Serious mental health problems among young people are on the increase in Western countries. Involving young people in their mental health care, and working in partnership with them during the treatment process, is a primary concern of all mental health services; their parents have also been promised a place in the health care team. Research into the process and outcomes of hospitalisation of young people in specialist mental health units is complex and therefore limited. Qualitative investigations into the experience of young people as users of these services are few. Making use of ethnographic methods, this study explored young people and their carers' (both parents and staft) experience regarding treatment and participation in decision-making in four Scottish adolescent inpatient or day-care mental health units. The findings suggest that the young people (n = 18) valued the personalised relationships they developed with the staff and their peers and that if these relationships were empowering, they facilitated both treatment and participation in treatment. However, the findings also show that the parents (n = 16) and staff members (n = 21) were sometimes disempowered and that this impaired the overall participative nature of the units. The unit culture was an important contributor to the effectiveness of young people and parent involvement. Making use of concepts from the neighbouring academic field of pastoral theology to interpret the findings, the study concludes with a conceptual framework of what is required for a unit to be more participative. This theoretical framework adds significant elements to the existing knowledge regarding participation in adolescent mental health units. It places relationships of justice and care between all stakeholders at the core of successful participation, hereby drawing attention to the importance of humanistic and ethical considerations in user and carer involvement.