The Circle of Security-Parenting (COSP™) program is an American psychoeducational intervention designed to improve parental sensitive responsiveness and foster secure attachment. This qualitative study explores the experiences of mothers of infants who participated in COSP™. Fourteen Danish mothers fulfilling diagnostic criteria for Postpartum Depression (PPD) were interviewed. Through reflexive thematic analysis, five main themes were developed: (1) Identifying negative lenses and connections to own childhood experiences led to the experience of relationship changes, (2) Experience of enhanced understanding of and ability to meet child’s needs, (3) Reflections in the group: a journey of insight and emotional strain, (4) Strengthening family bonds through collaborative parenting, and (5) Misalignment between program content and participants’ lived realities - developmental, emotional and cultural barriers. The results suggest that COSP™ was overall found to facilitate greater awareness of meeting the infant’s needs and for more mothers, an increased confidence in their parenting role. However, the results also indicate that COSP™ may not be the optimal choice of intervention for mothers diagnosed with PPD and their infants, as program adaptations may be needed for this population. Adaptations could include increased focus on the here-and-now relationship with the child, less emphasis on the parent’s own upbringing, strategies for how to cope with the depressive symptoms during interactions with the infant, culturally relevant materials, and more post-program support.
Infant-parent attachment quality plays a foundational role in child development, influencing psychological well-being and the capacity to form secure relationships throughout life (e.g., Britto et al., 2017; Groh et al., 2017). Secure attachment is thought to develop through responsive and sensitive caregiving, where a caregiver acts as both a secure base for exploration and a safe haven during times of distress (Ainsworth et al., 1978; Bowlby, 1969; Deans, 2020). Several interventions have been developed to enhance parental sensitivity and reflective functioning to promote attachment security in infants and toddlers (see, for example, Berlin et al., 2016). Among these interventions is the Circle of Security-Parenting (COSP™) program, which aims to support caregivers in understanding and meeting their child’s attachment needs (Huber et al., 2018). The current study qualitatively explores how mothers diagnosed with postpartum depression (PPD) experience participating in COSPTM.
Maternal Postpartum Depression as a Risk Factor for Insecure Attachment
PPD is a risk factor for insecure attachment and poor socioemotional development (Rogers et al., 2020; Śliwerski et al., 2020). The adverse effects of PPD on both the child and the infant-parent attachment relationship are thought to be primarily mediated by compromised interaction quality (Goodman & Gotlib, 1999; Reupert et al., 2013; Stein et al., 2014), and accordingly, PPD is found to compromise maternal sensitivity (Bernard et al., 2018) and mentalizing abilities (Georg et al., 2023).
Mothers diagnosed with PPD often experience profound emotional and psychological challenges that shape their perceptions of motherhood. Typical symptoms of PPD include feelings of inadequacy, guilt, detachment, and difficulty experiencing joy in motherhood or managing the demands of newborn care (Haga et al., 2012; Robertson et al., 2004), which can further intensify their emotional distress (Milgrom & Gemmill, 2020; Modak et al., 2023). One of the most distressing consequences of PPD is the way it may undermine a mother’s sense of connection with her infant, leaving her feeling inadequate in her ability to bond and care for her child (Bernard-Bonnin et al., 2004). These feelings of being “a bad mother” have been identified in a systematic review as a key barrier for mothers with PPD to participate in interventions (Hadfield & Wittkowski, 2017). A meta-analysis of qualitative studies revealed that many mothers with PPD symptoms felt they had failed to meet societal ideals of what it means to be a “good mother” (Knudson-Martin & Silverstein, 2009). Moreover, systematic reviews of mothers’ experience with PPD underscore a significant gap between their hopes and expectations and the reality of emotional distress during the transition to motherhood, often leading to feelings of helplessness and hopelessness. These mothers frequently report a self-perception of incompetence in their parenting roles, which further reinforces their depressive symptoms their belief that they are inadequate as mothers (Holopainen & Hakulinen, 2019; Highet et al., 2014).
Cognitive Behavioral Therapy (CBT) is documented to be effective in reducing depressive symptoms in general, and this is also the case for mothers suffering from postpartum depression (Huang et al., 2018). A systematic review found that the most effective interventions for reducing PPD symptoms were those that either focused solely on symptom reduction or combined support for the mother-child relationship with strategies for alleviating depressive symptoms. (Kumar et al., 2023). This is further underscored in a systematic review and thematic synthesis of the qualitative literature on women suffering from PPD and their experiences of psychological interventions (Hadfield & Wittkowski, 2017). The review found that the women valued learning more about parenting and receiving feedback, especially as they often worried about being seen as “a bad mother.” However, research on the treatment of maternal PPD has shown that interventions which solely focus on alleviating the mother’s depressive symptoms, such as medication or traditional psychotherapy, are often insufficient to buffer against the potential negative impact of PPD on child psychosocial development. Even when depressive symptoms improve, these changes do not necessarily translate into better mother-infant interaction quality or support long-term socioemotional and cognitive outcomes for the infant (Adouard et al., 2005; Berle et al., 2003; Boyce et al., 1993; Chaudron et al., 2010; Murray & Carothers, 1990). Likewise, a recent review and meta-analysis of parenting interventions for mothers with depressive symptoms and their infants found no evidence of the effect of parenting interventions on the parent-child relationship and child development (Rayce et al., 2020). Thus, there remains limited knowledge about what effectively supports mothers with PPD in their parenting role. This study aims to address these gaps by exploring the subjective experiences of mothers diagnosed with PPD who participated in COSP™. Specifically, it seeks to identify helpful and hindering program elements that contribute to - or hinder positive changes in their parenting experience.
The Circle of Security-Parenting (COSP™) Program
COSP™, rooted in attachment theory (Bowlby, 1969), aims to support parents in recognizing and responding sensitively to their child’s attachment needs (Poulsen et al., 2024). The assumed core mechanism of change in COSP™ is the enhancement of caregivers’ reflective functioning (mentalizing), which allows them to understand how their own emotional responses and relational histories shape their caregiving (Woodhouse et al., 2018). The model assumes that as caregivers develop this reflective capacity, they become more sensitive, emotionally available, and capable of regulating their own emotions, which is essential to fostering secure attachment (Poulsen et al., 2024).
The “Circle of Security” graphic is a visual framework illustrating the principles of the two infant behavioral systems: attachment and exploration as formulated by Bowlby (1969/1982). The graphic illustrates core attachment concepts and aims to guide caregivers in meeting the child’s needs: i.e. being a Secure Base that supports children’s exploration, and as a Safe Haven to which children can return for comfort during distress (Cooper et al., 2009; Poulsen et al., 2024). The concept of “secure hands” further encourages caregivers to be “bigger, stronger, wiser, and kind,” emphasizing the establishment of boundaries with kindness and sensitivity (Poulsen et al., 2024). Aligned with attachment theory (e.g., Cassidy, 2008), COSP™ proposes that children’s abilities to explore, play, and learn are reinforced when caregivers provide emotional attunement and availability, described as “filling their emotional cup” (Cooper et al., 2009). This principle underscores that while children benefit from comfort in times of distress, they also need a steady connection with caregivers to sustain engagement and curiosity when exploring. COSP™ guides caregivers to “Be With” their child’s emotions all around the Circle, engaging in a co-regulation process that promotes children’s emotional self-regulation and secure attachment (Poulsen et al., 2024). Reflective functioning is further reinforced by the concept of “Shark Music,” a metaphor representing the unconscious anxieties and discomfort rooted in caregivers’ own relationship histories that may affect their own current caregiving behaviors. These underlying emotional processes are activated by specific needs expressed by the child, which the caregiver may find unsettling or fear-inducing, even though the child’s needs are not inherently dangerous. By addressing these underlying patterns, it is assumed that caregivers can respond to their child’s needs with greater empathy and self-awareness (Poulsen et al., 2024).
COSP™ is a manualized, group-based intervention typically delivered over 8–10 sessions and designed for parents of children up to six years (Poulsen et al., 2024). The program combines pre-produced video content with guided group discussions to introduce attachment theory concepts and enhance caregivers’ observational and inferential skills. By blending educational and therapeutic elements, COSP™ aims to foster reflections by encouraging caregivers to share personal experiences and engage with their own parenting perspectives (Marvin et al., 2002; Woodhouse et al., 2018).
Quantitative Studies on COSP™
Despite widespread dissemination of the COSP™ program, quantitative research on COSP™ has yielded mixed results, highlighting both positive outcomes and limitations in its effectiveness (see Wright et al., 2023, for a recent review). Randomized controlled trials (RCTs) have not found evidence for the efficacy of COSP™ in improving child-caregiver attachment security, parental sensitivity or reflective functioning (Cassidy et al., 2017; Risholm Mothander et al., 2018; Zimmer-Gembeck et al., 2022). Like the previous RCTs, we also did not find any significant effects of COSP™ on infant-mother attachment, maternal sensitivity, or reflective functioning compared with care as usual for mothers of infants diagnosed with PPD (Stuart et al., 2025). Both Zimmer-Gembeck et al. (2022) and our RCT evaluation (Stuart et al., 2025), have interpreted the null-findings as COSP™ being insufficient in addressing the needs of at-risk parents. Qualitative inquiry is particularly valuable in evaluating psychological interventions, as it allows researchers to capture the complex and individualized ways psychological interventions like COSPTM may – or may not – benefit participants (Maxwell & Levitt, 2023). A qualitative study provides an in-depth understanding of participants’ experiences of what is experienced as helpful and hindering program factors for positive change and may inform how interventions might be adapted to meet diverse client needs (Moore et al., 2015; Yardley et al., 2021).
Qualitative Studies on COSP™
In Australia, Maxwell et al. (2021) conducted a qualitative study of both parental and facilitator perspectives on COSP™. Participants were fourteen parents who had completed COSP™ within the past two years and were the primary caregivers of at least one child. Their children ranged in age from 6 months to 6 years. The analysis indicated that the program positively transformed parents’ perceptions of the parent-child relationship, their child, and their role as parents. Parents identified the COS graphic and “shark music” as key components driving these changes, leading to improved confidence in parenting and increased experience of compassion and empathy towards their child. At the same time, some program features were identified as hindering: Several parents requested additional support following completion, and the introspection and childhood reflection components of COSP™ were seen as significant obstacles for some. These findings are supported by a mixed-methods study conducted by Sadowski et al. (2022), in which three parents partook in COSP™ through a local community service organization in Australia due to difficulties in family relationships. While the parents generally described COSP™ as “positively challenging”, which facilitated an experienced growth in their parenting strategies and skills, they also viewed the fixed structure and content as limiting. Some parents expressed a desire for more tailored materials and parenting strategies suited to their children’s ages and individual needs.
Muddle et al. (2022) explored the experiences of mothers of children aged 5–14 with learning disabilities who participated in COSP™. The mothers found the program relevant for children with learning disabilities and appreciated its emphasis on fostering a reflective stance and enhancing the parent-child relationship. While some mothers resonated with specific COSP™ concepts such as “shark music,” others found these less applicable due to the unique challenges of parenting children with learning disabilities. The requirement for parents to reflect on their interactions with their children was perceived as challenging and painful, as it underscored the atypical development of their own child. The additional challenges of parenting children with learning disabilities, including diverse caregiving responsibilities and a sense of being overwhelmed, were not adequately addressed in the COSP™ materials. The parental accounts from Muddle et al. underscore the importance of target group sensitivity and adaptability in COSP™ implementation, highlighting the need for intervention content to be adapted to diverse target groups to promote acceptability and effectiveness.
Finally, a recent study investigated the experiences of 12 Norwegian mothers who were diagnosed with eating, personality, mood, or anxiety disorders (Helle et al., 2023). The mothers generally reported that COSP™ positively influenced their perceptions of maternal competency and enhanced their self-awareness and emotion regulation capacities. Some mothers noted a change from viewing their children’s behavior as “difficult” to recognizing it as an expression of legitimate attachment needs. Additionally, concepts central to COSP™, such as “shark music”, were utilized as helpful tools to guide their behavioral patterns and actions and were perceived as effective in improving communication and meeting their child’s needs. However, it is important to note that the benefits of COSP™ in this study might have been influenced by concurrent psychological treatments, as all mothers were also receiving psychotherapy, including cognitive behavioral therapy (CBT), trauma-focused psychotherapy, and psychodynamic therapy. The authors discuss that this dual intervention approach likely played a significant role in the positive changes reported by some mothers. While the findings suggest that COSP™ may be an effective adjunct to other psychological interventions, it is challenging to disentangle changes attributable to COSP™ from those due to other interventions.
The Current Study
While qualitative studies of COS-P™ have thus shown promise in some populations, its specific impact on mothers with PPD, a group particularly vulnerable to parenting and attachment-related difficulties, has to the best of our knowledge not been explored qualitatively. This study seeks to fill this gap by providing insights into the experiences and perceived changes among mothers with PPD participating in COSP™ as part of a larger RCT evaluating the effects of COSP™ (Stuart et al., 2025). We explore what barriers for change the women may experience in regard to their participation. This allows for a deeper understanding of their experience of if and how they profit from COSP™ in their parenting practices and relationships with their children. By exploring the mothers’ perspectives, this study not only assesses the program’s experienced effectiveness, it also contributes to understanding of the experienced mechanisms of change - or lack of such - as well as potential avenues for refinement of interventions tailored to this vulnerable group. Thus, our research question was: What are the experiences of mothers diagnosed with PPD participating in COSP™, particularly regarding intervention-related changes and mechanisms of change?
Methods
Setting
This study was part of a larger research project, the Copenhagen Infant Mental Health Project (CIMHP; Væver et al., 2016), which included a randomized controlled trial (RCT) comparing COSP™ + care as usual (CAU) with only (CAU) in the municipality of Copenhagen. COSP™ + CAU and CAU were provided as preventative interventions for families where the mother suffered from PPD and/or the infant displayed social withdrawal (for further details, please refer to Væver et al., 2016, and Stuart et al., 2025). CIMHP was approved by the university’s ethical review board (2015–10), and all participants gave informed written consent prior to enrolment. The RCT was conducted between 2015 and 2020, with 196 mothers allocated to the COSP™ intervention arm, from which informants for the present study were recruited. Exclusion criteria were mothers being younger than 18 years, non-fluency in Danish, severe infant medical conditions/early developmental delay, premature birth (<28 weeks), mother diagnosed with bipolar/psychotic disorder or severe intellectual impairment, attempted suicide pre- or postpartum, alcohol/substance abuse, and if the family planned to move away from Copenhagen during the RCT.
Participants and Sampling Strategy
Following Cooper & McLeod’s (2015) recommendations for sampling in qualitative research on clients’ perceptions of change in counselling and psychotherapy, our sampling strategy for the current study focused on ensuring representation while acknowledging factors that might influence participant experiences. As our research question centered on mothers’ experiences of change following their participation in COSP™ in the context of PPD, we specifically included only mothers enrolled in the RCT based on a diagnosis of PPD. To obtain a representative sample, we invited all mothers who participated in COSP™ groups completed between February 2018 and April 2019. This period encompassed six COSP™ groups, led by nine different facilitators working in pairs, allowing us to account for potential influences from varying group dynamics and facilitation approaches on participants’ experiences. Recruitment coincided with the RCT follow-up assessments, and we advised mothers feeling overwhelmed to prioritize these assessments over the qualitative interview. Ultimately, of 26 invited mothers, 20 participated, with six declining: two due to moving to another part of the country, making participation in an interview infeasible, and four who were advised to prioritize the RCT follow-up assessments due to feelings of stress and overwhelm. Four interviews were further excluded because these mothers were included in the study based on infant social withdrawal, and two more were excluded due to incomplete audio recordings. The final dataset comprised fourteen mothers, aged 24–42 years (M = 31.1), with infants (9 girls, 5 boys) aged 2–10 months (M = 3.1) before to COSP™ (T1) and 7–28 months (M = 10.1) at the time of interviews (T2). Twelve participants were in a relationship, two were single, 85.7% had completed a higher level of education, six were first-time mothers, and six participated with a partner. The sample characteristics for this qualitative study are presented in Table 1.
Table 1
Sample characteristics
Mother Pseudonym
Age (Years)
Marital status
Education level
Child gender
Child age (months)
First time mother
Partner partaking
T1
T2
Emma
33
Partnered
Bachelor’s or Less
Girl
4
12
Yes
Yes
Nikoline
30
Partnered
Master’s or Doctorate
Girl
2
7
Yes
No
Anna
36
Partnered
Master’s or Doctorate
Boy
2
10
-
No
Rosa
26
Partnered
Bachelor’s or Less
Girl
2
7
-
No
Hanna
32
Partnered
-
Boy
2
10
No
No
Asta
24
Partnered
Bachelor’s or Less
Girl
10
18
-
No
Sofie
42
Single
Master’s or Doctorate
Boy
2
9
-
No
Ellen
28
Single
Bachelor’s or Less
Girl
2
8
Yes
No
Laura
25
Partnered
Upper Secondary or Less
Boy
4
12
Yes
Yes
Isabella
29
Partnered
Master’s or Doctorate
Girl
3
11
Yes
Yes
Marie
38
Partnered
Master’s or Doctorate
Girl
2
7
No
No
Emilie
27
Partnered
Bachelor’s or Less
Boy
3
10
-
Yes
Nora
33
Partnered
Master’s or Doctorate
Girl
3
9
-
Yes
Julie
32
Partnered
Master’s or Doctorate
Girl
3
11
Yes
Yes
T1 before the start of COSP™, T2 after COSP™ completion, at time of interview, - data not obtained
Interview Approach
We used the Client Change Interview (CCI), a semi-structured, exploratory approach developed to capture informants’ perspectives on psychosocial interventions (Elliott et al., 2001; Elliott, 2011). The CCI explores participants’ general experience with the intervention, perceived changes, and attributions of those changes. Informants evaluate the importance and likelihood of these changes occurring independently of COSP™, fostering a reflective and personalized understanding of their experiences. The CCI also includes probes for potential limitations or barriers, offering a holistic view of the intervention’s impact (Elliott et al., 2001; Elliott, 2011). Interviews were conducted by a trained research assistant with a master’s degree in ethnology. They were audio-recorded, transcribed verbatim, and anonymized to ensure confidentiality. Transcriptions preserved linguistic nuances, including hesitations and errors. Main question was transcribed in bold and underlined, reflecting how the interviewer phrased the question during interviews.
Data Analysis and Reflexivity
Interview data were analyzed using Braun et al. (2019) reflexive thematic analysis (TA), chosen for its ability to identify, analyze, and interpret shared patterns of meaning across the dataset. Reflexive TA emphasizes the researcher’s subjective role and acknowledges the researcher’s influence on data interpretation (Braun et al., 2019). The aim was to produce a coherent and compelling interpretation grounded in the data. TA is a recursive process that involves six phases: (1) familiarization with the data; (2) generating codes; (3) constructing initial themes; (4) developing and reviewing themes; (5) refining, defining, and naming themes; and (6) producing the report (Braun & Clarke, 2013). The analysis progressed iteratively between the data, coding, and theme development (Braun & Clarke, 2013). The flexibility of TA supported both inductive and deductive theme generation. While initial coding was conducted inductively, later stages incorporated COSP™-related concepts and theories during, enabling a theoretically informed interpretation (Braun et al., 2019; Braun & Clarke, 2013). KH, with no prior COSP™ experience, conducted the initial inductive coding to facilitate impartial interpretation of the data. In subsequent stages, themes were refined through discussions with NML, and AF, both of whom had COSP™ expertise. These discussions helped integrate theoretical insights, strengthening the plausibility of the interpretation within a more deductive framework. Coding and organization were conducted using NVivo 14. Throughout the process, KH reflexively considered how her position, beliefs, and prior experiences may have influenced her interpretation. Coding was conducted on a semantic, explicit level (Braun et al., 2019; Braun & Clarke, 2013). This study adopted an experimental and critical realist epistemology, recognizing participants’ experiences of reality as meaningful yet shaped by cultural and contextual factors. Participants’ accounts provided insights into lived experiences rather than direct representations of objective reality, requiring interpretation within broader contexts (Braun et al., 2019; Braun & Clarke, 2013).
Circle of Security - Parenting
COSP™ was delivered in groups of 6–10 participants over 10 weekly 90-min sessions. Both mothers and their partners were invited, and each group comprised 5–7 mothers, with or without their partners. On-site childcare was available, and sessions were held in a designated room within the research facility, equipped for group activities and video presentations. To ensure high attendance, parents anticipating more than two absences were encouraged to join a later group. Those who missed a session were offered a brief 15-min “brush up” before the next session. Throughout the intervention, parents watched pre-recorded video vignettes depicting parent-child interactions, which served as discussion prompts. They also participated in “circle stories,” reflecting on their child’s behaviors related to seeking closeness, emotional regulation, and exploration, as well as their own responses. Parents identified moments of difficulty or success in meeting their child’s needs, helping facilitators tailor discussion.
COSP™ facilitators were certified through training, where they received a manual summarizing key discussion themes for each chapter and video content. This study used the Danish version of the COSP™ manual (Cooper et al., 2009), translated and culturally adapted in collaboration with the original authors. While the materials were originally produced in the U.S. with English-speaking parents and children, the Danish version included a Danish-speaking narrator, subtitles for parent-child interactions, and supplementary resources in Danish. Certified facilitators, supervised by D. Quinlan and JSN (a fidelity coach and the Danish COSP™ trainer), completed fidelity journals after each session. These journals, developed by Circle of Security International, included reflection and fidelity questions assessing facilitators’ adherence to program objectives, management of relational challenges, engagement in reflective discussions, and ability to create a ‘holding environment’. Supervision sessions incorporated fidelity journals and group session recordings.
Results
Figure 1 presents our findings from the reflexive thematic analysis of mothers’ accounts of participating in the COSP™ program. Rather than portraying the intervention as uniformly beneficial, the results highlight the emotionally complex and, at times, distressing nature of the experience. While many participants described increased awareness of and new insights into their parenting practices, these shifts often emerged in tandem with moments of emotional strain, ambivalence, and a sense of dissonance between program content and lived experience. Five interrelated themes capture this complexity. Theme 1 explores how the program surfaced painful personal histories. Theme 2 examines heightened attunement to the child alongside increased self-doubt. Theme 3 focuses on vulnerability in the group-based format, Theme 4 captures the benefits of partaking with a partner, and Theme 5 considers contextual and relational constraints on applying program insights. Together, these themes point to the demanding and emotionally layered nature of the reflective work COSP™ elicited.
Fig. 1
Illustration of the Themes and Subthemes Identified Though the Reflexive TA
Theme 1: Identifying Negative Lenses and Connections to Own Childhood Experiences Led to the Experience of Relationship Changes
This theme explored how many mothers recognized how their own childhood experiences influenced their current emotional reactions to their children’s needs, leading to an experience of changes in their relational dynamics with their children. However, for some mothers, this process was challenging, as it involved confronting patterns and memories from their own past, which could evoke mixed feelings of progress and emotional strain:
I can see that many of the things I feel bad about myself stem directly from [my parents]. And I find that hard… That they could act that way toward me as a small child makes me feel like, honestly, they should never have had children because I wasn’t met at all. I was the one who had to contain them, not the other way around, and I found that quite difficult. (Nora)
Through reflection, mothers became increasingly aware of their “shark music”, and recounted a newfound understanding of how their own past caregiving histories and associated feelings were sometimes triggered by relational dynamics in the present. This recognition fostered a deepened understanding of how these patterns could influence their emotional responses to their infants’ needs. For instance, one mother reflected that her child’s frustration was not rooted in malice but was an expression of the child’s internal state and genuine needs. Marie specifically noted that she had come to understand her child’s crying as a form of communication rather than intentional disruption. Along the same lines Isabella noted “This is just shark music, like, there’s no real danger here.”
Exploring behavioral and cognitive patterns as a result of their own relationship history and upbringing was considered valuable by several participants. Rosa explained:
The primary reason for these changes is that I’ve gained insight into both my own behavioral patterns and, especially, my background, and how I was treated as a child. Because that’s the baggage I’ve carried with me, and those things naturally became behavioral patterns for me. Gaining insight into my own behavioral patterns, and how those patterns can affect my child, has definitely been the reason for the changes.
Some mothers reported that they also developed their emotion regulation capacities and had the experience of this positively influencing their interactions with their children:
I think the whole idea of the circle, like, if my child becomes upset, sad, restless, or something like that, I can now help us get to a place where it’s easier to manage. I can use the concept both in relation to my child, but I can also turn it around and say, okay, why do I act like this? Oh, it’s because I carry certain things with me from my past… so in that way, it’s like adding subtitles for myself to understand what’s happening in the situation. (Anna).
This reflective process allowed some mothers to experience an ability to pause and reassess and inhibit their automatic reactions, leading to more sensitive responses that were guided by their child’s emotional needs rather than letting their own emotions (i.e., “shark music”) determine the interaction. Ellen described how she used the “shark music” concept as a reminder to take a “mental time out” during emotionally charged moments, thereby recalibrating her responses to focus on her child’s needs: “I think I am more able to reflect. I used to panic, like, when she started crying. But now, I think I’m better at taking a deep breath and just saying, ‘OK.’”
Subtheme 1.1: Insight at a cost – The Emotional Toll of Self-Reflection
While many mothers reported experiencing positive changes in their emotion regulation and self-awareness, some also expressed ambivalence regarding the “emotional toll” of the process. For a subset of mothers, the program’s intense focus on emotional reflection and self-awareness was occasionally overwhelming to them. Revisiting their own childhood relationships and addressing long-term maladaptive thought patterns proved especially challenging for some participants. Becoming aware of their “shark music” and reflecting on its roots in their own childhood experiences, as well as how it influenced their parenting behaviors, was often experienced as emotionally exhausting. This was compounded by their realization of how central their relationship with their child was and how failure to address these issues could negatively affect their child’s development:
I easily get worried or feel guilty, and when something is shown to be wrong, or when you’re told to do this and that, I think, ‘Oh no, I’m not doing that, or I’m not doing it enough. Oh no, my poor child is being affected by this. (Sofie)
Along the same lines, for some participants, the process of reflection induced feelings of guilt and overwhelm regarding past parenting behaviors. For Nora, this led to her questioning her ability of being a competent mother:
It was overwhelming… because sometimes, I felt like it was because I was just a bad mom. And that feeling that I was a bad mom, was really awful to sit with while being there because, at times, it was what weighed on me the most. (Nora)
In some instances, the focus on past relationships, particularly with their own parents, was experienced as emotionally distressing to the extent that it overshadowed the mothers’ capacity to focus on present-day interactions with their children. Revisiting unresolved emotional neglect from their own upbringing sometimes strained the mothers’ relationships with their parents, and some participants noted that the group sessions did not provide sufficient time or resources to process these experiences:
I never thought that I had a bad childhood, and I never thought there were problems with my relationship with my parents until I attended this program. Now, suddenly, I can see where so many of the things I do myself come from, and I’ve actually found that really difficult because I like my parents a little less now after participating … I have found it hard to navigate that. (Julie)
Theme 2: Experience of Enhanced Understanding of and Ability to Meet Child’s Needs
This theme illustrated how the COSP™ program was experienced to lead to a deepened understanding and acknowledgment of the children’s emotional needs. While some mothers saw participating in the COSP™ group as the main driver of these experienced changes, others felt their child’s natural ongoing development and the passage of time were also important factors.
A number of participants observed positive changes in their interactions with their children. Hanna, for example, recognized that her previous behavior had signaled to her child that it was unsafe to explore. After adjusting her own behavior, she noticed her child becoming more curious and social:
If we went to the playground, she would always stay close to us, right? And it’s very clear that this was because I had been sending her signals that it was safest to stay with mom, because I needed that. But now, because she knows that I am her secure base and that I’m there for her, she just runs around and goes up to people to say hi, and she’s not at all insecure in her interactions with strangers.
Several mothers reported an increased focus on “being with” their child during difficult emotions, rather than attempting to distract them, another central concept to COSP™. Ellen, for instance, explained that she now avoids diverting her child with toys or attempting to change their emotions, opting instead to tune into her child’s emotional experiences. Similarly, Rosa emphasized the importance of validating, rather than distracting, the child’s negative feelings, staying with them until the feelings subsided. In this context, Emma emphasized that her child comes to her “to get her cup filled”, when she needs comfort.
Emma also described the benefits of reflecting her child’s emotions through her facial expressions and helping them work through their feelings: “by mirroring her mood with my expression and saying, ‘ooh yes, that was a bit scary,’ she can see that I understand her fear, instead of dismissing it by saying there’s nothing wrong.”
At the same time, the participants varied in how they perceived the driver of these changes. While some viewed their participation in the COSP™ group as the primary catalyst for their increased awareness and acknowledgment of their child’s emotional state and needs, others saw it as just one of many contributing factors. Again, several participants emphasized that the biggest driver of change was the passage of time, that is, their child growing older and, as a result, making it easier to communicate with them about their emotions.
Subtheme 2.1: Increased Confidence in the Parenting Role
Most participants highlighted a substantial boost in parenting confidence following their participation in COSP™. Gaining a deeper understanding of their children’s emotional needs and learning how to respond to them effectively led to increased feelings of competence in their parenting roles:
I’ve experienced a lot of changes, especially in how I understand [my child]. Before, I thought that when she lashed out, it was because I had done something wrong. Now I can see it much more from [my child’s] perspective—that it’s her way of communicating because she still can’t talk. So, when she gets angry, sad, or frustrated, it’s not because she wants to negatively affect me or anyone else, but it’s her way of showing frustration… I feel like I’ve changed a lot in my approach to her and have become much calmer in my role as a mom. (Hanna)
The COS graphic was highlighted as a valuable tool that enhanced the mothers’ understanding of their children’s needs and behaviors. Several mothers emphasized that the knowledge and skills acquired through the COSP™ program increased their confidence and calmness in their roles as mothers: “I feel more secure in being there for [my child], understanding [my child], and generally being a parent. This security gives me confidence…the information has helped me handle her and understand the underlying mechanisms” (Asta).
Again, the extent to which mothers attributed these changes to their participation in the program varied. For some, the changes in confidence were perceived as more closely related to the passage of time and for first time mothers, their increasing experience in the parental role.
Theme 3: Reflections in the Group: A Journey of Insight and Emotional Strain
This theme centered around how some mothers experienced the joint group reflections in the COSP™ group to enhance their reflective capacities. Participants noted that listening to other parents’ experiences fostered personal insights and broader perspectives on parenting. However, while this shared dynamic was beneficial, some mothers found the emotional intensity challenging, as it sometimes resurfaced distressing memories.
For example, Isabella explained how listening to others in the group stimulated her own thoughts, allowing her to gain new perspectives on her parenting and emotional experiences:
Because you also gained insight into yourself in ways you had not considered before—when someone said something, and you thought, ‘Wow, I feel that way too,’ but you had not yet had the chance to reflect on that yourself. And when others mentioned certain things, it gave you a new perspective to think about and develop further. I really liked that.
This aspect of group dynamics was experienced as crucial for several participants, as it provided them with diverse examples and situations to consider, thereby broadening their understanding of how COSP™ concepts could be applied. Nevertheless, some participants found the group format emotionally draining. Laura described the challenge of listening to others’ difficult stories, stating, “It was very intense with the group, and it frustrated me a bit to listen to others’ burdensome situations because I had no room for it, as I tend to internalize it.” Another mother echoed this sentiment, indicating that others’ reflections sometimes evoked past experiences she had tried to distance herself from.
Theme 4: Strengthening Family Bonds Through Collaborative Parenting
This theme focused on the program’s impact on the participant’s experience of co-parenting and family dynamics. Mothers reported that joint participation with partners improved communication and reduced conflicts, leading to a more cohesive parenting approach. The COSP™ program also had a ripple effect on broader family dynamics with many participants reporting that the program facilitated improvements in co-parenting and their relationship with their partner, as Emma exemplifies:
“We have developed a common language, and then [my partner] has improved his understanding of some of the things that I say and think, so in that sense I would say that our communication has improved a bit.”
Joint participation in the COSP™ program was identified as a crucial factor in fostering better communication between the parents and reducing conflicts. Several mothers explained how they as a couple brought the COSP™ concepts home, which helped in aligning parenting approaches with their partners. Emma, for instance, described her partner’s participation as of “immense significance,” arguing that COSP™ should be offered to both parents to be effective: “It’s useless if one learns it and the other doesn’t.”
Accordingly, those whose partners did not participate experienced difficulties, feeling frustrated by the imbalance of knowledge within their relationships. Nikoline expressed frustration at the imbalance created by her partner’s lack of the knowledge she had obtained by her participation in the COSP™ group: “It becomes very unbalanced, as if I have knowledge I want to share with him, but it’s like I’m speaking Chinese to him… it doesn’t matter how much I try.” Julie similarly noted that “for our relationship, it hasn’t helped—on the contrary, it has made things really difficult that I possess a lot of knowledge but can’t share it with him because he feels like I’m lecturing him or something”. She further added that the unequal level of knowledge led to conflicts, leaving her to implement the program’s learnings on her own. In general, mothers who attended COSP™ without their partners found it challenging to convey the program’s content effectively to them.
Theme 5: Misalignment Between Program Content and Participants’ Lived Realities – Developmental, Emotional and Cultural Barriers
This theme highlighted how several mothers found that key aspects of the COSP™ program did not align well with their current parenting experiences. Moreover, sustaining the use of COSP™ learnings post-program was also challenging, highlighting the need for some follow-up support. A frequently reported challenge was the difficulty in applying COSP™ concepts to infants. Many participants noted that most of the content, especially the videos, was designed for older children, making it hard for them to ’transfer’ the learnings to their parenting practices with infants. Mothers often felt that the concepts of exploration, integral to COSP™, were less applicable when their child had limited motor skills compared to the older children displayed in the videos. As Isabella shared, “[it is] a bit difficult to apply that [concept] of going out to explore when you have a small child compared to when you have a slightly older child”.
Beyond developmental misalignment, some participants reported feeling emotionally overwhelmed by the videos, especially those who described themselves as struggling with moderate or severe PPD symptoms. The portrayal of what secure parenting looked like triggered strong emotional reactions, leading to feelings of guilt and incompetence, particularly among first-time mothers:
It was [a] difficult [program] to get through, and having to tackle this notion of parenthood and being shown all of the things that one can do wrong… I thought [it] was presented in a manner that was quite explicit… because it was things that we were already struggling with. (Isabella)
Marie further exemplified how, for some mothers, the videos resonated with pre-existing insecurities in their role as mothers and may have inadvertently confirmed these negative beliefs:
I know that some people in the group reacted strongly to some of the videos. When you’re sitting with a group of mothers who are already struggling and maybe being a bit hard on themselves about how they are as mothers, some of the videos might have triggered some guilt (…) it was mentioned a few times that some couldn’t really understand why they needed to be shown that.
Several mothers also found the videos to be culturally out of touch, which further alienated them from the content. Many described the videos as “very American” and outdated, which limited their relevance to a Danish context. Sofie remarked:
It was a bit 80s-like, those videos. They had some points, but they were also a bit Americanized… I think if they could make something a bit more modern, Scandinavian, or culturally relevant for us, it would be easier to identify with.
These challenges highlighted that some mothers perceived the program’s content as lacking cultural, developmental, or emotional sensitivity, which, in certain cases, was seen as a barrier to meaningful change.
Discussion
This study explored the experiences of mothers diagnosed with PPD participating in the group-based parenting program COSP™, focusing on helpful and hindering program elements for change. The thematic analysis identified five themes: (1) Identifying negative lenses and connections to own childhood experiences led to the experience of relationship changes, (2) Experience of enhanced understanding of and ability to meet child’s needs, (3) Reflections in the group: a journey of insight and emotional strain, (4) Strengthening family bonds through collaborative parenting, and (5) Misalignment between program content and participants’ lived realities – developmental, emotional and cultural barriers. These findings highlight both the perceived benefits and limitations of COSP™ for mothers with PPD. While some participants reported increased self-awareness, confidence, and improved relationships with their infants, others felt the program did not reflect the emotional and practical challenges of parenting while depressed. This tension underscores the need to adapt reflective interventions to the psychological realities of clinically vulnerable populations. The following sections situate these findings within existing research on parenting and maternal mental health.
Theme 1: Identifying Negative Lenses and Connections to Own Childhood Experiences Led to the Experience of Relationship Changes
COSP™ emphasizes the development of reflective functioning by encouraging caregivers to connect past experiences with present parenting behaviors (Poulsen et al., 2024; Woodhouse et al., 2018). Consistent with prior qualitative research (e.g., Helle et al., 2023; Maxwell et al., 2021), several mothers in our sample described this introspective focus, especially tools like “shark music”, as meaningful in identifying intergenerational patterns and sustaining a mentalizing stance during emotionally charged interaction with their infants.
However, reflective engagement also appeared to incur psychological costs. For some mothers, revisiting painful childhood material evoked emotional distress, self-blame, and strained relationships with their own parents. These reactions suggest a core tension in the program’s design: While fostering emotional awareness is a central goal, the process may inadvertently exacerbate symptoms common in PPD, including guilt and negative self-perception (e.g., Milgrom & Gemmill, 2020). Consistent with concerns raised in broader psychotherapy research, insight-oriented interventions can be overwhelming when delivered without sufficient therapeutic containment (Berg & Jools, 2017).
This issue is not unique to COSP™ but reflects broader challenges with reflection-heavy models. McPherson et al. (2020) noted that interventions which emphasize past-oriented exploration can be misaligned with participants’ needs when they fail to consider therapeutic preferences. Some individuals benefit more from present-focused, skills-based approaches that emphasize regulation and behavioral activation rather than introspection. When such preferences are ignored, participants may find the intervention emotionally taxing or disengaging. COSP™, while not a form of psychotherapy, shares core features with such models through its structured reflective content and focus on internal emotional dynamics. For some mothers with PPD, these elements may activate depressive cognitive patterns rather than alleviate them. Although mothers in this study had access to external psychological support, many still found COSP™ emotionally demanding. For some, the program’s focus on early relational trauma amplified narratives of personal inadequacy. These findings highlight the need for clinical adaptation when implementing COSP™ in high-risk groups. Offering individual sessions, integrating COSP™ with concurrent psychological support, or allowing greater flexibility in reflective depth may help buffer emotional risks and enhance accessibility.
Theme 2: Experience of Enhanced Understanding of and Ability to Meet Child’s Needs
Many participants reported an increased understanding of their infants’ emotional needs. However, the lack of measurable improvement in sensitivity, reflective functioning, or attachment security, both in our own RCT Stuart et al. (2025) and in others (e.g., Cassidy et al., 2017; Zimmer-Gembeck et al., 2022), raises questions about the extent to which COSP™ supports actual behavioral change in clinically vulnerable populations such as mothers with PPD. This discrepancy between perceived insight and observed outcomes reflects a broader tension within COSP™ ‘s theoretical design. As Maxwell et al. (2021) noted, the program focuses primarily on enhancing observation and reflection rather than the development of specific caregiving behaviors. While reflective capacity is important, it may not be sufficient to support change for individuals already struggling with self-doubt or emotional overload (Hadfield & Wittkowski, 2017; Holopainen & Hakulinen, 2019). In such cases, introspection may exacerbate rather than alleviate depressive cognitions. Emerging research suggests that behaviorally oriented approaches, such as video-informed feedback, may offer clearer, more actionable pathways to change (Hackley et al., 2023; Wright et al., 2023). These interventions link reflective awareness to specific, observable parenting behaviors and may be particularly helpful for mothers managing both depressive symptoms and the demands of early caregiving.
Additionally, several participants in the present study attributed their perceived parenting improvements to contextual factors such as infant maturation or the accumulation of caregiving experience over time. These accounts highlight the importance of distinguishing subjective change from intervention-specific effects. While participants’ perceptions of increased understanding and confidence may reflect meaningful subjective experiences, these should be interpreted cautiously in light of broader developmental, relational, and contextual factors. Without a clearer understanding of which elements of COSP™ contribute to perceived or actual change, and for whom, it becomes difficult to determine its relevance or effectiveness for high-risk populations.
More broadly, these findings raise concerns about the generalizability of parenting programs developed for non-clinical populations. Without contextual or clinical adaptation, such interventions may fail to meet the needs of mothers with PPD (Nguyen & Pengpid, 2025). Mothers with PPD may require more than reflective prompts to support meaningful change. Interventions for this group may benefit from the integration of structured, staged supports that explicitly scaffold insight into action. Without such adaptation, reflective models like COSP™ risk overburdening participants who lack the internal resources or external support necessary to engage with the intervention as intended.
Theme 3: Reflections in the Group: A Journey of Insight and Emotional Strain
Group-based delivery of COSP™ was described by some participants as fostering connection and emotional resonance, consistent with previous research highlighting the value of group support in parenting interventions (Maxwell et al., 2021; Muddle et al., 2022). However, our findings also point to unintended consequences for mothers struggling with PPD, particularly that hearing about others’ difficulties may inadvertently exacerbate depressive symptoms.
These concerns are echoed in the broader psychotherapy literature regarding potential negative therapeutic outcomes (Rozental et al., 2018). While group formats can be effective for many, they also carry the potential for unintended harm. Recent studies highlight that not all individuals benefit equally from group-based approaches, and that some report emotional overwhelm when exposed to others’ distress or when asked to engage in emotionally intensive techniques (McPherson et al., 2020). Although some degree of challenge is inherent in most therapeutic settings, there is growing recognition that certain features of group therapy may precipitate adverse outcomes or lead to distress among vulnerable participants, especially when the group has not yet developed into a cohesive or supportive unit (McPherson et al., 2020). These findings underscore the importance of nuanced attention to group dynamics, especially when working with clinically vulnerable populations such as mothers with PPD.
Theme 4: Strengthening Family Bonds Through Collaborative Parenting
Several mothers in the current study reported that attending COSP™ with their partner led to improved communication, reduced conflict, and a more coordinated approach to caregiving. While not an explicit target of the program, these relational effects may be particularly relevant in the context of PPD, which is often marked by a diminished sense of competence in the parenting role (Holopainen & Hakulinen, 2019; Highet et al., 2014). For some mothers, participating alongside their partner appeared to mitigate these internalized perceptions by externalizing caregiving responsibilities and promoting a shared mental model of parenting. This aligns with findings from Glavin et al. (2023), where parents reported feeling more unified in their parenting approach due to enhanced communication. Moreover, feeling “on the same page” with one’s partner may serve as a form of relational validation, which, although not formally built into the COSP™ curriculum, could act as a protective mechanism against the negative cognitive patterns common in PPD.
In contrast, mothers who attended COSP™ alone frequently reported difficulty conveying key program concepts to their partner, which sometimes led to frustration, conflict, or a sense of carrying the parenting responsibility unequally. These accounts mirror evidence from a qualitative systematic review of partner-inclusive interventions for postpartum depression. They found that joint participation supports not only maternal mental health, but also the development of dyadic capacities such as emotion regulation and collaborative problem-solving within the couple relationship, as reported by women with PPD (Alves et al., 2018). This suggests that the structure of COSP™, when delivered as a couple-based intervention, may inadvertently address certain clinical vulnerabilities associated with depression, though it also raises the question of whether such outcomes could be more effectively harnessed through intentional design.
Theme 5: Misalignment Between Program Content and Participants’ Lived Realities – Developmental, Emotional and Cultural Barriers
Numerous mothers in the current study described a misalignment between COSP™ content and their lived parenting experiences, particularly among first-time parents. This raises important questions about the developmental and cultural fit of the program for Danish mothers caring for infants. Participants frequently reported that the COSP™ materials, especially the video vignettes, focused primarily on older, verbal children engaged in exploration, separation, or behavioral correction. In contrast, the mothers’ infants in the current study were between two and ten months old, and their immediate caregiving concerns included sleep regulation, infant crying, emotional soothing, and managing exhaustion. Although COSP™ includes a dedicated chapter on infancy, participants found it too limited in scope. It did not offer sustained, developmentally specific guidance that reflected the realities of parenting during the early postpartum period
For clinically vulnerable mothers, the absence of concrete strategies for responding to infant cues may not simply reduce engagement. It may also intensify feelings of inadequacy. Mothers with PPD often struggle with distorted self-appraisals and heightened guilt, which can be reinforced when they are unable to translate abstract program concepts into actionable caregiving practices (Holopainen & Hakulinen, 2019; Highet et al., 2014). Without age-appropriate content that affirms and equips their parenting, these mothers may interpret developmental challenges as personal failures rather than as typical infant needs.
Participants also expressed difficulty sustaining the use of COSP™ tools following the conclusion of the program. This concern aligns with previous research highlighting the need for continued support to ensure the long-term integration of parenting interventions (Maxwell et al., 2021). This challenge may be especially acute for mothers with PPD, who often face cognitive symptoms of depression (Kircanski et al., 2012). These symptoms can limit their ability to retain and implement psychoeducational material without structured follow-up.
Cultural disconnects further shaped how participants engaged with COSP™. Several mothers reported that the U.S.-produced video materials, even with Danish subtitles, felt emotionally exaggerated, stylistically outdated, and inconsistent with Danish parenting values. Parenting culture in Denmark, similar to other Nordic countries, emphasizes calm, egalitarian, and autonomy-supportive interactions (Hansen et al., 2020; Bornstein et al., 2011). Nordic caregivers typically view the child as an active relational partner and attribute caregiving success to mutual responsiveness rather than parental control. In contrast, COSP™’s pedagogical style, which is grounded in U.S. cultural norms, often reflects a more emotionally expressive, individual responsibility-based approach that may feel dissonant to Danish families (Bornstein et al., 2011). This cultural incongruence may have undermined some participants’ trust in the program’s relevance, particularly among mothers already experiencing reduced self-efficacy.
These cultural concerns must also be understood in relation to Denmark’s postpartum healthcare system. Most families, approximately 98 percent, receive four to six home visits from public health nurses during the infant’s first year, offering individualized guidance on development, parenting, and maternal well-being (Holstein et al., 2021). As a result, parents in this context may expect personalized, hands-on support. Group-based programs such as COSP™, which emphasize emotional reflection over practical caregiving guidance, may feel less aligned with these expectations, especially when paired with insufficient developmental specificity. For mothers with postpartum depression, the absence of tailored support and integration with existing municipal services may further limit the accessibility and perceived utility of the program.
As Lansford (2022) emphasize, effective cultural adaptation of parenting interventions requires both surface-level changes, such as updated examples and language, and deeper alignment with local caregiving values and relational norms. In the present study, the absence of both types of adaptation may have contributed to participants’ emotional ambivalence, limited perceived applicability of COSP™ tools, and difficulty maintaining their use over time. Notable, limited contextual adaptation has been linked to with reduced intervention effectiveness (Benish et al., 2011), which may also be relevant to the findings reported here.
Strengths and Limitations
The study has some limitations that should be considered when interpreting the results. While this was a study of mothers’ experience of COSP™, it is important to note that the RCT consisted of COSP™+care-as-usual. Our findings suggest that COSP™’s goal of fostering emotional insight may not function in isolation but rather in conjunction with other personal and external factors. This underscores the complexity of attributing perceived changes to a single intervention, particularly when participants were also engaged in concurrent therapies or medication, as in this sample. The interaction between COSP™ and other therapeutic influences likely contributed to the positive changes, complicating efforts to isolate COSP™ as the sole mechanism of change, as described by several mothers. In the same vein, we did not have any interviews with mothers who only received care-as-usual, meaning we are limited in attributing any perceived positive changes to only COSP™. Finally, 15.6% of mothers dropped out in the COSP™ group from baseline to follow-up, and if mothers felt overwhelmed, they were asked to prioritize the quantitative assessments at follow-up. Thus, we cannot rule out some form of selection bias in who decided to participate in the qualitative interviews. However, the fact that our analyzed themes are in line with previous qualitative studies of COSP™ point in the direction of some universal experiences of the intervention.
Conclusion
This study offers a nuanced view of how mothers with postpartum depression experience the COSP™ program, highlighting both perceived benefits and important limitations. While some reported increased emotional awareness, others found the program emotionally overwhelming, developmentally mismatched, or lacking sufficient support. These findings challenge assumptions of universal applicability and suggest that COSP™ may require adaptation when delivered to clinically vulnerable populations.
Modifications such as developmentally specific content for early infancy, culturally attuned materials, and embedded therapeutic support are essential to ensure relevance and safety. At the policy level, intervention scalability must be accompanied by clinical and contextual fit.
Future research should examine how parenting programs are understood and used in the context of psychological distress, with attention to which components support meaningful engagement and change. This work is critical to advancing interventions that are not only evidence-based but also clinically responsive and ethically grounded.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
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