Will 988 Be a Joke in Your Town?
A call for less public health virtue signaling and more serious conversations about the gaping hole in helpful emergency responses to behavioral health crises
The recent unveiling of the 988 mental health crisis support number has received nearly endless praise across our newsfeeds the past few days. Don’t get us wrong- we don’t like to dial 10 numbers on our phones either but how does this actually move the needle on mental health services in the United States? Spoiler alert: It doesn’t- at least not right now. Case in point: We could have said “It does not” but we saved some time there by using a contraction! Aren’t you impressed? Despite grand proclamations that July 16th is a “historic moment for crisis care and suicide prevention,” 988 is simply a shorter way to reach the pre-existing National Suicide Prevention Lifeline which could otherwise be dialed with 1-800-273-TALK. That’s literally it.
Was not being able to find the number to a crisis hotline an actual serious problem? We are trying not to be flippant but my darling policymakers, let me Google that for you. And if you type in anything even suicide-adjacent in any search engine or social media platform or watch any show touching on mental health, this number is served up to you as “bumper” at the start and end.
Help is Not on the Way.
We call bullshit that any of our patients will be meaningfully impacted in the near term by this change. But we’re nowhere near as good at that as our nation’s Hip-Hop professionals, so let’s defer to one of our most memorable public health critics in the public discourse.
Flavor Flav was the most flamboyant member of Public Enemy. His “911 is a Joke” is the classic hip-hop commentary on public health interventions, and features gems like this:
I dialed 911 a long time ago
Don't you see how late they're reactin'
They only come and they come when they wanna
So get the morgue truck and embalm the gonerThey don't care 'cause they stay paid anyway
They teach ya like an ace they can't be betrayed
I know you stumble with no use people
If your life is on the line then you're dead todayLate comers with the late comin' stretcher
That's a body bag in disguise y'all, I betcha
I call 'em body snatchers 'cause they come to fetch ya?
With an autopsy ambulance just to dissect ya
Mr. Flav provides a strong critique of the importance of prompt response of emergency services for general medical emergencies. A similar, if not stronger case is to be made using Mr. Flav’s relentless logic about 988’s overstated promises. The budget for the implementation is $282 million in 2021 and another $150 Million in 2022. This investment is the bare minimum necessary given how understaffed and underfunded the National Suicide Prevention Lifeline was before this initiative. Their data shows that 1 in 6 calls are disconnected before reaching a counselor and 80% of callers that abandon do so after waiting two minutes or less after the greeting, which can feel like an eternity to someone in crisis. While this initial funding push will help, serious doubts exist if it will be sustained or enough to meet increased demand caused by publicizing the new 988 number.
We do know that when someone calls and connects with a caring and trained human they often can benefit, but if they need more than a crisis counselor, the rest of our outpatient and inpatient mental health infrastructure is still woefully inadequate. This is not dissimilar to what happened with COVID-19. Sure, we could set up a memorable shortcut to reach an understaffed COVID hotline but what good will that do if the hospitals are full and all the ventilators are spoken for?
The issue of needing more than a crisis counselor brings us to another unintended issue with bifurcating emergency services as “medical emergencies” and “mental health emergencies.” It leaves it at the level of the person in crisis to decide which number to dial. The lines between a medical and mental health emergency can be blurry, especially to a non-medically trained layperson. Before July 16, if a loved one attempting suicide overdosed on Tylenol (which is all too often fatal in overdose), dialing 911 was the correct and only choice. Starting on July 16, however, the caller may logically think to themselves “Oh I should call that new mental health number about this suicidal crisis!” and dial 988. That would be wrong. Calling the wrong number wastes precious time your loved one’s poisoned liver does not have as the crisis counselor needs to redirect you to 911 and get an ambulance dispatched.
Ok, so maybe that re-routing only takes a few minutes but we have hit another “minor” little snag. Your cell phone has an area code from where you went to high school in 2005 and you very much do not live in that state anymore. Had you called 911, no big deal! 911 has enhanced geolocation and the proper local EMS team could be dispatched. 988, on the other hand, does not and goes by the area code. Gee, this is getting messy! Didn’t they promise 988 would make getting help easier?
Let’s also not forget that if the caller was the one who had overdosed, people who are suicidal often have deep ambivalence and are not forthcoming about their location so geolocation is especially important. As psychiatrists we vividly recall having patients call us from an undisclosed rooftop, a bridge and a subway platform and refuse to say where they were so geolocation is not a trivial matter.
Furthermore, the issue of 988 engaging in “imminent risk” and “active rescue” procedures by contacting 911 has been criticized for summoning the exact same law enforcement-heavy emergency responses and involuntary hospitalizations that we are trying to avoid. But what choice do they have?
911: Also a Joke in Your Town
The main crux of why all the glowing platitudes about 988 are getting under our skin is that we wish some of that $432 Million was instead spent on true 911 alternatives for mental health emergencies. We urgently need to fund new structures of first-responding that do not jeopardize the lives and well-beings of vulnerable individuals in crisis. Given that around 3% of US adults suffer from severe mental illness but data shows they make up at least 25% of all fatal law enforcement encounters, we need to take a hard look at what we can all do differently to reduce that number drastically.
We suggest starting by looking at what is going on in Eugene, Oregon with the CAHOOTS (Crisis Assistance Helping Out on the Streets) program. If a loved one is having a serious mental health crisis in Eugene, when 911 gets the call they can dispatch an unarmed outreach worker in addition to a medic (EMT or nurse) to de-escalate the situation. Police are not invited unless absolutely necessary, which is a contrast to how these calls go in most other parts of the country. Indeed, non-violent patients of ours in NYC have been handcuffed when they called 911 because of suicidal ideation. We were encouraged to learn that cities much larger than Eugene, like Oakland, Minneapolis and our very own NYC have started to implement similar pilot programs with some encouraging early findings.
While mental health rapid response programs have resulted in less police violence and unnecessary utilization of limited resources, is also worth noting, however, that CAHOOTS has faced difficulties with triaging between mental health and medical emergencies. This is precisely along the lines of concerns we have about the 988 vs. 911 split. In the Atlantic, they described:
Anecdotally, at least, Eugene’s citizens have come to appreciate the CAHOOTS approach to crisis response, perhaps too keenly. CAHOOTS exists in a society where many feel that the risk of police violence outweighs the potential benefit of calling 911, and where an encounter with EMS can wreck a household’s finances. Last December, a CAHOOTS team showed up to a fatal drug overdose hours after the victim’s friend had called in for help. The caller had avoided language that would have brought a faster police or EMS response.
Indeed, these fears are grounded in a sobering reality. There is a 17x greater likelihood that someone will be murdered by police if they have a mental illness, according to the treatment advocacy center. The numbers get even worse for black and brown individuals with mental illness:
“It should horrify but not surprise us that people with untreated mental illness are overrepresented in deadly encounters with law enforcement,” said Snook. “Individuals with untreated mental illness are vastly overrepresented in every corner of the criminal justice system. Until we reform the public policies that have abandoned them there, these tragic outcomes will continue.”
For those who really want a deeper dive on the problem of so-called help not being helpful for mental health emergencies, we previously held a panel discussion to generate ideas around a more coherent and less death-inducing emergency response. If you watch, you’ll notice none of the proposed solutions was a three digit shortcut to an existing perpetually underfunded hotline staffed by non-clinicians with limited training:
Losing the Game of Telephone
Speaking of underfunded and unprepared, let’s get back to 988. We lost track of time and got distracted. So too, did, the champions of 988 who seem to have neglected the local public health officials who are expected to carry out the grand promises of the new initiative. A recent rather bleak RAND Corporation survey found that:
More than one-half (51 percent) of survey participants reported that they had not been involved in the development of a strategic plan related to the launch of 988. Similarly, only 16 percent of respondents reported that they had helped develop a budget to support 988 operations.
Some other unfortunate fact-checking from the survey:
While 85% have a local mental health hotline already, less than 1/2 of these hotlines are part of the network 988 uses.
Only 22 percent of jurisdictions had crisis call centers or hotlines that can schedule intake and outpatient appointments on behalf of individuals in need.
A minority of staff had training to interact with special populations other than children, such as individuals experiencing homelessness (46 percent) or LGBTQ individuals (45 percent).
Given 988 is just billed as a Suicide Prevention hotline, we assume there is limited training on other types of psychiatric emergencies such as mania, psychosis, aggression or altered mental status.
None of those statistics surprise us. Just as it does not surprise us when we hear our patients complain that many mental health professionals they have worked with over the years are not available after hours. In fact we wouldn’t be phased if we learned of a therapists’ voicemail that said “I only check these messages between the hours of 2-3 PM on Tuesdays when Mercury is in retrograde, it is raining outside and there is nothing good on Netflix. At all other times, please call 911 or go to the nearest Emergency Room.” It is the standard of care in our field to redirect patients to emergency services after hours. While some practices thankfully have answering services, on-call rotations or clinicians who pick up the phone after hours, this is not the norm for many patients. We get it. No one wants to be “on call” 24/7 and the work we do as mental health professionals can be extremely intense but we owe it to our patients to work something out other than directing patients to access services we know to be potentially harmful at worst and marginally helpful at best. And 988 shouldn’t be doing our jobs for us. It would be like if a neurosurgeon deferred their neurosurgical emergencies to the OR technician when the clock strikes 5pm.
At our practice, we have solved for this through the use of Spruce Health, a telecommunications platform that allows for sophisticated team-based support of patients, systems for clinician coverage and after-hours triaging. It truly has been a vital part of our helping infrastructure and allowed us to take care of patients with complex mental health concerns, including chronic suicidal ideation and behavior. We only need to rely on emergency services as an absolute last resort or when there is a medical emergency. We know this is just one example of how to build safety nets that make sense to clinicians and to patients. There is no doubt lives have been saved because of it.
988 can save lives too if more effort and funding is directed at what happens when the callers needing more help than the line on its own hang up the phone. Otherwise, it would be like calling a “Fire Support Hotline” while your house is burning down only to be consoled by a validating counselor that “it must be hot in there for you.” Meanwhile the only firetruck in your town (correction- the town where your phone’s area code originated) is busy putting out a blazes elsewhere for the next 6 weeks for those with the appropriate fire insurance for that specific truck.
Please Stay on the Line
Seriously. We are staunch advocates of help that is actually helpful and would love to connect with anyone who is up for tackling Big Hairy Audacious Mental Health Goals in thoughtful ways. While we recognize many well intentioned people have put a lot of time and money into the implementation of 988, we are not pop-popping the Cris just yet. You may have to wait > 2 minutes to fix our broken mental health care system but we think you’ll like the hold music we have selected. It samples the actual National Suicide Prevention Lifeline’s hold music:
We out.
—O. Scott Muir, M.D. + Carlene MacMillan, M.D.
Really great write up