Implementing LGBTQ-affirmative CBT: study protocol for an effectiveness-implementation trial at 90 LGBTQ community centers

Background: Sexual and gender minorities (SGM) experience among the largest mental health disparities of any population. One driver has been the lack of evidence-based practices (EBPs) addressing the distinct mechanisms underlying SGM’s risk. LGBTQ-affirmative cognitive-behavioral therapy (CBT) is among the only EBPs specifically for SGM mental health. LGBTQ community centers represent an ideal implementation setting for LGBTQ-affirmative CBT given their wide reach. Although direct training of mental health providers at LGBTQ community centers by experts has been shown to improve providers’ LGBTQ-affirmative CBT skills, it is unclear how such training should be optimally delivered. This paper describes the protocol of a trial that seeks to compare the effectiveness of three training strategies for implementing LGBTQ-affirmative CBT, identify center-level moderators of implementation success, and examine the impact of the three strategies on client mental health through theory-informed organizational and provider mechanisms. Methods: This hybrid type III effectiveness-implementation trial will randomize 90 centers to receive one of three additive strategies for implementing LGBTQ-affirmative CBT: [1] a suite of self-paced digital learning materials (Materials Only condition); [2] these materials plus weekly live webinar training for 12 weeks (Direct Training condition); or [3] the above plus one year of supervision from a local supervisor who will receive expert consultation in a train-the-trainer format (Local Supervision condition). The primary outcome will be provider fidelity assessed via simulated practice. Implementation determinants (e.g., center resources, provider/client characteristics), mediators (e.g., implementation climate, provider self-efficacy), and other outcomes (e.g., intervention adaptation, sustainment) will be captured using a mixed-methods design. Clinical effectiveness outcomes (i.e., client mental and behavioral health symptoms) will be assessed through client surveys among a subset of 15 centers. Discussion: Now that LGBTQ-affirmative CBT has shown efficacy across several trials and generated high demand, research is needed to determine nationwide implementation strategies. This study will identify optimal means through which to implement this treatment innovation in the US’s large network of LGBTQ community centers, thereby producing generalizable guidance for EBP implementation across low-resource settings nationwide in which mental health disparities populations are likely to seek treatment. Trial registration: NCT05890404 (05/25/2023), https://clinicaltrials.gov/study/NCT05890404.