Substance Use in Early Psychosis: Mixed Methods Impact on Family

Abstract

Objective.

Nearly half of people with early psychosis report lifetime problematic substance use. Current treatments have limited impact on substance use and supporting the client’s family could improve recovery. The current study explored: 1) the impact of substance use and early psychosis on the family, and 2) experiences with their client relative’s treatment.

Methods.

Participants were family members (n=19) of clients with early psychosis and substance use. We used quantitative and qualitative data from the Community Reinforcement and Family Training for Early Psychosis and substance use (CRAFT-EP) pilot study to assess family members’ views.

Results.

Many participants reported concern about the client’s cannabis use and its negative impact on family wellbeing and communication, with most participants wanting more guidance on how to support the client’s treatment.

Conclusions.

Implementing family interventions are needed to improve family relationship quality and communication to promote recovery among people with early psychosis who use substances.

Introduction

Almost half of people with early psychosis have lifetime problematic substance use, especially alcohol and cannabis (Brunette et al., 2018; Shinn et al., 2017). Substance use poses challenges to treatment engagement and worsens symptoms and quality of life (Conus et al., 2010; Doyle et al., 2014; Oluwoye et al., 2019). Existing early psychosis treatments have limited impact on substance use (e.g., Cather et al., 2018; Johnson et al., 2019; Madigan et al., 2013; Siddiqui et al., 2024). However, involving family and natural supports in treatment could help address substance use in early psychosis care, aligning with treatment guidelines for clients with early psychosis (Claxton et al., 2017; Dixon et al., 2015; Mueser et al., 2015) and substance use (Bagley et al., 2021; Hogue et al., 2021). Working with families may also help address family conflict and caregiver burden that are common in families of young adults with problematic substance use and psychosis (McCann et al., 2011; Sadath et al., 2017; Wan & Wong, 2019) and are associated with poorer outcomes (Copello, 2022; Velleman et al., 2005).

Involving family in the treatment of people with early psychosis and substance use is growing in importance, and people with early psychosis are often open to family involvement (Jones et al., 2021). However, families are often not engaged (Hogue et al., 2021; Iyer et al., 2023; Oluwoye et al., 2018) or retained in psychosis treatment (Mueser et al., 2009). Understanding the family’s perspective on substance use and early psychosis treatment may aid in better implementing family components of care. The current study was aimed at characterizing the impact of substance use and early psychosis on the family and family experiences with their client relative’s treatment through secondary analysis of a pilot trial of telehealth Community Reinforcement Approach and Family Training (CRAFT; Meyers et al., 1999). We adapted CRAFT for family members of clients with early psychosis and substance use (CRAFT-EP; McCarthy et al., 2022). Examining these family perspectives has the potential to improve treatment engagement strategies and outcomes for individuals with co-occurring early psychosis and substance use.

Methods

We conducted a mixed methods secondary analysis of data from the completed single-group feasibility pilot of CRAFT-EP. We used quantitative survey data from baseline assessments and qualitative data from open-ended baseline survey responses and session 1 transcripts to assess family views on 1) the impact of the client’s substance use on the family, and 2) the client’s treatment engagement and level of family involvement.

Participants

Participants were family members (n=21) of clients with early psychosis and substance use who enrolled in the trial at an academic medical center between 2020 and 2021. Eligibility included: 1) 18–70 years of age, 2) having a client relative with (a) psychosis onset less than 6 years ago (McCarthy et al., 2022) (schizophrenia, schizoaffective disorder, schizophreniform, psychosis not otherwise specified, delusional disorder, brief psychotic disorder, major depression with psychosis, bipolar disorder with psychosis) and (b) who had used cannabis, alcohol, or nicotine in the past 90 days or had previously used one of those substances with no immediate interest in abstinence (e.g., due to restricted access to substances), 3) being the family member(s) who could best describe the client (in terms of their substance use, treatment views, and general behavior), 4) having in-person or electronic contact with the client on at least 4 days over the past month, 5) access to video conferencing, and 6) the ability to speak/read English. Exclusion criteria were family members having: 1) DSM-5 moderate or severe substance use disorder in the past year based on the Structured Clinical Interview for DSM-5 Research Version (SCID-5-RV; First et al., 2015), 2) history of psychotic disorder per the SCID-5-RV, 3) history of domestic violence with the relative, or 4) psychiatric, cognitive, or medical impairments that would interfere with the ability to follow through with the intervention. One participant withdrew prior to beginning the CRAFT-EP intervention due to significant prior experience with CRAFT, and one participant had missing data from the first coaching session due to a recording technical difficulty; thus, we report results for n=19 participants.

Procedures

The Mass General Brigham Institutional Review Board (ClinicalTrials.gov #NCT04284813) approved all procedures in accordance with the Declaration of Helsinki. After completing phone screens, participants provided written informed consent and completed assessments at baseline, mid-, post-intervention, and three months following the final CRAFT-EP coaching session on HIPAA-compliant Zoom. Study data were collected and managed using secure REDCap electronic data capture tools hosted at Mass General Brigham (Harris et al., 2019; Harris et al., 2009). Participants were compensated $165 for completing all assessments.

CRAFT-EP Intervention

The CRAFT-EP telehealth intervention included eight weekly, 1–1.5-hour, individual coaching sessions via Zoom video conferencing. Session content included self-care, communication, functional analysis, positive reinforcement, treatment engagement, natural consequences, problem solving, and review/next steps. CRAFT-EP aims to enhance readiness to change substance use, increase treatment session attendance (or treatment entry for those not connected to care), and improve family relationships and well-being. Of note, adaptations from the original CRAFT protocol include an option for psychosis and substance use psychoeducation, “Milestone Conversations” to gather key information to guide subsequent skills practice (e.g., positive reinforcement, treatment engagement), and inviting the client to join a session to share how the family member can be most helpful to support the client in recovery; see McCarthy et al. (2022) for additional adaptation details. Given the integrated nature of CRAFT-EP, family members flexibly apply skills to their self-defined priority needs (e.g., inviting the client to discuss how to manage substance use in ongoing therapy, consider medications, allow for family meetings with the treatment team). Data from session 1 were included in the analysis of the impact of substance use and psychosis on the family and experiences with the client’s treatment (see next sections).

Measures

Demographics and clinical characteristics.

At baseline, participants completed a demographic interview and the SCID-5-RV to characterize the sample and assess eligibility.

Impact of substance use and psychosis on the family.

To measure family member perceptions of the client’s substance use and psychosis, participants answered in the baseline interview: “Which substance (drug or alcohol) do you view as the most problematic for your relative (Alcohol, Marijuana, Nicotine, Other)? How confident are you in your answers regarding your relative’s substance use (Not confident, Somewhat confident, Very confident)? How serious do you think your relative’s [most problematic substance] use is 0=Not at all to 10=Extremely?”

Family perceptions of treatment engagement.

At baseline, participants responded to questions about whether the client was engaged in mental health treatment in the past 30 days, the nature of the treatment (e.g., coordinated specialty care program), history of substance use-specific treatments (e.g., self-help groups, detox), perceived degree that treatment focused on substance use, perceived treatment goals, and appraisal of current and desired personal involvement in the client’s care.

Coaching Session Qualitative Data

Impact of substance use and psychosis on the family.

In the first coaching session, participants were also asked to share their family’s experiences with substance use and psychosis and how life would be different if the client reduced their use of substances or started addressing their substance use in treatment.

Family perceptions of treatment engagement.

In session 1, participants discussed how they have tried to help the client to address their substance use in treatment, why they would like help now, and what they would like to gain from the CRAFT-EP program.

Data Analysis

Descriptive statistics were computed to characterize the quantitative data. Qualitative data from session 1 were analyzed using thematic analysis (Braun & Clark, 2006) to further inform the needs and perspectives of families with a client experiencing early psychosis and substance use. One research staff member transcribed session recordings, and a second member reviewed and confirmed transcription accuracy. Two research assistants independently reviewed transcripts for potential themes on the impact of the client’s substance use and psychosis on the family and perceptions of the client’s treatment engagement. They developed a codebook and independently coded the deidentified data with JM (principal investigator), resolving discrepancies and refining themes as a group. We followed the Standards of Reporting Qualitative Research (SRQR) guideline (O’Brien et al., 2014).

Results

Sample Characteristics

Demographic characteristics were previously reported (McCarthy et al., 2022) and are briefly summarized in Table 1. Most participants were non-Hispanic white women, all were parents except for one sibling, and two pairs of participants were related family members who completed separate individual coaching sessions.

Table 1.

Family Member Demographic Characteristics n=19

Age (years), mean (SD)	54.42	(8.87)
Sex, # (%)
Female	18	(95)
Male	1	(5)
Gender, # (%)
Female	18	(95)
Male	1	(5)
Race and ethnicity, # (%)
White	18	(95)
Asian	1	(5)
Non-Hispanic	20	(100)
Education (years), mean (SD)	17.47	(2.17)
Marital status, # (%)
Married	16	(84)
Divorced	2	(11)
Never married	1	(5)
Children, mean (SD)	2.47	(0.90)
Living with identified patient, # (%)	14	(74)
Work status, # (%)
Full-time	8	(42)
Part-time	9	(47)
Unemployed	2	(11)

Impact of Substance Use and Psychosis on the Family

At baseline, participants reported moderate (3–7 out of 10; n=8) to high (8–10; n=6) concern about the client’s most problematic substance use (M=7.4, SD=3.2). Participants were most concerned about the client’s cannabis use (n=14, 74%), followed by alcohol use (n=3, 16%) and nicotine use (n =2, 10%). Regarding types of cannabis, participants reported clients using flower/bud (n=9, 47%), edibles (n=5, 26%), oils (n=3, 16%), tinctures (n=1, 5%), and hashish (n=1, 5%). Participants reported that clients using alcohol were drinking beer (n=13, 68%), liquor (n=11, 58%), and wine (n=9, 47%). According to the participants, almost half of clients (n=9, 47%) were using nicotine products: electronic cigarettes (vaping; n=7, 37%), combustible cigarettes (n=4, 21%), pouches (n=9, 47%), spliffs (tobacco leaf wrapped around cannabis flower/bud; (n=1, 5%), and chewing tobacco (n=1, 5%). Participants estimated that clients used their most problematic substance an average of 38% of the past 30 days. Many participants were concerned about the effects of the substances on the client’s psychosis and other psychiatric symptoms (e.g., depression, anxiety). Of note, both participants who reported being most concerned about the client’s nicotine use also reported the client used other substances. Overall, most participants reported they were “very confident” in their knowledge regarding the types and frequency of the client’s substance use (n=13, 68%).

Theme 1: Need for Better Family Member Communication Due to Substance Use and Psychosis Problems.

In session 1, most participants expressed interest in improving communication skills with their client relative (n=17, 89%), “I get frustrated with him. I need a better way to communicate with him. We don’t really talk about his marijuana use or anything like that now.” Clients’ efforts to obtain substances such as theft, psychosis symptoms, and participants being blamed for facilitating the client’s hospitalizations led to additional family conflict, which manifested partly through tense and unpleasant communication or avoidance of communication; see Table 2 for illustrative quotes.

Table 2.

Themes

Theme	Illustrative Quotes
Impact of Substance Use and Psychosis on the Family
Theme 1: Need for Better Family Member Communication Due to Substance Use and Psychosis Problems	“When he is high, it’s really hard for me to stay in a loving space.” “We had a terrible blow-up because he stole some money and went and bought weed with it, so I just lost it, I was furious.” “Every time he has said to me ‘you put me in the hospital.’ I just say okay let’s stop, I didn’t put you in the hospital, I called because I was afraid for your safety and mine...I still think he’s angry.” “It would be easier to address the substance use if he was not disconnected from reality right now...it’s very hard to have a conversation with him about the importance of staying off substances because it clearly exacerbates...his psychotic symptoms.”
Theme 2: Worry about the Relative’s Relationships with Other Family Members and Friends	“His behavior affected the whole family...his brothers, our marriage, the way we parent our other sons.” “He’s lost all his friends.” “Even his friends were encouraging him to stop smoking pot because they saw the effect it was having on him, and they were all the kids who would smoke with him.”
Theme 3: Worry about the Impact of Substance Use on the Psychotic Disorder	“[Cannabis] was part of the whole psychosis [episode], so I was told by a number of practitioners a number of times that not only right now while [my son] is recovering, but forever [he] shouldn’t be using it.” “[I want to] have conversations with [my son] about...addictive substances and things that he has to look out for and for him to understand that it might be more dangerous for him than for other people to smoke marijuana.”
Theme 4: Caregiver Burden	“He’s a young adult, [but] emotionally, I still feel that it’s my job and it’s my fault if things did not go well in his life.” “I would love to be able to reduce my own anxiety about it, and to really, truly, give over responsibility to [son].” “I feel like I could be myself versus having to be the caregiver.”
Theme 5: Fear of Enabling Substance Use	“I feel like we are silently allowing it and I feel bad about it...it was just better to let him do what he needed to do with marijuana because of fear of what else he might do...When we said, ‘Don’t do marijuana,’ he went out and found pills he could do...things just seemed like they were going to escalate so dangerously that everyone just said let’s pull back and let’s not upset the apple cart.” “How did it feel to be in a position to supply him? Not that great, but I felt it was a compromise that I could make at the time. I’m not willing to make it anymore.”
Theme 6: Ambivalence and Minimizing Substance Use Compared to Other Recovery Challenges	“The nicotine products we’ve allowed, that was the one thing we started when he stopped everything else...he was in such a state of distress...so we started allowing him to get that...and I thought well it’s better than everything else.” “I mean he’s alive, that’s how I look at it...it’s keeping him alive right now, so I don’t have time to have feelings around [substance use] ...before I had a lot of feelings around it.”
Perceptions of Treatment Engagement and Family Involvement
Theme 1: Desire for and Barriers to Relative Engaging in Treatment	“[Our son] was literally sitting with us waiting for the [telehealth] appointment, and then when...[his psychiatrist] was going to appear, he just ran out of the house, like in a panic...we didn’t know the extent of some of his delusions, but he’d thought he was being livestreamed.” “The piece that’s missing is the insight and...I don’t 100% believe that she believes there is a problem.” “It feels like for a while every two or three weeks he was with a different team.” “He doesn’t want to let his boss down by taking time off to do any of the therapy.”
Theme 2: Lack of Communication with Relative and Exclusion from Treatment	“When he first came home, he completely avoided us and was always in the basement.” “He stopped listening to me and confiding in me.” “We were like what is going on? And he’d just say, ‘I can’t explain it to you, I can’t explain.’” “I feel like I know very little about what they’re working on in therapy.” “He moved through stages. So, every time he was with someone new, in the very beginning I was pretty involved. And as it’s gotten along, like right now, I’ve never spoken to his doctor.”
Theme 3: Desire for Information on How to Support the Relative	“We’re supporting her. We’re trying to figure this out. We don’t know what we’re doing.” “I’m trying to collect as much information as I can to do right by [my son]” “The support group...doesn’t really give us any sort of meaningful tools...there isn’t really a lot that I’m aware of that I can draw on in terms of resources” “ [I want] tips...in terms of...asking him to abstain from marijuana.”

Theme 2: Worry about the Relative’s Relationships with Other Family Members and Friends.

Participants described concern about substance use impacting the client’s other family members and friends (n=11, 58%), “I’m sure [my younger son] was very afraid of [my older son] and afraid that my husband and I couldn’t control the situation.” This participant highlighted feeling blamed by the younger son for “let[ing]” the older son use illegal substances at home. Additionally, participants expressed worry about how the client’s unstable mood and behavior (attributed to substance use and psychosis) had jeopardized their friendships, “Even his friends were encouraging him to stop smoking pot because they saw the effect it was having on him, and they were all the kids who would smoke with him,” or ended those friendships.

Theme 3: Worry about the Impact of Substance Use on the Psychotic Disorder.

Participants were concerned about substance use worsening the course of the psychotic disorder (n=14, 74%), “[my son] knows well that [cannabis] is the one substance that could knock him back into relapse.” Participants also wanted to help the client understand how using cannabis increases their risk of having a symptom exacerbation.

Theme 4: Caregiver Burden.

Many participants (n=11, 58%) described the weight of responsibility when caring for their relative, “I’ve been a single parent…it’s been a huge, heavy load on me all the time….It is my turn, and I should be able to finally go and have my life…I feel like I’m going to be taking care of [son] for a very long time.” Participants also described how relieved and liberated they would feel if the client no longer had a substance use problem.

Theme 5: Fear of Enabling Substance Use.

Several participants (n=4, 21%) were also afraid of unintentionally having enabled the client’s substance use, “I definitely think I’ve enabled him…I was giving him a fair amount of money every month, after the fact when he was no longer drinking, he told me I supported his drug and alcohol habit.” Others chose to allow cannabis use because they were even more concerned about the client using other substances.

Theme 6: Ambivalence and Minimizing Substance Use Compared to Other Recovery Challenges.

Some participants (n=5, 26%) described mixed feelings about the client’s substance use, “I think he knows at all times that smoking marijuana is not something we approve of…I would really not say anything most of the time because I felt like he had enough to deal with and if that made him feel better for five minutes, you know, what the heck…I don’t see that as all that different from all these drugs that people have been giving him his whole life.” Participants also expressed views minimizing substance use compared with other clinical concerns such as depression and “keeping [the client] alive.”

Perceptions of Treatment Engagement and Family Involvement

At baseline, 89% (n=17) of participants had client relatives who were currently enrolled in outpatient psychiatric treatment with 74% (n=14) engaged in a first episode psychosis coordinated specialty care. Participants reported that they believed the client rarely discussed substance use with treatment providers (M=3.0, SD=2.7). Most participants believed that the client had never attended substance use-specific treatments (n=13, 68%). All participants stated that they thought the client’s treatment goals targeted recovery areas other than reducing substance use, with most (n=11, 58%) believing that the client’s treatment focused primarily on managing symptoms and stress. Participants rated their own current involvement in the client’s treatment on average a 5.9 out of 10 (SD=2.6). Most participants (n=12; 63%) reported that they would like to be more involved in the client’s treatment with the remainder desiring no change.

Theme 1: Desire for and Barriers to Relative Engaging in Treatment.

Participants wished for the client to start or be more engaged in psychiatric treatment. Many participants were concerned about the client’s current mental health (n=18, 95%), substance use related to psychosis (n=14, 74%), and medication adherence (n=11, 58%). Multiple participants (n=8, 42%) wanted the client to be more engaged in psychiatric treatment, participating in additional components of existing treatment (e.g., therapy, medication, groups), attending more appointments, and/or discussing substance use and specific recovery goals. For instance, one participant reported, “I can’t even get him to see this therapist…he’s going from inpatient to inpatient for stabilization, but it’s kicking the can down the road.” Others noted that the client would meet with a new provider for only a session or two due to forgetting appointments, paranoia, and denying a need for treatment. Participants also described barriers that impeded the client’s ability to access to quality care such as lack of providers for clients not engaged in treatment, difficulty finding suitable and consistent providers with experience in both psychosis and substance use; limited frequency of contact with providers even in coordinated specialty care; and scheduling conflicts with work.

Theme 2: Lack of Communication with Relative and Exclusion from Treatment.

Many participants (n=17, 89%) experienced communication difficulties talking about mental health, managing conflict, and even being in the same space with the client that led to a lack of communication. This information void created uncertainty about the status of the client’s substance use, psychosis, and treatment. Participants shared that communication with the client decreased over time, which in some cases were due to evolving privacy preferences, “Once he turned 18, he doesn’t want me involved at all.” The lack of communication made participants unaware of major events in the client’s life (e.g., quitting school) and extended to the client excluding them from their treatment.

Theme 3: Desire for Information on How to Support the Relative.

Given limited communication with the client and involvement in their treatment, participants reported wanting more information about the client’s diagnoses and how to manage their substance use and mental health needs (n=14, 74%), “I have been asking from the day he got to [the hospital]…for some sort of parent support or therapy or something to help me help him. And so, I’m not really sure the best way to react…I don’t know if I’m making it worse.” Of these participants, n=9 reported wanting to be more involved in the client’s treatment, whereas the other n=5 did not. Thus, not all family members who wanted more information about how to help their relative wanted to be more involved in their relative’s treatment. Without sufficient information, participants some reported being unsure about how to effectively promote the client’s autonomy while also ensuring their safety and wellbeing.

Discussion

Much of what we know about family perspectives on addiction has focused on alcohol and drugs other than cannabis (Archer et al., 2020). However, cannabis use is an important concern in early psychosis as it both increases the risk of developing a psychotic disorder (Jefsen et al., 2023; Marconi et al., 2016) and of relapses following the onset of the disorder (Levi et al., 2023). In the present sample, the majority of participants reported that their relative’s use of cannabis was their greatest substance use concern. Our results complement prior work by characterizing families’ experiences primarily with the client’s cannabis use, which remains a top drug of choice for people with early psychosis (Cather et al., 2018).

In the current study, substance use of a relative with early psychosis had a multifaceted negative impact on the family, including poor communication between families, clients, and clinicians, worry about substances impacting client relationships with other family members and friends, and increased risk for relapses of psychosis. Participants also described their experience with caregiver burden, worry over enabling substance use, and ambivalence toward and minimizing of substance use compared to other aspects of recovery.

The communication difficulties represent the high level of conflict present in many families when discussing potentially polarizing topics like substance use, fearing the unknown, disagreements, dishonesty, and blame. Realistic concerns and negative views about relatives’ substance use disorders and/or psychosis could fuel family conflict and expressed emotion (a stressful communication style) (Phillips et al., 2002). Challenges with the greater social network align with reported social functioning difficulty among people with early psychosis (Robinson et al., 2004). Participants’ concerns about ongoing caregiving associated with the client’s psychosis and substance use are consistent with prior reports of increased caregiver burden for a relative with co-occurring schizophrenia and substance use disorder (Yerriah et al., 2022). People with early psychosis report appreciating their family’s love and support, especially from mothers (Boden-Stuart et al., 2021). However, fear of enabling a relative’s substance use was another participant concern. With increasing legalization of recreational cannabis, which reduces perceived risk of cannabis (Hammond et al., 2020), family members were understandably ambivalent about their relatives’ cannabis use despite its role in precipitating relapses of psychosis. Such ambivalence may also stem from higher priority concerns such as suicidality. Depression (prevalence up to 80%) and suicidality (up to 63%) can affect people experiencing a first episode of psychosis (Upthegrove et al., 2010). Thus, families who viewed potential depression and suicide as a greater risk than psychosis exacerbation may have less concern about cannabis use if they believe that cannabis might ease their relative’s distress. Overall, the impact of substance use and early psychosis on the family was significant and led to participants wanting greater support in helping the client.

Themes regarding perceptions of treatment engagement and family involvement included the desire for and barriers to the client’s treatment entry or further engagement in treatment, lack of communication and exclusion from the client’s treatment, and interest in professional guidance on what family members could do to better support the client’s recovery. Although most clients were already engaged in psychiatric care, many participants believed the client needed to be further engaged in substance use and psychosis treatment. Barriers to accessing quality psychiatric treatment in general may involve systemic workforce capacity constraints or limited adoption of or familiarity with integrated treatment for co-occurring disorders (Harris & Edlund, 2005). Internal barriers to engagement like anosognosia or limited insight regarding the need for treatment may also exist, as low insight is associated with interpersonal difficulties in early psychosis (DeTore et al., 2022).

Participants wanted to be supportive of the client’s recovery, but some participants’ interactions with the client and their treatment providers were limited, leaving them guessing how best to proceed despite being open to improving their communication. This lack of communication and involvement in treatment could partly be attributed to their relative’s substance use (Drapalski et al., 2018), illness-related factors (e.g., paranoia, anxiety), poor social skills (Miller et al., 2021; Mueser et al., 1993), or avoidance of negative family affect (Niv et al. 2007). Clients’ “sealing over” coping style (Mueser et al., 2010), feeling “unheard” in the family, and fear of upsetting or burdening others (Boden-Stuart et al., 2021) may also lead to difficulty having conversations about mental health. Alternatively, lack of family involvement in treatment may be due to providers’ limited efforts to motivate and work with clients to involve their families in care, and/or communicate with families even when the client is willing (Eassom et al., 2014). Thus, families experience the “paradox of not being invited to contribute to health-care discussions about the patient, despite being required to ‘care’ for them” (p.13, Outram et al., 2015). Of note, participants who experienced greater difficulty with knowing how to support the client may have self-selected to learn CRAFT-EP more than those with sufficient involvement in the client’s treatment.

Clinical Implications

First, our results emphasize the potential benefit of interventions that improve the quality of communication between family members, their relative(s) with substance use and early psychosis, and the clinical team. Second, the results suggest the utility of strategies to motivate clients and providers to actively involve families in care by systematically offering education and support to clients and family members on how to engage in successful interactions that all parties find helpful. Interventions that family members can access regardless of their relative’s involvement may improve treatment engagement and family communication and wellbeing. For instance, Community Reinforcement and Family Training for Early Psychosis and substance use (CRAFT-EP; McCarthy et al., 2022) and motivational interviewing (Kline et al., 2022; Kline et al., 2021), could be particularly helpful in instances where families are not currently part of the treatment conversation.

Limitations

The study has several limitations. First, the generalizability of these results may be limited as the sample was treatment-engaged/treatment-seeking and was homogeneous demographically and by family role. Participants were primarily mothers, like prior family studies (e.g., Clark, 2001), and views on substance use and mental health concerns can differ by race, gender, and culture (e.g., Thornton et al., 2013). Future research would benefit from including a more diverse set of families. Second, although we invited the participants’ relative to participate in the present study, very few opted to do so (n=4, 21%). Reasons for the enrollment of individual family members in the research rather than dyads involved participants’ concern about possibly upsetting the client by disclosing family engagement in the study coaching, the client’s ability to complete study procedures given current symptom severity or potentially exacerbating symptoms should recounting past experiences prove overly stressful, and client time constraints. Including both perspectives would be helpful to examine the concordance of perspectives on substance use, treatment, and preferences for family involvement in care. Third, we report on a small sample size. Given that the course of family recovery in early psychosis may improve over time (Addington et al., 2005), it is likely that family perspectives may depend on the stage of their family’s recovery journey. Future larger sample sizes may allow for a fine-grained analysis of families across substance use and psychosis trajectories. Fourth, this study was monocentric (greater Boston area) and may not generalize to other regions. Larger studies including representation from multiple regions (e.g., states, countries) and settings (e.g., rural, urban) would contribute to a more comprehensive understanding of family experiences with early psychosis and substance use.

Conclusions

Families of people with substance use and early psychosis want to support relatives in helpful ways and are often uncertain about how to do so most effectively. Creating opportunities for families and their relatives to communicate and gain professional and/or peer guidance on how to navigate substance use and early psychosis in an integrated manner may aid in overall recovery for the entire family.

Data availability statement:

The data that support the findings of this study are available from the corresponding author, JM, upon reasonable request.