part into two: one with the teacher and another with the counselor.’
Theme 4: Contextual relevance and realism
Families gave consistently helpful feedback about ways to address issues with the book content. In particular, the setting and experiences of the family in the book were reported to be more relevant to older generations, who faced active war and armed conflict. Most of the adolescents interviewed were from Palestinian camps, and were born in Lebanon so were exposed more to poverty and disadvantage than active conflict or war.
Father 1: ‘Somoud’s pain is temporary, ours was much more intense. We lived through the Israeli raids. There were almost 62 airstrikes per minute. We had no time to move the bodies off the streets. We developed crocodile skin to adapt and become immune.’
Interviewer: ‘Do you think of adaptation as a positive thing?’
Father 1: ‘It is a good thing because it helps you live, but it makes a part of you die.’
Father 1: ‘The main problem with children lies in their environment... They have no place to play at [sic] and release their energy. No place at all. I cannot take my children out to play once a week. The child cannot let out his energy in a positive way. The harder problem is that you cannot change your child’s environment. I understand what my environment is like, but I cannot extract my child out of it.’
Theme 5: Daily stressors
Families were concerned with chronic stress and uncertainty, social injustice, discrimination, bullying, parental fighting, and financial insecurity, and the need for children to be resilient and responsible to withstand these difficulties.
Father 1: ‘The camp is divided into districts with some safer than others. I know where we stand inside the camp, but, at the end of the day, we’re still inside the camp.’
Interviewer: ‘What other topics should be added to the book?’
Adolescent 4, 15 years old: ‘Getting bullied.’
Interviewer: ‘okay, by who?’
Adolescent 4, 15 years old: ‘Relatives, school children, even siblings!’
Father 1: ‘The lesson that I want to be taught to children: You have to adapt to tough situations. I have seen so many tragedies in the previous wars, but I learned to adapt to them…you should face your fears; confrontation is more important than breathing [exercises]. The book should focus more on teaching the child not to let the fear live with them.’
Father 1: ‘Trauma/shock (صدمة) is another problem children face. I want my child to be able to differentiate between my death in the camp by a random drug dealer and my death in the South of Lebanon in a protest for the Palestinian cause.’
Interviewer: ‘I’m not sure I understand what you mean?’
Father 1: ‘Life goes on regardless of what happens.’
Theme 6: Parental and social relationships
Many families described the need to include the parental struggle, and the importance of both parental and wider community relationship strengthening, in helping adolescents. Some adolescents also added the stressor of parental fights and family discord as challenging for their mental health and wellbeing.
Father 1: ‘The story needs to address the problems of the parents as well; that is not novel, that this is something your parents and their parents have also lived through. The father is doing all he can.’
Mother 1: ‘The kids are stronger than before, but friendships and social bonds are decreasing lately. Children can’t seem to find enough friends. They’re even worried about the cohesion of their own family. People only act for self-interest.’
Mother 3: ‘Parent’s anger is an issue.’
Adolescent 3, 15 years old: ‘How it affects the children.’
Mother 3: ‘How to resolve fights and control one’s emotions, such as by going out or revising one self.’
The interview reflections predominantly concerned the cultural and contextual response of the story and content of the book. Overall, the interviewer felt that concepts of talking to others, facing fears, and social support were culturally acceptable and well received. The use of a nightmare as the hook of the storyline was also thought to be helpful, given its cultural and religious significance. Dreams were found to be an accessible way to talk about mental states, and a helpful way to explore how nightmares can signify emotional distress in the same way that pain can signify physical injury. However, some families seemed to understand facing fears within the narrative of bravery vs cowardice, which inferred shame on those who feel fear or who avoid anxiety-provoking situations. Whilst facing fear is the backbone of psychoeducation on anxiety, shaming is likely to be harmful, and psychoeducation may therefore need to explicitly clarify the difference between anxiety and cowardice, in order to reduce shame and promote adaptive coping. The need to normalize avoidance, as well as nightmares and anxiety, as a core part of the story was felt to be important. Given the range of literacy levels within families, balanced with the need to provide detailed explanations, the interviewer suggested a solution to improve access across families. The solution was to maintain the comic book format, but integrate more explanations for parents, encouragement for children and parents to read together, and to provide audio recordings of the book.