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. 2025 Jun 18;81(10):930–939. doi: 10.1002/jclp.70007

Understanding Adolescents' Perceived Barriers to Engagement in Online Cognitive Behaviour Therapy Programs for Anxiety and Their Ideas for Enhancing User Experience

Emma‐Leigh Senyard 1,2,✉, Arlen Rowe 1, Govind Krishnamoorthy 1,2,3, Sonja March 1,2,3
PMCID: PMC12419237  PMID: 40531591

ABSTRACT

Background

Self‐Help Internet Cognitive Behavioural Therapy (iCBT) interventions are highly efficacious and overcome numerous barriers adolescents experience when accessing face‐to‐face interventions, including stigma, privacy, lengthy wait lists and cost. Despite this, adolescents struggle to engage in Self‐Help iCBT, which is problematic given that there is a relationship between higher engagement and better treatment outcomes. The reasons for poor engagement among adolescents are unclear. Using the iCBT program, BRAVE Self‐Help as an example, this study explored (1) the barriers to engagement directly from the adolescent's perspective and, (2) their viewpoints on enhancing engagement in iCBT.

Methods

Semi‐structured interviews were conducted with 14 adolescents aged 12–17 years (M = 14.36, SD = 2.12) who had participated in BRAVE Self‐Help in the previous 12 months. Reflexive thematic analysis was utilised to analyse data.

Results

Stigma, program factors (program design, content and length) and environmental factors (competing priorities and distractions), were identified as adolescent barriers to engagement. With respect to strategies to enhance engagement, adolescents identified (1) specific program factors (positive reinforcement and personalisation), and (2) support factors (reminders and optional support).

Conclusions

Codesign methods with adolescents at both the design and implementation stages of iCBT programs is imperative for engagement.

Keywords: adolescence, anxiety, child and adolescent mental health, child clinical psychology, cognitive behavior therapy

Digital Mental Health Interventions (DMHIs) are becoming widely used and accepted (Philippe et al. 2022). Internet Cognitive Behaviour Therapy (iCBT) is an effective DMHI for many mental health conditions, including depression and anxiety (Christ et al. 2020). iCBT overcomes many barriers faced by adolescents in accessing traditional therapy, including long waitlists, stigma, privacy concerns, lack of available services and financial constraints (Vigerland et al. 2016). Further, adolescents participating in iCBT do so usually without parent facilitation, unlike face‐to‐face therapy which relies on parents who may be involved in treatment or at least transport them to and from appointments (Grudin et al. 2024). Therefore, iCBT may allow for increased access and scalability of evidence‐based treatments.

Despite evidence showing that adolescents prefer self‐help interventions (Gulliver et al. 2010) and have positive attitudes towards computerised programs (Sweeney et al. 2019), many adolescents struggle to engage with iCBT and fail to complete more than a few sessions, or even any sessions at all (Calear et al. 2013; March et al. 2018; Spence et al. 2019). For example, March et al. (2018) found that only 30% of young people had completed more than three sessions of BRAVE Self‐Help, a self‐directed iCBT intervention for youth anxiety. Similarly, in an iCBT self‐help program for adolescents targeting anxiety and depression, MoodGYM, Calear et al. (2013) found that only 15% of the 1477 adolescents completed at least 20 of the 29 exercises in the program. Given that higher engagement in iCBT is linked to better clinical outcomes (El Alaoui et al. 2015; Hadjistavropoulos et al. 2016, and March et al. 2021), low program adherence and completion rates threaten the potential viability of iCBT approaches. For instance, in March et al.'s (2018) study of 4425 young people who completed BRAVE Self‐Help, there was a significant negative correlation between completed sessions and anxiety scores. Specifically, those who completed at least six sessions showed the greatest symptom improvement in anxiety, with over 70% of young people no longer being clinically anxious after nine sessions (March et al. 2018). Thus, there is a clear need to understand the reasons for low engagement to increase the success of such programs for adolescents.

There have been only limited attempts to understand the reasons behind poor engagement in self‐help iCBT programs, especially from adolescents' perspectives. In a systematic review, Borghouts et al. (2021) identified three broad factors that influence engagement in adult iCBT programs, user‐related factors (demographic factors, personality, beliefs, and mental health status), program‐related factors (social connectedness, content, guidance offered and perceived usefulness and fit) and factors associated with technology and implementation (privacy, usability, technical issues, social desirability, and cost). For youth, in one study that interviewed parents regarding barriers to their adolescent's engagement in BRAVE Self‐Help, Muller et al. (2024) identified that competing priorities, higher anxiety severity, lower existing health knowledge, poor usability, and lack of perceived usefulness were factors that could negatively affect engagement. Though this highlights the potential barriers to adolescent engagement, adolescents themselves were not directly consulted in this study. Understanding problems of engagement from adolescents'perspectives is crucial in identifying strategies to enhance their engagement.

Research examining methods for enhancing engagement in iCBT self‐help programs is varied, with suggestions including a “virtual coach,” designed to provide automatic feedback (Provoost et al. 2020), the use of Codesign (Radomski et al. 2019; Spence et al. 2019) and persuasive design (PD; e.g. avatars, reminders, personalisation, positive reinforcers, and progress monitoring). Whilst in its infancy, there is some research with adult iCBT programs to show the importance of PD and Codesign in producing higher levels of engagement and better treatment outcomes (Kelders et al. 2012; McCall et al. 2021; Patterson et al. 2022). In the limited literature on enhancing adolescent engagement, Radomski et al. (2019) identified that PD iCBT interventions, when delivered with a level of support (e.g. parental or therapist support), are related to moderate to high levels of program use. However, it is unclear whether this is the case for self‐directed iCBT programs. Thus, while there is some knowledge regarding the potential factors associated with adolescent engagement, and some strategies identified that might enhance engagement, the perspectives of adolescents, for whom the interventions are intended, has largely been ignored.

This study has two broad research aims. First, to understand the barriers to engagement in iCBT programs from an adolescent viewpoint, and second, to explore adolescents'ideas for improving engagement in these iCBT programs. A subsidiary aim was to explore the barriers and strategies for improvement across younger and older adolescents who may differ in the way they use iCBT. Results of this study will inform the conceptualisation of engagement within iCBT and facilitate the development of adolescent‐informed strategies for improving engagement and subsequently, the efficiency and scalability of self‐help iCBT interventions for anxiety.

1. Methods

1.1. Participants

Participants were fourteen adolescents aged between 12 and 17 years (M = 14.36 years, SD = 2.12), including four males (28.57%) and 10 females (71.43%). Younger adolescents were classified as being in the 12 to 15‐year‐old age group and older adolescents were defined as 16 or 17‐years old. Adolescents'location was categorised using the Australian Statistical Geography Standard, 3rd Edition (Australian Bureau of Statistics 2021) and described as “urban” or “rural.” Demographic, clinical information and number of sessions completed was gathered upon registration to the study, and a breakdown is provided in Tables S1 and S2.

To be included in this study, participants were required to have taken part in BRAVE Self‐Help (a 10‐session self‐guided iCBT program for adolescents with anxiety aged 12–17 years) in the last 12 months. Specifically, they had to have self‐registered for the freely available online program at least 10 weeks before being interviewed for this study, to allow enough time to complete the 10‐session program. As we were most interested in understanding why adolescents commence iCBT programs, but fail to continue, participants were required to have at least started the first session to ensure they were familiar with the program content, structure, and appearance and, therefore, could provide insights into their experience with the program. Participants included adolescents who completed between one to 10 sessions. Only participants with elevated anxiety levels when registering for the program were invited to participate, in line with the intended audience of BRAVE Self‐Help. In total, 977 eligible adolescents were invited to participate, with a 1.4% response rate. The mean age of all eligible participants was 14.02 years and 75.8% were female. Further information about BRAVE Self‐Help can be found in Material S1.

1.2. Intervention Description

BRAVE Self‐Help for Teenagers is an iCBT intervention for anxiety for adolescents aged 12 to 17. Adolescents who engage with the program have shown clinically meaningful and statistically significant reductions in anxiety (March et al. 2018, 2021). The self‐help program is based on the therapist‐assisted version, which has demonstrated efficacy across several randomised controlled trials for adolescents (Spence et al. 2006; Spence et al. 2011). The program is delivered in ten web‐based, interactive weekly sessions of 30 to 60 min each, followed by two booster sessions one‐ and 3‐months post‐completion of the 10‐session program (Spence et al. 2008). BRAVE employs CBT‐based strategies to target anxiety, including psychoeducation, cognitive restructuring, physiological awareness, relaxation, graded exposure, problem‐solving strategies, positive reinforcement and guided imagery (Spence et al. 2008). Homework tasks are assigned each week to consolidate and enhance learnings from each session (Spence et al. 2008). Reminders are sent to participants via email to complete sessions. The program is completed without therapist support, and sessions can be completed at any time, but must be completed sequentially. To access BRAVE Self‐Help, users must have an Australian‐based Internet Protocol (IP) address (Spence et al. 2008). There are no other restrictions to accessing the program; however, it is intended as an intervention for those with anxiety (March et al. 2018; March et al. 2021). Adolescents can self‐refer and self‐register for BRAVE Self‐Help at any time. Participants are recruited via internet‐search, social‐media advertising or may be referred by parents, schools, mental health professionals (e.g. doctors, psychologists and counsellors), teachers or Guidance Counsellors. Adolescents under the age of 16 require parental consent before participating in the program (parents/caregivers email addresses are gathered upon registration and a link is sent to their email asking them to provide consent for their child to participate in BRAVE Self‐Help). Once registered and all consent requirements are obtained, adolescents have immediate access to their first session. BRAVE Self‐Help is intended to be completed privately, without the presence of others, unless adolescents request social or parental support while participating.

1.3. Data Collection

This study was approved by the University of Southern Queensland Research Ethics Committee (Approval: H20REA291) before commencement. Participants had previously provided consent to be contacted for future research when they had registered for BRAVE Self‐Help. A BRAVE Project Officer (AR) sent email invitations with email addresses having been obtained from the BRAVE registration database. The email invitation contained a description of the research and a survey link to REDCap, a secure online program for managing data and online surveys (Research Electronic Data Capture 2022). Within REDCap, participants were provided the participant information sheet before giving informed consent to participate in the study and their contact details to arrange the interview with the Researcher. Participants under the age of 16 were required to obtain parental/caregiver consent, by parents being emailed program information and indicating consent separately to the adolescent.

A semi‐structured interview schedule (see Material S1) was developed using Braun and Clarke (2013) recommendations (i.e. non‐judgemental, open‐ended questioning), and explored participants'perceptions of the facilitators to engagement in iCBT programs. Interviews were conducted via telephone at a time convenient to the participant and were between 20‐ and 30‐min duration. All interviews were conducted by the first author for the benefit of consistency in interview style. The interviewer was not known to participants and had not previously been part of any BRAVE research projects. Participants were offered the opportunity for their parents to sit in on the interview if they wished and advised that they could have a break or cease the interview at any time. One participant (OM, a male aged 12) chose to have their parent sit in on the interview. Participants provided consent for the interview to be audio‐recorded and transcribed anonymously. All data collected and stored was deidentified. Participants were mailed a $40 gift voucher once the interview was complete in appreciation of their time commitment.

1.4. Data Analysis

Reflective Thematic Analysis (RTA) was used to analyse transcribed interviews (Braun and Clarke 2006). This study employed a predominately deductive approach, grounded in empirical engagement literature and the research aims, allowing the analysis to reflect the existing data (Braun and Clarke 2022). The influence of the research team's own theoretical and epistemological backgrounds was acknowledged and considered. Participants'verbatim transcripts were analysed utilising Braun et al.'s (2006) six steps to thematic analysis. Initially, transcripts and interviews were listened to numerous times by author ES to ensure accuracy and immersion in the topic. Following this, identification and generation of initial code and textual units for patterns and features amongst all interview questions was conducted by authors ES, SM and AR. Via a collaborative process with ES, SM and AR, meaning was elicited through analysing segments within the data and allowing opportunity for data immersion and reflection. Following identification of codes, themes and sub‐themes were then generated by EM, SM & AR via a reflexive, deductive process. In several meetings, discussion and feedback on data interpretation and analysis occurred, which allowed for theme and subtheme refinement (Braun and Clarke 2022). Themes generated were those that reflected meaningful, salient patterns in the data, in line with Braun and Clarke (2022) recommendations, and that were relevant to the study's research questions. Lastly, data extracts (quotes) were identified in the data for final write‐up by ES.

2. Results

RTA produced three main themes concerning the barriers to iCBT engagement and two main themes around enhancing engagement. These themes are summarised in Table 1 below. Interview questions that were closed in nature (e.g. Yes/No response), or that were not related to this study's research questions (e.g. BRAVE program likes and dislikes, and specific BRAVE program feedback), did not generate a theme and were not included in this paper's findings, respectively.

Table 1.

Themes and subthemes identified via RTA.

Research question Theme Subtheme
Barriers to engagement Stigma
Program factors
Environmental factors Distraction
Competing priorities
Enhancing engagement Program factors Positive reinforcement
Personalisation
Support factors Reminders
Option of support
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2.1. Barriers to Engagement

Participants described three broad barriers to engagement (1) stigma, (2) program factors, and (3) environmental factors.

2.1.1. Stigma

Whilst privacy and anonymity are benefits of iCBT, adolescents described stigma as a barrier to engagement, particularly if they had to complete the program in the presence of others. Adolescents spoke about feeling “embarrassed,” “judged or uncomfortable,” and fear that “people might know that I suffer from anxiety,” in both the school and home environments. This subsequently deterred their engagement in BRAVE Self‐Help. For example, AS, a female aged 17, who completed BRAVE Self‐Help in the school environment, noted, “You don't want to get labelled or characterised as the anxious/depressed kid in the class, and you become the sad kid, and everyone starts looking at you differently.” Here, AS highlighted the stigma attached to completing iCBT programs, and the desire to conform to the norm of not seeking mental health interventions, even when they are online. A male, aged 17, added, “There's social stigma about mental health. I'm more than certain that's not just my school, but schools all over the country.” Younger adolescents shared similar perspectives, with 12‐year‐old HG stating that “Sometimes people don't have the confidence to reach out in case people found out.”

Some participants noted that private spaces would reduce the stigma attached to engaging. To illustrate, HG stated that in the school context, “If they could find a safe place to do it at school or with a counsellor in a private space, they might feel more comfortable to start and finish the program.” While, 16‐year‐old CB commented about how it was hard to do the program at home as they did not have, “…private spaces to be able to sit there,” and they had “siblings nearby.” Here, adolescents highlighted that the anonymity and confidentiality of iCBT programs only extend so far, and that stigma remains a concern for adolescents, at least when delivered in an environment that is not completely private.

2.1.2. Program Factors

Factors related to the iCBT program itself, including the program design, content, and length of the program, were also expressed by participants as a barrier to engagement. Multiple participants spoke about how the program was experienced as monotonous and repetitive which resulted in them not completing the programs or sessions. A female aged 15 also commented about how the program design was unappealing for them, particularly in relation to the avatars used in the program, “It didn't become harder, it just became a little bit boring and really repetitive, so I stopped. I think for some people characters and scenarios are good, but others, it's a bit too young for them.” When talking about why he ceased the program early, RL, aged 12 spoke about both the repetitive nature of the program and the program design.

It became a little bit boring because there were a lot of checks for understanding, just re‐capping the same thing over and over. Maybe different ways of learning the same thing would be good. I kind of prefer visuals and interactive parts, like comics. I like that.

Thus, while self‐help iCBT programs are designed to facilitate self‐learning through repetitive application and practising of skills in different contexts without the support of a therapist, here, this was a barrier to engagement. In addition, adolescents highlighted the importance of considering the breadth of ages using the programs and whether the content would be suitable for all ages. For example, a 12‐year‐old may find avatars engaging, but older adolescents may find them condescending. This highlights the importance of designing the program with adolescents'developmental stage in mind, and the importance of age specific Codesign.

In addition, numerous adolescents of varying ages and both genders described the sessions and homework tasks as “very long,” hindering their engagement in the program. RL, aged 13, stated, “I just felt like there was a bit too much work, and so I stopped.” LA aged 16 added “It was long, I couldn't be bothered trying to do the textboxes and type things in. Homework tasks I couldn't be bothered.” Adolescents highlighted that iCBT is time‐consuming, particularly when completed as prescribed (i.e. completing all in‐session and homework tasks) and some even suggested that it required more effort than face‐to‐face therapy. A 12‐year‐old female IB commented,

There's other things like counselling and stuff, it takes a lot of time to do online things. It can be difficult to find time to do online things, because you're busy doing schoolwork, sport, music or whatever. It's easier to access and use a counsellor, otherwise you just forget and it's hard to be motivated when you've got other stuff on. It just takes too much time and work to do.

2.1.3. Environmental Factors

Factors external to the program, namely distraction and competing priorities, were also raised by adolescents as a barrier to engagement in the program.

2.1.3.1. Distraction

Adolescents identified distractions from outside environments as clear barriers to completing sessions and activities within the program. This was particularly the case for older adolescents, who described text messages as such barriers, “It's like, when you're trying to do something, and then your phone buzzes, and you see that it's like one of your mates texting you, and then you reply back and get distracted,” (AN, a female aged 17). These concerns are unique to iCBT, given it is inappropriate social etiquette to have a phone present in face‐to‐face therapy, and highlight the need to identify strategies to mitigate adolescents'distractibility and poor impulse control when engaging in online programs, particularly for older adolescents.

2.1.3.2. Competing Priorities

Older adolescents in particular spoke about competing demands that took priority over BRAVE, “… I was a bit busy with school…. It can be hard to complete it whilst you are trying to get schoolwork done,” (AS, 16 years). In addition, all participants (including younger adolescents) highlighted that the numerous demands of adolescence, such as social occasions, extracurricular activities and family commitments, might inhibit an adolescent's ability to fully engage in iCBT programs. ZB, a female aged 17, reflected, “I just got super busy with sport, school, casual work, and life and completely forgot about it.” A younger adolescent, aged 14, added, “I didn't end up completing it because I felt it was too much with everything else on.” Older adolescents who are completing their final years of schooling also reflected that prioritising iCBT programs over their many other conflicting demands was difficult. As adolescents age and develop their identities and personalities, it is not unusual for them to spend many evenings and weekends engaging in casual employment, obtaining a driver's license, social events, relationships, extracurricular activities and family commitments, in addition to completing homework and assessment tasks to obtain their High School Certificate. While this theme is likely not unique to iCBT programs, when combined with perceptions that face‐to‐face therapy would be less effortful and provide more accountability, competing priorities seems a significant barrier to engagement in online programs.

2.2. Enhancing Engagement

All participants identified strategies to enhance adolescent engagement in iCBT programs. Two themes were evident in the data: (1) program factors, and (2) support factors.

2.2.1. Program Factors

Two subthemes pertaining to program factors were identified: (1) Positive Reinforcement and (2) Personalisation.

2.2.1.1. Positive Reinforcement

Both younger and older adolescents felt that positive reinforcement through “unlocking” new games, or encouraging, motivational messages would be a beneficial strategy for enhancing their engagement in iCBT programs. A male, DM aged 17 explained that rewards in the form of games would be helpful in increasing engagement, “Games or rewards would definitely help people get more, not excited, but get people more involved in the program… getting points if you do certain activities, might be something to encourage people my age.” In terms of rewards, a 13‐year‐old male, LJ also spoke about using games as rewards and noted, “… a reward that could be anything, like access to a new, fun section,” and DM spoke about gathering “points,” for completing sections of the program, “…a little avatar, I guess, which can get points, and be happy, that kind of thing, if you do certain activities.” Other participants spoke about pop‐ups reinforcing participants'progress as a method to enhance engagement. For example, CL, a female aged‐13, explained, “I like when you finish something (and) it gives you like congratulations and like “that's really good.” To add, LJ highlighted that messages of encouragement already embedded in the program were helpful for her engagement, “So, just inside the program every now and then, there would be like a little motivational thing that came up.” Overall, participants had numerous ideas for positive reinforcement which included games, or “fun” sections could be achieved or “unlocked” as users progress through the program, and simple messages of encouragement. This theme was shared across participant ages and genders and reflected the importance of adolescents'desire to experience praise and reinforcement from iCBT programs.

2.2.1.2. Personalisation

A view shared across age groups and genders was that personalisation of iCBT programs to the individual would enhance engagement. Participants referred to this as personalising the activities and tasks to the adolescents'own design preferences and clinical presentation. While adolescents recognised this as difficult to achieve noting, “It's not possible to cater to absolutely every single individual,” they suggested that “it might help them be more engaged by personalising to each type of person.” Like traditional face‐to‐face therapy, adolescents also spoke about the importance of tailoring the intervention based on individual activity preferences. For example, CB noted, “I would like games, but others might like quizzes.” Adolescents here were suggesting individualisation similar to an in‐clinic CBT approach where the therapist would collaborate with the adolescent and design the treatment plan based upon their preferences in receiving CBT (e.g. talk therapy, worksheets, play therapy or art and craft). One adolescent spoke about tailoring the program based on clinical presentation, although this adolescent had misunderstood the level of support that would be provided during the program; 17‐year‐old female ED stated,

I'd probably just say, at the beginning, maybe just let them talk (write) a little bit about the things that are stressing them out at the moment. Because that's what I wanted, just someone or something to know what I was struggling with. I think most of them (other participants) probably go in with the same idea I had, that it would be like an online person and that they'd want to say what they're stressed to, because it's definitely someone that they can tell, but it's not going to be their parents or someone. So I feel like that's probably the biggest thing that people would stop it for, because even though you (the program) mention it once or twice, it would be good if the first two or three sessions were to be like “What are you stressed about? How can we help you?” and then the next one like “Are you still thinking about this? What can we do now,” try a different strategy.”

An older, 17‐year‐old male, DM spoke about what support he wanted for his mental health in iCBT programs, adding, “…at the start you try and identify what you need psychological help with and then focus the BRAVE program more around that.” Harder to achieve in iCBT, adolescents raised desires to be similar to face‐to‐face CBT, whereby a treatment is tailored to the individual's presenting concerns. Employing a ‘one‐size‐fits‐all’ approach to iCBT programs for adolescents runs the risk of disengagement if adolescents are not getting what they wanted out of the program.

2.2.2. Support Factors

Participants also spoke about support factors as an important tool to enhance engagement. Adolescents highlighted the importance of reminders and the option of support as subthemes.

2.2.2.1. Reminders

A dominant subtheme, reminders to use the strategies taught in the program and to do homework tasks, was raised by participants across ages and genders as a strategy to enhance engagement and skill rehearsal. A 17‐year‐old female, AS, noted, “A friendly reminder sort of slips it into your mind.” ZB, aged 16, further noted that these reminders could include statements to encourage participation, reporting, “You could send them a reminder stating, “It's not over yet, the program could really help with your anxiety.” Participants advised that reminders delivered could also include statements to prompt the use of skills; A younger participant, 14‐year‐old female RL, also spoke about how having reminders to use the skills in the program would be beneficial, “I needed some reminders when I was doing the program to use the strategies…when I was doing exams, I had forgotten to use what I was learning.” Participants also reported that using a variety of formats (e.g. text message, email or smartphone notification) to deliver reminders would be helpful.

While many iCBT programs such as BRAVE or MoodGYM are fit with general reminders via email or text message, adolescents expressed a desire for reminders to incorporate much more than just prompts to do homework or complete the program, but reminders to use and apply the strategies taught in the program, messages of encouragement and messages highlighting the efficacy of the program. Adolescents had different ideas about ways in which they receive reminders, including email alerts, smartphone notifications, text messages and pop‐ups within the program. As such, from adolescents'perspectives, having a choice of delivery (i.e. through reminder preferences options within the program) and much more personalised reminders may enhance their engagement.

2.2.2.2. Option of Support

Participants across genders and ages also identified that having optional support may enhance program engagement. Participants identified that the targets of support should be to assist with program accountability, understanding and application of skills, accessing resources and therapeutic support. For example, 17‐year‐old female, AS commented, “Support is good, I know for me, it helps me just knowing that someone knows that I'm doing it, I guess.” OM, a male aged 12, added, “Support to check if you're okay and if you don't understand, to explain it to you.” Surprisingly, these views were raised by the same adolescents who raised concerns with the anonymity of iCBT but highlighted the unique challenges adolescents experience as they become more independent.

Importantly, adolescents identified that support in the program should be optional and flexible. “Probably not something that I would be interested in. I do think having the option for others might be good for others just to talk to,” (female, 16 years). While a younger female adolescent, IB, a 12‐year‐old stated, “I think a person checking in with you would be great, even if it was just every four or five sessions or something.”

Another female aged 16 added,

(Support) would be good. Well, maybe not straightaway—one of the good things about it being online, it's kind of like really casual, I guess, and it's if not, there's someone there. But then maybe just halfway through or something or after a few sessions, it might be an option for it—optional.

There was less consensus on the mode and frequency of support, with adolescents'ideas ranging from emails and text messages to online therapists and phone calls or teleconferencing. Some reported that “zoom,” would be helpful for support, while, others endorsed emails or text messages “…like if you could get an email or like a text every so often maybe like once a fortnight checking in to see how you were doing (male, 13 years).” Therefore, optional support, and allowing a choice in how support is delivered, may cater to many more adolescents.

3. Discussion

Adolescents raised several user‐related, program‐related, and technology and implementation factors influencing their engagement in iCBT. Stigma, program factors and environmental factors were all identified as being barriers to engagement by participants. In relation to enhancing engagement, participants identified the program factors of positive reinforcement and personalisation, as well as support factors, as important in optimising engagement.

3.1. Integration of Codesign, Persuasive Design and User Involvement in Treatment Planning

Consistent with adult iCBT literature and parents'perspectives on barriers to engagement for youth, adolescents identified program‐related factors, including being unappealing, lengthy and lacking personalisation as barriers to engagement (Borghouts et al. 2021; Garrido et al. 2019; Muller et al. 2024). Specifically, adolescents thought that tailoring iCBT programs to their unique program design preferences and clinical presentation so that they could have more decision‐making and collaboration with the program as is done in traditional therapy, would be helpful in increasing engagement. Typically, standard self‐help iCBT programs have struggled to replicate and integrate these aspects of face‐to‐face therapy (e.g. personalisation, ownership, shared decision making and collaboration in treatment planning) into online programs. Therefore, consideration of both PD (e.g. personalisation, gamification, progress monitoring and positive reinforcement) and codesign with adolescents beyond the user interface and experience design level of iCBT programs, but also at the content and modality level (e.g. identification and development of treatment components and modalities of the program as they receive it), is needed to better personalise iCBT and enhance overall engagement.

For example, some adolescents also highlighted the potential use of gamification (employing game‐design and principles delivered in an entertaining manner to enhance intrinsic motivation) via iCBT programs having activities gamified in terms of design, to enhance engagement (Fleming et al. 2017). Other adolescents spoke about the importance of incorporating positive reinforcement into iCBT programs to enhance user engagement. Adolescents have higher levels of responsiveness to rewards and novelty than adults, and therefore respond well to positive reinforcement as a way to create behaviour change (Galvan 2013; Harden and Tucker‐Drob 2011). Whilst rewards have already been effectively incorporated into many iCBT programs, in the present study, adolescents spoke specifically about different positive reinforcers, such as “unlocking” new sections of the program or playing a “fun,” game once they have completed a section. Research has not yet uncovered if such methods are effective for adolescent iCBT programs targeting anxiety; however, adolescents have positive attitudes towards gamification (Gkintoni et al. 2024), and 97% of children have computer games in their homes in Australia (Brand et al. 2017). It is unknown if such elements detract from the effectiveness of CBT material and learning for adolescents. Some research exists that supports both codesign and PD as being helpful in enhancing engagement in iCBT programs, particularly for adults (McCall et al. 2021; Patterson et al. 2022), but it is important to implement these strategies across different age cohorts (Lattie et al. 2022; Muller et al. 2024).

3.2. Inclusion of Privacy Protocols

Despite the benefits of iCBT typically including confidentiality and anonymity (Carlbring et al. 2018), it was clear from this study that adolescents had concerns over privacy and related stigma when using iCBT, especially if these programs were being completed in a structured, group setting (e.g. school) or shared space (e.g. home living area). ICBT programs are generally suggested to be completed privately, thus, potentially overcoming barriers of stigma and confidentiality, however, adolescent environmental challenges (e.g. limited computer resources or internet access) and/or running iCBT programs in open‐shared environments where there is a lack of understanding by referrers regarding privacy, appears to be a barrier to iCBT engagement and may undermine the potential benefits (Andersson et al. 2016). Education on how iCBT is best delivered to ensure adolescents'privacy and safety is respected, is required and has been endorsed in other research (e.g. Lattie et al. 2022). Education could be provided upon sign‐on to the program and include suggestions on how the program could be delivered in such environments to promote privacy. Parents/caregivers (if involved) and adolescents themselves also need information on the importance of users having private, quiet spaces which is taken as seriously as face‐to‐face therapy. These recommendations will assist in ensuring the benefits of iCBT in reducing stigma promoting confidentiality are not undermined.

3.3. Early Identification of Disengagement and Individual Strategies for Enhancing Engagement

Adolescents also spoke about user‐related factors, including distractibility and competing priorities, which negatively impacted their engagement with iCBT programs. Both forgetting about the program and having competing priorities (e.g. schoolwork, extracurricular activities and family commitments) have been found to be barriers to engagement in adult iCBT programs (Donkin and Glozier 2012; Woolderink et al. 2015). However, adolescents specifically, may be more vulnerable to these barriers, with many adolescents engrossed in technology via social media or gaming, and juggling casual employment, extracurricular activities, social demands and schoolwork. In addition, it is thought that around a third of adolescents use two or more media inputs simultaneously (Rideout et al. 2010), and adolescents have a biological disposition to distractibility, poor planning and organisation strategies and impulsivity, as their brains develop and mature (Moisala et al. 2016; Sowell et al. 1999). Adolescents may not only struggle to resist the urge to multitask whilst completing the program, but also lack the skills in prioritisation needed to commit to the program (Moisala et al. 2016).

Therefore, identification of adolescents who struggle to engage early in the program due to these barriers is needed (Lattie et al. 2022; March et al. 2019). For these adolescents, a multi‐faceted approach on how to handle implementation barriers to engaging in iCBT programs should be considered. Upskilling adolescents, particularly those who struggle to engage early in the program with time management, prioritisation and organisational tools and tips (e.g. how to schedule the program into their routine, how to set personal reminders to do the program, and how to manage distractions) may be helpful. Given adolescents spoke about the program being too lengthy, required more “work,” than face‐to‐face therapy, and having too many competing priorities, adolescents will also benefit from having a clear understanding of the level of commitment and requirements of the program at the outset of the program. Further, as some adolescents had misunderstandings about what BRAVE Self‐Help entailed (e.g. confusion as to whether they would have an “online person,” as done in therapist‐assisted iCBT programs), clear information about the format and level of support provided will be helpful in assisting adolescents in making an informed decision about engagement in iCBT programs. Support could also be provided for adolescents who engage poorly at the start of the program, which could include automatic reminders and encouragement messages (i.e. ‘You can do it, not long to go!’) sent when users have not logged in for a certain period of time or failed to complete some or all homework or in‐session activities. Support messages may include tips on integrating the program into their lives via scheduling and organisation or tips for implementing skill rehearsal. Again, bridging the gap between face‐to‐face/therapist‐assisted iCBT and iCBT Self‐Help programs, where problem‐solving strategies would usually be discussed if there were concerns in commitment and application of strategies taught.

3.3.1. Optional Support

Support, whether through automated support (e.g. reminders, chatbot or encouragers) or human support, was also raised by adolescents as a factor to enhance engagement. Importantly, adolescents spoke about this support being optional to suit the different needs of adolescents. Both automated and human support has been found to be efficacious for enhancing engagement in iCBT programs (Olthuis et al. 2016; Radomski et al. 2020). However, adolescents often do not seek support when it is provided (March et al. 2019), suggesting that novel ways of providing support for adolescents is required. Adolescents identified that support could be provided in various formats (e.g. text message or email) and would be helpful for skills rehearsal/acquisition and implementation or progress monitoring. Text messages, in particular, could be useful, considering adolescents can send and receive up to 67 text messages a day, can be automated and is low‐cost (Borghouts et al. 2021; Lenhart 2015). Some research has also explored the use of chatbots (Yasukawa et al. 2024) or “virtual coaches” (Provoost et al. 2020) to bridge the gap between therapist‐supported/assisted and self‐help programs and improve engagement, but these interventions have not been formally assessed in adolescent iCBT programs, nor may they meet the level of personalisation desired by adolescents. Lastly, participants'ideas around integrating optional, rather than routine support has been found to be useful in adult iCBT programs (i.e. Hadjistavropoulos et al. 2019), but is yet to be trialled in adolescent programs.

3.4. Strengths, Limitations and Future Directions

A key strength of this study was that the barriers to engagement and strategies to improve it were examined directly from the adolescent's perspective, who often self‐refer to therapy, without the support of their parent (Grudin et al. 2024). Speaking with adolescents themselves, allowed for them to provide valuable insights and numerous perspectives of their engagement in iCBT programs. Another strength of this study was the breadth of participants interviewed, including different ages, genders, locations and referral sources. For example, participants resided in different parts of Australia, both city and remote and some had been referred clinically, while others self‐referred. In addition, an equal number of participants fell into each of the two age groups (12–15 years old and 16–17 years old). Such diversity in participants adds to the robustness and generalisability of the research findings.

However, this study also has some limitations. Consistent with the general uptake of mental health support and BRAVE Self‐Help participation, only four participants were male (Harris et al. 2015; March et al. 2018). Secondly, there is the potential for response bias, where adolescents may have not felt comfortable in interviews to honestly and openly negatively critique the BRAVE Self‐Help program. Third, this study yielded only a 1.4% response rate of the total participants invited to participate, and therefore the findings of this study may not be representative of the greater population of adolescents who participate in iCBT programs. Further, the interviewer may have missed some opportunities to ask adolescents to elaborate on their responses which may have helped better articulate adolescents'ideas (e.g. clarifying what adolescents meant by ‘fun’). This study also did not consider engagement with other iCBT programs, perhaps limiting the potential depth and generalisability of findings.

4. Conclusion

The current study provided a detailed account of the facilitators of engagement, directly from the perspective of adolescents. Further research is needed to assess the effectiveness of ideas raised by adolescents to enhance engagement, so that many more adolescents can benefit from iCBT programs.

Ethics Statement

University of Southern Queensland Research Ethics Committee (Approval: H20REA291).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supplementary ‐ Tables.

JCLP-81-930-s001.docx (15.7KB, docx)

Acknowledgments

Open access publishing facilitated by University of Southern Queensland, as part of the Wiley ‐ University of Southern Queensland agreement via the Council of Australian University Librarians.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, [ES], upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary ‐ Tables.

JCLP-81-930-s001.docx (15.7KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, [ES], upon reasonable request.

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