Cognitive flexibility and emotional self‐regulation of the elderly with Empty nest syndrome: Benefits of acceptance and commitment therapy

Abstract

Background and Aims

Empty nest syndrome (ENS) is a mental condition that affects both parents. When children leave their parents' home, the parents experience such feelings as unhappiness, loss, fear, inability, difficulty in adjusting roles, and changing their relationships. The present study aimed to evaluate the cognitive flexibility and emotional self‐regulation of the elderly with ENS: benefits of Acceptance and Commitment Therapy (ACT).

Methods

The research method was quasi‐experimental where a pretest‐posttest design was used with a control group. The statistical population included all the elderly with the ENS in Tehran in the academic year of 2019–2020. Thirty of them were selected by convenience sampling method and then stochastically placed in two experimental and control groups. Dennis and VanderWal's Cognitive Flexibility Inventory, and Hofmann and Kashdan's Emotional Self‐Regulatory Questionnaire for data collection in the pretest and posttest phases. Group‐based ACT was implemented on experimental group members in 8 sessions of 90 min, while controls received no intervention. The collected data were analyzed by SPSS version 25 and analysis of covariance.

Results

The results showed a significant difference between the posttest scores of the experimental and control groups so the group‐based ACT increased the cognitive flexibility and emotional self‐regulation of the experimental group members (p < 0.05).

Conclusions

According to our results, therapists and health professionals can use ACT for interventions related to the health of the elderly with ENS, especially to improve cognitive flexibility and emotional self‐regulation.

1. BACKGROUND

Empty nest syndrome (ENS) is a psychological condition that arises when children leave their parents' home and leads to such feelings as sadness, loss, fear, inability, difficulty in adjusting roles, and changing parental relationships. ¹ , ² ENS is a term used to describe long‐term maladaptive responses by parents as soon as their last child leaves home, leaving two middle‐aged/elderly parents alone at home. ³ These responses include depression, sadness, anxiety, guilt, physical symptoms, anger, resentment, irritability, frustration, and loneliness. Sometimes these maladaptive responses may be the beginning of an underlying psychological pathology such as major depressive disorder, anxiety disorders, and even a psychotic reaction. ⁴ Cognitive flexibility is a determining variable in the mental health of the elderly and can play a considerable role in adapting to the threats and problems created. ⁵ Decreased cognitive abilities in the elderly can lead to significant changes in socio‐emotional health and significantly reduce their perception of well‐being. ⁶ Natural aging is often characterized by decreased cognitive functions, which affect cognitive control, processing speed, long‐term memory, and other processes necessary for independent daily life. ⁷ Cognitive flexibility, developed based on schema theory, refers to the ability to change cognitive sets to better adapt to changing stimuli. ⁸ Cognitive flexibility shows the degree of experience of an individual versus internal and external experiences and exists in different people with different degrees. ⁹ People with flexible thinking, use alternative justifications, positively reconstruct their thinking framework in and have a higher resilience in the face of internal and external stresses. ¹⁰

These people are curious about their inner and outer experiences, and their lives are full of rich experiences; thus, they not only avoid confronting internal and external experiences but also seek new and challenging experiences. ¹¹ In contrast, those lacking cognitive flexibility insist on upgrading their initial learning, leading to maladaptation to new situations. ¹² The results show that cognitive flexibility is related to psychological well‐being, mental health, ¹³ and low levels of depression, anxiety and mental disorder. ¹⁴

Emotional self‐regulation is another key construct in the mental health of the elderly with ENS, which determines their ability to adapt to pressures and threats. ¹⁵ Studies have shown that emotional self‐regulation is associated with success in going through different stages of life or failure to go through these stages. Emotional self‐regulation expresses a wide range of conscious and unconscious biological, social, behavioral and cognitive processes, which is known as the central point of an effective function in controlling internal states, controlling impulses and behaviors to achieve higher goals. ¹¹ Hofman and Kashdan ¹⁶ classify emotional self‐regulation into three styles: concealing (inhibition of emotions), adjusting (ability to adjust and regulate emotions according to situational requirements) and tolerating (the arousal acceptance caused by emotional experiences). People who use more adaptive emotional self‐regulation techniques have more positive self‐esteem and emotional experiences and this helps them to cope effectively in stressful situations. ¹⁷ Those taking advantage of more adaptive emotional self‐regulation techniques have more positive self‐esteem and emotional experiences and this helps them to cope effectively in stressful situations. ¹⁷ However, people with low emotional self‐regulation suffer from feelings of self‐doubt, loss of control and failure. ¹⁸ Previous research has shown the relationship between emotional self‐regulation with psychological well‐being and emotional‐social adjustment, ¹⁹ depression and anxiety. ²⁰

Since cognitive flexibility and emotional self‐regulation are among the components that can have a significant impact on the psychological health and psychological well‐being of the elderly with ENS and can increase their adjusting, paying attention to solutions of increasing self‐regulation and flexibility is of great importance, emphasizing on providing psychological plans. Acceptance and Commitment Therapy (ACT) is one of the effective treatment methods that have valuable themes in improving psychological characteristics.

This treatment is one of the third‐wave therapies that is based on the Relational Frame Theory. This treatment does not seek to eliminate or suppress natural and unpleasant experiences, because the long‐term result of this work is associated with anxiety and psychological problems and prevents an individual from enjoying a meaningful, purposeful and happy life. ²¹ Instead, it encourages clients to accept, be aware, and observe so that they can move in a worthwhile direction. ²² The six components of ACT include acceptance, cognitive diffusion, being present, self as context, values and committed action. These six interrelated components target psychological flexibility. ²³ The results of recent research on the effectiveness of ACT in increasing cognitive flexibility of the following statistical population have been shown: students, ¹³ prisoners, ²⁴ patients with chronic disorders, ²⁵ students with anxiety disorders, ²⁶ Students ‘academic procrastination ²⁷ and divorced women. ²⁸ Other studies also have shown the effectiveness of this approach in improving emotional regulation strategies in depressed women, ²⁹ self‐harming students, ³⁰ coronary heart disease patients, ³¹ divorced women, ³² and psychotic people. ³³ Therapeutic methods are a kind of supportive process, which are based on scientific methods and theories that are divided into two categories of individual and group in terms of the form of implementation. ³⁴ Group therapies are important in several respects compared to individual therapies. For example, this treatment reduces the need for a long waiting list for training, the therapist can use his time better and more efficiently, and the group environment creates many benefits for patients such as experiencing being the same, modeling and supporting each other. ³⁵ Based on this and the theoretical foundations mentioned, it seems that group‐based ACT can be an appropriate intervention in the treatment of cognitive flexibility and emotional self‐regulation problems among the elderly with ENS.

Since the elderly with ENS are of the vulnerable groups in society whose health is very important for promoting community health and considering the role that each of the components of cognitive flexibility and emotional self‐regulation play on their psychological health and while the lack of these components creates problems in the individual, family and social dimensions for the elderly, the need to improve and enhance these variables by providing appropriate therapeutic interventions is very important. Therefore, the present study seeks to answer the question of whether group‐based ACT is effective on cognitive flexibility and emotional self‐regulation of the elderly with ENS.

2. MATERIALS AND METHODS

2.1. Population

The research method was quasi‐experimental where a pretest‐posttest design was used with a control group. The statistical population of the study included all the elderly with the ENS in Tehran in the year 2021, 30 of whom were selected by convenience sampling. The sample size for the intervention and expectation groups was calculated using the G*Power method (effect size = 0.45, α = 0.05, 1‐β = 0.80, number of groups = 2, and number of measures = 3). Each participant received an envelope containing a number and randomly selected an identifier to determine their membership in the intervention (n = 15) or expectation (n = 15) group. The criteria for enrollment in the study were the age range of 60–70 years, having mental health, having no history of severe mental and physical disorders (based on the clinical interview), having a diploma or higher education degree, not attending other treatment programs during the study, and obtaining scores below the mean in the questionnaires. The criteria for exclusion from the study were the absence of more than one training session, not answering all items in the questionnaires, and failure to complete the assignments presented in the sessions. To comply with ethical protocols during the study, the researcher obtained informed consent from the participants and they were told that their participation would be voluntary. Besides, the participants were told that their information would be kept confidential to avoid any bias in their responses.

2.2. Data collection tools

2.2.1. Cognitive Flexibility Inventory (CFI)

This inventory was developed by Dennis and Vander Wal ³⁶ and is a 20‐item short self‐report tool used to measure cognitive flexibility. This tool is used to assess the subject's progress in clinical and nonclinical work and also to assess the extent of his/her progress in the treatment of mental illness. How to score this questionnaire is based on a 7‐point Likert scale from score 1 (strongly disagree) to score 7 (strongly agree). Therefore, the minimum and maximum scores are 20 and 140, respectively. A higher score on this scale means more cognitive flexibility. The subscales of CFI include perception of different options, perception of controllability, and perception of justification of behavior. Dennis and Vander Wal ³⁶ showed that CFI has a factor structure, convergent validity and concurrent validity. The psychometric properties of this questionnaire in Iran have been studied by Soltani et al. ³⁷ and its reliability has been reported using the retest method and Cronbach's alpha of 0.71 and 0.90, respectively. In the present study, the calculated Cronbach's alpha coefficient was 0.84.

2.2.2. Emotional Self‐regulatory Questionnaire

This questionnaire was developed by Hofman and Kashdan. ¹⁶ It contains 20 questions and has three subscales including concealing (8 questions), adjusting (7 questions) and tolerating (5 questions). How to answer the questions is graded based on a 5‐point Likert scale from 1 (not true at all for me) to 5 (infinitely true for me). The score range of this questionnaire is 20–100. Hofman and Kashdan ¹⁶ reported the reliability of this questionnaire using Cronbach's alpha coefficient for the subscales of concealing, adjusting and tolerating as 0.84, 0.82, and 0.68, respectively. In addition, the validity of the questionnaire in their research was reported to be favorable. In Iran, Karshki ³⁸ studied the psychometric properties of this questionnaire and confirmed its content validity and construct validity. It also reported a Cronbach's alpha for concealing, adjusting and tolerating as 0.70, 0.75, and 0.50, respectively. In the present study, Cronbach's alpha coefficient was used to calculate the reliability of the questionnaire with a value of 0.76.

2.3. Procedure

The process of conducting the research was as follows: first, the emotional self‐regulatory questionnaire was distributed among the people who wanted to participate in the research, and a total of 67 subjects were eligible to participate in the research. Finally, 30 of these individuals who had the lowest scores in their emotional self‐regulatory questionnaire and were willing to participate in the study were selected. It should be noted that the subjects were randomly divided into experimental and control groups and their scores at this stage were considered as a pretest. The research procedure was the same for all participants. Moreover, the older adults who were willing to participate in the study received the questionnaires and completed the items. The researcher would provide necessary information for any item that was ambiguous for the participants. Although one requirement to attend the study was to have a diploma or higher education degree, the researcher read the items in the questionnaire for the participants with vision problems and marked their answers in the questionnaire. The ACT intervention was performed during eight 90‐min training sessions each week for the experimental group with an emphasis on members' empowerment.

Since this study was conducted during the COVID‐19 outbreak, the intervention program was conducted in groups in full compliance with health and physical distancing protocols by a health psychologist who had completed ACT courses. The structure and content of the meetings were also monitored by a professional supervisor. Data were collected over a period of 2 months from June to August 2021. At the end of the sessions, posttests was taken from members both groups. A description of group‐based ACT sessions according to the model of Hayes et al., ³⁹ is presented in Table 1.

Table 1.

A summary of group‐based ACT sessions. ⁴⁰

Session	Content
1	Introducing and building trust between group members and counselors, articulating group goals and regulations, examining members' expectations of treatment, providing general explanations about the ACT process, and talking about identifying aspects of the mind (thought, feeling, physical symptoms, desire and memories).
2	Reviewing the contents of the previous session, gaining insights about the problem and challenging the problem, reviewing previous solutions to solve problems and training creative frustration, and presenting homework.
3	Reviewing homework and the previous session, training mindfulness by trying to control the problem, conceptualizing psychological acceptance of mental experiences, thoughts and feelings, checking unhelpful coping styles for emotional self‐regulatory and cognitive flexibility, and presenting homework.
4	Reviewing the homework of the previous session, discussing the value‐oriented life and moving towards determining the value for change, specifying the values and goals necessary to achieve it, and presenting the homework.
5	Reviewing the homework of the previous session, identifying psychological barriers (such as having inflexible thinking) and training solutions (i.e. acceptance, diffusion and being present that help overcome obstacles), presenting the homework.
6	Reviewing the homework of the previous session, creating motivation and desire for active participation of members in actions that are likely to evoke a lot of negative thoughts, emotions and physical states, creating readiness for committed action, and presenting the homework.
7	Assessing homework and reviewing therapy, trying to detach from painful thoughts and feelings (cognitive defusion), trying to isolate cognition in a way that separates the individual from his/her mental experiences and acting independently of them, moving towards committed behavior, presenting the homework.
8	Reviewing group assignments, summarizing and reviewing the contents of previous sessions, giving feedback and expression of group members' feelings, preparing the necessary preparations to end treatment and prevent a recurrence, changing behavior in line with the values created and commitment to behavior, conducting posttest in both groups, appreciation and closing of sessions.

Abbreviation: ACT, Acceptance and Commitment Therapy.

2.4. Statistical analysis

The collected data were analyzed using descriptive statistics with measures of central tendency and dispersion and inferential statistics including analysis of covariance. The normal distribution of the data was assessed using Kolmogorov–Smirnov's test. Multivariate analysis of variance was used to assess the effect of the intervention on the three dependent variables. The variance homogeneity assumption was assessed using Levene's test. The multivariate equality of covariance matrices was evaluated using Box's M test. All statistical procedures were performed with SPSS software (version 25).

3. RESULTS

3.1. Sample characteristics

In this study, 30 elderly people with ENS were selected and entered the experiment. The oldest and youngest participants were 74 and 63 years old, respectively, with an average of 67 years. The nesting period of 13 participants was less than 6 years old, and that of 9 and 8 participants was 7–10 and above 10 years, respectively. Of the elderly, 18 were living with their spouses, 9 had lost their spouses, and 3 were separated from their spouses.

The mean and standard deviation of pretest and posttest scores of cognitive flexibility and emotional self‐regulatory variables in experimental and control groups are presented in Tables 2 and 3, respectively.

Table 2.

The statistical description of pretest and posttest cognitive flexibility scores separated by group.

Group	Variable	Pretest		Posttest
		Mean	SD	Mean	SD
Control	Perception of different options	18.40	3.098	18.87	3.173
	Perception of controllability	21.47	2.900	21.97	2.539
	Perception of justification of behavior	23.37	3.479	23.85	2.886
	Cognitive flexibility	63.24	4.494	64.69	3.739
Experimental	Perception of different options	19.93	3.039	22.12	2.834
	Perception of controllability	21.67	3.716	24.48	4.060
	Perception of justification of behavior	22.91	4.410	25.51	3.626
	Cognitive flexibility	64.51	7.086	72.11	7.084

Table 3.

The statistical description of pretest and posttest emotional self‐regulatory scores separated by group.

Group	Variable	Pretest		Posttest
		Mean	SD	Mean	SD
Control	Concealing	16.47	2.615	15.93	2.160
	Adjusting	14.47	5.383	14.87	5.111
	Tolerating	11.20	3.121	11.87	3.482
	Emotional self‐regulatory	42.13	7.019	43.67	6.563
Experimental	Concealing	16.87	2.549	18.90	3.127
	Adjusting	14.73	4.166	17.36	3.456
	Tolerating	11.60	2.849	14.13	2.806
	Emotional self‐regulatory	43.20	6.812	50.39	6.416

Multivariate analysis of covariance was used to evaluate the effectiveness of ACT on cognitive flexibility of the empty nested elderly. To evaluate the normality of the distribution of scores, the Shapiro–Wilk test was used, which due to the lack of significance of the obtained values, the hypothesis of normality of the distribution of scores was confirmed. The test results of homogeneity of pretest and posttest regression gradients in the experimental and control groups showed that the regression gradient is equal in both groups (F _{6, 42} = 0.491, p > 0.05). The results of Levine's test to examine the homogeneity of variance of dependent variables in groups showed that the variance of perception of different options (F _{1, 28} = 2.664, p > 0.05), perception of controllability (F _{1, 28} = 0.498, p > 0.05) and the perception of behavior justification (F _{1, 28} = 0.425, p > 0.05) are equal in the groups. The results of the box test to evaluate the equality of the covariance matrix of dependent variables between the experimental and control groups also showed that the covariance matrix of the dependent variables is equal in the two groups (M Box = 11.871, F = 1.747, p > 0.05). The results of Chi‐square Bartlett's test to check the sphericity or significance of the relationship between the variables showed that the relationship between these components is significant (χ ² = 26.241, df = 5, p < 0.01). After examining the conditions of multivariate analysis of covariance, the test results showed a significant difference between the cognitive flexibility of the two groups (Wilks Lambda = 0.503, F _{3, 23} = 7.573, p < 0.01). To examine which components of cognitive flexibility differ between the experimental and control groups, the results of univariate analysis of covariance are reported in Table 4.

Table 4.

The results of the univariate analysis of covariance between experimental and control group differences in cognitive flexibility components.

Variable	Source	Sum of squares	Degree of freedom	Mean of squares	F	Sig	Effect size
Perception of different options	Between groups	28.897	1	28.897	8.788	0.007	0.260
	Error	85.205	25	3.288
Perception of controllability	Between groups	34.483	1	34.483	9.158	0.006	0.268
	Error	94.133	25	3.765
Perception of justification of behavior	Between groups	26.103	1	26.103	11.755	0.002	0.320
	Error	55.512	25	2.220

According to Table 4, F‐statistics for the perception of different options (F _{1, 25} = 8.788, p < 0.01), perception of controllability (F _{1, 25} = 9.158, p < 0.01) and perception of behavior justification (F _{1, 25} = 11.755, p < 0.01) is significant. These findings indicate a significant difference between the cognitive flexibility of the control and experimental groups. Based on these results, it can be concluded that ACT has been effective and has increased the cognitive flexibility of the elderly with ENS. Also, the effect size in Table 4 shows that group membership explains 26% of the changes in perception of different options, 26.8% of the changes in perception of controllability, and 32% of the changes in perception of behavior justification.

Multivariate analysis of covariance was used to evaluate the effectiveness of ACT on the emotional self‐regulatory of the empty nested elderly. To evaluate the normality of the distribution of scores, the Shapiro–Wilk test was used, which due to the lack of significance of the obtained values, the hypothesis of normality of the distribution of scores was confirmed. The test results of homogeneity of pretest and posttest regression gradients in the experimental and control groups showed that the regression gradient is equal in both groups (F _{6, 42} = 0.709, p < 0.05). The results of Levene's test to examine the homogeneity of variance of dependent variables in groups showed that the variance of concealing (F _{1, 28} = 1.978, p > 0.05), adjusting (F _{1, 28} = 1.158, p > 0.05) and tolerating (F _{1, 28} = 1.523, p > 0.05) are equal in the groups. The results of the box test to evaluate the equality of the covariance matrix of dependent variables between the experimental and control groups also showed that the covariance matrix of the dependent variables is equal in the two groups (M Box = 11.080, F = 1.629, p > 0.05). The results of Chi‐square Bartlett's test to check the sphericity or significance of the relationship between the variables showed that the relationship between these components is significant (χ ² = 33.489, df = 5, p < 0.01). After examining the conditions of multivariate analysis of covariance, the test results showed a significant difference between the emotional self‐regulatory of the two groups (Wilks Lambda = 0.523, F _{3, 23} = 6.995, p < 0.01). To examine which components of emotional self‐regulatory differ between the experimental and control groups, the results of the univariate analysis of covariance are reported in Table 5.

Table 5.

The results of univariate analysis of covariance between experimental and control group differences in emotional self‐regulatory components.

Variable	Source	Sum of squares	Degree of freedom	Mean of squares	F	Sig	Effect size
Concealing	Between groups	19.365	1	19.365	7.384	0.012	0.228
	Error	65.562	25	2.623
Adjusting	Between groups	40.060	1	40.060	11.566	0.002	0.316
	Error	86.593	25	3.464
Tolerating	Between groups	26.731	1	26.731	10.064	0.004	0.287
	Error	66.404	25	2.656

According to Table 5, F‐statistics for the concealing (F _{1, 25} = 7.384, p < 0.01), adjusting (F _{1, 25} = 11.566, p < 0.01) and tolerating (F _{1, 25} = 10.064, p < 0.01) is significant. These findings indicate a significant difference between the emotional self‐regulatory of the control and experimental groups. Based on these results, it can be concluded that ACT has been effective and has increased the emotional self‐regulatory of the elderly with ENS. Also, the effect size in Table 5 shows that group membership explains 22.8% of the changes in concealing, 31.6% of the changes in adjusting, and 28.7% of the changes in tolerating.

4. DISCUSSION

This study aimed to evaluate the effectiveness of group‐based ACT on cognitive flexibility and emotional self‐regulation among the elderly with ENS. According to the research findings, there was a significant difference between the posttest variables of the research variables in the experimental and control groups, which indicates the effectiveness of group‐based ACT on cognitive flexibility and emotional self‐regulation of such elderly. Results of the effectiveness of group‐based ACT on cognitive flexibility are in line with Fasihi et al., ¹³ Valizadeh et al., ²⁴ Scott et al., ²⁵ and Ghorbani Amir et al. ²⁸ Explaining these findings, it can be said that ACT, by reducing empirical avoidance, trains people to reconsider their values and life goals and overcome unavoidable problems by increasing their psychological acceptance of inner experiences and active and effective coping with emotions, thereby increasing cognitive health and flexibility. ²³ To reduce the impact and importance of difficult internal events, ACT theorists change the context in which this event occurs. Cognitive defusion‐related interventions include exercises that break the literal meaning of events. These exercises aim to train clients to see through just as thoughts, emotions just as emotions and memories just as memories. According to the Iranian‐Islamic culture, it is also mentioned in the Holy Quran that whenever a bad suspicion arises in your mind, do not pay the slightest attention to it in practice, do not change your behavior, and visualize in your mind the correct possibilities that exist in that action. Therefore, the impact of ACT on the Iranian elderly community can be attributed to these insights and religious cultural beliefs. On the other hand, this treatment helps people identify life stresses and this leads to reducing psychological arousal, to coping with stressful conditions and ultimately increasing cognitive flexibility. ³⁴ Furthermore, with the help of mindfulness and being present, clients are taught to pay attention to their internal and external experiences and observe them without judgment or evaluation. This process raises the individual's tolerance threshold and increases flexibility. ⁴¹ Therefore, considering the proposed explanations and the special benefits of implementing ACT, it seems obvious that these pieces of trainings will lead to an increase in the cognitive flexibility of the elderly. In addition, being in the right atmosphere of a homogeneously guided group, providing and receiving positive feedback, benefiting from the support of group members and creating opportunities to express themselves appropriately and expressing views, opinions, confusions, pain and hearts, sharing experiences and helping other members to come together to reach the best solution, all provide the ground for improving cognitive flexibility.

Another finding of this study showed that group‐based ACT had a significant effect on the emotional self‐regulation of the elderly with the ENS. This finding is in line with the results of Tarkhan, ²⁹ Izakian et al., ³⁰ Sayafi et al., ³¹ Mahmoudpour et al., ³² and Spidel et al. ³³ The findings of these researchers indicate that based on the theoretical foundations and techniques used in the ACT, self‐regulation in emotions is one of the outcomes that can be achieved in this treatment. Explaining this finding in this way can be said that emotional disorders are largely the result of trying to control positive and negative emotions. People who have difficulty in expressing and experiencing their emotions use maladaptive emotion regulation strategies such as avoiding or suppressing and hiding or ignoring emotions that have unintended consequences. ⁴²

One of the limitations of the present study was that the participants were selected from the older adults with ENS in Tehran. Thus, the findings should be generalized with caution to other populations and situations. Due to the current COVID‐19 epidemic situation, the intervention sessions were held outdoors in full compliance with health protocols. Following the findings and limitations of this study, future studies need to evaluate and compare the effectiveness of ACT at a broader level and in different groups. Besides, the effectiveness of the intervention should be assessed in follow‐up phases to find out if the intervention has retention effects over longer periods. Geriatric psychologists and counselors are proposed to pay more attention to strengthening the cognitive flexibility and emotional self‐regulation of older adults with ENS and use ACT in the treatment programs for older adults.

5. CONCLUSION

The widespread consequences of the COVID‐19 pandemic have dramatically increased mental health problems. Thus, exploring psychotherapy options to cope with these problems is critical. Furthermore, quarantine measures have reduced support networks, increased social isolation, and disrupted daily routines, each acting as a buffer against the development of mental health problems following stressful events. COVID‐19‐related factors also appear to limit people who already have mental health problems from accessing support and make their problems worse. Hence, ACT helps people to engage in meaningful activities despite difficult and unchangeable circumstances. The findings of the present study indicated that by increasing cognitive flexibility and promoting emotional self‐regulation, ACT may moderate the distress associated with ENS during the COVID‐19 pandemic, making ACT a promising psychotherapy candidate.

ACT, due to its underlying mechanisms such as acceptance, being present, awareness‐raising, committed action based on values and avoidance of empirical avoidance can equip clients with tools to have more awareness and management of their emotions and regulate their emotions when unpleasant emotions and factors threatening emotional well‐being occur. ³³ Participating in ACT also helps people develop values and find meaning in life, which helps them to be less affected by negative and stressful situations and thus have a greater ability to regulate and manage their emotions. ³³ In general, because the components of ACT seek to increase the acceptance of inner emotions and experiences instead of avoiding negative experiences, increase the use of adaptive strategies instead of maladaptive strategies, and increase contact with inner experiences in the present instead of lack of awareness, emotional self‐regulation improvement was expected in the elderly following intervention in the group treatment. On the other hand, just as cognitive defusion and acceptance in the ACT are not the end of the road, acceptance is a way to increase value‐based actions. In Islamic teachings, acceptance of suffering and hardship to achieve spiritual and high human values is considered sacred, a clear example of which is seen in the epic of Ashura. In Islamic culture, the personality of individuals or the “divine self” of humans does not change after insult, humiliation, captivity and even apparent defeat, this is the same self that is mentioned in the ACT as the observer and transcendent self and does not hurt.

At last, being in the group process and enjoying benefits such as receiving positive feedback from homogeneous group members, being able to transfer experiences, presenting positive, inspiring and motivating experiences by the group leader, expressing emotions in the group, encouraging group members to speak positives, training imaging techniques, brainstorming, etc., provide the basis for improving emotional self‐regulation in the elderly and reducing the common psychological problems in these people.

One of the limitations of the present study is that the research community is limited to the sample of the elderly with ENS in Tehran, which should be used with caution in generalizing the results to populations and other situations. Due to the current Covid‐19 epidemic situation, it was tried to observe the maximum amount of health protocols, so the meetings were held outdoors. In future research, it is proposed to evaluate and compare the effectiveness of ACT at a broader level and in different groups, and determine follow‐up time to check the persistence of the results obtained. Psychologists and counselors in the field of geriatrics are proposed to pay more attention to strengthening the cognitive flexibility and emotional self‐regulation of the elderly with the ENS and the use of ACT in the treatment programs for the elderly.

AUTHOR CONTRIBUTIONS

Abdolbaset Mahmoudpour: conceptualization; data curation; funding acquisition. Kimia Ferdousi Kejani: writing—original draft; writing—review & editing. Mina Karami: project administration; supervision; visualization; writing—review & editing. Maryam Toosi: writing—original draft; writing—review & editing. Soliman Ahmadboukani: conceptualization; data curation; formal analysis; methodology; software.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

TRANSPARENCY STATEMENT

The lead author Soliman Ahmadboukani affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Mahmoudpour A, Ferdousi Kejani K, Karami M, Toosi M, Ahmadboukani S. Cognitive flexibility and emotional self‐regulation of the elderly with Empty nest syndrome: Benefits of acceptance and commitment therapy. Health Sci Rep. 2023;6:e1397. 10.1002/hsr2.1397

DATA AVAILABILITY STATEMENT

The data that support the finding of this study are available from the corresponding author upon reasonable request.