David Macfarlane

988 is No Substitute for an Actual Mental Health Care System

December 5, 2023

Addiction, Behavioral Health, Mental Illness 6 Minute Read

The goal is to create a memorable shorthand that becomes as deeply embedded in the national consciousness as 911. In the first year since the introduction of the 988 number to access help related to a mental health care crisis, evidence suggests the federal investment in 988 infrastructure is having a positive impact.

In the year since the introduction of 988, call centers associated with the number have received more than 5 million contacts via calls, chats, and texts. As of May 2023, contacts via 988 increased 33% from the same pre-988 month in the previous year. Answer rates have improved by 23% and wait times have decreased dramatically from what they were in the pre-988 system.

It’s a promising start, even if only 17% of Americans say they are familiar with it, but the 988 number is not without detractors. Or rather, many who work with the mentally fragile are concerned that 988 escorts desperate callers into a fragmented system that does not yet function like 911.

For example, many think that a call to 988 automatically dispatches assistance to the caller’s location. With isolated exceptions, that’s not the case, and sometimes when it is the case, the assistance arrives in the form of police officers, which for many is cause for concern.

In most jurisdictions, particularly, those in rural areas, the police are not well-trained to deal with people in mental health crises. The patience, indulgence, and nuanced understanding required of mental health workers often run counter to the skill set required to protect public safety — the primary charge of police officers. In any given year, people amid a mental health crisis make up roughly 20% of those killed by officers.

There is also concern that a person who calls 988 may later find themselves involuntarily detained, which usually has little positive outcome for the person detained.

“I realize there is an urge to rescue people in crisis, but the reality is the services that exist make the problem much, much worse,” said Liz Winston, who works in mental health and had her own crisis experience, in an interview with NPR.

And, because this is America, there is always the issue of billing. Imagine having a mental health crisis, being involuntarily detained, and later getting a huge bill to cap off the experience.

These concerns, according to those who administer the 988 line, are the exact reasons the service is necessary, not legitimate explanations for why one should avoid using it.

A call to 988 provides access to trained counselors, they say, who immediately engage in a process of listening, discussing, and collaborating to find a solution to the ongoing crisis. Only when the counselor is unable to find a resolution and believes that the caller is a danger to themselves will the counselor contact emergency services.

What happens next depends on where the crisis is happening, which is the crux of concern concerning mental health care and interventions. Data shows that in most instances before 988 went into effect, emergency services were deployed in response to 2% of calls. Those services could be a trained mobile crisis response team but, again, in some areas, they could just as easily be the police.

If it sounds like it’s better to have a mental health crisis in some states than others, it’s only because it is. Ideally, a crisis counselor is located within the same state as the caller and is aware of available resources. Thus far, in-state response rates by counselors range from 55% to 98%. When a call center or counselor is not available to a caller, the call is automatically routed to out-of-state call centers (roughly 8% of all calls) where knowledge of resources and the ability to provide targeted help is less certain.

It comes as no surprise that funding is one of if not the most pressing issues with regard to establishing quality state-level call centers and rapid response times. While money for national 988 infrastructure comes from the federal government, local call centers are funded by the states. While there is some momentum for establishing telecom fees to pay for call centers, only 6 states have fees in place with two more likely in coming months.

Interestingly, neither of those states is Arizona or Utah, both of which, nonetheless, have telling examples of the value of detailed metrics when determining the efficacy of robust call center and crisis response structures. Arizona contracts with Solari Crisis Response Network, which generates a comprehensive dashboard that summarizes need and response throughout the state. To the north, the University of Utah summarizes the state’s crisis data via a dashboard and annual crisis reports.

While the available data is useful, what might prove more valuable to crisis centers and mobile response teams would be real-time information on available beds and other resources in nearby facilities.

“One of the things, which is a challenge, is that when we send out a mobile team… they have to call facilities to see if there is a bed available,” explained Solari CIO Mark Griffiths. “One of the things we’d like to do in the future is to find a way of bringing all that information together so that we can provide the mobile teams with a quicker way of finding an available bed so they can take a patient there.”

It’s telling that data from both Utah and Arizona is not fed into a national portrait of mental illness in America. Local crisis centers are not required to participate in a national network, just as hospitals are not required to participate in health information exchanges, both of which feed the American healthcare technology narrative of siloed entities with rather limited broader engagement.

It’s not that the 988 number was hailed as the cavalry coming to save American mental healthcare, because it wasn’t. Like 911 and the EHR, 988 is a marginal technological improvement that builds on the existing system. And like 911 and the EHR, it also shines a spotlight on where there are holes, sometimes huge ones, in that system.

In American healthcare, so much depends on states and regions, and this is currently more true of mental health treatment and crisis response than it is acute care. One can hope that, with mental illness more prevalent and obvious in daily life than ever before, citizens will make their elected officials pay attention — oh, the burdens of democracy and federalism — to the issues that contribute to mental illness/addiction while also turning 988 into a reliable source of support and treatment regardless of where anyone lives.

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