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Background Blended therapy describes the use of computerised therapy combined with face-to-face therapy to extend the depth, range and nature of the face-to-face therapy. We wanted to develop a treatment manual for a randomised trial of blended therapy combining face-to-face problem solving and a smartphone app in men who present to hospital with self-harm. Objective To develop a treatment manual and to describe the experience of receiving and delivering a blended therapy. Methods After completion of the blended therapy, semistructured qualitative interviews were conducted with participants to describe their experience of the treatment. Two independent coders analysed the material using a thematic, grounded theory approach. Findings Seven men were enrolled in the study, and six completed the qualitative interviews. The two main themes identified were of trust and connection. Participants attended 85% of their appointments. Conclusions In the treatment manual, we emphasised the themes of trust and connection by allowing time to discuss the app in the face-to-face to sessions, ensuring that therapists are familiar with the app and know how to respond to technical queries. Identification of trust and connection generates novel questions about the importance of the therapeutic alliance with technology rather than with people. Clinical implications Clinicians and app developers need to pay attention to the therapeutic relationship with technology as trust and good communication can be easily damaged, resulting in disengagement with the app. Blended therapy may result in increased adherence to face-to-face sessions. Trial registration number NCT02718248

KEY POINTS Suicide is one of the leading causes of death in Canada, with about 10 Canadians dying by suicide each day.[1][1] Men represent nearly two-thirds of those who die by suicide after an index episode of self-harm.[2][2] However, interventions for these men have had modest effects, with poor

The recent closure of rural health services in many developed countries has been a natural experiment as health planners strategically adopt regionalized systems of care to combat staggering healthcare system costs. Regionalization is predicated on offering health services in selected discrete locations (‘referral centers’) as opposed to in every local community of reasonable size. Where complex, specialistbased care is required, this approach is fiscally sensible, professionally sustainable and leads to good patient outcomes. When the dislocated service falls under the umbrella of ‘primary care’ (those services that in usual circumstances do not require specialist support but instead benefit from a generalist, wholistic model of care), the efficacy of care in referral communities is not as clear. Notions of ‘risk’, both of local care and care in a referral center, is at the heart of this discussion. This phenomenon is perhaps best illustrated with the case of rural maternity care. The purpose of this Editorial is to extrapolate contemporary theories of risk and apply them to a current and pressing health service delivery issue as a way of illuminating their usefulness in framing the discussion.