Design and Effectiveness of an Integrative Psychoeducational-Therapeutic Package on Psychological Flexibility in Patients with Bipolar II Disorder
Keywords:
Bipolar II disorder, psychological flexibility, integrative intervention, Acceptance and Action Questionnaire, IIAbstract
Purpose: Bipolar II disorder is characterized by chronic mood instability, emotion dysregulation, and functional impairment. Reduced psychological flexibility may perpetuate symptoms and hinder adaptation. This study developed and tested an integrative psychoeducational-therapeutic package to improve psychological flexibility in Bipolar II patients, addressing the limitations of single-component interventions.
Materials and Methods: This study employed a sequential exploratory mixed-methods design. Qualitative analysis of semi-structured interviews with 20 patients, using Colaizzi's method, led to the development of an 8-session, 6-domain treatment package. In the quantitative phase, 40 patients from Vasei Hospital's Neurology and Psychiatry Department (Sabzevar, 2024) were randomly assigned to experimental (n=20) and control (n=20) groups. Psychological flexibility, measured by the AAQ-II (Bond et al., 2011), was assessed at pre-test, post-test, and 3-month follow-up. Data were analyzed using mixed-design repeated-measures ANOVA in SPSS 27.
Findigns: The Time × Group interaction significantly impacted psychological flexibility, F(1.68, 63.80)=70.73, p<0.001, η2=0.65. Specifically, the experimental group's psychological flexibility rose from 29.61±2.03 at pre-test to 33.68±2.03 at post-test, then stabilized at 33.55±2.18 by follow-up. In contrast, the control group's scores remained consistent across all assessments (31.45±1.80 pre-test, 31.64±1.75 post-test, and 31.52±1.50 follow-up).
Conclusion: The integrative psychoeducational-therapeutic package effectively enhances psychological flexibility in Bipolar II disorder patients, with sustained gains. This protocol could complement pharmacotherapy in clinical settings.
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References
Asgharzadeh, A., Janmohammadi, S., Pourabbas, M., Vahidi, M., & Rashti, B. (2025). The role of a transitional care program in supporting family caregivers to prevent relapse in severe mental illness: a qualitative study from Iran. BMC Nursing, 24(1), 1442. https://doi.org/10.1186/s12912-025-04077-7
Baburaj, K. (2025). Self-Compassion, Psychological Flexibility, and Resilience in Predicting the Levels of the Caregiver Burden in Caregivers of BPAD: A Comparative Study Central Institute of Psychiatry]. India.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior therapy, 42(4), 676-688. https://doi.org/10.1016/j.beth.2011.03.007
Burke, R., Sickman, E., Belisle, J., Taylor, S., & Paliliunas, D. (2024). Combined ACT-Based Contingency Contracting Intervention for Aggressive Behavior and Psychological Flexibility in an Adolescent With Comorbid Autism, Bipolar Disorder, and Schizophrenia. Clinical Case Studies, 23(1), 23-41. https://doi.org/10.1177/15346501231171867
Çifteci, K., Kurtulmuş Çalış, A., & Karatepe, H. T. (2026). Associations Between Theory of Mind Impairment, Psychological Flexibility, and Social Functioning during the Remission Phase of Bipolar Disorder. Behavioral Medicine, 1-12. https://doi.org/10.1080/08964289.2026.2627891
Davoudian, M., Hashemipor, F., Ghelichkhan, N., & Abouzari, F. (2022). The role of psychological flexibility, difficulty in emotion regulation and intolerance of uncertainty in predicting psychological distress and obsessive-compulsive symptoms in patients with type 2 diabetes during the COVID-19 epidemic. Quarterly Journal of Nursing Management, 11(2).
Deveci, N., Uğurlu, M., Uğurlu, G. K., Şahin, E. K., Erdoğan, E. Ç., & Çayköylü, A. (2024). The effects of psychological flexibility and resilience on psychopharmacological treatment response in patients with obsessive-compulsive disorder. International Clinical Psychopharmacology, 39(3), 181-186. https://doi.org/10.1097/YIC.0000000000000499
Ebrahimi, A., Khorasani, P., Andalib, S., Ahmadi, M., & Mousavi, S. M. H. (2024). Developing and validating of educational-therapeutic package based on psychological flexibility for nurses in the intensive care unit of COVID-19: Application of grounded theory. Journal of education and health promotion, 13(1), 274. https://doi.org/10.4103/jehp.jehp_908_23
El-Sayed, M. M., Elhay, E. S. A., Taha, S. M., Khedr, M. A., Mansour, F. S. A., & El-Ashry, A. M. (2023). Efficacy of acceptance and commitment therapy on impulsivity and suicidality among clients with bipolar disorders: a randomized control trial. BMC Nursing, 22(1), 271. https://doi.org/10.1186/s12912-023-01443-1
Gabal, S. A. (2025). Effect of a mindfulness-based psychoeducational program on psychological flexibility and perceived stress among psychiatric patients. Port Said Scientific Journal of Nursing, 12(2), 1-34. https://doi.org/10.21608/pssjn.2025.385286.1359
Güleç, V., Ulusoy, S., Ramakan, E. D., & Kurt, E. (2026). The Relationship Between Dyadic Adjustment, Internalized Stigma, Psychological Inflexibility, and Playfulness in Bipolar Disorder: A Mediation Model. International Journal of Social Psychiatry, 00207640261446100. https://doi.org/10.1177/00207640261446100
Hussain, S., Khawar, R., Amin, R., Hamdani, A., & Majeed, A. (2023). Psychological flexibility, cognitive emotion regulation and mental health outcomes among patients with asthma in Pakistan. Peerj, 11, e15506. https://doi.org/10.7717/peerj.15506
Karatepe, H. T., & Aktepe, M. (2020). Acceptance, Values and Mindfulness May Differentially Affect Functioning on Bipolar Disorder in Remission; A Single-Center Study. Psychiatry and Clinical Psychopharmacology, 30(2), 186-192.
Karim Soltani, S., Mousavi, S. A., & Amini, N. (2025). Investigating the Effectiveness of Treatment Based on Acceptance and Commitment on Executive Functions, Psychological Flexibility and Psychological Well-Being of Male Patients With Bipolar Disorder Type 1. Middle Eastern Journal of Disability Studies, 15, 96-96.
Khafif, T. C., Perez, W. F., Hamoui, S., Nardini, C., Biazus, T., Dayan, S., & Lafer, B. (2026). Efficacy of acceptance and commitment therapy (ACT) as a stand-alone treatment for bipolar disorder: Protocol for a randomized controlled trial. Journal of Behavioral and Cognitive Therapy, 36(1), 100545. https://doi.org/10.1016/j.jbct.2025.100545
Kocakaya, H., & Yetkin, S. (2024). Impact of biological rhythms on perception of illness and cognitive flexibility in bipolar patients in remission. Chronobiology International, 41(3), 406-416. https://doi.org/10.1080/07420528.2024.2312811
Köse, S., & Hocaoğlu, Ç. (2025). Investigation of the relationship between cognitive flexibility, theory of mind and creative thinking in patients with bipolar disorder. BMC psychiatry, 25(1), 455. https://doi.org/10.1186/s12888-025-06908-y
MacPherson, H. A., Kudinova, A. Y., Schettini, E., Jenkins, G. A., Gilbert, A. C., Thomas, S. A., & Dickstein, D. P. (2022). Relationship between cognitive flexibility and subsequent course of mood symptoms and suicidal ideation in young adults with childhood-onset bipolar disorder. European Child & Adolescent Psychiatry, 31(2), 299-312. https://doi.org/10.1007/s00787-020-01688-0
Malo, R., Acier, D., & Bulteau, S. (2024). Psychological flexibility: toward a better Understanding of a key concept. Trends in Psychology, 32(3), 734-759. https://doi.org/10.1007/s43076-022-00188-1
Mousavi, N., Norozpour, M., Taherifar, Z., Naserbakht, M., & Shabani, A. (2021). Bipolar I disorder: a qualitative study of the viewpoints of the family members of patients on the nature of the disorder and pharmacological treatment non-adherence. BMC psychiatry, 21(1), 83. https://doi.org/10.1186/s12888-020-03008-x
Pankowski, S., Adler, M., Andersson, G., Lindefors, N., & Svanborg, C. (2017). Group acceptance and commitment therapy (ACT) for bipolar disorder and co-existing anxiety-an open pilot study. Cognitive behaviour therapy, 46(2), 114-128. https://doi.org/10.1080/16506073.2016.1231218
Purcell, K. (2025). Regulation as modulation: autonomic flexibility as a physiological buffer in bipolar II disorder-a perspective on somatic regulation and mood stability. Frontiers in Psychiatry, 16, 1726708. https://doi.org/10.3389/fpsyt.2025.1726708
Sadeghi, A., Jalali, M., & Tavakoli Benizi, A. (2025). Effectiveness of Dialectical Behavior Therapy on Emotional Regulation and Cognitive Flexibility in Men with Type 1 Bipolar Disorder. Recent Innovations in Psychology, 2(2), 1-15.
Shabaninia, S., Golparvar, M., & Aghaei, A. (2025). Love in contrast: comparing emotionally focused therapy (EFT) and need-based educational package in women with low sexual desire. Sexual and Relationship Therapy, 40(2), 482-496. https://doi.org/10.1080/14681994.2025.2469299
Shi, J. Y., Na, L., Du, Y. H., Wang, J., Zhang, R. Z., Guo, C., & Wang, Z. H. (2026). Effect of a group-based acceptance and commitment therapy intervention on cognitive emotion regulation and psychological flexibility in patients with bipolar disorder. Psychology and Psychotherapy: Theory, Research and Practice. https://doi.org/10.1111/papt.70061
Temircan, Z. (2025). Psychological Flexibility in Borderline Personality Disorder: A Comparative Study with Healthy Controls. OBM Neurobiology, 9(4), 1-14. https://doi.org/10.21926/obm.neurobiol.2504316
Watson, D. C. (2026). Coping Flexibility and Psychological Flexibility/Inflexibility in Personality Disorder Traits. North American Journal of Psychology, 26(2), 1192. https://doi.org/10.65696/001c.162906
Zargar, F., Mansouri, R., & Tarrahi, M. J. (2023). Investigating the Relationship Between Psychological Flexibility, Mindful Ability, and Self-compassion With the Severity of Depression in Patients With Mood Disorders. Iranian Rehabilitation Journal, 21(2), 301-308. https://doi.org/10.32598/irj.21.2.1861.1
Zhylin, M., Zhylina, V. V., Ryhel, O., & Yudenko, O. (2024). Innovative rehabilitation strategies for chemical dependency: integrating biochemical insights and psychosocial approaches.
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Copyright (c) 2026 Safura Keyvanlo (Author); Mohammad Narimani; Seifollah Aghajani , Sajjad Basharpour (Author)
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