اثربخشی آموزش غنی‌سازی مبتنی بر تعهد و پذیرش بر ناگویی هیجانی، انعطاف‌پذیری ‌شناختی و اختلالات خواب در سالمندان دارای افکار خودکشی سرای سالمندان

Background: Given the growing older adult population and the increasing rate of suicide deaths in this age group, along with their substantial individual and societal consequences, investigating psychological factors associated with suicidal ideation among older adults is of considerable importance. Therefore, the present study aimed to determine the effectiveness of Acceptance and Commitment Therapy (ACT) on alexithymia, cognitive flexibility, and sleep disturbances in older adults with suicidal ideation.
Method: This study employed a quasi-experimental pretest–posttest–follow-up design with a control group. The statistical population consisted of older adults with suicidal ideation residing in a nursing home in Bandar Abbas, Iran, during the Iranian year 1404 (2025–2026), with a mean age of 68.94 years. A total of 32 participants (18 women and 14 men) were selected through convenience sampling based on the inclusion and exclusion criteria and were subsequently randomly assigned to either the intervention group (n=16) or the control group (n=16). Data were collected using the Cognitive Flexibility Inventory (CFI) developed by Dennis and Vander Wal, the Toronto Alexithymia Scale (TAS-20) developed by Taylor et al., the Pittsburgh Sleep Quality Index (PSQI) developed by Buysse et al., and the Beck Scale for Suicide Ideation (BSSI). Participants in the intervention group received ten 90-minute sessions of Acceptance and Commitment Therapy based on the protocol developed by Eifert et al., whereas the control group received no intervention. Data were analyzed using univariate analysis of covariance (ANCOVA) in SPSS version 27.
Results: The findings indicated that, at posttest, there were significant differences between the intervention and control groups in cognitive flexibility, alexithymia, and sleep disturbances (p<.05).
Conclusion: The findings suggest that Acceptance and Commitment Therapy may be an effective intervention for enhancing cognitive flexibility and reducing alexithymia and sleep problems among older adults with suicidal ideation. Therefore, ACT may be considered a complementary intervention for improving psychological factors associated with suicidal ideation in older adults.
EXTENDED ABSTRACT
 Introduction
Aging is a major stage of the life course in which physical, psychological, and social changes may affect mental health, adjustment, and quality of life. As the older adult population grows rapidly, greater attention is being directed toward psychological difficulties in this age group and the factors that contribute to mental health. Older adults may be particularly vulnerable to psychological distress and suicidal ideation because of chronic illness, bereavement, loss of social roles, loneliness, and reduced social support. Among the psychological factors associated with suicidal ideation in later life, alexithymia, reduced cognitive flexibility, and sleep disturbances are particularly important because they may impair emotional processing, adaptive coping, and adjustment to age-related stressors. Given the complex and multifactorial nature of suicidal ideation, interventions that target several related psychological processes simultaneously may be especially useful. Acceptance and Commitment Therapy (ACT), through acceptance, mindfulness, cognitive defusion, values clarification, and committed action, provides a process-based framework for improving responses to distressing internal experiences. However, the effects of ACT-based enrichment training on alexithymia, cognitive flexibility, and sleep disturbances in older adults with suicidal ideation have received limited attention. Therefore, this study examined the effectiveness of ACT-based enrichment training on these outcomes in older adults with suicidal ideation.
Method
This quasi-experimental study used a pretest–posttest control-group design with a three-month follow-up. The population comprised older adults with suicidal ideation residing in a nursing home in Bandar Abbas, Iran, in the Iranian year 1404 (2025–2026). Thirty-two participants (18 women and 14 men) were selected through convenience sampling and randomly assigned to the intervention and control groups (n = 16 each). Mean age was 68.94 years in the intervention group and 69.31 years in the control group. Inclusion criteria were willingness to participate, informed consent, ability to read and write, age 65–75 years, and a score of ≥3 on the Beck Scale for Suicide Ideation (BSSI). Exclusion criteria included severe physical, cognitive, or motor disability, memory problems, substance dependence, psychotropic medication use, and concurrent participation in another therapeutic or counseling program. The BSSI was used to determine eligibility. Outcomes were assessed using the Toronto Alexithymia Scale (TAS-20), Cognitive Flexibility Inventory (CFI), and Pittsburgh Sleep Quality Index (PSQI). The intervention group received ten 90-minute group sessions of ACT-based enrichment training, delivered twice weekly and adapted from the psychological flexibility model of Hayes et al. and the treatment structure of Eifert et al. The control group received no intervention during the study period. Outcome measures were administered at pretest, posttest, and three-month follow-up. After examination of statistical assumptions, separate univariate ANCOVAs were conducted for posttest and follow-up outcomes, controlling for baseline scores. Analyses were performed in SPSS version 22 at α = .05.
Results
Before the main analyses, the assumptions underlying ANCOVA were examined. Levene’s tests for alexithymia, cognitive flexibility, and sleep disturbances were nonsignificant, indicating that the homogeneity-of-variance assumption was satisfied. The interaction effects examined to assess the homogeneity of regression slopes were also nonsignificant, and the Shapiro–Wilk tests indicated no significant departures from normality. The assumptions required for ANCOVA were therefore considered to have been met.
After controlling for baseline scores, significant between-group differences were found for all three outcomes at posttest. The group effect was significant for alexithymia, F(1, 27) = 9.984, p = .004; cognitive flexibility, F(1, 27) = 11.900, p = .002; and sleep disturbances, F(1, 27) = 7.573, p = .010. Descriptive findings showed that, compared with the control group, participants who received ACT-based enrichment training had lower alexithymia and sleep-disturbance scores and higher cognitive-flexibility scores at posttest.
Significant differences between the intervention and control groups were also maintained at the three-month follow-up. The group effect remained significant for alexithymia, F(1, 27) = 8.963, p = .006; cognitive flexibility, F(1, 27) = 8.791, p = .006; and sleep disturbances, F(1, 27) = 6.124, p = .020. Across the three assessment points, the intervention group demonstrated improvement from pretest to posttest that remained evident at follow-up, whereas changes in the control group were comparatively small. Specifically, alexithymia and sleep-disturbance scores decreased, whereas cognitive-flexibility scores increased following the intervention. Overall, the findings indicate that ACT-based enrichment training was effective in improving the emotional, cognitive, and sleep-related outcomes examined among older adults with suicidal ideation and that these improvements persisted for at least three months after the intervention.
Conclusion
The findings can be interpreted in terms of the core processes of Acceptance and Commitment Therapy. ACT encourages individuals to approach unpleasant thoughts and emotions with greater openness while reducing experiential avoidance and rigid attempts to control internal experiences. Mindfulness and present-moment awareness may improve the recognition and processing of emotional experiences, thereby reducing alexithymia. Cognitive defusion, acceptance, and values-based action may weaken rigid thinking patterns and promote more flexible responses to age-related losses and stressful life changes. Reducing struggle with intrusive thoughts and improving emotional regulation may also contribute to better sleep. Among older adults with suicidal ideation, these processes may support adjustment by strengthening emotional awareness, adaptive coping, and engagement in meaningful activities. The persistence of significant group differences at the three-month follow-up suggests that the benefits extended beyond the immediate post-intervention period. Nevertheless, convenience sampling, reliance on self-report measures, recruitment from a geographically restricted institutional population, and limited control over social support, socioeconomic conditions, and family support restrict generalizability. Future studies should include larger and more diverse samples, multimethod assessments, and additional short- and long-term follow-up periods. ACT-based enrichment training may therefore be considered a useful complementary intervention for older adults with suicidal ideation.
  Ethical Consideration
Ethical Code
The study protocol was approved under the ethics code IR.PNU.REC.1404.235 and registered in the national research ethics system.
Funding
This study received no external funding.
Authors’ Contributions
A.M.: Conceptualization, methodology, data management, and writing of the manuscript; S.N.: Software, validation, and review and editing of the manuscript; S.N: Statistical analysis and data collection.
Conflict of Interest
The author had no conflicts of interest.
Acknowledgments
The authors would like to thank the older adult participants and the administrators of the nursing home in Bandar Abbas for their cooperation and support throughout the study.
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