Table 3.

Treatment Decision-Making Barriers and Facilitators with Exemplar Quotes

Barriers
Information/knowledge barriers (N=15) †
Too much information (N=4)	“I’m sure there was times when I got too much information. And especially when arguing because nobody gets their point across really” .
Not enough information (N=14)	“Well I felt unsure switching medications, because I didn’t know how it would affect my body. I didn’t know the side effects, until after the shot, then he told me. So I was worried about that” . Lack of knowledge linked to skepticism about treatment: “I would be taking [injection] once a month, and I was under the impression that I had to be taking medication every day, constantly, for it to work. So…I was just really skeptical about whether it would work or not” . Lack of knowledge linked to limited perspectives about available options: “It made decision-making difficult for me because I didn’t know whether or not there was other options I could take…” .
Negative past experiences bias processing of new information (N=6)	“[My past experiences] made me think that me and medication, we don’t work together. All the medications I’m ever going to take from here on out, it’s going to be bad” .
Social barriers (N=12)
Lack of trust/connection (N=5)	“It was a new person. I didn’t really know her like that to tell her my goals…” .
Perceived stigma (N=1)	“I felt that…the feeling I was getting from everyone else was something that would change the way that everyone looked at me. And I didn’t want to make anyone uncomfortable…” .
Others unavailable/unreliable (N=2)	“And I look at him and it’s almost like I can’t ask you for nothing. I can’t ask your opinion on what’s going on because you won’t give me the right answer. I watch the way you move and I can’t ask you for anything. I can’t go, ‘Dad, what should I do?’ because you can only give me so much because you live a certain way” .
Opposition/unwanted pressure (N=9)	“I feel like everybody wanted me to do one thing and I didn’t…And everybody was pressuring me to do the therapy and I don’t know why but they did” .
Internal barriers (N=12)
Cognitive challenges (N=1)	“It’s hard to make up my mind because mentally I’m fatigued” .
Communication challenges (N=1)	“All the times I wanted to tell my aunt about [the decision]…I didn’t know how to communicate to her about that” .
Low self-efficacy (N=2)	“Five years from now, where am I going to be at? Am I still going to be living off SSI? Am I going to be graduating from…college? What am I going to be? Am I just going to be another sick patient who can’t get it together?” .
Low motivation (N=11)	“Sometimes…I don’t feel like [making a decision]” . Low motivation linked to decision delay: “I felt like…if I motivated myself more or had someone motivating me like, ‘Think about meds more,’…I would have came to a quicker decision” .
Unappealing options (N=9)
Options inconsistent with preferences/sense of self (N=8)	Regarding activity groups at the program: “But I know activity is needed…to get up and moving – but there wasn’t much to do that kind of fit my interest of things” . Regarding difficulty with adjusting self-image after decision-making: “The reason why it makes it more difficult is because as soon as I took the injection, it’s like my whole self-image changed…I don’t even look like the same girl anymore…I gained like 50 to 60 pounds…And I’m not used to being this big. I’m used to being Miss Skinny Minnie and I got to get used to being bigger” .
No apparent benefits of any option (N=3)	“Because if I…stopped going to therapy, I automatically go in the hospital where I don’t want to be. And if I did go to therapy I might get my hopes up with this therapist and she leaves again” .
Facilitators
Information/knowledge facilitators (N=18)
Having desired information	“Well at first, I was just like, ‘No, I’m not taking any medicines. I don’t need it. I don’t want to. It’s going to be nasty. I’m going to have to swallow these pills, take these pills every day, and it won’t really help anything.’ Then we started talking more and more about it. She told me what they do. They help me relax, they help me to focus more, and they help. And she said they have very little to no side effects. And the one that got me to actually start taking medicines was I didn’t have to take pills. I could do an injection, and that worked” . Information linked to changing evaluations of the options: “It just made me think more about how there’s not all bad meds out there” .
Social facilitators (N=18)
Trust/connection (N=11)	“Well, I’ve built trust with my psychiatrist, and she kind of knew of my experiences before and what I was going through and kind of what my goals were and what I needed and how I was doing on the pill form of the medication. So when she recommended it to me multiple times, it was just kind of like I trusted her” . Connection as a motivator to stay in the EIP program: “I was thinking I don’t want to go to the program anymore…I ain’t quitting because I like the conversations that we have. Because it’s real, it’s unique, it’s intelligent” .
Learning from others’ experiences (N=7)	Learning from loved ones: “She went through some stuff that would, ultimately, make people feel like there is no hope, and she helped motivate me too when I started thinking about it…both my aunts actually…they helped me realize, ‘I’m doing it, too. I’m taking these [medications], too. It ain’t the worst thing in the world. You see me? Do I look okay?’ I’m like, ‘Yeah, you look fine. You look normal.’…It helped me because I didn’t feel like I was alone. So it boosted my confidence” . Learning from other program participants: “Well, what [other EIP participants] was experiencing is what I kind of experienced, so they kind of let me know, “Oh, [Participant], you’re not the only person who’s dealing with these problems” . Learning from media characters: “I always saw movies and clips and scenes of TV and the therapy, Will Smith movies, little clips like a therapy scene. And they just talking. So I was familiar of the concept of it…So it really didn’t scare me as much” . “I’d just seen [therapy] on movies, I’m like, ‘It don’t look like it’s helping [laughter].’” .
Encouragement (N=14)	“My baby mom, she was like, ‘Well, you got to do what’s best for you. Whichever one you feel best. Try some of them out, and then go back to see if there’s a different option that you could do.’ So she helped me make clearer my decision” . Positive pressure as a motivator: “It doesn’t make [decision-making] difficult. It just makes it more-- it gives you more motivation to complete it. That’s all. It’s like a hype man, basically, that’s shouting in your ear. It’s just some people hyping you on” .
Considering personal values (N=13)
Clear sense of personal values	Clear sense of personal values linked to narrowing down options when identifying treatment goals: “[I thought] about the things that were most important to me” . Clear sense of personal values as a motivator: “…after I realized, I got a son, that motivated me. It was like, ‘Yeah, you can’t keep feeling like this forever. You can’t keep feeling stuck on making a decision…’ So I was like ‘I can do this for you…I’m going to do this for my son’” .
Time (N=3)
Having ample time and space to consider a decision before taking action	“I was like, ‘All right. Give me some time. Give me a week or so, and I’ll come back to y’all. I’ll keep you posted on it.’ She was like, ‘Okay.’ After I got that time, then I realized – she gave me the information. I was like, ‘All right. Well, let me give that information to friends of the family.’ And after they got the information, they kind of helped me make a decision” . Repeated discussions about same decision linked to decision clarity: “So the more meetings we had, I started getting an idea of what I wanted to do with myself” .

^†N = Number of participants endorsing each theme. Ns within each theme are not mutually exclusive.