Development and Validation of an Acceptance and Commitment Therapy Program Based on an Exploration of Psychological Pain in the Midlife Crisis

Abstract

This study aimed to explore the nature of psychological pain in the midlife crisis, develop an acceptance and commitment therapy program grounded in the resulting conceptual model, and evaluate its content validity, face validity, acceptability, and preliminary feasibility. A sequential developmental design was used. In the qualitative phase, 18 employed middle-aged adults living in urban areas of Tehran were selected through purposive and theoretical sampling and interviewed using in-depth semistructured interviews. Data were analyzed through constructivist grounded theory using open, axial, and selective coding and constant comparison. The resulting conceptual model was translated into therapeutic change objectives and a 10-session acceptance and commitment therapy protocol through directed content analysis and intervention mapping. Ten experts evaluated the program’s necessity, relevance, clarity, face validity, and feasibility, while 10 members of the target population assessed its comprehensibility, cultural appropriateness, acceptability, and practical usability. Analysis of 385 initial codes identified existential grief as the core category of psychological pain in the midlife crisis. This phenomenon emerged from accumulated failures, unresolved developmental wounds, suppressed emotions, multidimensional midlife pressures, ineffective emotional relationships, and perceived closure of future opportunities. Existential grief was expressed through regret, persistent sadness, helplessness, and deep loneliness and was maintained by avoidant or temporarily relieving coping responses. Nine of the 10 sessions obtained acceptable content validity ratios of 0.80 or 1.00, whereas Session 10 obtained 0.40 and was subsequently revised. Item-level content validity indices ranged from 0.80 to 1.00, the scale-level content validity index was 0.93, and adjusted kappa coefficients ranged from 0.79 to 1.00. Expert and client-oriented face-validity means were both 4.20 out of 5, and overall feasibility ratings were 3.90 out of 5. Psychological pain in the midlife crisis can be conceptualized as existential grief for an unlived life and unrealized self, and the developed acceptance and commitment therapy program demonstrated satisfactory preliminary validity, acceptability, cultural relevance, and feasibility.