Doing the groundwork at home, working through it together: patient experiences of blended cognitive therapy for PTSD in routine care

ABSTRACT

Background:

There is limited access to evidence-based treatment for posttraumatic stress disorder (PTSD) in routine care. Therefore, scalable and resource-efficient treatment formats that are effective and acceptable are needed. We developed a blended format of cognitive therapy for PTSD, combining online modules with a limited number of therapy sessions, to improve resource efficiency, while maintaining the benefits of in-person therapy. This study aimed to explore patients’ experiences of blended trauma-focused cognitive therapy (bTF-CT) in routine care.

Method:

Semi-structured interviews were conducted with 11 participants following completion or dropout from bTF-CT, as part of an open feasibility study. Interviews were transcribed and analysed using qualitative content analysis.

Results:

Participants described the treatment as helpful and flexible, and valued the combination of online modules and therapist sessions. Trauma-focused treatment components were experienced as both particularly beneficial and emotionally demanding, especially when conducted independently. Some participants reported disengagement related to emotional intensity, unmet needs and time pressure, suggesting room for improvement. However, engagement and satisfaction were facilitated by factors such as in-person therapist support, motivation and valued therapeutic gains.

Conclusion:

This is the first study exploring patient experiences of blended trauma-focused cognitive therapy in regular clinical settings. The results suggest that bTF-CT may be acceptable and helpful across primary and secondary care; however, refinements related to therapist support, treatment content, and tailoring treatment to personal needs may improve engagement and acceptability.

Trial registration: ClinicalTrials.gov identifier: NCT04881643.

HIGHLIGHTS

• Participants described blended cognitive therapy as helpful and flexible, with trauma-focused components experienced as both the most demanding – particularly when conducted independently online – and the most beneficial, while in-person therapist support was described as crucial for sustaining engagement and retention.

• Possible improvements include better individual tailoring of treatment, particularly related to therapist support, pacing and sequencing of modules, and allowing greater flexibility for multi-trauma presentations.

• The findings inform how accessible, resource-efficient treatment formats can be developed and refined to better meet the needs of a broad PTSD population in routine care.

1. Introduction

Trauma-focused psychological treatments, primarily cognitive behavioural therapies (TF-CBT), are recommended as first-line treatments for post-traumatic stress disorder (PTSD) in clinical guidelines (Hamblen et al., 2019; Öst et al., 2023). Yet, only 17% of individuals with PTSD receive TF-CBT according to a recent WHO survey (Stein et al., 2023). Barriers that have been identified cross-nationally include long waiting lists for specialist services and a shortage of adequately trained clinicians (Kazlauskas et al., 2016). In addition, there are individual-level barriers, including uncertainty about treatment effectiveness, practical difficulties in attending in-person therapy, and fears related to stigma and shame, all of which can inhibit help-seeking among people with PTSD (Smith et al., 2020). As PTSD is a prevalent and debilitating condition that can persist if untreated (Kessler, 2000), reducing the treatment gap by improving the accessibility and scalability of TF-CBT in routine care remains an important clinical priority.

To address challenges related to treatment capacity and access, there has been growing interest in scalable and resource-efficient delivery formats for TF-CBT, with guided internet-based self-help being the most extensively studied. Two guided internet-based TF-CBT programmes have been recommended by the National Institute for Health and Care Excellence (NICE) for mild–moderate PTSD, supported by trials reporting large within-group effects comparable to face-to-face TF-CBT and low dropout (10%), although one study was limited to single-trauma, mild-to-moderate PTSD (Bisson et al., 2022; Ehlers et al., 2023; Warner & Raslescu, 2025). A Cochrane review found that internet-based TF-CBT improved symptoms post-treatment compared to controls, but effects did not persist at follow-up and the overall certainty of evidence was rated by the authors as very low, indicating limited confidence in the estimated effects (Simon et al., 2021). Meta-analyses report similar findings and relatively high dropout rates (25%–36%) (Siddaway et al., 2022). Together, these findings are mixed; a few trials report large effects, but broader evidence from reviews and meta-analyses points to more modest, uncertain effects and concerns about engagement and durability. Moreover, these trial outcomes offer limited insight into the reasons behind such concerns; qualitative studies of patient experience can provide further knowledge.

Studies of how patients experience internet-based TF-CBT are scarce. In two qualitative studies of web-based prolonged exposure (PE), participants valued the flexibility and autonomy of the online treatment but described a need for greater emotional support and therapist interaction. Some also reported that the flexibility of online programmes increased demands on personal responsibility, contributing to difficulties with engagement (Bragesjö et al., 2025; McLean et al., 2024).

Qualitative studies of face-to-face TF-CBT have reported similar findings. In a 2024 review of qualitative studies of TF-CBT, Gjerstad et al. identified therapist support as one of the most important factors for engagement and retention (Gjerstad et al., 2024). Trauma-focused components, such as revisiting trauma memories and addressing trauma-related appraisals, were often experienced as challenging and many considered discontinuing treatment early on. Nevertheless, most remained in treatment, describing trauma-focused components as necessary for recovery and emphasising the importance of therapist support and a safe therapeutic relationship for staying engaged in treatment (Gjerstad et al., 2024). Early treatment gains, social support, and a strong commitment to treatment have also been associated with retention (Gjerstad et al., 2024; Hundt et al., 2017). Taken together, these studies highlight therapist support as a relevant factor for engagement and for completing challenging components of trauma-focused treatment.

Blended treatment formats have been proposed as a way to address the challenges with internet-based TF-CBT outlined above by integrating online modules with face-to-face sessions. Online modules allow flexible access to treatment materials and may reduce therapist time, thereby retaining some of the resource-efficiency and accessibility advantages of internet-based treatment. Face-to-face sessions, in turn, enable therapists to support patients with treatment components often experienced as challenging, and to facilitate and adapt trauma-focused interventions to individual needs. As such, blended TF-CBT may be suitable for a broader PTSD population than the mild-to-moderate cases for which internet-based TF-CBT is currently recommended in NICE guidelines, including patients with greater clinical complexity, higher symptom burden, and multiple trauma exposures (National Institute for Health and Care Excellence, 2023). Studies on other conditions, such as anxiety disorders and people with multiple sclerosis experiencing severe fatigue, suggest that blended CBT yields outcomes comparable to face-to-face CBT and is generally more acceptable than stand-alone internet interventions (de Gier et al., 2023; Romijn et al., 2021).

We have developed a blended TF-CBT programme based on Ehlers and Clark’s cognitive therapy for PTSD and their internet-based version of trauma-focused cognitive therapy (Ehlers & Clark, 2000; Ehlers et al., 2023). The specific blended treatment evaluated in this study is referred to as blended trauma-focused cognitive therapy (bTF-CT). We first evaluated bTF-CT in an open feasibility study in routine care, where 17 patients received treatment. Results indicated low dropout (12%), high treatment satisfaction, and substantial reductions in PTSD symptoms (PCL-5; Cohen’s d = 2.13) (Lundin et al., 2024). While these findings provided preliminary support for the feasibility and potential effectiveness of bTF-CT, they did not capture how patients experienced the treatment, its blended format, or the factors that facilitated or hindered engagement. This qualitative study was therefore conducted alongside the feasibility study to explore patients’ experiences of bTF-CT, including its treatment content, therapy components, the integration of face-to-face sessions and online modules, and factors influencing engagement. To our knowledge, no previous study has explored patient experiences of a blended TF-CBT treatment for PTSD.

Research questions:

• How do patients with PTSD experience bTF-CT in routine care, including its acceptability and feasibility in everyday life?

• What factors do patients describe as influencing engagement in and completion of bTF-CT?

2. Method

2.1. Design

This qualitative study explored patients’ experiences of bTF-CT. Data were analysed using qualitative content analysis (Graneheim & Lundman, 2004). The analysis was primarily inductive, with no predefined hypotheses or theoretical framework guiding interpretation. This study was registered together with the feasibility trial at Clinicaltrials.gov (NCT04881643) and approved by the Regional Ethical Review Board in Stockholm (Dnr 2020-07130). All participants provided written informed consent.

2.2. Participants and setting

Participants were recruited from a feasibility study of bTF-CT (n = 17), conducted in two psychiatric and one primary-care clinic in Stockholm, Sweden, through routine patient flow. Inclusion criteria were a primary DSM-5 PTSD diagnosis, age ≥18 years, Swedish language proficiency, and no concurrent psychological treatment or ongoing trauma-related threat. If receiving antidepressant medication, stable use (≥6 weeks) was required. Comorbid diagnoses were permitted if secondary to PTSD. Diagnostic assessment was established through a structured clinical interview based on DSM-5 diagnostic criteria (Association AP, 2013), and the PTSD Checklist (PCL-5) (Blevins et al., 2015). Assessments were carried out by psychologists in the study clinics. The primary diagnosis was determined through an overall clinical assessment, taking into account the patient's perceived symptom burden, functional impairment, and duration of symptoms.

All participants had provided informed consent to a post-treatment interview. After treatment, participants were contacted by phone and invited to participate. Recruitment continued until 11 interviews had been completed; this was deemed sufficient due to substantial overlap in accounts and consistency with typical sample sizes in interview-based qualitative studies (Braun & Clarke, 2013). Non-participants had either declined, not responded, or completed treatment after recruitment closed. Efforts were made to include both treatment completers and non-completers. Of the 11 participants included in the study, 10 completed treatment and one dropped out. Participants were women aged 19–43 years (M = 30.1, SD = 7.6). The mean reduction in PCL-5 scores from pre- to post-treatment was 25.9 (SD = 12; range 15–40), comparable to the original study (n = 17; mean reduction 24 points; range 6–43). Among the participants, 45.5% were assessed as having a comorbid diagnosis at assessment. Participant characteristics, comorbid diagnoses, and individual PCL-5 scores are presented in Table 1.

Table 1.

Characteristics of participants.

Participant	Age	Gender	Main index trauma	PCL-5 pre treatmenta	PCL-5 post treatment (or last observation)	Comorbid condition
1b	30-35	Female	Interpersonal violence	42	20	Depression
2	35-40	Female	Interpersonal violence	47	14
3	35-40	Female	Rape	58	36	Panic disorder
4	18-25	Female	Interpersonal violence	47	9
5	18-25	Female	Sexual assault	56	16
6	18-25	Female	Rape	62	37
7	40-45	Female	Rape	45	19	Depression, SAD
8	25-30	Female	Rape	29	14	Eating disorder
9	30-35	Female	Birth trauma	24	0
10	18-25	Female	Death of family member	33	18
11	35-40	Female	Sexual assault	40	16	Depression, GAD

^aA PCL-5 score ≥31 was used as the cut-off for probable PTSD.

^bDropped out of treatment.

PCL-5, PTSD Checklist for DSM-5; SAD, social anxiety disorder; GAD, generalised anxiety disorder.

2.3. The treatment

bTF-CT is a blended format of TF-CBT that combines an online treatment programme with six in-person therapy sessions. The treatment is based on Ehlers and Clark's cognitive therapy for PTSD (Ehlers & Clark, 2000) and includes most of its core procedures. The online programme is adapted from their internet-based version of cognitive therapy for PTSD (Ehlers et al., 2023) and comprises seven core modules, including key therapy components such as processing and updating trauma memories, modifying maladaptive appraisals, discriminating trauma triggers, and conducting behavioural experiments to test and modify problematic trauma-related appraisals by dropping avoidance and safety behaviours. Three optional modules address shame, guilt, and rumination. Module content includes written materials, video examples, worksheets, and interactive exercises. The two introductory modules are completed independently online. Each of the subsequent five core modules is accompanied by a face-to-face therapy session. A sixth therapy session is used flexibly to support work on optional modules, when relevant, or to provide additional therapist support for treatment components requiring further attention. The purpose of the therapy sessions is to help patients understand, carry out, and refine core module exercises, providing therapist support for components often experienced as challenging in TF-CBT, such as approaching the trauma memory. Sessions build directly on module content; for example, trauma narratives written independently may be reviewed, elaborated, and further processed in session. Therapists also support motivation and help patients overcome avoidance. Between sessions, patients and therapists can communicate via secure messaging within the programme.

The treatment typically runs over 8–12 weeks. Patients complete two introductory modules independently in the first week, then work through the remaining core modules at approximately two weeks per module, with fortnightly therapy sessions. Pacing can be adjusted to individual needs. A full description of bTF-CT is provided in Lundin et al. (2024). A figure of the treatment timeline and structure, as well as illustrative examples of the online programme and treatment materials (original Swedish version) are provided in the supplementary materials.

2.4. Data collection

An interview guide consisting of open-ended questions and optional prompts was developed by the research group to structure the interviews. The guide covered four areas: (a) overall experiences of the treatment and format, (b) perceptions of the online programme, (c) experiences of therapy sessions, and (d) practical aspects of the digital platform and time commitment. A first draft of the interview guide was developed by J.L. and L.B.G. based on the study aims and research questions. Following discussion within the research group, the interview guide was revised and organised into the four areas described above. The interview guide is provided in the supplementary materials.

Semi-structured interviews were conducted at the clinic where participants received treatment (n = 9) or by telephone if preferred (n = 2). While interviews were intended to take place within one month of treatment completion to minimise recall bias, some were conducted later due to difficulties in scheduling. Interviews were conducted by two researchers (J.L. and L.B.G.) who had no prior contact with participants. Interviews lasted 37–86 min, were audio-recorded, and transcribed verbatim by J.L. and L.B.G.

2.5. Data analysis

Interviews were analysed using qualitative content analysis (QCA) as described by Graneheim and Lundman, and further elaborated by Lindgren et al (Graneheim & Lundman, 2004; Lindgren et al., 2020). The analysis was iterative and involved repeated reading of transcripts, identification of meaning units, coding, and organisation into subcategories and categories relevant to the research questions. Codes and categories were organised and analysed in Microsoft Excel (version 16.109). Initially, meaning units reflecting manifest content were identified and condensed into codes. In the subsequent abstraction phase, codes were grouped into subcategories and categories to capture broader patterns while remaining close to participants’ accounts. Thus, the analysis progressed from a descriptive to a more abstract, yet still close to the data, level of interpretation (Lindgren et al., 2020).

J.L. and L.B.G. independently read all transcripts and identified meaning units before reaching consensus through discussion. J.L. condensed meaning units into codes, which were jointly reviewed with S.S. and A.R. through iterative comparison and refinement. The abstraction process, from codes to categories, was led by J.L. in collaboration with S.S. and A.R., with repeated checks against the transcripts to ensure analytic coherence. Illustrative quotations are presented in the Results section; these were translated from Swedish to English, and all names are pseudonyms.

2.6. Reflexivity

Trustworthiness was enhanced through analytic triangulation within the research group. As both interviewers were involved in the feasibility trial, the potential influence of this dual role was regularly discussed. Two of the authors (J.L. and S.S.) have clinical experience in cognitive therapy for PTSD, contributed to treatment development, and served as therapists for a few of the patients in the original trial (none of whom they interviewed). These roles, as well as theoretical and clinical orientations, may have influenced the analysis. Reflexive dialogue was maintained throughout the research process to increase awareness of potential researcher influence, and coding decisions were revisited to mitigate bias.

3. Results

Four main categories and 11 subcategories (Figure 1) were identified from the content analysis, capturing participants’ experiences of blended trauma-focused cognitive therapy (bTF-CT). Together, these categories capture initial expectations, treatment experiences, perceptions of the blended format, and factors influencing engagement. Categories and subcategories are presented below with illustrative quotes from the interviews.

Figure 1.

Categories and subcategories.

3.1. Categories and subcategories

• 1.Hopes for change amid muted expectations

Participants often described entering treatment with both hope for improvement and cautious scepticism, hoping that treatment would provide symptom improvement and practical ways of managing PTSD while remaining uncertain whether it would actually help.

… That my anxiety level would go down. Not that I would go through the treatment and it would somehow just make the anxiety disappear on its own, but that I would learn to manage my anxiety and, like … learn to talk about the trauma with, you know … people I trust … That was what I had hoped for, but I had never received any treatment, only assessments. No one had ever given me any advice before, so I was half hopeful. (Alice)

This cautious outlook was commonly linked to previous negative experiences with mental health services. Some had waited for or undergone psychological assessments without being offered treatment due to long queues. Others had received counselling or CBT, either for PTSD or other problems, via internet or in-person, without finding it helpful.

 … Not that many expectations. I had never done this kind of therapy before – I had done online treatment and things like that, but not this type. It’s been a long journey, so I just felt, okay, it’ll be what it’ll be. I don’t think my journey through the healthcare system has been good before; it feels like some people haven’t taken me seriously. (Rana)

• 2.Perceived changes and their relation to the treatment components

Participants described improvements in symptoms, coping, and emotional well-being. Trauma-focused components were viewed as both the most helpful, and emotionally demanding, at times leading to disengagement.

• 2.1Valued changes in thinking, coping strategies and PTSD symptoms

Among the most valued therapeutic gains was an increased ability to distinguish then (the trauma) from now when exposed to trauma triggers, along with reduced intensity and frequency of reexperiencing symptoms.

These memories, they don’t hit the same sensitive spot anymore. It’s become a bit more de-dramatized, you could say. When I used to get different triggers, it was like I was back there again — I was a child, being exposed again. And when you’re a child, you can’t really defend yourself, you don’t have control. But now, I’m in control. (Lisa)

Participants also described cognitive and emotional changes including reduced self-blame, greater self-understanding, reduced overestimation of danger and alleviation of fear, shame and guilt.

I have, like, full respect for my 15-year-old self now, and it feels so good, because I used to feel so much shame about how I acted back then. Now I can work with myself without constantly feeling shame and guilt for who I am, like an acceptance and a respect for myself. (Sally)

For several participants, specific therapeutic procedures such as updating the trauma memory, and stimulus discrimination, were described as particularly valuable and contributing to emotional relief.

What has really helped me is that when it comes, when I start to feel my body, I stand up, a picture of my children on my phone, and I remind myself that I’m here now, I’ve survived. I tell myself: that was then, this is now, and I didn’t have these tools before. Because of that, I’m not as terrified anymore. I’ll carry that with me for life. (Martina)

• 2.2Trauma-focused work: demanding but helpful.

Trauma-focused components i.e. working with trauma memories and associated thoughts and emotions were often described as emotionally demanding, evoking reactions such as fear, sleep difficulties, and in one case vomiting. Despite this, these elements were consistently described as helpful and central to therapeutic change.

In the beginning, there were nightmares, panic attacks, anxiety — all because of the treatment. But then I noticed that all of that has kind of faded away, and now I basically have none of it. I’ve gotten the tools I’d been looking for, and I think in a different way now. (Farah)

• 2.3Remaining difficulties

Several participants described remaining PTSD-related difficulties after treatment. While a few framed this as persistence of symptoms, the more common reflection was that remaining difficulties required continued effort rather than being unchanged. Many emphasised that these difficulties felt more manageable, suggesting a sense of continued recovery rather than stagnation.

I don’t want to date anyone, no, no — just the thought of intimacy and all that still feels completely new. But I’ve lived with this for, like, 30 years — it’s not going to disappear overnight. This is something I need to keep working on, using the tools I’ve been given. (Sally)

• 2.4Factors undermining engagement

Some participants described parts of the treatment as overly demanding, affecting engagement, and at times leading to avoidance or thoughts of discontinuation. Emotional intensity during trauma-focused work, especially independently at home, could contribute to disengagement.

For me, who had avoided it for twenty years, to suddenly bring it up again was really tough. And especially, you know, when you were also working on it at home alone — then it was easier to just avoid it and skip doing it. (Lisa)

Others voiced challenges related to the workload. While some managed these concerns with therapist support, others experienced pressure, expressing worries of underperforming or failing to meet the treatment demands.

I don’t think I really understood how much time it would take. There was a lot to read and go through. And I just … I didn’t realize that. Then it turned into this kind of stress reaction, because it felt like I was failing at something since I didn’t have the time. (Molly)

Certain components were perceived as less relevant, or insufficiently adapted. While often described as minor grievances, for some participants these issues contributed to disengagement. A recurring difficulty was the instruction to initially focus on a ‘worst’ traumatic event for the memory work. This was experienced as insufficient, and neglectful of reactions tied to multiple traumas by some. At least two participants interpreted the instruction as meaning that the memory work was restricted to one trauma.

The hardest part of the treatment was that I had to choose one trauma. And [the therapist] said that when you work on that one, the rest will go down too. It was like — we should focus on this one, while my brain was showing me all these other images from other awful things … If I had known from the start that it was okay to work with two traumas, maybe I could’ve avoided two weeks of anxiety. (Martina)

• 3.Perception of the treatment format, structure and online programme

Participants described both advantages and challenges related to the blended format – the combination of online modules and face-to-face sessions – as well as the treatment structure, including the pacing, timing, and sequencing of treatment components, and how well both fit into their everyday lives.

• 3.1Perceived autonomy and flexibility

Participants described the flexibility of the blended format as valuable, allowing them to engage with the treatment at their own time and pace, revisit material, and reflect independently.

I think it’s been a really good combination — being able to sit and work in peace at home. I’ve decided myself when I’ve had the time to do it. I’ve been able to read everything through, had time to think and reflect. When I had those regular CBT sessions before … you didn’t get that time. (Farah)

Some described how engaging with the programme between sessions also gave a sense of agency and confidence in applying the methods independently, reducing reliance on the therapist.

I think the approach of sitting with a computer and then talking with a therapist was really good, because it felt like I was working on it myself. It didn’t feel like I’d been left by the therapist — rather, I was kind of on my own in it, but still had support when we talked. I know that I can handle it myself now, and that I have these methods. (Alice)

• 3.2Benefits and drawbacks with the format and structure.

Many highlighted the complementary nature of the blended format. One participant described how work completed at home provided a basis for more in-depth work in session. Others described how the dual formats enhanced understanding of the treatment rationale and how to carry out exercises.

The positive thing is that you do the groundwork at home — you kind of fill things in — and then you go through what you’ve written in session. It feels like that really captures the important things, like … my answers sort of became the actual meeting with the therapist. (Elsa)

Reported drawbacks included limited time to complete, or revisit modules, difficulties combining treatment with daily life and a wish for greater individual tailoring of modules. One participant reported that there was insufficient time for the ‘reclaiming your life’ module.

I was really excited to do things, write things down, plan my weeks. But it didn’t really turn out that way. Maybe between those other modules, we could have talked more about the ‘taking back your life’ part — and maybe it shouldn’t have been the very first module. It’s hard when you’re just starting treatment, there’s so much happening at once. (Rana)

Overall, however most participants did describe the blended format and structure in a very positive light.

I’m incredibly grateful to have had this opportunity, because it’s helped me so much and I really do feel much better. And I truly believe it’s this combination — meeting and having that contact, together with doing the exercises on my own — that has made the difference. (Nora)

• 3.3The significance of face-to-face therapist support

All participants emphasised the relevance of therapy sessions within the blended format. In-person contact was described as providing emotional support, safety and feeling listened to, and opportunities for individual tailoring beyond the online programme structure.

It helps so much just to be listened to, to have someone acknowledge what you’re saying. And that [the therapist] could put words to things I’d experienced. I think you really need that kind of validation when living with the kind of difficulties that PTSD brings. (Elsa)

Participants also highlighted the therapist’s role in clarifying treatment rationales, guiding interventions, and facilitating new more helpful perspectives. Therapist presence and support was particularly valued during emotionally demanding components such as approaching the trauma memory. Among participants who reported disengagement due to treatment demands, two patients highlighted that in-session therapist support was the main factor for remaining in treatment.

When you go into detail, it’s really emotional, and that’s something you really need to do together with the therapist. It was so good to do it with her. And also, when we worked on those hot spots and so on — it was really good to have her there and do it together. (Maria)

In contrast, the participant who discontinued treatment described the therapist’s guidance as overly rigid and insufficiently responsive to her difficulties, which contributed to a sense of not being understood and supported.

So (therapist) said, like — find one event, like the worst one. And I just felt it was weird, so I chose to just go through the events. It felt like, okay, I’ll pick this one because I wanted X to be satisfied. (Therapist) knew how many things that triggered me, so it felt very impersonal — that’s pretty much why I quit. (Molly)

• 3.4Perception of the online programme.

Participants described varied opinions on the content, design and usability of the online modules. While some found them lengthy, or difficult to navigate, most described them as easy to understand and helpful.

It was simple and good. You don’t have to be a genius, you don’t even need to be great at Swedish to understand it. What I really liked was that I didn’t have to read a hundred pages to get to the point — it was right there from the start, the core of it. (Martina)

A feature that evoked diverse views was the patient examples. The online programme included five main recurring fictional patient examples representing different index traumas and PTSD presentations to illustrate treatment principles. While many described them as helpful in normalising their experiences, and understanding the treatment, others struggled to relate to them due to differences in trauma type, or severity (e.g. too recent, severe, or slight).

Some of the examples were a bit long. And it could’ve been broader, you know — with more examples of things that aren’t as severe, or maybe on a milder level, if you know what I mean. Because I kind of felt like I couldn’t really identify with any of them. (Alice)

Overall, participants did not express strong opinions about the multimedia content (e.g. videos or images). A few appreciated small details like the animated coffee cup reminding them to take a break. Many found the platform outdated and not very user-friendly, particularly when navigating on a phone. Examples of the multimedia content referred to by participants are provided in the supplementary materials.

• 4.Personal and contextual factors influencing engagement

Participants described a range of contextual and individual factors that shaped their engagement with treatment, including motivation, self-initiated strategies, and life circumstances.

• 4.1Motivation and persistence.

Many participants described motivation to improve as central for persisting with treatment despite its demanding nature, both in session and in the online programme. Thus, aside from therapist support and helpful information in the modules, personal resources and motivational factors were referred to as crucial for engaging with therapy.

It was something I needed to face at some point. It’s hard, but you just have to do it. I would say, above all, that I had a strong will — I really wanted to recover from this. I want to succeed in life, and that will and that wish were a driving force in themselves. (Lisa)

• 4.2Strategies and pitfalls.

Participants described several different self-initiated strategies, not explicitly outlined in the treatment, to facilitate engagement with the online programme, such as structuring their time, managing technical obstacles, and adapting the work to individual circumstances.

What I did was that every day, except on weekends — because then I took the weekend off — I sat down and did a bit of the treatment. That’s how I planned it. And some days I forgot, but I planned it on a kind of to-do list. (Alice)

Participants also described common pitfalls that disrupted engagement, often reflecting general habits or tendencies, rather than being specific to PTSD, such as low motivation for reading or procrastination. However, these obstacles were often described as manageable through above-mentioned strategies.

I think I’ve been kind of moderately motivated all along, I usually find it really hard to sit and work or study on my own. But this felt important enough, so I’ve … well, if I was at home, I’d go sit in another room just to really focus. And that’s also why I chose to write by hand, with pen and paper — it just makes it easier for me. (Farah)

• 4.3Time and life circumstances.

Many participants described that the feasibility of the treatment depended on their life circumstances. Participants who described the treatment as relatively manageable in combination with daily life attributed this to having supportive families, flexible jobs or being off work or on sick leave.

Fitting it into my life has worked well, but then I also have a very flexible job and a very understanding family, so it really hasn’t been a problem at all (Nora).

Others described the treatment as difficult to fit with daily life due to the demands of family life and work. Furthermore, two participants told us they went on temporary sick leave to cope with and have time for the treatment.

You know, you have a life outside of this — small children, your job, your husband — and then you’re supposed to go through something this traumatic. I said, this would’ve been easier if I were single ((laughs)). It was hard to make it work in everyday life. I was on part-time sick leave; if I hadn’t been, I wouldn’t have managed. (Martina)

4. Discussion

This study aimed to explore patient experiences of blended trauma-focused cognitive therapy in routine care, including its acceptability, feasibility, and factors influencing engagement. Overall, participants described the treatment as helpful and flexible, valuing the integration of online modules and therapist sessions. Trauma-focused treatment components, such as memory-focused work and modifying trauma-related appraisals, were perceived as both the most beneficial and demanding elements, occasionally contributing to disengagement. Engagement appeared to be facilitated by treatment-related, individual and contextual factors such as feeling supported by the therapist, experiencing treatment components as helpful, personal motivation and persistence, and an enabling home and work context. These findings extend previous feasibility results (Lundin et al., 2024) by providing a more nuanced understanding of factors shaping acceptability and engagement.

Participants described changes in trauma-related beliefs, improved discrimination between past and present, and decreased shame, guilt and fear as valued outcomes. These changes align with the key mechanisms that maintain PTSD according to the cognitive model and therapeutic targets of cognitive therapy for PTSD (Ehlers & Clark, 2000). That participants identified these specific changes as meaningful outcomes points to bTF-CT targeting the intended mechanisms of change, which is a promising indicator of its theoretical and clinical coherence.

Beyond helpful therapeutic gains, participants also reported several advantages of the blended format, particularly the complementary nature of building therapist sessions on work completed online, which was perceived to add therapeutic value and strengthen learning. These findings are consistent with a qualitative study of blended CBT for alcohol use disorder where patients emphasised how online assignments facilitated engagement in therapy sessions (Tarp et al., 2024). Moreover, therapists have reported preferring blended to in-person CBT due to the complementary benefits of combining online modules and sessions (Titzler et al., 2018).

Similar to previous qualitative studies of both in-person and internet-based TF-CBT, trauma-focused components were described as both demanding and beneficial (Gjerstad et al., 2024; McLean et al., 2024). Some described these techniques as particularly demanding to engage with independently online, and therapist support was especially valued during these components. This is consistent with findings from Gjerstad et al.'s review and qualitative studies of internet-based PE, where therapist contact and emotional support were highlighted as important for managing the demands of trauma-focused work (Bragesjö et al., 2025; Gjerstad et al., 2024; Hundt et al., 2017). The current findings raise the possibility that reduced therapist contact in internet-based and blended formats may present particular challenges when delivering trauma-focused components online. This concern has not previously been reported explicitly in internet TF-CBT research, though a general desire for greater human contact has been noted (Bragesjö et al., 2025; McLean et al., 2024).

While most participants remained engaged despite the treatment's demands, emotional intensity, time pressure, and a sense of unmet needs contributed to disengagement for some, and discontinuation in one case. Feeling overwhelmed by trauma-focused work conducted independently and feeling insufficiently supported or understood by the therapist were described as contributing factors. In contrast, therapist support was described as important for remaining engaged in treatment, providing a sense of safety, facilitating trauma-focused work, and enabling individual adaptation. These experiences may partly reflect the inherent challenges of trauma-focused work, which is commonly perceived as demanding (Gjerstad et al., 2024), as well as relational difficulties that can arise regardless of treatment format.

The findings concerning treatment engagement may also inform improvements to bTF-CT. Further adapting therapist support to individual needs, particularly when trauma-focused components are introduced, and providing clearer guidance on expected transient increases in PTSD symptoms may support emotional coping and sustain engagement. This resonates with Gjerstad et al.'s review, where therapist support and ‘buying’ the treatment rationales were identified as important retention factors (Gjerstad et al., 2024). Additionally, providing clearer information about time demands, normalising feelings of pressure, and offering guidance on helpful contextual strategies may help participants manage workload-related challenges.

Another specific challenge that was raised concerned the instruction to initially focus on one trauma for memory-focused work. Some participants experienced this as insufficient given more complex trauma histories. Similar concerns have been reported in a qualitative study of face-to-face TF-CBT (Doran et al., 2021). This suggests that the rationale for initially focusing on one trauma may need to be better communicated in bTF-CT, with explicit clarification that additional traumas can be addressed over the course of treatment. Consistent with this, previous research has identified disagreement and misunderstanding of treatment rationales as common reasons for discontinuation (Hundt et al., 2017). Furthermore, flexible and individually tailored delivery has been associated with better retention and satisfaction compared to more rigid protocol delivery in TF-CBT (Kehle-Forbes et al., 2022). These findings also point to the potential benefits of a more flexible and personalised delivery of bTF-CT.

Cognitive therapy for PTSD, on which bTF-CT is based, is inherently case-formulation driven and as such shapes treatment based on individual PTSD presentations (Ehlers et al., 2023). The current blended treatment aims to adhere to these principles, and overall participants described bTF-CT as flexible and well suited to their needs. However, online modules need to be designed to accommodate a broad range of PTSD presentations, and there are inherent limitations to individualisation in a structured blended format. Greater personal tailoring could potentially be accommodated, for example, by allowing more flexibility in the order and pacing of modules, highlighting individual differences more clearly within the module texts, and strengthening therapists’ skills in delivering and tailoring interventions to patients. Future iterations of bTF-CT may benefit from incorporating such refinements to better accommodate the diversity of PTSD presentations seen in routine care.

Beyond treatment-specific elements, individual and contextual factors also influenced engagement. Participants valued the flexibility and agency provided by the online programme, yet many reported that engagement required high motivation and strategies to manage concentration and time. This aligns with findings from internet-based PE where flexibility can function as a ‘double-edged sword’, increasing personal responsibility and challenging engagement for some (Bragesjö et al., 2025; McLean et al., 2024). These findings highlight a potential challenge in blended approaches; while more therapist contact compared to internet-based CBT may support motivation, limited engagement with online modules risks shifting valuable session time towards motivational work rather than core treatment elements (Titzler et al., 2018). Further research on therapist experience of bTF-CT may help clarify how therapist time is best used in blended treatments for PTSD.

4.1. Strengths

Efforts were made to enhance credibility through thorough data familiarisation and adherence to the different phases of analysis in accordance with the qualitative data analysis method (Graneheim & Lundman, 2004; Lindgren et al., 2020). Investigator triangulation was applied, with two researchers involved in the data collection and initial analysis, and two additional senior researchers involved in the coding and categorisation.

Participants were recruited from the regular patient flow at the study clinics and were included in the order in which they completed treatment. Thus, the sample reflects clinical practice, supporting transferability of the findings to similar clinical settings. The study was conducted across both primary and secondary care, thus capturing variation in clinical complexity. Detailed descriptions of the clinical context, inclusion criteria, and analytic procedures are provided to enable readers to assess the relevance of the findings to other settings.

4.2. Limitations

Two participants scored below the selected cut-off for likely diagnosis on the PCL-5 at the pre-treatment assessment. While this introduces some uncertainty regarding PTSD symptom severity in these participants, it also reflects the broad clinical spectrum encountered in routine care.

Six patients from the original feasibility study were not included, either due to declining participation or completing treatment after data collection had ended. Their absence may reflect experiences not captured in the present sample, introducing potential selection bias and limiting transferability. Notably, only two patients discontinued treatment in the feasibility study, one of whom participated in the interviews, providing some representation of non-completers. All participants were women and, while women are estimated to be twice as likely to develop PTSD compared to men (McLean et al., 2011), this may limit the applicability of the findings to the broader PTSD population.

4.3. Reflexivity

Qualitative researchers are encouraged to be transparent and reflect on how prior experiences and assumptions may influence data collection and analysis (Korstjens & Moser, 2018). Two authors have clinical experience in cognitive therapy for PTSD, contributed to developing the treatment programme, and treated patients in the original trial, two of whom participated in this study. In addition, all authors are trained within the CBT tradition. While efforts were made to approach the data inductively, these backgrounds may have influenced the analytic process. JL conducted several of the interviews and some participants may have recognised him from the online programme, where he features in a video. This could have contributed to social desirability bias and influenced participants’ responses.

4.4. Future research

Future research should evaluate the clinical effects and cost-effectiveness of bTF-CT, as well as other blended TF-CBTs, in larger controlled studies. Of particular interest would be whether bTF-CT yields outcomes comparable to gold-standard face-to-face TF-CBT, a question that would shed further light on its clinical utility and whether broader implementation in routine care is warranted. As the present findings highlight the potential importance of in-person therapist support, flexibility, and treatment structure for engagement, and there is currently no established blueprint for how blended TF-CBT is optimally delivered, further research into variations in delivery and structure would be valuable. Exploring therapist perspectives on bTF-CT would also be a valuable complement to the present patient-focused findings.

5. Conclusion

Patients receiving blended trauma-focused cognitive therapy in routine care, across primary and secondary care, described the treatment as acceptable, helpful, and flexible. However, engagement challenges related to emotional demands, time pressure, and unmet needs highlight areas of refinement. The findings suggest that four key refinements could enhance impact: (1) tailoring therapist support, especially early in treatment; (2) adapting the treatment structure to individual needs; (3) clarifying the therapeutic rationales; and (4) allowing greater flexibility for multi-trauma presentations. Implementing these changes could hopefully improve both participant engagement and overall acceptability of blended trauma-focused CBT.

Funding Statement

The authors declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by research grants from Region Stockholm (Stockholm University–Region Stockholm and Innovationsfonden) and the Söderström-Königska Foundation (SLS). The funding bodies had no role in the design or conduct of the study; in the collection, management, or analysis of the data; or in the preparation, review, or approval of the manuscript.

Open Scholarship

This article has earned the Center for Open Science badge for Preregistered. The materials are openly accessible at.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical statement

The study was approved by the Regional Ethics Review Board in Stockholm (Dnr 2020-07130). All procedures were conducted in accordance with relevant local legislation and institutional requirements. Written informed consent was obtained from all participants prior to participation.

Data availability statement

Due to legal regulations governing access to research data in Sweden and the European Union, the data are not publicly available, as they contain information that could compromise participant privacy and personal integrity. Requests for data access must therefore be reviewed by the Swedish Ethical Review Authority. Access may be granted following such review. Requests to access the datasets should be directed to johan.lundin.1@ki.se.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2727212.