Effects of Cognitive Behavioral Group Therapy on Reduction of Anxious Thoughts among Selected High School Students in Iran: A Case Study

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Introduction
In the realm of anxiety disorders, the idea of worry is not new; nonetheless, since the 1980s, it has seen significant development.During this time, excessive or pathological worry was also recognized as a fundamental component of Generalized Anxiety Disorder (GAD) in the DSM III-R (APA, 1987).Subsequent DSM editions acknowledged the expanding significance of this component in GAD.The significant incidence of GAD in the community, its link with healthcare service usage frequency and its notable cost to society bestow these psychological illnesses enormous relevance (Chisholm et al., 2016;Morejón, Vázquez-Morejón, and Muñoz-Fernández , 2020).Additionally, research has demonstrated that worry is a frequent component of many diseases, particularly anxiety and depressive disorders (Startup et al., 2016).Bailey and Wells (2016) have argued that concern may play a causal role in the phenomenology of anxiety, both in terms of activation and maintenance.
One way to characterize worry is as a pattern of persistent intrusive, unpleasant thoughts about what might happen in the future.This is distinct from the physical activation component of anxiety as worry is cognitive in nature.The uncontrollable character of pathological concern is a crucial feature.This view of uncontrollability is thoroughly associated with metacognition, which implies the cognitive factors working in assessment and control of thought has been proven to be a fundamental construct in the presence and maintenance of several psychological disorders (Gkika, Wittkowski, & Wells, 2018).Wells (1997) created a metacognitive model that separates worry into two subtypes: Type 1, which is worry about external events and physical symptoms, and Type 2, which is worry related to negative thoughts.Some of these beliefs-particularly those that link thoughts to being dangerous and uncontrollable-are thought to be transdiagnostic factors that cause distress and give rise to a particular pattern of inner experience response known as cognitive-attentional syndrome (Fisher & Wells, 2009).Some research has indicated that metacognitive beliefs may be a predictor of psychological treatment outcomes, despite the paucity of studies on the prevalence of each of these beliefs in the outcomes of psychological therapies (Hagen et al., 2017).According to this paradigm, therefore, therapies ought to concentrate on altering metacognitive elements, such as unfavorable attitudes on worry per se (Morejón, Vázquez-Morejón, and Muñoz-Fernández, 2020).
Cognitive-behavioral therapy (CBT) has been suggested as an effective sort of therapy to consider as a treatment to lessen worry and anxious thoughts.CBT is a type of psychotherapy that draws from both basic behavioral and cognitive research.Positive outcomes have resulted from this treatment since it has enhanced coping mechanisms and decreased catastrophic pain thinking.CBT is thought to be a successful treatment for a variety of mental health issues (Abdolahi, et al., 2019).Moreover, CBT is one of the non-medical therapies used to treat various psychiatric illnesses, according to Alamdarloo et al. (2019), and it benefits from methods like cognitive restructuring and relaxation.Gupta and Kumarı (2023) claim that cognitive restructuring in CBT is an effective therapy that lowers relapse rates and enhances functioning.In specifics, CBT targets the ideas themselves, not the maladaptive metacognitive beliefs that surround them.Therefore, it will be crucial to examine how CBT affects dysfunctional metacognitive beliefs and to determine whether or not mindfulness-based interventions like guided imagery are effective.Concurrently, CBT has been proposed as a successful treatment for anxiety and depression, particularly among teenagers.CBT can be quick, guided self-help, individual, group, or web-based.Group CBT delivery is the most popular of them because it has been shown to be more successful than the individual formats.The benefits of CBT group therapy include improving service delivery efficiency and fostering connections among participants to promote insight and symptom reduction (Ugwuanyi, 2020).
In light of all of this, as a follow-up to a larger study previously conducted by Mostafavi (2024) and in the absence of inconsistent findings regarding the effect of CBT on reducing anxious thoughts and worries, this study was carried out to investigate the efficacy of CBT on reducing anxious thoughts among a sample of students in Mashhad, Iran, whose rates on the anxious thoughts inventory were high.Having this in mind, this paper is organized as follows: The next section introduces the research objectives and hypothesis.Section three sheds light on the literature review, while section four introduces CBT and Cognitive Restructuring Technique.Section five elaborates on methodology, to present the way the study is conducted.Section six presents results and findings and the paper culminates with discussion and conclusion.

Research Objectives and Hypothesis
Based on the research gap, the following objectives and the sole null hypothesis of the study were formulated: Objective 1: To determine the level of anxious thoughts among selected Iranian high school students.
Objective 2: To explore whether CBT curtails anxious thoughts among Iranian high school students Null Hypothesis 1: There is no significant difference in the pretest and posttest scores of anxious thoughts of elected Iranian high school students using the cognitive behavioral group therapy.

Literature Review
The impact of CBT on metacognitive beliefs, symptom severity, quality of life, and functionality was evaluated by Gupta and Kumarı (2023).Results showed that even after confounding variables were statistically controlled using propensity score matching and analysis of covariance, the CBT-alone group did not substantially differ from the CBT-with-medication group in terms of improvement.
A comprehensive review and meta-analysis on the impact of CBT-I on repetitive negative thinking (RNT) is carried out by Ballesio et al. in 2021.After searching seven databases, 15 randomized controlled studies were found.The findings indicated that CBT-I had moderate-to-large impacts on worry but minimal and erratic effects on rumination.There is no correlation between the reduction in RNT following treatment and the reduction in anxiety and depression following treatment.
The impact of CBT on self-care skills on anxiety and depressive symptoms in females with chronic schizophrenia was investigated by Kashani Lotfabadi et al. in 2021.Regarding changes in mean anxiety before and after the intervention, there was a significant difference between the intervention and control groups.It was determined that CBT was helpful in lowering anxiety symptoms; however, longer sessions might lengthen the impact of the treatment.
The effects of various anxiety treatment modalities on recurrent negative thought patterns were investigated by Monteregge et al. (2020).Treatments for anxiety that directly target repeated negative thinking (RNT, which includes worry, rumination, and content-independent perseverative thinking) may or may not have a greater impact on RNT than other psychological and nonpsychological interventions.Psychological treatments that focused on RNT and those that did not were found to have similar effects on RNT.Additionally, there was a strong correlation between the amount of anxiety and changes in both RNT and anxiety across all treatment types.
The effectiveness of CBT combined with music in lowering test anxiety in secondary school pupils was investigated by Ugwuanyi et al. (2020).Test anxiety scores were considerably lower in the participants who received CBT psychotherapy.Moreover, at the follow-up assessment, the CBT group's participants' test anxiety levels were considerably lower than the control group.Thus, the findings demonstrated that CBT significantly reduced secondary school students' exam anxiety related to physics.Alamdarloo, et al. (2019) looked into how CBT affected Iranian men's levels of stress, anxiety, and sadness.The results demonstrated that CBT was successful in lowering individuals' stress, anxiety, and depressive symptoms.
In 2019, Ramak, Jangi, and Sangani looked into how CBT methods helped students who were experiencing social anxiety.The findings demonstrated a decrease in the mean scores for social phobia in both the posttest and the follow-up, indicating that cognitive behavioral therapy (CBT) significantly lessens social anxiety in students.Spinhoven et al. (2018) carried out a thorough search of databases for randomized trials comparing CBT therapies for depression with control groups or with alternative treatments in adolescents, adults, and older individuals, and publishing results on RNT.They discovered that compared to other forms of therapies, RNT-focused CBT can have a more noticeable impact on RNT.Dousti, Mohagheghi, and Jafari (2015) looked into how Acceptance and Commitment Therapy affected students' ability to have fewer anxious thoughts.The sample was chosen at random into control and experimental groups from among the applicants who scored the highest on Wells' test of anxious thoughts.The Acceptance and Commitment Therapy methodology involved eight treatment sessions as well as a control session that lasted one month.According to the findings, acceptance and commitment therapy helps people have fewer anxious thoughts.
The ability of anxiety control and negative automatic thoughts to predict the transformation that CBT for young people with anxiety disorders produces was assessed by Muris et al. (2009).The outcomes showed that CBT was useful in lowering the symptoms of anxiety in kids.Most crucially, a decrease in automatic negative thoughts and an improvement in anxiety control were substantially correlated with a reduction in the symptoms of anxiety disorders.This suggests that these variables could be potential mediators of cognitive behavioral therapy (CBT) in young anxious people.

CBT and Cognitive Restructuring Technique
Depending on the severity of the ailment, medication or psychotherapy are typically used as therapies for anxiety disorders.A safer and non-invasive technique like neurofeedback training should be taken into consideration to help reduce anxiety disorder, even though pharmacological intervention is frequently utilized in addition to psychotherapy to treat anxiety disorders (Mutang, et al. 2021).Because of its high level of empirical support, CBT is the most widely used psychotherapy treatment for anxiety disorders.CBT was found to be effective for the majority of anxiety disorders in numerous controlled trials.Because of this, cognitive behavioral therapy (CBT) is frequently used as the main form of psychotherapy for anxiety disorders (Mutang, et al., 2021).CBT is a psychological technique that is used to treat different types of anxiety issues in people.Through this psychological intervention, a person can finally understand how their thoughts, behaviors, and emotions are all connected.It also highlights how discomfort and a sense of threat are caused by one's own underestimating of one's own abilities.CBT is an effective treatment for anxiety, which is a frequent illness (Ganaprakasam & Selvaraja, 2020;Watts, et al., 2015).
Cognitive restructuring is the term used to describe CBT treatments intended to overcome incorrect or negative thinking.Such strategies are founded on the assumption that changing the way clients think would change their emotions and behavior (Beck, 1988).Typical cognitive restructuring strategies involve questioning a thought's veracity by weighing the evidence supporting and refuting it, recognizing the thinking errors the thought illustrates, and formulating counterarguments that more accurately represent their experience (Larsson et al., 2016).The term "cognitive restructuring" refers to CBT interventions meant to dispel false or unfavorable thought patterns.These tactics are predicated on the idea that altering a client's thought process will alter their feelings and actions (Beck, 1988).Common cognitive restructuring techniques include challenging the validity of a belief by assessing the evidence for and against it, identifying the fallacies in the thought, and developing counterarguments that better capture their experience (Larsson et al., 2016).

The Research Design
In this research, a one-group pretest-posttest design was adopted (quantitative design).This design is widely used by behavioral researchers as a quasi-experimental research design with the aim of recognizing the effect of a treatment or intervention on a certain sample (Chen, Zhang, Jin, Quan, et al., 2021;Ganaprakasam & Selvaraja, 2020).In this research therefore a quasi-experimental research design was adopted to measure the effectiveness of anxious thoughts-reduction policies to reduce anxiety among Iranian high school students.

The Sampling Method
In this study, purposive sampling was recruited which is referred to as purposeful sampling too (Mweshi & Sakyi, 2020).Prior to conducting the study, a list of students who showed high scores of anxious thoughts in a larger study conducted prior to this study (mostafavi, 2024) was attained.Then an invitation link in addition to explanations for the study was sent to the students via email.Those willing to participate in this study were selected and the sessions for the taking the study tools and protocols were settled and arranged.The number of the participants who agreed to take part in this research reached a number of 20 male and female high school students who had enrolled for the academic year 2023-2024.

The Anxious Thoughts Inventory (AnTI)
In this study, the Persian Version of the anxious thoughts inventory (AnTI) was used which was designed originally by Wells (1994) as a multi-dimensional measure of worry.It aimed at capturing the distinction between content domains of worry and between non-metacognitive (Type1) and metacognitive (Type2) concerns.The AnTI is a 22-item self-report measure consisting of threes ubscales: social worry, health worry, and meta-worry.The social worry subscale consists of nine items, health worry six items, and meta-worry seven items (Wells, 2006).Alpha coefficients for the scale have been reported (Wells, 1994) as 0.84 for social worry, 0.81 health worry, and 0.75 for meta-worry and test-retest reliability showed correlations of 0.76 (social worry), 0.84 health worry, and 0.77 (meta-worry).This is a dispositional self-report measure of multiple dimensions of generalized worry.Each question has a scale of four."Almost never", "sometimes", "most of the time" and "almost always".The Persian version of this the test has been examined before showing high reliability.It is admitted by Morejón et al. (2020) that the AnTI (Wells, 1994) is one of the instruments most recognized for assessment of worry because it focuses on analyzing worry content and assesses different types of worries.

Cognitive Behavioral Group Therapy
The cognitive restructuring entail guiding participants to identify their patterns of maladaptive thinking and core irrational beliefs; learn to challenge and modify these maladaptive perceptions (Onyedibe, Nkechi, & Ifeagwazi, 2020).CBT is a practical and structured form of psychotherapy.Karekla, Georgiou, Panayiotou, Sandoz, et al. (2020) mention that a major CBT component is cognitive restructuring (CR), where unhelpful thoughts that lead to unwanted behavior are identified and replaced with more adaptive thought patterns.

Results and Findings
According to Table 1, of these 20 participants, 45% were males versus a portion of 55 females.In terms of age, two categories, namely 15-16 and 17-18were considered.A portion of 60% ranged in age from 15 to 16 while 40% were between 17 and 18, shown in Table 2 Before addressing the research questions in this study, the reliability of the distributed instrument was explored to see whether it was reliable or not.In this research, the Anxious Thoughts Inventory (AnTI) by Wells (1994) was distributed among the students to identify their levels of anxious thoughts.To explore the reliability, a Cronbach's Alpha was obtained, yielding a score of 0.814, which show an acceptable level of reliability.Table 3 reveals the reliability score related Anxious Thoughts Inventory.After transferring the answers given by the participants to the SPSS for further analyses, it was found that overall, the means score of the students at the beginning of the experiment in the pretest at Anxious Thoughts Inventory was 63 (out of a minimum of 0 and a maximum of 88).Therefore, it can be concluded that the Iranian high school students participating in this study showed a sever level of anxious thoughts at the pretest as their mean score was 63 with a standard deviation of 5.89.The detailed statistical description on the anxious thoughts levels of the participants has been delineated in Table 4.Further statistical analyses were conducted to better understand the anxious thoughts level among the participants.As such, it was found that of the 22 given questions examining the anxious thoughts, overall, the highest score belonged to "I worry about my appearance", "worry about my failures and weaknesses", "worry about death, and "give more thought to the negative things than the positive things" with a mean of 3.45, which was the highest of all.Table 5 tabulates the descriptive statistics concerning the anxious thoughts scores of the participants.
After determining the students' overall anxiety score on anxious thoughts, the second objective and also the first null hypothesis of the study was addressed, too.At the beginning, descriptive findings related to the anxious thoughts scores in the posttest were tabulated and it was found that the mean of overall anxious thoughts among the high school students after the cognitive behavioral group therapy reduced to a mean of 54.10 (SD=7.92).
Generally, there was lower anxious thoughts among the participants in comparison with the pretest.Table 5 reveals the details of the descriptive statistics in relation to the posttest scores of anxious thoughts.
Apparently, the cognitive behavioral group therapy influenced the anxious thoughts level, reducing it from 63 in the pretest to 54.10 in the posttest.In further details, it is observed that even after the CBGT, the highest score in the students' anxious thoughts score belonged to "I worry about my appearance" with a mean of 3.05 and a standard deviation of 0.39.overall, the anxious thoughts pattern shows a slight reduction while the same pattern in terms of order in relation to worrying about appearance.Table 7 details the information in relation with the participants' anxious thoughts scores per item in the posttest.
However, in order to identify whether this reduction in the mean of the anxious thoughts score in the posttest significantly differs from that of the pretest, a paired t-test was used, which is employed when each subject has a pair of measurements, such as a before and after score.In statistics, a paired t-test determines whether the mean change for these pairs is significantly different from zero.Table 8 indicates the means and other statistics for the score of anxious thoughts in the pretest and posttest.Moreover, Table 9 reports the Paired Samples Test results, in which the means of the anxious thoughts scores of the students in the pretest have been compared with that of the posttest to find out if this difference in the mean is statistically significant or not.The results prove that since the p-value (0.000) is less than the significance level (e.g., 0.05), the null hypothesis is rejected and it can be concluded that there is a significant difference in the pretest and posttest scores of anxious thoughts of the Iranian high school students after using the cognitive behavioral group therapy.

Discussion and Conclusion
Primarily, it was found in this study that the level of anxious thoughts among the selected Iranian high school students was at a severe level, at the beginning of this study and prior to conducting the cognitive behavior therapy (CBT).According to the studies reported through the literature, anxious thoughts exerts negative impacts on many aspects of a person' life (Mukhtar et al., 2021;Mutang et al., 2021;Stinson et al. 2020;Yüksel & Yılmaz, 2020).Meanwhile, there are numerous studies suggesting and confirming that cognitive behavior therapy (CBT) should be recruited as the most effective intervention to reduce it (Ganaprakasam & Selvaraja, 2020;Gaigg, et al., 2020;Mutang, Seok, & Ee, 2021).Considering this effectiveness and the urge to run CBT with the aim of reducing the anxious thoughts, this study conducted such an intervention and the results proved a statistically significant reduction in the level of anxious thoughts among the high school students.This finding is in line and congruent with many previously conducted research works, confirming the positive impact of CBT on reducing anxious thoughts (Ganaprakasam & Selvaraja, 2020;Gaigg, Flaxman, McLaven, Shah, et al., 2020;Mutang, Seok, & Ee, 2021).Therefore, the results of this study confirm the previous studies.All in all, the CBT was found to be useful in reducing anxious thoughts among the students and it seems that the students' level of anxiety would be still alarming, which necessitates implementation of systematic studies and as well the need for considering this issue by the Iranian educational body.
However, this research faced with a few limitations.First, in this study, only the students with rather higher rates of anxious thoughts were selected and the results could not be generalized to all adolescents of the same age.Moreover, this study was conducted between selected students who had participated in the main study, conducted earlier.Therefore, the other limitation could be the size of the participants.
Future studies are suggested to conduct the same study in other regions of Iran as the results of the current research could be either confirmed or rejected.Moreover, other age groups could be taken into consideration for a research with the same objectives.

Table 1 .
. Descriptive statistics for the gender of the participants

Table 2 .
Descriptive statistics for the age of the participants

Table 3 .
Reliability score of the Anxious Thoughts Inventory

Table 4 .
High school students' overall anxious thoughts in the pretest

Table 5 .
Detailed descriptive statistics on anxious thoughts questions in the pretest

Table 8 .
Paired Samples Statistics for the pretest and posttest score of anxious thoughts

Table 9 .
Paired Samples Test results for the anxious thoughts scores in the pre-post test