Dan Gorenstein: Hey, it’s Dan. Just a warning that today’s episode mentions suicide. Please listen with care. And if you or someone you know is having thoughts of suicide, you can call the National Suicide Prevention Lifeline at 1-800-273-8255…that’s 1-800-273-TALK.

DG: In less than 6 months, America is getting a new phone number. It’s a hotline for mental health emergencies that anyone, anywhere can dial with just 3 digits: 988.

Sfx: Phone dialing

DG: The goal…better help for people struggling with suicide, addiction, schizophrenia. The hurdles…are immense. 

Today, Part 1 of a special series about what’s at stake and who will answer the calls when 988 launches this July.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: Most of us, when we’re in a crisis, know who to call.

911 audio montage: 911 where is your emergency? // I have someone down in front of my house, they hit a pole. // Uh my husband … I don’t know if he’s breathing right now. // We are surrounded by fire. 

DG: And we know who will answer.

911 Sfx: Stay on the line with me, okay?

DG: Paramedics, police, firefighters.  

911 Sfx: Sirens

DG: But for people hallucinating, hurting themselves or on the edge of overdosing, a 911 response can be dangerous, if not deadly.

News clip montage: The family of a mentally ill woman gunned down by Chicago police says it didn’t have to happen. // Alex Domina // Michael Cordero // His name is William Sellers // Shot 52-year-old Patrick Warren // His mother now regrets calling the very agency she hoped would help her son.

DG: With no fast, safe alternative to 911, many people in crises like these simply go without any help. And the consequences are devastating. 

46,000 Americans died by suicide in 2020. More than 90,000 that year died from drug overdoses. And that fall, Congress took action.

Rep. Stewart: If you are in the middle of a mental health crisis and you need help … you need to know who to call.

DG: In the midst of a pandemic and on the eve of the presidential election…October 17th, 2020…lawmakers passed a bill… 

House Clerk: Senate 2661 to designate 988…

DG: …creating this new hotline: 988. 

The law converts the existing National Suicide Prevention Lifeline from 10-digits down to just three. But Congress wanted this phone number to be more than that. They saw it as a front door for people in all kinds of mental health crises. 

Rep. Gianforte: No matter where you are in the country, just like when you call 911, when you call 988, you’ll be connected to mental health resources.

DG: In 2020, the current Suicide Lifeline got roughly 3 million calls and texts.

As many as 12 million may come through this wider 988 door starting in July.

As mental health advocates see it, that’s 12 million opportunities to greet people with better, safer crisis services than they’ve had before.

Thanks to 988, some communities across the country are now hustling to make over their local mental health care systems, adding new places to send people and new staff to help.

Roughly 30 million Americans are not in any kind of treatment for their mental illness.

46-year old Andrea Harrison was one of them. Untreated childhood trauma had led her to pills then crack and then heroin.

Andrea’s story illustrates two things about those 12 million calls and texts that may come in. 

One: how quickly a crisis can strike, and two, how tenuous and potent a crisis can be — a rare chance to get someone the help they need or a missed opportunity that could cost someone their life.

Andrea’s crisis began in an alley in Huntington, West Virginia.

Andrea Harrison: I wake up and I’m terrified.

DG: She’d just been revived by paramedics after overdosing on heroin. 

All her usual thoughts tumbled through her mind that June morning in 2012. “Am I gonna be arrested? How am I gonna get my next fix?”…and a new idea. 

AH: I could choose to not be here.

DG: Her sons were 10 and 12. Andrea had vowed to never take her life. That’s how her mom, Dinah, had died. Andrea had never forgiven her for that.  

But today, the idea of suicide seemed to fit.  

AH: And that scared me. It scared me to death.

DG: Andrea’s life had ended up a lot like Dinah’s in nearly every other way — poverty, addiction, homelessness, drifting in and out of her kids’ lives.

Andrea wandered around all day haunted by thoughts of her mom and scared of what she might do to herself. In the evening, she camped out in an abandoned house. 

AH: It’s cold. It’s the middle of the night and it’s pitch black, and I’m alone.

DG: Shaking from withdrawal, Andrea made a decision. She would kill herself. 

AH: My kids would not have to suffer and be embarrassed and ashamed and neglected and abandoned by the person that they should be able to depend on the most.

And it was that moment of clarity…as soon as that thought crossed my mind, it just clicked. Oh mom, poor thing. Now I understand how you made the decision that you made. Bless your heart … the anger and the resentment disappeared in that moment. And I could only feel so sad that that was her only way out. 

DG: As much as Andrea’s life mirrored Dinah’s, Andrea knew something her mom didn’t: the long tail of suicide, the guilt, the hurt, the unanswerable questions. 

AH: I did not want that to happen to me and my children. I didn’t want that to be the story of the life. I wanted to change that. I wanted to end that cycle so I knew I had to do something to save them. And by saving them, I had to save myself first.

DG: And that was that. Andrea changed her mind. But she knew she needed help fast. 

She considered calling 911, but worried she’d end up in jail. She thought of her only other option. 

AH: 5-2-5-7-8-5-1 

DG: A place in town where she could detox for a few days. It was the help she could find, not the help she needed. She did detox for 48 hours, but stayed addicted to heroin for five more years.

Andrea got sober in 2017. She was 41, the same age as Dinah was when she died by suicide.

Andrea is 46 now and deeply involved in the local recovery community. She remembers everyone in the crowd she ran with had memorized that same number for the local detox center.

AH: Nobody in the history of addiction has ever been shooting heroin in their jugular and thinking, this is great. You know, you got eight people in a living room of somebody’s house sharing a needle, doing a little tiny bit of stuff so you’re not sick. We’re all miserable, and the conversation is always, always, how are we going to get away from this? How are we gonna get better? How am I gonna get the help that I need?

DG: Providing people the help they need in the moments they need it most is the highest hope for this new 988 number.

But as is so often the case with health care programs and policies, the difference between ‘high hopes’ and disappointment will be in the details. 

Who will provide that help? How? Where? And at what cost?

Those questions…after the break.

MIDROLL

DG: Welcome back. This is the first in a multi-part series following the launch of 988. It’s a new national hotline for people experiencing mental health crises.

Federal health officials estimate the line may get up to 12 millions calls and texts in its first year alone, starting when the number goes live this July. 

That’s a lotta calls, but for many mental health advocates, it’s just one piece of a loftier vision for 988 to be this front door to a broad spectrum of safer, better crisis services.

To help us better understand what that might look like and how close it is to becoming reality, I’ve asked senior producer Leslie Walker to join us.

Leslie, thanks for being here.

Leslie Walker: Thanks for having me.

DG: So maybe the best place to start here, Leslie, is with this phrase I’ve heard a bunch: ”988 could be the 911 for mental health crises.” What are people actually saying, Leslie, like what does that mean? 

LW: Well, to me that phrase really speaks to the potential for 988. And to understand that, Dan, I think it helps to understand how 988 and 911 are similar.   

First, they’re both national numbers, but the help you get depends on where you live.

DG: Like when you call 911, it matters how far you live from a fire station, or how much you trust your local cops. 

LW: Exactly. And every 911 call really has two key elements. There’s the people who respond and the places they take you. And whether this bolder vision of 988 ever materializes will turn a lot on that: people and places. 

DG: And money. 

LW: Well, definitely money, Dan. That’s big here too. Even though Congress created 988, Congress didn’t fund it. No new money.  

DG: Wait. Not a dime?

LW: Not a penny. 

There is some money coming from the Biden administration, but at least initially, what 988 becomes will depend largely on what states, cities and counties do.  

And there is a bunch of action out there already.

DG: Okay. So that brings us back to your “people” and “places.”

LW: Right. So the first people any 988 callers will encounter are the crisis counselors who staff the National Suicide Prevention Lifeline. 

DG: Now just to remind folks, that’s the 10-digit hotline that Congress repurposed as the foundation for 988.

LW: Exactly, and that Lifeline is staffed locally by counselors in more than 180 call centers around the country. They all look and operate pretty differently, but at their core, they provide the same basics: emotional support, possibly some referrals to local mental health services.

And experts estimate, Dan, for a big chunk of callers — about 80% — that’ll be it. The phone will be enough.

DG: But for the other 20% of callers?

LW: Ideally, the call center would dispatch some type of first responder to the caller’s location, just like 911.

And here, Dan, communities are already starting to make some pretty different choices. Because lots of those first responders are police, and police scare lots of people.

Madhuri Jha: If 988 is executed the way 911 is executed, people will die.

LW: Madhuri Jha directs the Kennedy Satcher Center for Mental Health Equity at the Morehouse School of Medicine, and she says the data justify people’s fears.

The Washington Post reports police have fatally shot more than 1,500 people with mental illness in just the last six years. That’s the fear that kept Andrea Harrison from calling 9-1-1 that night back in 2012.

AH: You know, I’m not in my right mind. I don’t even know what I’m capable of. I don’t know what I might do. I definitely do not want a police presence.

DG: And Andrea’s white. We know that Black people are already more than twice as likely to be fatally shot by police than white people.

LW: Yeah, and you add mental illness into that mix, Dan, and a Black person’s risk of being killed by police quadruples.

So there are lots of local experiments happening with who should show up at these scenes.

Some places, like Chicago, are piloting police-free options, staffing mobile crisis vans with social workers and paramedics, even people who have been through their own mental health struggles. 

Others, like Richland County, South Carolina are still using police, but pairing them up with mental health workers.   

DG: I’m guessing a lot of this work started before 988 but with the line coming on soon, that work is picking up.

LW: Definitely.

DG: I’ve got a lot more questions about these models, Leslie — especially the evidence behind them — but we’ll get into that later in our series. 

LW: Yes, in due time, my friend. 

DG: So to recap what you’re saying Leslie, I think…at a minimum, all 988 callers will get someone to talk to. In serious cases, police or mental health workers may come to their home.

Now what would happen from there? What are these places folks like Andrea will go if they need more help?

LW: Well, right now, a lot of the time, people like Andrea call 911 they end up in a hospital or in jail. 

Hannah Wesolowski: More than 2 million people each year with a mental illness are booked into our nation’s jails and prisons. It’s a huge number.

LW: Hannah Wesolowski directs policy for the National Alliance on Mental Illness. Advocates like her see 988 as a chance to really shrink that number. 

DG: And I can imagine that has appeal for policymakers. If you could keep people out of the hospital, keep them out of jail, maybe you could start to see some real cost savings. 

LW: That’s definitely a point advocates make, and there is some data to suggest that’s possible.

But callers will have a wide range of needs. If communities want to meet them, they’re gonna need traditional options like detox centers and inpatient beds…plus Dan, you’ve got some newer stuff happening too.

States like Arizona have even embraced a kind of short-term facility literally called a Living Room with recliners and couches where people in crisis can rest and make a recovery plan.

DG: So, Leslie, you’ve made it pretty clear that we’re in a moment here where 988 could be this rare national opportunity to welcome a lot more people in crisis into care. But with no clear blueprint of what to actually build, there’s a lot of concern this opportunity will slip away.

LW: Yeah, a lot of experts I talked to can easily imagine this local approach will, in lots of places, lead right back to the status quo: long wait lists, inadequate services.

And they know better than anyone what more of the same means: more suicides, more overdoses, more lives lost.

Ben Miller: This does represent a chance to get it right from the beginning. And I don’t want us to be coming back 10, 15 years from now trying to fix what we are about to roll out.

LW: That’s Ben Miller. He runs Well Being Trust, a national mental health philanthropy. I talked to him back in December. 

BM: My biggest fear is that we’re going to have 51 versions of bad. People are not necessarily going to have the comprehensive vision that they’re going to need for this to be meaningful.

DG: Leslie, there’s probably a laundry list of reasons we might end up with Ben’s 51 versions of bad — staffing, stigma, training, tech — and we’ll get into some of that later in our series, but I want to come back to what sounds like the single most important key to getting to 51 versions of good…that f-word I brought up at the start of our conversation.

LW: I thought we bleeped that out! 

DG: Funding, Walker. Funding.

LW: Right, so earlier, I did mention some federal dollars earmarked for 988. Last December, the Department of Health and Human Services committed nearly $300 million dollars to quote “shore up, scale up and staff up” the National Suicide Prevention Lifeline and its local call centers.

Advocates say it’s not enough, but it’s a start.

DG: And what about funding for all the services that could come after the call…the mobile crisis teams, the care facilities…

LW: So that picture’s a lot less clear. And that has states scrambling, piecing together federal mental health grants, Medicaid dollars, dipping into pots of money wherever they can find them.

It’s also got advocates like Hannah Wesolowski frustrated.

HW: ​​We have funded mental health this way for decades. It is pennies here, pennies there. It is out of the goodness of people’s hearts that organizations are there to support people, experiencing mental health conditions. I’m hoping policymakers make the investments that we know we need to make.

DG: Have these advocates outlined what a bigger, better funding strategy might look like? Cause I mean at its most ambitious, this sounds like a ton of stuff to fund, given how meager our mental health care system is to begin with. Where should all of this money come from, Leslie?

LW: So people like Hannah basically believe 3 different groups should split the tab for 988 and all the services that surround it.

The federal government, and there’s a couple of bills in Congress aimed at this.

Then there’s the states, who are allowed to tack fees onto people’s cell phone bills to pay for some 988 services.

DG: Isn’t that also how 911 is funded? Through your phone bill?

LW: It is – about a buck a month for most people. But these new charges have to pass through legislatures and that’s been tricky so far. Just 4 states succeeded last year.

DG: Who’s the third group?

LW: Well then, Dan, you’ve got health insurers.

And there’s this pretty interesting bipartisan bill in Congress right now that would require most insurers, including Obamacare plans, employer plans, even Medicare and Medicaid, to reimburse this full spectrum of crisis services, from mobile teams to urgent care facilities.

It would also, for the first time, set federal standards for what those services need to provide so insurers know what they’re paying for and what they’re getting in return.

DG: That sounds fascinating and like it could be, sorry for the cliche…it could be a game changer. Does it have any shot at passing? 

LW: It does have bipartisan support but it’s still in the pretty early stages, so it’s hard to say.

DG: So Leslie, I want to end this conversation with the sense that there’s this pretty huge gap in most places between what 988 will be and what it could be without a lot of hope that gap’s gonna close any time soon. Is that how you’re feeling at this point in your reporting? 

LW: I think there’s no doubt the road between here and July is gonna be bumpy, and most experts have told me they expect it’s going to be like that for a long time. 

But here’s why I think we’ll at least see some progress, I guess you can call it the x factor…all the people I’ve met who are digging in, rolling up their sleeves, excited to answer these calls. That includes Andrea Harrison…

AH: National Suicide Prevention Lifeline, this is Andrea. How can I help you? 

LW: …who now works for a crisis call center in West Virginia.

AH: Okay, so do you think that you need to go to a treatment center…or do you think…

LW: It’s a job that brings her almost as much joy as the bond she’s rebuilt with her two sons, one who texts her daily and the other who writes her weekly from his military base.

AH: They adore me. They think that I hung the moon. And I don’t deserve that, but it’s mine.

DG: Leslie Walker, thanks so much for your work reporting today’s story.

LW: You’re welcome, Dan. 

DG: And this is just the start, folks. With help from Leslie and the rest of our team, we will be following 988’s rollout over the course of this year…checking in with national experts and closely following the journeys of two local crisis care organizations, including Andrea’s in West Virginia. 

If you have a tip or a suggestion for our 988 series…something going wrong or right in your community’s preparations for 988…email us at info@tradeoffs.org.

I’m Dan Gorenstein and this is Tradeoffs.