Overcoming Inadequate Crisis Response: Why 988 is an Opportunity

Note: This article was originally published in the Spring 2021 Advocate as “988: An Opportunity to Change Crisis Response.”

A mental health crisis should not end in tragedy or trauma. In January, 52-year-old Patrick Warren, Sr. was shot by police during a mental health check. In February, police in Rochester, N.Y., handcuffed and pepper-sprayed a 9-year-old girl experiencing a mental health crisis. Last September, police in Salt Lake City shot and wounded a 13-year-old boy with autism spectrum disorder after his mother called 911 for help, saying he was having a “mental breakdown.”

No matter how many times we hear about a person in a mental health crisis being hurt or killed in an encounter with law enforcement, we feel shocked and horrified. The victims and their families might not have known about NAMI, but they are part of our “family” of everyone affected by mental illness.

The grief of these avoidable tragedies is even more poignant because there is a simple solution: providing a mental health response to mental health crises.

The Cost of Inadequate Care

Millions of people who experience mental health, substance use and suicidal crises each year do not get the help they need. The cost in anguish, suffering and death is astonishing:

Factors for an Effective Crisis System

We need to demand that people experiencing mental health, substance use and suicidal crises are:

• Treated with respect and dignity
• Kept out of the justice system
• Given the best treatment possible with health equity in mind
• Engaged in services and supports in the community
• Responded to compassionately regardless of who they are or where they live

Last year, we took a significant step in a positive direction with the enactment of the National Suicide Hotline Designation Act, establishing 988 as a nationwide number for suicide prevention and mental health crises, which will be available across the country by July 2022. The calls will be routed through the National Suicide Prevention Lifeline to local crisis call centers.

The act also declared that states may impose a fee on phone bills to support and fund crisis call center staffing and crisis outreach and stabilization services. This reflects the growing understanding that an effective crisis system should have at least three basic components: crisis call center hubs, mobile crisis teams and crisis stabilization services.

Crisis Call Center Hubs

Crisis centers should serve as central hubs and be staffed at levels to answer calls quickly, including by text and chat. Staff should be well-trained and experienced in responding to a wide range of mental health, substance use and suicidal crises.

Crisis call centers should be able to connect people to services, including dispatching mobile crisis teams. Some states are already doing this, such as Georgia with its statewide Crisis & Access Line, through which experienced clinicians can provide crisis counseling and conduct mental health assessments with callers. They can book urgent outpatient mental health appointments and are able to dispatch mobile crisis teams when needed. This capacity is a model of what should be available everywhere.

Mobile Crisis Teams

Some programs estimate that about 1 in 10 behavioral health crisis calls will require the dispatch of a mobile crisis team to provide on-site de-escalation and connection to crisis stabilization or other services. Communities are increasingly looking at having mobile crisis teams staffed by mental health professionals, including peers. In several states, successful mental health mobile crisis team models rely on law enforcement for support in less than 5% of their calls.

Connecticut and other states also have networks of children’s mobile crisis teams. As the tragic police responses in Rochester and Salt Lake City demonstrated, specialized children’s mobile crisis teams are desperately needed across the country.

Crisis Stabilization Services

The new standard in mental health crisis response is recovery-focused, trauma-informed, “living room-like” programs that provide short-term observation and stabilization. This also includes a “warm hand-off” to follow-up care, whether it is peer supports and outpatient services, or more intensive services like hospitalization or crisis residential care.

In states like Arizona, crisis stabilization includes a commitment to integrating peer supports and engaging families, addressing co-occurring substance use (they do not turn down people who are intoxicated or high), medical conditions and developmental disabilities, and nurturing a culture of hope and safety. They also work to coordinate with primary care, justice, housing, child welfare, intellectual and developmental disabilities supports, elder affairs and other services. Finally, they have a “no wrong door” approach that allows public safety officers to drop someone off and leave within minutes.

How This System Might Look in a Real-Life Situation

When my son experienced a psychotic episode a few years ago, a friend called a mental health crisis line for me. Thankfully, the crisis line dispatched a mobile crisis team that included CIT-trained police officers, but they took a back seat to the mental health clinicians, who quickly established a rapport with my son. The lead clinician assessed the situation, calmly approached my son and said, “I’m hearing you haven’t slept for days and things are getting kind of intense. I’ll bet you’d really like to get a good night’s sleep. Do I have that right?”

My son replied, “Yeah, my head hurts, and I just want to sleep, but I can’t.” The clinician said, “I know a doctor who will definitely be able to help you get to sleep and help your head stop hurting, if you’re willing to go with me to the hospital. Does that sound okay to you?” Remarkably, my son said, “Yeah, I’ll go. I want my head to stop hurting.”

The next step in his journey was a crisis stabilization unit, which, after 23 hours, moved him into a psychiatric inpatient unit because he was still delusional and paranoid.

While I cannot say the hospitalization and the rest of his journey went well, the immediate crisis response did. This is what we want across the country, because under different circumstances, my son could easily have ended up in jail or, worse, shot and killed.

Imagine if Patrick Warren, Sr., Walter Wallace, Jr., the young girl in Rochester, or the young boy in Salt Lake City had this kind of response when they were in distress. Imagine if this type of 988 crisis response system had been there when someone you love needed it.

It doesn’t have to be a faint hope; together, we can make this a reality. And there is a role for everyone in the NAMI Alliance.

How You Can Get Involved

To realize this vision of a 988 crisis response system, state legislatures should enact user fees on phone bills, similar to existing fees that support 911 police, fire and ambulance dispatch. As the 988 act outlined, these fees can be used to develop and maintain the capacity of crisis call centers and to help support services, such as mobile crisis teams and crisis stabilization services, with a stable source of revenue that can supplement other funding, like Medicaid and state general funds.

Our NAMI State Organizations and Affiliates can play an important role by:

• Connecting with partners and champions in the legislature
• Encouraging legislators to sign on as bill co-sponsors
• Sharing stories of what works, what doesn’t and the need for a 988 crisis system with call center hubs, mobile crisis teams and crisis stabilization programs

NAMI members have a unique opportunity to speak up and demand a mental health response to mental health crises. (See below for ways you can help.)

After decades of advocacy, we are at a turning point. There is growing recognition of the inherent injustice of a law enforcement response to mental health crises and, importantly, there are real vehicles for change to provide the compassionate response people with mental illness deserve.

Angela Kimball is National Director, Advocacy and Public Policy at NAMI

Your story about the care you received during a crisis call can help NAMI share real-life experiences that illustrate how crisis services can hurt or help. Your story can make a difference. Share yours now at nami.org/crisisstories. Want to write to your elected officials? Visit nami.org/takeaction.