Too often, people with mental illness do not receive the support they need when experiencing a mental health crisis. Instead, people in crisis often come into contact with law enforcement rather than someone trained to help them through whatever they are struggling with. This week, a look at 988 systems. What are they, why they are needed, and what the states and the country are doing about it.
What are N11 Codes?
N11 codes are numbers individuals within countries can use to access special services provided within the country. These codes are usually three digits. In the United States, the FCC controls approval and administration of the available N11 codes available within the country. Currently, the FCC recognizes and has functional 211, 311, 511, 711, 811, and 911. Here are the assignments, reservations, and traditional usage for the active codes:
- 211: Community Information and Referral Services
- 311: Non-Emergency Police and Other Governmental Services
- 411: Local Directory Assistance
- 511: Traffic and Transportation Information (US); Provision of Weather and Traveller Information Services (Canada)
- 611: Repair Service
- 711: Telecommunications Relay Service (TRS)
- 811: Access to One Call Services to Protect Pipeline and Utilities from Excavation Damage (US); Non-Urgent Health Teletriage Services (Canada)
- 911: Emergency
What are 988 Systems?
A 988 system is a new N11 code aimed at getting people more specialized help related to a crisis they may be going through. When people are struggling, currently they can call one of two N11 codes to get help: 211, for non-emergencies and a need to find and access community resources (think food banks and shelters) and 911, for all emergencies (think break ins, fires, and emergencies related to mental health). According to the National Institute of Mental Health, suicide rates have been steadily increasing in the United States. Suicide is the second leading cause of death in the United States for people ages 10 – 24 years old.
Having police and 911 dispatchers in charge of handling of mental health crisis has at times resulted in dangerous, traumatizing, and even deadly outcomes. Despite best efforts, police and 911 dispatchers usually have not received adequate training to re-regulate someone in emotional distress or suicidal crisis. Additionally, it is not always necessary or appropriate to have law enforcement respond to a situation where someone is having a mental health crisis.
According to Vibrant Emotional Health, Mental Health America, and data provided by Lifeline call centers, around 98% of Lifeline calls answered by trained staff do not require an emergency (911) response. For the 2% of the calls which do require an emergency response, they reported that 60% of the time, the caller agrees emergency services are needed/desired as part of the desired help response.
The purpose of 988 systems is to have mental health crisis calls handled by people with specific training first, and then, if necessary and appropriate, involve 911 emergency services. Dialing 988 will connect individuals to staff trained to answer calls related to mental health crisis (including risk for suicide) and substance use related emergencies. Centers handling 988 calls also employ staff specifically trained to help veterans, LGBTQ+ individuals, and other underserved groups with challenges that may specifically impact them.
What is the FCC doing when it comes to implementing a 988 System?
The National Suicide Hotline Designation Act required the FCC to approve a new N11 code (three-digit dialing system) in June of this year. The new code needs to allow people to reach the National Suicide Prevention Lifeline by dialing 988. Starting in July 16, 2022, if someone in a mental health crisis would rather contact a helpline focused on mental health crises instead of 911, they can dial 988 to receive that support.
When speaking about the value of this type of change, Lindsay Sandoval, media manager for the Colorado Office of Behavioral Health, stated, "Anyone experiencing an emotional or mental health crisis can call or text the crisis hotline 24/7/365 to reach a trained professional. It’s free and confidential. Callers can choose to speak to someone who has gone through a similar experience — i.e. a peer specialist — if that is their preference."
Currently, the major telecommunications companies are making changes to their infrastructure to allow individuals to access the National Suicide Prevention Lifeline by dialing 988 as well as still allowing for their original number (800-273-8255) to connect individuals to the line. The FCC is currently still attempting to define how text messages to the 988 system will be handled.
Vibrant Emotional Health and the Lifeline have put together a grant program for states to receive to help with the planning for the implementation of 988 within their state. The funding page states, "Vibrant, through a special funding opportunity, seeks to collaborate with public health and mental health agencies in all 50 states and the District of Columbia to plan for the development of appropriate infrastructure and operations necessary for the full implementation of 988." Any grants awarded should be used for developing "clear roadmaps" depicting how states will address foundational coordination, capacity, funding, and communication strategies for launching 988 on or before July 16, 2022 or for planning the long-term improvement of in-state answer rates for 988 calls.
What legislation is being proposed about 988 Systems?
In 2020, the United States took a significant step towards a nationally supported 988 system with the enactment of the National Suicide Hotline Designation Act. The purpose of this legislation is to help ensure states have the flexibility to strengthen local crisis call centers and save lives. The National Suicide Hotline Designation Act directed the FCC to designate a N11 code of 9-8-8 to route through the National Suicide Prevention Lifeline. The bill also requires that the hotline allow veterans to press “1” after dialing 9-8-8 to be routed automatically to the Veterans Crisis Line for veteran-specific mental health support.
The legislation also allows states to assess a fee on cell phone bills for calls made to 988 to allow a method recover the costs of the system and the associated services provided to individuals in crisis. Most states have a similar fee on cell phone bills that supports 911 services. This is an important element to the legislation, as people believe expanded access, scope, and visibility to this resource will create greater demand, and thus need much more funding. Many National Alliance on Mental Illness (NAMI) organizations are working with state policymakers to implement state legislation outlining the crisis services that will be available statewide and implement the cell phone fees.
In the last two years, there have been 74 bills proposed across the nation having to do with "988 Systems" and The National Suicide Hotline Designation Act. BillTrack50 mobile app users can access this stakeholder page using the following mobile access code: MIJSIU.
Alabama passed legislation establishing the Study Commission on the 9-8-8 Comprehensive Behavioral Health Crisis Communication System. The Commission must study and provide recommendations for the implementation of the 988 system to enhance and expand behavioral health crisis response and suicide prevention services. The Commision will be tasked with considering the following:
- How twenty-four seven statewide coverage for 988 calls, chats, and texts could be achieved in each county.
- Strategies for identifying and supporting investment in new technology to triage calls and link individuals to follow-up care.
- Funding to boost the financial stability and sustainability of call centers and evidence-based crisis services in every county, so that people experiencing behavioral health crises can receive higher quality support.
- Requirements for compliance with the National Suicide Prevention Lifeline Requirements and Best Practices Guidelines for Operational and Clinical Standards.
- Ways for call centers to maintain local resource and referral listings and ensure linkages to local community crisis services
Nebraska passed legislation to Create the Mental Health Crisis Hotline Task Force. The task force must develop an implementation plan for Nebraska to integrate and utilize the 988 mental health crisis hotline established pursuant to the federal National Suicide Hotline Designation Act of 2020. It also must identify a method to integrate local mental health crisis hotlines to ensure each individual who accesses a local mental health crisis hotline is connected to a qualified mental or behavioral health professional regardless of the time, date, or number of individuals trying to simultaneously access a local mental health crisis hotline. Finally, the task force is responsible for the plan for staffing a statewide mental health crisis hotline and coordinating with local mental health authorities.
Other states like Colorado, Idaho, Oregon, Utah passed legislation related to the federal mandate that all states implement the 988 crisis response service in order to comply with federal regulations. Some of these bills have language like requiring states "improve quality and access to behavioral health crisis services, especially for underserved populations and rural areas of the state" or reducing "stigma surrounding suicide, mental health, and substance use conditions".
Many other states proposed and passed legislation related to funding this service. Illinois proposed legislation that would create a statewide 9-8-8 trust fund. Their bill states, "the moneys in the fund shall be used by the department of human services for the purposes of establishing and maintaining a statewide 9-8-8 suicide prevention and mental health crisis system pursuant to the National Suicide Hotline Designation Act 2020." Michigan also proposed legislation aimed at creating the 9-8-8 suicide prevention and mental health crisis hotline fund. This bill provides for the imposition and collection of certain charges and outlines the powers and duties of certain state governmental officers and entities related to the fund.
Also of note is the proposed Behavioral Health Crisis Services Expansion Act. This national legislation directs the Department of Health and Human Services (HHS) to define national standards for behavioral health crisis care, expand coverage of mental health services for patients, and provide resources to communities expanding or implementing new behavioral health crisis services to meet local needs in an attempt to create a continuum of crisis services across the country.
Conclusion
Crisis care services are much more impactful when they include and are informed by individuals with diverse backgrounds and are trained to respond in an empowering and culturally appropriate manner. People in crisis often do not need to go jail, but instead need medical attention. 988 systems allow us the opportunity to invest in resources which allow for individuals in need to receive useful support like mental health evaluation and other resources (like crisis stabilization centers, crisis beds, or peer respite centers). Overall, I am very excited this legislation passed and we as a nation are starting to focus on mental health and the best way to support people in crisis.
Cover Photo by Dustin Belt on Unsplash
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