The term “public safety personnel” (PSP) refers to individuals whose work ensures the safety and security of citizens (eg, border security officers, correctional workers, firefighters, Indigenous emergency managers, operational intelligence personnel, paramedics, police, public safety communicators, and search and rescue personnel [1]). Due to high-stress work environments and exposures to potentially psychologically traumatic events (PPTE), PSP are at high risk of mental health challenges [2,3], with 44.5% screening positive for at least 1 mental disorder [2]. PSP also often experience barriers to receiving treatment such as workplace stigma toward mental health, the desire to self-manage symptoms of mental disorders, limited time available to attend treatment, limited accessibility of mental health providers in rural areas, and treatment costs [4,5].

Internet-delivered cognitive behavioral therapy (ICBT) is an effective psychological treatment for various mental disorders that includes evidence-based cognitive behavioral therapy (CBT) techniques in a digital format [6]. An advantage of ICBT is that clients can access it privately at a time and place that is most convenient for them. ICBT can be disorder specific [6,7] or transdiagnostic (ie, designed to treat symptoms of several disorders) and can be delivered in a self- or therapist-guided format (eg, phone and email [8]). Clients are more likely to choose transdiagnostic over disorder-specific ICBT despite comparable treatment satisfaction and outcomes [9,10]. Overall, ICBT is similarly effective to face-to-face CBT in managing mental health challenges such as anxiety, depression, and posttraumatic stress [6].

A clinical research unit called PSPNET was launched in 2019 with funding from the Government of Canada to develop, implement, and evaluate ICBT tailored to the needs of Canadian PSP [11]. PSPNET adapted a previously established ICBT course that has excellent treatment outcomes in Australia [10] and Canada [12,13] to address common mental health concerns of PSP. The course was titled the PSP Wellbeing Course and, like the established ICBT course upon which it was based, is therapist guided and transdiagnostic. Mental health outcomes of the PSP Wellbeing Course demonstrate moderate to large, statistically significant declines in PSP’s anxiety, depression, and posttraumatic stress symptoms from before to after treatment [14,15]. The PSP Wellbeing Course was tailored via interviews and focus groups to better understand PSP’s preferences in ICBT [16] and to develop fictional client narratives called case stories. Of note, PSP Wellbeing Course findings [17] parallel other ICBT program findings, with many clients reporting the case stories as helpful but needing improvement [17-20].

Case stories are illustrative examples that are commonly used in health care services to provide anecdotes, analogies, and metaphors to facilitate learning and enhance the client experience. Case stories can be sourced from real or fictitious user profiles [21]. Fictitious user profiles, also known as personas, are designed to represent current or prospective clients from specific groups with detailed characteristics (eg, name, photo, symptoms, and diagnosis). Information used to develop such personas can be sourced from clients [22] or experts (eg, clinician experiences working with PSP [23]). Shaffer and Zikmund-Fisher [21] identified five main purposes of case stories in health care: (1) to inform clients of basic knowledge and lived experiences, (2) to provide comfort to clients by normalizing their experiences, (3) to model targeted behaviors, (4) to persuade clients to use targeted behaviors, and (5) to enhance client engagement. This taxonomy offers a valuable guideline for designing, implementing, and evaluating case stories [21].

Client perceptions of case stories in health care services [18,24,25] and in ICBT programs are generally positive [17-20], but clients often suggest stories could be improved. Preliminary findings show that PSP are also generally satisfied with case stories in ICBT, citing them as a valuable component that portrays authentic and relatable experiences [26] while providing some feedback to improve content and delivery. Content feedback from PSP has centered on improving story authenticity [16,17,26] and relatability [17]. For example, some clients request the use of real, rather than fictitious, case stories [16]. Other feedback includes increasing the complexity of stories [17,26] and adding more examples on the application of treatment principles [27]. Delivery feedback has centered on improving story accessibility (eg, adding audio or video narratives [17,26]).

The extant research provides preliminary support for the inclusion of case stories in ICBT tailored for PSP, but some gaps in knowledge still exist, highlighting the need for further story evaluation. Improving health care services often relies on client perceptions and feedback [25,28]. Client perceptions can identify treatment satisfaction [29] and sustain good practices (eg, reinforce good practices among clinicians [25]), while client feedback can be used to identify problems, inform areas for improvement, evaluate improvements, and assess progress toward organizational goals [28]. To date, story feedback in ICBT has largely been gained through open-ended, web-based questions asking clients to provide brief written feedback about what they liked and disliked about ICBT generally [18-20,26,27]. In-depth client perceptions of and feedback on case stories in ICBT among PSP have not yet been obtained.

This study was designed to expand the literature on the use and evaluation of case stories in ICBT among PSP to help identify what is effective and ineffective about case stories and how limitations can be addressed. Specifically, this study investigated (1) PSP’s perceptions of the case stories using the theoretical model provided by Shaffer and Zikmund-Fisher [21] and (2) PSP’s feedback on the case stories in the PSP Wellbeing Course. The research team hypothesized that (1) PSP’s perceptions of the case stories would be generally positive, (2) PSP’s perceptions would align with the purposes of stories identified by Shaffer and Zikmund-Fisher [21], and (3) PSP would provide tangible feedback on ways to improve case stories in the PSP Wellbeing Course.

This mixed methods study was approved by the Research Ethics Board at the University of Regina (#2019-157) and was carried out within the context of a longitudinal, single-group, open trial registered on ClinicalTrials.gov (NCT04127032). Clients provided informed consent after being made aware of the study details and the potential benefits and risks of participation. Participants were provided with access to the PSP Wellbeing Course but were not offered other incentives to encourage participation. Client data were stored on a secure server and were deidentified prior to analyses.

Prospective clients signed up for a PSPNET account; provided informed consent to participate; and completed eligibility screening questionnaires that collected demographic, clinical, and occupational information. This was followed by a telephone interview, after which eligible clients were enrolled in an ICBT course appropriate to their symptoms and preferences. This study describes outcomes only for clients enrolled in the therapist-guided PSP Wellbeing Course (English version). At 6 weeks after enrollment, clients were invited to schedule a semistructured interview for around the 8-week postenrollment time point. At 8 weeks after enrollment, we administered the Stories Questionnaire, a bespoke questionnaire designed to assess perceptions of and feedback on the case stories (described in detail below).

Web-based screening took place between August 2022 and March 2023 and resulted in a sample of 36 PSP (Figure 1). Eligibility criteria required that all clients who enroll in the English version of the therapist-guided PSP Wellbeing Course to (1) be 18 years or older; (2) be current or former PSP; (3) have internet access; (4) provide local emergency medical contact if presenting with severe symptoms; and (5) live in New Brunswick, Nova Scotia, Prince Edward Island, Québec, or Saskatchewan. Individuals were excluded from the PSP Wellbeing Course, and correspondingly, this study (and referred to other services as appropriate) based on the following criteria: (1) reporting high risk of suicide; (2) reporting a suicide attempt or hospitalization for high suicide risk within the past year; (3) reporting primary problems of psychosis, mania, or severe alcohol or drug use; (4) being in receipt of psychological treatment from other health care services more than twice a month; (5) not being in Canada during the treatment period; and (6) no longer being interested in service (eg, seeking other services, no longer requiring services, and being unable to devote time). Furthermore, this study only included clients who accessed at least the first 4 of 5 lessons in the English version of the PSP Wellbeing Course to ensure adequate exposure to the case stories to provide feedback.

Quantitative data were analyzed using SPSS (version 28; IBM Corp) to provide descriptive statistics from all eligible clients (n=36) via the Patient Information Questionnaire and Stories Questionnaire. Qualitative data were then analyzed using NVivo 20 (QSR International) analysis software [30] using a reflexive approach to open-ended responses via the Stories Questionnaire (n=25) and the semistructured interviews (n=10). All client data were deidentified prior to analyses, and semistructured interviews were transcribed using a professional transcription service. The reflexive analysis was conducted by identifying, analyzing, and reporting coherent and meaningful patterns in the data [31]. Overarching topics were categorized as main themes and evaluated for any underlying topics using deductive and inductive approaches. The initial codebook was created by JG, revised by the primary coder (JABP), and reviewed by CAL. Upon completion of coding, each theme was assessed for semantic meaning and given an appropriate name [31].

Figure 1 shows the screening, enrollment, and treatment process. The mean client age was 41.4 (SD 11.3) years. Most clients resided in Saskatchewan (n=24, 67%) and self-identified as White (n=32, 89%), women (n=17, 47%), married (n=22, 61%), and parents (n=56, 56%). Clients also self-identified most frequently as police (n=17, 47%), with others self-identifying as paramedics (n=4, 11%), firefighters (n=6=, 17%), correctional workers (n=4, 11%), or other PSP sectors (n=5, 14%; Table 2). Overall, most clients who started the PSP Wellbeing Course self-reported that they reviewed at least one of the case stories (n=25, 69%).

Story perceptions were evaluated using quantitative data from the Stories Questionnaire for clients who self-reported viewing at least 1 of the case stories (25/36, 69%). Descriptive statistics showed of the 25 clients, most agreed or strongly agreed that “I could relate to at least one story” (n=15, 60%) and that “the stories show a bias-free perspective about what it is like to be a PSP” (n=21, 84%). Consistent with expectations, story perceptions in the PSP Wellbeing Course were generally positive with most clients endorsing the case stories as fulfilling the taxonomy proposed by Shaffer and Zikmund-Fisher [21]. Results showed that most clients agreed or strongly agreed that “I find that the stories are a trustworthy source of information” (n=16, 64%), “at least one story increased my knowledge about my mental health” (n=18, 72%), “reading the stories made me realize I am not alone with my mental health experiences” (n=18, 72%), “at least one story gave me ideas about how to use the skills to improve my well-being” (n=18, 72%), and “at least one story motivated me to use the skills” (n=16, 64%). Most clients also agreed or strongly agreed that “at least one story helped me better understand the lesson content” (n=14, 56%) and “at least one story made me want to continue on with the course” (n=14, 56%; Table 3).

Story feedback was evaluated using qualitative data from the Stories Questionnaire and interview to gain insight on ways to improve the case stories in the PSP Wellbeing Course. Clients recommended improvements to characters, content, and delivery (Table 3). Character feedback focused on demographics and photos. Clients most frequently requested improving character demographics by incorporating more ethnicities (eg, Indigenous PSP), sectors (ie, coroner service personnel, office worker), and employment status (eg, retired PSP). Some clients also recommended using real PSP photos instead of stock photos (Table 4).

Content feedback focused on modifying topics and vocabulary. Specifically, six topics were highlighted for improvement: (1) failure, (2) family, (3) grief, (4) positive self-talk, (5) PPTE, and (6) relationships. One client requested reducing the emphasis on failure in the case stories while other clients suggested adding more content on the impact of PSP mental health challenges on family members and how to navigate these relationships. Other topics that clients suggested for inclusion are grief, positive self-talk in the workplace, and PPTEs that precede characters’ mental health challenges. Clients further recommended tailoring story vocabulary to include terms more familiar to PSP such, as “fear” and “scared” in anxiety-related content, as well as the phrase “caring for those who care” among the general content (Table 4).

Delivery feedback focused on improving story formatting, media, realism, and quantity. Clients requested modifying story formatting by adding labels to improve recognition of characters throughout the course and inserting links to easily navigate from the case stories to relevant course material. One client advocated for the addition of video content in the case stories. Clients most frequently requested improving realism, citing a fictitious feel to the case stories (Table 4).

This study had several limitations that can further inform future research directions. First, the sample size was relatively small. Second, this study may be at risk of sampling bias, as clients with more favorable perspectives on the PSP Wellbeing Course or PSPNET may have been more receptive to PSPNET’s request for them to complete questionnaires and interviews than clients with less favorable perspectives, possibly leading to an overrepresentation of favorable perceptions of the stories in our sample. Relatedly, our exclusion of clients who had completed fewer than 4 of the 5 lessons of the course from this study may have resulted in the systematic exclusion of clients with unfavorable perspectives on the course as well. Further, most clients self-identified as White, police, or residing in Saskatchewan, and results may have limited generalizability to other groups of PSP. Third, some clients may have provided feedback without reviewing all case stories, resulting in recommendations already addressed in the case stories they did not review. Overall, results should be interpreted with caution. Future research should consider investigating whether improving the case stories in the PSP Wellbeing Course as described in this study impacts client perceptions, client engagement with treatment, and mental health outcomes. Future research could help identify perceptions of and feedback on case stories in other PSPNET courses. Finally, future research could explore whether artificial intelligence could be useful for personalizing case stories and its impact on treatment outcomes [54].

This study adds to the growing body of research on the use of case stories in internet-delivered interventions. First, clients’ perceptions of the case stories in the PSP Wellbeing Course were largely positive and adhered to the taxonomy proposed by Shaffer and Zikmund-Fisher [21]. Second, client feedback provides tangible ways to improve the case stories in the PSP Wellbeing Course. Client feedback specifically identified 3 areas for story improvement: characters, content, and delivery. Each area highlights the need for and potential benefits of further story development. These findings should be interpreted with caution due to the small sample size and possible concerns with sampling and response bias. Overall, this study adds to the growing body of research supporting the use of case stories in internet-delivered interventions among PSP.