Walk-in Therapy in Low Barrier Primary Care

Interactions between the multiple health threats of mental illness, substance use, and social vulnerabilities (homelessness, poverty) represent a syndemic that perpetuates the HIV epidemic. Mental health and substance use disorders have been shown to increase HIV risk behaviors and to have a negative impact on adherence to PrEP. Unhoused individuals face both individual-level (stigma, limited social support, and psychiatric symptoms) and structural-level (poverty, unstable housing, limited transportation, cost of medical care) barriers to healthcare. Walk-in clinics are designed to address these barriers to traditional primary care and provide immediate access to services when they are needed. King County WA has funded four low-barrier primary care clinics since 2018 as a key component of the King County EHE Plan. Data from these clinics suggest that untreated mental disorders are a critical barrier to engagement in low-barrier primary care. Integrated care models in which trained mental health specialists deliver evidence-based mental health care in primary care settings increase access to care by providing mental health treatment where people are already seeking care. Integrated care improves mental health outcomes, and models are feasible to implement even in very low resource settings. Walk-in counseling clinics throughout the province of Ontario, Canada, have implemented a single session narrative therapy intervention to increase access to mental health care. In this model, therapists use a single-session approach to help clients identify issues, recognize and build on their strengths and develop an action plan. Narrative approaches create a non-pathologizing, collaborative, and competency-oriented way of addressing mental health needs. Given the unpredictability of follow-up in walk-in primary care, a single session narrative approach can make the most of every single session, providing pragmatic therapeutic conversations to people when they need it and support coping, reduce feelings of isolation, and increase sense of validation. The goals of the current study are 1) to develop a single-session narrative therapy intervention to increase access to mental health care among people experiencing homelessness; and 2) conduct a 4-month pilot implementation trial of the adapted intervention in two low-barrier primary care clinics in North Seattle.