Reframing a Mental Health Crisis Through 988
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When 988 goes live on July 16, a tsunami-size sea change will be felt in the mental health community. The new three-digit number for suicide prevention and mental health crisis services will shift the country away from calling 911 and triggering a police response.
The new number, which replaces the National Suicide Prevention Lifeline (NSPL), 1-800-273-8255, takes law enforcement out of the equation. Instead, a counselor on the phone or a mobile crisis unit arrives on the scene to help de-escalate an individual in the throes of a mental health episode. The objective is to divert the individual from incarceration or hospitalization and navigate them toward mental health community services.
It’s not a panacea and it still might turn into a 911 call if safety issues become a factor. But by shifting calls to 988, mental health advocates and professionals hope to change the narrative, rebalance the scales, and decriminalize the illness.
Launching 988
Although the Federal Communications Commission adopted the 988 rules in 2020, achieving such lofty goals won’t be easy, said advocates and managers on the frontlines of the transition.
In California, there are 13 crisis centers certified by the Lifeline to respond to 988 calls. When calls come into the federally funded national hotline, those calls are redirected to the appropriate local network. Santa Clara and Kern counties are the only two counties in the state that operate crisis call centers. The other 11 crisis centers are operated by nonprofits.
Santa Clara County Suicide and Crisis Services Manager Lan Nguyen said our county is ahead of other crisis centers in planning and preparation for 988 due to available resources.
“We have been talking for close to two years about strategies in the county,” he said.
There are 15 cities in the county, but there are only 13 cities with their own 911 dispatch operations. Los Gatos-Monte Sereno police calls and Saratoga police calls are dispatched through the Sheriff’s Department, as are calls from unincorporated parts of the county.
“We had to meet with the county’s 911 operation managers and the 13 cities’ 911 operation managers to provide training and implementation, as well as planning for collaboration with all local 911 agencies,” Nguyen said.
California is our country’s most populous state with close to 40 million people, and 1 out of 8 calls to the Lifeline originate here, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the agency that provides federal funding for 988. The volume increased by 67% between 2016–2020 to more than 304,000 calls. SAMHSA estimates that number will skyrocket by 300% to more than 899,000 calls once 988 is activated.
Nguyen said he will have a much better idea of call volume trends and the impact on the crisis center’s workforce and funding needs about six months into the transition. He said the San Jose Police Department averages about 1,500–2,000 calls per month that could be deemed mental health-related calls, noting that the city of San Jose serves half of the county’s population of two million people.
“We probably could use that number and multiply by two the countywide number,” he said. “In addition, if we add the county 911/sheriff calls and individuals that call 988 directly, the total number of calls will be higher.”
In Santa Clara County, the number of crisis center calls received in 2021 directly and rerouted from the national hotline totaled 52,429. If that volume doubles, it will mean more than 100,000 calls being fielded locally through 988.
The fiscal 2021-year budget for Suicide and Crisis Services was about $1.3 million, through a combination of funding agencies. Last year, the California Department of Health Care Services announced $20 million in funding to support the 13 Lifeline agencies. These one-time funds must be spent by December 2022 for tech
upgrades, training, and a shared platform. Remaining funds can then be shared and applied toward increased staffing. Another $8 million was recently awarded by the state, with another $14.4 million coming in through SAMSHA in January 2023 earmarked for staffing.
Mobile Crisis Teams
For 988 to shift mental health crisis calls away from law enforcement, the use of mobile crisis teams will be integral. Even though 988 operators will be working to de-escalate situations on the phone, they will also be relying on the county’s mobile response teams to assess mental health crises in the field.
Santa Clara County has three mobile response team operations that will be under the 988 umbrella. The Mobile Crisis Response Team (MCRT) travels with two clinicians and a law enforcement member who is CIT (Crisis intervention Trained). This team responds to calls throughout the county. MCRT receives $3.5 million in annual funding from the county and services adults in mental health crisis.
The Mobile Response Stabilization Service Team (MRSS) also travels with master-level clinicians and a family specialist with lived experience. MRSS teams are contracted through Pacific Clinics (formerly known as Uplift). Pacific Clinics is a 24/7 operation throughout the county and focuses on youth and young adults ages 18–21. The county recently received a $2 million grant from the California Department of Health Care Services that enabled the units to expand into North and South counties and the West Valley.
The third mobile team in the system is Trusted Response Urgent Support Team (TRUST) which services all age groups. The TRUST team will include a First Aid professional, crisis intervention worker, and a peer outreach specialist. TRUST is expected to launch in the fall. TRUST received $7 million in funding through the Mental Health Services Act (MHSA).
Bruce Copley, County Director of Access and Unplanned Services in the Behavioral Health Services Department, oversees the suicide and crisis center. He said, “The goal of Community Crisis Response is to provide immediate services that can reduce the likelihood of needing access to Emergency Psychiatric Services and allow the individual to remain in the community with wraparound services.”
Sandra Hernandez, LCSW, Behavioral Health Division Director, Mobile Crisis Response for Adults and Older Adults, oversees a number of crisis services including MCRT, Psychiatric Emergency Response Team (PERT), and In-Home Outreach Response Team (IHOT). The IHOT program will also come under the 988 umbrella.
The IHOT program pertains to individuals with multiple emergency psychiatric service calls per month, or frequent jail bookings. The county wants to find a way to connect them with support services, she said.
Hernandez said the one program that will remain with 911 is PERT. This is a joint- response model that sends a CIT-trained officer and licensed clinician out on the call.
This is where 911 and 988 become more nuanced, Hernandez said. The 911 PERT calls are more acute. It might be a suicide attempt or a school where a weapon is involved. Safety issues are greater and time might be a factor. Still, she said the goal is the same: de-escalate the crisis and reduce the number of 5150s, or 72-hour psychiatric holds.
Workforce Build-Out
Even as the county prepares for the 988 rollout, success will be contingent on a robust referral and wrapround support services system. Each call will require a warm handoff from the operator or counselor on the line to a mental health referral, or it may involve a mobile response team rolling to the call.
John Costa, who is part of the County Law Enforcement Liaison team, said, “It’s about giving the people that do the work as many tools as possible. The more resources we have, the more we can make a custom fit for the situations we are in.”
Yet the county is suffering from a behavioral health staffing shortage and a dearth of supportive services from detox centers to residential treatment facilities to supportive housing. None of this is lost on Supervisor Susan Ellenberg.
“There will be a whole range of needs,” Supervisor Ellenberg said. “We need to prioritize workforce development over the next years and be creative and look at our employment requirements and add peer support specialists that would have an immediate impact. We also need to build out our infrastructure to support these services.” She acknowledges the process won’t happen overnight, but it can be pushed forward. “We can find ways to incentivize college students to enter the field by offering loan forgiveness and better starting pay when they graduate,” she said.
Supervisor Joe Simitian said that a mental health navigation system that pairs with 988 will help facilitate the warm handoff process from call center operators to service providers.
According to Hernandez, the navigator program is coming along, “but my biggest concern is where are we going to find the folks for these programs. We need everybody.”
The Future Is Now
Since mid-May, the Behavioral Health Services Department and the Suicide and Crisis Center have been quietly testing the 988 system. Hernandez said calls coming into the community service line have been going directly to 988. Operators are then passing the calls on to referrals or the crisis mobile unit MCRT.
The process has helped identify gaps and glitches in service and where to smooth over potential calls coming to 911 that need to be diverted to 988, Hernandez said.
One piece of the 988 system that will remain the same is the text feature. Individuals in crisis will be able to text the word “RENEW” to 741741 to receive immediate support from the Crisis Text Line, Nguyen said.
Nguyen, who has worked in the mental health sector since 1992 with various nonprofits including AACI, Bill Wilson Center, and Gardner Family Care Foundation, said, “I believe 988 will change the way most suicide and crisis centers function.”
To learn more about 988 and NAMI Advocacy go to nami.org/988
