Digital tools are increasingly used to support psychological treatment for adolescents [1,2], yet relatively little is known about how these tools function in the realities of adolescents' everyday lives. Digital formats can lower barriers related to travel, scheduling, and clinician availability, challenges that are particularly pronounced in rural regions [3]. At the same time, studies indicate that adolescents’ engagement with digital interventions is often shaped by day-to-day variations in energy, attention, school pressure, and emotional capacity [1,2]. These shifting conditions highlight the importance of flexible and accessible formats during the early stages of therapy, when stability and repeated practice of regulation skills are central. This is particularly relevant in trauma-focused treatments, where the stabilization phase serves as the initial foundation for later therapeutic work [4]. Given that little is known about how adolescents engage with stabilization work in digital formats, a formative study is needed to understand how an app-based approach functions in practice; what works, what does not, and what requires refinement before a pilot randomized controlled trial (RCT).

Exposure to potentially traumatic events is common among adolescents, with prevalence estimates indicating that up to 80% of adolescents experience at least 1 potentially traumatic event [5], and approximately 20% to 25% of adolescents develop posttraumatic stress disorder (PTSD) [6-8]. Untreated PTSD is associated with substantial long-term consequences, including emotional instability, academic difficulties, social withdrawal, increased risk of substance misuse, suicidality, and elevated psychiatric comorbidity [9-13]. Without timely and developmentally attuned intervention, these difficulties may persist in adulthood and affect relational, occupational, and overall functioning.

Trauma-focused cognitive behavioral therapy (TF-CBT) is the recommended first-line treatment for adolescent PTSD and is typically delivered across 3 phases: stabilization, trauma narration, and integration [14-16]. Despite a strong evidence base, implementing the model in routine care can be challenging. Many families struggle with between-session practice, caregiver availability varies, and emotional demands can make it difficult for adolescents to maintain consistent engagement [17,18]. These challenges are amplified in rural contexts where services span large geographical areas and access to trained clinicians is uneven [3,19,20].

Although stabilization is widely regarded as a crucial first phase of TF-CBT, this component has rarely been studied as a distinct therapeutic process. Research has primarily evaluated full TF-CBT protocols, whereas empirical work examining digital or preparatory emotion-regulation interventions for adolescents remains limited. Blended formats, where app-based exercises complement therapist-led sessions, may help address these gaps [21]. Digital components can provide flexibility, continuity, and short, manageable learning units suited to adolescents’ fluctuating emotional and cognitive capacities [2,22-24]. They may also support self-regulation between sessions, an area families consistently describe as difficult in routine care. These issues are particularly relevant in northern Sweden, where child and adolescent psychiatry services must operate across vast geographical areas with long travel distances and uneven specialist availability. Prior qualitative work from the region indicates that adolescents themselves express a clear preference for individualized, blended formats that can support continuity and reduce barriers to trauma therapy [25]. Integrating digital materials early in treatment may therefore strengthen treatment accessibility, readiness, and stability before entering trauma-focused work.

Compassion-focused strategies derived from compassion-focused therapy (CFT) may further strengthen the stabilization phase by addressing mechanisms that commonly hinder engagement in trauma-focused work among adolescents, such as shame, self-criticism, and persistent activation of the threat system [26-28]. Compassion practices are designed to cultivate emotional safety and self-soothing, which can increase adolescents’ tolerance for distress and facilitate an approach toward difficult memories and emotions [27,29,30]. Preliminary work suggests that compassion-based exercises may translate effectively to digital formats, offering grounding, support, and affect-regulatory scaffolding during emotionally demanding periods [30-33]. Compassion strategies may also enhance coregulation within caregiver-youth relationships, helping caregivers respond with greater attunement and reducing relational patterns that sustain avoidance or emotional dysregulation [29,34]. Because digital stabilization work unfolds across adolescents’ daily routines, caregiver involvement, and clinical workflows, multistakeholder perspectives are essential for determining whether an app-based stabilization phase is feasible and acceptable in real-world practice.

Although digital interventions have shown promise across a range of adolescent mental health difficulties, including anxiety and depression [1,2], research on app-based or blended trauma-focused treatments specifically for adolescents with PTSD remains scarce. Recent work has explored digital tools that complement standard TF-CBT, such as an app designed to support psychoeducation, coping, and between-session practice for adolescents [35]. However, these tools have primarily functioned as adjunctive support to standard treatment rather than as structured, clinician-supported stabilization phases delivered before trauma processing.

To our knowledge, no previous study has qualitatively examined a structured, clinician-supported, compassion-integrated, app-based stabilization phase delivered before trauma processing within TF-CBT for adolescents.

Furthermore, little qualitative research has examined adolescents’, caregivers’, and clinicians’ experiences of such interventions. Most existing studies rely on quantitative designs, adult samples, or single-stakeholder perspectives [36]. To our knowledge, no formative qualitative work has explored how digital stabilization components function within the service conditions of northern Sweden, where geographical distance and service variability shape treatment delivery.

Taken together, these gaps highlight the need for early, multistakeholder formative work to examine the acceptability, feasibility, and contextual fit of an app-based, compassion-integrated stabilization phase prior to a pilot RCT. Formative evaluation is essential to ensure that content, usability, safety routines, and clinical workflows align with adolescents’ living conditions and with the realities of routine child and adolescent psychiatry (CAP) practice.

This formative qualitative pretrial study aimed to examine the acceptability, feasibility, and contextual fit of a 5-week app-based stabilization phase within blended TF-CBT with compassion (bTF-CBT-C) for adolescents with PTSD. By integrating perspectives from adolescents, caregivers, and clinicians, the study aimed to identify concrete refinements to intervention content, caregiver involvement, usability, and clinical workflow prior to a planned pilot RCT.

The study addressed the following research questions:

This study used a formative qualitative pretrial design to explore how adolescents, caregivers, and clinicians experienced the 5-week app-based stabilization phase of bTF-CBT-C in routine CAP care. This approach aimed to obtain in-depth, multistakeholder insights to guide the refinement of the stabilization component before a planned pilot RCT. Formative evaluation assesses whether an intervention is acceptable, feasible, and appropriate for end users before scaling up and is commonly recommended as a preparatory step before later-stage trials. The study followed a user-centered design approach informed by the person-based approach, focusing on adolescents’, caregivers’, and clinicians’ lived experiences to guide the refinement of the intervention before pilot testing [20,37]. The person-based approach emphasizes grounding early-stage design decisions in rich qualitative insights to optimize usability, acceptability, and safety, which aligns with the aims of this formative work. Reporting of this study was informed by the Reflexive Thematic Analysis Reporting Guidelines (RTARG) developed by Braun and Clarke [38]. A completed RTARG reporting document is provided as Checklist 1.

This study was conducted in northern Sweden, specifically in the Västerbotten and Norrbotten regions. Norrbotten is Sweden’s largest county, covering approximately 25% of the country’s land area and home to about 250,000 people. Västerbotten is the second largest, with roughly 280,000 inhabitants [39]. Both regions are characterized by long geographical distances, low population density, and uneven access to specialized CAP services. Travel to CAP clinics may involve long distances, and specialist resources are concentrated in a small number of clinics. In total, 7 CAP clinics serve the two regions; however, participants in the present study were recruited from 1 clinic in each region (Umeå in Västerbotten and Luleå in Norrbotten). This setting is relevant for understanding how blended and digital components may support care delivery in sparsely populated health care systems.

A reflexive thematic analysis (RTA) was conducted following Braun and Clarke’s 6-phase framework [40-42]. RTA was selected because it is ideal for exploratory and developmental research aimed at understanding experiences and generating insights to refine interventions. Considering the study’s formative goal, all qualitative data (adolescent interviews, caregiver interviews, and clinician survey responses) were analyzed within a single, integrated RTA to identify patterns across stakeholder groups while still focusing on group-specific details.

An abductive analytic approach guided the interpretation, enabling shifts between data-driven insights and relevant conceptual elements of the blended TF-CBT model. This facilitated a nuanced understanding of user needs and areas for improvement within the stabilization component.

The Swedish Ethical Review Authority approved the study (Dnr 2024-07057-01 and 2025-04566-02), and it was conducted in accordance with the Declaration of Helsinki and national regulations for research involving minors and trauma-exposed populations. All data were deidentified during transcription and stored on secure institutional servers in compliance with General Data Protection Regulation (GDPR). The clinical team monitored participants’ well-being throughout the study and identified no safety concerns requiring intervention beyond routine care.

Adolescents received a 200 SEK (approximately US $20; SEK 1=US $0.1009 as of September 25, 2026) gift card for completing study assessments and an additional 200 SEK gift card for participating in the postintervention interview. Caregivers and clinicians received no financial compensation.

The intervention was delivered in a structured, blended format that combined app-based work with clinician support. After enrollment, adolescents and caregivers completed baseline self-report measures. Participants then received access to the introductory module of the stabilization phase, marking the official start of the 5-week app stabilization period. Adolescents accessed the app version of the introductory module, while caregivers received the corresponding materials in PDF format via secure delivery, as the caregiver app was not yet available in production.

After completing the introductory module, each family attended an in-person session at their local CAP clinic. During this visit, a licensed psychologist or psychotherapist introduced the bTF-CBT-C model, demonstrated app navigation, reviewed safety routines, and addressed initial questions. Adolescents also received a small “safety box” containing pens, colored pencils, a notepad, and a fidget tool to support emotion regulation during home-based practice.

To promote early engagement during the initial phase of app use, clinicians scheduled a follow-up videoconference about 1 week after the in-person introductory session, when adolescents had begun working with module 1. This meeting provided an opportunity to review experiences, clarify instructions, and address technical or emotional challenges. Throughout the 5-week stabilization period, clinicians remained available through brief in-app messages and, when required, telephone contact. Although no fixed schedule for messaging was prescribed, clinicians were encouraged to review participant progress regularly, typically at least once per week, and provide reminders, encouragement, clarification, or support as needed.

During the stabilization phase, the app-based intervention constituted the active treatment component while clinician involvement focused on support, monitoring, and preparation for the subsequent trauma-focused phases of TF-CBT. Safety monitoring followed routine CAP procedures and included opportunities to discuss emotional reactions and review concerns that arose during stabilization. Clinicians also participated in regular support meetings to discuss procedural questions; monitor adherence to safety routines; and identify potential adverse events, technical issues, and logistical challenges.

After completing the 5-week stabilization phase, adolescents transitioned to the trauma processing and integration phases of therapist-delivered TF-CBT with the same clinician at their local CAP clinic. No trauma processing was conducted during the stabilization phase, which was designed to prepare adolescents and caregivers for subsequent trauma-focused work.

Data were analyzed using the reflexive thematic analysis approach described in the Methods section. The analytic process began with repeated readings of all qualitative materials to achieve familiarity, followed by generating initial inductive codes across adolescent interviews, caregiver interviews, and clinician survey responses. Coding was conducted by LW and NN using OpenCode (version 4.03) and supplemented with manual coding using printed excerpts and paper slips to support reflexive engagement with the data.

Codes were then iteratively developed into initial theme candidates by examining patterned meanings across the integrated dataset. Through repeated movement between data, codes, and analytic memos, themes were reviewed, refined, and rearticulated. Theme development was led by LW in ongoing reflection and discussion with NN and ID. Final themes were defined based on their contribution to understanding acceptability, feasibility, and refinement needs prior to the pilot RCT.

Throughout the analysis, all authors reflected on how their professional backgrounds, experiences, and involvement in the project might shape interpretation of the data. LW is a licensed psychotherapist and doctoral student who led the present study. ID is a clinical psychologist, senior researcher (PhD), and principal investigator of the broader research project. LW and ID were involved in developing the intervention and had clinical experience in TF-CBT and CFT, which informed their understanding of the study context. The team developed interpretations through ongoing discussions to critically examine assumptions, challenge emerging interpretations, and consider alternative explanations. Consistent with reflexive thematic analysis, these discussions were intended to deepen interpretive understanding rather than achieve coding consensus.

Across adolescents, caregivers, and clinicians, the app-based stabilization phase was experienced as a dynamic process shaped by shifting emotional, cognitive, relational, and logistical conditions. Participants consistently described the intervention as meaningful, grounding, and clarifying, yet effortful to sustain within the realities of everyday life. Engagement depended not only on motivation but on the fluctuating resources that families could mobilize from week to week.

The 5 themes together illustrate how these shifting conditions played out. Adolescents and caregivers navigated the tension between support and strain in which moments of capacity enabled engagement, while fatigue, stress, and life pressures pulled against it. Even when the material was clear and accessible, pedagogical clarity sometimes collided with limited cognitive bandwidth, particularly after school or during periods of overload. Engagement also unfolded amid relational uncertainty, as adolescents sought autonomy while caregivers struggled to gage when and how to be involved.

Beyond these interpersonal and intrapersonal dynamics, logistical fragility often disrupted momentum, with small technical or procedural barriers (eg, login issues, missed notifications, unstable access) breaking flow even when motivation and readiness were present. Yet, despite these challenges, the stabilization phase seemed to foster emotional grounding and readiness for trauma-focused work, giving adolescents practical regulation tools, deeper emotional insight, and a shared language that supported the transition into therapist-delivered TF-CBT.

Taken together, these findings suggest that perceived feasibility was shaped by emotional, cognitive, relational, and logistical conditions. Aligning content design, technical stability, and clear relational guidance will therefore be essential to optimizing acceptability and feasibility in the upcoming pilot RCT.

To translate the thematic insights into practical improvements for the upcoming pilot RCT, we developed a set of refinements directly informed by the 5 themes. These refinements capture the lived constraints, cognitive and emotional capacities, relational patterns, and logistical realities described by adolescents, caregivers, and clinicians. By linking challenges to actionable adjustments, Table 2 summarizes how the intervention can be improved to boost feasibility and acceptability and better match families’ real-world situations.

These refinements show how thematic insights can directly guide intervention optimization before the pilot RCT. Overall, they emphasize that feasibility depends not only on content quality but also on the match between therapeutic material, users’ cognitive and emotional resources, family system dynamics, and the practical conditions for delivering digital care.

This qualitative formative study explored how adolescents with PTSD, their caregivers, and clinicians experienced a 5-week app-based stabilization phase delivered within the bTF-CBT-C intervention. In our analysis, we conceptualized digital stabilization as a dynamic rather than linear process, reflecting the overarching theme. Digital stabilization was identified as both meaningful and effortful, shaped by shifting emotional capacity, cognitive bandwidth, relational dynamics, and day-to-day practical conditions. Feasibility appeared to depend more on adolescents’ and families’ fluctuating access to internal and external resources than on motivation alone. Given the formative design and small sample, these findings should be interpreted as preliminary and specific to the study context.

The findings align with research indicating that digital and blended trauma-focused approaches can improve accessibility and reduce logistical and emotional barriers in youth trauma treatment [20,21,48]. Prior studies show that when digital formats fit adolescents’ needs, they can support engagement and emotional insight [20,22,36,49,50]. Our results extend this literature by clarifying how these engagement dynamics unfold within a digital stabilization phase, a component that has received limited empirical attention in digital trauma interventions.

Beyond these observations, our findings align with longstanding evidence from youth psychotherapy showing that engagement fluctuates with emotional regulation capacity, attentional variability, and family system load rather than treatment interest alone [51]. Similar fluctuation patterns are reported in digital youth mental health, where daily cognitive and emotional rhythms shape engagement [2]. This research helps contextualize how such dynamics operate during digital stabilization preceding trauma-focused work, a step rarely examined in prior studies.

Consistent with affect-regulation models, adolescents’ engagement fluctuated with arousal levels, cognitive load, and attentional variability [11,52]. Even structured and multimodal content was experienced as demanding during periods of fatigue or emotional overload. These fluctuations may be particularly pronounced when PTSD co-occurs with neurodivergent attentional profiles [53,54]. Within a CFT framework, these patterns align with shifts between threat and soothing systems [26], underscoring that cognitive and emotional availability (not motivational readiness) may be important for feasibility.

PTSD-related avoidance may also have contributed to some of the engagement patterns observed in the present study. Avoidance is a core feature of PTSD and may influence willingness to engage with trauma-related material, emotional reflection, or therapeutic exercises [4,11,52]. Consequently, fluctuations in participation, reduced engagement, or difficulty completing modules may reflect not only practical barriers, cognitive load, or usability challenges but also adaptive attempts to avoid distressing thoughts, emotions, or trauma-related content. Future studies should examine more explicitly how avoidance symptoms interact with engagement during digital stabilization and trauma-focused treatment.

These findings also resonate with qualitative work in Swedish CAP settings, where adolescents expressed a preference for blended formats that increase accessibility, reduce barriers, and offer stabilizing support between sessions [25]. At the same time, much of the existing evidence for digital youth interventions is based on samples with mild-to-moderate difficulties, with clinically complex populations often underrepresented in trials [1,55]. Engagement challenges and early dropouts are common in digital mental health [54,56], and therapists in our study noted that maintaining participation often required additional scaffolding such as reminders, troubleshooting, and brief check-ins. Against this backdrop, the meaningful engagement observed in our clinically complex CAP sample suggests that digital stabilization may be feasible for adolescents with clinically complex presentations who are often underrepresented in digital intervention research.

The findings also align with the literature, indicating that adolescents benefit from brief, visually supported, and flexible digital content [1,2]. Reviews similarly emphasize that short and adaptable modules are particularly important for adolescents with fluctuating attention [53,54]. Network meta-analytic evidence also indicates CBT-based digital interventions rank highly for youth anxiety, supporting structured, modular delivery in this population [57]. However, the observed tension between conceptual clarity and cognitive effort suggests that even well-designed material may be demanding during periods of low capacity, particularly for neurodivergent or highly burdened adolescents.

A notable contribution of this study concerns relational uncertainty around caregiver involvement in digital stabilization. Although caregivers accessed the content through PDFs and QR-linked materials rather than a dedicated app, their experiences highlighted how family routines, caregiver support, and relational dynamics influenced engagement throughout the stabilization phase.

While caregiver participation is known to enhance TF-CBT outcomes [58,59], less is known about how autonomy and support interact in digital modalities. Adolescents often preferred solitary work to avoid relational pressure, whereas caregivers struggled to provide nonintrusive support. CFT models can help explain this dynamic: threat-system activation and fears of misattunement can lead both youths and caregivers to withdraw or overcompensate [60,61]. These findings underline the need for explicit, developmentally attuned guidance for caregivers in blended stabilization, indicating that autonomy and support must be balanced.

Technical reliability also influenced feasibility. Even minor issues, such as login barriers or unstable notifications, affected adherence, mirroring findings across digital mental health research.

Despite a clinically complex sample characterized by PTSD, comorbidity, caregiver strain, and family adversity, adolescents engaged meaningfully with the stabilization module. This corresponds with emerging evidence that flexible, low-threshold digital formats can be feasible even for clinically complex youth [1,54,55], especially when supported through reminders, troubleshooting, and brief check-ins. In CAP contexts where emotional dysregulation, cognitive variability, and family strain are common, digital stabilization may therefore serve as a viable preparatory pathway.

Finally, the results are consistent with theoretical and clinical arguments for incorporating compassion-focused grounding in stabilization. CFT emphasizes soothing-system activation, shame reduction, and affect regulation as preparatory mechanisms for trauma work [26,62,63]. Participants described increased emotional insight, regulation capacity, and shared language for understanding emotional experiences, all of which align with the goals of TF-CBT’s stabilization. From a CFT perspective, compassion-based grounding may support emotional regulation and reduce threat-focused responding, which participants perceived as helpful when preparing for trauma-focused work [27,29]. These findings suggest that digital compassion-focused stabilization may serve as a bridge between early psychoeducation and later trauma-focused work.

The identified refinements highlight several principles for designing a feasible stabilization phase within blended TF-CBT-C: alignment with adolescents’ fluctuating emotional and cognitive rhythms, flexible pacing and lower information density, multimodal formats to support attentional variability, explicit caregiver guidance to balance autonomy and relational support, and reliable technical infrastructure. Grounding and compassion-based strategies should be explicitly connected to trauma-focused work to strengthen emotional readiness and shared understanding. Together, these principles underscore the broader design conditions required for digital components to function effectively within routine CAP practice.

Strengths include the multistakeholder design (integrating the perspectives of adolescents, caregivers, and clinicians), a reflexive analytic approach, and an ecologically valid CAP context. Several limitations should also be considered. First, the sample was small and context-specific, and the findings should therefore be viewed as exploratory. The study was designed to inform intervention refinement prior to a pilot RCT and was not intended to provide evidence of clinical effectiveness or broader implementation feasibility. Second, all adolescent participants were girls. Experiences of digital engagement, autonomy, caregiver involvement, emotional expression, and treatment participation may differ among boys and gender-diverse youth. The findings may therefore not be transferable to broader adolescent populations and should be interpreted with caution regarding gender diversity. Third, the intervention was evaluated within a research test environment rather than the final production version of the platform. Some of the technical challenges reported in this study may therefore not reflect the functionality of the final platform.

Finally, caregivers accessed the stabilization content through PDFs and QR-linked materials because the caregiver app was not yet available. Their experiences therefore reflect the caregiver intervention content delivered through an alternative format rather than the planned caregiver app.

For a pilot RCT to yield interpretable feasibility data, platform reliability, caregiver integration, and pacing flexibility should be prioritized. Regional conditions, such as long distances and uneven availability of specialists, necessitate attention to implementation outcomes, such as workflow compatibility and notification efficacy. Offline access, reduced data load, and low-bandwidth optimization will be important for equitable participation. Mixed-methods process evaluation can clarify dose-response patterns, identify bottlenecks, and inform iterative improvement.

This study suggests that an app-based stabilization phase for adolescents, together with parallel caregiver materials, within bTF-CBT-C may be acceptable and potentially feasible. Participants identified both strengths of the intervention and areas requiring refinement, particularly related to technical functionality, cognitive accessibility, and caregiver support. The findings highlight candidate refinements for evaluation in the pilot RCT and offer preliminary guidance for optimizing the intervention and its implementation. These findings are preliminary and should be interpreted within the context of this small formative qualitative study.