FTonja MYLES had thought about suicide since childhood. After a childhood of sexual abuse, Myles turned to drugs and prostitution to “mask the pain,” and twice she overdosed on prescription pills. She worked in advocacy for mental-health improvement in Baton Rouge, La. after her recovery.
In 2016, however, she was faced with a mental-health emergency. She sent a letter to her family, took some pills and drove to the remote location where she intended to end her life.
Her family discovered the note, and convinced her to go home. Concerned, they had already called 911—the only option they had for such an emergency—and the dispatcher sent police, since she had threatened to harm herself. Seeing police at her home, Myles became more agitated, especially after one of the two officers began treating her “like a criminal,” she says. It was possible she thought of provoking him to pull out a gun on her, and then end her life.
However, the second responding officer had been trained in crisis intervention. This is a way to treat mental-health emergency as a matter of public safety and public health. After seeing her presentation to the local police on crisis intervention, he recognized Myles and started calmly talking with her about her work. She agreed to be taken to the hospital by him.
Myles was placed in mental-health facilities for one week. She began therapy there and faced her first suicidal thought. Myles was later diagnosed with PTSD due to past sexual abuse. “When the pain finally had a name,” she says, ‘I felt, ‘Tonja, you are not crazy, you are not weak. You were wounded.’”
Myles was able to avoid a trip into jail because the officer who responded had been trained for crisis intervention. Six years later, this positive outcome for an emergency mental health call remains the exception and not the rule in America. Even though emergency response systems for medical, public safety, and fire crises are well-coordinated and integrated in nearly every community through 911, the same isn’t true for behavioral health or mental-health crises. The National Suicide Prevention Lifeline (USA) is the nearest thing to a national mental-health hotline. However, only 200 call centers are funded and distributed unevenly.
Until now. On July 16, the federal government will phase out the Lifeline’s clunky number —800-273-8255—and launch a new three-digit number, 988, for anyone in a mental-health crisis. The 988 Suicide and Crisis Lifeline will dramatically expand the capacity of call centers to answer calls, with the goal of instantaneously connecting people suffering mental-health crises to mental-health professionals—instead of police officers or EMTs, not all of whom are not trained to or comfortable de-escalating emergency situations involving mental illness.
Call 988 to speak with a trained counselor. The counselor will assist the caller in most cases. In exceptional circumstances, they can also send an emergency team consisting of counselors and peers. If those interventions aren’t sufficient, 988 will also direct people to stabilization facilities—mental-health facilities where trained staff can observe and provide additional counseling and support—or residential facilities for longer term care. Those settings are more appropriate for people with mental-health crises than where they currently end up — in the emergency room, jail, or, in worst cases, the morgue where if the incident escalates into deadly violence. “988 represents probably the most potentially transformative federal legislation in mental health that we’ve seen in decades,” says Dr. Ashwin Vasan, New York City health commissioner.
However, there are many obstacles to making this vision a reality. In a country with a history of neglecting and underfunding mental-health services, 988 will need to create a compassionate crisis management system. The task of funding, staffing and reimbursements for insurance will prove difficult. “We are sitting in the context of a system that is fragmented and frankly has a lot of gaps in terms of providing services for individuals,” says John Palmieri, director of 988 and behavioral health crisis at the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services, which funds the Lifeline and is helping states implement 988. While people who work in the mental-health field are optimistic about the potential 988 represents, hardly anyone—not even Palmieri—expects the system will work seamlessly at the outset.
Continue reading: How 988 Will Transform America’s Approach to Mental Health
Still, 988’s launch is a landmark moment. The new crisis line represents the first major investment—$432 million from the federal government—in mental-health services in the country in decades, and it couldn’t come at a more crucial time. The pandemic, widespread anxiety and depression in America and other emotional stressors caused by lockdowns and job loss, have led to mental-health problems that are unprecedented. The rates of anxiety and depression among Americans were four times higher in August 2020 than they were in 2019, and every eleven minutes an American committed suicide between 2019 and 2020. Teens are experiencing an increase in anxiety and depression. It is becoming increasingly difficult for mental-health professionals to meet the demands.
“After the pandemic started, it’s been significantly harder to connect people with [mental-health] providers who don’t have wait lists, and emergency department and psychiatric units are overflowing with people needing help,” says Shelby Zurick Beasley, associate director of crisis services at Provident Behavioral Health, a nonprofit community mental-health center in St. Louis. “That’s where 988 comes in. There may be a wait list for counseling, but if you’re in a crisis, you can reach out and talk to someone right now.”
If the stars align, 988 has transformative potential, says Dr. Margie Balfour, chief clinical quality officer at Connections Health Solutions, a nonprofit provider of behavioral health services in Tucson, Ariz. “This is mental-health crisis care’s carpe diem moment.”
Answering the Call
Since its inception in 2004, the National Suicide Prevention Lifeline Network has helped to reduce distressing mental and behavioral disorders. In 2018, Lifeline callers were anonymously interviewed and found that almost 80% felt they received support from counselors, which helped them to avoid making suicide plans. The number of calls increased, but there was not enough funding to support it.
The National Suicide Hotline Improvement Act was passed by Congress in 2018. Its purpose is to create a simple, three-digit hotline number that’s easy to remember. The Federal Communications Commission also designated 988 the new dial number in 2020.
American Rescue Plan of 2021 was created to provide emergency funding to combat the COVID-19 pandemic. It provided $105 Million in additional funding to support mental-health resources and make it possible to transition to 988. In spring 2021, states estimated that they had a collective $30 million to support call centers. However, over the last year, legislators committed $200 million more funds for 988 implementation. The money was earmarked to help with the mental health needs of the victims. States can now begin hiring people to answer the phones. While recruiting is still a difficult task, Lifeline centres will not have to rely on volunteers in the future. However, stable funding means that they won’t need as many people as before. “Call centers can now pay a living wage, and people can start building career pathways that the field of crisis care never had before,” says John Draper, executive vice president of national networks at Vibrant Emotional Health, which operates the network of Lifeline call centers.
The reality is, however, that as Myles’ family did, most people are used to dialing a different trio of numbers in case of emergencies of any type. “Most of the country still relies on 911 to manage mental-health crises,” says New York City health commissioner Vasan. “That’s not because they are sure they will get the response they need, but because they don’t have an alternative.”
The 911 operator is usually forced to dispatch paramedics or EMTs for people who are in serious mental distress once they have been contacted. The responders themselves are often limited in their options, with few alternatives once they arrive at the location. They may have to deliver the person who is upset to an emergency room and jail if they pose any threat to others or themselves.
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Matt Kudish (executive director, National Alliance on Mental Illness) New York City Metro, said that when law enforcement attempts to manage people who are agitated in the same way they handle people who pose a threat to public safety, it often escalates. Police responding to New York City incidents have killed nearly 20 mentally ill people since 2015. He says that managing mental illness crises requires more advanced training in empathy, active listening, and communication, which mental-health professionals feel more confident using.
Engaging trained professionals—plus peer support counselors, who can provide empathy from having experienced their own mental-health struggles—results in less collateral damage and better long-term outcomes. In a 2022 study of a pilot program in Denver in which civilian, health, and social work professionals—rather than police—responded to mental-health and substance-use calls, less serious crimes such as public disorder dropped by 34%. The more focused team seemed to be a better fit for the situation than the law enforcement.
New York City tested an unarmed mobile program in June 2021. It sent a peer counselor and a social worker to Harlem and Bronx, and also an EMT. This team has already responded to over 2,400 calls and is showing encouraging results. From January 2022 to March 2022 911 received 87% of mental-health calls. The mental-health crisis response team transported only 59% of their cases to the ER. They were also able to provide a broader range of services, including on-site counseling and referrals to follow-up care in the person’s community.
Although mobile crisis teams such as these aren’t common in all cities, SAMHSA hopes that more states will implement them once the 988 launch. Los Angeles County has the nation’s largest mental-health service system. Mobile crisis teams do not operate 24/7. Connie Draxler is the acting chief deputydirector for the Los Angeles County Department of Mental Health.
The 988 plan also includes training 911 dispatchers in recognition and routing mental-health emergencies over to 988 where professionals can take control. That’s what currently happens in Arizona, a state that’s become a model for what mental-health crisis response should look like. It recently conducted a pilot of a call diversion similar to New York City’s with its local 911 system in the Phoenix area. Since 2018, about 1,500 calls each month have been transferred from calls into the Phoenix Police Department’s 911 to the area’s mental-health crisis line. About half are stabilized without additional resources needed, and the other half are resolved by sending mobile crisis teams—professionals that respond to mental-health emergencies, similar to 911’s first responders.
Tucson has a more advanced system. In Tucson, the city adopted a system that was used in Austin and Houston. Behavioral health professionals are placed in 911 call centres to assist 911 dispatchers in determining if they need to connect to the crisis line or a mobile team. “The fire and police departments never see those calls on their board,” says Kevin Hall, assistant chief of the Tucson police department. “We’re hoping to expand on that with greater coordination and integration of 988 and 911 to transform 911.”
Be busy with signals
Most states, however, aren’t prepared to activate 988 call centers at the capacity that’s needed. Vibrant estimates that the volume of calls to the 988 Lifeline will increase by 50% in the crisis line’s first year, but current capacity is already strained. Vibrant reports that 17% of all callers have disconnected after not being connected within 30 seconds. Vibrant reports that callers who are not available at their local centers can be routed to national backup centers, where the waiting times may be longer due to the increased number of calls.
988’s rollout includes provisions to help guard against that happening. Vibrant and SAMHSA have set minimum standards for quality, including answering 90 percent of calls within 30 seconds, and 90% locally without relying on national backup centers. Yet in a survey conducted by RAND Health Care in June, only 16% of state and local mental-health program directors said they had received adequate funding to support their states’ 988 plans.
That’s not exactly encouraging, since 988 is also adding other ways to get in touch. The 988 Lifeline will support text and chat, but about 60% of states don’t yet have the technological capacity to provide robust services across all three platforms, the RAND survey found. It is important to increase those capabilities in order to reach young people who are increasingly affected by mental-health problems. The Crisis Text line is a nonprofit national provider of text-based mental support. 70% of its users are younger than 25, while 50% of them are below 18 years. “[Texting] allows anyone to have access to counseling in a moment that’s convenient for them, in an anonymous and confidential way, if they don’t want to have a conversation on the phone with a parent or guardian or someone who is bullying them present,” says Courtney Hunter, Crisis Text Line’s vice president of policy and advocacy.
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The first step in mental-health advocacy is reaching out to 988. While counselors can de-escalate about 90% of emergencies by phone, according to Vibrant’s data, that doesn’t mean the person’s mental-health issues have been resolved. To make this system efficient, it is essential to link people to appropriate follow-up treatment. “We know the safety net is riddled with holes, and people are falling through that net every single day, whether they end up on the street or in jail,” says NAMI’s Kudish. “It isn’t just about the crisis response, but about what happens next, and afterward. How do you sustain a person’s wellness? Who supports this individual’s recovery in a meaningful way?”
Many states don’t have the mental-health infrastructure in place to follow-up offline. Montana’s three call centers, for example, are highly efficient at answering phone lines. However, only a few mobile emergency teams are available throughout the state. This is because Montana’s rural areas and remote locations make it difficult to reach people with more serious medical needs. “It’s an example where the state is ready in terms of meeting contacts that will come through 988,” says Matt Taylor, director of network development at the National Suicide Prevention Lifeline, who has been tracking state readiness for 988. “But the crisis continuum of services has a long way to go.” Another technological problem 988 hasn’t addressed yet: the system cannot geolocate callers, as 911 does, so resources are provided based on the caller’s area code, despite the fact that many people no longer live where they originally registered for a number.
Ideally, the 988 counselor should connect the person who reaches out back to their own doctor or therapist, or to a local one if they don’t have a mental-health care provider. A list of local mental-health clinics can be provided for those who leave the meeting with information about available services. “That call to 988 is the front door to the rest of crisis services,” says Laura Evans, director of national and state policy at Vibrant. That’s harder if the connection isn’t local, which is why the 988 rollout is emphasizing building up local call center capacity so fewer calls are routed to national backup centers.
Numbers that are hard to find
Although many community-based and psychologists are open to the idea of partnering with 988 in some way, there are significant logistical and financial obstacles. Overbooked mental-health professionals mean that people who are in crisis require prompt follow-up appointments. Missouri 988 call centers have plans to connect with OpenBeds. This online service tracks immediately available behavioral health services so that counselors can swiftly link patients to either inpatient or outpatient care.
It is also important to consider the reimbursement of such services. At the moment, not all insurers will cover mental-health crises services. According to Kevin Ann Huckshorn (a registered nurse working with RI International), a non-profit that runs a national network of mental hospitals, the hope is that people will start calling 988 and that legislators will start paying more for coverage.
These economic obstacles are made even more severe if 988 counselors determine that the person in crisis is in need of immediate, in-person assistance. To build and sustain mobile crisis teams, it requires investment. These crisis services are only covered by Medicaid; Medicare and other commercial insurances don’t. This means states will have to subsidise mobile teams, even for those who are already insured.
Staffing call centers also remains a significant challenge, since funding for services hasn’t always been guaranteed long term. Current funding through the American Rescue Plan and SAMHSA grants is temporary. They will expire in one or two years. It’s up to states to build in funding for maintaining 988 centers and any additional mental-health care they provide. Some have begun leveraging dollars available through Medicaid expansion plans or mental-health block grants from the federal government, but those aren’t always sufficient. More continuous forms of funding, such as user fees collected from cell phone users—similar to the fees charged to maintain 911, which generate more than $3 billion annually—are another option. Virginia is the only state to have passed legislation to allow these charges. Other states, such as New York, Alabama, Nebraska and Oregon, have established commissions to investigate this possibility. Washington legislators passed legislation to make it mandatory that insurers cover crisis-response costs.
But in some places, where legislators aren’t stepping up yet, providers are stepping in. In Maryland, psychologists who want to volunteer their time have created a system in which they can be matched with patients who qualify for pro bono treatment, saving them the work of determining people’s eligibility. Others are looking at models like the Give an hour system in other states. This allows mental-health professionals to volunteer their time in order to connect with people in need.
The Future of 988
To illustrate 988’s potential, experts consistently point to Arizona. Arizona’s state legislature has allocated funds for maintaining an effective mobile crisis response system. The Phoenix metro area is home to 30 team members that are run by various providers. The teams are made up of two people—a counselor or social worker and a peer-support specialist. These teams are reimbursed by the state’s Medicaid regional behavioral health authorities, which are responsible for the crisis-care system in the state. These funds allow the state to keep the emergency teams and a network care facilities accepting people seeking longer-term care, regardless of insurance status. “Very few states set themselves up to be reimbursed this way,” says Andrew Erwin, chief operating officer of Solari Crisis and Human Services in Arizona. “That support has allowed us to take on the volume and continuum of services that we provide.”
Mobile teams provide assistance to local police officers, traditionally responsible for getting clearance for admission to psychiatric units. “The officer was left as the street-corner psychiatrist,” says Kevin Hall of the Tucson police department. The officers would need to assess whether the individual is a threat to their own safety or that of others. If so, they should call a psychiatrist for authorization to transport them to a mental hospital. The officer then initiated a petition to allow the individual admission for court-ordered treatment.
Hall said that it is not often now. This was possible because the Tucson police department joined forces with local mental health facilities in order to simplify the process. Officers now bring people who can’t be stabilized by mobile teams to a facility run by Connections Health Solutions, which will operate the state’s 988 crisis call centers. The team takes only 10 minutes to care for patients once they have been dropped off by officers at the facility. They also take no time dealing with complicated paperwork or insurance questions. If they require more intense support, mental-health professionals can either provide 24-hour supervision or admission. “It’s been wildly successful,” says Hall. “The community likes it, the officers like it, and the behavioral health folks love it.” Connections is reimbursed for their services through Medicaid for covered patients and through the state allocated budget for crisis care for people not covered by Medicaid.
Replicating such investment won’t be possible in every state, but officials from other states have consulted with Arizona’s administrators; Solari is working with Utah and Georgia to establish a network of stabilization facilities in those states that will be reimbursed for any long-term support people calling into 988 might need.
These will present challenges. “Any stress on the 988 system will be readily apparent; we can’t hide it,” says Jamie Sellar, chief strategy officer for RI International. “Everything else is going to have to catch up to it for it to work.” No one expects the system to be at full capacity on July 16, or even by the end of the year.
The key to enhancing 988 services—the call centers, mobile crisis teams, and stabilization facilities—is to secure steady funding, and experts believe that the best way to do that is to generate data proving to budget-conscious legislators that the investment is cost effective in the long run. It is expensive to handle people who are in mental-health crisis through prison or emergency rooms. Studies also show that such tactics can lead to them repeatedly cycling from one crisis to the next, which results in high costs for health care and law enforcement.
“Over time, we will be able to collect data about behavioral health, mental health and substance use and suicide prevention in ways we have never been able to document before,” says Vibrant’s Draper. It will enable supporters to present evidence-based arguments and convince state officials and local officials that they should continue to invest in this system rather than allow services to cease to exist when funds are available. Because treating the root cause of mental illness can be prevented, it is more affordable to invest in mental health.
Tonja Myles understands how precious a resource such as 988 is. She was saved when a professional treated her compassionately in an emergency. She had an amazing realization during her 2016 stay in the mental-health center. “I realized that all the pain I had been carrying, that I thought would die with me if I killed myself, would only transfer to my family and friends,” she says. “And I never want anybody to be in that kind of pain.” As a result of her experience, Myles started therapy and medication for her PTSD. Her current role is that of a pastor, and as a peer support specialist for others who are in need.
“I never thought I would see anything like 988 happen in my lifetime,” she says. “While it is a call for help, it also has to be a connection to hope.”
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