This is a non-blinded study with two parallel arms and an active control group (see Fig. 1). The allocation ratio of both groups is 1 to 1.
Participants will be recruited at kindergartens, nursery schools, and other facilities where children and their parents gather, in two prefectures in Japan. Recruitment material in the form of flyers and posters will be held to the following criteria:
Mothers and their partners who have at least one child between three and six years.
Those who are diagnosed with a mental disorder
Those who do not speak or read Japanese
Sample size calculation
Sample size was calculated using a statistical power analysis. To detect an effect size of d = 0.62 between the two conditions, with α = .05 (two-tailed) and β = 0.8, 64 dyads in each group are needed. Considering attrition possibility and feasibility, 140 mothers and their partners will be recruited.
After the baseline assessment, dyads will be randomly allocated to either the intervention or comparison group. Stratified-block randomization will be conducted according to the prefecture in which they live.
The intervention comprises a group-based training program on Cognitive Behavior Therapy (CBT)-based resilience-enhancement skills. It is structured across four sessions, with each session lasting 120 min. These sessions will be provided biweekly, considering the busy schedules of mothers. The first author, a qualified and experienced teacher of stress and emotion management as well as parenting, will facilitate the sessions. Each group will consist of 6–14 mothers, and they will receive homework assignments to apply their new knowledge to their daily lives and to share the content of the session with their partners and children at home. At the start of each session, participants will share their experiences with each other, including successes, challenges, and changes in themselves and their family members during the two weeks prior. Partners will not participate in the program.
In Session 1, the theme is, “Any emotion is a dear friend.” Participants will learn about resilience and its protective factors. The relationship between parental resilience and its impact on children will be explained. ER will be introduced as one of the protective factors. Participants will learn the meaning and importance of negative emotions, including anger, and why and how they occur. Eight ER skills will be taught in a realistic, applicable way. Using CR skills, participants will learn to recognize the underlying irrational cognitions and unrealistic expectations that may cause negative emotions. The homework assignment is to keep an anger log to monitor anger, to use an anger scale to express anger appropriately to their family, and to encourage their children to do the same.
In Session 2, the theme is, “Worry less and trust more.” Participants will learn how to apply the emotion regulation skills they learned in Session 1 to improve their relationship with their children. The development of children’s brains and emotions will be explained, including the important role of tantrums in the developmental process. In this session, participants will also learn how harsh verbal discipline negatively affects children’s brains and how to avoid it. They will learn how to reframe children’s weaknesses as strengths. The homework assignment is to conduct active listening and to find and verbally appreciate ordinary but appropriate behavior of their children instead of paying attention to and criticizing their misbehaviors and record them. Another assignment is to show empathy and validate children’s feelings when they throw a tantrum without changing the standard or rule.
In Session 3, the theme is, “Difference is strength.” Participants will learn how to improve their relationship with their partners applying the ER skills they learned in the first two sessions. They will discuss how men and women differ in many aspects. They will learn to use CR to recognize their partners’ weaknesses, or the differences between them, as strengths and be introduced to problem-solving strategies. They will be asked to write down five good characteristics of their partners and five things they are grateful for in relation to their partners. The homework assignment will be to tell their partners what they wrote down and to ask them to do some simple tasks, specifically expressing gratitude and appreciation.
In Session 4, the theme is, “I love and trust myself no matter what.” Participants will learn that self-esteem and anger are related, and that self-compassion and self-acceptance are the best skills they could develop – not only for themselves but also for their children’s happiness and resilience. Next, a small number of exercises will be conducted in pairs: drawing a lifeline, looking back at the past, sharing the strengths they have gained at their lowest moments, writing a “thank me letter,” and reading the letters to each other. They will discuss and share what they have learned and achieved through the program and the small, simple things they will continue to do for themselves and their families. The homework assignment is to use positive self-affirmation more often and give themselves a break to enjoy themselves.
Participants in the control group will attend discussion meetings led by a discussion leader, where they will be able to discuss their problems and share how they cope with them. No judgment or criticism will be given. After the two-month follow-up questionnaire, the control group will have the opportunity to participate in the same intervention. Partners will not participate in the discussion meetings.
A babysitting service, housed in a different room in the same building, will be available to participants of both groups upon request.
Psychological resilience will be measured using the Psychological Resilience Scale , which consists of three subscales and a total of 21 items. Items are scored on a five-point Likert scale. Examples of items are “I’m curious about many things” (novelty pursuit); “I can control my anger” (ER); and “I believe I have a bright future” (positive future outlook). Higher scores indicate a higher degree of resilience.
State-trait anger expression inventory
This widely used scale is a 44-item measure designed “to provide a means of measuring various components of anger” . It includes the following subscales: state anger (how you feel now), trait anger (how you usually feel), anger-in (how you suppress anger), anger-out (how you express anger, aggression or insults to others), and anger control (how you control anger or do not express it or express it more appropriately). Since anger is felt differently when directed toward different people, we will assess anger toward both children and partners in terms of how it is expressed —i.e. anger-in, anger-out, and anger control.
Self-esteem will be measured by the Japanese version of Rosenberg’s Self-esteem Scale . This is a 10-item inventory with higher scores indicating a higher degree of self-esteem.
The parenting attitude scale consists of five subscales measuring four negative and one positive attitude . Examples of items are: “I can’t do what I want to do, I’m spending too much time on parenting” (burden of parenting), “I feel disgusted when children keep making a mess” (burden from children’s attitude and behavior), “I’m not confident about my parenting” (anxiety about parenting), “I’m afraid my child is more childish than other children” (anxiety about child’s development), and “I feel I’m growing through parenting.” (positive attitude toward parenting). Higher scores indicate a higher degree of each attitude.
Problem-focused coping strategies
The Problem-Focused Coping Strategies Scale  will be used to measure how caregivers cope with stressful situations. The measure consists of five subscales: solution calculation, concrete solution behavior, gathering information, goal orientation, and seeking solutions. We will use the first two scales, which will be enhanced for the purposes of this program.
Family functioning will be measured by the Japanese version of Family APGAR . This measure consists of five parameters of family functioning: adaptability, partnership, growth, affection, and resolve. Items will be scored on a four-point scale, with higher scores indicating a higher degree of family functioning.
Cognition of children’s behavior
The Attribution on Children’s Misbehavior Scale consists of three subscales and measures the cognition of the attitudes and behavior of children . Examples of items are: “I feel judged as ‘a bad parent’” (hostile attribution), “I struggle not knowing how to handle my child” (negative attribution), and “It’s a natural part of growing up” (positive attribution).
The outcome measures will be assessed online at the baseline, post-intervention, and at a two-month follow-up. Demographic data will be collected at the baseline and a program evaluation survey will be conducted post-intervention. Partners will be assessed (using the same measurement as for mothers) to evaluate the indirect impact from mothers sharing the knowledge and skills they gained in the sessions or discussions or seeing the changes in mothers’ attitude or behavior by participation.
Data will be analyzed according to the intention-to-treat principle. The primary and secondary outcome measures will be analyzed at post-intervention and two-month follow-up using analysis of covariance to adjust for baseline differences between the groups. Subgroup analysis will be conducted using stratification factors including mother’s age, the area they live in, and number of children.