Positive reframing of Psychosis Risk is Perceived as Less Frightening and Stigmatizing by Adolescents with and without Prodromal Symptoms: An Experimental Simulated Feedback Study.

Positive reframing of Psychosis Risk is Perceived as Less Frightening and Stigmatizing by Adolescents with and without Prodromal Symptoms: An Experimental Simulated Feedback Study. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 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Authors : Yamit Sol-Nottes , Sujoud Saqer , David Roe 0000-0002-6197-0989 , Shlomo Mendlovic , Ayat Nasser , and Danny Koren 0000-0003-0238-766X [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173640372.21871537/v1 770 views 248 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background and Aims Recent studies have shown that communicating and psycho-educating young individuals and their families about high-risk psychosis can offer benefits, like validation and access to specialized care. However, it can also negatively impact self-perception, distress, and help-seeking behavior. In a recent study [(Sol-Nottes et al., 2024)](#ref-0030), we demonstrated that clinicians view positive reframing as a way to mitigate these concerns. This study aimed to extend those findings to community dwelling adolescents with high versus low levels of distressing ‘prodromal’ experiences. An additional goal was to explore the moderating role of sex and culture. Methods The study replicated the design from Sol-Nottes et al. (2024). 108 adolescents were randomly assigned to view either negatively or positively framed simulated feedback sessions, followed by questions about the session’s impact. Prior to viewing the simulated session, all participants completed the brief version of the Prodromal Questionnaire [(Loewy et al., 2011)](#ref-0019). Results As hypothesized, positive framing significantly reduced fear and stigma. However, contrary to our secondary hypothesis, these effects were not moderated by the level of prodromal symptoms. Finally, exploratory analyses revealed a moderating effect of sex and culture, with a stronger effect of positive reframing on stigma, mobilization to seek help, and hopefulness, among male and Arab adolescents. Conclusions These findings provide further support for the potential beneficial effect of positive reframing in the context of at-risk mental states and highlight the importance of cultural factors. Together, these results lay the groundwork for clinical trials on positive framing in real-world settings. Positive reframing of Psychosis Risk is Perceived as Less Frightening and Stigmatizing by Adolescents with and without Prodromal Symptoms: An Experimental Simulated Feedback Study. Yamit Sol-Nottes 1,2 *, Sujoud Saqer 1 *, David Roe 3 , Shlomo Mendlovic 2 , Ayat Nasser 1 , Danny Koren 1,4 1. School of Psychological Sciences, University of Haifa, Haifa, Israel 2. Shalvata Mental Health Center, Hod Ha’Sharon, Israel 3. Department of Community Mental Health, University of Haifa, Haifa, Israel 4. Psychiatry Division, Rambam Medical Center, Haifa, Israel * Equal contribution Running title: Positive framing reduces fear and stigma among adolescents Correspondence: Danny Koren, Ph.D., Psychology Department, University of Haifa, 199 Aba Khoushy Ave., Mt. Carmel, Haifa, 3103301, Israel. Telephone: +972-4-8240960, Fax: +972-4-8240966, email: [email protected] . Word count: Abstract, 249 words; Text, 2982 words Practitioner points • Recent studies suggest that psycho-educating young individuals and families about high psychosis risk can validate experiences and improve access to care but may also negatively impact self-perception, increase distress, and discourage help-seeking. • Our recent work indicates that clinicians view positive reframing of ”psychosis risk” as ”high risk remaining healthy” (e.g., using common-sense language) as a promising strategy to maximize benefits and reduce potential harms. • This study extends these findings to adolescents from the community, both with and without distressing prodromal symptoms. Background and Aims Recent studies have shown that communicating and psycho-educating young individuals and their families about high-risk psychosis can offer benefits, like validation and access to specialized care. However, it can also negatively impact self-perception, distress, and help-seeking behavior. In a recent study (Sol-Nottes et al., 2024), we demonstrated that clinicians view positive reframing as a way to mitigate these concerns. This study aimed to extend those findings to community dwelling adolescents with high versus low levels of distressing ‘prodromal’ experiences. An additional goal was to explore the moderating role of sex and culture. Methods The study replicated the design from Sol-Nottes et al. (2024). 108 adolescents were randomly assigned to view either negatively or positively framed simulated feedback sessions, followed by questions about the session’s impact. Prior to viewing the simulated session, all participants completed the brief version of the Prodromal Questionnaire (Loewy et al., 2011). Results As hypothesized, positive framing significantly reduced fear and stigma. However, contrary to our secondary hypothesis, these effects were not moderated by the level of prodromal symptoms. Finally, exploratory analyses revealed a moderating effect of sex and culture, with a stronger effect of positive reframing on stigma, mobilization to seek help, and hopefulness, among male and Arab adolescents. Conclusions These findings provide further support for the potential beneficial effect of positive reframing in the context of at-risk mental states and highlight the importance of cultural factors. Together, these results lay the groundwork for clinical trials on positive framing in real-world settings. Keywords: Psychosis risk, Stigma, False-positive predictions, Positive framing, Cultural differences. 1. Introduction The field of psychosis risk identification and intervention has made significant progress over the past three decades. However, these advancements have also generated some clinical and ethical concerns, particularly regarding the potential harmful effects of labeling young people as being at psychosis risk (PR). (Corcoran et al., 2005; Corcoran, 2016; Corcoran et al., 2010; DeLuca, 2020; Larkin & Marshall, 2010; Malhi et al., 2021; Mittal et al., 2015; Woods et al., 2021; Yang et al., 2010). Labeling often result in negative psychological (internalized stigma, demoralization), social (social stigma, discrimination), and medical consequences (risk of premature antipsychotic treatment). Conversely, avoiding any mention of PR can also be problematic, as it may seem paternalistic and disrespectful of the autonomy and preferences of clients and their families, especially as safer and more effective treatments become available (Corcoran, 2016; Mittal et al., 2015). Given that adolescence and young adulthood are critical periods for identity development, and considering the majority of those identified as PR do not progress to develop a psychotic disorder (Fusar-Poli et al., 2013), these risks are particularly concerning. Over the past few decades, several studies have shown that educating young individuals and their families about PR can validate their experiences and facilitate access to specialized care (Lee et al., 2016; Parrish et al., 2019). Additionally, effective communication strategies have been shown to reduce stigma and enhance engagement with mental health services. However, these studies also highlight that being identified as at-risk for psychosis can negatively impact self-image (Woodberry et al., 2021), cause emotional distress (Polari et al., 2021), and deter help-seeking, even when information is conveyed empathetically and collaboratively (Yang et al., 2015). These negative consequences underscore the importance of refining communication methods to minimize adverse emotional reactions and support the mental health of young individuals at risk. Building on Tversky and Kahneman’s (1981) framing effect and Aaron Beck’s (1985) cognitive reframing (Beck et al., 2005; Tversky & Kahneman, 1981), we have proposed that positive reframing of the top-down organizing schema of PR can mitigate these concerns (Koren, 2013). Positive reframing involves focusing on potential gains (e.g., ”preservation of remaining healthy abilities at high risk”) rather than losses (e.g., ”prevention of high risk for psychopathology”) (Koren, 2013). We have argued that this approach has the potential to alleviate the unintended harms associated with early psychosis-risk detection. First, adolescents and young adults tend to be more risk-averse when outcomes are framed as gains rather than losses (Herrera et al., 2023). Second, research on stigma reveals that credible and innovative framing methods can effectively reduce mental health stigma (Feagin, 2020). Third, positive framing that emphasizes preserving remaining strengths may reduce the likelihood of unnecessary antipsychotic use. Fourth, positive framing can alter the interpretation of cases that do not transition to psychotic disorders, viewing them as accurate predictions of risks to residual healthy abilities rather than as false-positive predictions. Consistent with our proposal, a recent study from our group (Sol-Nottes et al., 2024), using an experimental simulated videotaped design, demonstrated that positively reframed feedback about being identified as at-risk for psychosis is perceived as more beneficial and less harmful than negatively framed feedback by clinicians, regardless of their familiarity with PR. Most importantly, it left unanswered how the target audience—young individuals at risk for psychosis, as well as their families and peers—perceives this shift in framing. It also did not explore whether clinical and contextual factors, such as severity of symptoms, sex, and culture, might moderate the effects of positive reframing. This lack of data is important because research suggests these factors influence how people process health-related messages (Rothman & Salovey, 1997). To ensure a clear understanding of our previous and present studies’ methods and results, it is important to clarify that positive framing \soutentails does not entail concepts like re-labeling, positive psychology, positive feedback (i.e., reinforcement), or the de-medicalization of normal human experiences. While these approaches are related, they represent distinct strategies. A more detailed discussion of these potential misconceptions is provided in the Discussion section. The primary aim of the present study was to address these limitations by examining adolescents’ perceptions of positive versus negative framing related to psychosis risk. A secondary aim was to assess whether levels of distressing prodromal symptoms moderate these effects. This is important because of the likely association between prodromal experiences and the participants’ personal engagement with the videos. A third, exploratory, goal was to explore the extent to which sex and culture, especially along the dimension of collectivism versus individualism (Arab versus Jewish adolescents), moderate the effect of positive framing. We chose to focus on these two socio-demographic background variables because the literature suggests that they are associated with mental-health stigma and help-seeking-behaviors among adolescents (Alhomaizi et al., 2018; Corrigan et al., 2014; DeLuca, 2020; Papadopoulos et al., 2013). For our first objective, we hypothesized that adolescents would perceive positively framed feedback as less anxiety-provoking and stigmatizing, while also being more encouraging of help-seeking and optimism, compared to negatively framed feedback. For our second objective, we expected that participants with high levels of distressing prodromal experiences would find positive framing more beneficial due to their more systematic processing of the messages (Rothman & Salovey, 1997). 2. Methods and Materials 2.1. Study Design The study utilized an experimental design involving videotaped simulated feedback sessions to examine the effects of positive versus negative framing. Dependent variables included perceived stigma, fear, help-seeking motivation, and hopefulness. Feedback session scripts, adapted from Sol-Nottes et al. (2024), featured professional actors enacting a clinical scenario involving an adolescent and their parent after a psychosis-risk assessment. The study was approved by the IRB Committee of the University of Haifa (Approval number 091/24). 2.2. Participants Participants were 108 adolescents aged 15–18 years, recruited through advertisements on social media platforms. Recruitment materials outlined the study’s voluntary nature and offered participants a token of appreciation upon completion. Parental consent was obtained before adolescents accessed the online survey, which included sociodemographic questions and familiarity with psychosis-related experiences. Figure 1 presents the study flow diagram. Originally, 118 adolescents and their parents gave informed consent to participate in the study. All of them met the inclusion criteria (ages 15-18, proficiency in Hebrew or Arabic, and adequate hearing and vision). Two participants dropped from the study before viewing the videos, six participants stopped seeing the videos prior to the feedback (negative = 1, positive =5), and two had an invalid (no variance) response pattern. The final sample included 108 participants. Demographic and clinical characteristics of the final sample are presented in Table 1. 2.3. Procedures and Randomization Participants were randomly assigned to one of two conditions (positive or negative framing) using Qualtrics randomization. Before watching the video, participants received a brief contextual introduction. They were allowed full control over playback to ensure comprehension. 2.4. Measures and Materials 2.4.1 Sociodemographic and Psychosis-related Experiences Participants provided demographic details, including age, gender, and familiarity with psychosis through personal or family experiences. 2.4.2 Prodromal symptoms Prodromal experiences were assessed using the Prodromal Questionnaire Brief (PQ-B: Loewy et al., 2011), a self-report tool for identifying individuals who may benefit from further clinical assessment for psychosis risk. A positive screening result among adolescents has recently been proposed as nine or more endorsed items and a cumulative distress score above 24 (Fonseca-Pedrero et al., 2018). 2.4.3. Videotaped simulated feedback sessions The core component of the study involved participants being randomized to watch one of two versions of a video-recorded simulated feedback session. The sessions were structured to align with the ComPsych model’s guidelines for SIPS feedback meetings (Loughland et al., 2015), which represent the contemporary benchmark in the field (Schiffman et al., 2022). The negatively framed video followed the structure of a training video originally developed by Dr. Yulia Landa and colleagues (Icahn School of Medicine at Mt. Sinai), with modifications to align with the study’s objectives. The positively framed video reframed diagnostic feedback to emphasize protective factors and remaining strengths. Specifically, it replaced each instance of negative framing (e.g., ‘high risk for psychosis’) with positive framing (e.g., ‘intact common sense at high risk’). The video-taped sessions were in English with either Arabic or Hebrew sub-titles. The Arabic translation was prepared by the second and third co-authors (SS and EN). The complete scripts are available in Table S1. The videos are available upon request from the last author of the paper (DK). 2.4.4. Dependent Variables: Perceived Effect of the Feedback Session Upon watching the video-recorded feedback session, participants were asked to rate their perceptions regarding the effect of the feedback on the adolescent. This evaluation utilized a questionnaire that was specially tailored for the study. Respondents rated their agreement with six statements on a Likert scale ranging from ”1” (strongly disagree) to ”5” (strongly agree), addressing the following dimensions: (1) the feedback was experienced as clear and understandable, (2) the feedback was experienced as empathetic, (3) the feedback was experienced as provoking worry and fear, (4) the feedback was experienced as self-stigmatizing, the feedback was experienced as motivating to seek-help, and (6) the feedback was experienced as generating optimism about the treatment outcome. The six-item scale demonstrated acceptable to high internal consistency\RL, with values of Cronbach’s Alpha at 0.75 for negative framing and 0.78 for positive framing, and an overall reliability of 0.79 across conditions. Specifically, the internal consistency was at the higher end of the acceptable spectrum under both the negative (Cronbach’s Alpha = 0.75) and positive framing (Cronbach’s Alpha = 0.78) conditions. This level of reliability was consistent across both framing conditions (Cronbach’s Alpha = 0.79). The scores for items 3 (anxiety-provoking) and 4 (stigmatizing) were reversed for these analyses only; all other analyses used the original item values. 2.5. Statistical Analysis First, differences in demographic and psychosis-related background variables based on framing type were analyzed. Independent samples t-tests were conducted for continuous variables, while categorical variables were assessed using the χ2 test for independence, Fisher’s exact test, or the Fisher-Freeman-Halton exact test. Associations between study variables within each of the two framing conditions were evaluated using Pearson’s correlations. Hypothesis 1 , regarding differences in study variables by type of framing, was examined via a one-way multivariate analysis of variance (MANOVA) followed by univariate post-hoc analyses. Hypothesis 2 , which proposed a moderating effect of distressing prodromal symptoms, was tested using a two-way MANOVA, incorporating the positive versus negative screening result on the PQ-B (Fonseca-Pedrero et al., 2018), as a moderator of the main effect of framing type. Finally, the exploratory goal, regarding the potential moderating effects of sex and cultural background (Arab vs. Jewish), was tested using two two-way MANOVAs with sex and culture as moderating factors of the main effect of framing type. The data were analyzed using IBM SPSS Statistics version 29 with an alpha set at .05 two-tailed for all statistical tests. 3. Results 3.1. Sociodemographic, professional, and psychosis-related background Table 1 presents the demographic and psychosis-related background characteristics of the total sample stratified by framing type. Analyses of between-group differences in these characteristics yielded non-significant results for all tests, indicating that randomization successfully created well-matched groups. 3.2 Associations Between Perceived Effectiveness Variables Table 2 summarizes means, standard deviations, and bivariate correlations between the six study variables by framing type. All correlations were medium to high and statistically significant, consistent with internal consistency measures. 3.3 Hypothesis Testing 3.3.1 Perceived Effect of Framing Table 3 and Figure 2 compare the six variables assessing the perceived effect of feedback session by framing type. A one-way MANOVA revealed a significant effect of framing type [Pillai’s trace = 1.53, F(6, 101) = 3.04, p = .009, η² = .15]. Post-hoc tests showed the positive-framing group scored significantly lower on anxiety-provoking and stigmatizing measures than the negative-framing group. Differences in other dimensions (e.g., clarity, empathy, motivation, and hope) were in the hypothesized direction but not significant, partially supporting Hypothesis 1. 3.3.2 Prodromal Experiences as Moderator Table S2 and Figure S1 compare perceived feedback by framing type and level of distressing prodromal experiences (PQ-B scores). Contrary to Hypothesis 2, a two-way MANOVA revealed no significant framing by prodromal interaction effect [Pillai’s trace = .021, F(6, 99) = 0.36, p = .901, η²p = .02]. This suggests positive framing’s effects on stigma and anxiety do not depend on prodromal symptom severity. 3.4 Exploratory Analyses: Moderating Effects of Sex and Culture Table S3 and Figure S2 examine interactions by sex. A two-way MANOVA revealed a medium framing by sex interaction effect (η²p = .112) that was marginally significant (Pillai’s trace = .112, F(6, 99) = 2.08, p = .06). Cultural background (Arab vs. Jewish adolescents) showed a statistically significant framing by culture interaction (η²p = .13) [Pillai’s trace = .130, F(6, 99) = 2.47, p = .03]. 4. Discussion 4.1 Key Findings Aligned with the primary hypothesis, adolescents in the positive-framing condition perceived the feedback as more beneficial, particularly in reducing anxiety and stigma. However, only the reductions in anxiety-provoking and stigmatizing effects were statistically significant. Contrary to expectations, prodromal symptoms did not moderate these effects, suggesting perceived benefits of positive framing are not contingent on symptom severity. The exploratory analyses revealed framing effects may vary by sex and culture, with positive framing showing stronger benefits among males and Arab adolescents. 4.2. Research, Clinical, and Ethical Implications Although the current study did not directly assess the attitudes of help-seeking adolescents who have already been identified as being at-risk, it provides preliminary support for the feasibility and likely usefulness of studying it in this population. Positive framing’s focus on preserving strengths rather than preventing deficits appears especially beneficial for mitigating stigma and emotional distress. Additionally, these findings underscore the importance of tailored communication strategies in clinical contexts. Specifically, they suggest that the effect of positive framing might benefit from being personalized according to sex and collectivistic versus individualistic cultural background that have been found to be related to levels of social mental health stigma and reluctance to seek help (Abo-Rass et al., 2023; Elroy et al., 2017; Manor-Binyamini, 2020). However, this suggestion should be regarded as tentative because the simulated feedback sessions in the study depicted only a male adolescent and a female clinician that were played by Jewish professional actors. This could have caused bias in the way participants in each sex and cultural group identified with the adolescent in the simulated feedback session. 4.3. Clarification of Possible Misconceptions As already mentioned, a clear understanding of the study’s results requires addressing potential misconceptions about positive framing. Importantly, positive framing should not be confused with related concepts such as re-labeling, positive psychology, positive feedback (e.g., praise), or the de-medicalization of ”normal human experiences.” Positive framing differs from re-labeling, which involves altering the vocabulary or terminology used to describe an at-risk mental state. Positive framing, however, seeks to transform the overarching cognitive schema that guides how information is processed and prioritized. Research shows that merely changing terminology has limited effects on reducing stigma (Lasalvia et al., 2015). Likewise, positive framing is closely related to but distinct from positive psychology. While both approaches emphasize positive elements, their goals and methods differ. Positive psychology focuses on enhancing mental health through strengths and positive emotions (Rashid, 2017). In contrast, positive framing is a communication strategy that shapes meaning and decision-making by presenting information in terms of gains rather than losses. Positive Framing is also different from p ositive feedback. The latter refers to reinforcement mechanisms, such as verbal praise or rewards, aimed at encouraging specific behaviors. Positive framing, on the other hand, influences how individuals interpret information, particularly in clinical and diagnostic contexts. Finally positive framing is different from d e-medicalization. The latter involves redefining conditions previously considered illnesses as part of the natural human experience. Positive framing on the other hand, does not challenge the medical validity of a condition but rather contextualizes the at-risk state in a manner akin to general medical terminology—for instance, describing a ”high-risk pregnancy” rather than a ”clinical high-risk for pre-term delivery.” 4.4. Strengths and Limitations This study has several strengths. Its experimental design allowed for the controlled comparison of framing effects, providing robust insights into adolescents’ perceptions. Additionally, the use of videotaped simulated feedback sessions enhanced ecological validity compared to traditional vignette or transcript methods. The inclusion of cultural and sex-based exploratory analyses further enriches the study’s implications. However, several limitations should be acknowledged. First, the focus on non-help-seeking adolescents from the general population limits the generalizability of findings to clinical populations actively seeking mental health care. Future studies should include clinical populations to address this gap. Second, participants viewed feedback sessions individually, whereas real-world scenarios often involve a parent or guardian—a factor that may influence perceptions and responses. Future research should explore family-inclusive scenarios. Third, this study focused on initial reactions to risk-related feedback, leaving the longer-term effects of framing on help-seeking behavior and treatment engagement unexplored. Another limitation is the lack of baseline data on stigma levels across sex and cultural groups, which restricts our ability to isolate framing effects from pre-existing differences. Finally, while efforts were made to align actors with the target demographic, biases may have arisen from participant identification with actors (e.g., all actors were Jewish). 4.5. Future Directions Replication of findings with clinical populations and diverse sociocultural contexts is crucial. Expanding framing research to other mental health conditions—such as bipolar disorder or mood dysregulation—would further elucidate the versatility of positive reframing. Additionally, randomized controlled trials are needed to test framing effects on actual behavioral outcomes, including help-seeking and treatment adherence. Lastly, exploring parent-adolescent dynamics in framing contexts will yield deeper insights into family-centered intervention strategies. 4.6. Conclusion While the present findings are undoubtedly preliminary, they suggest that adolescents from the community view a shift in the way the top-down organizing schema of early identification and intervention in the at-risk mental state is framed as worthy of further consideration and study. Specifically, they suggest the focus should shift from identifying and preventing psychosis to preserving and strengthening intact healthy functions. Conflict of Interest The authors declare that they have no conflicts of \RL interests concerning this study. Funding This work was supported by NARSAD Independent Investigator Grant from the Brain and Behavior Research Foundation to Dan Koren (Grant ID: 18523). Acknowledgements The authors wish to thank Dr. Yulia Landa and Mr. Rachel Jespersen, from the Icahn School of Medicine at Mt. Sinai, New York, for their kind sharing with us the training video of a simulated SIPS feedback meeting, which served as a model for the simulated feedback sessions in the study. The authors wish to thank Dr. Merav Adres for her invaluable review and comments regarding the transcripts of the two simulated feedback sessions. Ethical standards The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008 References Abo-Rass, F., Abu-Kaf, S., Matzri, D., & Braun-Lewensohn, O. (2023). Mental health underutilization by Palestinian-Arabs in Israel: Stigma-related, attitudinal, and instrumental barriers. International Journal of Social Psychiatry , 69 (4), 1015-1023. Alhomaizi, D., Alsaidi, S., Moalie, A., Muradwij, N., Borba, C. P., & Lincoln, A. K. (2018). 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Demographic and clinical-related characteristics of the total sample and the study groups Total Negative Framing Positive Framing Variable ( N = 108) ( n = 55) ( n = 53) A. Continuous M SD M SD M SD U P Age 16.56 1.11 16.66 1.09 16.47 1.14 .884 .379 PQB Items 7.12 5.05 7.15 4.37 7.09 5.66 .06 .95 PQB Distress 23.17 18.58 22.18 16.11 24.23 21.07 .55 .58 Similar 3.02 2.42 3.15 2.55 2.89 2.31 1398 .703 B. Categorical N % n % n % χ 2 P Gender .13 .72 Male 45 41.7% 23 43.4% 22 40.0% Female 63 58.3% 30 56.6% 33 60.0% Culture a \RL1.\RL84 .\RL18 Jewish 56 51.9% 31 58.5% 25 45.5% Arab a 52 48.1% 22 41.5% 30 54.5% Relative with mental health problem(s) .72 No 96 92.6% 50 94.4% 50 90.9% Yes 52 7.4% 3 5.6% 5 9.1% Friends with mental problem(s) .112 .737 No 85 78.7% 41 77.4% 44 80% Yes 23 21.3% 12 22.6% 11 20% I have mental problems .804 No 89 82.4% 43 81.1% 46 83.6% Yes 13 17.6% 10 18.9% 9 16.4% Index, PQ-B = Prodromal Questionnaire – Brief a Muslims = \RL59, Christians = \RL1, Other = 2 Table 2 Means, standard deviations, and correlations between the six variables assessing the perceived effect of the feedback session. 1. Clear and understandable 3.93 0.89 ─ \RL \RL \RL \RL 2. Sensitive and empathic 4.10 0.80 .44 *** ─ 3. Anxiety-provoking 2.67 0.92 -.05 -.16 ─ 4. Stigmatizing 2.16 1.10 -.21 * -.08 .29 * ─ 5. Mobilizing to seek help 4.19 0.86 .36 *** .44 *** -.00 -.28 * ─ 6. Instilling hope 4.13 0.86 .34 *** .42 *** -.15 -.34 *** .63 *** Note. N = 108. * p < .05, ** p < .01. *** p < .001. Table 3 Means, standard deviations, and results of one-way MANOVA for the six variables assessing the perceived effect of the feedback session by framing type. ( n = 53) ( n = 55) Variable M SD M SD F p η² Clear and understandable 3.85 0.79 4.00 0.98 .77 .383 .01 Sensitive and empathic 4.04 0.76 4.16 0.83 .672 .414 .01 Anxiety-provoking 3.00 0.78 2.35 0.93 15.63 < .001 .13 Stigmatizing 2.40 1.11 1.93 1.03 5.14 .025 .05 Mobilizing to seek help 4.21 0.86 4.16 0.86 .0.07 .791 .001 Instilling hope 4.05 0.89 4.20 0.86 0.76 .386 .01 Figure \RL 1 Study flow diagram Figure 2 Means and standard errors of the study variables by framing type Supplementary Material File (image1.emf) Download 7.88 MB Information & Authors Information Version history V1 Version 1 09 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Early Intervention in Psychiatry Keywords cultural differences false-positive predictions positive framing psychosis risk stigma Authors Affiliations Yamit Sol-Nottes University of Haifa School of Psychological Sciences View all articles by this author Sujoud Saqer University of Haifa School of Psychological Sciences View all articles by this author David Roe 0000-0002-6197-0989 University of Haifa Department of Community Mental Health View all articles by this author Shlomo Mendlovic Shalvata Mental Health Center View all articles by this author Ayat Nasser University of Haifa School of Psychological Sciences View all articles by this author Danny Koren 0000-0003-0238-766X [email protected] University of Haifa School of Psychological Sciences View all articles by this author Metrics & Citations Metrics Article Usage 770 views 248 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Yamit Sol-Nottes, Sujoud Saqer, David Roe, et al. 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