The following mixed-methods study captured the experiences of CWs involved in a clinical trial comparing the efficacy of e-CBT to treatment as usual for individuals diagnosed with major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD) (6). Clinical trial participants were current or previous CWs in Canadian federal and provincial facilities in Ontario, Canada, who were between 18 and 55 years of age at the start of the study and diagnosed with MDD, GAD, or PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (15). A minimum age of 18 was selected per the province of Ontario’s requirements for CW employment (16). In line with the most common mental health disorders reported amongst CWs (1), three diagnosis-specific e-CBT programs for depression (13 weeks), anxiety (12 weeks), and PTSD (12 weeks) were delivered as weekly sessions and assignments through OPTT. OPTT’s CW-specific programs comprise pre-designed online asynchronous psychotherapy sessions, followed by homework assignments to reinforce the session’s concepts. The sessions can be accessed via computer or mobile phone. The modules integrated examples and case studies obtained from interviews with CWs as well as literature reviews (9, 17). Program participants were instructed to complete their weekly sessions and submit the corresponding homework assignments to their assigned therapist through OPTT. The therapist was responsible for answering questions asynchronously and providing personalized feedback on participants’ session-specific weekly assignments.

The current study used a purposive sample of CWs who had either completed or dropped out of the clinical trial after at least one e-CBT session. A one-year cutoff from the date of participation was established to prevent recall bias (18). Following study completion or dropout, participants were emailed a fillable PDF copy of the survey and asked if they were interested in participating in a one-on-one interview to capture their experiences with the therapy. Those who agreed to take part in the interviews received a 25 CAD Amazon gift card for their time. Participants emailed the completed surveys to the research coordinator after their completion. Surveys and interviews were conducted from March 15, 2022, to August 4, 2023. Participants who were not interested were instructed to notify the research coordinator and their names were removed from the contact list. Ethical clearance was given by the Health Sciences and Affiliated Teaching Hospitals Research Ethics Board at Queen’s University in Kingston, Canada (File: 6029966).

The CW post-participation self-reporting survey was adapted from previous surveys developed by the research team through extensive literature reviews, consulting previously validated instruments, and reviewing qualitative data collected at the first stage of the trial (8, 9, 19). Following revisions from members of the research team, the final survey (Supplementary Data 1. Survey Results) captured demographic variables (19 items), general impressions (4 items), interactions with technology (3 items), interaction with the care provider (10 items), opinions of the online psychotherapy sessions (9 items), opinions of the exercises and homework (3 items), long term effects of the treatment program (5 items), and module-specific questions (3 items). The remaining six questions were open-ended and enabled participants to provide additional feedback. Due to time constraints and limited scope, the validity and reliability of the final survey were not assessed.

For an in-depth and nuanced understanding of the insights captured in the survey data, semi-structured interviews were conducted by two trained research assistants (RAs) not involved in the clinical trial. The interviews were no more than 60 minutes in length, and a guide with 28 open-ended questions was used. Before the interviews, the guide was pilot-tested and focused on the participant’s treatment expectations as well as interactions with OPTT, their care provider, and the e-CBT program. All interviews were held over Microsoft Teams, a secure video-conferencing platform, and screen-recorded. Participants were given the option to keep their webcams on or off based on their level of comfort.

The screen-recorded sessions were transcribed verbatim by an RA not involved in the interviews. The resulting transcripts were proofread by the RAs conducting the interviews as well as members of the research team involved in analyzing the qualitative data for finalization. All identifying information was omitted from the transcripts and instead followed a labelling convention of gender (W=woman; M=man), group (A=anxiety, D=depression, P=PTSD), completion status (D=dropout; C=completer), and a random number (e.g., MDC1, WPD2). All presented quotes were edited for correct grammar and spelling while preserving meaning and tone.

Surveys were analyzed using Qualtrics (Qualtrics, Provo, UT) statistical analysis software. Missing data were excluded, and each survey item analysis was assessed individually relative to the total responses of the specific item. Response frequency and percentages were used to report categorical variables. Medians, means, ranges, and standard deviations were used for continuous variables. Correlations between demographic characteristics (i.e., age, race, gender, education, marital status, employment status, etc.), completion status, and perceptions of the program were evaluated using Chi-squared tests. Independent samples t-tests and Mann-Whitney U tests were used to assess continuous parametric and non-parametric variables at a significance level of α=0.05. Quantitative analysis was conducted using IBM SPSS Statistics for Mac, version 24 (IBM Corp., Armonk, NY, USA).

This study followed the consolidated criteria for reporting qualitative research (COREQ) checklist to report qualitative findings (20). Textual data from open-ended survey responses and individual interviews were analyzed using thematic analysis methods (21) using NVivo 12 (QSR International Pty Ltd, 2020) by two RAs. Codes generated from the data were organized into themes that described the participants’ opinions and feedback. The final themes were discussed amongst the research team and revised where necessary.

The survey was sent to 35 eligible participants. In total, 14 responses were recorded (response rate=40.0%, completion rate=92.86%; n=13/14). On average, the respondents were 37.50 (SD=8.10) years of age, ranging between 25 and 54 years. At the time of the survey, 92.86% of the respondents (n=13/14) were currently employed as correctional workers with an average of 9.90 (SD=7.00) years of experience in their respective roles. Most respondents (64.29 n=9/14) had children (average number of children=2). Among survey respondents, n=9 agreed to take part in the semi-structured interviews. A demographic description of the survey and interview participants can be found in Table 1.

Survey non-respondents (n=21) were, on average, 41.00 (SD=9.179) years old and 81.82% of the sample identified as women (Supplementary Table 1. Demographic Information of Survey Non-Respondents). Most non-responders were employed (92.86%), had children (64.86%), and were currently on medication for their mental health (57.14%). Approximately one-quarter (22.73%) of non-respondents completed the e-CBT program in full, significantly less than the survey respondents (p=0.014).

Most respondents (64.29%; n=9/14) were on medication for their mental health at the time of the survey. When asked to rate the severity of their mental health disorder symptoms, half (50.00%; n=7/14) said their symptoms were somewhat severe, with approximately half (42.15%; n=6/14) saying their symptoms were not severe. One (7.14%; n=1/14) respondent said their symptoms were very severe. Nearly half (46.15%, n=6/13) of the respondents had not previously received any psychotherapy. Those who received therapy either engaged in-person (38.46%; n=5/13) and/or online/telephone delivery of psychotherapy (38.46%; n=5/13). Over half of the respondents (53.85%, n=7/13) had previously received CBT, either in-person (23.08%, n=3/13) or remotely (30.77%, n=4/13).

Nearly three-quarters (69.23%; n=9/13) of respondents completed all sessions of OPTT’s e-CBT program. After taking part in the e-CBT program, most respondents (61.54%; n=8/13) preferred to interact with their care provider in person, followed by online video (30.77%; n=4/13) and online-text-only (7.69%; n=1/13). Nearly one-quarter (23.08% n=3/13) had no preference, and one participant (7.69%) was unsure about their preferred method of interacting with their care provider. None of the participants preferred phone calls. Participants were relatively evenly split between the devices they used most to access their e-CBT program on OPTT (computer=57.14%; n=8/14, cellphone=42.86%; n=6/14).

Most respondents (64.29%; n=9/14) felt the program increased their confidence in their ability to manage their mental health symptoms, and all (100.00% n=14/14) felt the e-CBT program was worth their time. An overall positive perception was observed regarding the OPTT platform and satisfaction levels, particularly with the technology and homework assignments. Encouragingly, a large majority (84.62%; n=11/13) of respondents also said they were “likely” to “very likely” to seek treatment again in the future.

Respondents had a positive response towards their care providers, with all respondents ranking their care providers’ degree of empathy displayed to them as either “good” or “very good” (Table 2). Moreover, there were positive perceptions of the individual sessions for the online psychotherapy, including the appropriateness of the number of sessions, the amount of time spent on each session, and the order of the sessions (Table 2). For diagnosis-specific questions (i.e., depression, anxiety, PTSD), participants generally expressed neutral-positive feelings toward the content and skills covered in the sessions (Table 3).

Interviews exploring participants’ experiences of the therapy program revealed five themes: 1) The research study as a support for CWs, 2) User-friendliness of the Online Psychotherapy Tool (OPTT), 3) Tailored therapy experience, 4) Online therapy as an accessible way to normalize experiences and learn coping skills, and 5) Limitations in therapist-client interactions and online format. The themes and associated subthemes are described below.

Despite its strengths, the study also had several limitations that warrant consideration. Compared to survey respondents, most non-respondents did not complete the e-CBT program. As such, the findings may support more favorable or beneficial views of the program. Although selection bias is a common concern in survey and qualitative studies (26, 27), all OPTT participants, irrespective of their completion status, were engaged in the current study. Differences in the profiles of study participants and non-participants may indicate other factors that influence the willingness of an individual to take part in post-intervention assessments. Second, the sample was relatively homogenous, comprising individuals who were white, cis-gender, and highly educated. The literature is scarce in terms of mental health interventions targeting racialized CWs, which may be due to the low racial diversity that exists in this line of work (28, 29). Accordingly, most related studies either fail to report the ethnicity of their sample or report data primarily from cis-gender, white, and well-educated populations (30–33). Although the content of the e-CBT acknowledged the importance of diversity and inclusion, future studies need to identify effective avenues to enhance equitable treatment accessibility and address any systemic limitations that prevent or discourage racialized CWs from seeking care. While the insights collected from the small sample size provide important insights into CWs’ experiences of e-CBT, the findings should be interpreted with caution. At the same time, the qualitative findings were sufficient in fruitfully outlining areas of strength and improvement in e-CBT, which are necessary for guiding the development of this field.

This study used a survey and semi-structured interviews to investigate the experiences of CWs who participated in a diagnosis-specific online psychotherapy program. Overall, there was a positive perception of the psychotherapy program, the technology, the therapist interactions, and the exercises and homework assignments. Despite the positive response to the online program, most respondents still preferred in-person therapy, reaffirming the need for further improvements to therapeutic rapport within digital mental health interventions. End-users felt more prepared to handle their symptoms post-treatment and felt that the program would have long-term benefits. Nevertheless, participants felt their therapists displayed empathy and were able to develop a good rapport with them, an encouraging note as the therapist interaction was through an asynchronous, written format. Qualitative data revealed stigma in the workplace as a large deterrent to seeking treatment. Future research should investigate how the CW work environment can increase treatment-seeking behaviors.