Public safety personnel (PSP) include border security officers, correctional officers, dispatch/communication workers, paramedics, firefighters, and police officers. A study investigating the mental health of Canadian PSP found that 44.5% had screened positive for one or more mental health disorders, which contrasts with the diagnostic rate of 10.1% in the general population [1
]. Past research on various PSP sectors has shown that PSP in other countries also struggle with high rates of mental health problems (e.g., [2
]). PSP are routinely confronted with traumatic stressors as part of their regular duties [5
] and have been shown to deal with high levels of work demand and physical and psychological stressors [5
]. They regularly work overtime, face close public scrutiny, take part in labour and management conflicts, and routinely experience harassment [5
]. PSP have experienced high rates of trauma exposure and mental health disorders but have avoided seeking psychological services, due, in part, to concerns about mental health stigma [6
]. Despite successful initiatives to provide resiliency training and reduce the stigma surrounding mental health problems, such as the Road to Mental Readiness for First Responders program [7
], a recent study found that many Canadian PSP still report experiencing limited workplace support for mental health-related problems [8
]. PSP face several other barriers to mental health services, including long waiting times, distance from services, concerns about privacy and confidentiality, and cost of treatment [8
Internet-delivered cognitive behaviour therapy (ICBT) is an alternative form of cognitive behaviour therapy (CBT) that is delivered online, often in the form of weekly lessons [10
]. It can address common barriers to mental healthcare because it requires less therapist time than face-to-face treatments and can be accessed from virtually any location at any time [11
]. Meta-analyses have found moderate to large effects of ICBT for several conditions, including major depression, generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder [10
]. Furthermore, there is mounting evidence that ICBT is effective when offered in routine practice [12
], and studies have shown that ICBT with therapist support is comparably efficacious to face-to-face therapy [10
]. ICBT may benefit both individuals and organizations by decreasing the amount of time people are off work due to mental health-related disability [14
Despite its effectiveness, research suggests that ICBT is not perceived as positively as face-to-face therapy. Participants in prior studies have acknowledged the advantages of ICBT, such as convenience, flexibility, and anonymity [15
], but have also perceived disadvantages such as low credibility and concerns about e-therapists’ ability to display empathy or build trust [16
]. Participants in several studies have overwhelmingly expressed a preference for face-to-face therapy over web-based interventions [15
]. Perceptions of ICBT as less helpful than face-to-face therapy could limit the utility of ICBT for expanding access to mental health treatment because treatment expectations are related to treatment outcomes in psychotherapy [18
Negative perceptions of ICBT appear to result, at least in part, from a lack of awareness of and knowledge about ICBT. In one study [19
], participants indicated that they would have a 48% likelihood of using computerized CBT if they were depressed and would expect it to lead to a 35% improvement in symptoms, on average. After watching an educational video, participants indicated that they would have a 70% likelihood of using computerized CBT and would expect a 60% improvement in symptoms. In addition to its effect on intentions to use treatments, mental health knowledge is related to lower levels of stigma among PSP [20
]. However, past research has not examined how stories impact the perceptions of ICBT. Compared to other means of relaying information, stories allow for a more personal connection to and a deeper understanding of the information [21
]. Prior research has shown that stories can have positive influences on advertising services and health communication [22
The present study addresses four main research questions. First, how do PSP perceive ICBT after viewing educational materials? Second, do PSP who learn about ICBT from a poster and a story perceive ICBT more favourably than PSP who learn about ICBT from a poster alone? Third, do certain demographic or clinical characteristics predict perceptions of ICBT? Fourth, how would PSP prefer for ICBT to be delivered, especially in terms of therapist support and, particularly, with regard to therapist guidance? Regarding our first research question, based on the literature on educating people about ICBT, discussed above, we hypothesized that our sample would report relatively positive perceptions of ICBT after viewing the educational materials. Regarding our second research question, we hypothesized that the group presented with the poster and story would report more positive perceptions of ICBT than the group presented with the poster only. Our third and fourth research questions were exploratory; we expected that further examination of PSP’s perceptions of ICBT and the predictors of their perceptions could help inform education and implementation efforts (e.g., identifying specific client concerns about ICBT or groups who have elevated concerns).
2. Methods and Measures
In 2019, the Government of Canada initiated a national Action Plan entitled Supporting Canada’s Public Safety Personnel: An Action Plan on Posttraumatic Stress Injuries [24
]. Through this initiative, the Federal Government provided our research unit, PSPNET, with funding to develop and evaluate ICBT tailored for PSP. We began recruitment for the present study at approximately the same time as we launched our first ICBT program, called the PSP Wellbeing Course, in the province of Saskatchewan in January 2020. The PSP Wellbeing Course is based on a course initially developed at Macquarie University in Australia [25
] and is designed to treat symptoms of depression, anxiety, and post-traumatic stress among PSP.
We recruited participants through email announcements sent to various PSP organizations across Saskatchewan, representing the following sectors: border security, corrections, communication/dispatch, emergency medical services, firefighting, and police. Invitations were also given in the form of unpaid advertisements on Facebook. We excluded 18 participants from data analysis for several reasons. Some participants (n = 7) indicated having previous experience with ICBT. One participant self-identified as a non-PSP, and another indicated that they had completed the survey twice. Lastly, some participants (n = 9) did not provide enough data to allow for meaningful data analyses. We analyzed data from 132 participants.
Participants completed an online questionnaire, including demographic questions and questions about their recent mental health status. Participants were then randomly assigned to one of two groups. One group (n
= 61) was presented with a poster describing the PSP Wellbeing Course
, and the other (n
= 71) was presented with the same poster along with a client story about a PSP using ICBT. The ICBT poster included a general description of ICBT being offered to PSP in Saskatchewan, including an overview of what ICBT is, the evidence for its effectiveness, and how the course is delivered. The poster is displayed in Appendix A
. The ICBT client story followed a PSP character named Sam, whose story was derived from those of various PSP interviewed in a separate study [8
]. Sam’s story described his experience using an ICBT program, including the knowledge, tools, and resources he received from ICBT and how they helped him manage his wellbeing and mental health as a PSP. The story is shown in Appendix B
Both groups were then asked if they had any questions about ICBT based on the information. The group receiving the story was asked how much they related to the story and how much they expected other PSP would relate to the story. All participants completed a battery of questionnaires (described in detail below), including measures of the acceptability and credibility of ICBT and general help-seeking. We also administered questions pertaining to the participants’ perceptions of ICBT (e.g., preferences for the level of therapist support, general likes and dislikes). At the end of the survey, participants were given the option to click on a link to pspnet.ca if they wanted to learn more about ICBT for PSP.
2.4. Demographics Information
Participants answered questions regarding age, gender, education level, relationship status, the size of the community they live in, ethnicity, employment, years of experience in PSP roles, past-year psychotropic medication use, past-year mental health treatment, and knowledge and experience of ICBT.
2.5. Patient Health Questionnaire 4-Item (PHQ-4)
] is a 4-item measure of depression and anxiety. Each item is answered on a 0–3 response scale, resulting in a total score ranging from 0 to 12. PHQ-4 has demonstrated good internal consistency and construct validity [26
]. The Cronbach’s alpha for PHQ-4 was 0.87 in this study.
2.6. PTSD Checklist for DSM-5 (PCL-2)
] consists of two items related to symptoms of post-traumatic stress disorder (PTSD). Each item is answered on a 1–5 response scale. The measure has good specificity and sensitivity [27
]. The Cronbach’s alpha for PCL-2 in this study was 0.88.
2.7. Story Relatability
Participants in the poster and story condition answered two questions about the relatability of the story: “Do you feel Sam’s experiences are similar at all to your own?” and “Do you feel Sam’s experiences are similar to any first responders/public safety personnel you know?”. Participants responded using a 0–100% response scale.
2.8. Treatment Acceptability and Adherence Scale (TAAS)
] is a measure assessing the acceptability of a treatment and a respondent’s anticipated adherence to that treatment. It is composed of ten questions, which respondents answer via a 7-point Likert scale. The items are summed with scores ranging from 10–70, with higher scores representing greater acceptability and anticipated adherence to the treatment in question [28
]. The Cronbach’s alpha for TAAS was 0.86 in this study.
2.9. General Health Seeking Questionnaire (GHSQ)
] was used in this study to assess the respondent’s perceived likelihood of seeking various sources of help. Response options ranged from 1 (extremely unlikely) to 7 (extremely likely). GHSQ has demonstrated good reliability and validity [29
2.10. Credibility and Expectations Questionnaire (CEQ)
] is a questionnaire assessing the perceived credibility and expected outcomes of a treatment. It includes four items employing 9-point Likert scales and two items that respondents answer by selecting a percentage between zero and 100. We measured the credibility of treatment by calculating the mean of the first three items and expectancy by using the last item [31
]. CEQ has demonstrated high internal consistency and good test–retest reliability [30
]. The Cronbach’s alpha for the credibility subscale of CEQ was 0.86 in this study.
2.11. ICBT Treatment Support Preference Questionnaire
This bespoke questionnaire consists of four items regarding preferences related to therapist support. First, we asked, “Do you think ICBT is a mental health support you would access if you needed help?” and participants selected “yes” or “no”. We then asked participants how often they would like therapists to check in on their progress by email and how often they would like to send emails to e-therapists. Response options included “never”, “only if I [request/feel like] it”, “once a week”, and “twice a week”. Lastly, we asked participants to indicate whether they would prefer to complete ICBT with no therapist involvement, therapist involvement on demand, a therapist who checks the website and responds to questions once per week, or a therapist who does so twice per week.
2.12. Treatment Preference
We presented participants with 12 treatment options and asked them to rank the three options they would most prefer if they were dealing with depression, anxiety, or PTSD. The 12 options were as follows: ICBT with therapist support, ICBT with no therapist support, online counselling, psychologist, social worker, counsellor, doctor/GP, nurse practitioner, psychiatrist, self-help book, website information, and other (please specify). We also allowed participants to indicate if they “would not seek help from anyone”.
2.13. ICBT Likes and Dislikes
Using open-ended text boxes, we asked participants what they liked and disliked about ICBT, about their perceptions of the advantages and disadvantages of ICBT, and whether they had any questions about ICBT.
2.14. E-Therapy Assessment Measure (ETAM)
] consists of three items related to the perceived effectiveness of ICBT, appropriateness of ICBT, and preference for ICBT compared with conventional face-to-face therapy. Responses are rated on a 5-point Likert scale ranging from “Disagree Strongly” to “Agree Strongly”. We presented participants with an additional item using the same response scale: “In case of mental health problems, I would attend ICBT”.
We employed a mixed-methods approach to data analysis. We conducted all quantitative analyses using SPSS (version 23). We used descriptive statistics to examine the background characteristics of the sample, overall perceptions of ICBT, and the relatability of the story for those assigned to the poster and story condition. We compared conditions on demographic and clinical characteristics using t-tests and chi-square analyses. In order to test our hypothesis that participants presented with the poster and story would report more positive perceptions of ICBT than participants presented with the poster alone, we conducted an ANOVA to examine whether the perceptions of ICBT (measured via CEQ, ETAM, and TAAS) differed between conditions. We also conducted three linear regressions to examine the predictors of the perceived credibility (measured via CEQ), treatment expectations (measured via CEQ), and acceptability and anticipated adherence (measured via TAAS) of ICBT. Predictors inputted into each regression analysis included age, gender, size of home community, PSP sector, years of experience as a PSP, education level, familiarity with ICBT, relationship status, medication, mental health treatment, and PHQ-4 and PCL-2 scores. We used descriptive statistics to examine how ICBT ranked in preference compared to other treatments and how PSP indicated they would prefer ICBT to be delivered.
We supplemented these quantitative analyses with qualitative analyses to further explore PSP’s perceptions of ICBT. Specifically, we used an inductive qualitative content analysis [33
] to examine participants’ responses concerning their likes and dislikes of ICBT and their questions about ICBT. First, the author A.S. reviewed participants’ responses to the open-ended questions and developed a coding guide for participants’ perceived likes and dislikes of ICBT. Next, A.S. and authors H.M. and J.D.B. reviewed and refined the initial coding guide. All authors then met to finalize the coding guide, and H.M. and J.D.B. recoded several responses and reviewed all data to ensure it was coded consistently with the finalized coding guide.
2.16. Power Analysis
We conducted power analyses using G*Power 3 [34
]. For our multiple regression analysis, given an alpha of 0.05, a power level of 0.80, and 12 predictors, and assuming a medium effect size of f2
= 0.15, we required a sample of 127 participants. For the ANOVA analysis, given an alpha of 0.05, a power level of 0.80, and two conditions, and assuming a medium effect size of f
= 0.25, we required a sample size of 128.
3.1. Participant Characteristics
Participants had an average age of 39.90 (SD = 9.54) years. The gender ratio was relatively evenly split between male and female PSP (male n = 68; 52%; female n = 62; 47%; nonbinary n = 2; 2%). Approximately half the participants (n = 70, 53%) reported living in communities with a population over 100,000 and half (n = 62, 47%) in communities under 100,000. Most PSP were married (n = 89, 67%), had attained a postsecondary degree (n = 85, 64%), and identified themselves as white (n = 119, 90%). Only 5 (4%) reported not being employed at the time of survey completion, and most (n = 86, 65%) had 10 or more years of experience working as PSP. The sample included PSP from various sectors: border security (n = 10, 8%), corrections (n = 18, 14%), communications/dispatch (n = 8, 6%), emergency medical services (n = 41, 31%), firefighting (n = 20, 15%), and police (n = 35, 27%).
About a quarter of participants (n
= 32, 24%) reported using medication for a mental health problem within the previous year, and nearly half (n
= 59, 45%) reported receiving professional help for a mental health problem within the previous year. When asked how familiar they were with ICBT, many participants (n
= 56, 42%) indicated that they had at least “a little knowledge” of it. Participants had a mean PHQ-4 score of 3.4 (SD
= 3.0), and most (n
= 73, 55%) had clinically significant scores (i.e., scores greater than 3 [26
]). The mean PCL-2 score was 4.25 (SD
= 2.01), and most participants (n
= 81, 61%) had clinically significant scores (i.e., scores greater than 4 [27
]). Chi-square analyses and t
-tests revealed no differences between conditions on any demographic or clinical characteristics (p
s > 0.05). The demographic and clinical characteristics, collapsed across conditions, are summarized in Table 1
3.2. Quantitative Analyses
To test our hypothesis that participants presented with the poster and story would report more positive perceptions of ICBT than participants presented with the poster alone, we used an ANOVA to compare the conditions on attitudes towards ICBT. The results indicated there were no differences on the expectancy subscale of CEQ (F(1, 130) = 0.198, p = 0.657), the credibility subscale of CEQ (F(1, 130) = 0.406, p = 0.525), ETAM (F(1, 130) = 0.001, p = 0.979), or TAAS (F(1, 130) = 0.006, p = 0.94). Given that demographic and clinical characteristics, credibility, expectancy, and e-therapy measure scores did not differ across conditions, both conditions were collapsed for the remainder of the analyses.
To test our hypothesis that participants would report relatively positive perceptions of ICBT, we calculated descriptive statistics to examine participants’ attitudes towards ICBT. Across both conditions, participants provided mean scores of 18.52 on the credibility subscale of CEQ (SD
= 4.87), 53.79 on the expectancy subscale of CEQ (SD
= 22.16), 9.20 on ETAM (SD
= 3.19), and 51.86 on TAAS (SD
= 9.42). On average, participants randomly assigned to review the story reported finding it to be 50% similar to their own experiences (SD
= 30%) and 73% similar to the experiences of other PSP they knew (SD
= 28%). When participants were asked to rank their top three most preferred sources of treatment, psychologists were most frequently ranked in the top three (n
= 77, 58%), followed by therapist-guided ICBT (n
= 68, 52%), counsellors (n
= 50, 38%), and doctors (n
= 47, 36%). See Table 2
for details. Results from the ICBT Therapist Support Preferences Questionnaire indicated that most participants (n
= 123, 93%) would access ICBT if they needed help.
To explore our research question concerning possible predictors of perceptions of ICBT, we conducted three regression analyses. Clinical and demographic variables did not significantly predict scores on the expectancy subscale of CEQ (R2
= 0.10, F
(13, 113) = 0.98, p
= 0.48), but they did significantly predict scores on the credibility subscale of CEQ (R2
= 0.20, F
(13, 113) = 0.2.19, p
= 0.014). This second regression showed that identifying as female significantly predicted higher scores on the credibility subscale of CEQ (β = 0.29, t
(113) = 3.26, p
= 0.001). Lastly, a third regression showed that the clinical and demographic variables predicted TAAS total scores (R2
= 0.20, F
(13, 113) = 2.20, p
= 0.014). In this regression, years of experience as a PSP negatively predicted TAAS total scores (β = −0.23, t
(113) = −2.22, p
= 0.03). The results of these regressions are summarized in Table 3
Results from the ICBT Therapist Support Preferences Questionnaire addressed our research question concerning PSP’s preferences for the delivery of ICBT. Many expressed a preference to have a therapist check in on their progress by email once (n = 84, 64%) or twice (n = 15, 11%) per week, although approximately one in four (n = 32, 24%) indicated that they would prefer therapists to be available upon request. Similarly, most participants indicated that they would prefer to have a therapist monitor their progress and respond to questions once (n = 55, 42%) or twice (n = 31, 23%) per week, and one in three indicated a preference for no monitoring and guidance on demand instead (n = 42, 32%). About half of our participants (n = 66, 50%) responded that they would email a provider “only if [they] feel like it”, followed by once per week (n = 52, 39%). Few (n = 9, 7%) indicated that they would email their therapists twice per week.
3.3. Qualitative Analyses
When invited to ask questions about ICBT, several participants (n = 7, 5%) asked logistical questions. For example, participants asked what would happen if users did not complete therapy, how many sessions users typically complete per week, and how long it takes to complete the program. Participants also asked questions about anonymity (n = 1, 1%) and costs (n = 1, 1%).
The most common “like” identified with ICBT was accessibility (n
= 111, 84%). The theme of accessibility was subcategorized into seven categories, as presented in Table 4
. The most frequently endorsed subcategories were convenience (n
= 25, 19%) and the time-flexible nature of ICBT (n
= 37, 28%). The two most common likes after accessibility were anonymity/privacy (n
= 16, 12%) and that ICBT provides information/techniques/advice on mental health (e.g., “covers a large range of issues”; n
= 14, 11%). The most common “dislike” was the lack of face-to-face interaction with a therapist or the belief that ICBT would feel impersonal (n
= 41, 31%). Other participants expressed concerns about the effectiveness of ICBT (n
= 11, 8%) or issues related to clients’ accountability and motivation (n
= 14, 11%).