Introduction
Adolescence is generally marked by the onset of physical puberty and during this developmental period, individuals experience physical changes while also being required to respond to social expectations such as becoming independent, changing and readjusting relationships with peers and adults, sexual adaptation and preparing for a career. They are also seeking to establish an independent identity while coping with all these changes (Gallant et al., Reference Gallant, Hebert, Thibault, Mekari, Sabiston and Bélanger2023). Due to the significant physical and psychological changes experienced during adolescence, individuals face challenges and stresses that, if not successfully navigated, may pre-dispose them to developing disorders such as aggression, depression, and anxiety, including social anxiety disorder (SAD) (Anderson et al., Reference Anderson, Valiauga, Tallo, Hong, Manoranjithan, Domingo, Paudel, Untaroiu, Barr and Goldhaber2025).
Among the common disorders that typically emerge during adolescence, SAD stands out (Haugan, Reference Haugan2023). The high prevalence, early onset, and negative impact of this disorder on an individual’s education, career, and personal life, as well as its high co-morbidity with major depressive disorder, various phobias, substance abuse, and generalized anxiety disorder, underscore the importance of its control and treatment (Leigh and Clark, Reference Leigh and Clark2018). SAD is characterized by a persistent and excessive fear of social or performance situations, stemming from the individual’s belief that they will behave in a humiliating or embarrassing manner in these situations. Individuals with SAD typically avoid these feared situations or endure them with significant distress (Pickering et al., Reference Pickering, Hadwin and Kovshoff2020). Adolescents with this disorder exhibit weak social interactions and reduced adaptation compared with their peers, are at greater risk of social avoidance and withdrawal, and face more challenges in meeting the expectations of adulthood, ultimately leading to impaired personal functioning (Leigh and Clark, Reference Leigh and Clark2018).
Internal shame and negative interpretation bias are critical maintaining factors of SAD, perpetuating a cycle of fear, avoidance, and distress (Leigh and Clark, Reference Leigh and Clark2018; Swee et al., Reference Swee, Hudson and Heimberg2021). Internal shame is a psychological construct linked to social anxiety (Schuster et al., Reference Schuster, Beutel, Hoyer, Leibing, Nolting, Salzer, Strauss, Wiltink, Steinert and Leichsenring2021). Shame, as a self-conscious emotion, has garnered significant attention in recent decades due to its prominent role in individual susceptibility to personality and psychological disorders (Swee et al., Reference Swee, Hudson and Heimberg2021). This painful emotion is characterized by self-abasement, self-diminishment, and ultimately, feelings of worthlessness. With its focus on negative self-evaluation, shame permeates both individual and relational dimensions, stemming from individuals’ social experiences (Wang et al., Reference Wang, Zhao, Mu, Rodriguez, Qian and Berger2020). Shame is typically conceptualized as having two components: internal and external. Internal shame generally involves a heightened focus on oneself, while external shame encompasses the thoughts and feelings experienced based on the perceived opinions and judgements of others (Khanjani et al., Reference Khanjani, Gharraee, Ramezani Farani and Foroughi2020). Internal shame reinforces social anxiety by intensifying negative self-perceptions, leading adolescents to anticipate rejection or judgement in social situations, thus perpetuating avoidance behaviours (Schuster et al., Reference Schuster, Beutel, Hoyer, Leibing, Nolting, Salzer, Strauss, Wiltink, Steinert and Leichsenring2021).
Shame ultimately leads to mental and physical distress and tension from inappropriate behaviours or even negative thoughts about engaging in inappropriate behaviours (Dolezal, Reference Dolezal2022). Theoretically, there is a clear connection between shame and anxiety and anxiety disorders due to shared elements such as feelings of self-loathing and inferiority, low self-esteem, negative self-evaluation, fear of losing social status, and avoidance behaviours that are common in both shame and anxiety disorders (Nikolić et al., Reference Nikolić, Hannigan, Krebs, Sterne, Gregory and Eley2022). From Bonavia & Brox-Ponce’s perspective (Reference Bonavia and Brox-Ponce2018), feelings of shame lead to misinterpretations and pave the way for various disorders. Interpretation bias is a significant cognitive factor in SAD, defined as the tendency to attribute threatening meanings to ambiguous stimuli (Miers et al., Reference Miers, Blöte, Bögels and Westenberg2008; Miers et al., Reference Miers, Sumter, Clark and Leigh2020). This bias maintains social anxiety by causing adolescents to misinterpret neutral or ambiguous social cues as threatening, reinforcing their fear of negative evaluation and prompting avoidance or heightened anxiety in social contexts (Miers et al., Reference Miers, Sumter, Clark and Leigh2020). Evidence of interpretation bias has been observed in studies by Everaert et al. (Reference Everaert, Podina and Koster2017) in individuals with depression and anxiety disorders.
Negative interpretation bias arises from the activation of anxiety-related schemas, which become active in the presence of competing processing choices. This ultimately facilitates the processing of potentially threatening information, leading to both threat-related and threat-unrelated appraisals (Puccetti et al., Reference Puccetti, Villano, Stamatis, Hall, Torrez, Neta, Timpano and Heller2023). In anxious individuals, negative and threat-related interpretation bias is particularly pronounced, consuming a significant portion of the individual’s processing resources (Mogg and Bradley, Reference Mogg and Bradley2016). Individuals with SAD exhibit distortions and biases in their processing of social information both before and after encountering social situations. This leads them to engage in negative predictions about their future actions (Mobach et al., Reference Mobach, Rapee and Klein2023).
Rumination, characterized by repetitive and intrusive negative thoughts, is increasingly recognized as a core factor underlying both anxiety and depression disorders (Joubert et al., Reference Joubert, Moulds, Werner-Seidler, Sharrock, Popovic and Newby2022). This understanding has led to the development of rumination-focused cognitive behavioral therapy (RFCBT) as a promising approach within the third wave of CBT interventions. Rumination, defined as repetitive and intrusive negative thoughts, is increasingly acknowledged as a central factor in the development and maintenance of both anxiety and depressive disorders (Joubert et al., Reference Joubert, Moulds, Werner-Seidler, Sharrock, Popovic and Newby2022). This understanding has spurred the creation of RFCBT, a promising intervention within the third wave of CBT approaches. RFCBT posits that rumination is a blend of habitual thought patterns and a form of avoidance behaviour (Hvenegaard et al., Reference Hvenegaard, Watkins, Poulsen, Rosenberg, Gondan, Grafton, Austin, Howard and Moeller2015). Consequently, treatment in RFCBT addresses two primary areas: (1) modifying avoidance behaviours, which involves identifying and addressing strategies individuals employ to escape negative thoughts, and (2) promoting adaptive behaviours, focusing on developing and implementing healthier coping mechanisms for managing negative thoughts and emotional difficulties.
A distinctive feature of RFCBT is its emphasis on transitioning information processing styles from unhelpful evaluative patterns to more constructive and problem-focused approaches (Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011). Specifically, rumination is a critical maintaining factor in SAD, as it intensifies negative self-focused thoughts and reinforces maladaptive interpretations of social interactions (Nolen-Hoeksema et al., Reference Nolen-Hoeksema, Wisco and Lyubomirsky2008; Sandford et al., Reference Sandford, Thwaites, Kirtley and O’Connor2022). Adolescents with SAD frequently ruminate on perceived social failures, which exacerbates feelings of shame and strengthens negative interpretational biases, thereby perpetuating the cycle of anxiety and avoidance (Joubert et al., Reference Joubert, Moulds, Werner-Seidler, Sharrock, Popovic and Newby2022). By directly targeting rumination, RFCBT aims to disrupt these repetitive thought patterns, thereby reducing their impact on social anxiety symptoms (Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011).
Research consistently shows the effectiveness of RFCBT in treating individuals with depression and anxiety (Feldhaus et al., Reference Feldhaus, Jacobs, Watkins, Peters, Bessette and Langenecker2020; Hvenegaard et al., Reference Hvenegaard, Moeller, Poulsen, Gondan, Grafton, Austin, Kistrup, Rosenberg, Howard and Watkins2020; Soleymani et al., Reference Soleymani, Masjedi Arani, Raeissadat and Davazdahemami2020; Umegaki et al., Reference Umegaki, Nakagawa, Watkins and Mullan2022). Furthermore, growing evidence suggests that RFCBT may be even more effective than mindfulness-based interventions in addressing mental health disorders, demonstrating greater reductions in rumination and anxiety symptoms (Mak et al., Reference Mak, Tong, Fu, Leung, Jung, Watkins and Lui2024).
SAD is a prevalent mental health condition characterized by an intense fear of social situations and scrutiny. This fear can significantly impair an individual’s social, academic, and professional functioning. Left untreated, SAD can have detrimental consequences for adolescents’ personal and social development, hindering their ability to form healthy relationships and pursue their aspirations. In the context of SAD, rumination can exacerbate social fears and perpetuate negative self-perceptions. Additionally, internalized shame, the internalization of negative judgements and criticisms, plays a crucial role in maintaining SAD. Individuals with SAD often experience intense feelings of shame related to their perceived social inadequacies, further fuelling their anxiety and avoidance behaviours. Moreover, individuals with SAD are more likely to perceive social situations as threatening and interpret others’ actions and intentions negatively. This biased interpretation reinforces their social fears and maintains the cycle of anxiety and avoidance. RFCBT targets the underlying processes of rumination, internalized shame, and interpretation bias, helping individuals break free from the cycle of negative thoughts and social anxiety. Given the limited research on RFCBT for SAD in adolescents, the present study aimed to investigate the efficacy of RFCBT in reducing internalized shame, interpretation bias, and rumination among adolescents with SAD in Ahvaz City, Iran. It was hypothesized that RFCBT would lead to significant reductions in internalized shame, interpretation bias, and rumination, thereby alleviating symptoms of SAD.
Method
This study employed a quasi-experimental design with a pre-test, post-test, and follow-up with a control group. The target population included all high school students (male and female) with SAD in Ahvaz City, Iran, in the year 2023. One girls’ high school and one boys’ high school were randomly selected from the city’s high schools. Students were asked to complete the SAD Questionnaire. Using purposive sampling, 48 students with social anxiety scores above the mean and who met the study’s inclusion criteria were selected as the sample. To ensure a homogenous sample and minimize extraneous variables, the study employed specific inclusion and exclusion criteria. Participants had to be high school students between 15 and 18 years old and diagnosed with SAD through a diagnostic interview and the SAD Questionnaire. Participants with a history of diagnosed depression or other psychological disorders, as determined by clinical interviews, were excluded to ensure the sample was specific to SAD. Additionally, participants with diagnosed physical disorders were excluded, and all participants provided informed consent. To maintain engagement and data integrity, participants unwilling to continue or missing more than two treatment sessions were excluded, ensuring sufficient exposure to the RFCBT intervention.
Instruments
Social Anxiety Disorder Questionnaire
The study utilized the Social Anxiety Disorder Questionnaire (SADQ) developed by La Greca and Stone (Reference La Greca and Stone1993) as a self-report measure to assess the severity of social anxiety symptoms in adolescents. This instrument was primarily used to identify and select participants with elevated social anxiety symptoms for inclusion in the study, ensuring that only those meeting the diagnostic criteria for SAD were included. This 18-item questionnaire yields three subscales. The first, Fear of negative evaluation, with 8 items, measures adolescents’ anxieties and worries about being judged negatively by their peers. Social avoidance and distress in new situations, a 6-item subscale, assesses how adolescents avoid and experience distress in unfamiliar social situations. Finally, the General social avoidance and distress subscale, with 4 items, measures overall social avoidance and discomfort. Each item is rated on a 5-point Likert scale, ranging from ‘not at all like me’ (1) to ‘exactly like me’ (5). Higher scores on the SADQ indicate a greater prevalence of social anxiety symptoms. In this study, the SADQ was translated and validated for the Iranian adolescent population, demonstrating acceptable internal consistency with a Cronbach’s alpha of 0.83. Although the SADQ was not administered at post-test or follow-up in this study, repeating this measure could have provided valuable insights into whether reductions in internalized shame and interpretation bias corresponded to overall improvements in social anxiety symptoms, potentially strengthening the link between these cognitive factors and SAD severity.
Internalized Shame Scale
The study employed the Internalized Shame Scale (ISS) developed by Cook (Reference Cook1988) to assess the participants’ level of internalized shame. This 30-item self-report measure consists of two subscales. The Shyness subscale (15 items) evaluates the tendency to feel shy, awkward, or uncomfortable in social situations. The Self-Esteem subscale (15 items) assesses an individual’s overall sense of self-worth and confidence. Each item is rated on a 5-point Likert scale. The total score on the ISS ranges from 30 to 150, with higher scores indicating greater levels of internalized shame. In this particular study, the ISS demonstrated good internal consistency with a Cronbach’s alpha of 0.85.
Revised Interpretation Inventory (RII)
The original version of the Interpretation Inventory was developed by Butler and Mathews (Reference Butler and Mathews1983) to assess interpretation bias in individuals with anxiety, depression, and a normal control group. Amin et al. (Reference Amin, Foa and Coles1998) revised the questionnaire in terms of content, form, and number of items to study interpretation bias in individuals with SAD. The questionnaire has two versions: a self-report version (events or scenarios that the person is assumed to be involved in) and an other-report version (events that another person is assumed to be involved in). Each version consists of 22 items, with 15 items related to social events or scenarios and the remaining seven items related to non-social events or scenarios. Each item also has three interpretation options with positive, negative, and neutral connotations. In this study, the Cronbach’s alpha reliability coefficient for the RII was 0.89.
The Rumination Response Scale (RRS)
The Rumination Scale, developed by Nolen-Hoeksema and colleagues (Reference Nolen-Hoeksema, Wisco and Lyubomirsky2008), measures maladaptive cognitive responses. It features 22 items divided into two 11-item subscales: ruminative responses and distracting responses. Each item is rated on a 4-point Likert scale, ranging from 1 (‘never’) to 4 (‘often’), yielding a total score between 22 and 88. While previous research has consistently shown high internal consistency for the scale (e.g. Cronbach’s α=0.90 in Mousavi et al., Reference Mousavi, Mousavi and Shahsavari2023), our study found a Cronbach’s α of 0.84, indicating satisfactory reliability within the current sample.
Intervention
Participants in the RFCBT group received 10 weekly 90-minute group-based sessions based on the RFCBT protocol (Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011). The group format facilitated peer support and collaborative learning, allowing participants to share experiences and practise skills in a supportive environment. To ensure the validity of the RFCBT intervention, sessions were delivered by two trained clinical psychologists with expertise in CBT, following a standardized manual (Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011). Treatment fidelity was assessed through weekly supervision sessions and random audits of session recordings, ensuring adherence to the RFCBT protocol. Participant engagement was monitored via attendance records and homework completion rates, with 90% of participants completing at least eight sessions. A summary of the RFCBT sessions is provided in Table 1. Two months after the post-test, a follow-up assessment was conducted with both the RFCBT and control groups to examine the sustainability of treatment outcomes. Of the 24 control group participants, 20 (83%) elected to receive RFCBT after the follow-up assessment. Post-intervention assessments for these participants showed reductions in internalized shame (M=52.10, SD=8.15), interpretation bias (M=188.45, SD=19.22), and rumination (M=36.80, SD=5.90), consistent with the experimental group’s outcomes, although these data were not included in the primary analysis to maintain study design integrity. In accordance with ethical research practices, members of the control group (waitlist) also received RFCBT after the completion of the study and the follow-up assessment.
Table 1. Content of rumination-focused cognitive behavioural therapy (RFCBT)
Data analysis
Data were analysed using mixed-design repeated measures ANOVA to examine the effects of RFCBT on internalized shame, interpretation bias, and rumination over time. To explore relationships between changes in rumination, internalized shame, and interpretation bias, Pearson correlation analyses were conducted on the change scores (pre-test to post-test) for these variables in the RFCBT group.
Results
In the present study, 48 adolescents with social anxiety were assigned to either an RFCBT group (11 girls and 13 boys) or a control group (14 girls and 10 boys). The mean age of participants in the RFCBT group was 17.24±1.80 years and 16.75±2.39 years in the control group. Table 2 shows the means, standard deviations, and Shapiro–Wilk statistics (significance level) for internalized shame, interpretation bias, and rumination in the RFCBT and control groups at the three stages of pre-test, post-test, and follow-up.
Table 2. Means, standard deviations (SD), and Shapiro–Wilk statistics for internalized shame and interpretation bias
Table 2 revealed that in the RFCBT group, the mean scores for internalized shame, interpretation bias, and rumination decreased significantly at the post-test and follow-up stages. In contrast, no substantial changes were observed in the control group at these stages. The Shapiro–Wilk values for all three variables in both groups and at all three stages (pre-test, post-test, and follow-up) were non-significant, indicating that the study variables were normally distributed. Levene’s test was used to assess the assumption of homogeneity of error variances for the study variables. The results showed that the difference in error variance for each of the three dependent variables was not significant between the two groups at the three stages, confirming that the assumption of homogeneity of error variances was met.
Table 3 presents the results of the repeated measures ANOVA for the effect of RFCBT on internalized shame, interpretation bias, and rumination. The results revealed significant main effects of time for all three variables (p<0.01), indicating reductions in internalized shame, interpretation bias, and rumination across RFCBT group from pre-test to post-test and follow-up, likely reflecting general improvements over time, possibly due to factors such as familiarity with the testing environment or natural symptom fluctuations. Significant group × time interactions were also observed for internalized shame, interpretation bias, and rumination (p<0.01), suggesting that the reductions in these variables were significantly greater in the RFCBT group compared with the control group. The moderate to large effect sizes (η2=0.24–0.68) indicate a substantial impact of RFCBT on these cognitive factors, although the small sample size (n=48) suggests the study may be under-powered, potentially limiting the detection of smaller effects.
Table 3. Results of repeated measures ANOVA for the effect of RFCBT on internalized shame and interpretation bias
Table 4 presents the results of the Bonferroni post-hoc tests for the differences in internalized shame, interpretation bias, and rumination scores between the three stages of pre-test, post-test, and follow-up. The results revealed that the mean differences in internalized shame, interpretation bias, and rumination scores between the pre-test and post-test stages, and between the pre-test and follow-up stages, were significant (p<0.01). However, the mean differences between the post-test and follow-up stages for all three variables were not significant, indicating that the reductions achieved post-treatment were maintained at follow-up (Fig. 1).
Table 4. Results of Bonferroni post-hoc tests for internalized shame and interpretation bias scores at the three stages
Figure 1. Changes in internalized shame (a), interpretation bias (b), and rumination (c) scores in RFCBT and control groups.
Pearson correlation analyses of change scores (pre-test to post-test) in the RFCBT group revealed significant positive correlations between reductions in rumination and internalized shame (r=0.62, p<0.01) and between rumination and interpretation bias (r=0.58, p<0.01). The correlation between reductions in internalized shame and interpretation bias was also significant (r=0.55, p<0.01), suggesting that improvements in one cognitive factor were associated with improvements in the others.
Discussion
This study aimed to investigate the effectiveness of RFCBT on internalized shame, interpretation bias, and rumination in adolescents with SAD. The findings demonstrated that RFCBT significantly reduced all three variables in adolescents with SAD, with these effects maintained at follow-up. These results are consistent with previous research highlighting the efficacy of RFCBT in addressing internalized shame, interpretation bias, and rumination in various mental health conditions (Feldhaus et al., Reference Feldhaus, Jacobs, Watkins, Peters, Bessette and Langenecker2020; Hvenegaard et al., Reference Hvenegaard, Moeller, Poulsen, Gondan, Grafton, Austin, Kistrup, Rosenberg, Howard and Watkins2020; Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011). A pilot study by Feldhaus et al. (Reference Feldhaus, Jacobs, Watkins, Peters, Bessette and Langenecker2020) suggests that RFCBT is a promising intervention for adolescents with co-morbid depressive and anxiety symptoms, while Hvenegaard et al. (Reference Hvenegaard, Moeller, Poulsen, Gondan, Grafton, Austin, Kistrup, Rosenberg, Howard and Watkins2020) demonstrated the superiority of group RFCBT over group CBT in treating major depressive disorder, supporting its potential as a valuable therapeutic approach.
RFCBT effectively reduces internalized shame, interpretation bias, and rumination in adolescents with SAD by targeting their underlying cognitive and behavioural mechanisms, which are central to the maintenance of social anxiety (Leigh and Clark, Reference Leigh and Clark2018; Nolen-Hoeksema et al., Reference Nolen-Hoeksema, Wisco and Lyubomirsky2008). Specifically, RFCBT’s functional analysis (sessions 3–4) identifies triggers and consequences of rumination, enabling adolescents to recognize how shame and negative interpretations arise in social contexts (e.g. fear of public speaking). This process directly addresses the function of rumination as a maladaptive coping strategy. Self-compassion training (sessions 8–9) reduces internalized shame by fostering self-acceptance and challenging negative self-judgements, which are often amplified in SAD (Schuster et al., Reference Schuster, Beutel, Hoyer, Leibing, Nolting, Salzer, Strauss, Wiltink, Steinert and Leichsenring2021). Cognitive restructuring and ‘if-then’ planning (sessions 4–5) target negative interpretation bias by helping adolescents replace threat-focused interpretations with more balanced perspectives, reducing the time spent ruminating on perceived social failures. Behavioural interventions, such as exposure and skills training (sessions 7–8), decrease avoidance behaviours emanating from rumination, encouraging engagement in social situations (Watkins et al., Reference Watkins, Mullan, Wingrove, Rimes, Steiner, Bathurst, Eastman and Scott2011). The significant correlations between reductions in rumination, shame, and interpretation bias suggest that these components are interlinked, with RFCBT’s multi-pronged approach disrupting their synergistic effects on social anxiety.
As a practical implication, clinicians can apply RFCBT’s multi-pronged approach to target internalized shame, interpretation bias, and rumination in adolescents with SAD. For example, functional analysis can identify specific social triggers (e.g. speaking in class) that elicit shame, negative interpretations, or ruminative thoughts, enabling tailored interventions (Warnock-Parkes et al., Reference Warnock-Parkes, Wild, Thew, Kerr, Grey and Clark2022). Self-compassion exercises can reduce self-criticism and ruminative self-blame, while exposure-based strategies can desensitize adolescents to feared social situations, ultimately reducing avoidance and improving social functioning. The group format of RFCBT fosters peer support, which may enhance treatment engagement and outcomes, particularly for adolescents who often ruminate on perceived social failures (Hvenegaard et al., Reference Hvenegaard, Moeller, Poulsen, Gondan, Grafton, Austin, Kistrup, Rosenberg, Howard and Watkins2020; Joubert et al., Reference Joubert, Moulds, Werner-Seidler, Sharrock, Popovic and Newby2022).
RFCBT is a structured approach that utilizes functional analysis to guide individuals in practising behavioural, imaginal, and experiential exercises. These exercises aim to transform ruminative patterns from maladaptive and unproductive to helpful and constructive ones (Carey and Wells, Reference Carey and Wells2019; Mak et al., Reference Mak, Tong, Fu, Leung, Jung, Watkins and Lui2024). Functional analysis is a process that identifies the functions and contexts in which adaptive and maladaptive behaviours occur. By understanding these functions, therapists can develop strategies to increase or decrease target behaviours (Lincoln et al., Reference Lincoln, Riehle, Pillny, Helbig-Lang, Fladung, Hartmann-Riemer and Kaiser2017). In RFCBT, functional analysis is employed to uncover the content of rumination and avoidance patterns. The identified patterns are then addressed through therapeutic interventions. These interventions are subsequently tested and refined through practice and experimentation. If found effective, the interventions are integrated into the client’s daily life through structured planning (Umegaki et al., Reference Umegaki, Nakagawa, Watkins and Mullan2022).
As a practical implication, clinicians can apply RFCBT’s multi-pronged approach to target internalized shame and interpretation bias in adolescents with SAD. For instance, functional analysis can help identify specific social triggers (e.g. speaking in class) that elicit shame or negative interpretations, enabling tailored interventions. Self-compassion exercises can reduce self-criticism, while exposure-based strategies can desensitize adolescents to feared social situations, ultimately reducing avoidance and improving social functioning. These strategies, delivered in a group format, also foster peer support, which may enhance treatment engagement and outcomes (Hvenegaard et al., Reference Hvenegaard, Moeller, Poulsen, Gondan, Grafton, Austin, Kistrup, Rosenberg, Howard and Watkins2020).
Overall RFCBT tackles rumination through a multi-pronged approach. Clients develop ‘if-then’ plans to identify triggers and practise healthier responses, replacing unproductive rumination. Thought experiments challenge the validity of negative thoughts, promoting a more balanced and objective perspective. RFCBT also equips clients with alternative coping strategies like mindfulness and problem-solving skills to manage distress without resorting to rumination. Furthermore, self-compassion training fosters self-acceptance and reduces self-criticism, lessening the urge for ruminative self-blame. Gradually, exposure and behavioural activation techniques are introduced to decrease avoidance behaviours and encourage engagement in daily activities. Finally, imagery and visualization exercises enhance the effectiveness of these strategies by allowing clients to rehearse alternative coping mechanisms and cultivate a more positive outlook.
Limitations of this study include its small sample size, which may limit statistical power and the generalizability of findings. The lack of an active control group (e.g. standard CBT) prevents comparisons with other interventions, and the absence of post-test and follow-up SADQ assessments limits conclusions about overall reductions in social anxiety symptoms. Additionally, the study did not control for variables such as family dynamics or socioeconomic status, which may influence outcomes. Finally, the study’s cultural context in Ahvaz, Iran, may limit generalizability, as collectivist values may amplify shame and social anxiety. Future research should include larger samples, active control groups, and longitudinal assessments of social anxiety symptoms to confirm RFCBT’s efficacy and explore its impact on broader social functioning.
Conclusion
This study investigated the effectiveness of RFCBT in addressing internalized shame, interpretation bias, and rumination in adolescents with SAD. The findings demonstrated that RFCBT led to significant reductions in all three variables compared with the control group, with these effects maintained at follow-up. These results contribute to the growing body of evidence supporting the use of RFCBT for anxiety disorders, particularly by targeting core cognitive processes such as negative self-beliefs, biased interpretations, and repetitive negative thinking. RFCBT appears to be a promising approach for reducing social anxiety in adolescents, offering a sustainable intervention that addresses key maintaining factors of SAD. Further research is warranted to explore the long-term effects of RFCBT and its potential to improve overall social functioning and quality of life in this population.
Key practice points
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(1) Use functional analysis to identify specific triggers and consequences of rumination in adolescents with SAD, tailoring interventions to address individual social fears (e.g. public speaking or peer interactions).
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(2) Integrate self-compassion exercises into therapy to reduce internalized shame and self-criticism, encouraging adolescents to develop a kinder self-view to mitigate social anxiety.
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(3) Apply cognitive restructuring techniques and develop ‘if-then’ plans to shift adolescents from negative interpretation biases to balanced perspectives, reducing ruminative thoughts about perceived social failures.
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(4) Deliver RFCBT in a group format to foster peer support, which can enhance engagement and provide a safe space for adolescents to practise social skills and challenge avoidance behaviours.
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(5) Equip adolescents with relapse prevention strategies, such as identifying warning signs and practising mindfulness, to maintain reductions in rumination and social anxiety symptoms post-treatment.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
None.
Author contributions
Fardokht Farahnak: Data curation (equal), Funding acquisition (equal), Investigation (equal), Resources (equal), Writing - original draft (equal); Sahar Safarzadeh: Conceptualization (equal), Formal analysis (equal), Methodology (equal), Software (equal), Supervision (equal), Writing - original draft (equal), Writing - review & editing (equal).
Financial support
This article did not receive any government or university funding for the project.
Competing interests
All the authors declare that they have no conflict of interest.
Ethical standards
This study was conducted in accordance with the ethical principles stipulated in the Declaration of Helsinki. Ethical approval for the research protocol was secured from the Ethical Committee of Islamic Azad University, Ahvaz Branch (reference code: IR.IAU.AHVAZ.REC.1403.060). Informed consent was obtained from all participants and their legal guardians, thereby ensuring their voluntary participation and safeguarding their privacy and rights.
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