988 Response Must Be Coordinated to Work Well

Response to the 988 Suicide & Crisis Lifeline has some kinks that need to be ironed out, but coordinating services from mental health professionals, peer supporters, local health care facilities, and law enforcement can go a long way toward ensuring that callers get the help they need, said experts at APA’s Mental Health Services Conference.

Joshua Reed

Margaret Balfour, M.D., Ph.D., an assistant professor of psychiatry at the University of Arizona College of Medicine in Tucson, spoke about the challenges of a fragmented mental health crisis response, especially when 988 calls route to the state associated with the caller’s area code rather than the caller’s location.

“For the ideal outcome, you need the call to be routed to a local call center that is able to connect to local community resources like mobile crisis units and crisis facilities and to local agencies for outpatient care,” said Balfour, who is chief of quality and clinical innovation at Connections Health Solutions, a crisis response center with sites in Tucson and Phoenix.

Balfour added that misinformation about 988 presents another hurdle. She cited social media posts that claim calls could be tracked, police would respond, and callers would be taken against their will to an emergency department. Yet only 2% of calls to 988 result in activating a police dispatch, and in half of cases in which police are dispatched, it is with the caller’s consent, Balfour said.

“The take-home message is that if you want to address this perception problem, you need to have a consistent response of the services that people need and not a law enforcement response,” Balfour said.

Kenneth Minkoff, M.D., an assistant professor of psychiatry at Harvard Medical School, said that the services available through 988 should be a priority and not an afterthought. He is a senior system consultant at ZiaPartners, a California-based international behavioral health and health system consulting firm.

“An excellent behavioral health crisis system has to be considered an essential community service just like police, fire, and EMS, not like, ‘Well, we’ll have one if we can find some extra money,’” Minkoff said. “It’s something that we have to dedicate resources to because otherwise we’re failing ... the people who need the help.”

Minkoff said that each step during a mental health crisis response should be connected to every other step. To that end, he discussed three key elements of a well-prepared behavioral health crisis system: accountability and finance, a basic array of services that are adequately staffed, and clear best practices that define the roles of each person involved in the response.

The Importance of Relatability

Jason Winsky, a sergeant with the Tucson Police Department and a member of the department’s Mental Health Support Team, discussed dedicated law enforcement mental health teams like Tucson’s, which embeds mental health professionals and people with lived experience.

Winsky stressed that an understanding of these services among local law enforcement is crucial.

“If a police department or sheriff’s department doesn’t have a culture around training and responding to vulnerable populations, these teams will not be nearly as effective,” Winsky said. He added that law enforcement’s role in responding to mental health crises needs to be a welcoming one.

“We drive unmarked cars and don’t wear uniforms. When we knock on the door, people will look out the window, and if they see that the officers are [not in uniform], they open the door, [whereas] if they see uniforms, they might think ‘Am I going to jail?’”

Law enforcement is slowly but surely becoming more amenable to involvement in mental health crisis response and diverting people in crisis away from jail and toward help, Winsky said.

“Five years ago you could go to any high level law enforcement conference in this country and find sessions that were titled ‘Is Diversion Worth It?’ If you go to those same conferences today, the sessions have names like ‘Divert to What?’” Winsky said. “The outcry from law enforcement all across the country now is [that] we don’t have a place in our community to take this population to other than an emergency department or a jail.’”

Preston Looper, M.S., L.P.C.-S., discussed the structure of mental health crisis services. He is a principal at Full Tilt Strategies LLC in Colleyville, Texas, which specializes in designing and implementing crisis care training and program design.

Looper said that only 20% of mobile crisis teams are standalone. “Most other mobile crisis teams are embedded within other, larger organizations, with the two largest being traditional community mental health centers or crisis receiving facilities and crisis hotlines [that share staff],” he said.

Looper stressed that 988 and other hotline staff need to be aware of the services in their communities and be prepared to make decisions on where to send callers.

“About 80% of calls that come to hotlines can be managed telephonically, but the other 20% need to go to the next step,” Looper said. He added that hotline staff and other crisis responders need to have working relationships with receiving facilities in case they cannot resolve the crisis immediately.

Keris Myrick, M.S., M.B.A., discussed the importance of including in mental health crisis response peer supporters and others who have lived experience with mental illness. She is vice president of partnerships at Inseparable, a nationwide coalition of mental health advocates.

“Peer supporters reduce the use of very expensive services, such as hospitalization and emergency department [visits], not because we tell people not to go, but because of the support that we provide,” Myrick said. She added that peer supporters help families feel far more confident in their understanding of mental illness and how to help their loved ones.

The trouble is that peer support is often shrouded in mystery, Myrick noted.

“A lot of times people don’t understand peer support, especially if they have not done it before or they have not been trained in it. A lot of people who supervise peers are not people who are trained in peer support themselves,” Myrick said. “[But] peer supporters aren’t running around doing whatever they want. There are guidelines, standards, and national core competencies for them.” ■