Public safety personnel (PSP) include border services officers, public safety communicators, correctional workers, firefighters (career and volunteer), Indigenous emergency managers, operational intelligence personnel, paramedics, police, search and rescue personnel, and those in other occupations that uphold the safety and security of communities [1]. PSP encounter significant occupational stressors [2] and an increased risk of experiencing symptoms of mental health disorders [3], all of which can affect family relationships. Spouses and significant others (SSOs) of PSP are impacted by the demands of public safety occupations [4]. SSOs of PSP report chronic and cumulative stressors related to both the risks and requirements of public safety work and their provision of emotional and instrumental support for their PSP significant other [5]. The demands of PSP work (eg, shiftwork, dangerous environments, and trauma exposure) impact the couple relationship and family functioning [6-8]. SSOs of PSP may experience worry regarding the risks of PSP work, indirect trauma, and other negative mental health consequences [4,9,10]. Mental health resources and supports for both PSP and their SSOs are essential to support the well-being and resilience of PSP families [11].

Recognizing the need for mental health supports designed for PSP, the Government of Canada’s National Action Plan for Addressing Post Traumatic Stress Injuries identified internet-delivered cognitive behavioral therapy (ICBT) as a valuable tool for providing mental health care to Canadian PSP [12]. This action plan led to the development of PSPNET, which delivers ICBT tailored to the needs of Canadian PSP. ICBT provides cognitive behavioral treatment materials through a web-based course, a format that has garnered extensive research support for the treatment of posttraumatic stress disorder (PTSD), depression, and anxiety disorders [13-15]. Of note, ICBT clinics typically refer clients presenting with severe and complex mental health problems (eg, psychosis, high risk of suicide, and severe substance use disorders) to more appropriate services [16]. ICBT can be delivered in a scalable and cost-effective manner [17] and addresses several barriers to face-to-face therapy, including barriers related to transportation, concerns about privacy and stigma, time constraints, and treatment costs [18,19]. Self-guided ICBT (ie, ICBT without a therapist) is particularly scalable [20] and cost-effective [21] and has demonstrated good outcomes for treating anxiety, depression [22], and PTSD [15], although therapist-guided ICBT tends to be somewhat more effective [23,24]. Research has shown that clients of both therapist-guided [17] and self-guided ICBT [25-27] maintain treatment gains at 1 year or longer after treatment.

PSPNET’s ICBT courses were developed using interview and survey feedback from PSP stakeholders [28,29]. Initially, the PSPNET team adapted an existing transdiagnostic ICBT course that had demonstrated effectiveness in the general population in Australia and the Canadian province of Saskatchewan [30-33]. This course was tailored for Canadian PSP and was titled the PSP Wellbeing Course. Initial research results from the PSP Wellbeing Course showed that tailored ICBT was used by PSP to address both occupational and personal concerns [34] and was viewed as beneficial [35]. Clients of the PSP Wellbeing Course showed good engagement and reported high treatment satisfaction, with 77% completing all modules of the course and 98% reporting that the course was worth their time [36]. Clients who reported clinically significant difficulties with depression, anxiety, PTSD, panic, or anger before treatment reported large improvements in these symptoms after taking the course [36]. A recent study showed that the PSP PTSD Course (a disorder-specific ICBT program for PTSD tailored to PSP) showed outcomes comparable with those of the PSP Wellbeing Course [37].

The results of qualitative research with PSPNET clients also yielded important insights into the challenges faced by PSP families and couples [34] and demonstrated a need to extend ICBT to SSOs of PSP. Specifically, PSP reported the following themes related to family life: communication and anger issues, withdrawal or lack of intimacy, lack of work-life balance, inadequate support from spouse or partner, scheduling conflicts, and vigilance regarding family safety. PSP clients reported an interest in having more support related to relationship and family issues. In addition, SSOs have contacted PSPNET to express their interest in participating in ICBT, noting a lack of accessible support that recognizes their unique challenges. Therefore, we sought to create and assess the first ICBT program specifically designed to support SSOs of PSP. PSPNET’s expansion of ICBT services to this group based on its initial research findings is consistent with a learning health system model [38], whereby data are continually collected and analyzed to inform iterative changes to a service.

This study focused on the development, delivery, and formative evaluation of a self-guided, transdiagnostic ICBT course tailored to SSOs of PSP (the SSO Wellbeing Course). The SSO Wellbeing Course was adapted from the PSP Wellbeing Course offered through PSPNET and was part of a larger project (PSPNET Families) that focused on creating and disseminating web-based evidence-based resources and supports for family members of PSP. The SSO Wellbeing Course represents the first specialized ICBT program to support the mental health and well-being of SSOs of PSP across Canada. As such, the evaluation focused on assessing usability and acceptance, which is an integral first step in evaluating the effectiveness of new tailored interventions [39]. A mixed methods approach, including both quantitative and qualitative data, was used to identify opportunities to improve ICBT for this group.

The main objectives of this research were to (1) assess initial course use (eg, client demographic and clinical characteristics, progress through course, and use of additional resources and discussion forum), (2) identify clients’ perceptions of the course (eg, likes, helpfulness, and areas for improvement), and (3) use data to inform course improvements. To meet these objectives, data were collected from multiple sources, including interviews, open-response questionnaire items, observational data (eg, the number of lessons accessed by clients), and symptom and relationship measures. Owing to the exploratory nature of the research, no hypotheses were made.

PSPNET was launched in 2019 to provide ICBT to Canadian PSP. In 2022, contract funding was secured to expand PSPNET to create PSPNET Families, a web-based well-being hub that provides information and resources to support family members of PSP. The development, delivery, and evaluation of the SSO Wellbeing Course constitute 1 component of the PSPNET Families project.

This study was approved by the Research Ethics Board of the University of Regina (#2022-054). All client data were stored on a secure server and deidentified before analysis. Besides granting participants access to the SSO Wellbeing Course, we offered no incentives to encourage participation. All clients of the SSO Wellbeing Course were made aware of these and many other details of this study, and they voluntarily provided informed consent before participating.

Consistent with the PSP Wellbeing Course, the SSO Wellbeing Course included 5 web-based lessons that were released gradually over 8 weeks and included weekly automated emails and messages within the intervention designed to prompt lesson completion. The lessons addressed (1) symptom identification and the cognitive behavioral model, (2) thought monitoring and challenging, (3) managing physical symptoms with dearousal strategies and pleasant activity scheduling, (4) managing unhelpful behaviors and graded exposure, and (5) relapse prevention. Each lesson contained the following: a slide show, downloadable and printable readings and activities, frequently asked questions, illustrative fictional case stories of individuals who took the course, and additional resources on various topics (eg, PTSD, communication skills, and sleep) available for clients to access based on their needs and interests. Written lesson materials were designed using Microsoft PowerPoint. Clients accessed all course materials by logging into their accounts on PSPNET’s website.

The SSO Wellbeing Course was offered as a self-guided program. To support the safety of clients, PSPNET Families clinicians completed weekly safety checks (ie, review of symptom measure scores) to monitor elevated scores and followed up with clients by phone if potential safety concerns were identified. The development of the SSO Wellbeing Course was guided by user-centered design principles, which endorse the active involvement of target users in the design process from the outset and the importance of a user-centered approach together with empirical research [40]. Adapting the course to the experiences and needs of SSOs was informed by regular feedback and suggestions from a working group (WG) consisting of 5 SSOs from across Canada whose significant others worked in various public safety sectors (ie, police, fire, and corrections). WG members participated in 6 meetings over the course of the project and provided integral information about their experiences, preferences, and needs as SSOs that informed content adaptations, visual presentation of course materials, and ideas for outreach strategies. Once launched, WG members were given access to the course and had the option of participating and providing feedback on the user experience.

Adaptations made to the PSP Wellbeing Course to create the SSO Wellbeing Course included adding (1) information on the unique lifestyle dimensions of PSP families to lesson 1, (2) new overview videos for each lesson, (3) a therapist-moderated discussion forum as an optional component of the course to provide a platform for peer discussion and support, and (4) new case stories about SSOs. The case stories represented the primary adaptation to the course and were used throughout the course to provide relatable examples of symptoms, challenges, and skill application. The story characters were based on the clinical team’s knowledge and the experiences shared by WG members. WG information helped to create and refine the stories, and WG members provided specific feedback on the SSO stories regarding content, relatability, diversity, helpfulness, visual presentation, and character photos. The course initially included stories of 7 fictional SSO characters with diverse backgrounds in terms of age, vocation, ethnicity, gender identity, family structure, and the PSP occupation in which their spouses or significant others worked. Each lesson included stories (eg, reflections and homework examples) from several characters. Consistent with the Shaffer and Zikmund-Fisher [41] taxonomy, the purpose of the stories was to enhance learning, increase engagement, model the implementation of skills and helpful behaviors, persuade clients to practice skills, and comfort and validate them. Stories have been found to help improve client understanding, enhance support, and potentially impact behavioral change [42].

The SSO Wellbeing Course was designed to be implemented and evaluated across Canada. Prospective clients were deemed eligible to participate if they self-reported that they were (1) a current or former SSO of a current or former PSP; (2) aged ≥18 years; (3) a Canadian resident; (4) able to regularly access the internet through a computer; and (5) not reporting a primary problem of psychosis, mania, or substance use.

Recruitment began in July 2022 and is ongoing. Data collected as recently as June 2023 from clients who enrolled as recently as May 2023 were used in this evaluation. The course was advertised through Google Ads, the PSPNET website, presentations and attending conferences, PSPNET’s social media pages, the use of social media influencers (ie, an SSO and a PSP), and direct contact with PSP organizations and other groups to request that they inform their members about the course (eg, via email). Interested SSOs were directed to a website with information about the course and instructions for enrollment. Following the provision of informed consent, clients were asked to complete screening questionnaires assessing their demographic characteristics, symptoms of mental health disorders, and relationship satisfaction and functioning. Subsequently, clients received secure log-in information and could begin the course. Clients who participated in the interviews also provided verbal consent by phone before beginning the interview process.

We used a mixed methods approach. Descriptive statistics were used to summarize the quantitative data (ie, demographic and clinical characteristics and course use data). Qualitative content analysis [48] was used to analyze qualitative data (ie, open-ended questionnaires and interview data). Quantitative data were used to address objective 1 (assessment of course use), qualitative data were used to address objective 2 (client perceptions of the course), and both sets of data were used to address objective 3 (inform course improvements). Data analyses were consistent with a learning health system model [38], which focuses on using data to inform improvements and further tailoring of course processes and materials to meet the specific needs of the users.

Conventional qualitative content analysis [48] was used to analyze all qualitative data, including the semistructured interviews and the open-ended questionnaire items. Conventional qualitative content analysis uses an inductive approach without preconceived categories [48]. Data from all open-ended questionnaire items were combined in the analysis, and interview data were analyzed separately from questionnaire data. All data were uploaded into the qualitative analysis software NVivo (Lumivero) [49]. Data were coded by meaning units into overarching categories and subcategories. The initial coding was conducted by JDB and then reviewed by ID. All disagreements were resolved through discussion.

At the time of data analysis, 142 Canadian SSOs completed the web-based screening and were enrolled in the course, and 118 started the course. These 118 clients were aged between 22 and 71 years, with a mean age of 42.03 (SD 9.36) years. Most clients resided in the provinces of Ontario (36/116, 31%), Saskatchewan (23/116, 19.8%), or Alberta (17/116, 14.7%). Most clients identified as White (110/116, 94.8%), women (108/116, 93.1%), employed (97/116, 83.6%), and living in an area with a population of <100,000 (72/116, 62.1%). Most clients indicated that their significant other is or was employed in the police sector (61/116, 52.6%) and that they were currently, rather than formerly, married to or in a relationship with a PSP (114/116, 98.3%). Nearly half of the sample (53/116, 45.7%) had elevated scores in at least 1 symptom area. PSPNET Families clinicians conducted safety check phone calls with a total of 5 clients, owing to a score increase of ≥5 on any symptom measure or the endorsement of potential suicidal ideation (as measured by item 9 of the PHQ-9). Upon completion of a risk assessment, further follow-up was not required for these clients. Nearly half of the sample (43/101, 42.6%) reported relationship dissatisfaction on the 4-item version of the Couples Satisfaction Index, and most clients (66/116, 56.9%) reported moderate relationship functioning on the General Functioning subscale of the McMaster Family Assessment Device. The subset of 26 clients who completed the interviews reported similar demographic (Table 1) and clinical and relationship characteristics (Table 2) to the overall sample. An overview of the flow of participants through the study, including recruitment, program use, and the provision of feedback via questionnaires and interviews, is displayed in Figure 1.

Of the 118 clients who started the course, 71 (60.2%) accessed most lessons (ie, at least up to lesson 3). The most commonly used additional resource was Communication with a Significant Other (40/118, 33.9%). Details regarding progress through the lessons and use of additional resources are shown in Table 3.

The discussion forum had minimal use. A total of 18 user comments from 10 clients were posted. Despite efforts to engage clients through changes to the placement of the forum within the course, the addition of a video showing how to use the forum, and prompts from the therapist moderating the forum, most clients did not use the forum.

Areas for improvement were identified based on qualitative data, quantitative data, or both. Many changes were made based directly on qualitative client feedback. For instance, new content and revisions made to both the additional resources and case stories were informed by client feedback. Some changes were implemented specifically based on quantitative data. For example, a certificate of completion was added to increase motivation for completion, based on findings that most clients did not complete the full course. Other changes were made based on a combination of both qualitative and quantitative data. For instance, the discussion forum was removed based on interview feedback that it was not being used and quantitative data showing low use. Table 8 outlines the areas for improvement and details regarding changes made within each area.

Changes were primarily made based on the teams’ capacity to make the changes. We were unable to implement some suggestions. For instance, the request to have therapist support added to the course could not be accommodated because the course was designed as a self-guided program, and the addition of therapist support is beyond available funding. As another example, changes to the wording of clinical symptom surveys (eg, PHQ-9 and GAD-7) could not be adjusted because such an adjustment could impact the validity of these measures.

There is a growing body of research demonstrating the impacts of the occupational demands of public safety work on SSOs [4,9,10,50], highlighting a need for resources that support SSOs’ mental health and well-being [11]. In addition to providing care to a population in need of tailored supports, enhancing the well-being of SSOs may positively impact the well-being of PSP and PSP families more broadly [5]. To address the gap in services available to SSOs, PSPNET Families tailored a transdiagnostic, self-guided ICBT course for SSOs (the SSO Wellbeing Course). There is extensive research supporting the use of ICBT in the general population [14,15] and, more recently, for PSP specifically [35,36]. This study was a formative evaluation of the SSO Wellbeing Course, which represents the first specialized ICBT program created to support SSOs across Canada. This research was designed to assess the initial use and perceptions of the SSO Wellbeing Course. The objectives were to gain an understanding of who was enrolling in and using the course, what clients liked about the course, what components they found helpful or challenging, and their feedback regarding areas for improvement. The overall goal was to use this information to enhance the program and continue to tailor the course to the specific needs of SSOs while raising awareness of this population’s needs and informing other groups who may be developing services or resources for SSOs.

The development and continuous adaptation of the SSO Wellbeing Course was a collaborative effort between PSPNET Families clinicians and researchers, the WG, and clients of the course. In presentations regarding initial research findings and conversations with SSOs, PSP, and public safety organizations across Canada, there has been widespread interest in the SSO Wellbeing Course. Given the extensive positive feedback from clients, the findings of this study support the value of co-design, user-centered design principles [40], and making ongoing adaptations [51]. This study also demonstrates how mixed methods research can be used to make rapid and ongoing improvements to an intervention. The results of this study support the value of qualitative research for assessing clients’ perceptions of ICBT; for understanding the needs of a specific group; and for making ongoing, iterative improvements [35,52,53]. The additional inclusion of quantitative data alongside qualitative feedback to inform course improvements adds to the existing literature by showing how a mixed methods approach can provide further insights for course adaptations. Overall, the results reveal that many SSOs had positive perceptions of the course and found many aspects of the course helpful, indicating that the course was appropriately tailored to meet the needs of this group. The helpful aspects of the course and areas for improvement that were identified are consistent with previous qualitative research on the PSP Wellbeing Course [35] as well as qualitative research on the version of the Wellbeing Course offered to the general public in the province of Saskatchewan [53]. Similar to previous research on ICBT, the findings of this study also reflect that ICBT is not a panacea that will meet the needs of all clients [54]. Some clients felt that the course was not meeting their specific needs, and alternative intervention approaches and formats may be better suited to some SSOs seeking treatment.

Clients endorsed diverse mental health challenges, both in terms of areas of concern and severity of concerns, which supported the use of a transdiagnostic program. Previous findings from ICBT clinics demonstrate that many clients experience comorbid symptoms; therefore, the use of transdiagnostic ICBT is often preferable over a disorder-specific approach for reaching diverse populations [54]. Transdiagnostic ICBT has been shown to be as effective as disorder-specific ICBT [13,30]. Approximately half of the SSOs who enrolled in the course did not endorse clinically elevated symptoms of depression, anxiety, or PTSD, suggesting that there may have been an interest in the course for preventive or other reasons, such as supporting the mental health of their SSO working in the public safety sector. Previous research has demonstrated that ICBT can help prevent mental health concerns, such as anxiety and depression [55,56], supporting the extension of this course to SSOs who are seeking a preventive intervention.

SSOs who enrolled in the course resided in many provinces and territories across Canada and reported that their SSOs worked in various PSP sectors. This study’s sample identified primarily as White women whose SSOs worked in policing. A likely reason our sample included so many SSOs of police officers is that the number of police officers in Canada is more than double the number of PSP in most other PSP occupations, including border services officers, public safety communicators, correctional workers, career firefighters, and paramedics [57]. The interview sample generally reflected the demographics of the entire sample. Therefore, feedback on the course came from a relatively homogeneous sample, and reach to other groups is needed. Further outreach is ongoing and is required to recruit a more diverse sample. Over the course of creating PSPNET Families, we have learned that outreach and recruitment are challenging with this population. SSOs do not often identify themselves as a unique population and often see themselves as the ones who give rather than receive support, which were common themes that arose in WG discussions. Moreover, for many PSP sectors, there is no national organizational body; this introduces challenges in advertising and promoting the course to SSOs connected with certain PSP occupations. Continued engagement with relevant parties to assist in spreading the word about the SSO Wellbeing Course and using creative ways to reach SSOs across Canada (eg, through social media platforms and at PSP organization family events) are necessary to increase reach. Some sector-specific national organizations are only able to promote programs that are offered in both English and French. The recent completion of a French version of the course is intended to remove this barrier and to increase reach to French-speaking Canadians. The research component of the course (eg, completing questionnaires) could also hamper participation. Another potential barrier to client recruitment was that the SSO Wellbeing Course was offered through the PSPNET Families website, which contains extensive content and skills that are offered without registration or screening; access through the website may be hindering signup for this specific course because potential clients have immediate access to the website content. Accordingly, our team has recently relaxed the eligibility criteria for the SSO Wellbeing Course and streamlined the eligibility screening process (eg, reducing the number of questionnaires) to facilitate quicker access to the course for new clients. Additional pathways for course signup on the PSPNET Families website as well as ways to connect website users to the service that best suits their needs are under consideration.

Both quantitative and qualitative results suggested that relationship dissatisfaction was a common concern among SSOs seeking ICBT. On the basis of this information, additional resource content was created to address both general and specific (eg, intimacy issues, loneliness, and infidelity) relationship concerns. The PSPNET Families team continues to monitor whether the addition of this information meets the needs of course clients or whether additional changes are required (eg, adding a separate lesson on relationship challenges). Given that relationship concerns were a primary challenge reported by SSOs, other services designed to support SSOs may benefit from explicitly assessing and addressing relationship challenges within this population.

All 16 additional resources were viewed by multiple clients, suggesting that the additional resource topics were relevant to this population. The additional resource with the most unique viewers was on communication with an SSO. On the basis of client feedback, additional content was created to address the topics of supporting a partner with mental health concerns and specific relationship challenges (ie, intimacy issues, loneliness, and infidelity). Additional content on retirement was suggested but was determined to be outside the scope of this project. The PSPNET Families team is considering ways to address this topic (eg, adding content to the PSPNET Families website) to meet the needs of SSOs in this career stage.

One component of the course that had little uptake was the discussion forum. A therapist-moderated discussion forum was included as an optional component of the course to facilitate peer support and potentially improve outcomes, based on previous studies showing that unguided ICBT offered with a web-based discussion forum shows equivalent outcomes to guided ICBT [58-60] and previous research suggesting that forums may be particularly beneficial for SSOs [5]. However, the forum was ultimately removed from the course because of low use and client feedback. Other ways to potentially increase forum engagement (eg, making it more easily accessible on the PSPNET Families external website) are under consideration, and depending on the security of longer-term funding, the forum may be reinstated in the future.

With respect to barriers to completing the course, a few SSOs (4/81, 5%) indicated that time constraints were a primary challenge. Similar challenges were experienced by PSP in the PSP Wellbeing Course [35]. On the basis of client feedback, there was a need to increase flexibility with course timelines to accommodate SSOs, which is consistent with previous research indicating that time-based stressors are often experienced by SSOs because of the scheduling demands of PSP work [11]. These insights can help inform other service providers about potential barriers regarding internet-delivered supports for SSOs and the importance of flexible timelines when providing support to PSP families. To address timeline challenges in the SSO Wellbeing Course, the release of lessons was adjusted to allow for immediate access to the next lessons following the completion of a previous lesson (instead of a gradual release of lessons over 8 weeks). An extension to the course timeline (from 8 weeks to 6 months after enrollment) was also implemented. We did not eliminate timelines entirely because previous research indicates that some timelines are needed to ensure accountability with course completion and to improve outcomes [61]. Of the 118 clients who started the course, 71 (60.2%) clients completed the majority of the lessons. To encourage course completion, a certificate of completion was added.

ICBT addresses many barriers associated with face-to-face therapy [18,19]. ICBT offers treatment in a convenient and accessible format, which can be particularly advantageous for SSOs who live in rural or remote areas with limited access to specialized services. Most clients (72/116, 62.1%) reported living in rural or small communities across Canada. In the interviews and open-ended surveys, convenience and accessibility were frequently cited as reasons why ICBT worked for SSOs or as helpful aspects of ICBT. These findings support the idea that more services are needed for SSOs [11], particularly those that are accessible and can address the unique needs of SSOs (eg, address geographical and time constraints, are developed using knowledge about PSP families’ unique lifestyles, and confidentiality concerns).

There are a number of limitations of this study that require consideration. First, the sample primarily comprised SSOs who identified as White women. Future research should focus on collecting data from SSOs with diverse backgrounds to increase the generalizability of the findings and to enhance the program by ensuring that the course captures diverse experiences and meets the needs of SSOs from across Canada. This can be achieved through increased promotion of the course to SSOs with diverse backgrounds and through purposive sampling. Second, although the clients who participated in the interviews appeared representative of the total sample in most respects, their rate of course completion was nearly double that of the total sample. It is possible that clients who were less engaged with the course were less likely to agree to an interview, and it is also possible that clients made an effort to engage with the course more after agreeing to an interview; in either case, there was minimal representation of low-engagement clients among the interviewees. Third, although most of those who participated in the interviews completed the course (ie, all 5 lessons), the interviews took place at various stages of course completion. Therefore, answers to questions querying course helpfulness and areas for improvement would be limited for SSOs who had not yet completed the course, which was beneficial in capturing perspectives on barriers to course completion. Fourth, this study focused on a formative evaluation of the SSO Wellbeing Course. Although this is an important first step to assessing and improving the course, future research should be conducted to investigate both short-term and long-term clinical outcomes (eg, symptom changes) and potential impacts on the relationship (eg, changes in relationship satisfaction and function) and the broader PSP family. In addition, a few clients requested the addition of therapist support to the course, a change that could not be accommodated in this study. Future research could expand to include therapist-assisted ICBT programs for SSOs and compare use, perceptions, and outcomes between self-guided and therapist-guided ICBT for SSOs.

To our knowledge, this formative evaluation of the SSO Wellbeing Course is the first study of a self-guided, transdiagnostic ICBT program tailored to SSOs of PSP. The results indicated that most clients had positive feedback about the course, including finding the course and specific skills helpful, liking the case stories, and appreciating the convenience and accessibility of ICBT. Clients also provided feedback on areas for improvement, which largely represent common themes related to how ICBT can be improved (eg, more audio-visual content and improved timelines). Some unique suggestions, however, were identified related to some content (eg, how to support a spouse with mental health needs, more information on moral injury, and ensuring that content is appropriate for those taking the course for preventive as well as clinical reasons). Both client feedback and quantitative data were used to make iterative changes to enhance the course. Most clients identified as White women, suggesting a need to reach more diverse groups of SSOs. This study highlights the importance of tailoring support services to the experiences of SSOs and provides knowledge about the unique needs of this population that can help inform other services designed to support SSOs and PSP families.