Trauma-focused cognitive behavioural therapy (TF-CBT) is an effective intervention for post-traumatic stress disorder, yet implementation may be hindered by practitioners' concerns about how treatment is experienced by users. This metasynthesis systematically reviews qualitative evidence on youth and caregivers' experiences of TF-CBT to better understand user perspectives on process and outcomes of treatment. A systematic review and metasynthesis were undertaken for qualitative studies of treatment experience related to TF-CBT. Data were extracted according to Evidence for Policy and Practice Information and Coordinating Centre guidelines, and studies were critically appraised using Critical Appraisal Skills Programme checklists. Findings from included studies were coded and synthesized using thematic synthesis methodology. Eight studies were selected after a full-text review of 39 papers. Findings were organised around nine sub-themes, under three broad thematic categories: 'engagement in TF-CBT'; 'experience of treatment components'; and 'therapeutic outcomes'. Youth were often unclear about what to expect from treatment and concerned about (in)compatibility with their therapist. Youth reports indicated how such misgivings can be addressed through early psychoeducation and efforts to strengthen the therapeutic alliance. Once underway, treatment was viewed as a place of refuge and validation, aided by therapist competence and confidentiality. Youth and caregivers felt that constructing a trauma narrative was instrumental for recovery. Cognitive-behavioural coping techniques were useful during treatment and in the long-term. While participants in TF-CBT may begin treatment with unclear expectancies, careful attention to early engagement and other process issues can optimise process and outcomes. Implications for clinical practice and further research are discussed.