On 988
I have worked in crisis care and suicide support for most of my career. Recently, I have seen an outpouring of posts discouraging people from calling 988, and I understand why. I am concerned about the amount of people in the crisis field who are upset by the community’s response. We have been getting clear messages that the carceral logics implemented as a part of crisis care are a problem for our communities. Liberation HAS to be a component of our work. We have to listen to people who have been harmed by our institutions. We need care, not cops. If we proceed like this, communities we serve will be asking for alternatives to crisis care along with alternatives to policing.
That said, I don’t actually recommend AGAINST using 988. I DO recommend understanding what the service is and what will happen when you call.
What it is…
988 designates the suicide prevention lifeline as a the national mental health crisis line. You can reach it by dialing 988. The service isn’t entirely new, but it is new that states are responsible for delivering the service and that the network is expanded to all crisis instead of a focus on suicide. First, the National Suicide Hotline Designation Act of 2019 required the FCC to designate a hotline. In the Hotline Designation Act, the FCC was required to designate 988 as the universal telephone number for a national suicide prevention and mental health crisis hotline. Vibrant Emotional Health won the SAMHSA grant to be the administrator of 988. Since the states have to administer it, the act also gave them the ability to collect a fee for providing 988 related services. The FCC must submit an annual report on state administration of these fees, and they can’t be used for anything else. The Department of Health and Human Services (HHS) and the Department of Veterans Affairs had to report together on how to operationalize 988 across the country, and HHS has to develop a strategy to provide access to competent, specialized services for high-risk populations such as lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth; minorities; and rural individuals. Later, text to 988 was approved. Currently, there is no plan for peer support to be independently accessed by 988, meaning that calling 988 for peer support will require a clinical screening/assessment by counselors.
Vibrant says that 988, when properly resourced will be able to…
Connect a person in a mental health crisis to a trained counselor who can address their immediate needs and help connect them to ongoing care
Reduce health care spending with more cost-effective early intervention
Reduce use of law enforcement, public health, and other safety resources
Meet the growing need for crisis intervention at scale
Help end stigma toward those seeking or accessing mental healthcare
The service…
988 uses The Safety Assessment Model. You will be asked:
Are you thinking of suicide?
Have you thought about suicide in the last two months?
Have you ever attempted to kill yourself?
The suicide assessment used is based on the Interpersonal Theory of Suicide. You will be asked about Desire, Intent, Capability, and Buffers. The assumption of this assessment is that suicidal desire with intent and acquired capability is associated with increased risk for suicide.
Desire - expression of psychological pain, feeling intolerably alone, trapped and a burden to others. It is often driven by hopelessness.
Intent - indicates the probability of enactment and encompasses certain factors, including an attempt in progress (the clearest indicator), an imminent plan to hurt self/others, preparatory behaviors and intent to die.
Capability - relates to the fearlessness of taking action that could be self-harming, a sense of competence, availability of means, specificity of plan, and preparation of attempt.
Buffers - such as immediate supports, planning for the future, engagement with the crisis counselor, and core values can tip the scale of ambivalence more toward the wish to live.
The Safety Assessment is divided into three general phases:
CONNECTION and IMMEDIATE SAFETY.
Encourages the crisis counselor to LISTEN to the individual's narrative, CLARIFY any missing pieces of information, and develop a PLAN for safety.
Involves WRAPPING UP the conversation and offering the caller FOLLOW-UP as needed.
How the network works…
When you call 988, your phone’s area code routes you to your state’s 988 provider. Every state was required to resource their 988 services to meet certain delivery standards. Back up centers pick up calls that have to wait an extended period of time. Every state is resourcing 988 differently. Text and chat crisis services have historically been extremely under-resourced across the country, and Vibrant has employed Crisis Text Line to be the provider of the back up center. A quick google about problems with crisis text line will give you ideas about potential concerns with their work.
This is where everything gets complicated. Each center trains staff differently. The more training and experience a person has, the less likely they are to use coercive and carceral interventions, if they have values against that. Not everyone does have values against forced treatment or coercion. Even fewer people know how to act within those values when a situation feels very unsafe to them. The network says that crisis care is supposed to use the least restrictive intervention, but it still recommends involuntary interventions in the moment and the use of assessment tools that are notoriously unreliable at predicting risk to make those determinations. There is not good evidence that either suicide assessment or forced hospitalization are reliable ways to predict/prevent suicide.
It is pretty common for people to get involved in suicide prevention because they are loss survivors. Sometimes that means that they are willing to try to prevent suicide at all costs. This mentality is what leads to carceral logics and “interventions” like active/emergency rescue (911/Welfare Checks), using geolocation, mental health holds, etc.
“Carceral logics” refers to the variety of ways our bodies, minds, and actions have been shaped by the idea and practices of imprisonment. The idea that we need to act against someone’s wishes to send “mental health support” particularly in the form of 911 intervention that could expose people to risks like death, jail, etc., takes the perspective that people in crisis cannot make decisions for themselves. This fundamental mistrust of people accessing crisis services is where the problems come in.
The emergence of 988 could be an opportunity to define crisis services as a unique, supportive service. People already know 911. If that's what they wanted, they would call 911. Replicating that service and calling it suicide prevention is a colossal waste of all of our money and time, and creates yet another barrier between people having their worst day and the support they need/want.
The feds are looking into the feasibility of geolocation services (beyond routing based on your area code). This is extremely expensive, and is based on carceral logics I mentioned above. Geolocation is always already coercive. Tracking people’s location without consent assumes that the service may send emergency services without your consent. It puts us on the wrong side of history here. Crisis services can do better than this. 988 can’t claim to really care about reducing the “use of law enforcement, public health, and other safety resources” and also require the use of things like non-consensual welfare checks, referrals to services that use involuntary treatment without discussing that the treatment is used, etc.
Deciding to call…
There are a million reasons to call for crisis support. All of them are valid. Many communities do not have alternative resources, or those alternative resources (like some warmlines) will default to a referral to 988 when there is “risk.” They also likely don’t have the funding or capacity to answer the number of live calls that 988 does. We can’t just divert everyone there. Other resources also have probably already failed you if you are experiencing a crisis. They may not be accessible, or may not provide what you need. It is helpful to remember that this resource is primarily going to be an emotional support. If what you need is practical assistance, you might be able to get it through a referral, but there may be other ways to get that need met. It is also possible that the resource you need doesn’t exist (at least not through a formal mechanism like non profit or government support). It might exist only through community or mutual aid. I recommend that everyone spend some time doing research about their local centers, their practices, and doing the same with the back up centers.
Protecting yourself in crisis…
Before a crisis: build your community. Make sure you know who you can call to get you through a hard time. Share with them what things help and what things hurt. Make sure you understand what each other needs and wants in crisis, and what is off the table. This is the single best strategy because it keeps you from needing to call a stranger for support. It is also the hardest strategy and may not be possible for everyone all the time.
Make sure 988 is the right call for you. If you have a medical emergency you want attention for, that is the purpose of 911. 211 can help with other resources. Knowing your community resources in advance can help with this decision, too.
You do not have to use a traceable phone. You can use an internet (like Google voice) or burner phone to call. You can also use a VPN to make yourself more difficult to find.
You don’t have to tell the whole or even partial truth. Disclose only details you want to disclose, and remember, you don’t have to tell the truth, but not telling the truth about some things may make it harder to get the support you are seeking.
Know your rights. Create a psychiatric advance directive and file it at all the hospitals in your area. If you are taken to a hospital involuntarily, remember that you generally have a right to refuse medication and other treatments, ask for an advocate, and speak to your providers and other supports. Going into a hospital or crisis unit involuntarily doesn’t mean that everything there is involuntary.
Reduce the potential harms of law enforcement interactions. If you think 911 may come to your location, clean up any drugs or other illegal things that would be visible. Put your dog in another room. Make sure there are no weapons. If you or others have an outstanding warrant or could be detained for another reason, you may want to leave that location. Meeting law enforcement outside of your home may be easier than having them enter. If you are deaf or you do not speak English, it would be helpful to have someone there who can translate for you.
The Bottom Line for Me…
The world is already hard enough to navigate. It is untenable that we have to find ways to reduce potential harms with a service that is supposed to help. The reality is that the best way to protect ourselves is to protect each other. Take care of each other. Build the world you want to live in. The only way we survive is together.
