How Psychological Flexibility Mediates the Relationship Between Psychological Resilience and Mental Health: A Study of Diagnosed Cancer Patients

Reviewer Revisions

Author’s Revisions /Answers

First, the conceptual status of psychological resilience could be clarified. While resilience is treated as a predictor in the proposed model, the employed measure (CD-RISC-10) is often considered sensitive to contextual and situational factors. Clarifying whether resilience is conceptualized as a relatively stable trait or a more state-like resource would help justify the assumed causal ordering in the mediation model.

L 55-64: We thank the reviewer for this important conceptual clarification. In the revised manuscript, we explicitly describe psychological resilience as a relatively stable yet context-sensitive personal resource rather than a fixed trait. We clarify that the CD-RISC-10 reflects perceived adaptive capacity under current life conditions, which justifies its positioning as a predictor within the proposed mediation model. This clarification has been added to the Introduction section.

Second, given the cross-sectional and correlational design, the directionality of the proposed relationships cannot be conclusively established. Although the tested model is theoretically plausible, alternative directional models (e.g., mental health or psychological flexibility as antecedents of resilience, or resilience as a mediator) are also conceptually defensible. Testing and briefly reporting such alternative models, or explicitly acknowledging them in the Discussion, would strengthen the interpretive rigor of the study.

L 336-341: We agree that the cross-sectional design limits causal interpretation. Accordingly, we have explicitly acknowledged alternative directional models and reciprocal processes in the Discussion section. We emphasize that the proposed mediation reflects a theoretically informed interpretation rather than a definitive causal pathway and highlight the need for longitudinal research to clarify temporal ordering.

Third, while the authors appropriately refer to ACT and the Broaden-and-Build Theory, the manuscript would benefit from a more explicit explanation of why resilience is positioned as the distal resource and psychological flexibility as the proximal mechanism. Strengthening this theoretical link would enhance the coherence between the conceptual framework and the analytic model.

L257-267: We expanded the Discussion section to explicitly clarify why resilience is conceptualized as a distal resource and psychological flexibility as a proximal mechanism, integrating ACT and Broaden-and-Build Theory.

Fourth, the constructs examined in the study—resilience, psychological flexibility, and mental health—are dynamic and conceptually overlapping. A more explicit acknowledgment that the observed associations may reflect reciprocal or evolving processes, rather than strictly unidirectional effects, would be appropriate, particularly in light of the correlational design.

L352-358: Given the correlational design, the relationships among resilience, psychological flexibility, and mental health may reflect reciprocal rather than unidirectional processes.

Reviewer Revisions

Author’s Revisions /Answers

Introduction section:

While the authors are interested in resilience and psychological flexibility, it seems to me that the descriptions of these concepts do not allow for a clear distinction between the two (lines 67 to 69). Furthermore, shouldn't the “definition” of resilience appear in line 46 rather than line 67?

The authors should explain more clearly the specific dimensions of each of these concepts in the introduction and not wait until the discussion section. 

This clarification from the outset would also provide better support for the hypotheses and the mediating role of psychological flexibility.

Done

Line 65: There is an extra parenthesis!

Done

Materials and methods section:

Lines 89-90: What does “potentially eligible” mean? What where the inclusion criteria?

L102-106: We clarified the meaning of “potentially eligible” by explicitly defining the inclusion criteria in the Data Collection Procedure section. Eligible participants were adults diagnosed with cancer who were able to complete self-report measures and provide informed consent.

Lines 125-132: Of more importance, regarding psychological flexibility, the authors refer to the scale developed by Francis et al., but their description of this scale does not correspond to my understanding of it. Unless I am mistaken, this scale comprises 23 items (not 28) and 3 sub-dimensions (not 5). The three sub-dimensions are:

“Openness to experience,” which refers to acceptance and defusion

“Behavioral awareness,” which refers to present moment awareness and self as context

“Valuing action,” which refers to values and committed actions.

Could the authors review this point and/or clarify whether the description of the scale corresponds to the Turkish version and not the original version?

Depending on their response, the statistical analyses will need to be redone. 

We have changed

Line 117: the abbreviation for the psychological resilience scale should be given in the descriptive section and not just in the results section.

L132-134: We added the abbreviation of the psychological resilience scale (CD-RISC-10) at its first mention in the Measures section, as suggested.

Lines 134-135: the authors announce 3 controlled variables and cite 5.

L149: We corrected the inconsistency by revising the Control Variables section to accurately reflect that five control variables were included.

 Results section:

As mentioned above, the descriptive statistics section may need to be revised in light of the three sub-dimensions of the Psychological Flexibility original scale.

There is also a display issue with Table 2. The arrows and variables are not appearing in the correct place. 

Table 2 has been revised, and the Turkish version of the Psychological Flexibility scale was confirmed to consist of five sub-dimensions.

Discussion section:

To improve the demonstration, I believe that part of what is mentioned in the discussion should be placed in the introduction. Indeed, it seems to me that the first part of the discussion is not really a discussion. Many of the references cited in this first part should perhaps be mentioned in the introduction instead, in order to explain and support the mediation tested.

These elements could then be taken up again in the discussion to better explain how flexibility and its sub-elements mediate the relationship between resilience and mental health.

We thank the reviewer for this thoughtful suggestion. In the revised manuscript, we aimed to strengthen the conceptual framework of the mediation model by clarifying key theoretical distinctions and justifications in the Introduction. We therefore chose to retain the structure of the Discussion section, as its opening part was intentionally designed to integrate relevant theoretical perspectives with the interpretation of the empirical findings rather than to introduce new background information. We believe that this approach allows the Discussion to more directly link the study results to existing theory and to explain how psychological flexibility and its subcomponents function in mediating the relationship between resilience and mental health.

Regarding bibliographic references: the numbering in the text does not always correspond to the correct references. For example, it seems that on line 125, reference 30 actually corresponds to reference 38 in the list...

In addition, there are sometimes spelling errors: on line 60, Frederickson in the text and Fredrickson in the references. Please verify all your references.

We carefully checked and corrected all in-text citation numbers to ensure they correspond to the appropriate entries in the reference list, including the example identified by the reviewer.