From seeing difficult behaviour to recognizing legitimate needs – A qualitative study of mothers' experiences of participating in a Circle of Security Parenting program in a public mental health setting

ABSTRACT

Objective

Mental health challenges can interfere with caregivers’ self-efficacy and their ability to engage with their children in developmentally appropriate ways. The goal of this study was to explore whether the intervention Circle of Security Parenting (COS-P) was experienced as a meaningful adjunct to psychological treatment.

Method

Individual qualitative semi-structured interviews were conducted with twelve female COS-P participants, exploring how taking part in COS-P had changed the way they related to themselves and others. Data were analyzed using a team-based, reflexive thematic analysis.

Results

The analysis resulted in three main themes: (i) Connecting dots: A new perspective on one’s past, (ii) Seeing oneself more clearly: Increased capacity to recognize and tend to own needs, and (iii) Gaining a map: Becoming a more competent parent.

Conclusion

Taking part in COS-P as an adjunct to psychological treatment positively impacted participants’ sense of competence as mothers. They used the COS-P framework to make sense of their interaction with their child, enabling them to understand the child’s behaviour and communication as expressing legitimate attachment needs. They also experienced that the course strengthened central psychological capacities, such as insight into their own developmental histories as well as increased self-awareness and self-care. Implications are discussed.

Keywords:

• attachment
• Circle of Security
• COS-P
• parenting intervention
• patient experience
• qualitative interviews

Clinical or methodological significance of this article: Mental health challenges can interfere with parents’ sense of mastery and the ability to engage with their children in developmentally appropriate ways. It is therefore important to explore how interventions targeting parenting functioning may be of help as an adjunct to other psychological treatment. One such intervention is Circle of Security-P (COS-P), a psychoeducational group-based program aimed at strengthening parents’ ability to recognize and relate to their children’s attachment cues and needs. In this study we interviewed 12 mothers who had participated in COS-P alongside their treatment in a public mental health care setting in Norway. The results showed that taking part in COS-P had a positive impact of the participants’ sense of competence as mothers. They described a change from experiencing children’s behaviour as “difficult” to expressing legitimate attachment needs. They also experienced that the program provided insight into their own family background, as well as increased their self-awareness, emotion regulation, and self-care. COS-P may therefore be a valuable adjunct to psychotherapy.

Introduction

Common mental health challenges such as anxiety, depression, trauma and personality disorders may negatively influence parental self-efficacy (Jones & Prinz, 2005). Lacking mastery in the role as a parent may maintain or exacerbate the emotional difficulties of the parent, creating a feedback loop in which parental stress, low self-efficacy, and psychopathology reinforce each other in an ongoing process (Crnic & Ross, 2017). Psychological distress may also interfere with the capacity of parents to attune to and engage with their children in developmentally appropriate ways, for instance by making it difficult to take the perspective of and respond to the needs of the child (Katznelson, 2014). Deficiencies in responsiveness and flexibility in parent–child interaction could impact negatively on the psychological safety of children and impair the acquisition of social competence and emotion regulation skills (Lobo & Lunkenheimer, 2020; Kao et al., 2020). Children of parents with mental health issues are at risk for social and emotional problems during childhood and adolescence, and for developing clinical syndromes such as anxiety or depression later in life (Breaux et al., 2014; McLaughlin et al., 2012). While not a traditional focus in mental health care, it is therefore important to explore whether and how interventions targeting parenting functioning might be of help as an adjunct to other psychological treatments.

One set of approaches to strengthen parental functioning is based on attachment theories. The goal in such interventions is to enable parents to improve the quality of the interactive relationship with their children in ways that will facilitate their emotional development. The Circle of Security Parenting (COS-P; Cooper et al., 2009; Woodhouse et al., 2018) is one widely applied intervention that aims to strengthen parents’ ability to recognize and relate to their children’s emotional cues and needs. COS-P is a psychoeducational group-based program that utilizes didactic teaching, video clips of parent–child interactions, and extensive group reflection to strengthen parental functioning. It is based on a framework emphasizing the attachment needs of safety and exploration in all human development. The aim is to help participants understand their children’s overt behaviour in light of these psychological motivations, and to respond accordingly. COS-P also encourages participants to reflect on their own inner working models of attachment relationships, and how these may be activated in emotionally charged situations with their children (Cooper et al., 2009; Woodhouse et al., 2018). Thus, COS-P addresses both how individuals relate to their children and to their own experiences and needs with regard to attachment.

COS-P has been most widely disseminated either in general community settings or targeting particularly vulnerable populations, such as those in the care of child protective services. Despite growing clinical use there is relatively little research on the intervention. Results are mixed and the methodological quality varies. Yet, there are promising findings indicating that COS-P may lead to improved parental functioning (See Maxwell et al., 2021a for a recent summary of outcome studies). However, less is known about how caregivers experience participating in COS-P, and what changes they describe as significant following participation. This is important, as different research methods give access to different types of knowledge, and because quantitative outcome measures do not always tap what is experienced as relevant outcomes from key stakeholders (Krause et al., 2021).

While qualitative studies are particularly suited to investigate how participants experience, make sense of, and benefit from psychological interventions, we have only been able to locate one prior publication reporting on participant experiences of COS-P (Maxwell et al., 2021b). In this study, 14 parents who had taken part in COS-P programs offered by different service providers in Australia were interviewed. However, the parents’ experiences were synthesized with the perspective of COS-P facilitators, making it difficult to distinguish the experiences of participants from those of the professionals. With this limitation in mind, findings from the perspectives of both these groups indicated that the COS-P program led to increased empathy and perspective taking of the child. Understanding child behaviour in light of emotional needs and the dynamics of the parent–child relationship also led to less negative attribution of behaviour. The COS-P program was also seen as encouraging self-compassion and room for failure, as well as increased confidence in the parent role (Maxwell et al., 2021b). Aside from the findings from this recent study, very little is known about how the COS-P program is perceived by those taking part in them. However, a recent Ph.D. thesis explored nine parents’ experience of participating in COS-P and found that they reported both improved parental functioning and increased awareness and management of their own emotions (Gilhooly, 2018).

As mental health challenges may pose particular problems for parental functioning, it is of relevance to investigate how the treatment system can accommodate this domain of patients’ lives. When patients that are parents have already sought help and established a trusting relationship within therapy, it is a potentially valuable opportunity to also address their role as parents and challenges they may experience in this regard. COS-P aims to strengthen parental skills which are not necessarily addressed in regular psychotherapy and can therefore be seen as a relevant adjunctive intervention for caregivers within public mental health care. We have, however, not been able to locate any studies exploring COS-P within a an adult public mental health setting. The current study contributes to the field by exploring how participants experience completing the COS-P program as an adjunctive intervention to their psychological treatment. Specifically, we wanted to explore how taking part in the COS-P program changed the way participants understood and related to themselves and others.

Method

The current article reports from a mixed-methods study exploring parents’ experiences of COS-P in an adult public mental health context. The effects of the intervention were explored with a pre–post-design, while we used individual, qualitative, semi-structured interviews to generate data on how parents experienced participating in COS-P in this context. This article reports on the qualitative data. Data was analyzed, as detailed below, focusing on how taking part in the COS-P program changed the way participants understood and related to themselves and others, using a team-based, reflexive thematic analysis (Braun & Clarke, 2006, 2019).

Study Setting

The study was conducted within the frame of a public mental health care system in Norway, where most of the costs of treatment are covered by the government given fulfillment of an assessed right for prioritized treatment. The setting for the study was a district psychiatric health centre in Western Norway. The centre has both inpatients and outpatients, and the COS-P course is offered to all patients with children aged 0–15 years, including pregnant patients. The exclusion criteria for participation in COS-P courses are severe substance abuse, psychosis, or ongoing suicidality. The larger study that this qualitative investigation was embedded in featured a naturalistic sample of 42 patients that completed a COS-P program as an adjunct to their ongoing outpatient psychotherapy. The individual treatment they received in addition to the program was determined according to clinical decision making as routinely practiced in the clinic, and thus varied in length and content. All participants completed self-report measures before and after the COS-P course, assessing parental mentalization, parental stress/helplessness and psychological distress. Results from self-report measures will be reported in a separate publication.

Intervention

COS-P is a psychoeducational program based on attachment theory and research (Cooper et al., 2009; Woodhouse et al., 2018). The program aims to strengthen parental skills by way of increased mentalization, also referred to as reflective functioning, of the child. This entails the ability to take the perspective of the child and understanding his or her intentions, emotions, and mental states according to a framework of developmental attachment needs (Luyten et al., 2020). The course is manual-based, and includes written materials, a DVD, and an instructor handbook (Cooper et al., 2009). Meetings are organized as an alternation between watching clips from the DVD, reflecting on these clips in the group, and bringing in participants’ own experiences in relation to what is discussed. Originally COS-P is provided within a framework of eight sessions. However, many patients in mental health care have experienced trauma and neglect in their own upbringing that may be useful to address as a part of the COS-P. Therefore, the course was extended from eight to twelve sessions, in consultation with one of the developers of COS-P (B. Powell, personal communication, 2011). The rationale for this expansion was to provide patients with more room for reflection both on their own upbringing experiences and their parenting. The sessions were given on a weekly basis, with each session lasting 90 min. Please see Table I for an overview of the content of the COS-P sessions and central concepts in the program.

Table 1. Themes and central concepts for each session in the original eight-session format (adapted from Cooper et al., 2009).

Chapter 1: Welcome to Circle of Security Parenting The goals are for the participants to experience safety and an engaging context to explore parenting, and to introduce the concept of the Circle of Security. The Circle is a visual model illustrating the natural rhythm of children’s needs for safety and exploration, and the caregiver’s corresponding roles in meeting these attachment needs.

Chapter 2: Exploring Our Children’s Needs All the Way Around the Circle The goals are to increase the caregivers’ observational and inferential skills, and to help them determine whether the child is exhibits safety-seeking or exploratory needs and behaviour according to the Circle of Security model. Further, the intention is to enable caregivers to alternate between supporting exploration and nurturing safety needs as required. The caregivers are also introduced to the challenge and importance of being the adult in the relationship, metaphorically expressed as being “bigger, stronger, wiser and kind” in relation to the child.

Chapter 3: “Being With” on the Circle The goal is to help caregivers to meet the child’s emotions in a non-judgmental manner, as opposed to distracting from them or in other ways changing the child’s experience.

Chapter 4: Being with Infants on the Circle The goals are to help the caregivers understand that we all need relationships, and to teach them attunement to the child’s shifts in attention and emotions. Further, to show that children can’t learn to organize their emotions without ongoing support.

Chapter 5: The Path to Security The goal is to help the caregiver explore their own emotional vulnerability in attachment contexts using the metaphor of “Shark Music”. This refers to the discomfort and/or sense of threat that certain emotions or behaviours in the child can elicit in the caregiver due to their relational experiences from their own upbringing. The program emphasizes relating to the discomfort represented as “Shark music” with curiosity and non-judgment, and understanding its developmental origins and function.

Chapter 6: Exploring Our Struggles The goal is to help caregivers further develop the understanding that their role as caregivers entails being “Bigger, Stronger, Wiser, and Kind”. They are also made aware of how imbalance between these four qualities can create fear in the child.

Chapter 7: Rupture and Repair in Relationships The goal is to help caregivers recognize that when children are acting out, they are actually trying to get help managing genuine attachment needs. Caregivers are also introduced to the concept of relational rupture and repair, metaphorically expressed as caregivers stepping out of and taking responsibility for returning to the Circle.

Chapter 8: Summary and Celebration Participants are given the opportunity to revisit the various themes, ask questions, and celebrate their achievements during the program.

Recruitment and Participants

Patients participating in COS-P courses between March 2016 and January 2018 were invited to take part in the study. They received information about the study prior to the first session of the COS-P course. It was emphasized that participation was voluntary, and that their decision would have no consequences for their participation in the COS-P course. Twelve participants (all women) volunteered for the qualitative interviews. Participants were aged 23–49 years at the time of participation (mean 39.8, SD = 7.5). They had primary diagnoses of either mood disorder (n = 2), anxiety disorder (n = 8), personality disorder (n = 1) or eating disorder (n = 1). All patients received concurrent individual therapy and continued this treatment while attending the COS-P course. Examples of psychological treatment offered in the naturalistic setting of the outpatient clinic included cognitive behavioural therapy, psychodynamic or relationally oriented therapy, and trauma-focused psychotherapy.

Data Collection

Participants were interviewed within one month of completing the COS-P course. The interviews were conducted at the outpatient clinic by one of the last three authors. None of the interviewers knew the participants in advance or had been involved as instructors in the courses. A consent form was signed prior to the interview. A semi-structured interview guide with open and overarching questions was used to promote an exploratory dialogue about the participants’ perceived benefits of the program. The participants were interviewed about their reason for signing up for the course, the advantages and disadvantages of participating, and the experience of being part of a group. Furthermore, they were interviewed about what they had learned from the course and to what extent it had changed how they experienced and practiced the parental role. The participants were also asked whether the course had changed their views on their own upbringing and difficulties and how they saw the future. They were also asked if they had any views on the course being arranged within the framework of mental health care. The length of the interviews varied from 43 min to 1 h and 30 min. The interviews were audio recorded and transcribed verbatim by a graduate student in clinical psychology.

Data Analysis and Reflexivity

A team-based reflexive thematic analysis (Braun & Clarke, 2019) was used to analyze the transcripts. Analysis was initiated with all authors reading the transcripts thoroughly, writing down initial impressions. We then met for a half-day meeting discussing our impressions of the data material, ideas for analytical foci, and to use each other’s perspective as an aid in the reflexive processes of becoming more aware of our own preunderstandings and how this influenced our reading of the material. This was important, as our positions in relation to the program and the data material varied. The first author initiated the project and took part as an instructor of one of the COS-P courses but did not take part in the data collection. The three other authors had no allegiance to or experience with the COS-P program, although they did have knowledge of the content and organization of the program. This starting point helped us maintain a reflective distance to the data material, while ensuring sufficient engagement with the phenomenon under study (Stige et al., 2009). We emphasized an inductive approach in the initial stages of analysis, staying close to the data material and participants’ use of language (Braun & Clarke, 2006). Based on our initial reading of the material and discussions among authors, we decided on the following analytical focus: How has taking part in COS-P changed the way participants relate to themselves and others?

Following this meeting, the first, second, and third authors coded the data material under supervision of the last author. They coded four interviews each. In this process we met several times, ensuring good quality of the coding, including code names that were close to participants’ own words, yet abstracted sufficiently to fill the function of bridging the codes to the data material while easing cognitive strain. Following this initial coding, we met to abstract codes into tentative sub-groups. This process progressed in several stages, alternating between group meetings, and the first, second, and third author working on their own on the interviews they had initially coded. The three coders had slightly different coding styles, and we used this as a gateway to important reflections and discussions aiding our reflexive processes. For example, some codes were too brief, making interpretation difficult without consulting with the interview context, and we therefore frequently moved between codes and full interviews in the process of abstraction.

Finally, we used these sub-groups of codes as our starting point for constructing tentative themes. In this process, we had several meetings, and went back and forth between the data material as a whole, the individual codes with quotes, and the proposed thematic structure. During a process alternating between writing, reading, and discussing as a team, we reached the final thematic structure, presented below.

Ethics

The study has been approved by the regional ethics committee in Western Norway (REK-Vest; reference number 2015/2329) and the participants gave informed written consent to take part in the study. Consent and participation could be withdrawn at any time during the study. The identifying names in connections with the quotes are pseudonyms.

Results

Our analysis of participant experiences after taking part in the COS-P course resulted in three main themes: (i) Connecting dots: A new perspective on one’s past, (ii) Seeing oneself more clearly: Increased capacity to recognize and tend to own needs, and (iii) Gaining a map: Becoming a more competent parent.

Theme One: Connecting Dots: A New Perspective on One’s Past

Most participants described the COS-P program as a learning experience regarding their own background. For some, this gave rise to a revised view of the emotional climate in their family of origin, and the consequences this had for them. This included coming to terms with the fact that one’s childhood may have been characterized by less emotional support than originally supposed. The family environments ranged from being characterized by neglect and aversive childhood experiences, to being apparently normal yet lacking adequate emotional attunement. Despite these challenges being of a varied nature, it was a common theme that the participants came to realize that they had not had their emotions validated and had lacked adequate role models in relation to becoming parents themselves.

I have grown up with a father who hasn’t been present. And I see what I have lacked there, right, and my mother was depressed when I was growing up, and she was a single mother and sole provider, so I see what kind of limitations I have had (…) And I see how it has affected me (“Lily”)

This discovery did not necessarily entail a judgment of their childhood as all bad. Instead, more nuances emerged in how they viewed their past:

I still see that I had a safe, good and stable childhood. Two parents that were mostly capable, we went on a lot of hikes, we were in the mountains, we were outdoors people. There was nothing wrong with that side of things. But at the same time, I discovered that it has been very cold in a way (“Margaret”).

Some participants shared how the course had helped them understand and acknowledge how their childhood experiences still influenced them. They expressed an understanding that emotional patterns are established early in life, and that the past in this sense leaves traces in the present. This involved seeing how one’s attempts to adapt to childhood relational conditions had led to later difficulties emotionally and in the role as a parent. For instance, participants described patterns of overprotection, emotional suppression, or disconnection that they linked to their own background: “Because of things that happened when I was little, I am very overprotective of those around me” (“Susan”).

For some participants, the process of acknowledging what had been missing in their past was accompanied by a new ability to take the perspective of one’s parents and a greater understanding for and empathy with them. This enabled the realization that parents had a difficult background themselves, and in many instances were trying their best with the limitations they had. A few had also been able to talk to their mothers about these issues in a non-blaming manner, thereby contributing to an improved relational connection: [about mother] “When I know how her childhood was, I understand very much why she does things the way she does” (“Mary”).

For most participants, then, taking part in the COS-P course provided increased understanding and acceptance of their own developmental history that elicited both a sense of risk and a sense of possibility. Participants expressed their wish to do things differently than their parents, to disrupt the problematic emotional patterns that had been repeating themselves across generations. They presented an increased awareness of what they wished to break with, and what they saw as valuable and wished to carry with them going forward. As such, the painful realization that their own past was more troubled than originally thought became a resource and motivation for change: “That I won’t have to transmit it, because that’s what I have been fearing, that I will transmit what mum has done because I don’t want that to happen” (“Jennifer”).

Theme Two: Seeing Oneself More Clearly: Increased Capacity to Recognize and Tend to Own Needs

The second theme encompassed experiences of becoming more able to relate to oneself in a more supportive manner. This involved the capacity to recognize, contextualize, and normalize emotions, needs, reactions, and behaviour patterns—and to be able to manage difficult emotions in constructive ways. Notably, this included becoming aware of impulses that were at odds with how one wanted to be as a parent, and an ability to not act on such impulses. Participants thus did not aim for perfection, but rather viewed themselves with less judgment and greater patience and self-care.

Nearly all the participants described an increased awareness of their inner experiences, and greater understanding of their own reactions and behaviours. They thus described a greater clarity in seeing their role in everyday situations, both how they were impacted by emotional events and how they tended to respond to them. This included being able to sense and notice feelings and sensations in a nuanced manner, to tolerate distress better, to be more aware of their boundaries, and to detect dysfunctional patterns as they were unfolding. In a variety of ways, participants gave voice to experiences of being able to give room for and make use of their emotional reactions – in contrast to these reactions being seen as merely unwanted or disruptive: «I have begun to learn to know when different emotions arise, instead of being like totally overwhelmed by them» (“Lily”).

Several participants used the notion of “shark music” from the course to make sense of their own reactions. That is, they linked their own current emotional patterns to aversive experiences from their own childhood. In that way, reactions the participants had been ashamed of could be understood and normalized as consequences of maladaptive learning. This insight could in turn either help them not to act on these impulses, or to be able to be less judgmental of themselves when old patterns were repeated. Some participants also expressed greater clarity about their particular vulnerabilities, such as being tired or having difficulties with certain emotional reactions in their children.

In a way, handling things much, much better now after the course, after getting to know that shark music and when it comes. And not necessarily starting to work on it, but being able to place it. It can be here now and then I can take care of the kids (“Emily”).

Some participants also described increased degrees of freedom regarding their own responses, where they were able to reflect on what was happening to them, thus opening up for more adaptive avenues of action.

For some participants this increased awareness seemed to extend further than their own mind and emotional life. They noted being more present with their surroundings, observing more clearly and discovering things afresh.

You know? Just to see the small joys in life. I mean, experiencing that we want to go for walks more often, and things like that. We have been inside a lot, so, I look forward to experiencing the world with them [the children] (“Lily”).

A few participants also mentioned seeing both one’s own children and other people more clearly and with more empathy after the course. This was described in terms of “waking up again”, or “coming out of a slumber”, accessing curiosity as a resource:

I think I became more curious. About her as a human and as a person. I used to think that she’s just a copy of me and my husband, but then I started thinking and being more aware of her being her own person (“Isabella”).

About half of the participants also described an increased acceptance of their own feelings, experiences, and limitations following the course. Some felt that there was more room to make mistakes, and not having to be perfect as a parent or as a person. Some gave voice to a more non-judgmental attitude to the shifting nature of emotional experience, and being able to allow and give space also to uncomfortable experiences:

Yes, ehm, when people said something that perhaps wasn’t even meant to be mean, but I got so sad. So just being able to accept the fact that they did it, that’s the way it is now. That is, I am … I am sad. That’s, that’s the way it is (“Charlotte”).

Many participants also experienced an increased ability to gather themselves in emotionally challenging situations. This included descriptions of emotional reactions being experienced as less intense, as well as feeling calmer, more patient, and less stressed. Another notable feature here was descriptions of emotions appearing, but without escalating. Participants were either able to stay with emotions and allow them to pass, or they would use effective strategies to regulate their emotions—such as staying calm in the face of strong feelings, counting to ten, taking pauses or telling themselves that it’s okay not to be fully in control:

Well, really pausing for a bit, and managing to think first. Because what it was like for me, I had blown a fuse so many times with my kids. So, I have been working on that. Pausing, calming myself, and then stepping into the situation. Taking, eh, taking a bit of a time-in with myself (“Sarah”).

Increased self-care was another facet of this theme for many participants. It concerned being more aware of and considerate towards own needs, using supportive self-talk, seeking support in others, as well as doing constructive activities. Some also described being more able to stand up for themselves and setting clear boundaries: «At the same time, I can tell my kids that, you know what, right now mommy is really tired. I need to be allowed to relax. I didn’t dare to say that for the world» (“Margaret”).

Finally, half of the participants described being on an ongoing trajectory of learning and change. This was related to attitudes of not having to be perfect but being allowed to work on things without necessarily getting it right at first. The changing of patterns was seen as a process that the participants had begun, but that was by no means finished: «You are never fully educated as a parent. You aren’t. And that’s so nice, I think, just being able to remind myself a little about these things» (“Margaret”).

Theme Three: Gaining a Map: Becoming a More Competent Parent

All participants shared how the COS-P course in various ways had changed their perception of the parenting role. They gave descriptions of feeling safer, stronger, calmer and more clearly in charge as a parent: “I got stronger. Now they know it's mom. Mom's the boss” (“Margaret”). Many participants had adopted the COS-model and concepts from the course and used them on a daily basis. Many referred to how they used the circle to observe and understand their child and its needs in challenging situations: «Because you can easily place him in a category in those situations – where is he on the circle?» (“Emma”). The same mother described how the circle helped her understand that when the child moved away from her, it meant that the child felt safe and wanted to explore, and that it was not a sign of rejection: «Now it’s like, you know what, he’s so secure in himself. He’s enjoying himself with others because he knows that mommy is there» (“Emma”).

Several participants developed new insight into the importance of emotions, both in understanding their child and in understanding themselves. They had seen the importance of being able to acknowledge and accept the child’s feelings, instead of meeting them with rejection or distraction. This was accompanied by an increased ability to provide the child with more space to express and act in accordance with their feelings:

I can relax and receive his feelings, and be in touch with his feelings, and accept that, okay, now he’s angry, and it’s okay. Now he’s grumpy and that’s okay. And now he wants to joke around, and now he wants to explore and then he must be allowed to do so. So, I sit back a bit more, and let him find his way and figure out things on his own (“Jennifer”).

The notion of “shark music” was also important for many participants to understand how their own background and experiences affected how they met and communicated with their child. This understanding helped them cope with their own anxiety and meet the child in a better way:

I think it’s very much about using the shark music we learned about (…) I try to analyze myself and think like, okay, can I handle that he is sad right now? Or can I handle that he is angry? If I don’t, I try to think about the reason that I don’t, that I get it [the shark music], that I can’t stand this. And then I try to get a grip on that (“Jennifer”).

Some participants found new ways of helping their child deal with anxiety, fear and overwhelming emotions. They also emphasized the change they saw in the child when they managed to handle the child’s feelings more flexibly. Situations that previously would have escalated and become conflict situations, were now resolved calmly:

You know, it’s easy to escalate a conflict with kids. If you in a way can’t stand to listen or just walk away, it just makes it much worse. Or it explodes if you start to argue against. So, I’ve noticed that if you just let them be, or in a way are there and curious as to why, it’s like they get the real feeling off their chest, and then it immediately subsides (“Jessica”).

Some participants shared how they now thought about the reason behind the child's emotional expression and behaviour, and thus had gained a new understanding of the child's intentions. Linked to this was also fewer negative attributions about the child’s motivation. These emotional expressions in the child would previously have created unrest and discomfort in the adult and could at times lead to rejection of the child. A better understanding of the child's intention had therefore contributed to a new way of meeting the child for these participants. “And I learned much about how children never choose to be difficult. They never do. It is practically their last resort of getting attention. That became a lightbulb moment for me.” (“Margaret”)

Some of the participants also shared how they had become better able to see the child as a child, not as a tiny adult. This opened up new curiosity and openness towards the child. Several participants described how the communication with their child changed, in that they gave the child more room for speaking freely and participating more actively in the family's daily life:

It was almost as if when they had things to tell me, I could suddenly just walk away, right? (…) But now I let them finish talking. And we talk about things in a more thorough way, and they are allowed to voice their opinions and participate in activities in a whole new way (“Margaret”).

A few participants, who had previously struggled with the child’s need for physical closeness and soothing, experienced being better able to cope with this following the COS-P program. From seeing the child’s behaviour as an expression of clinginess, they were now able to recognize it as an expression of a legitimate attachment need. For many participants, attending the COS-P course had contributed to a new understanding of the parental role and how important they were as parents: «It was very instructive and there were many aha-experiences, about how extremely dependent they are on us, how much they need us» (“Emily”). Some participants said they had become more aware of the responsibility they have as an adult in the relationship with their children: «I carry it with me and bring it out in order to remind myself: you are supposed to be stronger, you are supposed to be wiser, you are supposed to be safer. It is you who are the caregiver» (“Margaret”). Several participants also experienced that the course had helped them understand their own need for control, and how this could prevent the child from exploring. They described having to work on letting go of the child and managing their own reactions evoked by the child's need to explore: «To accept that I have to work on myself to give them that freedom. That it’s natural, that I don’t need to hold their hand. And that they are little free people that are supposed to experience things» (“Lily”).

Importantly, most participants experienced these processes of understanding and integrating the concepts from the program, and changing their behaviour accordingly, as continuous and ongoing. Some participants also expressed that although they now better understood what their child needed, they still at times found it difficult to respond adequately.

Discussion

Our analysis of the interviews with participants who had been offered the COS-P course as an adjunctive intervention to their treatment in a public mental health setting resulted in three main themes. First, the participants in various ways described a revision of their view of their own past. This encompassed both a clearer recognition of shortcomings with regard to emotional validation and care in their own upbringing, leaving vulnerabilities that had played out in their lives and relationships. For some, this was also accompanied by a more empathic understanding of their caregivers, seeing that they enacted dysfunctional emotional patterns that they themselves had not freely chosen. Second, they felt that the COS-P course had helped them to become more in touch with their own feelings, reaction patterns, and needs. This increased self-awareness enabled them to take better care of themselves and deal with challenging experiences in more helpful ways. Third, the participants described being strengthened in their role as parents, having gained both a clearer understanding of their children’s intentions and emotional needs, as well a more flexible repertoire in interacting with them. The understandings gained from COS-P emerged as a resource in their everyday life and interactions with their children, as reflected by numerous examples of linking concepts such as the “circle” and “shark music” to their own experiences. A central shift here seemed to be a newfound ability to understand their children’s behaviour in light of developmentally adequate emotional needs, thus becoming more accepting of it and less likely to see it as an expression of malicious intentions on the part of the child.

Our findings are in line with previous qualitative research on parents’ and facilitators’ experiences of COS-P, in that they shed light on how taking part in the course impacts how participants view themselves, their children, and the parent–child relationship. Specific changes include parents’ increased capacity for self-compassion and emotion regulation, increased empathy for the child, increased sense of mastery of the parenting role, and a shift in focus from child (mis)behaviour to parent–child relationship (Gilhooly, 2018; Maxwell et al., 2021b). Our findings also expand on existing knowledge, by exploring the parent perspective of participation in depth, and reporting exclusively on the parent perspective (in Maxwell et al., 2021b only facilitators are quoted regarding a shift from child behaviour to relationship, for example). Our findings also contribute with new knowledge by showing how participation in the COS-P program influenced the way participants viewed and understood their own past relational experiences, and how they used this new and more nuanced understanding as a resource for acceptance and self-compassion, but also as a motivation for working hard to break unhelpful intergenerational patterns. How, then, should we understand the changes reported by participants in how they relate to themselves and others following participation in COS-P?

The COS-P program is aimed at facilitating parenting skills by way of learning about normal expressions of developmental needs and the attachment dynamics between safety seeking and exploration or individuation. The participants clearly in diverse ways conveyed an experience of having been strengthened as parents through new modes of understanding their children and more rewarding and meaningful ways of interacting with them. They experienced themselves as empowered: as more competent and confident caregivers, and as in charge of the situation, while being flexibly attuned to the psychological needs of their children. These are qualities that have been found to be associated with beneficial developmental trajectories (Albanese et al., 2019). These changes are in accordance with the intentions and didactical focus of the program, and are also in line with previous qualitative studies on parents’ perspective on change following COS-P (Gilhooly, 2018; Maxwell et al., 2021b). This might not be a surprising finding. It may nevertheless be important, as there are indications that conventional psychotherapy—even when effective for symptom improvement—does not necessarily lead to less parenting stress or better parenting skills (e.g., Forman et al., 2007). Our finding regarding experienced empowerment aligns well with quantitative research of COS-P, which albeit being somewhat mixed indicates that COS-P is associated with reduced caregiver helplessness (Kohlhoff et al., 2016) and increased parenting self-efficacy (Maxwell et al., 2021a).

It is perhaps more intriguing that participation in a program that to such a large degree is dedicated to parenting, led to participants experiencing changes in the attitudes and relationship to themselves. In line with previous qualitative research, these beneficial developments included being better able to notice, stay with, and accept feelings and emotional reaction patterns (Gilhooly, 2018), as well as an increased awareness of their boundaries and a greater emphasis on self-care (Maxwell et al., 2021b). These are factors that are empirically linked to mental health and well-being, such as flexible emotion regulation (Kashdan & Rottenberg, 2010) and the use of acceptance-based strategies to manage psychological distress (MacInnes, 2006; Tibubos et al., 2019). The experienced strengthening of such capacities aligns well with what is seen as central goals in many forms of psychotherapy.

In the current study we cannot ascertain whether these therapeutic gains were due to the COS-P program or to the other forms of psychological treatment that participants received in parallel. The experience of COS-P and its benefits may very likely have been influenced by the fact that the participants received concurrent psychological treatment. As such, we cannot be certain that the changes described are due to the COS-P program alone. The changes they experienced in relation to themselves and others may be a consequence of the dual set of interventions they participated in. This is the phenomenon we set out to investigate, but care should be taken not to generalize these finding to other contexts where COS-P is offered as a standalone intervention. However, the convergence of our findings with previous qualitative research from a community setting, suggests that these processes might be facilitated by COS-P participation. Participants clearly experienced their personal growth to result from the processes elicited by the COS-P program. Moreover, while COS-P is often offered in community settings, all participants in this study had mental health problems serious enough to fulfill a right to prioritized treatment in specialized mental health care. In this respect it is interesting that participants experienced such substantial changes in what is viewed as significant factors for good mental health and well-being. The finding that parents experience benefits for their own well-being despite the course’s focus on parenting has also been reported in quantitative studies on COS-P, where participation has been linked to significant decrease in depressive symptoms (Maupin et al., 2017). This points to the potential of exploring further how COS-P can be integrated in mental health care, not only as a means to improve parenting skills and secondary prevention, but also as a path to improve parents’ own mental health. A particular feature in the current study is that the COS-P program was extended and that all participants received concurrent therapy. It may be that these features of the intervention facilitated the process of reflections, insight, and growth.

It is also noteworthy that a number of participants described attaining a more nuanced and emotionally integrated view of their own past and significant others. Thus, benefits were not described only in terms of parenting skills and personal self-regulatory capacities. They also seemed to experience a shift in how they viewed their own attachment histories, and a corresponding increase in agency for to how they would like to break with intergenerational cycles of emotional invalidation or neglect. Thus, participants seem to have undergone meaningful and relevant changes in their self-understanding, as well as in their states of mind and inner representations with regard to attachment. These processes may be seen as constituting an increase in reflective functioning or mentalizing (Luyten et al., 2020), a crucial capacity that has been empirically shown to be associated with more adaptive parent–child interaction and better long-term outcomes for attachment security and socio-emotional functioning (Camoirano, 2017). The experienced changes described by some participants in their view of the child and its intentions can also be interpreted within the lens of improved mentalizing. The quantitative literature on COS-P has mixed findings regarding improved mentalizing as an outcome, but some studies do find such an effect (Kohlhoff et al., 2016; Maxwell et al., 2021a). The narratives provided by our participants seem to point to the strengthening of this capacity as a possible result of the program. This will be important to explore in future research.

A notable feature of the COS-P program is that it is not exclusively focused on overt behaviour or skills training. While parental behaviour toward the child is seen as important, especially the responsiveness to the mental states and emotional cues of the child, COS-P also emphasizes the caregiver’s own developmental history and current emotional reactions in attachment contexts. The experiences that participants gave voice to in this study clearly indicate that such a dual focus was experienced as meaningful. It enabled them to become aware of how parent–child interactions evoked powerful emotions in them, which the COS-P program helped them both understand and also regulate.

Limitations

While the current study contributes with new knowledge about the parents’ perspective on how participation in COS-P changed the way they related to themselves and others, there are also limitations that should be noted. First, the participants had all self-selected, both to join the COS-P course, to follow through with it, and to be interviewed afterwards. Thus, we do not know whether there are experiences that we have not been able to access, for instance for those who chose to drop out of the intervention or those who did not wish to be interviewed. On a related note, all participants were women, having important implications for the transferability of the findings. In the overall study, 7 out of 42 participants were men. We do not know why none of these men agreed to be interviewed after the intervention. As such, this is a limitation of our study that can hopefully be ameliorated by securing that future research also includes fathers’ experiences. Second, we have limited information about the participants, both with regard to the number of children they had and their age, their family situation, their concurrent treatment, and to whether they had been in treatment previously. This makes us unable to form a coherent picture of their caregiving circumstances or their history of psychological distress, features that may be important for their experiences or sense-making processes. Various diagnoses and family contexts may clearly have impact on parenting. Such potential associations are outside the focus of analysis of the present study. Our aim has been to explore subjective experiences and meaning dimensions of participating in COS-P. Our data do not enable us to draw any conclusions about how variables such as diagnostic status or parenting configuration may have entered into the experience of outcome from COS-P. Third, our analytical focus narrowed on the experienced change in how participants related to themselves and others following COS-P. While a clear analytical focus is important for an in-depth analysis, it means there are other important aspects of participation in COS-P within a context of mental health care that are not illuminated in the current article. For example, we did not focus on the collaborative experience of raising children, or of perceived change in other caregivers. Also, due to our chosen analytical focus on changes following COS-P, we did not explore the participants’ experience of the content and process of the intervention. Neither did we explore experiences of how the type of psychological treatment participants received may have impacted how they benefitted from COS-P. Future research should aim at also illuminating these aspects of participation of COS-P within mental health care. Fourth, we do not know whether the narratives and themes that emerged from our material would be found to the same degree in other cultural contexts. Norway has a strong welfare system where mental health treatment is both relatively accessible and inexpensive, and we do not know to what extent our findings will generalize to other countries. Relatedly, all our participants belonged to the majority population. Norway is becoming more ethnically and culturally diverse, but due to limitations in our sample we were unfortunately not able to get access to the experience of minorities. Going forward it would be useful to secure the inclusion of participants with ethnic or cultural minority backgrounds in clinical trials of COS-P. Finally, the current study gives no indication to whether participation in COS-P changed actual caregiving practices, as it explores participants’ experienced change in their own way of relating to themselves and others. Future research should aim to integrate different knowledge sources to contribute to a more comprehensive picture of the changes in caregivers following participation in COS-P.

Conclusion

Findings from this qualitative study indicates that COS-P may be a valuable adjunct to psychotherapy, and one potential way of addressing the vital issue of parenting for individuals suffering from psychological disorders. Attending a COS-P course within a public mental health care setting positively impacted participants’ sense of competence as parents. They used various aspects of the COS-P framework to make sense of their interaction with their child, enabling them to understand the child’s behaviour and communication as expressing legitimate attachment needs. In addition, they experienced that the course strengthened central psychological capacities, such as insight into their own developmental histories and resulting psychological vulnerabilities. They also described increased capacity to understand and regulate their own emotions, and to practice better self-care. The study points to the importance of future research expanding our knowledge of how to integrate interventions targeting parenting functioning in mental health care in an effective and meaningful way.

Acknowledgements

We thank all the patients who participated in the COS-P courses, and in particular those who shared their experiences so openly during the qualitative interviews. We are also grateful to the staff at Solli DPS who led the COS-P groups or otherwise contributed to the implementation of the intervention: Kirsten Runeberg Broch, Mari-Janne Oosterman Boonstra, Bernt Ingve Rød, Anne Cathrine Ulvik Holten, Audun Røren and Kristine Sørensen. This study would not have been possible without them.

Disclosure Statement

No potential conflict of interest was reported by the author(s).