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���������� Note: Sunday was the one-year anniversary of the establishment of the National 988 Suicide and Crisis Lifeline. In its first year the lifeline has proved to be extremely effective, receiving close to 5 million contacts and offering support or connections to services for those in crisis. While these numbers are incredible and show the desperate need for crisis and other mental health services in the US, there is still much work to be done to improve the hotline and, more importantly, the crisis care infrastructure on the ground. Issues with staffing and local routing of calls are expected to persist as the system continues to be built out, but we must work on advertising the line so everyone knows about it. The most critical area with needed improvement, however, is not the crisis line itself, but the local crisis infrastructure the lines rely on to get people in person support. Most in person crisis responses are conducted by law enforcement in the US. This leads to more involuntary removal, forced hospitalization, and deadly encounters between police and people experiencing crisis. The expansion of the 988 line has led to increases in police initiated forced removals after hotline operators notify police of the potential for self-harm from callers, as required by operator guidelines. This is extremely concerning and will only keep people in need from utilizing this resource due to fear of forced treatment. The only way to effectively address this issue is building out non-police mental health response systems throughout the US. Local hotline systems which have peer led crisis response teams, like the San Francisco , can utilize these teams instead of police when there is a need for in person support. For instance, Maine’s crisis call center utilizes 911 responders for less than 1% of calls, connecting around 14% of callers to mobile crisis response teams instead. States and localities must focus on building out these peer led crisis response teams as an essential component for not only the 988 Line but the general mental health services continuum. While the federal government’s Community Mental Health Services Block Grant has a for states to use in crisis care services, more funding from Congress and states must be offered to create and expand these services. Read below for more information.

In First Year, 988 Crisis Line Represents a Step Forward, But Work Remains
By Ron Manderscheid | Behavioral Healthcare Executive | July 13, 2023

The first anniversary of the new 988 Suicide and Crisis Lifeline already is upon us. During this past year, millions of words have been written about this phone number. Some have focused on the potential of a hoped-for future; others have emphasized the need to build key community infrastructure to support those who call. All agree that it represents a major step forward.

At this anniversary juncture, it is important for us to take stock. We need to assess what already has been accomplished and what next steps will be needed.

In May 2023, the total number of routed 988 contacts was 469,000, of which 67,000 were routed to the Veteran Crisis Line (see ). These numbers can be compared to 361,000 and 52,000, respectively, for August 2022, the first full month of system operation. For both types of contact, the May 2023 numbers represent about a 30% increase over those for August 2022.

Of the 402,000 non-veteran contacts in May 2023, 65% were calls, 17% were chats, and 18% were texts. The percentage of calls actually answered and not abandoned was 89% in May 2023, up from 84% in August 2022. The comparable percentages for answered chats and texts were in the high 90s for both periods.

The reports coming from the field over the past 12 months have been quite divergent. Some have emphasized the fact that many calls to 988 are not, in fact, emergencies, but rather are calls to report a problem or concern with a social determinant, e.g., loss of housing. Other reports have expressed concern with the continued involvement of police in some jurisdictions. Still others have noted lack of coordination between 988 and earlier local call systems which still are operating. It would seem that many of these concerns are transitional and that they will be addressed over time.

Dr John Draper, a prominent figure in this work, noted that we finally have created a front door for a behavioral health emergency response system. He then went on to express his hope that our next efforts will involve building a house to go with this door. Clearly, this will include developing local capacity to staff mobile crisis response teams with peers and behavioral health professionals, developing diversion and other short-term crisis response centers, developing respite capacity, and linking this entire enterprise more closely to our intersectoral efforts to reduce involvement with the criminal justice system and emergency rooms.

SAMHSA funding for this effort has grown rapidly from slightly less than $25 million per year to slightly more than $500 million in FY23. We expect that this higher level of funding will continue during the Biden Administration.

Going forward, it seems very clear that we must improve system capacity at the local level for call responders, mobile crisis teams, and staff of short-term crisis services, particularly in rural areas and other areas with vulnerable populations. Because of our current behavioral health workforce crisis, this will be a challenging task. Efforts should be made to expand the use of peers, paraprofessionals, and suitably trained community members to conserve scarce professional personnel.

We also must enhance our efforts to move upstream to identify and address the social determinants of health that cause trauma, behavioral health conditions, and crises. Without doubt, it is always better to prevent a crisis rather than to address it later. As we develop our local crisis response staff, we need to ensure that they have appropriate training and skills, together with program structures, to do this essential upstream work.

Congratulations to all who have played such a significant role in developing and implementing the new 988 Suicide and Crisis Lifeline over the past year. All that you have accomplished is appreciated, and your continued achievements in the coming years are greatly anticipated.

Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work

Psychiatric Detentions Rise 120% in First Year of 988
By Rob Wipond | Mad in America | May 20, 2023

The rapid growth of the new 988 mental health hotline has been greeted with . As many people expected, calls, texts, and chats to the National Suicide Prevention Lifeline, now renamed “988 Suicide and Crisis Lifeline,” started climbing immediately with the launch of the 988 number in July of 2022. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the nonprofit that was given centralized control over the 988 system,  (VEH), have been releasing  on key metrics.

In April 2023, compared to April 2022, calls answered increased by 52%, chats by 90%, and texts by 1022%. The trend was heralded by federal Health and Human Services Secretary Xavier Becerra : “Our nation’s transition to 988 moves us closer to better serving the crisis care needs of people across America. 988 is more than a number, it’s a message: we’re there for you.”

However, as  by Mad in America, a percentage of people who contacted the former National Suicide Prevention Lifeline were subjected to geolocation tracing of their phone, computer, or mobile device. The Lifeline advertised itself as a place for confidential discussions about suicidal feelings but, according to , if a call-attendant believed a person might be at “imminent risk” of taking their own life in the next few hours, days, or week, the call-attendant was required to contact 911 or a Public Safety Answering Point to send out police and/or an ambulance to forcibly take the person to a psychiatric hospital.

Many Lifeline users described the experiences of betrayal, public exposure, police interactions, loss of freedoms, and forced psychiatric treatment as dangerous, harmful and traumatizing.

So, since the transition to 988, has anything changed? As contacts to 988 rise, how many people are getting forcibly subjected to these types of unexpected, unwanted interventions?

It appears detention numbers are climbing dramatically, too—even as VEH, SAMHSA, and many news outlets continue to obfuscate the facts publicly.

Contacts and Detentions Rising Together

For the ten-month period from July 2022 to April 2023, the new 988 Lifeline received more than 4 million total contacts—on pace to double the average  to the Lifeline from 2017 to 2021.

The 988 metrics that are publicly shared, though, do not include any information about call tracing and involuntary interventions.

Replying in an email, Hannah Collins, the Director of Marketing and Communications for VEH, told Mad in America: “Still less than 2% of all contacts, for use of emergency services.”

SAMHSA spokesperson Dani Bennett gave the same approximation: “Based on the network call centers that collect and report this data, we estimate that fewer than 2% of 988 Lifeline calls require connection to emergency services like 911.”

Both VEH and SAMHSA refused to share any of the underlying data on which this 2% estimate was based.

It’s the same rate that VEH and SAMHSA have been publicly reporting for the Lifeline for several years. It’s also consistent with a 2018  obtained by Mad in America through a freedom of information request—to this point in time the only actual data on the Lifeline’s involuntary interventions that’s been publicly released—which showed that on average 2% of total contacts, or 44,000 people, had been subjected to involuntary interventions over the previous year.

However, continuing at 2% means that detentions are climbing on pace with the rising number of contacts to 988. This means that, over the past ten months, a staggering 81,000 Americans who’ve reached out to 988 for confidential conversations have ended up being coercively taken to psychiatric hospitals. In 988’s first full year of operation, its call centers are on pace to incarcerate nearly 100,000 people.

Clarifying the Policies, Facts, and Obfuscations

Yet despite the rapidly expanding assault on many people’s basic civil rights, VEH and SAMHSA, aided by inaccurate reporting from major news outlets, continue to misrepresent what’s going on.

The 988 Suicide and Crisis Lifeline’s  still misleadingly reassure the public that all contacts are “confidential.”

And many news outlets falsely assert, as a Cosmopolitan  did, that “[I]f you aren’t in the middle of a suicide attempt while calling, you don’t need to be afraid of being hospitalized or having emergency services called on you.” This, though the Cosmopolitan article, inscrutably, also linked to a  that specifically clarifies that Lifeline’s “imminent risk” policy applies to a much broader range of situations than an “imminent death” policy. VEH also produced an  in December of 2022 that re-affirmed its practice of conducting “involuntary emergency service interventions” when a call-attendant feels that a person could be at “imminent risk” for suicide within an undetermined “short time frame” in the future.

Still, perhaps the Cosmopolitan journalist can be forgiven for being misled because, in explaining the 988 intervention policy, SAMHSA’s Bennett recently wrote even to Mad in America that “some safety and health issues may warrant a response from law enforcement and/or Emergency Medical Services (namely when a suicide attempt is in progress).”

Bennett added that a majority of the interventions “are done with the consent and cooperation of the caller”—a talking point from 988 leadership that’s repeated often, even by journalists . It remains unclear what “consent” means, though, when some Lifeline call-attendants reportedly tell certain callers that police will come for them whether they voluntarily disclose their location or not. It seems likely that, as police shootings during wellness checks have gained notoriety in recent years, many people now quickly realize it’ll be much safer to be described to police as “cooperative” rather than as in dangerous emotional distress and uncooperative.

With similar smokescreening, a  reassuringly reported that “a representative for SAMHSA told VICE, ‘988 does not currently use geolocation.’” It wasn’t clarified that 988 call-attendants simply contact 911 to do the geolocating for them.

And typical of most 988 news coverage, NPR and Kaiser Health News  to correct alleged social media alarmism and  by characterizing the likelihood of these unwanted interventions as “rare” and “remote.” The underlying disregard for the basic rights and freedoms of people who call mental health hotlines is striking—If the state was locking up 1 in every 50 journalists in America for purveying dangerous misinformation, or jailed 58,000 of America’s 2.9 million daily airline travelers as potential terrorists, would major news outlets blithely reassure their audiences that these unsettling occurrences were nevertheless “rare”?

In any case, the actual rate of the involuntary interventions is much higher than 2%. When asked by Mad in America, neither VEH nor SAMHSA provided data on the main reasons for calls since the transition to 988. But data previously obtained from the National Suicide Prevention Lifeline  that only 20% of people typically called to discuss suicidal feelings—many people called to discuss other kinds of issues and problems or for referrals to community services. Calculating the rate of interventions on suicidal callers as a percentage of the “total contacts,” then, concealed a much more telling and alarming rate: Apparently, about 1 in 10 of callers with suicidal feelings were getting subjected to coercive interventions.

And since 988 has been heavily promoted as a, it seems likely that callers with suicidal feelings are a shrinking percentage of the “total contacts.” So, if callers with suicidal feelings now represent, say, 15% of total contacts, that would mean involuntary interventions are being imposed on 1 in every 7.5 people with suicidal feelings who call 988.

Both Promising and Concerning Developments

There are nevertheless some slightly promising new developments for 988 on the horizon—or at least, promises of promising developments.

According to its updated policy document, VEH has instituted a requirement that all involuntary emergency service interventions by 988 call centers must undergo a “supervisory review” in which the call-attendant and center supervisor document what, if anything, could have been done differently.

VEH also encourages call centers to “investigate alternatives” to sending out police and ambulances for imminent risk cases, and to “document strategies for outreach/education efforts to public/private entities to address this need” in their communities.

And in response to my queries about releasing more detailed data on involuntary interventions, VEH’s Collins’ replied, “We do not publish this data set yet, but work is underway to expand and improve the collection of this type of information so that we can publish with the other reports that we have made public.”

Yet there are some disturbing developments as well. As previously  by Mad in America, members of the Lifeline’s own Lived Experience Committee had begun vehemently protesting the Lifeline’s policy of initiating unwanted interventions against people deemed to be at imminent risk, and had noted the  that the practice saves lives or helps more than harms people. According to 988 Lifeline internal minutes from a March 2023 meeting obtained by Mad in America, VEH has disbanded the Lived Experience Committee and shut it down.

Overall, it’s astonishing that these 988 Suicide and Crisis Lifeline practices are not generating broader public concern. A wave of recent  in ����������, California, and elsewhere around the nation allege that there’s a desperate “” for helping the most  people. As I discuss in  and in a recent Los Angeles Times , such claims tend to be mired in poor science, prejudicial over-generalizations, and incorrect data on bed numbers and forced treatment rates. Regardless, what impact is it having to be filling those psychiatric inpatient beds with nearly 100,000 people annually who are doing nothing more “dangerous to self or others” than simply calling 988 to discuss their feelings?

One Year into 988 Hotline, Staff Push for Fixes to Ambitious New System
By Theresa Gaffney | STAT News | July 12, 2023

One year after 988 launched as the new number for the national U.S. mental health hotline, the people behind the system say they’re still working out some kinks.

 

In an ideal world, for example, a caller in ���������� looking to talk would be routed to a ���������� call center, so that hotline workers could direct them to the most relevant information on local resources. But right now, calls are routed to the system by area code — meaning someone based in ����������, but whose phone has a Massachusetts area code, will be routed to a Massachusetts call center.

“I would say the routing issue is the biggest thorn in our side right now,” said Kathy Allen, the program manager at Help Center, Inc., a crisis center that answers the hotline in Montana. In ����������, Danielle Silverstein, the 988 director at the Long Island Crisis Center, estimates that 15-20% of the calls her center receives are from people who are out of the state. This glitch affects callers nationwide, and will require national-level action to fix.

In the year since the new, easy-to-remember 988 number , call center staff have worked hard to keep up with increasing calls to the system while also building new infrastructure to grow the program. There are over 200 local call centers across the country that answer the line, and nobody knew what to expect.

Local leaders and directors at call centers say they’re proud of how they’ve handled the last year, but that there’s a lot of work left before the system works in the way everyone wants it to. A look at the particular issues plaguing 988 is a reminder of just how long the road is toward establishing a robust, reliable mental health crisis system.

Better Staffing to Help Callers in Mental-Health Crisis

Calls, texts, and online chats to the 988 line have continued to increase since the number first launched in July 2022, with about 250,000 contacts that month. By comparison, over 400,000 calls and messages were made in May of this year. It’s a major  from calls to the national hotline before the three-digit number became available, despite public awareness of the line remaining relatively .

Amid such volume, each center strives to answer calls  of the time, with varied success. In May 2023, 18 states had phone answer rates above 90%, according to data from Vibrant, the company that administers the line. Across the network nationally, 89% of calls were answered that month.

Call centers have struggled to figure out how to forecast volume and plan their staffing accordingly. But patterns can be unpredictable: One call center found their calls at night have increased while their daytime calls have stayed consistent. Others may experience completely different patterns.

“You have absolutely no idea if people are going to sit idly by or they’re going to be overtaxed and [you have to] know how to support both of those scenarios,” said Eileen Davis, director of Call2Talk in Massachusetts.

Brooke Pochee-Smith, the 988 and crisis system reform project manager at Maine’s Office of Behavioral Health, said centers used models provided by Vibrant to calculate how many staff members they may need, which she found helpful at the beginning.

That said, models don’t always match reality. A center may know they need more staff, and even have the funds to hire and train them. But answering calls on a mental health hotline is a very intensive type of work that involves many hours of training, and not always a lot of pay. “It’s not a cashier job. It’s a crisis call-taker.”

Workforce shortages are a problem across mental health care fields, said Holly Wilcox, a professor in the department of mental health at Johns Hopkins and chair of the Maryland Commission on Suicide. Beyond the call centers, Wilcox says the shortage could be addressed by filling more frontline roles in mental health crisis care with peer-to-peer professionals, who may have lived experience with mental health struggles, and who know how to engage with the system to get people the help that they need.

“We only have a certain amount of psychiatrists, we only have a certain amount of psychologists, but we can also increase the workforce in terms of people who are on the front line, who answer the calls, who can go to the home, who do a lot of the outreach, and they can escalate when needed,” Wilcox said.

In creating a more holistic crisis care system, peer counselors can do daily work like safety planning — helping someone create specific action steps they can take when they feel suicidal — and motivational interviewing, which involves asking open-ended questions to encourage somebody to find their own motivation to make positive change. All that can be hugely helpful in saving lives.

Permanent Funding for 988

Sometimes calls go unanswered for reasons that have nothing to do with staffing issues. One day in early December, about six months after the launch of 988, the national phone line went . For hours, no calls could be answered across the country.

Once calls finally routed to the network’s 12 national backup centers, Rachelle Pellissier’s team at Crisis Support Services of Nevada sprang into action, staffing up to answer calls. When it was over, Pellisier, the executive director at CSSNV, and her program director looked at each other and groaned:  “Oh, we’ve got to go back to the normal crisis.”

The normal crisis, Pellisier said, is figuring out how to stay funded. “We can handle these huge national disasters in crisis,” Pellisier said, “[but] dealing with not having the right funding or funding withheld or the loss of funding? Now there is some frickin’ stress.”

Nevada passed  to fund and implement 988 back in 2021, directing telecommunication companies to collect a fee on phone bills to pay for the call centers. Yet, Pellisier says that funding system has still not been implemented, and progress has only seemed to slow since the new number was launched.

“Right now, we’re using a bunch of piecemeal funds that the state has gotten over the last couple years. I call it a patchwork quilt of funding — we’re trying to hold it together until we figure it out,” Pellisier said.

While call centers have received federal funds distributed through the states where they operate, some are still cobbling together additional grant funding to stay afloat. Just over half of all states have enacted some type of legislation to fund the line, according to  from the National Academy for State Health Policy in June. But it’s unclear how far along in the implementation process each state is.

“That’s what is still being solved for — permanent funding for 988 either at the federal level or on the state level,” said Mandy St. Aubyn, development and communications coordinator at Montana’s Help Center.

Robust Mental-Health Response Teams

While crisis centers continue to staff up to handle the higher volume of people reaching out, they’re also working to build mobile response teams that can travel directly to a person experiencing a mental health emergency. The hope is that these teams can eventually take the place, for the most part, of police responses to the public’s mental health needs.

For now, crisis centers still work with 911 operators and police for the small