Experiences of Emotional Healing After Figurines Intervention in Rural Thai Primary School Children: A Mixed-method Study

INTRODUCTION

Emotional health is a vital component of overall well-being in primary school children and adolescents. Poor emotional health can manifest various difficulties, including increased vulnerability to depressive symptoms, anxiety, and other mental health challenges. Globally, concerns about children’s emotional well-being have grown, with depression rates among primary school children and adolescents estimated at 21.30% for mild to severe depression, 18.90% for moderate to severe depression, and 3.7% for major depression. ¹ In Southeast Asia, including Thailand, these challenges are increasingly evident. For example, 17.2% of Chinese primary school students exhibit depressive symptoms, ² while approximately 32% of children and adolescents in Thailand experience symptoms related to emotional distress or depression. ³ The situation is particularly pressing in rural areas such as Nakhon Si Thammarat in Southern Thailand, where limited access to mental health services exacerbates emotional health concerns. ⁴ Reports indicate a rising prevalence of emotional and mental health problems among children in these regions, with younger children showing increasing symptoms of depression and anxiety. ⁵ These findings underscore the urgent need for targeted emotional health interventions and support systems in rural communities to promote resilience and well-being among children. ⁶

Emotional health in childhood is crucial for a child’s overall development and quality of life, impacting not only the children but also their family, community, and society. Poor emotional health, if left unaddressed, can lead to serious problems such as complex mental health disorders, substance abuse, self-harm, and even suicide. ⁷ Children struggling with emotional challenges often experience academic problems, social withdrawal, and trouble forming healthy emotional relationships, which can result in long-term adverse effects. ⁸ These challenges extend beyond the individual, causing emotional distress and financial strain for families and placing additional burdens on healthcare systems. ⁵ On a broader scale, inadequate support for children’s emotional health limits their potential, affecting societal well-being and future national development. ⁵

The causes of emotional health challenges in children are complex and multifaceted, often arising from a combination of biological, psychological, and environmental factors. For children, especially in rural areas, a significant barrier is the lack of emotional awareness and emotional literacy. Many children are unaware of their feelings and find it difficult to express their emotions effectively, which can lead to internalized distress and emotional problems. ⁷ In rural Thailand, cultural norms may discourage open discussions about emotions, making it harder for children to seek help when they experience feelings such as sadness or hopelessness. ⁹ Moreover, limited access to mental health resources and professionals in these areas worsens the situation as children’s emotional needs often go unnoticed or are misunderstood. ^{4 , 10} The lack of emotional vocabulary and supportive community structures makes it challenging for children to process and understand their emotions, increasing the risk of developing more serious emotional health problems. ¹¹

In rural Thai schools, emotional health care for children is often assigned to a single teacher, usually one with a background in physical education or general education but without specialized training in emotional or psychological support. These teachers are responsible for monitoring students’ overall well-being, but they often lack the skills needed to identify, assess, or provide support for children facing emotional difficulties. ¹² Emotional challenges remain stigmatized and poorly understood in Thai society, leaving teachers feeling unprepared to address them effectively. Consequently, emotional health issues are often only recognized when they become severe, such as through prolonged sadness or noticeable behavioral changes. ⁴ In these cases, teachers typically involve parents or guardians to seek assistance from local healthcare providers or mental health specialists. This delayed response is further complicated by the scarcity of mental health resources in rural areas, limiting timely and effective emotional support. These constraints make it difficult to provide adequate care, leaving children vulnerable to worsening emotional and psychological conditions. ¹³

Figurine-based Neuroscience and Satir in the Sand Tray self-discovery offer a safe, effective, and accessible approach to supporting children’s emotional health, especially in rural areas where mental health resources are limited. By using miniature figurines as a tool for self-expression, children can safely explore and articulate their emotions, enhancing their understanding of their inner experiences. ¹⁴ This method promotes emotional literacy, encourages self-reflection, and helps children develop healthy coping strategies. ⁹ Moreover, studies have demonstrated that art-based interventions like figurine therapy are practical and beneficial in real-world settings such as schools and community centers, where children can receive ongoing emotional support. ^{7 , 10} Grounded in research and positive outcomes, this approach presents a promising and sustainable way to nurture emotional well-being, particularly in underserved communities.

Exploring children’s personal experiences using figurines to promote self-discovery can enhance their understanding and capacity for positive emotional growth. This phenomenological approach offers valuable insights into how children navigate their emotional challenges, particularly in rural areas where support for emotional health is scarce. ^{7 , 9} The process of self-discovery and healing through figurines helps children manage and express their emotions while empowering them with tools for self-care and emotional resilience. ^{10 , 15} Although previous studies have demonstrated the benefits of art-based therapy, there remains a gap in understanding the internal emotional journeys children experience during these transformative processes. ^{16 , 17} By focusing on the lived experiences of primary school children in rural Thailand, we aims to fill that gap and deepen our understanding of how self-discovery and emotional healing contribute to long-term emotional well-being. Therefore, this study aimed to explore the lived experiences of emotional healing after figurines intervention in rural Thai primary school children.

MATERIALS AND METHODS

This is a mixed-method research design conducted from March to May 2025 in Tha Sala Sub-District, Tha Sala District, Nakhon Si Thammarat Province, Thailand. In the first phase, a pre- and post-test design was performed on adolescents aged 10 to 12 years; the inclusion criteria were being in grades 4-6 at a rural primary school where socio-economic challenges and mental health concerns were prevalent, and having mild (scores 5–9) to moderate (scores 10–14) levels of depression according to the Patient Health Questionnaire for Adolescents (PHQ-A).

The questionnaire contains 9 questions scored on a 4-point Likert scale with values from 0 (Not at all) to 3 (Nearly every day). A total score is calculated by summing the item responses ranging from 0 to 27; higher scores are associated with higher levels of or more severe depression. The score ranges of PHQ-A are categorized into five levels: 0–4 indicates no depression, 5–9 mild depression, 10–14 moderate depression, 15–19 moderately severe depression, and 20–27 severe depression. ¹⁸ As the PHQ-A is a standardized tool, validity testing was not conducted before its use. However, reliability was estimated using 30 primary school students from another school, resulting in a reliability coefficient of 0.87.

Of the 109 students in the rural primary school which completed PHQ-A, 22 had mild to moderate levels of depression that were willing to participate in the emotional care intervention using figurines.

This intervention aimed to use figurines to facilitate emotional expression, self-awareness, and self-care. The intervention consisted of both group activities and individual sessions designed to foster a supportive environment and help the children explore their emotions. In this intervention, group activities referred to two workshop sessions attended by all participating students, held once a week for two consecutive weeks. Each session lasted five hours and included two short breaks and one lunch break. The workshop process incorporated both large-group and small-group activities. Students were divided into smaller groups of 5–6 participants to allow for open discussion and personal sharing before regrouping for large-group activities. After the workshops, each student also participated in one individual session, which provided a space for self-reflection. During this session, they explored their emotions, thoughts, and expectations, and were engaged in self-care using figurines as a medium. Group activities began with ice-breaking exercises to build rapport, set expectations, and create a safe space for learning. Grounding and mindfulness exercises, including the butterfly hug technique, were also introduced to help students relax and focus on the present moment. In individual sessions, students selected a figurine that resonated with them and participated in reflective discussions facilitated by trained nursing students, exploring their emotions, thoughts, and self-perceptions.

After the intervention, the PHQ-A was readministered, and all 22 students completed the questionnaire to assess changes in their emotional well-being. In the second phase of this study, a descriptive phenomenology study was done to explore lived experiences of the students from emotional healing after figurines intervention. Based on purposeful sampling and data saturation, nine students (four boys and five girls) were selected to participate in in-depth interviews. Their inclusion criteria in this phase included: participation in all sessions of the figurine-based emotional care intervention, the ability to provide rich and meaningful descriptions of their experiences, willingness to participate in the interview, and parental or guardian consent for participation. The exclusion criteria included students who were unwilling to participate in the study after the interview, and a lack of consent from parents or guardians. In this study, PHQ-A scores were considered as a quantitative indicator of depression to reflect dimensions of emotional health. Symptoms of depression across emotional, cognitive, behavioral, and physical domains shape how individuals perceive and live with their emotional well-being. Such symptoms often lead to distress that is both deeply felt and embodied. To enrich this understanding, emotional health was explored through the analysis of children’s healing stories.

Participants were interviewed using a semi-structured design, using questions such as: “What insights did you see when looking at the figurines?” “What was happening with the figurine—how did it feel or what was it expressing?” and “What did you desire, and how might the figurine care for itself?”. After viewing and tending to their inner selves with the figurines, the interviewer asked: “What internal changes have you noticed since using the figurines?” “How did the figurine feel?” “What helped the change?” “If you feel worse in the future, how would you use the figurines to care for yourself?” The interviewer was the first author, a psychiatric nurse trained in figurinebased emotional care using the sand tray modality, assisted by Madeleine De Little, originator of the Neuroscience and Satir in the Sand Tray approach in Thailand. To gather in-depth phenomenological data, each participant was interviewed individually in a private room at the school for 30 to 60 minutes, depending on their comfort and engagement. The interviews began by establishing trust and ensuring a safe, supportive environment, followed by a casual conversation to ease into the discussion. Open-ended questions were then asked, with probing questions to encourage deeper reflection on their experiences. The children were invited to share any events or observations related to using figurines for emotional care. Data collection and analysis occurred concurrently, allowing for the identification of the key themes related to the children’s experiences of using figurines for emotional healing and psychological well-being. Sampling continued until data saturation was reached, meaning interviews were conducted until rich, relevant, and abstract data were consistently obtained, and no new insights regarding the essence of the phenomenon emerged.

The goal of the analysis was to achieve a meaningful understanding of the socialemotional experiences of rural Thai primary school children when interacting with figurines. The study adopted Colaizzi’s sevenstep descriptive phenomenological method. ^{19 , 20 , 21} Analysis was conducted manually without the use of qualitative data analysis software. The steps followed were: (1) reading all participant transcripts repeatedly to gain a general understanding, (2) extracting significant statements directly relevant to the phenomenon of emotional healing/psychological wellbeing, (3) formulating meanings from those significant statements, (4) organizing the formulated meanings into themes and subthemes, (5) constructing an exhaustive description of emotional status experiences with the figurines, (6) identifying the fundamental structure of that phenomenon of emotional healing or psychological wellbeing, and (7) validating findings with participants (member checking) to ensure that the description faithfully represents their experiences. Interview responses were transcribed verbatim. Transcript validity and accuracy were checked by comparing the transcripts with the original audio recordings. The research team manually coded and sorted the data using thematic tables. Throughout all steps, the team engaged in discussion to reflect on possible biases considering the backgrounds, experiences, and assumptions of the researchers. The final verification process included peer debriefing and participant feedback to confirm or refine the themes and ensure authenticity of the findings.

To ensure the rigor and trustworthiness of this phenomenological study, we applied the four criteria of credibility, dependability, transferability, and confirmability. ^{22 , 23} Credibility was strengthened by member checking, where selected participants reviewed summaries of their interviews to confirm accuracy; peer checking among the research team members to ensure consistency in interpretations; and prolonged engagement in the field, which allowed the first author to build trust and deeply understand the sociocultural context. Dependability was maintained via a detailed audit trail documenting all steps of analysis, including verbatim transcripts, extraction of significant statements, formulation of meanings, thematic tables, coder discussions, and reflective notes capturing decision points and changes over time. Transferability was supported by maximum variation sampling combined with thick, rich descriptions of participant characteristics, rural school setting, intervention process, and cultural background, allowing the readers to assess applicability in similar contexts. Confirmability was ensured by reflexivity: the research team considered how their own assumptions, backgrounds, and potential biases might influence interpretation; data interpretations were grounded in the participants’ own quotes; and peer debriefing and team discussions checked the findings to be rooted in the data rather than researcher expectations. Analysis was concluded when the themes consistently reflected the participants’ perspectives and no new relevant insight emerged, indicating data saturation.

This research was part of a large Path 2 Health project: “Development of the Cooperation among Education, Health, and Community Systems to Promote Youth Leaders Caring for their Mind and the Mind of People in their Families, Schools, and Communities”.

The project was also approved by the Committee on Human Rights Related to Research Involving Human Subjects, Walailak University, Thailand (No: WUEC-21-271-01). The present study was approved by the Ethics Committee in Human Research Walailak University, Thailand (No: WUEC-25-081-01). Participants and their parents/guardians were informed about the purpose and nature of the research before providing written consent, with the understanding that they could withdraw consent at any time during the interview and were assigned an identification number used to maintain the participants’ anonymity.

RESULTS

After the intervention, all 22 participants showed a decrease in their individual PHQ-A scores. Each student’s pre- and post-intervention scores were compared. The mean PHQ-A score for the entire group of 22 students decreased from pre-test (10.05±2.87) to post-test (4.09±1.41) (P=0.01). Based on data from 9 participants in the qualitative phase of the study, the mean depression score decreased from pre-test (10.78±2.33) to post-test (3.33±0.87), (P=0.08).

The qualitative phase of the study was conducted with 9 primary school students. The participants’ characteristics are presented in Table 1. From data analysis, 29 codes, 10 sub-themes, and three themes were identified, which are fully detailed in Table 2. The themes were awakening self-awareness, emotional healing, and developing personal growth.

1. Awakening Self-awareness

Within the dimension of awakening self-awareness, three sub-themes emerged: “Recognizing and understanding one’s emotions”, “Understanding connections between emotions, thoughts, needs, and behaviors”, and “Recognizing personal needs and self-care”.

1.1. Recognizing and Understanding One’s Emotions

Under the first sub-category, there were three codes: recognizing a range of emotions, recognizing the intensity of emotions, and identifying emotional triggers.

1.1.a. Recognizing a Range of Emotions

The first experience of almost every student is understanding that a single event or situation can evoke multiple feelings simultaneously. This awareness often comes as a first step toward self-awareness. One emphasized:

“…When my parents fought and left, I felt sad, angry, lonely, lost, and like I didn’t matter. I felt unwanted and unloved. It was the first time I saw so many different feelings in myself. Sometimes, I even felt guilty and hoped they’d come back…” (P2).

1.1.b. Recognizing the Intensity of Emotions

Recognizing the change in the intensity of emotions in a spectrum-like manner, with shifts between high and low levels, is significant, as one person mentioned:

“…My friend bullies me, calling me “fat pig” and “big bowl”. At first, I tried not to get mad, but over time, I got so angry and hated them because it was just too mean…” (P5).

1.1.c. Identifying Emotional Triggers

Participants were able to recognize and identify triggers that stimulated their emotions. This awareness helped them develop greater understanding and sensitivity. Analyzing the causes allowed them to know and understand themselves better, making them more equipped to face triggering situations. As one person mentioned:

“…Every time my mom compares me to my siblings or others, and uses a stern, disappointed voice, it hurts my heart. I feel sad, pressured, and my body feels empty, like I don’t exist in that moment…” (P8).

1.2. Understanding Connections between Emotions, Thoughts, Needs, and Behaviors

For the sub-theme of understanding the connection between emotions, thoughts, needs, and behaviors, there were three codes: recognizing how emotions influence thoughts and behaviors, understanding how thoughts and needs influence emotions, and recognizing that emotions can motivate or limit actions.

1.2.a. Recognizing How Emotions Influence Thoughts and Behaviors

Using figurines to reflect on emotions helps the participants understand how their feelings influence their thoughts and behaviors. This insight allows them to recognize the connection between emotions and actions. As one participant mentioned:

“…When I reflected on my figurine, I saw myself when I was really angry. I started thinking that everything was unfair, and then I said hurtful things to my friend. Sometimes, when my anger got worse, it made me think about kicking my friend too…” (P3).

1.2.b. Understanding how Thoughts And Needs Influence Emotions

Encouraging the participants to analyze their thoughts and needs helps them understand how these factors influence their emotions. By recognizing this connection, they can gain greater clarity and insight into their feelings. As one participant mentioned:

“…I’ve just realized that the reason I felt so guilty, sad, and disappointed is because I overthink. I care about how they feel, and I just want them to love me, pay attention to me, and care for me like they used to…” (P4).

1.2.c. Recognizing that Emotions Can Motivate or Limit Actions

Encouraging the participants to recognize how their emotional state affects their actions helps them understand how emotions can either motivate or limit their behavior. This awareness allows them to better manage their emotions and responses. As one participant mentioned:

“…Even when I do my best to do my homework and tests, sometimes when I feel scared, stressed, or worried, I end up avoiding doing them. Or sometimes, when I feel sad, I don’t want to do anything at all…” (P9).

1.3. Recognizing Personal Needs and Self-care

As to recognizing personal needs and self-care, the study found three codes: understanding the importance of self-care in emotional well-being, recognizing when I need self-care, and recognizing when to ask for help.

1.3.a. Understanding the Importance of Self-care in Emotional Well-being

Experiencing and acknowledging emotional struggles helps the participants understand the importance of self-care in maintaining emotional balance. By recognizing the need to take responsibility for their own well-being, they learn to prioritize actions that promote healing. As one participant mentioned:

“…When I feel sad or upset, I know I need to take care of myself by talking to someone or doing something that makes me feel better…” (P7).

1.3.b. Recognizing when I Need Self-care

Encouraging the participants to recognize signs of overwhelm or emotional burnout helps them become more aware of when they need rest and self-care. This awareness empowers them to take the necessary steps to restore their well-being. As one participant mentioned:

“…I’ve found that if I feel tired, disappointed, or drained from school, friends, and family for a long time, my body and mind need rest and self-care to feel better again…” (P1).

1.3.c. Recognizing when to Ask for Help

Helping the participants recognize the warning signs that indicate when they need to ask for help enables them to seek support on time. This awareness empowers them to reach out when needed, preventing emotional struggles from becoming overwhelming. As one participant mentioned:

“…I realize that if I cry every day, feel bad, sad, lost, stressed, or worried, I can ask for help from my grandma, teacher, or friends. It would be better to ask for help early rather than to wait until it gets worse and try to fix it later. I can ask as many times as I need without worrying. It’s okay…” (P6).

2. Emotional Healing

Four sub-themes were identified in the dimension of healing from depression: “Self-compassion and acceptance”, “Emotional healing through expression”, “Building emotional resilience”, and “Finding hope and positivity”

2.1. Self-compassion and Acceptance

We found four codes in this sub-theme: accepting mistakes and imperfections, recognizing and validating emotions, nurturing inner peace and forgiveness, and encouraging self-care and self-kindness.

2.1.a. Accepting Mistakes and Imperfections

Self-reflection helps participants recognize mistakes and imperfections as part of growth, encouraging them to learn from errors without self-blame. As one participant mentioned:

“…I made a mistake, and that’s okay. Everyone makes mistakes sometimes, and it doesn’t mean I’m bad. I’ll just learn from it and do better next time…” (P3).

2.1.b. Recognizing and Validating Emotions

The process of grounding helps the participants recognize and validate their emotions, allowing them to accept their feelings without judgment. This practice encourages self-compassion and helps them move forward with greater resilience. As one participant mentioned:

“…I feel really upset right now because I didn’t do well on my test, but I know it’s okay to feel this way. It doesn’t mean that I’ m a failure. I’ll just try harder next time…” (P7).

2.1.c. Nurturing Inner Peace and Forgiveness

The focus on positive changes in the process of self-care helps the participants nurture inner peace and practice forgiveness. By disregarding negative emotions, they create space for healing and emotional well-being. As one participant mentioned:

“…I’m still mad at my parents for what happened, but I know holding on to this anger is not helping me feel better. I’ll forgive them and let it go, so I can feel more peaceful…” (P2).

2.1.d. Encouraging Self-care and Self-kindness

Focusing on positive self-perception helps the participants prioritize self-care and kindness, encouraging them to take time for activities that promote relaxation and well-being. As one participant mentioned:

“…Today, I studied hard and came home to work hard helping my grandpa. I’m going to reward myself by watching TV and listening to my favorite music, so I can feel better and relax…” (P4).

2.2. Emotional Healing Through Expression

In emotional healing through expression, we found three codes: releasing emotions through talking, healing through creative expression, and engaging in mindfulness or meditation practices.

2.2.a. Releasing Emotions Through Talking

Encouraging the participants to reflect on their feelings, emotions, thoughts, and needs helps create a natural flow, allowing them to process and release difficult emotions. This approach facilitates continuous expression and provides an opportunity to speak about what has been weighing on their hearts. As one participant mentioned:

“…I feel a lot better after talking. Sometimes, when I’m upset, I don’t even know what is bothering me, but when I say it out loud, it makes sense. It’s like all the bad feelings get out of my chest, and I feel lighter…” (P1).

2.2.b. Healing Through Creative Expression

Speaking out and expressing everything helps the participants release their emotions, creating a sense of relief and healing. This process allows them to externalize their feelings, leading to greater emotional clarity and calmness. As one participant mentioned:

“…I can share my feelings, thoughts, and everything in my mind through my figurines. It’s like telling the figurines everything that’s making me feel upset. After I say it all, I feel calmer. It’s like talking to my figurines helps make the bad feelings go away…” (P8).

2.2.c. Engaging in Mindfulness or Meditation Practices

During the grounding process, using the Butterfly Hug along with alpha wave music helps the participants reconnect with themselves in the present moment. Focusing on their breath and cultivating feelings of happiness lead to a state of mindfulness, promoting calmness and concentration. As one participant mentioned:

“…When I do the Butterfly Hug with my eyes closed, slowly moving my hands back and forth, breathing deeply, and thinking about happiness, I find my focus and connect with myself. When I listen to music during this, I feel so peaceful and relaxed that I don’t want that moment to end…” (P1).

2.3. Building Emotional Resilience

The results revealed three codes: overcoming negative emotions, gaining strength from challenges, and developing a positive mindset.

2.3.a. Overcoming Negative Emotions

Seeing negative emotions through the figurine helps the participants acknowledge and understand their feelings, providing a clearer path to overcoming them. This perspective allows them to manage their emotions more effectively, embracing the process of healing without rushing. As one participant mentioned:

“…When I see my sadness through the figurine, I feel really sad, but I tell myself, “It’’s okay; this feeling will pass.” I just try to take it one step at a time and not expect myself to feel better right away…” (P7).

2.3.b. Gaining Strength from Challenges

Challenges and suffering help the participants grow by providing valuable lessons in problem-solving and resilience. These experiences serve as exercises in understanding, processing, and moving forward, ultimately leading to personal growth. As one participant mentioned:

“…Even though I feel bad every day, I know it helps me learn how to be stronger. Even if I fail, I’ll just get up and try again. I can get through this…” (P5).

2.3.c. Developing a Positive Mindset

Focusing on change in a positive direction helps the participants shift their perspective, allowing them to recognize the strength and resilience that support their journey. This mindset fosters hope, patience, and the ability to find the good, even in challenging times. As one participant mentioned:

“…When I see the figurine in the sand tray, even though life has been through so many tough things, I can still see the good aspects. I see the patience and strength that have helped me get through. I just need to give myself time and look for it…” (P7).

2.4 Finding Hope and Positivity

In this sub-theme, there are three codes: shifting focuses to positive aspects, discovering the possibility of change, and building a sense of gratitude.

2.4.a. Shifting Focuses to Positive Aspects

Shifting focuses to positive aspects through asking positive questions, even in tough situations, helps the participants find hope and appreciation in their surroundings. As one participant mentioned:

“…Even though today feels really tough, I can still think about how my dog always makes me smile, and how my mom makes me feel safe…” (P9).

2.4.b. Discovering the Possibility of Change

Helping the participants see and explore different options allows them to recognize the possibility of change. This approach encourages them to stay open to new possibilities and take proactive steps towards improvement. As one participant mentioned:

“…Maybe if I keep trying to talk to people more, I feel better, and things could get a little easier. I don’t know how yet, but I can try. I’ll give myself the chance to change…” (P8).

2.4.c. Building a Sense of Gratitude

The process of cultivating positive energy through overcoming challenges and growth helps the participants develop a sense of gratitude. By recognizing the support they have around them, they learn to appreciate even the smallest blessings in their lives. As one participant mentioned:

“…I know I’m not alone; even though I feel bad. I’m thankful for the small things, like having myself, I have teachers, friends, figurines, and my grandma still with me. I still have toys, food, and snacks at school…” (P4).

3. Developing Personal Growth

This study revealed three sub-themes of developing personal growth components: “Increased self-confidence and self-worth”, Understanding and managing emotions, and “Developing coping skills”.

3.1. Increased Self-confidence and Self-worth

Three codes were extracted from the data in the sub-theme, including recognizing personal strengths and potential for growth, challenging negative self-beliefs, and recognizing one’s value and self-worth.

3.1.a. Recognizing Personal Strengths and Potential for Growth

By viewing themselves more holistically and realistically, the participants can recognize their strengths and potential, even in challenging situations. They begin to see their self-worth and develop a more positive outlook, understanding that they can grow and improve despite setbacks. As one participant mentioned:

“…I didn’t think I was good at anything, but I started to notice that I’m good at helping my friends when they feel bad. Maybe I can help people more. I think I can get better at a lot of things if I try…” (P3).

3.1.b. Challenging Negative Self-beliefs

The process of self-transformation helps the participants challenge negative self-beliefs. They learn to accept that nobody is perfect and that mistakes are part of growth. This shift in mindset allows them to release self-criticism and view their flaws as opportunities for learning and improvement. As one participant mentioned:

“…Sometimes I think I’m not good enough, but I know that everyone has things they’re not perfect at. I can make mistakes and still be okay. I can learn from them and try again…” (P6).

3.1.c. Recognizing One’s Value and Self-worth

The process of self-reflection helps the participants rediscover their value and recognize their self-worth. This understanding empowers them to overcome feelings of invisibility and embrace their unique contributions. As one participant mentioned:

“…I sometimes feel like I’m invisible or that I don’t matter, but I know now that I do. I have things to offer, and I deserve to be happy. I’m not just a kid; I’m important too…” (P9).

3.2. Understanding and Managing Emotions

The sub-themes were developed from two codes: identifying and naming emotions, and learning how to regulate emotions.

3.2.a. Identifying and Naming Emotions

Participants can identify the events and their emotional and physical responses. This process helps them identify and name the specific emotions they experience, providing greater clarity and self-awareness.

“…My mom said that I would not be able to continue my studies because we don’t have enough money at home, and I need to help with work. When I think about this, my stomach hurts, my heart races, and I feel restless. I think I’m feeling anxious…” (P3).

3.2.b. Learning How to Regulate Emotions

They have learned to recognize their emotions, responses, and their impacts, along with various methods for regulating emotions through the figurine application process, helping them develop self-care tools. As one person stated:

“…When I feel angry, I try to take deep breaths. It helps me feel a little better. I can’t stop being angry, but I can make myself calm down…” (P1).

3.3. Developing Coping Skills

In developing coping skills, two codes were found: practicing self-care to enhance well-being and developing healthy coping strategies.

3.3.a. Practicing Self-care to Enhance Well-being

The practice of self-healing through happiness, using the process of applying figurines, helps the participants learn how to take care of their own emotional well-being and create happiness. It also enables them to manage challenging emotional states on their own. As one person mentioned:

“…When I feel like crying, I take a break and listen to music or draw. It helps me feel calmer, like I’m not so alone with my feelings…” (P3).

3.3.b. Developing Healthy Coping Strategies

The participants have developed better coping strategies, starting with reconnecting with themselves. This process begins with calming down and practicing mindful breathing to achieve a sense of “grounding,” which helps them gain better control over their emotions and situations. Additionally, they have learned to communicate or seek support from trusted individuals. As one person mentioned:

“…When I get really upset, I try to talk to my mom or take a few deep breaths. It makes me feel like I can handle things better…” (P1).

DISCUSSION

This study investigated the healing experiences of rural Thai primary school children with mild to moderate depressive symptoms who participated in a school-based figurine program, identifying three central themes: awakening self-awareness, emotional healing, and developing personal growth. These themes shed light on significant facets of emotional health development within an underserved population, yet also raise important concepts about the efficacy, sustainability, and cultural contextualization of such interventions.

The first theme, “awakening self-awareness,” revealed that children reported enhanced abilities to recognize, identify, and understand their emotions, which are essential skills for building psychological resilience and promoting preventive mental health care. ²⁴ These developments may stem from the process of symbolic expression through the use of figurines, which allows children to safely externalize their internal experiences through scene creation, storytelling, and role playing. This is especially valuable during early developmental stages when children still face limitations in language and emotional expression. The figurine activity naturally encourages self-reflection, enabling children to begin naming their emotions, identifying triggers, and connecting these experiences to their personal lives. Furthermore, supportive interactions with teachers or facilitators through open-ended questions can help deepen their thinking, emotional analysis, and understanding of self. ¹⁴ However, the depth and authenticity of this self-awareness should be carefully examined, as emotional development in children is still emerging and often unstable. The interview format and social expectations may also influence children’s responses and perceived emotional insight. ²⁵ In addition, cultural norms in rural Thai communities, where children may have limited emotional vocabulary or socially accepted ways of expressing feelings, can restrict how effectively figurine-based methods support genuine self-awareness. ⁹ Without ongoing pedagogical reinforcement and emotional practice in daily life, the self-awareness gained through such interventions may remain fragile and short-lived.

The second theme, emotional healing, encompasses key processes reported by participants, including self-compassion, self-acceptance, emotional expression, and the development of psychological resilience. These healing processes may arise from the nature of activities that facilitate exploration of internal states using figurines, which provide children with a safe and informal means to communicate their emotions, thoughts, and experiences. This approach helps reduce resistance to verbal expression, especially among children who may have difficulty articulating their feelings clearly. Symbolic emotional expression through figurines tends to encourage children to recognize and accept their internal feelings without judgment, fostering greater self-compassion and understanding. ¹⁴ Moreover, attentive listening from teachers or facilitators during reflective discussions further enhances the children’s confidence in self-disclosure, promoting a sense of being valued and accepted, which are fundamental to emotional healing. ²⁶ Additionally, witnessing their own transformation through the scenes they create helps children become more aware of their inner strengths and gradually develop coping mechanisms for stress and emotional challenges. Although these outcomes are based on subjective experiential reports, they highlight the potential of arts- and play-based interventions to effectively support emotional healing, particularly for children who may have limited access to mental health services. ²⁷

The third theme, developing personal growth, emphasizes increases in self-confidence, self-worth, emotional regulation, and coping skills among participants. The use of figurines in the intervention likely fosters this growth by providing a tangible and creative medium through which children can express and explore their inner experiences. By constructing and enacting scenarios with figurines, children engage in symbolic play that promotes self-reflection, perspective taking, and problem-solving, leading to a deeper understanding of themselves and their emotions. ¹⁴ This process helps children practice emotional regulation and develop coping strategies within a safe and supportive environment, which may contribute to greater resilience and psychosocial development beyond the intervention itself. These findings suggest that the figurine program may facilitate not only symptom alleviation but also broader social and psychological growth. However, these outcomes should be interpreted cautiously, as the absence of formal clinical diagnoses and reliance on self-reported progress limit the ability to determine whether observed changes represent genuine psychological transformation or transient positive mood states. Moreover, the multifaceted nature of personal growth, shaped by factors beyond the intervention, such as family dynamics, peer relationships, and the educational context, which schools must actively engage with and support necessitates more comprehensive, mixed-methods research was used to disentangle these influences. ^{27 , 28} Potential selection bias toward children predisposed to engage with figurine therapy also constrains the generalizability of the findings.

Despite these limitations, the strengths of the study lie in its focus on an underrepresented population and its qualitative exploration of children’s internal experiences with emotional healing, contributing valuable contextualized knowledge. The use of Colaizzi’s phenomenological method allowed for the systematic extraction of meaning from the participants’ narratives, yet this methodology inherently prioritizes subjective interpretation, which may obscure objective assessment of intervention efficacy. The lack of longitudinal follow-up precludes assessment of the durability of the reported emotional gains, a crucial factor in the context of preventive mental health. Additionally, without triangulation of data from caregivers, teachers, or mental health professionals, the study findings remain uncorroborated and limited to children’s self-perceptions. Given the central role of schools in children’s daily lives, greater involvement of educational institutions is essential to reinforce emotional learning and healing processes. Schools can provide ongoing support, integrate culturally sensitive mental health education, and facilitate communication among children, families, and professionals, thereby enhancing the sustainability and effectiveness of figurine-based interventions. ^{25 , 27 , 29}

In sum, this study offers insightful contributions regarding how figurine-based interventions may nurture awakening self-awareness, facilitate emotional healing, and promote personal growth in rural Thai children. Nonetheless, it underscores the necessity for more rigorous research designs that incorporate cultural sensitivity, objective measures, and longitudinal assessment to substantiate and extend these preliminary findings. Addressing these gaps will enhance our understanding of how such interventions can be effectively tailored and scaled to promote sustained emotional well-being and resilience in children facing complex psychosocial challenges.

CONCLUSION

This study highlights how rural Thai primary school children with mild to moderate emotional distress experienced increased self-awareness, emotional healing, and personal growth through a creative figurine-based intervention. The participants described small but meaningful practices, such as self-kindness, focusing on positive experiences, and accepting imperfections, which helped them manage emotions and build resilience. These findings emphasize the importance of community-based, child-centered approaches in supporting emotional health within school settings, especially in resource-limited rural areas. The study offers valuable insights for nursing and midwifery professionals working to promote emotional well-being and early support among children. Future research with diverse samples and longer follow-up is needed to strengthen evidence and guide effective emotional health interventions in schools.

Acknowledgement

The authors give sincere gratitude to Dr. Madeleine De Little, originator of the Thailand Neuroscience and Satir in the Sand Tray approach, and Professor Andy Garbacz, PhD and Co-Chair of the University of Wisconsin-Madison School of Education School Psychology Program, for comments on an earlier version of the manuscript. This work was conducted without external funding.

Authors’ Contribution

SA and LD contributed to the conceptualization and design of this study. The data collection was conducted by SA. The data analysis and interpretation were carried out by SA and LD. SA and LD drafted the initial manuscript. All authors critically reviewed, revised the manuscript, and approved the final version for publication. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding Source

This project had no dedicated funding source.

Conflict of interest

None declared.

Declaration on the use of AI

No artificial intelligence was employed in the production of the submitted work.

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