Demographic data were collected via the Participant Information Questionnaire and analyzed using SPSS (version 28; IBM Corp). Results showed that eligible clients predominantly enrolled in the PSP Wellbeing Course (n=9, 90%) and self-identified as employed (n=8, 80%), White (n=8, 80%), and men (n=7, 70%) with an average age of 45 years. Half of the clients reported working within policing (n=5, 50%) and half in various other public safety sectors. Clients resided in communities with less than (n=6, 60%) and greater than 100,000 citizens (n=4, 40%) across various Canadian provinces. At pretreatment, 80% of clients endorsed clinically significant symptoms of one or more mental disorders, with 50% endorsing clinically significant symptoms of 3 or more mental disorders. In total, 70% of clients endorsed clinically significant symptoms of depression, 60% endorsed clinically significant symptoms of anger, 50% endorsed clinically significant symptoms of generalized anxiety, 30% endorsed clinically significant symptoms of posttraumatic stress, and 10% endorsed clinically significant problems with alcohol and drug use. Further details surrounding sample characteristics are presented in Table 1.

Qualitative data (N=10) were sourced from open-ended questions via the semistructured interviews, which were deidentified and transcribed by author SAD. Transcriptions were then analyzed using the NVivo (version 20; Lumivero) analysis software using a reflexive thematic approach. The initial codebook was created by the primary coder, author JABP, to align with questions posed during the semistructured interviews. These themes were then reevaluated to identify, analyze, and report on any subthemes [46]. The authors acknowledge that we hold certain preconceived attitudes and beliefs about ICBT and recognize that, as non-PSP, our understanding of PSP experiences is limited. To help minimize bias, themes were reviewed by author SMS to identify and discuss any conflicts. Themes were then discussed among all other co-authors for diverse perspectives. Upon consensus of coding, each theme was assessed for semantic meaning and given an appropriate name [47]. Client demographics were pulled from the closed-ended survey questions and were imported into IBM SPSS Statistics (version 26) to compute descriptive statistics.

Qualitative analyses identified two reasons why leaders within public safety enrolled in the PSP Wellbeing Course (n=9) and PSP PTSD Course (n=1): (1) to seek support for their mental health (n=6, 60%) and (2) to review the course for their members (n=4, 40%). Leaders cited two themes of stressors that impact their mental health and well-being: (1) occupational (N=10) and (2) nonoccupational (n=3, 30%). Occupational stressors were further categorized into operational (ie, related to tasks in the workplace; n=7, 70%) or organizational stressors (ie, related to the job setting or context). The operational stressor most reported was workload (n=7, 70%). One client said “The challenge I find as a leader is I work a lot of extra hours” while another stated, “I'm on call 24 hours a day.” Additionally, clients reported operational stress due to PPTE exposures (n=5, 50%). One client explained, “in leadership positions…you get exposed to a lot of things” while another client elaborated, “I’ve been through riots… finding dead bodies.”

Clients further identified a variety of organizational stressors that impact their well-being. Most clients highlighted the continued presence and impacts of mental health stigma (n=7, 70%) within their organizations. One client said, “I’ve been in the service for 29 years and the only place it’s safe to have a meltdown is at home or behind closed doors” while other clients clarified, “Creating a safe space for a leader is really, really difficult because you don’t know who you can trust” and “If you come out and say you have problems, you’re damaged goods in their eyes. So, you keep that to yourself.” Many clients reported a lack of support within their organization (n=6, 60%), stating, “My officers know they can come to me at any time with any issues whether its work or personal. I don’t get that from my leaders” and “There's no [union] representation of being in a management position whereas frontline workers have representation.” Clients indicated concerns related to staffing (n=5, 50%) with one stating, “Most people who would merit that type of a position don’t want the job” and another reporting that “My staff are stretched fairly thin.” Clients reported the impacts of guilt because of their job (n=4, 40%) with one explaining that “You are the ones who are setting up the plans and the ones who are directing people to act and so it's going to be a lot of guilt and trauma.” Another client elaborated “You’re always worried about the safety of the people under you, so you always carry that burden. You want to make sure they’re happy, cared for, looked after, their families are looked after, so you carry that a little bit more.” Clients also highlighted concerns related to interpersonal difficulties (n=4, 40%), “I don’t know how to handle him anymore. I’m beyond being able to deal with him… Dealing with him on a day-to-day basis left me with no energy to deal with stuff at home” and middle management (n=3, 30%), “The stressors come from below as well as above...it comes uphill and it goes downhill and we’re sort of the in between.” Finally, clients identified the impact of resources (n=3, 30%), “I'm burning through cash…I've been addressing some of the staffing issues we have, which has been great, but I've been doing it double time and there's only a finite amount of money.” Nonoccupational stressors were recognized by many, but not all, clients (n=3, 30%) with all identifying familial concerns specific to the death of a loved one (n=1, 33%), interpersonal violence (n=1, 33%), or marital problems (n=1, 33%). More information about these occupational and nonoccupational stressors are discussed in Table 2.

Clients generally engaged well with ICBT, as most accessed at least the first 4 of 5 lessons in their selected course (7/10, 70%), completed posttreatment mental health measures (9/10, 90%), and used optional therapist support (7/10, 70%) via phone (3/7, 42%), email (1/7, 14%), or both (3/7, 42%). Clients’ perceptions of ICBT were largely positive. Most clients reported in the treatment satisfaction questionnaire that the course was worth their time (8/10, 80%), that they were satisfied with the course overall (n=9, 90%), and that they would recommend the course to other PSP (N=10). One client stated that “Every lesson has given me something as a first responder leader,” while another recognized that “It is changing my life. I feel less angry and less frustrated.” Of those who had contact with their clinician (7/10, 70%), most clients reported that their therapist support met or exceeded their expectations (6/7, 86%). One client explained, “I think I can be helpful to other leaders if they find themselves in this position.”

Skills most commonly cited as helpful were controlled breathing (6/10, 60%) followed by challenging unhelpful thoughts (4/10, 40%) and graduated exposure (4/10, 40%). Many clients reported positive perceptions of the course delivery (6/10, 60%), highlighting the program’s flexibility (4/6, 67%), structure (2/6, 33%), free-of-cost availability (2/6, 33%), confidentiality (1/6, 17%), and audio features (1/6, 17%). For example, 1 client stated, “You don’t have to go out somewhere to meet with somebody or those kinds of things like for an introvert like me, it’s perfect that it’s like this.”

All clients accessed at least 1 case story (N=10), and most accessed at least 1 additional resource (6/10, 60%). Clients perceived the case stories as authentic representations of PSP (9/10, 90%) that were relatable to their own experiences (9/10, 90%). One client explained, “I’ve seen my staff go through some of the things that they were talking about…So, I could sort of go through the story and empathize with it and possibly be able to use that to help my staff.” Most clients agreed that the case stories were modeled (9/10, 90%) and motivated the use of targeted behavior learned in the course (9/10, 90%). One client stated, “Just reading it…was one thing but then to kind of take those stories and put them into a real-life situation, that absolutely helps.” Clients also described stories as helping to normalize mental health symptoms (8/10, 80%), with 1 client highlighting that “Knowing it’s so common makes it much easier to start facing things.” Moreover, most clients recognized that the case stories increased understanding of and engagement with the course material (7/10, 70%). One client stated, “[The stories] put it into perspective what the material was teaching us so like okay I can see how this applies to a situation or to real life.” Some clients also recognized the case stories as a source of mental health information (4/10, 40%).

Clients provided tangible feedback on ways to optimize therapist-guided ICBT for leaders via the case stories, additional resources, and delivery. Most clients (n=6, 60%) recommended a new story tailored for leaders within public safety. One client stated, “Yeah, it could be beneficial. Especially if…you’re in that middle or senior position.” while another stated “It could be an interesting avenue if you wanted to do a leadership version of this. So, the story is not about you. The story is about somebody on your team.” Two clients were unsure if a leadership story is necessary with one elaborating, “We do have unique issues but there’s also similarities and I think…how they deal with them is going to be the same. So, it’s just that we’re more isolated.” One client recommended removing the stories entirely, stating, “Get rid of them…It makes you feel like – well this person has it worse than you.”

Clients (n=4, 40%) provided topic suggestions for additional resources. Three clients recommended a leadership-specific resource with 2 clients recommending ways to apply the skills learned to a leadership position. Another client requested tools to build confidence, explaining, “For leadership…the huge thing is confidence, self-awareness, and being able to project that confidence and your abilities and skills.” One client also recommended a resilience-based resource that provides tools and skills to maintain mental health. Finally, 1 client suggested an unconscious bias resource, explaining, “Unconscious biases seems to be like a real cancer because everybody has a different one and you don’t know what it is. So, that means everybody’s discriminated against in some way and it makes moving forward in any capacity hard.”

Additionally, clients (n=7, 70%) provided recommendations for tailoring the course delivery. Three clients highlighted technological challenges in navigating the web-based platform. One client stated, “I don't know if this was myself or the system. The site would load fairly slowly. And it would crash a lot” while another said, “As an older person, technology's not my forte…This isn't just with your course it's with everything.” Two clients suggested incorporating more audiovisuals, with one explaining, “There is sections of the course that are narrated, and they do have someone talking to you and kind of walking you through it, and I liked those parts the best. That’s where I absorbed the most information, I don’t absorb the most if I’m just reading a screen.” Two clients also revealed challenges with the pace of the course, with one explaining “You kind of feel like oh, I should get through this lesson quick because I have another one” and another stating, “It would sure be nice if I didn't have to give the survey on the module I hadn't done yet.”

ICBT is an effective and convenient mental health treatment among the general population [19,20]. To increase awareness of and access to ICBT, PSPNET was developed with and for PSP across Canada. Previous results show favorable mental health outcomes, treatment engagement, and treatment satisfaction [21,30]. Leaders previously recognized the need and suitability of PSPNET for Canadian PSP and provided advice to optimize implementation generally [32]. This study expands on these findings by exploring ways to optimize the implementation of therapist-guided ICBT specifically among Canadian PSP in leadership roles.

Leaders reported concerns with occupational and nonoccupational stressors impacting their well-being. Occupational stressors included both operational stressors (ie, workload and PPTEs) and organizational stressors (ie, mental health stigma, lack of support, staffing challenges, guilt, interpersonal difficulties, middle management, and lack of resources) [16]. While these findings are broadly consistent with previous research showing the prevalence and diversity of occupational stressors within public safety organizations, it is notable that leaders in the current study described a higher proportion of organizational stressors relative to operational stressors than did a general sample of PSP who were not necessarily leaders in a past study [33]. PSP’s most salient stressors may then shift from operational to organizational in nature as they progress into leadership roles. Some leaders also reported nonoccupational stressors specific to their families. Leaders enrolled in PSPNET most frequently described seeking support for their mental health, with some enrolling instead to review the course for other employees in their organizations. Therefore, despite leadership stereotypes [48], the study shows that Canadian PSP in leadership roles are susceptible to occupational and nonoccupational stressors and may have an interest in seeking therapist-guided ICBT to support their mental health (among other reasons).

Leaders in this sample showed good treatment engagement and satisfaction, including satisfaction with therapist support, which is consistent with findings of prior research on ICBT tailored for PSP at varying levels of leadership [21,22]. Self-managing mental health symptoms appear to be a priority among leaders just as it is among PSP more broadly [34], although several leaders indicated that they were reviewing the course before recommending it to colleagues. Many leaders in this study cited controlled breathing, challenging unhelpful thoughts, and graduated exposure as helpful skills learned in PSPNET’s courses.

Previous research found that many (ie, 69% [34]), but not all, PSP accessed at least 1 case story in ICBT compared to all leaders in this study. Leaders, in general, report increased social isolation [14,15,49] and decreased social support [15] compared to nonleaders. Perhaps leaders are then more likely to engage in ICBT case stories as a result. Nevertheless, most leaders indicated that the case stories represented authentic and relatable experiences [34,50], but still recommended the development of a new story tailored to their needs. Research supports tailoring case stories to current and prospective clientele as it may improve story interest and engagement [51,52]. Therefore, this study highlights the need for and potential benefits of a leadership-based case story in the PSP Wellbeing Course. Specifically, content could include: (1) mental health stigma, (2) lack of support, (3) staffing challenges, and (4) guilt, among other topics provided in Table 2.

Leaders similarly recommended the development of a new resource that provides information on the application of the content and skills learned in the course to address their unique stressors. Offering a variety of additional resources provides a flexible way for clients to access psychoeducation and strategies relevant to their needs, without requiring them to seek external support or engage with content irrelevant to their needs [53]. Additional resources can also improve treatment engagement and satisfaction by allowing clients to personalize treatments [53]. This recommendation may then offer promising outcomes given that additional resources are perceived as a valued component of ICBT even though previous research [34] and this study showed that not all clients access them. A leadership-specific resource could support leaders in applying CBT skills to manage the unique issues they identified (eg, how to use thought challenging to address unhelpful thoughts that induce feelings of guilt in leaders and how to use assertive communication skills to manage interpersonal difficulties with staff).

Leaders continue to recognize the benefits of delivering CBT via a web-based platform. The delivery feature most appreciated by leaders in this study was flexibility, allowing clients to work at their own pace in the privacy of their home or office, with optional therapist support. This finding is consistent with previous research highlighting the need for flexible mental health support for PSP [26,28,32]. For example, McCall et al [26] found that PSPs prefer therapist-guided ICBT that is delivered within a flexible timeframe for course completion and with a choice of communication modes with their assigned therapist. Some leaders also remarked on their appreciation that PSPNET is free and confidential with the accessibility option of audio narratives. To further optimize ICBT delivery, leaders generally recommended improving the platform technology and adding audiovisual content. Technological barriers are a common concern with internet interventions [54] because they play a critical role in treatment engagement and satisfaction [55]. Audiovisual content can also improve treatment engagement and satisfaction by improving accessibility options [56]. Yet, little is known about PSP dropout rates in ICBT and whether they mirror the general population.