Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)

Clinician bias constitutes a critical and unaddressed determinant of implementation for any Evidence-Based Practice (EBP). Implicit bias interferes with clinical decision-making and negatively impacts the clinician-patient relationship, leading ethnic/racial minoritized youth to receive suboptimal care resulting in disparate (worse) outcomes compared to their NHW peers. This is a preventable implementation gap (e.g., inequitable adoption, penetration, fidelity, sustainment) that substantially and unjustly limits the reach and public health impact of many of our most well-established EBPs in mental healthcare. This gap is particularly problematic in schools, where access to mental health services is significantly improved for ethnic minority youth, leading to more opportunities for disparate care quality. Despite the established knowledge base on implicit bias and bias reduction strategies, very little research has been done with mental health professionals; our team's previous work constitutes the first studies with mental health providers in the school setting. To address this gap in implicit bias intervention research and the lack of equity-focused implementation strategies, the investigators are conducting a pilot Hybrid Type 3 Effectiveness-Implementation Trial of a Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)-a highly efficient (\~45 minutes), usable, and scalable intervention (interactive online training module) to address implicit bias among school mental health clinicians and support the equitable implementation of EBPs.

With previous NIMH funding, VIBRANT was iteratively developed for school mental health clinicians employing user-centered design principles. In a small proof-of-concept study (N = 12), school mental health clinicians found VIBRANT to be highly usable, appropriate, acceptable, and feasible to implement in their clinical practice. After completing the VIBRANT training, clinicians demonstrated notable improvements in implicit bias knowledge, and a downward trend in implicit bias (as measured by the Implicit Association Test) over 14 weeks. Moreover, clinicians with the greatest reductions in implicit bias also reported the strongest alliance with their youth patients. These results from our preliminary studies suggest that VIBRANT is an efficient and highly usable implementation strategy that holds promise for addressing clinician implicit bias to promote equitable implementation of other highly scalable evidence-based interventions.

Although VIBRANT is EBP-agnostic, it will be tested in the context of measurement-based care (MBC) implementation given (1) the high potential for MBC to optimize school mental health services, but currently inconsistent use in school mental health, and (2) MBC's vulnerability to inequitable delivery. Specifically, this study will evaluate the preliminary effectiveness of VIBRANT as an equity-focused implementation strategy for MBC. In addition to assessing VIBRANT's impact on equitable MBC adoption, penetration, fidelity, and sustainment within and between clinician caseloads, the investigators will also examine impact on proximal mechanisms of change (clinician implicit bias, therapeutic alliance) and distal youth clinical and functional outcomes.

Control group clinicians will complete the Brief Online Training (BOLT) for Measurement-Based Care (MBC) and consultation packages (4 online training modules supported by two 1-hour long, live post-training consultation sessions and expert-facilitated asynchronous online discussion board).

Behavioral: Brief Online Training (BOLT) for measurement-based care (MBC) · Behavioral: Live Post-Training Consultation · Behavioral: Asynchronous Discussion Board

Experimental condition clinicians will complete the same online training modules for MBC (BOLT) as the control group, but also complete the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) module (45 minutes). They will also receive two 1-hour long, live post-training consultation sessions and expert-facilitated asynchronous online discussion board.

Behavioral: Brief Online Training (BOLT) for measurement-based care (MBC) · Behavioral: Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) · Behavioral: Live Post-Training Consultation · Behavioral: Asynchronous Discussion Board

Brief Online Training (BOLT) for measurement-based care (MBC) is a series of 4 interactive, self-paced, online training modules that takes approximately 75 - 120 minutes to complete. Clinicians are trained on the core functions, procedures, and best practice approaches for delivering MBC in the school mental health setting. MBC is the systematic collection of patient-reported data to support collaborative clinical decision-making from intake to termination.

The Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) is a brief (45-minute), self-paced, interactive online training module designed to help school-based mental health clinicians understand and manage their implicit bias in clinical interactions.

Two 1-hour long small group consultation sessions with an expert consultant designed as additional opportunities to support knowledge elaboration and skills generalization.

An expert facilitated online Discussion Board for additional opportunities of knowledge clarification, practice reinforcement, and community building to support implementation sustainment.

Time frame: 4 months after training

Clinicians will complete weekly caseload service logs, that document whether each of the 3 core MBC practices (i.e., measure administration, clinician reviewing results, discussing results with patient to support collaborative treatment planning) were used with each identified patient in their caseload. MBC adoption (client level) will be a binary measure for each youth on the clinicians' caseload-evidence of any MBC practice will be considered adoption. This is a longitudinal outcome that will be collected on a weekly basis to allow for the observation of growth over time.

Time frame: 4 months after training

Clinicians will complete weekly caseload service logs, that document whether each of the 3 core MBC practices (i.e., measure administration, clinician reviewing results, discussing results with patient to support collaborative treatment planning) were used with each identified patient on their caseload. MBC penetration will be derived from dividing the number of youths on the clinician's caseload who is receiving any MBC practices by the total number of youths on the caseload, which should yield a percentage score.

Time frame: 4 months after training

Clinicians will complete weekly caseload service logs, that document whether each of the 3 core MBC practices (i.e., measure administration, clinician reviewing results, discussing results with patient to support collaborative treatment planning) were used with each identified patient on their caseload. Fidelity will be measured by percentage of a clinician's caseload with whom all 3 MBC core components were reported on their caseload service logs.

Time frame: Baseline (Right before training; 0 months), Post-training (Right after training; 0 months), Follow-up 1 (1 month after training), Follow-up 2 (2 months after training), Follow-up 3 (3 months after training)

The Implicit Association Test (IAT), the most well-established measure of implicit racial attitudes with over 20 years of empirical support, is a computer-based reaction time task that measures the relative strength of association between pairings of two groups with two evaluative attributes. The difference in reaction time between the two pairings would reveal the respondent's relative bias. Clinicians will complete 4 distinct IATs (via the online surveys) at each data collection timepoint, which will be averaged. The IATs will measure (1) implicit prejudice toward Black (2) and Latinx youth (both in comparison to White youth), (3) implicit stereotyping of Black youth as aggressive compared to White youth (peaceful), and (4) implicit stereotyping of Latinx youth associated with academic failure and White youth with academic success.

The averaged IAT is reported as D-scores, which range from -2.0 to +2.0; being closer to the extremes corresponds to more bias.

Time frame: Baseline (Start of treatment), Post (3 months after treatment)

Working Alliance Inventory--Short Form is a 12-item clinician- and patient-report rating scale of the therapeutic relationship with items that capture agreement on the goals and tasks of therapy as well as the therapeutic bond. It has been validated for use with youth 11-18 years old, demonstrating excellent internal consistency (α = 0.93 to 0.96) for both youth and clinician rating forms, and evidencing a single-factor structure.

The WAI is scored on a 5-point Likert scale (1= Strongly Disagree, 3= Neutral, and 5= Strongly Agree).

The total score for WAI is the sum of all items.

Time frame: Baseline (Start of treatment), Post (3 months after treatment)

The Strengths and Difficulties Questionnaire (SDQ) is a 25-item self- and informant-reported symptom questionnaire that has been validated for use with youths ages 4-18 (self-report for 11-18+) with 5 subscales (emotional distress -items: 3, 8, 13, 6; conduct problems - items: 5, 7, 12, 18, 22; attention -items: 2, 10, 15, 21, 25; peer relationships - items: 6, 11, 14, 19, 23; prosocial behaviors -items: 1, 4, 9, 17, 20). Internal consistency for these subscales is adequate, ranging from α = .78 to .82.

It is scored on a 3-point Likert scale, which ranges from 0= Not true, 1= Somewhat true, and 2= Certainly True.

Items 7, 11, 14, 21, and 25 are reverse-scored. The SDQ total score is the sum of the 4 subscales (emotional distress, conduct problems, attention, and peer relationships). Each subscale has 0 as the lowest score and 10 as the highest score; therefore, the lowest possible total difficult score is 0, and the highest possible total difficult score is 40.

Addressing Clinician Bias to Improve Equitable Implementation of Evidence-Based Practice-Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)