One year into 988 hotline, staff push for fixes to ambitious new system

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 New York looking to talk would be routed to a New York 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 New York, 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 New York, 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 went live, 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 increase from calls to the national hotline before the three-digit number became available, despite public awareness of the line remaining relatively low.

Amid such volume, each center strives to answer calls at least 95% 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 dark. 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 legislation 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 data 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 percentage — less than 2% overall — of calls in which somebody is in acute danger and needs immediate assistance.

“It’s been sort of miraculous how they can find folks,” said Allen in Montana about 911 dispatchers’ ability to locate a caller who is in danger but may not share their location. “It’s never a problem.”

But that doesn’t hold true in every state. On Long Island, Silverstein said, the police have never been able to geolocate a caller for her. “There are instances where, unfortunately, the call with 911 ends with them saying, ‘unless you get more information [from the caller], we can’t really help you.’ In which case we try to keep the client talking and try to de-escalate and work on a safety plan, which we would do anyway,” Silverstein said.

And while many program directors said they have had good experiences working with 911 dispatchers and police, others said that it can be difficult. “Those rural sheriffs are like, ‘We don’t want this new-fangled 988 thing,’” Pellisier in Nevada noted.

“It’s not just a given when we call law enforcement, [and say] ‘We need you to go to this person, they’re dying right now.’ The sergeant on duty can say, ‘No, we’re not going to that person. It’s not a safety risk to anyone else,’” she said.

When the police do respond to calls about mental health, it can lead to more violence than assistance. Patients and advocates have long decried police responses to people with mental illness. Since 2015, over one-fifth of people shot by on-duty police have been in a mental health crisis, according to data from the Washington Post.

Pellisier has hopes for the creation of mobile crisis response teams in Nevada. But she said the slow progress on funding 988 in the state does make her worry about how long it will take to get something like that up and running. “I don’t want to act like it’s the state’s fault or anything else. This is just difficult and complex.”

Many centers around the country already have or are building capacity for mobile crisis units, as it’s part of a wider effort from the Substance Abuse and Mental Health Services Administration to enhance crisis care. At the Maine Crisis Line, less than 1% of callers receive emergency responses through 911, while 14% of callers are connected with a mobile crisis response team, made up of crisis workers trained in face-to-face interventions.

In Maine, these mobile crisis units have been working with the hotline since it started taking calls in 2018. The state is now working toward elevating those services — to go from having not just a mobile response team, but mobile outreach teams. Eventually, the hope is that these outreach teams will be able to build relationships within communities so that they become a known resource, and even provide non-urgent follow-up care to people who have called the line in the past.

Wilcox believes that down the line, 988 operators could also provide proactive outreach to people who may post online in ways that are indicative of mental distress or suicidal ideation. “Going onto social media platforms, finding people with risky behavior, engaging with them, trying to help them — there are some crisis services that are really cutting edge that are doing that,” she said.

Despite the ongoing challenges faced by 988 centers, staff across the country say they’re honored to be part of the effort to address mental health and provide crisis care to anyone, at any time.

“Not to sound too Pollyanna about it, but it’s really a huge opportunity to be able to have something like 988 that catalyzes so much conversation,” said Pochee-Smith.

If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.