Table 4 Barriers to participation and retention in study - Agency of and burden on service users from the crisis and severe depression (Theme 2)

Clinicians pointed out that the decision to seek help from accident and emergency departments after an episode of self-harm was often made by family members or carers who persuaded the person who had self-harmed to get medical help, not necessarily psychological help. As a result they might have superficially agreed to participate in the research to get home quickly.

“A lot were wanting to put it behind them, people were a bit like, you know, no most people accepted actually, and would sort of say “yes yes yes”, having done it myself – you say “yeah yeah yeah I’ll fill in that thing for the prize draw” and you’re just saying to kind of move on.” (NHS Adult Site B)

Clinicians also reported that they tended to receive the same response if they offer an intervention, regardless of whether it is part of a research study.

“People just genuinely want to forget about it and don’t want to… they might agree to it at the time, but then when they think about it at home afterwards its, no I actually don’t want to be involved in psychiatry” (NHS Adult Site C)

Participants highlighted that both the initial response to participation in the study or psychological treatment reflects their mood.

“Personally, in some of my lowest times, had I been asked by a doctor to take part in something like this, I simply would not have gone back to the doctor. Not because I don’t feel that work like this is important but because when I’m struggling I don’t want to be given more pressures, no matter how slight, and I don’t want to be boxed into another part of the system when it’s taken all my energy just to take this one small step”. (Service User Group)

One participant highlighted that they took part because their depression symptoms were not too severe but would not have engaged if these symptoms were more severe.

“I think it was probably the perfect time, because I wasn’t, I wasn’t like down completely down in the dumps - I wasn’t like the best I’ve ever felt - I was sort of like in the middle, normal sort of…if completely down in the dumps, I probably would have took it on but it would have been a case of not answering my phone or you know missing appointments and forgetting and being you know still in bed and you know not hearing the door kind of thing, that’s, that’s what it’s like so.” (Participant, TAU)

Other participants struggled to engage in the study because of the recent distress leading to their self-harm episode while another chose not to participate in the study for this reason.

“I think it was a bit too soon because I was still in, obviously, a lot of shock… I was upset. They could have left me a couple of days and then come to see me.” (Participant, Intervention Arm)

“I think I was too nervous at the time to talk about it… maybe it was probably just too soon”. (Non-participant)

However, CAMHS clinicians noted that many children and young people will soon want to put their self-harm behind them and could be difficult to engage two to three days after the self-harm episode.

“That window of opportunity I think is quite brief that you can actually talk about it still in an objective way, and I think the longer you leave that – certainly over two or three days it’s gone.” (NHS Child & Adolescent Site A)