{"paper_id":"2c2a2feb-9974-4cb3-8d75-b0a9e6e4f5db","body_text":"Exploring Attachment, Trauma, and Cannabis Use in Psychotic Disorders: A Qualitative Study of Patient and Family Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Attachment, Trauma, and Cannabis Use in Psychotic Disorders: A Qualitative Study of Patient and Family Perspectives Samantha Carley, Robert Laprairie, Stephen Adams, G. Camelia Adams This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7483679/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Psychotic disorders are debilitating mental illnesses that affect individuals psychologically, occupationally, and socially. Several modifiable risk factors were shown to increase the risk for psychosis and associated consequences (i.e., severity, chronicity, and suicide). Research suggests that insecure attachment styles, history of psychological trauma, and substance use disorders (of which cannabis is the most frequent) can increase the risk for and severity of psychotic illness. However, it remains unclear how these known risk factors interact with each other and create different pathways of vulnerability. Most importantly, while clinicians are becoming more aware of these interactions, little is known whether these risk factors are recognized and addressed by patients and their families to prevent illness or support recovery. In fact, many clinicians report that patients and their main supports (family and friends) are often unaware of these risks or unable to address them. This study aims to fill this gap by qualitatively examining the understanding that patients and family members have regarding their illness and these risks for their illness, in order to better inform the interventions needed for optimal recovery. Method Patients and family members were recruited from the Early Psychosis Intervention Program in Saskatoon and the Schizophrenia Society of Saskatchewan. Semi-structured interviews were conducted with 17 patients experiencing first-episode psychosis and 9 family members. Interviews were coded and analyzed using thematic analysis based on Braun and Clarke’s 6-phase framework. Results Five major themes were generated: 1) Confusion: the mark of illness onset, and a shared experience; 2) Cannabis: the snake in the grass; 3) Shifts in relationships mirror shifts in recovery, and vice versa; 4) Trauma at the centre: significant impact and insignificant recognition; and 5) Looking forward: healing while belonging: the role of family and specialized programs. Conclusion Our findings reveal that patients and their families often have varying and inadequate understanding of the common risk factors affecting early psychosis. While the psychoeducation offered in the specialized clinic is highly valued, it is not always accessible or sufficient to alleviate these risks. The results highlight the necessity for targeted interventions aimed at increasing knowledge translation and treatment engagement. Psychiatry Psychosis First-Episode Cannabis Trauma Attachment Qualitative Themes Intervention Figures Figure 1 Figure 2 Introduction Psychotic disorders are defined as “abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behaviour (including catatonia), and negative symptoms.” 1 Psychotic disorders are thought to be caused by a mixture of genetic predispositions (e.g. inherited, unmodifiable risk factors) and environmental risks (often modifiable psychosocial factors). 2 – 4 While psychosis affects a small percentage of the population (approximately 1% of people), 5 individuals suffering often face substantial challenges such as high rates of homelessness and unemployment, 6 , 7 a reduced life expectancy often due to increased suicide rates, 1 , 8 – 10 and an overall diminished quality of life. 10 Individuals with psychotic disorders frequently face stigma and shame, creating further barriers to recovery. 11 – 13 Furthermore, psychotic disorders have a significant economic cost, with estimates at over two billion dollars per year in Canada. 14 These striking impacts highlight the need for enhanced interventions meant to help individuals with psychotic disorders in achieving higher rates of remission, and also to better prevent relapses, in order to improve quality of life, function and benefit society as a whole. Some of the common and well-established environmental risks include insecure attachment, 15 psychological trauma, 16 and substance abuse or dependence, of which cannabis, tends to be the most common. 17 – 19 Attachment styles describe patterns of relating in close relationships that develop early in life in relationship with caregivers and tend to perpetuate throughout life, colouring the interpersonal world of adults. 20 , 21 , 22 These attachment styles are characterised by specific ways of thinking about oneself and others, that can be classified into secure (healthy) ways, or insecure (e.g. anxious or avoidant) styles of relating. 23 , 24 Insecure attachment has been correlated with numerous mental health 25 , 26 and personality disorders, 27 substance abuse/dependence, and suicide. 28 Insecure attachment is highly prevalent among individuals with psychosis and is associated with greater symptom severity, including both positive and negative symptoms. 29 , 30 Moreover, adult attachment was shown to impact mental health treatment engagement, utilization and success. 31 , 32 Psychological trauma, particularly early in life, is an established major risk factor for mental disorders, increasing severity and relapse, as well as suicidal risk. 33 , 34 Recent evidence shows that up to 94% of individuals diagnosed with psychotic disorders have been exposed to trauma at some point in their life. 16 Early life trauma (ages 0–17) has been considered particularly harmful, as it increases the odds of experiencing psychosis in adulthood. 35 Moreover the effects on psychosis are larger for repeated exposure, multiple types of trauma and more recent exposure to trauma. 35 Finally, cannabis use, particularly chronic use, can have a significant biological impact on the human brain, creating abnormalities and increasing vulnerability to mental health. 36 Similarly, cannabis use in young patients (particularly with high Δ 9 -tetrahydrocannabinol [THC] content and frequent use) has been shown to increase the risk for psychosis and suicide. 37 , 38 In fact, a recent Danish study of over 6 million individuals has demonstrated that cannabis use disorder is a major risk factor for schizophrenia, particularly among males. 38 , 39 Moreover, given the legalization of cannabis in Canada and some parts of United States, the perceived harmfulness of cannabis has continued to decline while the cannabis use in youth (the most vulnerable age group) has increased, (partly due to the common impression that cannabis is actually helpful). 41 , 42 To complicate matters further, the individual risk factors described are likely to interact and augment each other in various ways. 43 This often creates dangerous pathways of vulnerability and relapse, which are associated with increased illness severity and worsened treatment outcomes. 43 For example, childhood trauma and early attachment insecurity have been linked to cannabis misuse later in life, and shown to have additive effects (where the combined consequences are worse than the sum of the individual risks) in creating risk for psychosis. 43 , 44 Interestingly, some research has shown that attachment anxiety can mediate the relation between childhood trauma and psychosis, pointing towards a significant perpetuating role of attachment. 45 Moreover, individuals with psychosis and anxious attachment might perceive cannabis as a method of coping, without always acknowledging its negative impact on psychotic illness. Therefore, the co-occurrence and co-augmentation of these modifiable risk factors can lead to increased severity, chronicity or relapse, that ultimately can be prevented, if better understood. 46 The complexities of psychotic disorders and the influence of a variety of risk factors have prompted the emergence of specialized treatment clinics with interdisciplinary teams, meant to approach the treatment through a holistic, biopsychosocial model for treatment. There is now sufficient evidence to support that early intervention programs can prevent relapse, reduce admission and suicidal rates and reduce treatment costs. 47 Yet, even with the help of multidisciplinary teams harnessing great expertise, the rates of recovery are improved but still not ideal. 48 In fact, despite recognizing these interconnected vulnerabilities through numerous research studies and making tremendous efforts to translate the information clinically, it is not clear how much of this information is properly understood by those who ultimately are supposed to benefit from it. Specifically, there is limited understanding on how much patients’ and their families recognize the risk factors that predispose to and perpetuate psychosis, and how their decision-making processes might mitigate potential harm. This is unfortunate since the recovery of patients is mostly dictated by their own motivation and treatment engagement. 49 Similarly the involvement of family members in the treatment of patients with psychosis was shown in previous research to be either a critical tool, or potential detriment to recovery. 50 , 51 To summarize, there is now sufficient evidence supporting the deleterious risk posed by trauma, insecure attachment and cannabis use in psychotic patients. Yet, research showing how these factors can often be overlooked by patients, their families and, sometimes, even by their physicians, is in early stages The current qualitative study aimed to fill this gap by exploring the views held by patients diagnosed with early psychosis, attending specialized programs, as well as their family members’ perspectives. In particular, the study investigated their views with respect to their understanding of their illness and on their opinions regarding these three risk factors (attachment in relationships, history of trauma, and cannabis use patterns) in creating vulnerability for the onset of their illness and preventing recovery. The qualitative nature of our study allowed us to explore the level of understanding as well as its impact on the sense of agency and the ability to adapt to the illness circumstances to better engage in treatment, prevent relapse, and facilitate recovery. Moreover, comparing and contrasting patients’ perspectives with those of their close family members and the influences on the patients’ decisions was also considered. Methods Settings and Participants Purposive sampling was used to recruit patients and family members attending specialized programs for early psychosis. Patients diagnosed with early psychosis, aged 18–35 were recruited through advertisements and referrals by staff at the Early Psychosis Intervention Program (EPIP) or the Schizophrenia Society of Saskatchewan (SSS). Patients were excluded if they had other primary psychiatric diagnoses or they had severe neurological disorders or learning disabilities that could affect their ability to give informed consent or communicate in interviews. Family members were similarly recruited through clinic advertisements or referred by patients, and were deemed eligible if they had a first-degree relative who met the inclusion criteria and participated in one of the two specialized programs. Based on previous research, it was estimated that 9 to 17 participants would be needed to achieve thematic saturation. 52 Our samples also achieved thematic saturation after interviewing 17 patients and 9 family members. Procedure Research ethics approval was obtained from the University of Saskatchewan Behavioural Research Ethics Board (REB #Beh-565). All procedures were conducted in accordance with REB guidelines. The study was advertised in the two programs through posters, and the community mental health nurses. Interested participants were then contacted by email or phone by an investigator who screened them for inclusion and exclusion criteria. Eligible and consenting individuals were offered an interview date. Permission to record the interview was also obtained prior to participation. Data Collection Two semi-structured interview guides (one for patients and one for family members) were developed for this study. The guides included 18 questions for patients and 17 for family members (See Supplementary Information, Appendix 1–2). Each question was accompanied by a set of potential probes, which were used flexibly depending on participants’ responses. The interviews focused on experiences of psychotic illness, related risks, including the three examined risk factors, and how these were understood or addressed in recovery. All questions were open-ended to encourage an accurate depiction of the subjective experience of each participant, while minimizing the researcher’s influence. Interviews were conducted either in person or by phone, depending on participant preference and availability. The interviews ranged from 30 to 90 minutes in length and were followed by a short debriefing exploring the experience of being interviewed. Participants received a $ 40 cash honorarium for their participation. All interviews were audio-recorded and transcribed verbatim. Data Analysis This study adopted a constructionist stance, with data analyzed in an inductive, data-driven manner. A reflexive approach was loosely followed, allowing for flexibility in the interpretation of findings based on the researchers’ perspectives. Thematic analysis was selected as the method of analysis, as it enables the identification of patterns or “themes” within a target population and supports nuanced interpretation. Braun and Clarke’s six-phase approach guided the analysis process. 53 Transcripts were manually coded by the first author (S. Carley) using an inductive approach. NVivo 12 was used to assist with organization, coding, and analysis. 54 All themes were reviewed, iteratively refined, and agreed upon by all authors. All data were maintained securely in DataStore, on a password-secured server accessible only to the authors. Results Participant Characteristics Detailed characteristics of our sample are presented in (Table 1 ). Almost 65% of interviewed patients were male and almost 50% were unemployed. Also, 88% of patients were enrolled in the EPIP and 12% were attending SSS in Saskatoon at the time of their interview. Table 1 Summary of demographic data for patients interviewed. Total interviewed 17 Clinic enrolled in at the time of the interview EPIP: 15 SSS: 2 Gender Male: 11 Female: 6 Occupation Student: 3 Employed: 5 Unemployed: 8 Unknown: 1 Of the interviewed family members almost 90% were parents of the patients ( Table 2 ). Table 2 Summary of demographic data for family members interviewed. Total interviewed 9 Mother 5 Father 3 Sibling 1 Thematic Structure Five major themes and two subthemes were generated. A thematic map is shown in Fig. 1 . Theme 1. Confusion: the mark of illness onset, and a shared experience In the journey toward recovery from psychotic illness numerous obstacles were identified by both patients and family members. These obstacles ranged from early stages of recognizing the symptoms and searching for diagnosis and professional help, to engaging with the treatments offered. Often, before family members became aware of their loved one’s condition, they experienced confusion and lacked the ability to articulate what is happening. As a result, they lacked a sense of direction, and did not access professional help. F1: I was trying to put myself in his shoes., but I couldn’t actually, I didn’t completely comprehend when he talked to me about these voices in his head… F3: I knew she needed help but I don’t know if I really identified it as psychosis, because I really didn’t know much about mental health at that time. Consequently, early signs were dismissed or misinterpreted. For instance, families often attributed symptoms to other possible causes such as developmental stages (being a teenager), or poor choices (e.g. misreading psychosis as substance intoxication). Disrespectful behaviours were occasionally punished (e.g. removing the patient from home) or ignored (as just a phase) rather than being recognized as symptoms of an illness requiring care. F5: I honestly think this is why psychosis is such a big problem, because first of all, I had never even heard of something like that, like I honestly wasn’t sure what that is. My mind never would have went there. I just thought, “ugh he is becoming disrespectful, he is rude, we should just kick him out” and like that was my mind set. I had no idea that he was like really slipping or already was in a psychosis. We just ignored him, we didn’t spend time with him… The lack of early recognition contributed to delays in help-seeking, that was often delayed until an emergency occurred. In some cases, this resulted in drastic interventions, including certified hospital admissions. F8: We tried to get her to go to sleep and she wasn’t going to sleep so it was, she was up all night. It was seven a.m. and I think she ran outside. And at that point we knew there was nothing we could do other than call ambulance, and we did. Individuals’ experiencing a first episode of psychosis were even less aware of what was happening to them, and less capable of communicating it to their families. This often left family members in the dark about their loved one’s situation. Interestingly most of the patients articulated their experience of the early stages of illness as “scary,” but did not expand on this information in the interviews. It was the family members that were able to articulate the overall confusion and lack of communication that characterised the onset of the illness. F6: To this day he will not say a word to me (regarding) anything has happened to him so I don’t know because he was gone for almost a year …So if anything happened to him, I don’t know because he won’t tell me. Unfortunately, in the early stages, the confusion surrounding the diagnosis of psychosis was shared by healthcare providers also. The prodromal phase of illness was often hard to diagnose, particularly in the absence of clear psychotic symptoms. This contributed to the angst and uncertainty experienced by patients and families, feeling often unsupported by professionals. F3: … you take a person to the hospital five or six times and they just keep you there for 15 hours and then send, send you home with no resources or anything, that’s, I mean that is a bit of a bone I have… F6: …I took him three times and they kept sending us home. One of them even said it sounds like a domestic dispute. And that was really frustrating. Once the diagnosis was made and a treatment plan was outlined, patients started a clearer but harder journey for which they often felt unprepared and (unfortunately) insufficiently supported. P27: I was completely delusional for my hospital stay... When I was in the hospital for the 10 days, I should have been in there for another two weeks. They sent me home and from the day they sent me home to the six-week mark when I met my psychiatrist, were the absolute darkest days of my life. In summary, the early stages of psychosis were marked by widespread confusion. Families often misread symptoms as typical behaviour or substance use, delaying support until emergencies arose. Patients struggled to articulate their experiences, and even professionals sometimes failed to recognize the signs, leaving both patients and families feeling unsupported and uncertain. Theme 2. Cannabis: the snake in the grass Subtheme 2.1. Recognition brings clarity: from early appeal to lasting harm In total, 16 out of 17 patients had tried cannabis at least once and the majority continued to use it regularly up to their enrolment in the specialized programs. While treatment engagement was often accompanied by a decrease or cessation in cannabis use, patients did not always understand the connection between cannabis and their mental health struggles, leading to a polarized view. Still, there seemed to be a progression in understanding over time, with most patients seeing cannabis initially as helpful, but later as harmful, particularly with respect to its influence on interpersonal relationships and mental health. For instance, in early stages of cannabis use and even in early stages of illness, cannabis use was described as facilitating new social bonds, increasing sociability, and providing opportunity for a shared activity with peers. P5: Cannabis was socially acceptable, my friends all smoked. Yeah, it was (the) thing to do with your peers you know… P26: Cannabis was really like a social thing when I was a teenager. Like, all my friends used, and we kind of, I had a lot of friendships that kind of bonded over that. Similarly, early on, participants perceived cannabis as helpful in managing psychiatric symptoms, particularly anxiety and agitation. P1: Well, cannabis is relaxing to me. You know it helps me relax and not be so edgy because of the voices *chuckles*… It helps me out. It keeps my mind off of it. P23: Cannabis was definitely a way to manage those panic and anxiety attacks that I was having. Despite these early perceived benefits, majority of participants acknowledged on some level (e.g. some more than others) that cannabis use eventually harming healthy relationships and their own health. For instance, several participants were able to identify that cannabis use was associated with social withdrawal and isolation, often negatively impacting healthy relationships with family members or friends who disapproved of its use. P11: …my parents were always super antidrug, so they weren’t too happy when they found out what I was using. That relationship got worse. P18: Cannabis was ruining my relationships... I felt like I couldn’t talk to them (family and friends). Similarly, the perception of the benefit of cannabis on mental health eventually shifted for most (but not all) patients. Despite descriptions of short-term benefits, participants with heavier use patterns described cannabis as ultimately detrimental to their mental health by recognizing that cannabis use was linked to increased mental health struggles, such as anxiety, depression, psychotic symptoms and cognitive impairments. P20: … I was smoking at the very beginning of my episode I was still smoking cannabis through it and so I think it definitely made it worse. P4: I feel that cannabis is portrayed as a heal all and I feel like it has a lot of downfalls and we maybe don’t know all of them yet. I think that it creates or it can create some mental illnesses like psychosis, I mean not for everybody, but for some of us for sure… Some participants clearly recognized cannabis as a main contributing factor to their illness and had quit using it entirely since receiving treatment, possibly reflecting the positive impact of specialized care. P16: If I smoked now probably would get really bad anxiety and delusions and stuff like that. But now that I don’t smoke, I don’t get anxiety and delusions. P4: I haven’t used cannabis since I was in the hospital. So that is over two years ago. Similarly, this acquired clarity with respect to the deleterious effect of cannabis on psychosis, was often expressed by family members who often recognized the harmful link between cannabis and psychosis severity, and associated suicidality F4: …he (the patient) told me that the reason that he did cannabis this time was because he thought it would kill him . Other family members recognized how using cannabis (especially at a young age or heavy use), increased their loved one’s vulnerability to developing psychosis. F5: I think, from everything that has happened in our family and just all of that, that if you started cannabis early, and you do like too much of it, you are at a great risk of falling into psychosis. In summary, because of this progression in understanding, most patients in specialized programs and their family members gained some clarity on the impact of cannabis on psychosis, and as a result made the decision to reduce or quit their cannabis use entirely by the time of the interview. This positive shift in behaviour, reflected the increased clarity gained by the patient, but it was also the result of a concerted effort to support the patient in this decision, coming from families, friends and the specialized program. Subtheme 2.2. Conflicted perspectives: recognition doesn’t always bring clarity, if it comes at all Despite these positive developments, not all patients and family members held the same views with respect to the role of cannabis impact on psychosis, and mixed opinions remained. Some patients reduced their use for reasons unrelated to their illness, while others continued to use cannabis despite experiencing ongoing symptoms, which was more concerning. Similar variation was seen among family members, with some clearly recognizing the harms, while others remaining uncertain or holding misguided beliefs. Some patients had reduced or quit their use, which was beneficial to their health, but their decisions were driven by factors unrelated to their understanding of the deleterious effect of cannabis but rather motivated by financial constraints that made continued heavy use unsustainable. This might represent a potential area of vulnerability, should those circumstances change. P10: I stopped using a large amount just because of a personal decision…I just decided it could be money…you don’t have money so you can’t go grab it today… Most concerning were the accounts of participants who continued to use cannabis despite experiencing ongoing psychotic symptoms. A few even believed that cannabis had mental health benefits, such as helping them socialize, boosting positive emotions, or distracting them from their symptoms. P21: I feel like cannabis doesn’t amplify psychosis that much. Like it gives you a good mental state and plus it allows you to socialize and stuff like that… P1: Cannabis actually helps me out a little bit. It like, draws my focus away from my illness, and then I don’t really pay attention too much to it. Family members’ perspectives on cannabis also varied. Some showed limited awareness of its potential risks and even described cannabis as medicinal when used moderately. References to legalization were also mentioned, which is relevant in the context of Canada. F2: With cannabis I imagine there are other drugs that are more you know, not as legalized so it’s you know… Medicinal now too so I think’s it, not using it or you know, in moderation of course but… In summary, despite involvement in specialized programs, gaps persist in the understanding of cannabis and its impact on psychosis among several patients and family members. These differing perspectives highlight the ongoing challenges in developing a shared understanding of cannabis’s role in psychosis— an understanding that is both highly relevant and essential for achieving optimal treatment outcomes. Theme 3. Shifts in relationships mirror shifts in recovery, and vice versa The majority of participants described strained relationships during the early stages of illness. For those who improved, the recovery from illness occurred in parallel with an improvement in relationships. However, the direction of these associations varied, and was often bidirectional (e.g. once psychosis improved, relationships with family regained their closeness, but other times, an improvement in relationships lead to better health decisions that facilitated recovery). In early stages of illness, some patients described troubled relationships within the family that were long-standing. They were often the result of an abusive upbringing, which resulted in lack of trust, avoidance and isolation, perpetuating an insecure style of attaching in relationships into adulthood. P24: … My only like female role models were ones that beat me and used me and called me stuff and so it was kind of hard to trust women like growing up and it kind of it was hard to interact and kind of be myself until my teenage years and then that kind of all went downhill after I moved because I was isolating myself again… P25: Well, I was isolating myself a lot…essentially, I couldn’t trust anybody… For others, relationship strain was intensified by more recent life events, including trauma in adulthood or harmful behaviours such as substance use and illegal activity. Several participants identified cannabis use as a significant factor contributing to relational breakdowns, often leading to disconnection from family or feelings of being misunderstood. P26: I definitely stole from them, I took money I took like booze…I just wasn’t like a really good person when I was sick or when I was using cannabis… our relationship was strained quite seriously. P10: I felt like my parents never understood me since I was a kid…and that was even more…intensified when I started using cannabis, because they don’t use. In either case, the descriptions fit the characteristics of insecure attachment styles, lacking trust, impacting interpersonal reliance and safety, known to be significant risk factors for psychosis and relapse. 29 , 30 Even patients who had access to supportive, well-intentioned influences faced relational challenges, brought about by illness itself. The onset of illness often brought confusion, fear, and mistrust, which disrupted existing relationships and created emotional distance between patients and their families. Some family members felt their loved was transformed by the illness, and described shifts in personality and behaviour that made it difficult to maintain closeness. F6: We used to be close before all of this happened and it just felt like… he wasn’t him for the past two years. Two, three years. But he is slowly getting back to himself but I know he will never fully be himself again. The emotional distance created by the illness also often left families uncertain about how best to support their loved one. Some struggled to define their role early on in the recovery process, particularly when their loved one was an adult. They expressed fear of crossing boundaries or appearing overly controlling, recognizing that too much involvement could be counterproductive. F8: We were very protective as parents not to not to “save” her in a sense, right? What 21-year-old wants to be saved. Nobody… it is like you think that you are being parented and then you just run faster and harder… Because of this, even when family members recognized harmful behaviours, such as ongoing cannabis use, they often hesitated to intervene directly out of concern that doing so might further strain the relationship. F4: …Hearing her cough, you know, knowing that that must be some inhaling going on. This…is frustrating. We have been careful not to tell her that she couldn’t, or can’t do that in our house, because we are concerned of what that might cause. Patients also reflected on how their illness affected their social world, and described difficulties in forming or maintaining relationships. P12: I realized I can’t really handle friends at same time of schizophrenia. Despite these challenges, many patients reported a gradual shift in perspective as treatment progressed, likely influenced by the insights gained through the treatment program. This often translated into more openness to help from families, friends and professionals, and more selectivity in maintaining healthy influences and protecting from unhealthy ones. While this often resulted in having fewer relationships overall, the remaining relationships were described as being of higher quality (as reported by 12 out of 17 patients). Specifically, those relationships that endured were characterized as more supportive, respectful, and beneficial to the patients’ well-being. P5: Oh yeah, I have lost tons of friends… Because I don’t smoke and I don’t drink that is all they do whenever they get together. So, I have a few friends now who don’t pressure me, who don’t judge, me who don’t do those things. P22: I think I was in some unhealthy friendships before I went through my psychosis… and going through my psychosis just highlighted that, and so after that episode, I actually cut out quite a few people from my life…I didn’t make plans with family because I was with my friends…now that I’ve quit using cannabis I see my family a lot more. These re-established connections with healthy friends, trustworthy clinicians and/or renewed family support became paramount to successful treatment and recovery. Relying on these supports was described as essential to healing by 14 out of 17 patients, and by all 9 participating family members. These relationships ultimately became a pillar of support, extending even to everyday tasks such as medication reminders. P23: I think I was in a pretty safe environment in general which helped... I think that if I had been on my own maybe the psychosis would have gotten a lot worse or been a lot more out of control because I had my parents at least being there for me… P24: I give a lot of credit to my mom um for being there for me and kind of helping me move forward early on…now that I have moved out, she is always checking up on me and just making sure I am doing okay. F2: Both me and my wife, his mother were supportive of him and whenever he goes, he comes with us now to go to the cottage and he brings his meds and we make sure he keeps that up to date… These relationships were also described as serving as valuable models coping, supporting positive change and helping patients to replace previously engrained habits of drug use or other harmful coping methods. P11: I will talk to my girlfriend when feeling real stressed out, when I would normally take drugs. Similarly, the improved relationships were beneficial for family members, who faced significant stress while witnessing their loved one’s illness. Strengthened connections, in turn, enabled them to continue providing support throughout the recovery process. F3: I think that is our main coping strategies, is with each other. F4: I think *spouse’s name* and I are closer together, closer now that we are now both retired and have more time… So, I think that probably allows us to support each other better and also to support (the patient) more. In summary, the impactful role of healthy relationships in recovery was acknowledged by most patients and all family members. These positive relationships often came from family, but other times came from dating relationships, friends or professional supports. The role of these positive influences was reflected in the hopefulness for recovery and the willingness to make the necessary efforts to pursue it. Theme 4. Trauma at the centre: significant impact and insignificant recognition A majority of participants (12 out of 17) self-reported experiencing one or more traumatic events, including childhood abuse (n = 5), sexual abuse (n = 3), and physical violence (n = 1). Notably, several participants (n = 3) acknowledged a history of trauma but did not provide specific details, even when prompted. Moreover, patients seldom identified the direct relationship between their history of trauma and their diagnosis of psychosis. They were however more aware in describing the relationship between trauma and other risk factors creating vulnerability for psychosis. While each risk is important individually, psychological trauma stands out as especially central, since it is often closely connected to relational difficulties and substance use along the pathway to vulnerability. As with cannabis use, participants showed varying understanding of how psychological trauma relates to psychosis. While some saw a clear connection, others were unsure. Unaddressed, these risks also seemed to increase the likelihood of serious outcomes, including suicidality. Participants often described a link between past trauma and relational difficulties. One patient noted that unresolved trauma made it hard to trust others, which in turn limited the effectiveness of their medication. P23: I think that those trust bonds that you know get destroyed with trauma and then with the psychosis I was just latching on to kind of anything that I could because I was bottling things up and not dealing with it properly. And medication only goes so far… Other patients echoed this connection, explaining how early childhood trauma and abuse led to a lifelong difficulty trusting others. P25: Yeah, like I have had childhood trauma where things weren’t great as a kid…And that kind of affected me a lot throughout life…Not being able to trust people I guess is the main one. Losing trust in people. P21: I think my trauma stems to the fact that I have trust issues because I still remember a lot of the abuse I got from my parents… Family members also reinforced this connection, with one describing how their loved one’s past trauma contributed to harmful relationship choices and behaviours. F8: The trauma that happened, and the rebellion, and the losing of her friends, and you know kind of pushed her further to people that weren’t good for her which pushed her further to being part of that party scene. Cannabis and trauma were also closely intertwined, with cannabis often described as a harmful coping mechanism for managing past trauma. It was perceived as therapeutic or numbing, used to block emotional pain or thoughts of suicide. P11: …there’s some things that when you smoke weed you kind of forget about it. and it kind of makes the pain go away…so I can think that’s one reason why I smoked so often. P11: I just started smoking to help. I was always pretty depressed and felt really lonely and isolated so I was hopeless lots, thoughts of suicide at the time. P22: It was actually after I was assaulted that I started using marijuana more. Interestingly, while many used cannabis to cope with trauma-related pain, it often increased their exposure to the very harms they were trying to escape. These patterns reinforced a cycle of risk, raising the likelihood of poor mental health and adverse outcomes. Three participants reflected on cannabis’s dangerous potential, linking it to violence, psychological stress, and worsening mental health. P5: … I started using cannabis even more so and the violence kind of just came at the same time… So started making bad friends and felt like the depression and suicidal thoughts kind of came at the same time while the violence grew and…yeah that’s the best way I can explain that… This decline in mental health also involved an increase in psychotic symptoms, with some patients acknowledging that past trauma likely contributed to the severity of their experiences during psychosis. P11: Some of the stuff when I was having the psychosis, some of the thoughts I had were because of things that happened in the past, I think. P21: …Over the course some of time, if you keep bottling it up, then suddenly it just, it just kind of like goes down to psychosis…And trauma has a lot to do with it. However, not all participants shared this view, as some patients and family members remained uncertain about the role of trauma, particularly in the early stages of illness. P10: I’m not sure. I don’t know if trauma played a role (in my psychosis). F5: I just felt like we were so little, like the trauma wasn’t that serious…I had no idea that the childhood abuse impacted him (the patient). Overall, leaving these risks unaddressed can be dangerous and may increase the likelihood of adverse outcomes, including suicide. Some participants described how unaddressed trauma, substance use, or relational difficulties contributed to greater vulnerability, including heightened suicidal thoughts and exposure to harm. P21: …Well I almost committed suicide when I was still a kid back then and I was just unhappy… with what life is... F8: …that is why we put her in the hospital because we were like okay this is getting too risky. Her life is getting worse, she might actually get into like harm, getting hurt unknowingly by just being at the wrong place at the wrong time. P27: When I was a teenager, I was suicidal…that was when I was going through being molested… One patient acknowledged the severity of their experiences and expressed gratitude for having survived them, highlighting the dangerous situations that can arise over the course of illness when these risks are left unaddressed. P22: When I was going through my episode, I am lucky I didn’t die honestly. In summary the three major risk factors of insecure attachment, psychological trauma, and cannabis use were present in most of the patients interviewed. Yet, as noticed earlier the recognition of these factors varied, and the interaction between them was often mentioned but not always seen as pathway towards vulnerability or illness. However, what most patients seem to recognize was the role of trauma in creating vulnerability for the other risk factors (cannabis use and interpersonal struggles), which ultimately amplified the psychotic risk. Unfortunately, none of the patients or family members fully recognized the close interplay between these three vulnerabilities in amplifying each other and the cumulative risk for psychosis. Theme 5. Looking forward: healing while belonging: the role of family and specialized programs The path to recovery from psychotic illness is often marked by significant challenges. For some, the long and difficult process of adjusting to a diagnosis and engaging with treatment eventually led them to a specialized treatment program, which many described as a key turning point in their recovery. Both patients and family members expressed deep appreciation for the support they received through these programs. Family members also highlighted their continued commitment to their loved one’s healing. As recovery progressed, participants described a growing sense of stability, optimism, and hope for the future. Because recovery is often complex and challenging, both patients and their families expressed deep gratitude for the comprehensive support provided by professionals at specialized clinics. This cohesive support offered by specialized teams, offered a sense of belonging and modeled healthy relationships, where hope and healing were possible again. P26: EPIP was amazing. I had support for everything. I am so fortunate that I got into that program because I know a lot of people probably struggle with that and mental health and psychosis, and they don’t get that chance to be a part of something like that. P27: Honestly, I think the Early Psychosis Intervention Program really changed my life for the better after going through my psychosis. I feel like the nurses; my nurse was an angel…I am telling you she was an angel heaven sent. She is the kindest, sweetest, most caring yet supportive person I have ever met. F7: I think the biggest thing is his nurse has been fabulous…. Like his nurse had been a life saver…we couldn’t have done it without him, he has been a life saver and has gone above and beyond. In addition to supporting patients, EPIP staff played a key role in supporting family members. They helped families better understand the illness and treatment process, and included them in care and treatment planning whenever possible. F8: The doctors at EPIP were good to us. They let us always come with them… And they listened. They were good listeners too. F9: They have done a great job like explaining to us how psychosis works. This added support for families was especially valuable, as many family members expressed unwavering commitment to their loved one’s recovery and a strong desire to remain actively involved in the healing process. F9: He is my son, that’s that. I always put it into my mind that he is my son, I would not give him up. F1: …Everything is always for him (the patient) in my life, it’s always the best for him, and he knows that… Notably, one family member even demonstrated an ability to adopt their loved one’s perspective (a process known as mentalization) which may be crucial in building empathy and supporting communication, ultimately contributing to long-term treatment success. F1: I was trying to put myself in his shoes and try and think of different scenarios how I can better understand him... Looking ahead, many patients expressed optimism about the future and shared their hopes and goals. For some, returning to a sense of normalcy brought renewed hope and future-oriented thinking. P55: I am fairly level headed now…. The only thing I wish was that I had a good career, well paying, family wife and kids. That is what I wish. P14: I do want to go to university… Patients also described a growing sense of acceptance and adjustment to their current circumstances, having learned to live with the realities of their illness, such as the need for ongoing medication. This adjustment was often accompanied by a reduction in symptoms and an overall improvement in quality of life. P26: I think I am doing very well. I just got done work placement program. I am living on my own. I haven’t had symptoms in over a year. I am doing very well actually. I am still taking medication but that’s just kind of my life right now. I am keeping myself clean. I am keeping my space clean. I am really doing a lot better. Some patients even saw a silver lining in their experiences, reflecting on how their illness had brought unexpected insight or personal growth. P27: I think my illness was a blessing in disguise because it really you know, woke me up in a sense and showed me that there is a different way about things. In summary, specialized programs and their staff are often described as essential turning points in recovery from psychosis, alongside family support when available. As recovery progresses, hope and future-oriented thinking are frequently restored. Although the process is challenging, patients sometimes experience unexpected personal growth, highlighting the resilience that is created throughout their journey. A summary of the topics discussed in the themes is presented in Fig. 2 . Figure 2: This figure illustrates the interconnected roles of psychological trauma, insecure attachment, and cannabis use in contributing to the development of psychosis. These factors interact and compound individual vulnerability. Without intervention, psychosis may lead to relapse, chronicity, or suicidality. However, specialized, enhanced treatment that addresses these underlying risk factors can support improved outcomes and long-term recovery. Key components of care include medication, trauma-informed and attachment-focused interventions, cannabis cessation, and relational support through family and group therapy. Discussion This study explored the lived experiences of individuals diagnosed with first-episode psychosis, alongside perspectives from their family members, with a specific focus on how psychosis was experienced and how patients and family members understood the role of insecure attachment in relationships, psychological trauma, and cannabis use in creating vulnerability for illness and impacting recovery. Five interconnected themes were identified: 1) Confusion: the mark of illness onset, and a shared experience; 2) Cannabis: the snake in the grass; 3) Shifts in relationships mirror shifts in recovery, and vice versa; 4) Trauma at the centre: significant impact and insignificant recognition; and 5) Looking forward: healing while belonging: the role of family and specialized programs . Together, these themes highlight the challenges of navigating psychosis and show how these interrelated risk factors shape both the course of illness and the pathways toward recovery. Summary and Implications In the initial stages of the illness, confusion was a shared experience among patients, families, and even healthcare providers. Symptoms such as social withdrawal, mood changes, and unusual behaviour were frequently misinterpreted as signs of poor personality or discipline problems, rather than emerging psychosis. These misattributions often led to conflict within relationships due to ill loved ones feeling misunderstood, and contributed to delays in help-seeking, with many families only pursuing care once a crisis had developed. These findings align with previous research documenting delays in treatment and misinterpretation of early symptoms. 55 Our study also adds novel insight, by emphasizing the importance of improved public education on psychotic disorders, which may help families with higher genetic risk recognize early signs of illness and seek care sooner. Additional training for primary healthcare professionals may also be warranted to support timely and accurate diagnosis and intervention. These findings may be especially relevant in publicly funded healthcare systems like Canada’s, where early intervention services for psychosis are available, but awareness and access may still be limited. 56 The patients and family members’ awareness of the risk factors reflected their engagement and commitment to treatment, and the efforts to learn and adapt to the challenges posed by the illness. While significant progress was obvious in most cases, it wasn’t the case in all participants, unfortunately. However, a certain pattern of understanding emerged, with cannabis being seen as playing a particularly complex role in participants’ lives, being described as both an initial helpful coping strategy and, eventually, a detrimental factor for recovery. Some participants turned to cannabis as a way to manage anxiety or loneliness, or as a social tool to increase belonging. This finding is consistent with previous research suggesting that individuals with unmet attachment needs may use substances as substitutes for intimacy or emotional closeness. 57 , 58 Despite this apparent facilitation of interpersonal bonds, the relationships that formed through cannabis use were often negative, marked by harmful decisions and behaviours, which further increased the cycle of vulnerability. Fortunately, many of the participants of the study became aware of the harmful effects on their relationships and mental health and eventually quit cannabis. This however, may reflect the benefits of specialized treatment programs that provide targeted psychoeducation on the harms of cannabis, 59 and might overestimate the likelihood of cannabis cessation in underprivileged areas, with limited access to specialized care. After quitting cannabis, patients described feeling closer to their healthy supports, reinforcing the idea that cannabis dependence can replace healthy attachments. Similarly, healthy relationships helped patients make healthier choices and stick to them. Yet, this wasn’t something that was always clear or discussed within the network of supports for all patients. The dual role of cannabis seen in our study, as both initially appealing, but in fact insidiously damaging, echoes prior literature. 60 , 61 Despite admittance in specialized programs and the benefits seen with cessation, not all of the patients interviewed were able, or willing, to quit cannabis entirely. There were varying levels of understanding among both patients and family members regarding the role that cannabis might have in relation to psychotic illness. Most alarming are the comments that cannabis might have some benefits, which often led to continued use despite experiencing clear symptoms. While the patients who continue to use received the same psychoeducation from their specialized treatment program as those who eventually quit, there is still a clear disconnect in understanding regarding its harmful role. This ambivalence or perhaps ignorance of clinicians’ advice may reflect a gap in knowledge between patients and clinicians. However, it could also point to broader societal shifts and attitudes in cannabis normalization, especially in the Canadian context. 62 This is further supported by a statement from a family member (F2) who referenced cannabis legalization, suggesting that cannabis may not be as harmful as other drugs simply because it is legal. These findings highlight the need for enhanced psychoeducation efforts that not only convey clinical risks, but also address common misperceptions shaped by public messaging and policy. Integrating attachment-informed approaches into early psychosis interventions may also help address the underlying relational needs that contribute to cannabis use. Relationship patterns, particularly those rooted in early attachment, played a significant role in participants’ recovery. Many described histories of childhood instability or emotional neglect that affected their ability to trust others or seek support in adulthood. This is concerning, as secure attachment and strong social networks have been associated with more effective recovery, while attachment insecurity may contribute to cycles of avoidance, isolation, and worsening symptoms. 50 , 51 These relational difficulties often persisted into the illness period, contributing to isolation and disengagement from care. However, when secure, supportive, healthy relationships were re-established (either through family, peers, or clinical staff), they became a key source of support, coping, and healing for patients. Nearly all the participants who reported strong relational support also described positive recovery paths, with 14 out of 17 patients mentioning the positive role of these relationships. In some families, the experience of psychosis even appeared to strengthen bonds, subsequently creating a pillar of support for healing. In contrast, the three participants who did not indicate a healthy support system reported greater life dissatisfaction, lower functioning, and more frequent symptoms. These findings align with evidence showing that secure attachment predicts better clinical and functional outcomes in psychosis. 50 , 63 Our study also adds to existing literature, by highlighting the importance of team-based, family inclusive healthcare models that not only involve family members in treatment plans when appropriate, but also provide them with direct support, recognizing their role in promoting the patient’s recovery. Interconnections between cannabis use, trauma, and insecure attachment were evident in participants’ accounts. These risk factors often formed a harmful cycle, with trauma frequently at the centre, ultimately contributing to a decline in mental health. This aligns with previous research linking trauma to a range of psychiatric risks and outcomes. 57 , 58 Some patients articulated a clear understanding of how these factors interacted and influenced their illness, while others struggled to recognize these connections. A similar variability in insight was observed among family members. Notably, patients who were less able to see the relationships between these risks often presented as more acutely unwell, experiencing communication challenges or difficulty with the interview process. This suggests that individuals with a deeper understanding of not only the individual risks but also their interplay may be better positioned for recovery. Given this variability, even among patients receiving the same specialized care, psychoeducation may need to be tailored to cognitive and emotional readiness. An integrative approach that contextualizes these risks in relation to one another may be more effective than a focus on symptoms alone, which risks overlooking the underlying drivers of psychological distress. These findings suggest that psychoeducation in early psychosis care may be more effective when it moves beyond symptom management to include tailored, integrative discussions that contextualize trauma, attachment, and substance use as interconnected drivers of psychological distress and recovery. While specialized programs often address these risk factors individually, they may not consistently highlight their interconnections, which is an important and necessary component emphasized by this research. As a result of these harmful patterns that sometimes went unnoticed, many participants described experiences of self-harm or suicide attempts, particularly during periods of cannabis use or relational instability. This is consistent with previous research linking these risk factors with increased suicidality. 8 , 9 However, despite facing significant adversity (including trauma, strained relationships, substance use, and suicidality), most participants spoke of their experiences in the past tense, and several described them as turning points that motivated change, ultimately leading to greater self-awareness, personal growth, and stronger relationships. The majority of participants expressed hope, resilience, and optimism. These narratives suggest a potential therapeutic value in exploring past adversity as a means to build hope and resilience over time, which aligns with existing literature on recovery and post-traumatic growth in early psychosis. 64 This perspective helps support more nuanced, recovery-oriented approaches to care. For many, the path to recovery involved reducing cannabis use, strengthening relationships, and re-engaging with treatment. A central factor in this process was the role of specialized early intervention services. The EPIP clinic was consistently described as a safe and personalized environment that supported both patients and their families. This added support was invaluable, as all family members expressed a deep commitment to helping their loved one, something shown to be critical for recovery. 50 , 63 For those without stable family supports, some participants described their care team as stepping into a family-like role. These findings reinforce the value of multidisciplinary early psychosis intervention programs, 65 which not only address symptoms, but also fill critical relational gaps. This is in contrast to emergency care settings, which were often experienced as invalidating or inadequate, potentially undermining trust and delaying engagement. Limitations This study has several limitations. First, participants were recruited primarily through the EPIP clinic and were all in the recovery phase of illness, which may have introduced sampling bias. Individuals who were more engaged in treatment and further along in their recovery may have been more willing to participate and reflect on their experiences. As a result, the findings may not fully represent the perspectives of individuals in earlier stages of psychosis or those with more limited treatment engagement. In addition, the study focused on patients’ and family members’ comprehension of psychological trauma, insecure attachment, and cannabis use, but other relevant risk factors such as other alcohol or substance use disorders, lifestyle, medical health, or socioeconomic disadvantage were not explored. Finally, no formal clinical assessments or chart reviews were used to corroborate participants’ self-reported experiences. However, quantitative data collected from this study will be reported elsewhere. Conclusions This study contributes to the growing literature on lived experience and recovery in first-episode psychosis by illustrating the complex ways in which trauma, insecure attachment, and cannabis use interact to shape both illness and healing. These risk factors were often misunderstood, unrecognized, or unaddressed by patients, families, and healthcare providers alike, at least in early stages. Many patients and families lacked the foundational knowledge needed to navigate the illness, and healthcare systems were not always equipped to address these challenges. Our findings underscore the importance of early identification, family-inclusive support, cannabis cessation efforts, and trauma and attachment informed interventions, in addition to standard care. Integrated models that promote insight, encourage secure relationships, and build trust across systems may strengthen long-term recovery. More broadly, these results highlight the need for public education efforts that frame psychosis as a complex yet treatable health issue. Future research should explore the consistency of these findings across different specialized programs, but also in areas with less access to specialized care. Larger quantitative studies will benefit the exploration of possible pathways of vulnerability created by the interplay between these three main risk factors. We hope this study informs future research, supports the development of targeted interventions, guides educational and public health efforts, and ultimately enhances psychosocial treatment strategies aimed at improving engagement and recovery outcomes. Abbreviations EPIP Early Psychosis Intervention Program THC Δ-9-tetrahydrocannabinol SSS Schizophrenia Society of Saskatchewan Declarations Ethics approval and consent to participate This research was reviewed and approved by the University of Saskatchewan Behavioural Research Ethics Board (Beh #565). All participants who took part in this study were consenting participants. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to confidentiality reasons, and the personal nature of the interviews, but are available from the corresponding author on reasonable request. Competing interests RBL reports a past board membership with Shackleford Pharma Inc., consulting for Lewin and Sagara LLP, laboratory funding from private cannabis companies and patents pending to University of Saskatchewan. The other authors declare that they have no competing interests. Funding We would like to acknowledge the support of the various scholarships and grants that enabled us to conduct and complete this work. These include the Department of Psychiatry’s Intramural Award (including Laura E. Chapman award, Alfred G. Molstad Trust, and Aruna Kripa Thakur award), the Health Sciences Graduate Scholarship (2023 and 2024), the Saskatchewan Royal University Hospital Foundation Award, the Schizophrenia Society of Canada Foundation and Canadian Consortium for Early Intervention in Psychosis studentship, and the Canada Graduate Scholarships- Master’s (CIHR) award. Authors' contributions Samantha Carley analyzed and interpreted all of the qualitative data, wrote the first draft of the manuscript, and read and approved the final manuscript. Dr. Robert Laprairie guided Samantha on data analysis, edited the manuscript drafts, and read/approved the final manuscript. Dr. G. 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Saskatchewan Health Authority, Royal University Hospital (2019) Available from: https://www.schizophrenia.sk.ca/public/CKeditorUpload/EPIP_-_Pamphlet.MHAS_March_2019_compressed.pdf Chesney E, Oliver D, McGuire P (2022) Cannabidiol (CBD) as a novel treatment in the early phases of psychosis. Psychopharmacology 239:1179–1190. 10.1007/s00213-021-05905-9 Morrison PD, Zois V, McKeown DA, Lee TD, Holt DW, Powell JF et al (2009) The acute effects of synthetic intravenous Delta9-tetrahydrocannabinol on psychosis, mood and cognitive functioning. Psychol Med 39(10):1607–1616. 10.1017/S0033291709005522 Government of Canada. Cannabis legalization and regulation (2021) Jul 7. Available from: https://www.justice.gc.ca/eng/cj-jp/cannabis/?wbdisable=true McCarthy-Jones S, Marriott M, Knowles R, Rowse G, Thompson AR (2013) What is psychosis? A meta-synthesis of inductive qualitative studies exploring the experience of psychosis. Psychosis 5(1):1–16. 10.1080/17522439.2011.647051 Ng F, Ibrahim N, Franklin D, Jordan G, Lewandowski F, Fang F et al (2021) Post-traumatic growth in psychosis: a systematic review and narrative synthesis. BMC Psychiatry 21(1):607. 10.1186/s12888-021-03614-3 Anderson KK, Norman R, MacDougall A, Edwards J, Palaniyappan L, Lau C et al (2018) Effectiveness of early psychosis intervention: comparison of service users and nonusers in population-based health administrative data. Am J Psychiatry 175(5):443–452. 10.1176/appi.ajp.2017.17050480 Additional Declarations The authors declare potential competing interests as follows: RBL reports a past board membership with Shackleford Pharma Inc., consulting for Lewin and Sagara LLP, laboratory funding from private cannabis companies and patents pending to University of Saskatchewan. The other authors declare that they have no competing interests. Supplementary Files SupplementaryInformationAppendix12.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7483679\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":507145668,\"identity\":\"da8318b0-9fd3-46e4-9c85-2178915c1b92\",\"order_by\":0,\"name\":\"Samantha Carley\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYPCCAxDqAQODHIhmbCCoIwGqJYGBwZh0LYkNhLTIt59O/Fz44448A/vhZx8SKg6nbzh/+PHHGQx28ri0GJzJ3Sw9I+GZYQNPmvGMhDOHczfcSDOT3MCQbIjLJgOG3A3SPAmHGRskgN5IbANpYTBjfMBwAKfj5Pvfbv4N1GLfIMH+mSHx3+F0g/PHP38EarHH6Z8budtAtiQ2SPAAbWk4nGBwIMcA6LADiTgdduPtNmuetMPJbTw5xQwJx9INZ97IKZOcYZCcjNthuZtv89gctu1nP76Z4UONtTzf+eObP/ZU2NnidBgMsEGoZpjthNQjQB3xSkfBKBgFo2DEAAAH41+k1qTZtgAAAABJRU5ErkJggg==\",\"orcid\":\"https://orcid.org/0009-0006-0003-195X\",\"institution\":\"Department of Psychiatry, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Samantha\",\"middleName\":\"\",\"lastName\":\"Carley\",\"suffix\":\"\"},{\"id\":507145669,\"identity\":\"a5996c13-50db-4737-b429-94e920c90434\",\"order_by\":1,\"name\":\"Robert Laprairie\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0002-9994-433X\",\"institution\":\"College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Robert\",\"middleName\":\"\",\"lastName\":\"Laprairie\",\"suffix\":\"\"},{\"id\":507145670,\"identity\":\"337654e6-c5f6-4441-86de-09d8cad5a7c8\",\"order_by\":2,\"name\":\"Stephen Adams\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Psychiatry, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Stephen\",\"middleName\":\"\",\"lastName\":\"Adams\",\"suffix\":\"\"},{\"id\":507145671,\"identity\":\"0158b25a-de1b-4e95-970b-a7999f259867\",\"order_by\":3,\"name\":\"G. Camelia Adams\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0001-5253-1426\",\"institution\":\"Department of Psychiatry, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"G.\",\"middleName\":\"Camelia\",\"lastName\":\"Adams\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-08-28 23:59:09\",\"currentVersionCode\":1,\"declarations\":{\"humanSubjects\":true,\"vertebrateSubjects\":false,\"conflictsOfInterestStatement\":true,\"humanSubjectEthicalGuidelines\":true,\"humanSubjectConsent\":true,\"humanSubjectClinicalTrial\":false,\"humanSubjectCaseReport\":false,\"vertebrateSubjectEthicalGuidelines\":false},\"doi\":\"10.21203/rs.3.rs-7483679/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7483679/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":90320201,\"identity\":\"6dc331ec-01c4-436b-97e9-f37a26c545c8\",\"added_by\":\"auto\",\"created_at\":\"2025-09-01 10:43:27\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":147983,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eThematic Map.\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7483679/v1/2b070a1f0b8224d97b0b39a4.png\"},{\"id\":90320205,\"identity\":\"5ad2fe84-26d6-4b5d-a90b-8a06a64e89ef\",\"added_by\":\"auto\",\"created_at\":\"2025-09-01 10:43:27\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":257091,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eRisk Pathways and Intervention Targets in Psychosis: Summary of Thematic Findings.\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7483679/v1/ee9d6a67edcf47f2d4a2e0c9.png\"},{\"id\":90321794,\"identity\":\"a922b269-032d-400f-9af5-b657d5a5bd0f\",\"added_by\":\"auto\",\"created_at\":\"2025-09-01 10:59:28\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1381462,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7483679/v1/1852dd1e-ac4e-4e16-863e-3524272fdd58.pdf\"},{\"id\":90320202,\"identity\":\"a510f306-30e9-4a46-b951-1995401fba84\",\"added_by\":\"auto\",\"created_at\":\"2025-09-01 10:43:27\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19742,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryInformationAppendix12.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7483679/v1/d3a8c1ae8cec46d9843f8706.docx\"}],\"financialInterests\":\"The authors declare potential competing interests as follows: RBL reports a past board membership with Shackleford Pharma Inc., consulting for Lewin and Sagara LLP, laboratory funding from private cannabis companies and patents pending to University of Saskatchewan. The other authors declare that they have no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003eExploring Attachment, Trauma, and Cannabis Use in Psychotic Disorders: A Qualitative Study of Patient and Family Perspectives\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePsychotic disorders are defined as \\u0026ldquo;abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behaviour (including catatonia), and negative symptoms.\\u0026rdquo;\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e Psychotic disorders are thought to be caused by a mixture of genetic predispositions (e.g. inherited, unmodifiable risk factors) and environmental risks (often modifiable psychosocial factors).\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR3\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eWhile psychosis affects a small percentage of the population (approximately 1% of people),\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e individuals suffering often face substantial challenges such as high rates of homelessness and unemployment,\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e a reduced life expectancy often due to increased suicide rates,\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR9\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e and an overall diminished quality of life.\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Individuals with psychotic disorders frequently face stigma and shame, creating further barriers to recovery.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e Furthermore, psychotic disorders have a significant economic cost, with estimates at over two billion dollars per year in Canada.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e These striking impacts highlight the need for enhanced interventions meant to help individuals with psychotic disorders in achieving higher rates of remission, and also to better prevent relapses, in order to improve quality of life, function and benefit society as a whole.\\u003c/p\\u003e\\u003cp\\u003eSome of the common and well-established environmental risks include insecure attachment,\\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e psychological trauma,\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e and substance abuse or dependence, of which cannabis, tends to be the most common.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR18\\\" citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eAttachment styles describe patterns of relating in close relationships that develop early in life in relationship with caregivers and tend to perpetuate throughout life, colouring the interpersonal world of adults.\\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e These attachment styles are characterised by specific ways of thinking about oneself and others, that can be classified into secure (healthy) ways, or insecure (e.g. anxious or avoidant) styles of relating.\\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e Insecure attachment has been correlated with numerous mental health\\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u003c/sup\\u003e and personality disorders,\\u003csup\\u003e\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e substance abuse/dependence, and suicide.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e Insecure attachment is highly prevalent among individuals with psychosis and is associated with greater symptom severity, including both positive and negative symptoms.\\u003csup\\u003e\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e Moreover, adult attachment was shown to impact mental health treatment engagement, utilization and success.\\u003csup\\u003e\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003ePsychological trauma, particularly early in life, is an established major risk factor for mental disorders, increasing severity and relapse, as well as suicidal risk.\\u003csup\\u003e\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e\\u003c/sup\\u003e Recent evidence shows that up to 94% of individuals diagnosed with psychotic disorders have been exposed to trauma at some point in their life.\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e Early life trauma (ages 0\\u0026ndash;17) has been considered particularly harmful, as it increases the odds of experiencing psychosis in adulthood.\\u003csup\\u003e\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e\\u003c/sup\\u003e Moreover the effects on psychosis are larger for repeated exposure, multiple types of trauma and more recent exposure to trauma.\\u003csup\\u003e\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eFinally, cannabis use, particularly chronic use, can have a significant biological impact on the human brain, creating abnormalities and increasing vulnerability to mental health.\\u003csup\\u003e\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e\\u003c/sup\\u003e Similarly, cannabis use in young patients (particularly with high Δ\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e-tetrahydrocannabinol [THC] content and frequent use) has been shown to increase the risk for psychosis and suicide.\\u003csup\\u003e\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e\\u003c/sup\\u003e In fact, a recent Danish study of over 6\\u0026nbsp;million individuals has demonstrated that cannabis use disorder is a major risk factor for schizophrenia, particularly among males.\\u003csup\\u003e\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e\\u003c/sup\\u003e Moreover, given the legalization of cannabis in Canada and some parts of United States, the perceived harmfulness of cannabis has continued to decline while the cannabis use in youth (the most vulnerable age group) has increased, (partly due to the common impression that cannabis is actually helpful).\\u003csup\\u003e\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eTo complicate matters further, the individual risk factors described are likely to interact and augment each other in various ways.\\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e This often creates dangerous pathways of vulnerability and relapse, which are associated with increased illness severity and worsened treatment outcomes.\\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e\\u003c/sup\\u003e For example, childhood trauma and early attachment insecurity have been linked to cannabis misuse later in life, and shown to have additive effects (where the combined consequences are worse than the sum of the individual risks) in creating risk for psychosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u003c/sup\\u003e Interestingly, some research has shown that attachment anxiety can mediate the relation between childhood trauma and psychosis, pointing towards a significant perpetuating role of attachment.\\u003csup\\u003e\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u003c/sup\\u003e Moreover, individuals with psychosis and anxious attachment might perceive cannabis as a method of coping, without always acknowledging its negative impact on psychotic illness. Therefore, the co-occurrence and co-augmentation of these modifiable risk factors can lead to increased severity, chronicity or relapse, that ultimately can be prevented, if better understood.\\u003csup\\u003e\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe complexities of psychotic disorders and the influence of a variety of risk factors have prompted the emergence of specialized treatment clinics with interdisciplinary teams, meant to approach the treatment through a holistic, biopsychosocial model for treatment. There is now sufficient evidence to support that early intervention programs can prevent relapse, reduce admission and suicidal rates and reduce treatment costs.\\u003csup\\u003e\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e\\u003c/sup\\u003e Yet, even with the help of multidisciplinary teams harnessing great expertise, the rates of recovery are improved but still not ideal.\\u003csup\\u003e\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e\\u003c/sup\\u003e In fact, despite recognizing these interconnected vulnerabilities through numerous research studies and making tremendous efforts to translate the information clinically, it is not clear how much of this information is properly understood by those who ultimately are supposed to benefit from it. Specifically, there is limited understanding on how much patients\\u0026rsquo; and their families recognize the risk factors that predispose to and perpetuate psychosis, and how their decision-making processes might mitigate potential harm. This is unfortunate since the recovery of patients is mostly dictated by their own motivation and treatment engagement.\\u003csup\\u003e\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u003c/sup\\u003e Similarly the involvement of family members in the treatment of patients with psychosis was shown in previous research to be either a critical tool, or potential detriment to recovery.\\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e To summarize, there is now sufficient evidence supporting the deleterious risk posed by trauma, insecure attachment and cannabis use in psychotic patients. Yet, research showing how these factors can often be overlooked by patients, their families and, sometimes, even by their physicians, is in early stages\\u003c/p\\u003e\\u003cp\\u003eThe current qualitative study aimed to fill this gap by exploring the views held by patients diagnosed with early psychosis, attending specialized programs, as well as their family members\\u0026rsquo; perspectives. In particular, the study investigated their views with respect to their understanding of their illness and on their opinions regarding these three risk factors (attachment in relationships, history of trauma, and cannabis use patterns) in creating vulnerability for the onset of their illness and preventing recovery. The qualitative nature of our study allowed us to explore the level of understanding as well as its impact on the sense of agency and the ability to adapt to the illness circumstances to better engage in treatment, prevent relapse, and facilitate recovery. Moreover, comparing and contrasting patients\\u0026rsquo; perspectives with those of their close family members and the influences on the patients\\u0026rsquo; decisions was also considered.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSettings and Participants\\u003c/h2\\u003e\\u003cp\\u003ePurposive sampling was used to recruit patients and family members attending specialized programs for early psychosis. Patients diagnosed with early psychosis, aged 18\\u0026ndash;35 were recruited through advertisements and referrals by staff at the Early Psychosis Intervention Program (EPIP) or the Schizophrenia Society of Saskatchewan (SSS). Patients were excluded if they had other primary psychiatric diagnoses or they had severe neurological disorders or learning disabilities that could affect their ability to give informed consent or communicate in interviews. Family members were similarly recruited through clinic advertisements or referred by patients, and were deemed eligible if they had a first-degree relative who met the inclusion criteria and participated in one of the two specialized programs. Based on previous research, it was estimated that 9 to 17 participants would be needed to achieve thematic saturation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e\\u003c/sup\\u003e Our samples also achieved thematic saturation after interviewing 17 patients and 9 family members.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eProcedure\\u003c/h3\\u003e\\n\\u003cp\\u003e Research ethics approval was obtained from the University of Saskatchewan Behavioural Research Ethics Board (REB #Beh-565). All procedures were conducted in accordance with REB guidelines. The study was advertised in the two programs through posters, and the community mental health nurses. Interested participants were then contacted by email or phone by an investigator who screened them for inclusion and exclusion criteria. Eligible and consenting individuals were offered an interview date. Permission to record the interview was also obtained prior to participation.\\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection\\u003c/h3\\u003e\\n\\u003cp\\u003eTwo semi-structured interview guides (one for patients and one for family members) were developed for this study. The guides included 18 questions for patients and 17 for family members (See Supplementary Information, Appendix 1\\u0026ndash;2). Each question was accompanied by a set of potential probes, which were used flexibly depending on participants\\u0026rsquo; responses. The interviews focused on experiences of psychotic illness, related risks, including the three examined risk factors, and how these were understood or addressed in recovery. All questions were open-ended to encourage an accurate depiction of the subjective experience of each participant, while minimizing the researcher\\u0026rsquo;s influence.\\u003c/p\\u003e\\u003cp\\u003e Interviews were conducted either in person or by phone, depending on participant preference and availability. The interviews ranged from 30 to 90 minutes in length and were followed by a short debriefing exploring the experience of being interviewed. Participants received a \\u003cspan\\u003e$\\u003c/span\\u003e40 cash honorarium for their participation. All interviews were audio-recorded and transcribed verbatim.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eData Analysis\\u003c/h2\\u003e\\u003cp\\u003eThis study adopted a constructionist stance, with data analyzed in an inductive, data-driven manner. A reflexive approach was loosely followed, allowing for flexibility in the interpretation of findings based on the researchers\\u0026rsquo; perspectives. Thematic analysis was selected as the method of analysis, as it enables the identification of patterns or \\u0026ldquo;themes\\u0026rdquo; within a target population and supports nuanced interpretation. Braun and Clarke\\u0026rsquo;s six-phase approach guided the analysis process.\\u003csup\\u003e\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eTranscripts were manually coded by the first author (S. Carley) using an inductive approach. NVivo 12 was used to assist with organization, coding, and analysis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e\\u003c/sup\\u003e All themes were reviewed, iteratively refined, and agreed upon by all authors. All data were maintained securely in DataStore, on a password-secured server accessible only to the authors.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eParticipant Characteristics\\u003c/h2\\u003e\\u003cp\\u003eDetailed characteristics of our sample are presented in (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e\\u003cb\\u003e).\\u003c/b\\u003e Almost 65% of interviewed patients were male and almost 50% were unemployed. Also, 88% of patients were enrolled in the EPIP and 12% were attending SSS in Saskatoon at the time of their interview.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eSummary of demographic data for patients interviewed.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"2\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal interviewed\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e17\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eClinic enrolled in at the time of the interview\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eEPIP: 15\\u003c/p\\u003e\\u003cp\\u003eSSS: 2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGender\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMale: 11\\u003c/p\\u003e\\u003cp\\u003eFemale: 6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eOccupation\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eStudent: 3\\u003c/p\\u003e\\u003cp\\u003eEmployed: 5\\u003c/p\\u003e\\u003cp\\u003eUnemployed: 8\\u003c/p\\u003e\\u003cp\\u003eUnknown: 1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOf the interviewed family members almost 90% were parents of the patients \\u003cb\\u003e(\\u003c/b\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e\\u003cb\\u003e).\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eSummary of demographic data for family members interviewed.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"2\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal interviewed\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMother\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFather\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSibling\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eThematic Structure\\u003c/h3\\u003e\\n\\u003cp\\u003eFive major themes and two subthemes were generated. A thematic map is shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eTheme 1. Confusion: the mark of illness onset, and a shared experience\\u003c/h3\\u003e\\n\\u003cp\\u003eIn the journey toward recovery from psychotic illness numerous obstacles were identified by both patients and family members. These obstacles ranged from early stages of recognizing the symptoms and searching for diagnosis and professional help, to engaging with the treatments offered. Often, before family members became aware of their loved one\\u0026rsquo;s condition, they experienced confusion and lacked the ability to articulate what is happening. As a result, they lacked a sense of direction, and did not access professional help.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF1: I was trying to put myself in his shoes., but I couldn\\u0026rsquo;t actually, I didn\\u0026rsquo;t completely comprehend when he talked to me about these voices in his head\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF3: I knew she needed help but I don\\u0026rsquo;t know if I really identified it as psychosis, because I really didn\\u0026rsquo;t know much about mental health at that time.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eConsequently, early signs were dismissed or misinterpreted. For instance, families often attributed symptoms to other possible causes such as developmental stages (being a teenager), or poor choices (e.g. misreading psychosis as substance intoxication). Disrespectful behaviours were occasionally punished (e.g. removing the patient from home) or ignored (as just a phase) rather than being recognized as symptoms of an illness requiring care.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF5: I honestly think this is why psychosis is such a big problem, because first of all, I had never even heard of something like that, like I honestly wasn\\u0026rsquo;t sure what that is. My mind never would have went there. I just thought, \\u0026ldquo;ugh he is becoming disrespectful, he is rude, we should just kick him out\\u0026rdquo; and like that was my mind set. I had no idea that he was like really slipping or already was in a psychosis. We just ignored him, we didn\\u0026rsquo;t spend time with him\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe lack of early recognition contributed to delays in help-seeking, that was often delayed until an emergency occurred. In some cases, this resulted in drastic interventions, including certified hospital admissions.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF8: We tried to get her to go to sleep and she wasn\\u0026rsquo;t going to sleep so it was, she was up all night. It was seven a.m. and I think she ran outside. And at that point we knew there was nothing we could do other than call ambulance, and we did.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIndividuals\\u0026rsquo; experiencing a first episode of psychosis were even less aware of what was happening to them, and less capable of communicating it to their families. This often left family members in the dark about their loved one\\u0026rsquo;s situation. Interestingly most of the patients articulated their experience of the early stages of illness as \\u0026ldquo;scary,\\u0026rdquo; but did not expand on this information in the interviews. It was the family members that were able to articulate the overall confusion and lack of communication that characterised the onset of the illness.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF6: To this day he will not say a word to me (regarding) anything has happened to him so I don\\u0026rsquo;t know because he was gone for almost a year \\u0026hellip;So if anything happened to him, I don\\u0026rsquo;t know because he won\\u0026rsquo;t tell me.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eUnfortunately, in the early stages, the confusion surrounding the diagnosis of psychosis was shared by healthcare providers also. The prodromal phase of illness was often hard to diagnose, particularly in the absence of clear psychotic symptoms. This contributed to the angst and uncertainty experienced by patients and families, feeling often unsupported by professionals.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF3: \\u0026hellip; you take a person to the hospital five or six times and they just keep you there for 15 hours and then send, send you home with no resources or anything, that\\u0026rsquo;s, I mean that is a bit of a bone I have\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF6: \\u0026hellip;I took him three times and they kept sending us home. One of them even said it sounds like a domestic dispute. And that was really frustrating.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOnce the diagnosis was made and a treatment plan was outlined, patients started a clearer but harder journey for which they often felt unprepared and (unfortunately) insufficiently supported.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP27: I was completely delusional for my hospital stay... When I was in the hospital for the 10 days, I should have been in there for another two weeks. They sent me home and from the day they sent me home to the six-week mark when I met my psychiatrist, were the absolute darkest days of my life.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary, the early stages of psychosis were marked by widespread confusion. Families often misread symptoms as typical behaviour or substance use, delaying support until emergencies arose. Patients struggled to articulate their experiences, and even professionals sometimes failed to recognize the signs, leaving both patients and families feeling unsupported and uncertain.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eTheme 2. Cannabis: the snake in the grass\\u003c/h2\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section3\\\"\\u003e\\u003ch2\\u003eSubtheme 2.1. Recognition brings clarity: from early appeal to lasting harm\\u003c/h2\\u003e\\u003cp\\u003eIn total, 16 out of 17 patients had tried cannabis at least once and the majority continued to use it regularly up to their enrolment in the specialized programs. While treatment engagement was often accompanied by a decrease or cessation in cannabis use, patients did not always understand the connection between cannabis and their mental health struggles, leading to a polarized view. Still, there seemed to be a progression in understanding over time, with most patients seeing cannabis initially as helpful, but later as harmful, particularly with respect to its influence on interpersonal relationships and mental health.\\u003c/p\\u003e\\u003cp\\u003eFor instance, in early stages of cannabis use and even in early stages of illness, cannabis use was described as facilitating new social bonds, increasing sociability, and providing opportunity for a shared activity with peers.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP5: Cannabis was socially acceptable, my friends all smoked. Yeah, it was (the) thing to do with your peers you know\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP26: Cannabis was really like a social thing when I was a teenager. Like, all my friends used, and we kind of, I had a lot of friendships that kind of bonded over that.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSimilarly, early on, participants perceived cannabis as helpful in managing psychiatric symptoms, particularly anxiety and agitation.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP1: Well, cannabis is relaxing to me. You know it helps me relax and not be so edgy because of the voices *chuckles*\\u0026hellip; It helps me out. It keeps my mind off of it.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP23: Cannabis was definitely a way to manage those panic and anxiety attacks that I was having.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eDespite these early perceived benefits, majority of participants acknowledged on some level (e.g. some more than others) that cannabis use eventually harming healthy relationships and their own health. For instance, several participants were able to identify that cannabis use was associated with social withdrawal and isolation, often negatively impacting healthy relationships with family members or friends who disapproved of its use.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP11: \\u0026hellip;my parents were always super antidrug, so they weren\\u0026rsquo;t too happy when they found out what I was using. That relationship got worse.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP18: Cannabis was ruining my relationships... I felt like I couldn\\u0026rsquo;t talk to them (family and friends).\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSimilarly, the perception of the benefit of cannabis on mental health eventually shifted for most (but not all) patients. Despite descriptions of short-term benefits, participants with heavier use patterns described cannabis as ultimately detrimental to their mental health by recognizing that cannabis use was linked to increased mental health struggles, such as anxiety, depression, psychotic symptoms and cognitive impairments.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP20: \\u0026hellip; I was smoking at the very beginning of my episode I was still smoking cannabis through it and so I think it definitely made it worse.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP4: I feel that cannabis is portrayed as a heal all and I feel like it has a lot of downfalls and we maybe don\\u0026rsquo;t know all of them yet. I think that it creates or it can create some mental illnesses like psychosis, I mean not for everybody, but for some of us for sure\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSome participants clearly recognized cannabis as a main contributing factor to their illness and had quit using it entirely since receiving treatment, possibly reflecting the positive impact of specialized care.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP16: If I smoked now probably would get really bad anxiety and delusions and stuff like that. But now that I don\\u0026rsquo;t smoke, I don\\u0026rsquo;t get anxiety and delusions.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP4: I haven\\u0026rsquo;t used cannabis since I was in the hospital. So that is over two years ago.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSimilarly, this acquired clarity with respect to the deleterious effect of cannabis on psychosis, was often expressed by family members who often recognized the harmful link between cannabis and psychosis severity, and associated suicidality\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF4: \\u0026hellip;he (the patient) told me that the reason that he did cannabis this time was because he thought it would kill him\\u003c/em\\u003e.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOther family members recognized how using cannabis (especially at a young age or heavy use), increased their loved one\\u0026rsquo;s vulnerability to developing psychosis.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF5: I think, from everything that has happened in our family and just all of that, that if you started cannabis early, and you do like too much of it, you are at a great risk of falling into psychosis.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary, because of this progression in understanding, most patients in specialized programs and their family members gained some clarity on the impact of cannabis on psychosis, and as a result made the decision to reduce or quit their cannabis use entirely by the time of the interview. This positive shift in behaviour, reflected the increased clarity gained by the patient, but it was also the result of a concerted effort to support the patient in this decision, coming from families, friends and the specialized program.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSubtheme 2.2. Conflicted perspectives: recognition doesn\\u0026rsquo;t always bring clarity, if it comes at all\\u003c/h2\\u003e\\u003cp\\u003eDespite these positive developments, not all patients and family members held the same views with respect to the role of cannabis impact on psychosis, and mixed opinions remained. Some patients reduced their use for reasons unrelated to their illness, while others continued to use cannabis despite experiencing ongoing symptoms, which was more concerning. Similar variation was seen among family members, with some clearly recognizing the harms, while others remaining uncertain or holding misguided beliefs.\\u003c/p\\u003e\\u003cp\\u003eSome patients had reduced or quit their use, which was beneficial to their health, but their decisions were driven by factors unrelated to their understanding of the deleterious effect of cannabis but rather motivated by financial constraints that made continued heavy use unsustainable. This might represent a potential area of vulnerability, should those circumstances change.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP10: I stopped using a large amount just because of a personal decision\\u0026hellip;I just decided it could be money\\u0026hellip;you don\\u0026rsquo;t have money so you can\\u0026rsquo;t go grab it today\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eMost concerning were the accounts of participants who continued to use cannabis despite experiencing ongoing psychotic symptoms. A few even believed that cannabis had mental health benefits, such as helping them socialize, boosting positive emotions, or distracting them from their symptoms.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP21: I feel like cannabis doesn\\u0026rsquo;t amplify psychosis that much. Like it gives you a good mental state and plus it allows you to socialize and stuff like that\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP1: Cannabis actually helps me out a little bit. It like, draws my focus away from my illness, and then I don\\u0026rsquo;t really pay attention too much to it.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eFamily members\\u0026rsquo; perspectives on cannabis also varied. Some showed limited awareness of its potential risks and even described cannabis as medicinal when used moderately. References to legalization were also mentioned, which is relevant in the context of Canada.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF2: With cannabis I imagine there are other drugs that are more you know, not as legalized so it\\u0026rsquo;s you know\\u0026hellip; Medicinal now too so I think\\u0026rsquo;s it, not using it or you know, in moderation of course but\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary, despite involvement in specialized programs, gaps persist in the understanding of cannabis and its impact on psychosis among several patients and family members. These differing perspectives highlight the ongoing challenges in developing a shared understanding of cannabis\\u0026rsquo;s role in psychosis\\u0026mdash; an understanding that is both highly relevant and essential for achieving optimal treatment outcomes.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eTheme 3. Shifts in relationships mirror shifts in recovery, and vice versa\\u003c/h2\\u003e\\u003cp\\u003eThe majority of participants described strained relationships during the early stages of illness. For those who improved, the recovery from illness occurred in parallel with an improvement in relationships. However, the direction of these associations varied, and was often bidirectional (e.g. once psychosis improved, relationships with family regained their closeness, but other times, an improvement in relationships lead to better health decisions that facilitated recovery).\\u003c/p\\u003e\\u003cp\\u003eIn early stages of illness, some patients described troubled relationships within the family that were long-standing. They were often the result of an abusive upbringing, which resulted in lack of trust, avoidance and isolation, perpetuating an insecure style of attaching in relationships into adulthood.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP24: \\u0026hellip; My only like female role models were ones that beat me and used me and called me stuff and so it was kind of hard to trust women like growing up and it kind of it was hard to interact and kind of be myself until my teenage years and then that kind of all went downhill after I moved because I was isolating myself again\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eP25: Well, I was isolating myself a lot\\u0026hellip;essentially, I couldn\\u0026rsquo;t trust anybody\\u0026hellip;\\u003c/h2\\u003e\\u003cp\\u003eFor others, relationship strain was intensified by more recent life events, including trauma in adulthood or harmful behaviours such as substance use and illegal activity. Several participants identified cannabis use as a significant factor contributing to relational breakdowns, often leading to disconnection from family or feelings of being misunderstood.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP26: I definitely stole from them, I took money I took like booze\\u0026hellip;I just wasn\\u0026rsquo;t like a really good person when I was sick or when I was using cannabis\\u0026hellip; our relationship was strained quite seriously.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP10: I felt like my parents never understood me since I was a kid\\u0026hellip;and that was even more\\u0026hellip;intensified when I started using cannabis, because they don\\u0026rsquo;t use.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn either case, the descriptions fit the characteristics of insecure attachment styles, lacking trust, impacting interpersonal reliance and safety, known to be significant risk factors for psychosis and relapse.\\u003csup\\u003e\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eEven patients who had access to supportive, well-intentioned influences faced relational challenges, brought about by illness itself. The onset of illness often brought confusion, fear, and mistrust, which disrupted existing relationships and created emotional distance between patients and their families. Some family members felt their loved was transformed by the illness, and described shifts in personality and behaviour that made it difficult to maintain closeness.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF6: We used to be close before all of this happened and it just felt like\\u0026hellip; he wasn\\u0026rsquo;t him for the past two years. Two, three years. But he is slowly getting back to himself but I know he will never fully be himself again.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe emotional distance created by the illness also often left families uncertain about how best to support their loved one. Some struggled to define their role early on in the recovery process, particularly when their loved one was an adult. They expressed fear of crossing boundaries or appearing overly controlling, recognizing that too much involvement could be counterproductive.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003e F8: We were very protective as parents not to not to \\u0026ldquo;save\\u0026rdquo; her in a sense, right? What 21-year-old wants to be saved. Nobody\\u0026hellip; it is like you think that you are being parented and then you just run faster and harder\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eBecause of this, even when family members recognized harmful behaviours, such as ongoing cannabis use, they often hesitated to intervene directly out of concern that doing so might further strain the relationship.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF4: \\u0026hellip;Hearing her cough, you know, knowing that that must be some inhaling going on. This\\u0026hellip;is frustrating. We have been careful not to tell her that she couldn\\u0026rsquo;t, or can\\u0026rsquo;t do that in our house, because we are concerned of what that might cause.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003ePatients also reflected on how their illness affected their social world, and described difficulties in forming or maintaining relationships.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP12: I realized I can\\u0026rsquo;t really handle friends at same time of schizophrenia.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eDespite these challenges, many patients reported a gradual shift in perspective as treatment progressed, likely influenced by the insights gained through the treatment program. This often translated into more openness to help from families, friends and professionals, and more selectivity in maintaining healthy influences and protecting from unhealthy ones. While this often resulted in having fewer relationships overall, the remaining relationships were described as being of higher quality (as reported by 12 out of 17 patients). Specifically, those relationships that endured were characterized as more supportive, respectful, and beneficial to the patients\\u0026rsquo; well-being.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP5: Oh yeah, I have lost tons of friends\\u0026hellip; Because I don\\u0026rsquo;t smoke and I don\\u0026rsquo;t drink that is all they do whenever they get together. So, I have a few friends now who don\\u0026rsquo;t pressure me, who don\\u0026rsquo;t judge, me who don\\u0026rsquo;t do those things.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP22: I think I was in some unhealthy friendships before I went through my psychosis\\u0026hellip; and going through my psychosis just highlighted that, and so after that episode, I actually cut out quite a few people from my life\\u0026hellip;I didn\\u0026rsquo;t make plans with family because I was with my friends\\u0026hellip;now that I\\u0026rsquo;ve quit using cannabis I see my family a lot more.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese re-established connections with healthy friends, trustworthy clinicians and/or renewed family support became paramount to successful treatment and recovery. Relying on these supports was described as essential to healing by 14 out of 17 patients, and by all 9 participating family members. These relationships ultimately became a pillar of support, extending even to everyday tasks such as medication reminders.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP23: I think I was in a pretty safe environment in general which helped... I think that if I had been on my own maybe the psychosis would have gotten a lot worse or been a lot more out of control because I had my parents at least being there for me\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP24: I give a lot of credit to my mom um for being there for me and kind of helping me move forward early on\\u0026hellip;now that I have moved out, she is always checking up on me and just making sure I am doing okay.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF2: Both me and my wife, his mother were supportive of him and whenever he goes, he comes with us now to go to the cottage and he brings his meds and we make sure he keeps that up to date\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese relationships were also described as serving as valuable models coping, supporting positive change and helping patients to replace previously engrained habits of drug use or other harmful coping methods.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP11: I will talk to my girlfriend when feeling real stressed out, when I would normally take drugs.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSimilarly, the improved relationships were beneficial for family members, who faced significant stress while witnessing their loved one\\u0026rsquo;s illness. Strengthened connections, in turn, enabled them to continue providing support throughout the recovery process.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF3: I think that is our main coping strategies, is with each other.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF4: I think *spouse\\u0026rsquo;s name* and I are closer together, closer now that we are now both retired and have more time\\u0026hellip; So, I think that probably allows us to support each other better and also to support (the patient) more.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary, the impactful role of healthy relationships in recovery was acknowledged by most patients and all family members. These positive relationships often came from family, but other times came from dating relationships, friends or professional supports. The role of these positive influences was reflected in the hopefulness for recovery and the willingness to make the necessary efforts to pursue it.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eTheme 4. Trauma at the centre: significant impact and insignificant recognition\\u003c/h2\\u003e\\u003cp\\u003eA majority of participants (12 out of 17) self-reported experiencing one or more traumatic events, including childhood abuse (n\\u0026thinsp;=\\u0026thinsp;5), sexual abuse (n\\u0026thinsp;=\\u0026thinsp;3), and physical violence (n\\u0026thinsp;=\\u0026thinsp;1). Notably, several participants (n\\u0026thinsp;=\\u0026thinsp;3) acknowledged a history of trauma but did not provide specific details, even when prompted. Moreover, patients seldom identified the direct relationship between their history of trauma and their diagnosis of psychosis. They were however more aware in describing the relationship between trauma and other risk factors creating vulnerability for psychosis. While each risk is important individually, psychological trauma stands out as especially central, since it is often closely connected to relational difficulties and substance use along the pathway to vulnerability. As with cannabis use, participants showed varying understanding of how psychological trauma relates to psychosis. While some saw a clear connection, others were unsure. Unaddressed, these risks also seemed to increase the likelihood of serious outcomes, including suicidality.\\u003c/p\\u003e\\u003cp\\u003eParticipants often described a link between past trauma and relational difficulties. One patient noted that unresolved trauma made it hard to trust others, which in turn limited the effectiveness of their medication.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP23: I think that those trust bonds that you know get destroyed with trauma and then with the psychosis I was just latching on to kind of anything that I could because I was bottling things up and not dealing with it properly. And medication only goes so far\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOther patients echoed this connection, explaining how early childhood trauma and abuse led to a lifelong difficulty trusting others.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP25: Yeah, like I have had childhood trauma where things weren\\u0026rsquo;t great as a kid\\u0026hellip;And that kind of affected me a lot throughout life\\u0026hellip;Not being able to trust people I guess is the main one. Losing trust in people.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP21: I think my trauma stems to the fact that I have trust issues because I still remember a lot of the abuse I got from my parents\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eFamily members also reinforced this connection, with one describing how their loved one\\u0026rsquo;s past trauma contributed to harmful relationship choices and behaviours.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF8: The trauma that happened, and the rebellion, and the losing of her friends, and you know kind of pushed her further to people that weren\\u0026rsquo;t good for her which pushed her further to being part of that party scene.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eCannabis and trauma were also closely intertwined, with cannabis often described as a harmful coping mechanism for managing past trauma. It was perceived as therapeutic or numbing, used to block emotional pain or thoughts of suicide.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP11: \\u0026hellip;there\\u0026rsquo;s some things that when you smoke weed you kind of forget about it. and it kind of makes the pain go away\\u0026hellip;so I can think that\\u0026rsquo;s one reason why I smoked so often.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP11: I just started smoking to help. I was always pretty depressed and felt really lonely and isolated so I was hopeless lots, thoughts of suicide at the time.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP22: It was actually after I was assaulted that I started using marijuana more.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eInterestingly, while many used cannabis to cope with trauma-related pain, it often increased their exposure to the very harms they were trying to escape. These patterns reinforced a cycle of risk, raising the likelihood of poor mental health and adverse outcomes. Three participants reflected on cannabis\\u0026rsquo;s dangerous potential, linking it to violence, psychological stress, and worsening mental health.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP5: \\u0026hellip; I started using cannabis even more so and the violence kind of just came at the same time\\u0026hellip; So started making bad friends and felt like the depression and suicidal thoughts kind of came at the same time while the violence grew and\\u0026hellip;yeah that\\u0026rsquo;s the best way I can explain that\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis decline in mental health also involved an increase in psychotic symptoms, with some patients acknowledging that past trauma likely contributed to the severity of their experiences during psychosis.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP11: Some of the stuff when I was having the psychosis, some of the thoughts I had were because of things that happened in the past, I think.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP21: \\u0026hellip;Over the course some of time, if you keep bottling it up, then suddenly it just, it just kind of like goes down to psychosis\\u0026hellip;And trauma has a lot to do with it.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eHowever, not all participants shared this view, as some patients and family members remained uncertain about the role of trauma, particularly in the early stages of illness.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP10: I\\u0026rsquo;m not sure. I don\\u0026rsquo;t know if trauma played a role (in my psychosis).\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF5: I just felt like we were so little, like the trauma wasn\\u0026rsquo;t that serious\\u0026hellip;I had no idea that the childhood abuse impacted him (the patient).\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOverall, leaving these risks unaddressed can be dangerous and may increase the likelihood of adverse outcomes, including suicide. Some participants described how unaddressed trauma, substance use, or relational difficulties contributed to greater vulnerability, including heightened suicidal thoughts and exposure to harm.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP21: \\u0026hellip;Well I almost committed suicide when I was still a kid back then and I was just unhappy\\u0026hellip; with what life is...\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF8: \\u0026hellip;that is why we put her in the hospital because we were like okay this is getting too risky. Her life is getting worse, she might actually get into like harm, getting hurt unknowingly by just being at the wrong place at the wrong time.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP27: When I was a teenager, I was suicidal\\u0026hellip;that was when I was going through being molested\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eOne patient acknowledged the severity of their experiences and expressed gratitude for having survived them, highlighting the dangerous situations that can arise over the course of illness when these risks are left unaddressed.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP22: When I was going through my episode, I am lucky I didn\\u0026rsquo;t die honestly.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary the three major risk factors of insecure attachment, psychological trauma, and cannabis use were present in most of the patients interviewed. Yet, as noticed earlier the recognition of these factors varied, and the interaction between them was often mentioned but not always seen as pathway towards vulnerability or illness. However, what most patients seem to recognize was the role of trauma in creating vulnerability for the other risk factors (cannabis use and interpersonal struggles), which ultimately amplified the psychotic risk. Unfortunately, none of the patients or family members fully recognized the close interplay between these three vulnerabilities in amplifying each other and the cumulative risk for psychosis.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eTheme 5. Looking forward: healing while belonging: the role of family and specialized programs\\u003c/h2\\u003e\\u003cp\\u003eThe path to recovery from psychotic illness is often marked by significant challenges. For some, the long and difficult process of adjusting to a diagnosis and engaging with treatment eventually led them to a specialized treatment program, which many described as a key turning point in their recovery. Both patients and family members expressed deep appreciation for the support they received through these programs. Family members also highlighted their continued commitment to their loved one\\u0026rsquo;s healing. As recovery progressed, participants described a growing sense of stability, optimism, and hope for the future.\\u003c/p\\u003e\\u003cp\\u003eBecause recovery is often complex and challenging, both patients and their families expressed deep gratitude for the comprehensive support provided by professionals at specialized clinics. This cohesive support offered by specialized teams, offered a sense of belonging and modeled healthy relationships, where hope and healing were possible again.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP26: EPIP was amazing. I had support for everything. I am so fortunate that I got into that program because I know a lot of people probably struggle with that and mental health and psychosis, and they don\\u0026rsquo;t get that chance to be a part of something like that.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eP27: Honestly, I think the Early Psychosis Intervention Program really changed my life for the better after going through my psychosis. I feel like the nurses; my nurse was an angel\\u0026hellip;I am telling you she was an angel heaven sent. She is the kindest, sweetest, most caring yet supportive person I have ever met.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF7: I think the biggest thing is his nurse has been fabulous\\u0026hellip;. Like his nurse had been a life saver\\u0026hellip;we couldn\\u0026rsquo;t have done it without him, he has been a life saver and has gone above and beyond.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn addition to supporting patients, EPIP staff played a key role in supporting family members. They helped families better understand the illness and treatment process, and included them in care and treatment planning whenever possible.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF8: The doctors at EPIP were good to us. They let us always come with them\\u0026hellip; And they listened. They were good listeners too.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF9: They have done a great job like explaining to us how psychosis works.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis added support for families was especially valuable, as many family members expressed unwavering commitment to their loved one\\u0026rsquo;s recovery and a strong desire to remain actively involved in the healing process.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF9: He is my son, that\\u0026rsquo;s that. I always put it into my mind that he is my son, I would not give him up.\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eF1: \\u0026hellip;Everything is always for him (the patient) in my life, it\\u0026rsquo;s always the best for him, and he knows that\\u0026hellip;\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eNotably, one family member even demonstrated an ability to adopt their loved one\\u0026rsquo;s perspective (a process known as mentalization) which may be crucial in building empathy and supporting communication, ultimately contributing to long-term treatment success.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF1: I was trying to put myself in his shoes and try and think of different scenarios how I can better understand him...\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eLooking ahead, many patients expressed optimism about the future and shared their hopes and goals. For some, returning to a sense of normalcy brought renewed hope and future-oriented thinking.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP55: I am fairly level headed now\\u0026hellip;. The only thing I wish was that I had a good career, well paying, family wife and kids. That is what I wish.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eP14: I do want to go to university\\u0026hellip;\\u003c/h2\\u003e\\u003cp\\u003ePatients also described a growing sense of acceptance and adjustment to their current circumstances, having learned to live with the realities of their illness, such as the need for ongoing medication. This adjustment was often accompanied by a reduction in symptoms and an overall improvement in quality of life.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP26: I think I am doing very well. I just got done work placement program. I am living on my own. I haven\\u0026rsquo;t had symptoms in over a year. I am doing very well actually. I am still taking medication but that\\u0026rsquo;s just kind of my life right now. I am keeping myself clean. I am keeping my space clean. I am really doing a lot better.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eSome patients even saw a silver lining in their experiences, reflecting on how their illness had brought unexpected insight or personal growth.\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP27: I think my illness was a blessing in disguise because it really you know, woke me up in a sense and showed me that there is a different way about things.\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn summary, specialized programs and their staff are often described as essential turning points in recovery from psychosis, alongside family support when available. As recovery progresses, hope and future-oriented thinking are frequently restored. Although the process is challenging, patients sometimes experience unexpected personal growth, highlighting the resilience that is created throughout their journey.\\u003c/p\\u003e\\u003cp\\u003eA summary of the topics discussed in the themes is presented in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eFigure \\u003cspan class=\\\"InternalRef\\\"\\u003e2:\\u0026nbsp;\\u003c/span\\u003eThis figure illustrates the interconnected roles of psychological trauma, insecure attachment, and cannabis use in contributing to the development of psychosis. These factors interact and compound individual vulnerability. Without intervention, psychosis may lead to relapse, chronicity, or suicidality. However, specialized, enhanced treatment that addresses these underlying risk factors can support improved outcomes and long-term recovery. Key components of care include medication, trauma-informed and attachment-focused interventions, cannabis cessation, and relational support through family and group therapy.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study explored the lived experiences of individuals diagnosed with first-episode psychosis, alongside perspectives from their family members, with a specific focus on how psychosis was experienced and how patients and family members understood the role of insecure attachment in relationships, psychological trauma, and cannabis use in creating vulnerability for illness and impacting recovery. Five interconnected themes were identified: \\u003cem\\u003e1) Confusion: the mark of illness onset, and a shared experience; 2) Cannabis: the snake in the grass; 3) Shifts in relationships mirror shifts in recovery, and vice versa; 4) Trauma at the centre: significant impact and insignificant recognition; and 5) Looking forward: healing while belonging: the role of family and specialized programs\\u003c/em\\u003e. Together, these themes highlight the challenges of navigating psychosis and show how these interrelated risk factors shape both the course of illness and the pathways toward recovery.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSummary and Implications\\u003c/h2\\u003e\\u003cp\\u003eIn the initial stages of the illness, confusion was a shared experience among patients, families, and even healthcare providers. Symptoms such as social withdrawal, mood changes, and unusual behaviour were frequently misinterpreted as signs of poor personality or discipline problems, rather than emerging psychosis. These misattributions often led to conflict within relationships due to ill loved ones feeling misunderstood, and contributed to delays in help-seeking, with many families only pursuing care once a crisis had developed. These findings align with previous research documenting delays in treatment and misinterpretation of early symptoms.\\u003csup\\u003e\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u003c/sup\\u003e Our study also adds novel insight, by emphasizing the importance of improved public education on psychotic disorders, which may help families with higher genetic risk recognize early signs of illness and seek care sooner. Additional training for primary healthcare professionals may also be warranted to support timely and accurate diagnosis and intervention. These findings may be especially relevant in publicly funded healthcare systems like Canada\\u0026rsquo;s, where early intervention services for psychosis are available, but awareness and access may still be limited.\\u003csup\\u003e\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe patients and family members\\u0026rsquo; awareness of the risk factors reflected their engagement and commitment to treatment, and the efforts to learn and adapt to the challenges posed by the illness. While significant progress was obvious in most cases, it wasn\\u0026rsquo;t the case in all participants, unfortunately. However, a certain pattern of understanding emerged, with cannabis being seen as playing a particularly complex role in participants\\u0026rsquo; lives, being described as both an initial helpful coping strategy and, eventually, a detrimental factor for recovery.\\u003c/p\\u003e\\u003cp\\u003eSome participants turned to cannabis as a way to manage anxiety or loneliness, or as a social tool to increase belonging. This finding is consistent with previous research suggesting that individuals with unmet attachment needs may use substances as substitutes for intimacy or emotional closeness.\\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u003c/sup\\u003e Despite this apparent facilitation of interpersonal bonds, the relationships that formed through cannabis use were often negative, marked by harmful decisions and behaviours, which further increased the cycle of vulnerability. Fortunately, many of the participants of the study became aware of the harmful effects on their relationships and mental health and eventually quit cannabis. This however, may reflect the benefits of specialized treatment programs that provide targeted psychoeducation on the harms of cannabis,\\u003csup\\u003e\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e\\u003c/sup\\u003e and might overestimate the likelihood of cannabis cessation in underprivileged areas, with limited access to specialized care. After quitting cannabis, patients described feeling closer to their healthy supports, reinforcing the idea that cannabis dependence can replace healthy attachments. Similarly, healthy relationships helped patients make healthier choices and stick to them. Yet, this wasn\\u0026rsquo;t something that was always clear or discussed within the network of supports for all patients. The dual role of cannabis seen in our study, as both initially appealing, but in fact insidiously damaging, echoes prior literature.\\u003csup\\u003e\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eDespite admittance in specialized programs and the benefits seen with cessation, not all of the patients interviewed were able, or willing, to quit cannabis entirely. There were varying levels of understanding among both patients and family members regarding the role that cannabis might have in relation to psychotic illness. Most alarming are the comments that cannabis might have some benefits, which often led to continued use despite experiencing clear symptoms. While the patients who continue to use received the same psychoeducation from their specialized treatment program as those who eventually quit, there is still a clear disconnect in understanding regarding its harmful role. This ambivalence or perhaps ignorance of clinicians\\u0026rsquo; advice may reflect a gap in knowledge between patients and clinicians. However, it could also point to broader societal shifts and attitudes in cannabis normalization, especially in the Canadian context.\\u003csup\\u003e\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e\\u003c/sup\\u003e This is further supported by a statement from a family member (F2) who referenced cannabis legalization, suggesting that cannabis may not be as harmful as other drugs simply because it is legal. These findings highlight the need for enhanced psychoeducation efforts that not only convey clinical risks, but also address common misperceptions shaped by public messaging and policy. Integrating attachment-informed approaches into early psychosis interventions may also help address the underlying relational needs that contribute to cannabis use.\\u003c/p\\u003e\\u003cp\\u003eRelationship patterns, particularly those rooted in early attachment, played a significant role in participants\\u0026rsquo; recovery. Many described histories of childhood instability or emotional neglect that affected their ability to trust others or seek support in adulthood. This is concerning, as secure attachment and strong social networks have been associated with more effective recovery, while attachment insecurity may contribute to cycles of avoidance, isolation, and worsening symptoms.\\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e\\u003c/sup\\u003e These relational difficulties often persisted into the illness period, contributing to isolation and disengagement from care. However, when secure, supportive, healthy relationships were re-established (either through family, peers, or clinical staff), they became a key source of support, coping, and healing for patients. Nearly all the participants who reported strong relational support also described positive recovery paths, with 14 out of 17 patients mentioning the positive role of these relationships. In some families, the experience of psychosis even appeared to strengthen bonds, subsequently creating a pillar of support for healing. In contrast, the three participants who did not indicate a healthy support system reported greater life dissatisfaction, lower functioning, and more frequent symptoms. These findings align with evidence showing that secure attachment predicts better clinical and functional outcomes in psychosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e Our study also adds to existing literature, by highlighting the importance of team-based, family inclusive healthcare models that not only involve family members in treatment plans when appropriate, but also provide them with direct support, recognizing their role in promoting the patient\\u0026rsquo;s recovery.\\u003c/p\\u003e\\u003cp\\u003eInterconnections between cannabis use, trauma, and insecure attachment were evident in participants\\u0026rsquo; accounts. These risk factors often formed a harmful cycle, with trauma frequently at the centre, ultimately contributing to a decline in mental health. This aligns with previous research linking trauma to a range of psychiatric risks and outcomes.\\u003csup\\u003e\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e\\u003c/sup\\u003e Some patients articulated a clear understanding of how these factors interacted and influenced their illness, while others struggled to recognize these connections. A similar variability in insight was observed among family members. Notably, patients who were less able to see the relationships between these risks often presented as more acutely unwell, experiencing communication challenges or difficulty with the interview process. This suggests that individuals with a deeper understanding of not only the individual risks but also their interplay may be better positioned for recovery. Given this variability, even among patients receiving the same specialized care, psychoeducation may need to be tailored to cognitive and emotional readiness. An integrative approach that contextualizes these risks in relation to one another may be more effective than a focus on symptoms alone, which risks overlooking the underlying drivers of psychological distress. These findings suggest that psychoeducation in early psychosis care may be more effective when it moves beyond symptom management to include tailored, integrative discussions that contextualize trauma, attachment, and substance use as interconnected drivers of psychological distress and recovery. While specialized programs often address these risk factors individually, they may not consistently highlight their interconnections, which is an important and necessary component emphasized by this research.\\u003c/p\\u003e\\u003cp\\u003eAs a result of these harmful patterns that sometimes went unnoticed, many participants described experiences of self-harm or suicide attempts, particularly during periods of cannabis use or relational instability. This is consistent with previous research linking these risk factors with increased suicidality.\\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e However, despite facing significant adversity (including trauma, strained relationships, substance use, and suicidality), most participants spoke of their experiences in the past tense, and several described them as turning points that motivated change, ultimately leading to greater self-awareness, personal growth, and stronger relationships. The majority of participants expressed hope, resilience, and optimism. These narratives suggest a potential therapeutic value in exploring past adversity as a means to build hope and resilience over time, which aligns with existing literature on recovery and post-traumatic growth in early psychosis.\\u003csup\\u003e\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e\\u003c/sup\\u003e This perspective helps support more nuanced, recovery-oriented approaches to care.\\u003c/p\\u003e\\u003cp\\u003eFor many, the path to recovery involved reducing cannabis use, strengthening relationships, and re-engaging with treatment. A central factor in this process was the role of specialized early intervention services. The EPIP clinic was consistently described as a safe and personalized environment that supported both patients and their families. This added support was invaluable, as all family members expressed a deep commitment to helping their loved one, something shown to be critical for recovery.\\u003csup\\u003e\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e\\u003c/sup\\u003e For those without stable family supports, some participants described their care team as stepping into a family-like role. These findings reinforce the value of multidisciplinary early psychosis intervention programs,\\u003csup\\u003e\\u003cspan citationid=\\\"CR65\\\" class=\\\"CitationRef\\\"\\u003e65\\u003c/span\\u003e\\u003c/sup\\u003e which not only address symptoms, but also fill critical relational gaps. This is in contrast to emergency care settings, which were often experienced as invalidating or inadequate, potentially undermining trust and delaying engagement.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eLimitations\\u003c/h2\\u003e\\u003cp\\u003eThis study has several limitations. First, participants were recruited primarily through the EPIP clinic and were all in the recovery phase of illness, which may have introduced sampling bias. Individuals who were more engaged in treatment and further along in their recovery may have been more willing to participate and reflect on their experiences. As a result, the findings may not fully represent the perspectives of individuals in earlier stages of psychosis or those with more limited treatment engagement. In addition, the study focused on patients\\u0026rsquo; and family members\\u0026rsquo; comprehension of psychological trauma, insecure attachment, and cannabis use, but other relevant risk factors such as other alcohol or substance use disorders, lifestyle, medical health, or socioeconomic disadvantage were not explored. Finally, no formal clinical assessments or chart reviews were used to corroborate participants\\u0026rsquo; self-reported experiences. However, quantitative data collected from this study will be reported elsewhere.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThis study contributes to the growing literature on lived experience and recovery in first-episode psychosis by illustrating the complex ways in which trauma, insecure attachment, and cannabis use interact to shape both illness and healing. These risk factors were often misunderstood, unrecognized, or unaddressed by patients, families, and healthcare providers alike, at least in early stages. Many patients and families lacked the foundational knowledge needed to navigate the illness, and healthcare systems were not always equipped to address these challenges. Our findings underscore the importance of early identification, family-inclusive support, cannabis cessation efforts, and trauma and attachment informed interventions, in addition to standard care. Integrated models that promote insight, encourage secure relationships, and build trust across systems may strengthen long-term recovery. More broadly, these results highlight the need for public education efforts that frame psychosis as a complex yet treatable health issue.\\u003c/p\\u003e\\u003cp\\u003eFuture research should explore the consistency of these findings across different specialized programs, but also in areas with less access to specialized care. Larger quantitative studies will benefit the exploration of possible pathways of vulnerability created by the interplay between these three main risk factors. We hope this study informs future research, supports the development of targeted interventions, guides educational and public health efforts, and ultimately enhances psychosocial treatment strategies aimed at improving engagement and recovery outcomes.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eEPIP\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEarly Psychosis Intervention Program\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eTHC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eΔ-9-tetrahydrocannabinol\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eSSS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eSchizophrenia Society of Saskatchewan\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research was reviewed and approved by the University of Saskatchewan Behavioural Research Ethics Board (Beh #565). All participants who took part in this study were consenting participants.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analysed during the current study are not publicly available due to confidentiality reasons, and the personal nature of the interviews, but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eRBL reports a past board membership with Shackleford Pharma Inc., consulting for Lewin and Sagara LLP, laboratory funding from private cannabis companies and patents\\u0026nbsp;pending to University of Saskatchewan. The other authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to acknowledge the support of the various scholarships and grants that enabled us to conduct and complete this work. These include the Department of Psychiatry\\u0026rsquo;s Intramural Award (including Laura E. Chapman award, Alfred G. Molstad Trust, and Aruna Kripa Thakur award), the Health Sciences Graduate Scholarship (2023 and 2024), the Saskatchewan Royal University Hospital Foundation Award, the Schizophrenia Society of Canada Foundation and Canadian Consortium for Early Intervention in Psychosis studentship, and the Canada Graduate Scholarships- Master\\u0026rsquo;s (CIHR) award. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSamantha Carley analyzed and interpreted all of the qualitative data, wrote the first draft of the manuscript, and read and approved the final manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDr. Robert Laprairie guided Samantha on data analysis, edited the manuscript drafts, and read/approved the final manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDr. G. Camelia Adams guided Samantha on data analysis, edited the manuscript drafts, and read/approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eDr. Stephen Adams edited the manuscript drafts, provided clinical relevance, and read/approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to thank Dr. Lloyd Balbuena, Dr. Linda McMullen, and Dr. Lachlan McWilliams for generously sharing their expertise on these topics.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; information\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSC is currently a PhD student at the University of Saskatchewan.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eAmerican Psychiatric Association. Schizophrenia spectrum and other psychotic disorders. 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Am J Psychiatry 175(5):443\\u0026ndash;452. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1176/appi.ajp.2017.17050480\\u003c/span\\u003e\\u003cspan address=\\\"10.1176/appi.ajp.2017.17050480\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"University of Saskatchewan\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Psychosis, First-Episode, Cannabis, Trauma, Attachment, Qualitative, Themes, Intervention\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7483679/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7483679/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003ePsychotic disorders are debilitating mental illnesses that affect individuals psychologically, occupationally, and socially. Several modifiable risk factors were shown to increase the risk for psychosis and associated consequences (i.e., severity, chronicity, and suicide). Research suggests that insecure attachment styles, history of psychological trauma, and substance use disorders (of which cannabis is the most frequent) can increase the risk for and severity of psychotic illness. However, it remains unclear how these known risk factors interact with each other and create different pathways of vulnerability. Most importantly, while clinicians are becoming more aware of these interactions, little is known whether these risk factors are recognized and addressed by patients and their families to prevent illness or support recovery. In fact, many clinicians report that patients and their main supports (family and friends) are often unaware of these risks or unable to address them. This study aims to fill this gap by qualitatively examining the understanding that patients and family members have regarding their illness and these risks for their illness, in order to better inform the interventions needed for optimal recovery.\\u003c/p\\u003e\\u003ch2\\u003eMethod\\u003c/h2\\u003e\\u003cp\\u003ePatients and family members were recruited from the Early Psychosis Intervention Program in Saskatoon and the Schizophrenia Society of Saskatchewan. Semi-structured interviews were conducted with 17 patients experiencing first-episode psychosis and 9 family members. Interviews were coded and analyzed using thematic analysis based on Braun and Clarke\\u0026rsquo;s 6-phase framework.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eFive major themes were generated: 1) Confusion: the mark of illness onset, and a shared experience; 2) Cannabis: the snake in the grass; 3) Shifts in relationships mirror shifts in recovery, and vice versa; 4) Trauma at the centre: significant impact and insignificant recognition; and 5) Looking forward: healing while belonging: the role of family and specialized programs.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e\\u003cp\\u003eOur findings reveal that patients and their families often have varying and inadequate understanding of the common risk factors affecting early psychosis. While the psychoeducation offered in the specialized clinic is highly valued, it is not always accessible or sufficient to alleviate these risks. The results highlight the necessity for targeted interventions aimed at increasing knowledge translation and treatment engagement.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Exploring Attachment, Trauma, and Cannabis Use in Psychotic Disorders: A Qualitative Study of Patient and Family Perspectives\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-01 10:43:22\",\"doi\":\"10.21203/rs.3.rs-7483679/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"29f2437d-f274-47d4-965d-893a131aa08b\",\"owner\":[],\"postedDate\":\"September 1st, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":53870030,\"name\":\"Psychiatry\"}],\"tags\":[],\"updatedAt\":\"2025-09-01T10:43:23+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-01 10:43:22\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7483679\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7483679\",\"identity\":\"rs-7483679\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}