Whereas the growing host of parenting programs has triggered considerable research on evaluating program-specific methods, common factors that produce positive program outcomes are typically overlooked (cf. Asmussen, 2011; Morris et al., 2020). This article considers the practitioner’s therapeutic competence as a traversal feature across different parenting programs.
Therapeutic competence is activated when practitioners translate program-specific knowledge and intervention techniques to the unique setting of each parenting group. The basics of therapeutic competence include establishing a working alliance through empathic communication that breathes emotional security (Koddebusch & Hermann, 2018, p. 18). Although measurement and assessment of this activity may be difficult, therapeutic competence is now regarded in the literature as a critical factor for successful outcomes in various interventions (Koddebusch & Herrmann, 2019; Kühne et al., 2020). However, therapeutic competence is still unexplored when it comes to parenting programs. There are indications in previous research about the importance of minimizing barriers to parent engagement (Morris et al., 2020), as well as creating a workable practitioner–parent alliance in adherence with the program manual (Scott & Gardner, 2015). Nevertheless, a recent systematic review of 24 quantitative parenting program studies indicates that “both the therapist’s interpersonal actions and more active skills relate to parent change”, while at the same time highlighting that the role of practitioner’s therapeutic competence is still “scarcely or poorly studied” (Leitão et al., 2021, p. 84).
This article addresses that lacuna through a qualitative analysis of parenting program practitioners’ own experiences in Sweden. Instead of comparing intervention procedures of different parenting programs, the analysis focuses on how practitioners reach beyond the program manuals to employ their therapeutic competence for tailored interventions and optimized outcomes. The empirical data consists of focus group interviews with practitioners from two of Sweden’s most adopted parenting intervention programs: Circle of Security-Parenting (COS-P) and Communication Method (COMET).
Circle of Security was initially launched as a 20-week intervention protocol designed to improve “patterns of attachment–caregiving interactions in high-risk caregiver-child dyads” (Marvin et al., 2002, p. 7). Circle of Security-Parenting (COS-P) is a condensed version with eight parent group meetings (Powell, 2014). The program, rooted in attachment theory and developmental psychology (Risholm Mothander et al., 2018), aims to enhance the parent’s reflective capacity and capability to comfort and support the child. The long-term goal is that the child will learn, through these experiences, to regulate his/her feelings (Mercer, 2015). COMET, an abbreviation of Communication Method, is a program for parent-education interventions that springs from the behavioral tradition and typically includes eleven group meetings (Kling et al., 2006). Inspired by the Parent Management Training–Oregon-Model (Forgatch & Patterson, 2010), the objective of COMET is to change negative child behavior by modifying the parent-child interaction (Stattin et al., 2015).
Evidence suggests that both parenting programs are efficient; COS-P improves child attachment security (Krishnamoorthy et al., 2020; Yaholkoski et al., 2016), COMET reinforces parenting competence and prevents negative child behavior (Jakobsson, 2013; Stattin et al., 2015). However, COS-P and COMET, rooted as separate theoretical traditions, are rarely analyzed conjointly – even though they are used interchangeably in the Swedish context. The current study was designed to capture, in this particular context, the transversal factors and experiences of the practitioners.
The Current Study
Method
The empirical material was collected through four focus group interviews with practitioners from both parenting programs. The focus group method was chosen to document experiences and reflections from practitioners working with different parenting programs in Sweden. Since “focus group conversations are inherently social in their form” (Cyr, 2019, p. 9), this qualitative method was particularly apt for capturing what is considered consensus and what is up for debate among the interviewees. The current study thereby followed the qualitative research tradition that, since the 1980s onwards (Morgan, 1998), has employed the focus group method to “enhance the collection of deep, strongly held beliefs and perspectives” (Carey & Asbury, 2016, p. 17). Hence, whereas in-depth interviews would have gathered individual reflections on the role of therapeutic competence, the focus group method instead captured interactive reflections between parenting program practitioners in Sweden.
Participants
Thirteen parenting program practitioners participated in the focus group study. They were recruited through a snowball sampling (Noy, 2008) from various health and social care institutions working with parenting programs in Stockholm, Sweden. The participants included both women (n = 9) and men (n = 4). They were social workers (n = 8), nurses (n = 3), and psychologists (n = 2). Every participant had formal education in the parenting program they practiced, and the majority (n = 10) also had a two-year basic education in psychotherapy. It should be noted that, in alignment with the ethical procedures stipulated by the Swedish Research Council (2017), all participants gave their full consent to partake in the study and not disclose discussion entries outside the focus group. The study involved no personal data, and pseudonyms have been used for all participants quoted in this article to maintain confidentiality.
Data Collection
The study included four focus groups to secure qualitative data saturation (Cyr, 2019, p. 42); after the completion of these four focus groups, the empirical material reached a point of saturation which implied that further data collection would have been redundant. The focus groups were conducted in 2019, between January and April. Each group consisted of three to four participants to maximize group dynamics and individual engagement (Wilkinson, 2008). The participants were arranged into four focus groups, where two groups were dedicated to each parenting program: COS-P (n = 6) and COMET (n = 7). As the group participants knew each other beforehand and typically had collaborative experiences working with the parenting programs, the focus group conversations allowed for open and reflective discussions about the role of the practitioner’s therapeutic competence as program leaders.
To increase the confidence in expressing their views freely, thereby enhancing data validity, the focus groups took place at sites familiar to the participants (Hennink, 2013; Wilkinson, 1998). They lasted approximately 90 min and followed a semi-structured interview guide based on thematic discussion topics, orbiting the practitioners’ views on the strengths/limitations of the parenting programs and how they strived to optimize program outcomes. By avoiding standardization of question protocols and minimizing the risk of the “fallacy of adhering to fixed questions” (Morgan, 1996, p. 142), the current study followed the procedure of having a “rolling interview guide” (Stewart & Shamdasani, 2015, p. 70). The thematic conversation topics were, in this sense, not static but flexible, in tune with the unfolding knowledge production. However, the focus group conversations subscribed to the seasoned routine of having a loose structure of opening questions, introductory questions, transition questions and ending questions (Krueger & Casey, 2015, pp. 44–47).
In the focus group setting, Susanna Lundström used her role as a clinical expert in child psychiatry to infuse engaging topics and moderate the group discussions, while Markus Lundström used his qualitative research expertise as an observer, note-taker, and conversation facilitator. This clinical-scholarly collaboration allowed for fruitful discussions and enabled registration of the unfolding discussion’s shifts in mode, intensity, and engagement (Hennink, 2013). To optimize the documentation of these notations, the recorded focus groups were transcribed as soon as possible after being conducted.
Data Analysis
The qualitative data analysis followed an inductive coding procedure stemming from the grounded theory approach (Glaser & Strauss, 1967). The work of thematic coding was conducted exclusively by Susanna Lundström. The procedure unfolded in three refinement stages with the aim to extract notable aspects of therapeutic competence from the transcribed focus group conversations. The data were first submitted to an open coding: the transcriptions were printed and read several times to assign every text segment with descriptive classifications (Corbin & Strauss, 2014). In the second stage, the focused coding, all initial classifications were organized into clusters with headings that soon became recognized as tentative themes (Charmaz, 2006). These themes were successively refined by reviewing and re-organizing them along with the connected interview excerpts (Braun & Clarke, 2006). In the third stage, the theoretical coding (Qureshi & Ünlü, 2020), the refined themes related to therapeutic competence were then linked to three theoretical concepts established by the psychological literature: positive reinforcement, self-disclosure, and mentalization. These empirical results are presented in the following section.
Results
The interviewed COS-P and COMET practitioners emphasized that their respective parenting programs produced outstanding results but also that they constantly had to be flexible and sidestep or modify the program manuals to address the particular needs of each parent group. The qualitative data analysis revealed that therapeutic competence was at the heart of this flexibility. The focus group conversations recurrently included discussions and examples of various approaches employed to meet the parents of each group setting. The thematic coding of the four focus group conversations uncovered that the interviewed practitioners employed select therapeutic techniques and capabilities to validate and support the parents: positive reinforcement, intentional self-disclosure, and mentalization.
Positive Reinforcement
Positive reinforcement of the child’s behavior is a fundamental part of COMET, a parenting program rooted in the behavioral tradition. In the current study, the COMET focus groups (FG1, 2019; FG2, 2019) typically mirrored the program’s confidence in positive reinforcement techniques to empower the parent-child relationship. However, the interviewed practitioners also shared experiences about using positive reinforcement towards the parents; they encouraged positive parenting behaviors instead of lingering on the mistakes recalled in the parent groups. A common assumption was that the practitioner-parent interaction was an essential facet of the educative process. Although active learning, including role-playing and take-home assignments, is integral to this parenting program, the practitioners also made use of positive reinforcement in the parent groups to, when the timing was right, encourage parents to “think for themselves” (FG1, 2019). From this supportive perspective, the practitioners described a heartfelt delight when the parents, after a few weeks of education and support, came to the point where they recognized how their own behavior was shaping the parent-child relation (FG2, 2019):
Carl I find that in nearly all groups, there is a point when they suddenly shift focus toward themselves, away from [the behavior of] the child. […]
Susanna When does this happen? How does it come about?
Johan I think it always happens, although on slightly different occasions.
Carl No – it is during the third or fourth meeting, somewhere around that point.
Malin Because they, as parents, are understood and listened to, and they begin to grasp that there are tools. They find hope in what they can achieve; they begin to notice that ‘if I do this in another way, everything will turn out differently,’ which is actually quite hopeful.
In this COMET focus group, the practitioner Carl depicts a situation when the parents “shift focus toward themselves” instead of focusing on the child’s actions. He portrays this introspection as a turning point in which the parents recognize how their own interaction can influence the child’s behavior. As Carl’s statement produces affirmative nods and hand gestures from the other focus group participants, Susanna (interviewer) asks how this turning point occurs. Johan emphasizes that the turning point is commonplace in parenting groups but happens on different occasions. Carl breaks in with a more specific notion, which is immediately followed up by Malin’s locating of the turning point as the time when the parent “begins to grasp that there are tools [to improve the parent-child relation]”. Here, Malin’s qualification implies that the practitioner herself has an important therapeutic role in reinforcing the parents’ positive behavior and validating their newfound hope.
The interviewed practitioners thus portrayed how they used the technique of positive reinforcement to acknowledge the parents’ positive behavior and their thoughtful considerations. This notion of critical reflection was even more apparent in the COS-P focus groups. Since this parenting program builds on attachment theory, the manual includes therapeutic techniques to reflect on child needs and parenting practices. While these participants did not speak about positive reinforcement as a specific technique in their therapeutic repertoire, they used role modeling to teach the practice of critical reflection. In this type of role modeling, the COS-P practitioners typically used personal parenting experiences in order to, like the COMET practitioners, actively refrain from taking on the “expert role” (FG4, 2019). Instead, the participants of all focus groups accentuated that the practitioner’s role was to reinforce critical reflection around the parent-child interaction. A valuable technique for the practitioners to model critical reflection was to employ a certain degree of intentional self-disclosure.
Intentional Self-disclosure
In the COS-P and the COMET focus groups, the interviewed practitioners portrayed that they frequently used personal life stories to demonstrate how critical reflection can improve parenting practices. Therapeutic competence here translated into the capability of intentional self-disclosure, a deliberate revelation of select personal experiences to validate or reassure the parents. By “getting private”, as one interviewee put it, “we open up the conversation by showing that we also aren’t perfect” (FG4, 2019). The interviewed practitioners explained that this therapeutic technique enables a conversation climate in which the parents feel safe to disclose their own experiences, thoughts, and reflections.
As a reflection on the parent-child interaction can bring about stark feelings of shame and remorse, the practitioners intentionally shared personal parenting examples to create a productive sense of being “good enough” by sharing personal experiences of “how hard parenting can be” (FG2, 2019). Intentional self-disclosure also addressed the challenge of leading groups where the parents were variously receptive to learning critical reflection. As one interviewee put it: “some parents simply aren’t there; they aren’t particularly interested in understanding what they carry with them, and how it affects the relationship with their children” (FG3, 2019). At the same time, the interviewed practitioners also report that when parents do begin, perhaps for the first time, to reflect upon deep childhood experiences in relation to their parenting practices, the situation tends to become rather emotional. Here, the practitioners found themselves validating the parents’ emotional insights and regulating heavy feelings of remorse and failure (FG1, 2019):
Lena Sometimes you notice that, perhaps in meeting eight or nine, toward the end, so to speak, that many parents begin to feel, begin to recognize their influence in it all, and feel shameful.
Karin The shame…
Lena …and the sadness of realizing that ‘wow, I’m really a part of why it has turned out this way.’ But then also to let go, to accept that we all have flaws, to pat oneself on the back, to be good enough and all that.
Karin Yes, we normalize all that.
Lena Yes, we really do, but I often see sorrow, and many parents cry – it happened in our last group.
Karin The realization that ‘maybe it wasn’t harder than this’ can be quite heartbreaking – but there are ways to manage [these emotions].
In this focus group, the COMET practitioners Karin and Lena share experiences about the emotional turbulence that can stir up in parenting programs. Lena initiates this thread by mentioning that parents “sometimes” express their shame as they begin to grasp their fundamental role in the parent-child interaction. After Karin affirms the recurrence of shame, Lena adds that the parents’ insights can also result in sadness. In direct relation to that depiction, Lena exemplifies a practice of emotional regulation employed in such cases, examples that Karin summarizes in terms of normalization. Lena accepts the normalization terminology but then returns to emotional surfacing as if to highlight its centrality in the parenting program course. Karin confirms the presence of difficult emotions in these situations – and here she describes the practitioner’s role in terms of emotion management support. This focus group excerpt demonstrates how the interviewed practitioners used intentional self-disclosure to encourage parents to share experiences and emotions of parenting, to create a reassuring conversation climate with a “good enough” standard, but also to validate the complexity of emotions brought into the parent groups. This art of validation was, in turn, linked to the therapeutic competence of mentalization.
Mentalization
The interviewed COS-P and COMET practitioners underlined that the therapeutic techniques of positive reinforcement and intentional self-disclosure required a certain amount of timing to be functional. They highlighted how emotional validation is essential to foster parent education and support and that validation requires an ability to attune to each parent’s mental state to help the parents understand and commit to the respective program. Especially in applying the program manual to the particularity of each parent group, the practitioners pointed towards the ability to perceive and reflect on mental states in the self and the other: mentalization. One practitioner explicitly declared how leading a parent group “has so much to do with mentalization” (FG3, 2019). However, this concept was mainly discussed implicitly and surfaced as a refined theme through the thematic coding in the qualitative data analysis. One example of this thematic refinement is how an interviewed practitioner describes that the parent group leader must “deliver the message with pace, tone, and recognition” (FG2, 2019), which builds on the capability to mentalize the parents.
Mentalization was also a pertinent theme in focus group discussions on the difficulty of implementing the manuals while at the same time securing a workable group climate. In COMET, attunement to the parents’ assumed reception capability was described as integral to the program. In addition to this procedure, the COMET (as well as COS-P) practitioners reported how they also strived to arrange the parent groups based on the children’s age to foster recognition between the parents – which was not a procedure stipulated by the manuals. They were modifying or sidestepping the manuals flexibly, using their therapeutic competence to connect with the parents, support their formative learning, and validate their emotions along the way. The program manual became one tool among others, a broader frame rather than strict guidelines to be followed, as one practitioner put it, “in a confined manner” (FG3, 2019).
The focus group participants also described how tailored manual adjustment was essential for an efficient program with a positive outcome. To optimize parent reception, the practitioners of both programs put additional work into the group composition and actively strived to mentalize each parent’s emotional state on the journeys towards improved parenting. Therapeutic competence here became pertinent, not only to manage individual parent behaviors while facilitating a productive group dynamic, but also with regard to mentalizing capabilities. Being attuned to the parent’s mental state, as well as having a good pace and timing with the therapeutic intervention, were described as challenging but essential. When these difficulties were brought to the fore, there was a consistent response immediately across all focus groups: collaboration. The interviewees strongly accentuated the benefit of being two practitioners that could “complement each other” (FG3, 2019). Here the process of mentalization – used and taught by the practitioner – was strengthened through the collaborative practices of the parenting programs.
Discussion
The qualitative analysis of the focus group interviews demonstrates how therapeutic competence is a vital aspect of a positive outcome in different parenting programs. The interviewed practitioners of COS-P (Circle of Security) as well as COMET (Communication Method) discussed how they were actively adjusting the educative level and pace to support the parents with precise timing. Creating a safe and conducive conversation climate, while simultaneously validating emotions on various levels, was portrayed as necessary for efficiently adopting parenting program manuals in different settings. In the focus group interviews with the Swedish practitioners, therapeutic competence was crystalized in using the techniques of positive reinforcement and intentional self-disclosure, with presice timing and pace, as well as attuning to the needs of the parents through mentalization.
The practitioners of COS-P and COMET emphasized how they found it helpful, while validating the parents’ varied feelings of success and failure, to use positive reinforcement to affirm constructive parenting practices. However, this should not be conflated with the parent’s positive reinforcement of the child’s behavior, which is an integral part of the Parent Management Training program COMET. Whereas several studies confirm that parental reinforcement practices can break disruptive child behavior (Cova et al., 2020; Fang et al., 2022; Leijten et al., 2019), research also indicate that positive reinforcement can be a valuable therapeutic technique for changing parental behavior (Borrego & Urquiza, 1998). In this vein, the current focus group study shows that the interviewed parenting program practitioners were reinforcing the parents’ reflections regarding their interactions with their children. Direct interventions of positive reinforcements were here accompanied by “modeling reflectiveness” (Slade, 2007, p. 645); by openly yet carefully reflecting upon the parents’ shared experiences, the practitioners showed how reflective parenting could unfold (Slade, 2005).
The current study also shows that positive reinforcement was an approach interconnected with intentional self-disclosure, a well-chosen sharing of personal experiences to create a safe and reflective conversation climate. While the interviewed practitioners sometimes employed intentional self-disclosure to exemplify good parenting, they mainly brought personal experiences into the room to disarm feelings of shame and parental failure. Self-disclosure was, in this sense, used by the practitioners for “affirming or reassuring” the parents and challenging their “thought processes or behavior (Tanner, 2017, p. 8). It was portrayed as a valuable resource to the interviewed practitioners’ efforts of modeling reflectiveness. At the same time, the focus group discussions indicated that intentional self-disclosure was a difficult affair, a delicate balance that required a certain degree of “facilitative interpersonal skills” (2017, p. 45). In this regard, intentional self-disclosure may prompt empathy (Aveline et al., 2007), a key factor in most therapeutic approaches (Elliott et al., 2019; Wampold, 2015). Intentional self-disclosure has been considered an “inevitable, integral, and essential therapeutic tool” (Bridges, 2001, p. 22; 21), and thus “typically a ‘safe’ intervention when done skillfully, thoughtfully, and with good timing” (Hill et al., 2019, p. 415). By downplaying the practitioner’s role as an expert (Farber, 2006), the interviewed practitioners used the therapeutic technique of intentional self-disclosure to create a productive conversation climate for critical reflection on parenting practices.
The focus group discussions also showed that the therapeutic competence of balancing and timing the use of positive reinforcement and intentional self-disclosure heavily depended on the practitioner’s capability of mentalization. The capability to reflect upon his/her and the parent’s mental states was described as vital for applying the program manuals to each group setting and validating the parents’ different needs and emotional states. The interviewed practitioners emphasized that a mentalizing competence enabled a tailored adjustment of the program manual to each group setting. Mentalization – “seeing ourselves from the outside and others from the inside” (Bateman & Fonagy, 2016, p. 5) – is an approach that captures the intersubjectivity of the parent-child relationship (Fonagy et al., 2003). In recent years, Mentalization-Based Treatment has been increasingly applied in group therapy and child psychiatry (Karterud, 2016; Midgley et al., 2017). Evidence also suggests that mentalization is useful in psychodynamic and cognitive behavior treatments (Goodman, 2013; Goodman et al., 2016). The current focus group study similarly shows how practitioners of different parenting programs, rooted in separate theoretical traditions, accentuate mentalization as a vital therapeutic competence for efficient parenting programs.
Limitations and Implications
The focus group study highlights that the therapeutic competence of the practitioner is vital for efficient parenting programs. The interviewed practitioners deployed therapeutic techniques of positive reinforcement and intentional self-disclosure with an attuned flexibility enabled by their capability of mentalization. At the same time, more studies are needed to qualify this conclusion since knowledge of the role of therapeutic competence in parenting programs is still in its cradle (Leitão et al., 2021, p. 84). The current study, limited to focus groups with thirteen practitioners from two parenting programs, outlined the therapeutic techniques and capabilities suitable in these settings. Research with interviewees from other contexts, and experiences from other parenting programs than COS-P and COMET, could indeed complement and refine the results presented in this article. Nonetheless, the current focus group study has strong implications for family social work, child psychiatry, and other institutions supporting and educating parents; it points to the importance of maintaining high therapeutic competence in parenting programs.
Acknowledgements
The authors would like to express sincere gratitude to all focus group participants for a most generous sharing of their time and thoughts; to Bo Vinnars and Agneta Thorén for supportive guidance during the research project; and to Fredrik Odhammar and Johan Åhlén for their critical and valuable comments on the manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare no competing interests.
Informed consent
Informed consent was obtained from all interviewees. All personal names have been pseudonymized in this article.
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