An epic challenge: Running the 988 crisis line as the US suicide rate rises
If you or someone you know needs mental health resources and support, please call, text, or chat with the 988 Suicide & Crisis Lifeline or visit 988lifeline.org for 24/7 access to free and confidential services.
Tiffany Jones sits in front of her computer at home and mentally prepares herself for her upcoming shift as a 988 Suicide & Crisis Lifeline operator.
She’s been a call-taker for nearly four years, first as a full-time staffer at the Arkansas Crisis Center and now as a volunteer remotely in Redlands, California.
Jones lifts the delicate headset over her ears and lowers the microphone to her mouth. She is ready for her first call.
“This is the 988 Crisis Line, this is Tiffany. I’m so glad you called today.”
One person calls to ask about housing resources. Another one calls after having a panic attack about what to make for dinner that night. Jones listens intently to everyone’s story with compassion and without judgment.
Some calls have stuck with her over the years – a caller struggling with alcohol abuse who contemplated suicide after relapsing and seeking medical help. Instead of receiving care, the person was met with contempt and disdain. “As soon as you sober up, you’re out of here,” emergency room nurses told the caller.
Another caller contemplating suicide had been waiting on the line for a few minutes before Jones was able to pick up the call. “I could have killed myself by now,” the caller said. “The recording kept telling me my life matters, but does it?”
While the 988 Lifeline has likely helped millions of people in crisis since its launch in July 2022, mental health experts say the nationwide public health program is far from perfect. The lack of stable funding, lack of awareness and the absence of mental health resources have prevented the lifeline from realizing its full potential, experts say.
“It’s an entry point for people who haven’t had access before, but it’s ultimately still limited,” said Angeleena Francis, a licensed mental health counselor and executive director of AMFM Healthcare, a mental health treatment center in northern Virginia, California and Washington.
The suicide rate among Americans has reached its highest point since 1941, preliminary data for 2022 shows. Nearly 50,000 people died by suicide in 2022, the Centers for Disease and Control said, an increase of 2.6% since 2021.
And as the nation approaches the holiday season – a time that often intensifies feelings of despair and loneliness – mental health experts say it's vital to assess the effectiveness of the 988 line and begin taking steps to improve it. We need people and resources on the receiving end for people in need, Francis said.
“988 isn’t the solution to the mental health epidemic,” she said. “If there isn’t something on the other side to support these individuals, then we are still failing as a country in addressing mental health needs.”
Funding the crisis line
The federal government has invested nearly $1 billion since 2022 to transition and expand the National Suicide & Crisis Lifeline first established in 2005 into the new 988 line, which offers free and confidential support for people in distress over call, text, or chat through a three-digit number that's easy to memorize.
The new program also launched special services for LGBTQ+ callers and those who speak Spanish.
This federal appropriation came with the caveat that states would also organize funding to help support the line. That plan hasn't played out evenly across the country. Several states have organized stable funding through telecommunication fees, which is how most states fund 911, while under half have created or are in the process of creating legislation to fund the 988 line.
But at least half of the states have no pending legislation to financially support the line, according to the National Alliance on Mental Illness, or NAMI. The nonprofit's chief advocacy officer Hannah Wesolowski sees that as a major stumbling block.
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Call centers across the country depend on a hodgepodge of financial support to cover the bills, a combination of state and local funding and grants. The boost in federal aid has helped get programs up and running, but call centers say they need more to support the growing line.
Perhaps the only thing in abundance in this situation is the steady stream of incoming calls. They keep coming, the centers say.
In 2022, the 988 line received 2.5 million calls. It's now on track to receive 6.5 million calls by the end of the year, according to Vibrant Emotional Health, a mental health organization contracted by the Substance Abuse and Mental Health Services Administration to administer the 988 line.
Rebecca Brubaker, executive director of the Arkansas Crisis Center, said her center is forced to rely on volunteers to cover all the incoming calls. Jamie Brill, call center director for Community Crisis Services Inc. in Hyattsville, Maryland, said call-takers frequently burn out quickly given the high volume and often emotionally difficult content of calls, which leads to high turnover. Given the growing volume of calls, Brill and Brubaker said they need additional funding to hire and retain call-takers and decrease reliance on volunteers.
Wesolowski said the most reliable source of state funding is through a telecommunications fee that would appear on Americans’ mobile phone bills every month.
Even though all 50 states have a 911 fee, which no one questions, most states haven’t embraced the 988 fee. Only eight states have implemented it and the automatic cost tacked onto phone bills ranges from about 12 to 60 cents per month, according to NAMI.
Politicians don’t want to be associated with requesting a telecommunications fee for 988 services because it’s seen as a tax, Wesolowski said. While some states have other methods of funding the program, she said, they’re more susceptible to political changes. She and others who support the toll-free line say a 988 fee is the best source for reliable support.
In reflecting on the success of the call centers since 2022, Brill said, “The boost in (federal) funding has been transformative." But with that money comes increasing expectations and it’s been hard to keep up.
Building awareness of the 988 hotline
Although calls to the crisis line continue to grow, only 13% of Americans were familiar with the 988 line by a May 2023 survey from The Pew Charitable Trusts.
Federal, state and local health officials have launched awareness campaigns and held events to spread the word about the nationwide three-digit number available to everyone experiencing suicidal thoughts or other mental health crises.
But experts say more organizations and leaders need to spread awareness.
Jonathan Purtle, associate professor at New York University’s School of Global Public Health, said state and local politicians could be a good avenue for educating the public. However, a study he authored, which was published in October, found that politicians, regardless of party, had done little to promote the line since it first launched, except during September for Suicide Prevention Month.
Even those legislators who promoted the line did not explicitly encourage people to use 988 as a lifeline, the study found.
Experts said the lack of public awareness means not only do people have limited knowledge that the line exists but they also have minimal information about how it’s used. Simply put, people – and loved ones of people – experiencing a mental health crisis don’t know when it's appropriate to call 988.
For emergency services, most people know when it's appropriate to call 911 for help. But since 988 is just a year old, there isn’t that same cultural awareness, mental health professionals said.
"People are becoming more aware of 988 as a concept, but not to the point of what situations would you call 988 and what kind of support do you get," said Francis, from AMFM Healthcare. Spreading awareness also means educating people on how the line can best help them.
She noted that the best time to use 988 is when a person is in crisis or they’d like to learn more about available mental health resources in their area. Incoming calls are directed to local call centers based on a caller's area code. Call-takers go through a 32-hour training provided by SAMHSA and Vibrant Emotional Health in addition to local training, depending on their call center, to learn how to de-escalate a crisis and direct callers to more help.
Lack of mental health services
The goal of 988 call-takers is to de-escalate a crisis and direct callers to the appropriate mental health resources. But that’s only effective when there is accessible support for the person on the other side of the call.
Callers are often confronted by the harsh realities of the mental health care system: A shortage of providers, long wait times and a lack of affordable options covered by public and private insurance or available to those who are uninsured.
These systemic barriers to mental health resources can undermine the credibility of 988 even though the lifeline or the people behind it have nothing to do with those barriers, mental health experts say.
“It can be really disheartening,” Francis said. “You’re already in a place of isolation and loneliness and hopelessness. It can feel disempowering.”
The consequence is that people who call the line often don't feel encouraged to call again when they are in need. An October survey of nearly 5,000 respondents found that most people who called 988 during an episode of psychological distress were not willing to use the lifeline again.
Out of 388 participants who reported serious psychological distress, only 23 reported using the 988 lifeline, according to the research published in JAMA Network Open. When asked if they would use 988 in the future, six said they were very likely to use it again.
"More and more people are seeking mental health services in a formalized way. ... It's important to ensure that the workforce is there to meet the need," said the study's co-author Michael Lindsey, dean and Paulette Goddard professor of social work at the New York University Silver School of Social Work.
Jones, the 988 operator in California, said she receives many repeat callers who say they have been unable to pursue long-term mental health care because they can't afford it.
She can't change the system overnight but she's trying. While volunteering for the 988 line, she's also pursuing a doctorate in clinical psychology. Jones wishes she could do more to help her callers but the best she can do right now is to answer the phone and listen.
Send tips to Adrianna Rodriguez: [email protected].
Health and patient safety coverage at USA TODAY is made possible, in part, by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.
This article originally appeared on USA TODAY: Why suicide hotline number 988 is still not running at full capacity