Effects of Online Acceptance and Commitment Therapy for Family Members of Individuals With Early Psychosis on Self‐Stigma, Coping Strategies and Resilience: A Randomized Controlled Trial

ABSTRACT

Introduction

Early psychosis represents a critical period that may profoundly affect not only individuals but also their family members, often leading to increased psychological distress, stigma and caregiving burden.

Aim

This study aimed to evaluate the effects of online Acceptance and Commitment Therapy (ACT) on self‐stigma, stress coping strategies and resilience levels among family members of individuals with early psychosis.

Methods

This study was designed as an exploratory randomized controlled trial. The study population consisted of 41 caregivers of individuals diagnosed with schizophrenia and other psychotic disorders according to DSM‐5 criteria, who had received their diagnosis within the past three years and applied to a psychiatry outpatient clinic at a training and research hospital between August and October 2024. Eligible participants were randomly allocated to the intervention group (n = 20) or the control group (n = 21). The intervention group participated in an eight‐session online group‐based Acceptance and Commitment Therapy program, while the control group did not receive any structured intervention. Data were collected using the Self‐Stigma Inventory for Family Members, the Stress Coping Strategies Inventory and the Brief Resilience Scale. Evaluations were conducted at pre‐test, post‐test and three‐month follow‐up.

Results

No significant differences were observed between groups at baseline (p > 0.05). Post‐intervention and follow‐up assessments showed significantly lower self‐stigma scores in the intervention group compared to controls (p < 0.05). Additionally, coping strategies and resilience scores were significantly higher in the intervention group at post‐test and follow‐up (p < 0.05).

Conclusion

The findings suggest that online ACT may be effective in reducing self‐stigma and improving coping strategies and resilience among family members of individuals with early psychosis.

Implications for Practice

ACT‐based interventions may represent a promising approach to supporting family members during early psychosis. Psychiatric nurses may play a central role in integrating ACT‐informed approaches into routine mental health services, thereby supporting family‐centered care. Online delivery may serve as a complementary method to facilitate and support the delivery of nursing care by enhancing accessibility and continuity of psychosocial support.

Relevance Statement

This study is relevant to psychiatric mental health nursing as it addresses the role of family‐centered care during early psychosis. The findings demonstrate that ACT‐informed psychosocial approaches may reduce self‐stigma and enhance coping and resilience among family members. Psychiatric nurses are well‐positioned to identify family needs, deliver psychoeducation and support adaptive coping within routine care. Integrating such approaches into practice may strengthen holistic care and improve outcomes for both individuals with early psychosis and their families.

Trial Registration

ClinicalTrials.gov ID: NCT06655688

Accessible Summary

• Key Points

  • ○
    This randomized controlled trial examined the effectiveness of an online Acceptance and Commitment Therapy (ACT) program for family members of individuals with early psychosis.
  • ○
    The intervention significantly reduced self‐stigma and improved coping strategies and resilience compared to the control group.
  • ○
    Strengthening coping and resilience among caregivers may contribute to improved family well‐being and support the recovery process in early psychosis.
  • ○
    Psychiatric nurses can play a key role in integrating ACT‐informed, family‐centered interventions into routine mental health care.
• Originality (what the paper adds to existing knowledge)

  • ○
    This is the first randomized controlled trial to evaluate an online Acceptance and Commitment Therapy (ACT) program for family members of individuals with early psychosis.
  • ○
    The study suggests that ACT interventions may reduce self‐stigma and improve coping strategies and resilience among caregivers.
  • ○
    It highlights the feasibility of delivering structured psychosocial interventions within psychiatric mental health nursing practice.
• Significance (What Are the Implications or Potential Impacts of the Paper)

  • ○
    Psychiatric nurses and mental health professionals may integrate ACT‐informed approaches into routine care to support family members of individuals with early psychosis
  • ○
    Strengthening caregivers' coping and resilience skills may help reduce caregiving burden and may positively influence the recovery process.
  • ○
    Training psychiatric nurses in ACT may contribute to enhancing holistic, family‐centered mental health services.
• Rigour (What Approach Was Taken to Ensure the Method Used Was of Good Quality)

  • ○
    The study used a randomized controlled trial design with a CONSORT flowchart to ensure methodological transparency.
  • ○
    Randomization was performed by an independent statistician with allocation concealment, and blinded statistical analysis was applied to minimize bias.
  • ○
    Validated and reliable psychometric instruments were used to assess self‐stigma, coping strategies and resilience.

1. Introduction

Psychosis, which usually appears at an early age and is characterized by severe psychotic symptoms, not only affects the individual but also affects the foundations of the family (Simon et al. 2017). According to the literature, it is estimated that approximately 115,000 individuals experience a first episode of psychosis (FEP) annually (Simon et al. 2017), with 70% of these cases occurring before the age of 25 (Oluwoye et al. 2020). The first five years following FEP are considered a critical period during which mental health interventions are most effective. In the absence of effective treatment during this period, individuals may experience recurrent relapses, along with marked cognitive impairments and significant functional decline. Although 58% of individuals achieve remission (Lally et al. 2017), relapses occur in 50% of cases within the first three years (Alvarez‐Jimenez et al. 2012).

The emergence of psychosis profoundly affects not only the individual but also the family system. During early psychosis, families are typically characterized by intense and abrupt emotional reactions, with family members frequently experiencing shock, denial, guilt, fear, helplessness and emotional avoidance (Özer 2025; Radley et al. 2023). Families often struggle to make sense of the sudden changes in their loved ones, while simultaneously assuming responsibilities related to diagnosis, treatment and caregiving, and facing significant uncertainties about the future (Sarı and Duman 2020). The ongoing need for care by a family member imposes substantial social, psychological and economic burdens on the family, which can negatively impact family functioning (Sarı and Duman 2020). Moreover, studies have shown that family members employ a variety of coping strategies, including information‐seeking, utilization of social support, religious coping, meaning‐making and problem‐focused approaches (McCann and Lubman 2017; Tager et al. 2025). The use of effective coping strategies by families has also been found to positively influence the individual's psychotic process (Özer 2025). Therefore, the coping strategies adopted by families during this period may be considered to play a critical role in the prognosis of psychosis and in maintaining family functioning.

One of the most significant psychosocial challenges faced by family members during this process is stigma (Yıldız et al. 2019). The widespread misunderstanding of psychosis in society leads not only to the labeling of the individual but also their family members, triggering behavioral reactions such as social exclusion, shame and concealment (Chakraborty et al. 2024; Duran and Can Öz 2022). Stigmatization is not only external but can also be internalized, causing family members to question their self‐efficacy and leading to chronic stress, grief, burnout, depression and withdrawal from social support systems (Shi et al. 2019; Sengün Inan et al. 2021). Stigma not only increases the caregiving burden but also exacerbates the psychotic symptoms experienced by the individual (Alvarez‐Jimenez et al. 2012; Doval et al. 2018).

These challenges can significantly affect the resilience levels of family members. The concept of resilience has gained increasing importance in maintaining family functioning following an early psychosis. Resilience is defined as the capacity to adapt flexibly in the face of crisis, maintain emotional balance and sustain functionality (Rutter 2006). Family members' levels of resilience may influence not only their ability to cope with stress but also their help‐seeking behaviours, problem‐solving skills and long‐term caregiving motivation (Hasson‐Ohayon et al. 2014).

Considering the experiences of family members during early psychosis, strengthening their coping strategies and enhancing resilience may help to reduce the burden of illness on the family and positively contribute to the individual's psychotic process (Metel et al. 2018; Özer 2025). In this context, psychosocial interventions aimed at improving family members' coping skills and mental health in the early stages of psychosis are of particular importance. Recent research indicates a growing interest in Acceptance and Commitment Therapy (ACT), a third‐wave cognitive behavioural approach, particularly in the context of psychosis (Morris et al. 2023; Morris and Simsion 2025; Pena‐Garijo et al. 2025). However, despite this increasing attention, studies examining ACT interventions for family members remain limited. Importantly, existing studies also appear to primarily focus on family members of patients with chronic schizophrenia (Chakraborty et al. 2024; Rahmatnejad et al. 2022; Tunç et al. 2025). In Türkiye, ACT interventions targeting family members of individuals with schizophrenia have been found to increase knowledge and psychological flexibility while reducing self‐stigma (Tunç et al. 2025). International studies also suggest that ACT applied to family members may enhance meaning in life and family functioning, while reducing caregiver burden (Chakraborty et al. 2024; Esfahani and Haghayegh 2019; Rahmatnejad et al. 2022). These findings highlight the value of psychosocial interventions targeting family members. In contrast, early psychosis may represent a distinct period that may involve different emotional and caregiving challenges. Therefore, interventions delivered during early psychosis may have differential or potentially stronger effects compared to those implemented in later stages, as they may support the strengthening of family processes, enhance adaptive coping within the family system and contribute positively to the illness trajectory of individuals with psychosis (Han et al. 2020; Özer and Dişsiz 2024). Importantly, to the best of our knowledge, there is a lack of studies specifically focusing on family members during early psychosis, rather than during the later or chronic stages of the illness. Furthermore, given the growing prevalence of digital health tools, evaluating the effectiveness of online therapies has become increasingly important. Delivering ACT as an online group therapy may represent an accessible and flexible option to in‐person services, particularly for caregivers who cannot leave their loved ones unattended (Han et al. 2025). Accordingly, the present study aims to evaluate the effects of online ACT delivered to family members during early psychosis on self‐stigma, coping with stress and resilience.

This research may contribute to the scientific understanding of early psychosocial interventions and support the integration of family‐focused approaches into mental health nursing practice. Importantly, these findings may highlight the role of psychiatric nurses in identifying family needs and facilitating access to psychosocial support during the early stages of psychosis. As frontline professionals, psychiatric nurses may be well‐positioned to provide psychoeducation, support coping processes and promote engagement in evidence‐based psychosocial interventions such as ACT within routine care settings. By strengthening psychiatric nurses' awareness of family‐centered care and their role in supporting caregivers, this study may contribute to more integrated and responsive mental health services.

2. Aim

This study aimed to evaluate the effects of online Acceptance and Commitment Therapy (ACT) delivered to family members during early psychosis on self‐stigma, coping strategies and resilience levels.

3. Hypotheses

Family members in the intervention group who received online group‐based ACT will report significantly lower levels of self‐stigma compared to those in the control group.

Family members in the intervention group who received online group‐based ACT will demonstrate significantly higher use of coping strategies than those in the control group.

Family members in the intervention group who received online group‐based ACT will show significantly higher levels of resilience compared to those in the control group.

4. Methods

4.1. Design

This study was designed as an exploratory randomized controlled trial with a repeated‐measures design, including pre‐test, post‐test and three‐month follow‐up assessments (Figure 1). The trial was officially registered at Clinicaltrials.gov under the identifier (ID: NCT06655688).

FIGURE 1.

CONSORT flow diagram of the study.

4.2. Population and Sample

The study population included family members of individuals with early psychosis who attended the psychiatric outpatient clinic of a tertiary hospital in Turkey between August and October 2024. A convenience sampling approach was used, whereby eligible participants who met the inclusion criteria and were available during the study period were invited to participate and were then randomly allocated to the intervention and control groups. A sample size calculation was performed using the G*Power 3.1.9 software. Given the absence of prior randomized controlled trials targeting family members during early psychosis and the lack of directly comparable studies in terms of population and outcomes, the sample size was estimated based on conventional statistical parameters (α = 0.05, power = 0.80). The study was planned using a repeated‐measures design with two groups (intervention and control) and three measurement time points (pre‐test, post‐test and three‐month follow‐up). A medium effect size was assumed for the group × time interaction (f = 0.25), consistent with conventional assumptions for behavioural interventions, with a correlation among repeated measures set at 0.50 and a sphericity correction of ε = 1.00. Based on these assumptions, the minimum required sample size was calculated as 28 participants. To account for potential attrition, an additional 20% was added, resulting in a target sample size of 34 participants. Inclusion criteria required participants to be first‐degree caregivers (e.g., parents, spouses, or children) of individuals diagnosed with schizophrenia spectrum or other psychotic disorders according to DSM‐5 criteria within the past three years, to have lived with the individual for at least one year, to have a suitable environment for online sessions (e.g., access to the internet, a smartphone or computer and a private space), to be literate and free from communication difficulties and to provide informed consent. To account for possible attrition, 41 participants were enrolled in total, with 20 assigned to the intervention group and 21 to the control group. Notably, no participants dropped out during the intervention period (Figure 1). The final sample exceeded the required sample size. The trial was completed as planned without early termination or stopping.

4.3. Bias Control and Blinding Procedures

To guarantee impartial selection of participants and unbiased assignment into intervention and control groups, a simple randomization procedure was applied. Randomization was performed by an independent statistical expert using SPSS 27.0, who was blinded to the study objectives. The random allocation sequence was implemented centrally by the independent statistical expert and concealed from the study team until participants were assigned to groups. Allocation concealment was ensured by using sequentially numbered codes stored in a password‐protected computer file, which was revealed only after assignment.

To reduce bias in outcome assessment, data were collected online using Google Forms and distributed to both groups via WhatsApp. This approach ensured standardized data collection and minimized direct researcher involvement during the assessment process, thus reducing the risk of assessor‐related bias. The responses were accessible only to an independent statistician, who was blinded to group assignments and responsible for all statistical analyses. Group codes were disclosed only after data analysis, table preparation and report writing were completed. The researcher who delivered the intervention did not have access to the raw data during the trial, ensuring separation between intervention delivery and outcome assessment.

4.4. Randomization

Before initiating the intervention, 47 first‐degree relatives of individuals with early‐phase psychosis who visited the outpatient clinic during the study period were screened for eligibility. Six individuals were excluded based on the eligibility criteria: two due to unsuitable home environments for online sessions, and four who declined to participate. The remaining 41 eligible participants were enrolled in the study and randomly allocated to groups. No statistically significant differences were found between the intervention and control groups regarding their sociodemographic characteristics (Table 2).

TABLE 2.

Sociodemographic characteristics of family members and their relatives (n = 41).

Characteristics	Intervention group (n = 20)	Control group (n = 21)	Test
	X ± SD (min–max)	X ± SD (min–max)
Individual diagnosed with FEP
Age (years)	25.67 ± 3.08 (21–32)	24.26 ± 3.72 (21–34)	t = 0.433 p = 0.222
Year of disease diagnosis	2.00 ± 0.48 (1–3)	2.26 ± 0.56 (1–3)	t = 1.470 p = 0.098
Family members
Age (years)	43.66 ± 10.99 (23–57)	41.89 ± 9.93 (23–55)	t = 0.260 p = 0.610
	n (%)	n (%)
Proximity
Mother	10 (50.0)	8 (38.1)	X 2 = 1.518 p = 0.678
Father	4 (20.0)	7 (33.3)
Brother/sister	2 (10.0)	1 (4.8)
Spouse	4 (20.0)	5 (23.8)
Gender
Female	13 (65.0)	13 (61.9)	X 2 = 0.040 p = 0.842
Male	7 (35.0)	8 (38.1)
Marital status
Married	18 (90.0)	20 (95.3)	X 2 = 0.442 p = 0.515
Single	2 (10.0)	1 (4.7)
Education status
Elementary/middle school	12 (60.0)	14 (66.6)	X 2 = 1.252 p = 0.535
High school	4 (20.0)	5 (23.8)
Undergraduate and above	4 (20.0)	2 (9.6)
Employment status
Working	12 (60.0)	15 (71.4)	X 2 = 0.667 p = 0.414
Not working	8 (40.0)	6 (28.6)
Income status
Income more than expenditure	2 (10.0)	2 (9.5)	X 2 = 1.248 p = 0.526
Income equal to expenditure	14 (70.0)	17 (80.9)
Income less than expenditure	4 (20.0)	2 (9.6)
Smoking use
Yes	9 (45.0)	11 (52.4)	X 2 = 0.248 p = 0.618
No	11 (55.0)	10 (47.6)
Alcohol use
Yes	4 (20.0)	6 (28.6)	X 2 = 0.410 p = 0.522
No	16 (80.0)	15 (71.4)
Having a family history of mental disorders
Yes	4 (20.0)	4 (19.1)	X 2 = 0.298 p = 0.585
No	16 (80.0)	17 (80.9)
Status of having social support
Yes	15 (75.0)	12 (57.1)	X 2 = 1.508 p = 0.219
No	5 (25.0)	9 (42.9)
Previous psychoeducation status
Yes	7 (35.0)	6 (28.6)	X 2  = 0.227 p = 0.682
No	13 (65.0)	15 (71.4)
Status of receiving professional psychological support
Yes	—	1 (4,8)	—
No	20 (100)	20 (95,2)

Abbreviations: SD, standard deviation; t, independent t‐test; X, mean; X ², Chi‐square test.

4.5. Intervention Program and Data Collection

The intervention was implemented in five structured phases, including development, pilot testing, randomization, program delivery and follow‐up assessment. During the initial stage, the researcher designed an ‘Acceptance and Commitment Therapy (ACT)‐Based Program’ informed by an extensive review of the literature (Rahmatnejad et al. 2022; Rosas‐Santiago et al. 2023). Each session was organized based on the six central processes of psychological flexibility that constitute the foundation of ACT (Table 1).

TABLE 1.

Acceptance and commitment therapy‐based program.

Sessions	Objective
Session 1: Preparation session	Information about the program was given and its purpose was explained The individuals were introduced to each other and asked to talk about their stories voluntarily Pre‐test data were collected
Session 2: Values	It aimed to determine the intervention goals with the individuals and increase their awareness of their values to reveal their values and to enable them to establish a connection with their values
Session 3: Creative despair	The aim was to examine specific control strategies previously used by individuals and to create creative hopelessness
Session 4: Acceptance	The aim was to make room for individuals' thoughts and feelings and to help them stop struggling with them. Teaching acceptance instead of control
Session 5: Contextual Self and Cognitive Dissociation	Enabling individuals to connect with a sense of awareness that is detached from thoughts and feelings. providing a safe and stable advantage from which to observe and acknowledge them It was aimed to enable him/her to see the real/true nature of thoughts and to recognize dysfunctional/automatic thoughts
Session 6: Being present in the moment	The aim was to increase individuals' awareness of their immediate experience
Session 7: Value‐Based Behaviours	The aim was to try to increase individuals' connection to their values and to use their values as a guide for their behaviour
Session 8. Closing	To ensure that individuals can continue the exercise techniques learned in the program in daily life The aim was to evaluate the program and collect post‐test data

In the second stage, a pilot study was undertaken with four family members to assess the suitability of the program's content, materials and data collection instruments. Participants provided feedback on the clarity, relevance and comprehensibility of the session content and materials, as well as the feasibility of the data collection process. Minor revisions were made based on this feedback. Those who participated in the pilot study were excluded from the main trial. During the third stage, the 41 eligible participants were randomly distributed into intervention and control groups using simple randomization. The intervention group was divided into two subgroups, each consisting of ten participants.

In the fourth phase, the intervention was implemented over eight weekly sessions, each lasting approximately 60–90 min, including a warm‐up and discussion of session‐specific themes. During the first session, participants were introduced to the program and informed consent was obtained. At this stage, baseline (pre‐test) assessments were administered prior to the start of the intervention. Sessions 2 through 7 focused on ACT's core processes through experiential exercises, including mindfulness practices, cognitive defusion techniques, values clarification and acceptance‐based strategies delivered using a structured manual (Table 1). In the final session, participants completed the post‐test assessments immediately after the 8‐week intervention. The control group did not receive any structured intervention during this period. The control group did not receive any structured psychosocial intervention from the researcher during this period and received no additional support beyond the routine care provided to the patient.

In the fifth stage, follow‐up assessments were conducted three months after the completion of the intervention. Participants were contacted via phone calls and asked to complete the follow‐up forms sent via WhatsApp. Once the follow‐up data had been collected, the ACT‐based program was also made available to the control group. The ACT program was delivered by the first author, a doctoral‐level psychiatric mental health nurse with formal training in Acceptance and Commitment Therapy. All intervention sessions were conducted as planned, and all participants in the intervention group attended at least 7 of the 8 sessions, indicating high adherence. Fidelity to the intervention protocol was maintained using a structured session manual and standardized exercises. The control group did not receive any structured intervention during the study period and continued with routine outpatient care.

4.6. Measures

4.6.1. Personal Information Form

Developed by the researcher based on literature (Tunç et al. 2025; Özer 2025; Parvin et al. 2024), the form collected demographic information including age, gender and marital status via 15 questions (Table 2).

4.6.2. Self‐Stigma Inventory for Family Members (SSI‐F)

Designed by Yıldız et al. (2019) to evaluate self‐stigma among relatives of individuals diagnosed with schizophrenia, this tool consists of 14 items across three subscales: Concealment of Illness, Social Withdrawal and Perceived Devaluation. Responses are given on a 5‐point Likert scale, producing total scores between 14 and 70, where higher scores reflect higher levels of self‐stigma. In the original validation study, convergent validity was supported through correlations with related psychological variables, such as caregiver burden and depression (Yıldız et al. 2019). The Cronbach's alpha was 0.88 in the original study (Yıldız et al. 2019) and 0.85 in the current study.

4.6.3. Stress Coping Strategies Inventory (CSI)

Originally created by Folkman and Lazarus (1980) within the framework of the Psychological Stress Model, this inventory was translated and validated for Turkish use by Türküm (2002). This 23‐item scale measures coping strategies across three factors: Problem‐Focused Coping, Seeking Social Support and Avoidance Coping. Items 10, 17 and 20 are reverse coded. Responses are recorded on a 5‐point Likert scale, yielding total scores from 23 to 115, where higher scores denote greater reliance on coping strategies. In the Turkish adaptation, construct validity was confirmed through factor analysis and concurrent validity was demonstrated by comparison with other coping‐related scales (Türküm 2002). The Cronbach's alpha was 0.78 (Türküm 2002), while in this study it was calculated as 0.81.

4.6.4. Brief Resilience Scale (BRS)

Designed by Smith et al. (2008) and later adapted into Turkish by Doğan (2015), this scale measures psychological resilience using six items scored on a 5‐point Likert format. Items 2, 4 and 6 are reverse coded, and higher total scores represent higher resilience levels. In the adaptation study, construct validity was supported through factor analysis, and convergent validity was confirmed via significant correlations with life satisfaction and psychological well‐being measures (Doğan 2015). The original validation reported Cronbach's alpha between 0.80 and 0.91, with test–retest reliability ranging from 0.62 to 0.69 (Doğan 2015). In the present study, Cronbach's alpha was found to be 0.77.

4.7. Ethical Considerations

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Bartin University Ethics Committee (approval no: 2024‐SBB‐0501, dated July 8, 2024), and official permission was secured from the hospital administration. Written and verbal informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without any consequences. Confidentiality and anonymity of the participants were strictly maintained throughout the study.

The researcher, a doctoral‐level psychiatric and mental health nurse, possessed formal training in both the theoretical foundations and practical applications of ACT. Potential harms were defined as any emotional distress or discomfort that might arise during participation in the ACT sessions and were assessed through informal monitoring by asking participants at the end of each session whether they had experienced any emotional distress or negative effects rather than using a standardized assessment tool.

4.8. Statistical Analysis

All statistical analyses were conducted using SPSS software, version 27.0. Normality was assessed visually (histograms, Q‐Q plots) and analytically (Kolmogorov–Smirnov test). As the data did not meet the assumptions of normal distribution, non‐parametric tests were used for the analyses. Descriptive analyses included percentage distributions, arithmetic means, standard deviations and minimum‐maximum values. Between‐group comparisons of categorical variables used Chi‐square tests, while continuous variables were compared with Mann–Whitney U tests. Within‐group comparisons were performed using Friedman tests with Wilcoxon signed‐rank tests as post hoc analyses. Effect sizes for the Friedman tests were determined by calculating Kendall's W coefficient. A threshold of p < 0.05 was considered statistically significant across all analyses. All randomized participants were included in the analysis according to their originally assigned groups (intention‐to‐treat principle). There were no missing data for the primary or secondary outcomes; therefore, no imputation methods were required. No additional subgroup or sensitivity analyses were conducted beyond the pre‐specified statistical analyses.

5. Results

In the intervention group, the average age of participants was 43.66 ± 10.99 years (Table 2). Half of the participants were mothers, 60% had completed primary or middle school education, 20% reported having a family history of psychotic disorders, and 65% indicated they had not previously received psychoeducation related to psychotic conditions. No significant differences were observed between the intervention and control groups in terms of sociodemographic characteristics (p > 0.05), suggesting that the groups were comparable.

At baseline (pre‐test), comparison of SSI‐F subscale and overall mean scores revealed no significant differences between the intervention and control groups (p > 0.05) (Table 3). By contrast, post‐test and three‐month follow‐up assessments indicated that participants in the intervention group had significantly lower mean scores across all SSI‐F subscales and in the total score compared with those in the control group (p < 0.05). Furthermore, in the intervention group, significant reductions were observed in both subscale and total scores at post‐test and three‐month follow‐up compared with pre‐test values (p < 0.05).

TABLE 3.

Comparison of the mean scores of the individuals on the SSI‐F (n = 41).

Scale	Intervention group (n = 20)	Control group (n = 21)	Test
	X ± SD (min–max)	X ± SD (min–max)
SSI‐F total
Pre‐testa	44.83 ± 3.03 (31–53)	43.79 ± 3.05 (29–54)	U = 272.000 p = 0.656
Post testb	32.68 ± 3.11 (25–45)	44.61 ± 3.12 (29–53)	U = 136.500 p = 0.000
3rd‐month follow‐upc	33.26 ± 3.15 (25–44)	44.06 ± 3.07 (30–54)	U = 151.000 p = 0.001
Test	X 2  = 34.740	X 2 = 3.395
	p = 0.000	p = 0.183
Post hoc test	b, c < a
Kendall's W	0.780
Social withdrawal
Pre‐testa	19.85 ± 2.82 (14–21)	19.06 ± 2.17 (12–22)	U = 263.000 p = 0.832
Post testb	13.79 ± 3.04 (10–19)	19.58 ± 2.39 (13–22)	U = 103.500 p = 0.000
3rd‐month follow‐upc	15.37 ± 2.96 (11–20)	19.96 ± 3.01 (14–23)	U = 112.500 p = 0.000
Test	X 2  = 42.153	X 2 = 6.322
	p = 0.000	p = 0.236
Post hoc test	b, c < a
Kendall's W	0.814
Concealment of the illness
Pre‐testa	10.66 ± 3.14 (5–13)	10.25 ± 2.09 (6–13)	U = 261.5000 p = 0.848
Post testb	6.83 ± 2.89 (4–10)	11.06 ± 2.67 (5–14)	U = 176.500 p = 0.000
3rd‐month follow‐upc	7.46 ± 3.04 (4–11)	10.95 ± 2.01 (5–13)	U = 202.000 p = 0.032
Test	X 2  = 31.621	X 2 = 5.275
	p = 0.000	p = 0.351
Post hoc test	b, c < a
Kendall's W	0.723
Perceived devaluation
Pre‐testa	13.64 ± 2.28 (9–16)	13.15 ± 1.77 (8–15)	U = 143.000 p = 0.391
Post testb	9.42 ± 2.12 (7–12)	13.26 ± 2.06 (8–15)	U = 119.000 p = 0.000
3rd‐month follow‐upc	9.88 ± 2.17 (7–13)	13.52 ± 2.11 (9–15)	U = 122.500 p = 0.001
Test	X 2  = 44.906	X 2 = 4.456
	p = 0.000	p = 0.310
Post hoc test	b, c < a
Kendall's W	0.796

Note: Bold values indicate statistically significant results (p < 0.05). Superscript letters denote pairwise group comparisons.

Abbreviations: Post hoc test, Wilcoxon test; SD, standard deviation; SSI‐F, Self‐Stigma Inventory for Family Members; U, Mann–Whitney U test; X, mean; X ², Friedman test.

With respect to CSI subscales and total mean scores, no significant group differences were detected at pre‐test (p > 0.05) (Table 4). During post‐test and three‐month follow‐up evaluations, the intervention group demonstrated significantly higher mean scores than the control group on the ‘Seeking Social Support’ and ‘Problem‐Focused Coping’ subscales, along with higher overall scores (p < 0.05). Significant differences in the ‘Avoidance Coping’ subscale were observed between groups only at post‐test, where the intervention group scored higher than the control group (p < 0.05). In addition, participants in the intervention group exhibited significant increases in all subscale scores and the overall CSI score at post‐test and three‐month follow‐up compared with their pre‐test scores (p < 0.05).

TABLE 4.

Comparison of the mean scores of the individuals on the CSI (n = 41).

Scale	Intervention group (n = 20)	Control group (n = 21)	Test
	X ± SD (min–max)	X ± SD (min–max)
CSI total
Pre‐testa	73.53 ± 6.67 (47–99)	71.70 ± 6.99 (42–98)	U = 288.000 p = 0.472
Post testb	85.12 ± 7.33 (51–108)	72.92 ± 7.12 (44–99)	U = 112.500 p = 0.000
3rd‐month follow‐upc	83.27 ± 7.22 (49–103)	74.31 ± 7.75 (43–101)	U = 99.000 p = 0.001
Test	X 2  = 44.351 p = 0.000	X 2 = 8.685 p = 0.098
Post hoc test	a < b, c
Kendall's W	0.846
Seeking social support
Pre‐testa	22.29 ± 3.62 (12–30)	21.57 ± 3.71 (12–30)	U = 261.500 p = 0.764
Post testb	27.87 ± 4.18 (15–35)	22.18 ± 3.56 (13–30)	U = 71.500 p = 0.000
3rd‐month follow‐upc	25.62 ± 3.74 (15–34)	23.03 ± 3.43 (12–31)	U = 131.500 p = 0.004
Test	X 2  = 34.861 p = 0.000	X 2 = 6.426 p = 0.122
Post hoc test	a < b, c
Kendall's W	0.791
Problem‐focused coping
Pre‐testa	25.76 ± 4.37 (17–35)	24.64 ± 3.95 (16–35)	U = 297.500 p = 0.613
Post testb	34.13 ± 5.01 (21–40)	25.93 ± 4.17 (16–34)	U = 82.500 p = 0.000
3rd‐month follow‐upc	32.23 ± 4.52 (22–38)	26.69 ± 4.25 (17–36)	U = 105.000 p = 0.001
Test	X 2  = 41.029 p = 0.000	X 2 = 7.620 p = 0.103
Post hoc test	a < b, c
Kendall's W	0.806
Avoidance coping
Pre‐testa	26.60 ± 4.93 (17–36)	25.71 ± 3.74 (16–34)	U = 214.000 p = 0.594
Post testb	23.03 ± 4.38 (13–32)	24.85 ± 3.89 (16–35)	U = 186.500 p = 0.018
3rd‐month follow‐upc	25.12 ± 4.40 (15–33)	25.81 ± 0.84 (17–36)	U = 290.000 p = 0.691
Test	X 2  = 29.125 p = 0.000	X 2 = 6.540 p = 0.126
Post hoc test	b < a
Kendall's W	0.514

Note: Bold values indicate statistically significant results (p < 0.05). Superscript letters denote pairwise group comparisons.

Abbreviations: CSI, Stress Coping Strategies Inventory; Post hoc test, Wilcoxon test; SD, standard deviation; U, Mann–Whitney U test; X, mean; X ², Friedman test.

For the BRS total scores, no significant differences emerged between the intervention and control groups at baseline (pre‐test) (p > 0.05) (Table 5). Although post‐test BRS scores did not significantly differ between groups (p > 0.05), 3‐month follow‐up results showed the intervention group achieving significantly higher total scores than the control group (p < 0.05). Moreover, within the intervention group, follow‐up BRS scores were significantly higher than pre‐test scores (p < 0.05).

TABLE 5.

Comparison of the mean scores of the individuals on the BRS (n = 41).

Scale	Intervention group (n = 20)	Control group (n = 21)	Test
	X ± SD (min–max)	X ± SD (min–max)
BRS Total
Pre‐testa	13.33 ± 1.67 (9–18)	14.37 ± 1.49 (10–20)	U = 187.000 p = 0.272
Post testb	15.12 ± 2.13 (10–20)	13.92 ± 1.72 (10–21)	U = 132.500 p = 0.106
3rd‐month follow‐upc	15.97 ± 2.62 (10–23)	14.11 ± 1.75 (10–21)	U = 92.500 p = 0.001
Test	X 2  = 27.521 p = 0.000	X 2 = 4.685 p = 0.188
Post hoc test	a < c
Kendall's W	0.483

Note: Bold values indicate statistically significant results (p < 0.05). Superscript letters denote pairwise group comparisons.

Abbreviations: BRS, Brief Resilience Scale; Post hoc test, Wilcoxon test; SD, Standard deviation; U, Mann–Whitney U test; X, Mean; X ², Friedman test.

6. Discussion

This study examined the effects of Acceptance and Commitment Therapy (ACT) applied to family members of individuals with early psychosis on self‐stigma, coping strategies and resilience levels. Accordingly, it was found that ACT was associated with reductions in self‐stigma levels and improvements in coping and resilience levels among the family members of individuals with early psychosis. These findings suggest that interventions targeting family members in the early stages of psychosis may play an important role in both individual and family‐based recovery processes, particularly by supporting adaptive coping within the family system and facilitating more flexible responses to illness‐related challenges.

A review of the existing literature revealed a limited number of studies utilizing ACT‐based interventions for families after early psychosis. Importantly, previous studies have largely focused on chronic stages of psychotic disorders, whereas evidence targeting family members during early psychosis remains limited. In this context, the present study may contribute to the literature by addressing this gap through examining ACT within an early psychosis context and a family‐focused framework.

Individuals with mental disorders and their families are often subject to stigma, which is frequently internalized by both the individual and the family (Ebrahim et al. 2020; Özer 2025). In this study, ACT for family members of individuals with early psychosis was found to be associated with reductions in self‐stigma levels. Parvin et al. (2024) reported positive effects of ACT on self‐stigma and family functioning among family members of individuals with mental disorders. Studies conducted primarily with family members of individuals with schizophrenia have shown that ACT‐based interventions are associated with reductions in self‐stigma and caregiver burden, along with improvements in family functioning, knowledge and psychological flexibility (Chakraborty et al. 2024; Rahmatnejad et al. 2022; Tunç et al. 2025). While these findings are consistent with previous studies, the present results extend this evidence by focusing specifically on family members during the early psychosis period. This stage is particularly important given that early psychosis represents a critical period in which family responses may shape longer‐term illness trajectories and caregiving outcomes.

Family members of individuals with early psychosis may internalize societal stigma, developing negative feelings such as worthlessness. They may also engage in behaviours such as social withdrawal, concealing the illness from the public and hiding the patient's condition (Shi et al. 2019; Duran and Can Öz 2022). This study found that ACT was associated with reductions in these subdimensions of self‐stigma, including feelings of worthlessness, social withdrawal and concealment of illness among family members. These findings may be explained by the core processes of ACT, which target both cognitive and behavioural responses to stigma‐related experiences. Through cognitive defusion and acceptance processes, ACT helps individuals create psychological distance from stigmatizing self‐beliefs and reduce identification with negative thoughts. In doing so, it enhances psychological flexibility, which has been shown to act as a buffer against negative emotional experiences and is associated with improved well‐being and personal efficacy (Morris et al. 2023; Pittman et al. 2024). As a result, stigmatizing thoughts may be experienced as transient mental events rather than objective truths (Wakefield et al. 2018). Additionally, the contextual self‐session supports this process, enabling family members to develop a flexible perspective‐taking repertoire regarding stigmatizing thoughts (Tarbox et al. 2020). Furthermore, ACT encourages individuals to identify their values and take committed actions accordingly. Family members may become more resilient to stigma by focusing on intrinsic values such as ‘being a good caregiver’ rather than ‘what society thinks’ (Johns et al. 2016). Mindfulness exercises facilitate remaining present without becoming entangled in negative thoughts and emotions, which can reduce the mental burden of past stigmatizing experiences or future fears (Chakraborty et al. 2024; Chan et al. 2018; Kao et al. 2024).

In addition to stigma, family members may not fully understand how to cope with psychotic symptoms and the challenges posed by the process. During this period, they may develop ineffective coping strategies such as avoidance, anger and guilt (Radley et al. 2023). This study found that ACT was associated with improvements in coping with stress among family members. Furthermore, ACT was associated with increases in social support seeking and problem‐focused coping, and reductions in avoidance‐focused coping. Rosas‐Santiago et al. (2023) reported that after ACT interventions with family members of individuals diagnosed with FEP, effective coping strategies increased while perceived overload and burnout syndrome decreased. In a systematic review, Byrne et al. (2021) identified positive effects of ACT on stress levels and coping strategies among family members of individuals with chronic illnesses. Pennefather et al. (2018) found that ACT applied to parents of children with autism had a moderate effect on parental coping strategies and a small effect on parental stress. These findings may be explained by the core processes of ACT, which target experiential avoidance and promote more adaptive coping responses. Mindfulness exercises used in this process help individuals remain present, while also fostering a focus on personal values and meaningful life goals, which in turn may positively contribute to their stress‐coping abilities (Pena‐Garijo et al. 2025). Additionally, ACT facilitates connection with personally valued life directions, enabling family members to fulfil their caregiving roles more meaningfully and sustainably (Johns et al. 2016). By reducing avoidance and promoting value‐based action, ACT may support a shift toward more active coping strategies, such as seeking social support and problem‐solving, which may in turn reduce stress‐related burden over time (Rosas‐Santiago et al. 2023).

Throughout this process, resilience plays a critical role in how family members cope with challenges. Resilience, defined as an individual's ability to adapt and recover after adverse life events, is especially important to preserve and enhance among family members after an early psychosis diagnosis (Esfahani and Haghayegh 2019). This study found that ACT was associated with improvements in resilience levels among family members. The significant difference in resilience scores in the intervention group emerged at the 3‐month follow‐up, indicating that ACT may have a delayed and cumulative influence on resilience. Evidence on ACT‐based interventions targeting resilience in family members remains limited, particularly in early psychosis contexts. Esfahani and Haghayegh (2019) reported a significant increase in resilience levels among families of individuals diagnosed with schizophrenia after ACT, though no significant difference was found at the 1‐month follow‐up. Chakraborty et al. (2024) noted that family members of individuals with schizophrenia reported feeling more empowered after ACT, based on qualitative interviews. Other studies have demonstrated increased psychological flexibility following ACT among families of individuals with schizophrenia (Han et al. 2020; Jolley et al. 2020). Additionally, ACT has been shown to increase psychological flexibility and reduce anxiety, stress and caregiver burden in families of children with special needs (Magnacca et al. 2021; Lobato et al. 2022; Maughan et al. 2024) and caregivers of individuals with dementia (Han et al. 2025; Fauth et al. 2022). These outcomes suggest that improvements in psychological flexibility may act as a key mechanism through which ACT contributes to resilience. ACT provides individuals with mindfulness skills that promote adaptation to challenging life circumstances, help identify personally meaningful values, and encourage committed action (Tyndall et al. 2020; Morris and Simsion 2025). In this context, ACT may support family members in adapting to the challenges of early psychosis by fostering flexible coping, value‐based action, and sustained engagement in caregiving roles. Overall, these findings suggest that ACT may play a supportive role in enhancing resilience among family members during early psychosis.

One finding of this study is that ACT delivered as a group‐based online intervention was associated with positive outcomes among family members after an early psychosis diagnosis. These findings are consistent with those reported in face‐to‐face ACT studies (Chakraborty et al. 2024; Esfahani and Haghayegh 2019; Parvin et al. 2024; Rosas‐Santiago et al. 2023), suggesting that similar therapeutic processes may operate across different delivery formats. The online format was used as a feasible and accessible mode of delivering the intervention. In contexts where access to face‐to‐face services may be limited, online psychiatric interventions may offer advantages such as flexibility and accessibility (Han et al. 2025; Morris and Simsion 2025; Özer and Dişsiz 2024). Accordingly, the findings suggest that ACT‐based interventions may be feasibly delivered online to individuals with early psychosis and their families.

7. Strenght and Limitations

The use of three‐month repeated measures experimental design with pre‐test, post‐test and control groups to observe behavioural changes, alongside the random assignment of participants to intervention and control groups and the homogeneity between groups, represents a strength of this study. Additionally, while the international literature on this subject remains limited, no studies conducted in Turkey involving this therapy model applied as online group therapy for family members after early psychosis have been identified. Therefore, this study may contribute to the existing literature. Moreover, it suggests the potential importance of early interventions for individuals diagnosed with early psychosis and their families.

This study also has some limitations. First, the single‐center design may limit the generalizability of the findings. This design was primarily influenced by feasibility considerations, including access to a specific clinical population and the structured implementation of the intervention. Furthermore, the relatively small sample size and lack of long‐term follow‐up may restrict the ability to evaluate the sustainability of the intervention's effects. Future studies with larger samples and longer follow‐up periods are needed to confirm the stability of these findings over time. Another limitation is the reliance on self‐report measures, which may be subject to response biases such as social desirability and recall bias, potentially affecting the objectivity of the findings. As the study was conducted by a single researcher who also delivered the intervention, the possibility of bias cannot be fully excluded. However, this risk was partially mitigated through the use of a structured intervention manual, standardized session procedures, and independent statistical analysis conducted by a blinded statistician. Future research may benefit from including multicenter studies with larger samples and extended follow‐up periods. In particular, multi‐center designs may enhance the external validity and generalizability of the findings.

8. Conclusion

This study suggests that ACT, delivered online to family members during early psychosis, may be associated with reductions in self‐stigma while improving coping with stress and psychological resilience. These findings highlight the potential importance of including family members in psychosocial interventions during the early stages of psychosis.

In addition, further research with larger samples and longer follow‐up periods is warranted to better understand the effectiveness and sustainability of ACT interventions in this population. Such studies may contribute to the development of evidence‐based, family‐centered approaches in mental health care.

9. Implications for Practice

Psychiatric nurses may play an important role as frontline professionals in delivering holistic and family‐centered care. Within their professional scope, psychiatric nurses are actively involved in assessment, care planning, implementation and evaluation processes, which may place them in a favorable position to integrate family‐focused psychosocial support into routine clinical practice. Their continuous interaction with caregivers may further enable them to identify emotional distress, provide psychoeducation, and support engagement in psychosocial interventions within routine care.

The findings of this study suggest that increasing psychiatric nurses' awareness of ACT principles may be beneficial in supporting family‐centered care practices. In this context, ACT‐informed approaches may be integrated into routine psychosocial support provided to families of individuals with early psychosis. To improve the quality of care, psychiatric nurses may benefit from ACT‐based training, enabling them to apply more advanced psychosocial interventions in supporting individuals with psychosis and their families. Such competencies may contribute to improved coping, reduced caregiver burden, and enhanced family well‐being.

Author Contributions

Study conception/design: D.Ö. Data collection: D.Ö. Data analysis: D.Ö. Drafting of the manuscript: D.Ö. Critical revisions for important intellectual content; supervision: D.Ö. Statistical expertise: D.Ö. Administrative/technical/material support: D.Ö.

Funding

The author has nothing to report.

Ethics Statement

The study was conducted, and the ethics committee approval was obtained from the Bartin University Ethics Committee (numbered 2024‐SBB‐0501, dated July 8, 2024).

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data of this study could be shared upon reasonable requests from the corresponding author.