Virtual Reality and Mindful Strategies: Enhancing Metaemotional Awareness and Social Efficacy in Socially Anxious Youth

Social anxiety disorder (SAD) is consistently ranked among the most prevalent mental health conditions in the general population, with its onset frequently occurring during early to middle adolescence (1). Lifetime prevalence rates are estimated at approximately 8 - 9% among adolescents globally, underscoring the disorder's widespread impact during this critical developmental stage. Adolescence amplifies SAD risks due to heightened sensitivity to social evaluation amid rapid hormonal shifts, intensified peer dynamics, and the consolidation of self-identity, which can transform transient fears into entrenched patterns of avoidance and distress (2). The disorder is defined by an intense, persistent fear of social or performance situations in which the individual is exposed to potential scrutiny by others (3). Untreated, SAD in adolescents can lead to profound long-term functional impairment, including chronic peer rejection, academic underachievement, social isolation, and an elevated risk for developing secondary disorders such as Major Depressive Disorder and substance use problems (4). Therefore, targeted and highly effective psychological interventions are imperative for mitigating the pervasive social and developmental costs associated with SAD in this vulnerable group.

A pivotal cognitive model explaining the maintenance of SAD is the Metacognitive Model, which shifts focus from the content of anxious thoughts to beliefs about the thoughts and emotional processes themselves (5). These metacognitive beliefs about emotions — commonly referred to as metaemotions and defined here as individuals' attitudes, evaluations, and beliefs regarding their own emotional experiences (6), which are the focus of this study, include two critical and interconnected dimensions: Positive meta-emotions (beliefs reflecting compassion toward and interest in one's emotions, fostering adaptive engagement) and negative metaemotions (beliefs involving anger, shame, suppression, or perceived uncontrollability of emotions, promoting avoidance and distress). In adolescents with SAD, these maladaptive metacognitive beliefs about emotions drive the pervasive cycle of excessive self-focused attention, worry, and post-event rumination, preventing the individual from fully engaging in social situations and obtaining necessary reality-testing information (7). Effectively challenging and restructuring these specific emotional and cognitive processes is a fundamental goal in successful anxiety treatment (8).

In addition to the cognitive domain, social self-efficacy plays a direct and critical role in the expression and maintenance of SAD. Derived from Bandura's Social Cognitive Theory, social self-efficacy refers to an individual's belief in their capability to successfully execute the behaviors required to produce desired social outcomes (9). Adolescents suffering from SAD typically exhibit significantly lower social self-efficacy, perceiving themselves as incapable of handling challenging social interactions, expressing opinions, or managing negative feedback effectively (10). This deficiency acts as a central mediating factor, leading directly to the hallmark feature of the disorder: Avoidance behavior (11). By pre-empting social engagement, avoidance prevents the accrual of successful social experiences that could naturally bolster self-efficacy. Consequently, therapeutic approaches that directly enhance social self-efficacy are vital for promoting sustainable behavioral change and confidence (12).

Previous research has established the efficacy of interventions targeting these mechanisms in adolescent SAD. For instance, mindfulness-based approaches, including mindfulness-based cognitive therapy (MBCT), have shown promise in reducing anxiety symptoms and maladaptive metacognitions through enhanced emotional regulation (13-15). Similarly, exposure-based therapies, particularly those augmented by virtual reality (VR), have demonstrated robust reductions in avoidance and improvements in social functioning via simulated real-world practice (16-19). A limited number of comparative studies exist, primarily in adult populations; for example, investigations comparing VR exposure to mindfulness-acceptance therapies have reported VR's advantages in symptom reduction and engagement for social anxiety, though often without adolescent-specific adaptations or focus on intermediate outcomes like self-efficacy (20).

One highly regarded therapeutic approach is MBCT, an established, evidence-based intervention that integrates techniques from Cognitive Behavioral Therapy with mindfulness meditation practices (21). The core therapeutic mechanism of MBCT is the development of decentering, which enables individuals to observe their thoughts, feelings, and metacognitive processes as transient mental events rather than identifying with them as literal reality (22). For adolescents with SAD, MBCT offers a powerful tool to interrupt the automatic loop of anxious worrying and rumination, thereby reducing the influence of rigid negative metacognitive beliefs about emotions (13). A growing body of research supports the efficacy of MBCT in reducing overall anxiety symptoms and improving emotional regulation, with several studies specifically highlighting its positive effects on reducing maladaptive metacognitive beliefs in both adult and adolescent anxiety populations (14, 15).

In contrast, virtual reality-based worry exposure therapy (VR-WET) represents a cutting-edge technological advancement of the gold-standard exposure treatment (23). Virtual reality environments allow for the creation of controlled, highly realistic, and customizable simulations of feared social or worry-eliciting situations that might be impractical or unethical to replicate in real-life settings (24). The therapeutic mechanism of VR-WET relies on habituation and extinction learning, enabling participants to repeatedly confront feared social stimuli in a safe and supportive context until the associated anxiety response diminishes (16). This method is particularly effective for SAD, as the high sense of control and systematic nature of VR exposure enhances treatment engagement and directly challenges the avoidance behaviors that maintain the disorder (17). Recent clinical trials have demonstrated that VR-based exposure is highly effective in reducing SAD symptoms and simultaneously improving self-reported social self-efficacy through successful behavioral performance within the virtual environment (18, 19).

Despite these advances, a critical research gap persists: No studies have directly compared MBCT and VR-WET in adolescents with SAD, particularly regarding their relative impacts on theory-driven mechanisms such as metacognitive beliefs about emotions and social self-efficacy. Prior comparisons have largely overlooked adolescent developmental contexts, focused on broad symptom outcomes rather than these specific mediators, or examined mindfulness variants without VR-WET's worry-focused exposure hierarchy. This omission limits evidence-based personalization of treatments, as adolescents may respond differentially to cognitive decentering versus behavioral mastery via immersive simulations. Addressing this gap is urgent to optimize interventions that disrupt SAD's maintenance cycles early, preventing lifelong sequelae.

Therefore, the present study was conducted to critically compare the effectiveness of MBCT and VR-WET on the positive and negative metacognition subscales and social self-efficacy in adolescents diagnosed with SAD.

The research involved 45 adolescents aged 15 - 18 years with a confirmed SAD diagnosis. The participants' average age was 16.62 ± 1.73 years. Table 3 presents the descriptive statistics (means and standard deviations) for positive metaemotion, negative metaemotion, and social self-efficacy across the three study phases. The intervention groups exhibited changes in mean scores from pre-test to post-test and follow-up, while the control group showed small variations, including a minor increase in social self-efficacy (Δ = 0.07) that was non-significant (P > 0.05).

Prior to ANOVA, data normality was assessed using the Kolmogorov–Smirnov test for each variable across groups and time points (all P > 0.05). Homogeneity of variances was confirmed via Levene’s test (all P > 0.05). Mauchly’s test of sphericity was significant for negative metaemotion (χ² = 12.45, P = 0.002, ε = 0.855) and social self-efficacy (χ² = 18.32, P < 0.001, ε = 0.560); thus, Greenhouse-Geisser corrected degrees of freedom were applied for these variables. Sphericity was assumed for positive metaemotion (χ² = 3.21, P = 0.201). Table 4 summarizes the repeated measures ANOVA results, indicating significant main effects of time and group, as well as time × group interactions for all variables (all P < 0.001). The partial eta squared (ηp²) values ranged from 0.45 to 0.78, reflecting large effect sizes.

Table 5 presents Bonferroni post-hoc comparisons, revealing no significant pre-test differences between groups (all P > 0.05). At post-test and follow-up, VR-WET significantly outperformed MBCT in positive metaemotion, negative metaemotion, and social self-efficacy (all P < 0.05). Both interventions significantly outperformed the control group (all P < 0.001), with VR-WET showing larger mean differences.

The present study compared the efficacy of MBCT and VR-WET in adolescents aged 15 - 18 years with SAD, focusing on metacognitive beliefs about emotions (positive and negative subscales) and social self-efficacy. Consistent with prior evidence on third-wave cognitive-behavioral and technology-enhanced exposure interventions, both treatments yielded sustained improvements relative to a waiting-list control, underscoring their utility in disrupting SAD maintenance cycles (15, 24).

A closer examination of between-group differences highlighted VR-WET's advantages over MBCT across outcomes, a pattern that aligns with theoretical models emphasizing behavioral mastery as a primary driver of self-efficacy gains. Specifically, VR-WET's immersive simulations facilitate enactive mastery experiences — repeated, graduated successes in feared scenarios — that directly challenge avoidance and recalibrate efficacy beliefs more potently than MBCT's metacognitive decentering, which primarily fosters observational distance from thoughts (12, 17). This integration of Bandura's social cognitive framework with extinction principles explains VR-WET's edge: Virtual successes not only extinguish conditioned anxiety but also accumulate "efficacy-building" evidence, accelerating shifts in metacognitive beliefs about emotional controllability and adaptive engagement (9, 16). In contrast, MBCT's effectiveness in mitigating negative metacognitive beliefs about emotions — such as perceived uncontrollability — stems from decentering, which promotes non-reactive awareness of worry as transient rather than veridical. These gains mirror findings from Aydın et al., where mindfulness interventions reduced metacognitive rigidity in anxiety disorders via similar awareness mechanisms, though with more modest effects on behavioral confidence (29).

The observed superiority of VR-WET echoes and extends comparative trials in adolescent SAD. For example, Razzaghi et al. reported VR exposure outperforming MBCT in enhancing social engagement and fear of negative evaluation, attributing this to VR's immersive extinction context (20). Methodological parallels include equivalent session durations (8 weekly sessions), adolescent samples (n ≈ 40 - 50), and focus on exposure hierarchies, alongside shared use of self-report outcomes like the Liebowitz Social Anxiety Scale. However, differences temper direct equivalence: Razzaghi et al. emphasized broad symptoms without dissecting metacognitive subscales or self-efficacy mediators, and employed non-random allocation, potentially inflating VR effects; our randomized, blinded design with follow-up assessments provides stronger causal evidence for sustained mechanism-specific changes (20). Broader literature reinforces this, as meta-analyses indicate VR exposure yields larger effect sizes than mindfulness for SAD behavioral outcomes, particularly in youth where engagement barriers are high (17).

Clinically, these results position VR-WET as a frontline option for adolescent SAD when prioritizing rapid self-efficacy enhancement and metacognitive restructuring, especially in settings like Ahvaz where scalable, low-burden interventions are needed. virtual reality's cost-effectiveness — initial hardware investments offset by reduced therapist time and dropout rates — makes it viable for resource-limited regions, though accessibility barriers such as device availability and cultural adaptation for low-SES youth warrant targeted subsidies or mobile VR adaptations (18, 23). Nonetheless, MBCT remains a valuable alternative for clients preferring non-technological approaches or with access constraints.