This randomized controlled trial will evaluate two Acceptance and Commitment Therapy (ACT)-based counseling approaches for mothers whose infants are hospitalized in a Neonatal Intensive Care Unit (NICU). Mothers of infants in the NICU may experience high levels of stress, anxiety, and depressive symptoms. ACT is an approach that aims to improve psychological flexibility by helping people respond more effectively to difficult thoughts, emotions, and stressful experiences.
A total of 135 mothers will be enrolled from two hospitals in Istanbul, Türkiye. Participants will be randomly assigned to one of three groups: an individual online ACT-based workshop, an ACT-based chatbot counseling program, or standard care.
Mothers in the online workshop group will receive one individual 60-minute online session that includes mindfulness, acceptance, cognitive defusion, values clarification, and committed action exercises. Mothers in the chatbot group will receive ACT-based psychoeducation, guided exercises, and supportive digital counseling through a mobile application for four weeks. Mothers in the control group will receive the routine information and care normally provided in the NICU.
Psychological flexibility will be the primary outcome. Depression, anxiety, and stress symptoms will be evaluated as secondary outcomes. Assessments will be completed at baseline, Week 2, Week 4, and at the 6-month follow-up.
The study aims to determine whether ACT-based online and digital counseling can improve psychological flexibility and reduce psychological distress among mothers of infants hospitalized in the NICU.
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Parallel
ACT-Based Online Psychoeducational Workshop
BehavioralParticipants will receive one individual, synchronous online psychoeducational session based on Acceptance and Commitment Therapy (ACT), lasting approximately 60 minutes. The session will include present-moment awareness and mindfulness exercises, acceptance of difficult emotions, cognitive defusion, values clarification, and committed action. Participants will also be encouraged to practice brief mindfulness exercises during the four-week follow-up period.
ACT-Based Chatbot Counseling
BehavioralParticipants will receive ACT-based digital counseling through a mobile chatbot for four weeks. The intervention will provide structured psychoeducation, brief guided exercises, and supportive counseling based on mindfulness, acceptance, cognitive defusion, values clarification, and committed action. The chatbot will not provide diagnosis, treatment recommendations, medication advice, or clinical decision-making. Predefined safety and referral messages will be used when risk-related expressions are detected.
Change in Psychological Flexibility Scale Total Score
Psychological flexibility will be assessed using the 28-item Psychological Flexibility Scale. Items are rated on a 7-point Likert scale. The scale assesses core dimensions of psychological flexibility, including openness to experience, behavioral awareness, and valued action. Changes in total scores over time will be compared among the ACT-based online workshop, ACT-based chatbot counseling, and standard care groups.
Change in DASS-21 Stress Subscale Score
Stress symptoms will be assessed using the Stress subscale of the 21-item Depression Anxiety Stress Scale (DASS-21). The stress subscale consists of 7 items rated from 0 to 3. Subscale scores are calculated according to the DASS-21 scoring procedure, with higher scores indicating greater stress symptom severity.
Change in DASS-21 Anxiety Subscale Score
Anxiety symptoms will be assessed using the Anxiety subscale of the 21-item Depression Anxiety Stress Scale (DASS-21). The anxiety subscale consists of 7 items rated from 0 to 3. Subscale scores are calculated according to the DASS-21 scoring procedure, with higher scores indicating greater anxiety symptom severity.
Change in DASS-21 Depression Subscale Score
Depressive symptoms will be assessed using the Depression subscale of the 21-item Depression Anxiety Stress Scale (DASS-21). The depression subscale consists of 7 items rated from 0 to 3. Subscale scores are calculated according to the DASS-21 scoring procedure, with higher scores indicating greater depressive symptom severity.
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Meserret Aslan
Lead sponsor
Atlas University
Sponsor institution
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