The active participation of young adults with serious mental illnesses (SMI) in making decisions about their psychotropic medications is beneficial to their care quality and overall health. Many however report not expressing treatment preferences to psychiatrists. Qualitative methods were used to interview 24 young adults with SMI about their experiences making medication decisions with their psychiatrists. An inductive analytic approach was taken to identifying conceptual themes in the transcripts. Respondents reported that the primary facilitators to active participation were the psychiatrist's openness to the client's perspective, the psychiatrist's availability outside of office hours, the support of other mental health providers, and personal growth and self-confidence of the young adults. The primary barriers to active participation reported were the resistance of the psychiatrist, the lack of time for consultations, and limited client self-efficacy. Young adults with SMI can be active participants in making decisions about their psychiatric treatment.