Answering the Call, Part 2: Struggling to Staff the Nation's New Crisis Line

June 2, 2022

A crisis counselor answers calls at First Choice Services in West Virginia. (Photo by Lata Menon)

In Part 2 of our special series on 988, we explore the scramble to staff the country’s new mental health crisis line and the workforce lessons 988 can learn from 911.

Listen to the full episode below, read the transcript, or scroll down for more information.

Learn more about how 988 came to be, what’s at stake and what it will take to succeed in the first episode in our series.

If you want more deep dives into health policy research, check out our Research Corner and subscribe to our weekly newsletters.

Content warning: This episode includes mentions of suicide. If you or someone you know is having thoughts of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

Jennifer Battle is open to just about anything to find people to answer the phones at her Houston-area crisis line.

“It’s like we need to have some kind of dating app except for crisis work. Like swipe here if you want to work in the middle of the night and talk to people in need,” joked Battle, Director of Access at the Harris Center, Texas’ largest public mental health agency.

Battle has been trying for the last 18 months to hire 25 counselors to answer 988, the country’s new mental health crisis line. Her center is one of more than 200 agencies that currently answer the National Suicide Prevention Lifeline and will begin answering 988 on July 16.

A 2020 law converted the 10-digit Lifeline number down to three and expanded the line’s mandate to encompass all mental health care needs, including suicide, addiction and severe mental illness. 

Some have described 988 as “911 for mental health,” and lawmakers hope the 3-digit number will make it easier for the 50 million Americans with a mental illness to get help. Today, fewer than half get treatment.

As many as 12 million people could reach out to 988 in its first year, according to federal officials, quadruple the number the Lifeline served in 2020. 

The people setting up 988 agree the counselors answering these calls, chats and texts will be critical to the new line achieving its goals. But with just six weeks before it goes live, hundreds of positions remain unfilled — putting those looking to the line for help at risk. It also makes it more likely that those who have been hired will end up overworked.

In her 20 years running crisis lines, Battle said this is the most trouble she’s had hiring. “There’s always been this core pocket of people who are right for us. And now it feels like that pocket of people, I don’t know where they’re going,” she said.

911 as a cautionary tale 

As 988 creeps closer to launching without sufficient staffing, some experts worry that workers for the new crisis line could face the same challenges as their cousins at 911.

Understaffing has long plagued 911 call centers, and it has intensified during the pandemic. 911 call-takers earn $47,000 a year, on average, and research shows more than half are obese, with many workers reporting high levels of physical pain from sitting through tense 8-12 hour shifts. One-quarter of 911 professionals have symptoms of depression and post-traumatic stress disorder, on par with rates among police officers and firefighters.

“Whether you want to admit to it or not, it affects you,” said Rita Salazar, who’s been answering 911 calls near Seattle for more than 20 years. Salazar was diagnosed with PTSD last year after a traumatic call nearly forced her to quit her job. 

There’s no direct evidence linking 911 call-takers’ health to their job performance, but Northern Illinois University psychology professor Michelle Lilly, a leading 911 researcher, said a large body of evidence from other fields shows, “when you have PTSD and depression, it affects your decision-making, your concentration, your attention, your sleep. And all of these things are critical in being able to perform successfully, particularly under pressure.”

Rebecca Neusteter, the executive director of the Health Lab, a health care and criminal justice research group at the University of Chicago, worries the efforts to form the 988 workforce are being built on the same swampy foundation as 911.

The Biden administration has committed about $400 million to scaling up 988, but like 911, there is no new sustained federal funding. Instead, both lines primarily rely on state and local funding, and neither has uniform national training standards.

“If we’re not attending to the staff, ultimately that has huge detrimental impacts on communities,” Neusteter said. “People won’t call anymore, which could leave people in crisis with even fewer resources to seek help.”

Learning from 911’s mistakes

988 leaders are taking concrete steps to build up a robust workforce.

To avoid overworking and burning out staff, many 988 centers are raising starting salaries by as much as 30 percent and offering remote work options to attract more applicants. At least one center in Washington state has hired counselors based in Virginia.

SAMHSA, the federal agency that oversees 988, is trying to drum up interest in the work with a new website that links to the open positions. A spokesman said they plan to post on social media and talk up the job to college students and administrators. In a nod to how much work remains, the agency has pushed back its public campaign to promote the line until 2023.

There are also efforts to standardize the training 988 call-takers receive, with the first-ever mandatory training program set to roll out this fall. Historically, the National Suicide Prevention Lifeline has recommended evidence-based trainings, but each center has been in charge of its own training program.

One of the greatest areas of focus is supporting the mental health of 988 counselors. 

Unlike 911, where some have questioned whether call-takers can even suffer ill-effects from the work, 988 leaders say staff mental health has and will continue to be a top priority. But they know that with low staffing levels, more calls and the high-pressure nature of those calls, they will need to do more to ensure their staff don’t face similarly high levels of depression and PTSD.

“I was first and foremost afraid that the counselors’ mental health would suffer, that they would experience higher levels of burnout,” said Courtney Colwell, the 988 program manager for Volunteers of America Western Washington.

In response, Colwell has added more managers to help staff handle tough calls and jump in if someone needs a break. She also established a staff advisory committee to get call-taker feedback and give them a voice in policy decisions. 

In Houston, Jennifer Battle says her supervisors hold regular debriefings with call-takers and write 4-5 personalized thank you notes to them each week.

Like many call center leaders, Battle does not expect to be fully staffed when 988 goes live on July 16. She is confident she will get there eventually, but what’s impossible to know is how long that will take and how many people in crisis will suffer until it does.

This episode is part of a series on 988 supported, in part, by the Sozosei Foundation.

Want more Tradeoffs? Sign up for our weekly newsletter!

Episode Resources

Selected Research and Reporting on 988:

988 Crisis Response State Legislation Map (National Alliance on Mental Illness)

988 Convening Playbook: Lifeline Contact Centers (National Association of State Mental Health Program Directors, 5/2022)

New Federal Bill Would Boost Funding for 988 Mental Health Crisis Line (Lauire Udesky and Rob Waters, MindSite News, 3/18/2022)

As a Crisis Hotline Grows, So Do Fears It Won’t Be Ready (Steve Eder, New York Times, 3/17/2022)

Answering the Call, Part 1: America’s New Mental Health Crisis Line (Tradeoffs, 2/3/2022)

U.S. suicide hotline 988 is set to go live, but many states may not be ready (Barbara Goldberg, Reuters, 1/14/2022)

Phone-Bill Fees to Fund Suicide Hotline Spark Statehouse Debates (Ryan Tracy, Wall Street Journal, 1/5/2022)

988 Appropriations Report (SAMHSA, 12/2021)

Selected Research and Reporting on 911:

Florida county struggles with understaffed 911 call center (Associated Press, 4/27/2022)

Transforming 911: Assessing the Landscape and Identifying New Areas of Action and Inquiry (Transform911, 2/28/2022)

The Troubling History of 911 and How 988 Can Avoid the Same Missteps (Stephanie Hepburn, #CrisisTalk, 5/25/2021)

Predictors of Obesity and Physical Health Complaints Among 911 Telecommunicators (Michelle Lilly, Melissa London and Mary Mercer; Safety and Health at Work; 9/12/2015)

Psychological Inflexibility and Psychopathology in 9-1-1 Telecommunicators (Michelle Lilly and Christy Allen, Journal of Traumatic Stress, 5/11/2015)

Episode Credits

Guests:

Rebecca Neusteter, PhD, Executive Director, Health Lab, University of Chicago

Rita Salazar, 911 call-taker, Valley Communications Center

Michelle Lilly, PhD, Associate Professor of Clinical Psychology, Northern Illinois University

Jennifer Battle, MSW, Director of Access, Harris Center for Mental Health and IDD Services

Lata Menon, MSW, CEO, First Choice Services

Courtney Colwell, 988 Program Manager, Volunteers of America Western Washington

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions and Epidemic Sound.

This episode was reported by Ryan Levi and mixed by Andrew Parrella. Editing assistance from Cate Cahan.

Special thanks to Steven Perry, Shye Louis and John Draper.

Additional thanks to:

Travis Atkinson, Emily Blomme, Daryl Branson, Meryl Cassidy, Hannah Collins, David Covington, Kelsey DiPirro, Tracy Eldridge, Robin Engel, Mary Giliberti, Madeyln Gould, Terrance Hamm, Andrea Harrison, Frank Hartman, Karl Hatton, Samantha Hawkins, Angela Kimball, Ted Lutterman, Jim Marshall, Ben Miller, Brian Mishara, Sue Ann O’Brien, Erica Olson, Jessica Pirro, Karina Putnam-Kaminski, Eric Rafla-Yuan, Rosa Ramos, Shelene Richards, Tiffany Russell, Connie Tolson, Lora Ueland, Adam Wasserman, Hannah Wesolowski, Levi Van Dyke, the Tradeoffs Advisory Board and our stellar staff!