Putting 988 into Context: Crisis Intervention in the USA

Starting July 16, 2022, individuals experiencing a mental health or substance abuse crisis (including suicidality) in the USA will be able to dial 988 to speak with a crisis counselor and be connected to local resources for additional support.

Why is 988 necessary?

Historically, many mental health crisis calls have been routed through 911, leading to police or EMS services being dispatched to the address of the individual experiencing a crisis. This has caused a lot of harm to BIPOC, LGBTQIA+, Disabled/Mad communities, as well as members of other vulnerable and marginalized communities throughout the USA.

According to Vibrant Emotional Health, the current administrator of the National Suicide Prevention Lifeline, the goals of 988 include: reduce health care spending with more cost-effective early intervention; reduce use of law enforcement, public health, and other safety resources; and meet the growing need for crisis intervention at scale in the USA.

That sounds good, right? But let’s unpack those goals a little further.

The History of Crisis and Suicide Intervention in the USA

This article by Hannah Zeavin provides important historical context into the creation and evolution of crisis and suicide hotlines internationally, including their relationship to both psychiatry and law enforcement. The article notes that suicide intervention historically means “preventing suicide by any means necessary,” which includes both calling the police and forced inpatient psychiatric hospitalization. 988 continuing the language of intervention in their goals is a red flag indicating their underlying philosophy remains unchanged.

The Relationship Between Crisis Intervention and Law Enforcement

This article by Slate explains more about how risk is assessed by crisis hotlines, and the internal policies and procedures which impact the type of support and resources any given individual in crisis will receive. Many individuals think that contacting a hotline or lifeline is safer or more beneficial than calling 911, but it isn’t always functionally different.

Historically, individuals calling the National Suicide Prevention Lifeline in the USA have had police sent to their address if the crisis counselor determined they were at “imminent risk” of harm. Technology like GPS tracking on cell phones makes these types of interventions relatively straightforward to implement. Because of this history, it is also a red flag that the stated goal of 988 is to reduce, rather than eliminate, the use of law enforcement in response to mental health crisis and suicidality.

The Difference Between Crisis Intervention and Crisis Prevention

It is additionally problematic that a stated goal of the program is to save money, when the USA will not invest in universal healthcare, increasing the minimum wage, affordable housing, or other preventative initiatives related to systemic failures of the government to meet the basic needs of American citizens.

Stagnant minimum wage, rising housing costs, racial violence, anti-trans legislation, the COVID-19 pandemic, and so much more significantly contribute to the growing need for mental health crisis support across the USA. 988 may be one step in a larger process, but reflects the government’s tendency to be reactive instead of proactive when implementing solutions to systemic issues.

What We Know About 988 So Far

The website for 988 openly admits that 988 “will route callers to the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline).” What isn’t clear is whether any of the internal policies and procedures of that lifeline will shift as a result of this change.

Vibrant Emotional Health argues that “Increased collaboration between 911 and 988 can provide more options for those in crisis,” (emphasis original) which indicates these services will remain interrelated moving forward. Creating two different numbers may give citizens the false impression that these are two separate and unrelated services, minimizing the fact that 988 is being encouraged to collaborate with 911 (and by extension law enforcement).

The 988 website contains an infographic which takes visitors through the process of what happens when someone calls 988. The infographic explains how Individuals are routed to preexisting crisis centers spread throughout the USA. These centers are also “independently owned and operated,” so it isn’t clear whether they all share the same internal policies and procedures, or whether these procedures vary based on geographic location.

Current and Potential Future Limitations of 988

This article by Vera Institute of Justice indicates that the goal of 988 is to “drive communities to invest in services,” and goes on to assert that “states and localities need to invest in extended crisis services” to support their communities. But what about the ones that don’t?

The article goes on to state that without infrastructure in place, “911 and 988 operators alike will often have no choice but to dispatch police” if that is the only local resource available.

One concern is that individuals may use less discretion when calling 988 on behalf of a neighbor or stranger, when that person would not have called 911. And, if 988 is collaborating with 911, this could actually potentially increase the use of law enforcement to respond to mental health crisis in certain communities, rather than decreasing it.

State vs Federal Funding of 988

Axios Media has a map on their website showing all the states which have enacted legislation to implement and fund the 988 hotline. The map shows that approximately 50% of US states have done so as of June 29, 2022. What happens when individuals in states who have not implemented any funding or infrastructure for mental health crisis services call 988?

Vibrant Emotional Health admits that “the transition to 988 requires additional policy changes and substantial funding support from federal and state governments” and argues that “states should exercise their authority to implement a 988 fee” to fund the program. But what if they don’t?

According to the U.S. Department of Health and Human Services (HHS) website, 988 is the result of a joint effort between the U.S. Department of Health and Human Services (HHS), Federal Communications Commission (FCC), and the U.S. Department of Veterans Affairs (VA).

HHS openly admits, “The success of 988 depends on our continued partnership with states, as the federal government cannot do this alone. We urge states and territories to join us and invest further in answering the call to transform our crisis care response nationwide.” 

Where To Go From Here?

It seems likely that 988 will be of the most use to individuals who live in areas that are already highly resourced, and which already have existing infrastructure related to mental health crisis response. The existence of 988 may not do anything to support US citizens living in rural areas or states that have not chosen to invest in infrastructure related to mental healthcare.

BIPOC, LGBTQIA+, and Disability communities already have grassroots supports and initiatives in place to best meet their needs without intervention from psychiatry and law enforcement. It is possible that 988 could encourage divestment from those resources in favor of sending everyone to 988, when 988 may not have enough crisis counselors in place to meet this increased demand (and whatever counselors they do have may not be culturally competent to meet the needs of marginalized communities).

It is important to remain aware of intersectionality, and to use discretion when supporting marginalized individuals who are experiencing a mental health crisis. It is necessary to collaborate with individuals experiencing a crisis and empower them to choose what resources or supports they want or need.

What Are Safe Resources For Those in Crisis?

Trans Lifeline does NOT ever collaborate with law enforcement, and you can learn more about their commitment to creating a crisis caller’s bill of rights.

The National Domestic Violence Hotline also takes as many steps as possible to protect the anonymity and safety of survivors of abuse as possible. If given a name and address an advocate may have to file an APS/CPS report due to state mandatory reporting requirements. But those who call or chat with the hotline are not asked for identifying information (as of 2019).

Conclusions

I am not saying, “Never refer anyone to 988.”

I am saying, “If you are going to create a safety plan with a person experiencing mental health crisis, make sure you are clear on their view of psychiatric hospitalization and law enforcement. Collaborate with that individual to ensure they understand the risks and possible consequences involved by seeking support from any given resource.”

988 may in fact be a beneficial resource that supports a shift away from the entanglement of law enforcement with mental health crisis response, and creates necessary national infrastructure. But it could also exacerbate current inequalities in access to necessary services and reduce the growth of grassroots initiatives led by those with lived experience of marginalization.

Only time will tell.

So for now, use 988 with discretion, and research what organizations and initiatives exist in your local area to support individuals who are experiencing a crisis.

Additional Resources

For a deeper dive into the connections between psychiatry and law enforcement in the USA, I recommend Decarcerating Disability: Deinstitutionalization and Prison Abolition.

For more information about community care, grassroots community organizing, and Disabled/Mad activism, I recommend Care Work: Dreaming Disability Justice.

You can access my local and national resource list, supporting and uplifting a variety of forms of mutual aid and community care throughout the greater Austin area, Texas, and across the USA.

And if you want a deeper understanding of anything I have outlined in this article, you can also contact me to schedule an individual consultation.

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