Dan Gorenstein: Hey, it’s Dan. Today’s episode is the second in a yearlong series on the launch of a new national mental health crisis line: 988.

Our first episode explored what’s at stake and what it will take for 988 to succeed. Check it out if you missed it.

A warning about today’s show: There is some strong language, and it mentions suicide. 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.

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DG: The country’s new mental health crisis line — 988 –  is going live in July.

988 is a big deal. 

It’s often described as 911 for mental health: a simple, 3-digit number to make it easy for people dealing with addiction, mental illness or suicide to get help fast.

But with just about 40 days before the launch, 988 call centers are facing an enormous problem.

Jennifer Battle: We need new people. We need them now.

Courtney Colwell: We’ll need around 50 additional staff.

Lata Menon: We’re struggling to find people who are a great fit for this.

DG: To fulfill 988’s promise … helping people in crisis … the folks actually answering the calls must be well-paid, well-trained and well-supported…but first…they’ve got to be found 

Today, Part 2 of our special series “Answering the Call” — the mad dash to staff 988 and what the new line can learn from its cousin, 911.

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: More than 50 million Americans live with a mental illness.

Fewer than half get any kind of treatment.

Congress set out to address that problem in the fall of 2020.

That’s when lawmakers decided to convert the 10-digit National Suicide Prevention Lifeline into an easy-to-remember 3-digit hotline — a front door of sorts for people to access mental health care.

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: On July 16, 200+ state and locally supported Lifeline centers around the country will start taking 988 calls, chats and texts.

They could get as many as 12 million in the first year,  quadrupling what the Lifeline gets.

The people who answer those calls are critical to the safety of folks reaching out.

There’s no official count, but based on our reporting, there are hundreds of open jobs with just six weeks before the line goes live.

Will 988 call-takers find themselves overworked, underpaid and stressed out?

University of Chicago’s Rebecca Neusteter worries about that, and it reminds her of a very similar group of first responders — 911 call-takers. 

Rebecca Neusteter: They’re working. Lots of hours, many times forced overtime. It can be a very draining, very difficult job with not a lot of breaks, not a lot of support.

DG: Rebecca runs the Health Lab, a criminal justice and health care research group, and she’s studied 911 for a decade.

She says 911 centers have long been understaffed, and during the pandemic, it’s gotten worse

Clip:Hillsborough county is hiring 12 additional dispatchers…

Clip: The city is actively trying to hire for 56 open dispatcher positions.

Clip: The Broward Sheriff’s office says that this 911 dispatcher shortage is a…

Clip: …problem in many parts of Indiana.

DG: The average 911 call-taker makes about $47,000 a year.

They spend 8-12 hours a day sitting at a desk listening to people describe shootings, suicides, and child abuse.

988 counselors’ work and pay will look similar.

Rebecca says there’s a lot riding on the 988 workforce being treated as the professional first-responders they are.

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

DG: Rebecca points to the 911 workforce as a cautionary tale for their 988 cousins.

After 50 years, many in the first-responder world still see taking 911 calls as glorified secretarial work.

In fact, the federal Bureau of Labor Statistics classifies the job in the same category as bank tellers and receptionists.

Here’s what it takes to do this job — keeping your head in a crisis, managing up to six monitors of information and moving from one emergency to the next. 

It’s punishing and takes a toll.

Just ask Rita Salazar.

Rita Salazar: I just felt like something was wrong. 

DG: Rita’s handled 911 calls south of Seattle for more than 20 years now.

RN: I didn’t want to do anything that I love to do.

DG: She’s 52 with long black hair and a soft spot for colorful necklaces.

RS: I don’t know if I can help people anymore because I feel like I can’t help myself.

DG: The call that broke Rita came a few days before Thanksgiving 2020.

RS: You just know that tone in their voice, even if they can’t explain what they see. You just know that this is life threatening.

DG: It was the middle of the day.

Rita listened as a man described a chaotic scene.

RS: He said, this one guy was chasing another. And he has a knife and he is stabbing him repeatedly and he’s covered in blood.

DG: Rita alerted law enforcement, thanked the man for his information, and hung up.

The veteran call-taker was shaken enough by the call that she wanted to learn more.

But what she learned just made things worse.

RS: A brother who killed his brother, who murdered his brother in broad daylight.

DG: The attacker was 22.

The victim: his 11 year old kid brother.

RS: This child was only a couple of years younger than my grandson. And this happened about a mile away from where my daughter lived.

DG: Rita began to spiral. 

RS: I was starting not to give a damn about anything. And it scared the shit out of me. 

DG: Rita had taken hard calls in the past; it’s part of the job.

Before, she’d always moved on.

RS: You just deal with this shit, right? You don’t let it get to you. You don’t reach out for help because you’re strong. You can do this. Suck it up, buttercup. Get back on the phone. What’s wrong with you?

DG: Rita wasn’t sure what was wrong with her.

Over the next several weeks, she had trouble sleeping and put on weight.

Getting out of bed was hard.

Going to work was even harder.

DG: Northern Illinois University psychology professor Michelle Lilly has spent the last decade studying the physical and psychological toll the job takes on people like Rita.

Michelle Lilly: My research has shown that 911 telecommunicators report PTSD symptoms that are consistent with if not higher than law enforcement officers.

DG: Let me say that one more time.

911 call-takers have equal or even higher levels of PTSD than the police and firefighters who arrive on the scene.

Michelle says nearly a quarter of the call-takers suffer from PTSD symptoms like nightmares and distracting thoughts that make it hard for them to work and live.

A similar percentage suffer from depression.

More than half are obese, and they regularly report physical pain from the long days sitting in a chair, staring at screens.

ML: Headaches, backaches, eye problems.

DG: There’s no direct evidence that links 911 call-takers’ health to their job performance, but Michelle says research from other fields paints a frightening picture.

ML: We know from a pretty robust literature that 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.

DG: This is exactly what Rita Salazar was dealing with in the months after that horrible call.

She wondered if it was time to walk away.

Instead, she took a different route. She got peer counseling at work.

And met with a therapist who diagnosed her with PTSD.

The therapist helped Rita realize that 20 years of “suck it up buttercup” had pushed her to this breaking point.

RS: Whether you want to admit to it or not, it affects you. It’s okay to ask for help. It’s okay not to be able to handle some of this shit on your own.

DG: This is a lesson that 911 has to offer 988.

It’s imperative to treat well-trained, dedicated professionals like Rita with the care they need, so if trauma of the job hits, they’ll be taken care of.

But before that can even happen, hundreds of 988 jobs have to be filled. And the clock is ticking.

The University of Chicago’s Rebecca Neusteter worries the efforts to create a robust 988 workforce are being built on the same swampy foundation as 911. 

RN: Similar to 911, 988 legislation was passed without a mechanism to fund it.

DG: Congress allocated zero dollars when it created 988.

The Biden administration has chipped in at least $282 million to scale up the program.

But cities, counties and states are responsible for sustaining these centers, just like 911.

RN: What that has resulted in in terms of the 911 system is that we have a patchwork of over 6,000 primary 911 centers, many of which are underfunded.

DG: Rebecca sees that underfunded patchwork as the root of the problems that plague 911 professionals, the original sin she’s afraid 988 may be repeating.

Three issues stand out:

Understaffing.

Uneven training.

Little support for call-takers’ mental health.

Rebecca says failing to learn the workforce lessons of 911 could have devastating consequences for 988 professionals and the people they’re hired to help.

RN: 988 is only as good as the person who answers the phone.

DG: When we come back, what 988 call centers are doing to build a stronger workforce and avoid the mistakes of 911.

MIDROLL

DG: Welcome back.

The people building 988 know the counselors who will pick up these calls are critical to the crisis line’s success.

But with just six weeks before 988 goes live, they still have a lot of jobs to fill.

Joining me to talk about the push to create a strong 988 workforce is Tradeoffs producer Ryan Levi. 

Ryan, so glad you’re here.

RL: Thanks, Dan.

DG: So you’ve spent the last several months talking with people in the 988 world about their workforce.

How’re they feeling?

RL: They are stressed, Dan. 

I’ve talked with about a dozen people who either run or support 988 centers and hiring is the number one concern for pretty much all of them.

DG: Makes sense. People are going to start calling the line in about 40 days. 

RL: Exactly. And when you don’t have enough butts in seats, there’s real world fallout. 

Like, this is not a drill. 

A New York Times analysis from March found about 1 in 6 of some 2 million calls to the Suicide Prevention Lifeline in 2021 were abandoned. That means people hung up before talking with someone, and experts believe missed calls like these can be a matter of life and death.

DG: Now you’ve been talking with all these 988 centers about those three big issues Rebecca Neusteter from the University of Chicago brought up: hiring, training and support.  

Let’s take those one at a time.

You said hiring is people’s top concern. So let’s start there. 

RL: Yeah, people I talked to are trying just about anything to find people.

Jennifer Battle: It’s like we need to have some kind of, like, dating app except for crisis work. Swipe here if you want to work in the middle of the night and talk to people in need, we’ve got a job for you.

RL: Jennifer Battle is the Director of Access at the Harris Center, the largest public mental health agency in Texas.

She’s run the Suicide Prevention Lifeline there for nearly two decades.

She knows how tough this job is, Dan. She knows a lot of people want less stress, you know, something 9 to 5.

But she says she’s never had to work this hard to find people.

JB: There’s always been sort of this core pocket of people who are the right who are right for us. And now it feels like that pocket of people. I don’t know where they’re going. I don’t know where they’re working right now. But if you’re listening to this podcast, please come work for me.

RL: Dan, right now, Jennifer is looking to hire 25 new people for 988, and to do that, she’s taken some unprecedented steps.

DG: Like what?

RL: Well, first her agency changed the educational requirements so anyone with a bachelor’s degree could work there instead of them needing a degree in psychology, sociology or social work.

That didn’t do much.

So then recently Jennifer’s agency hiked starting salaries from $42,000 to $51,000 a year. 

DG: Some quick math — my dad, a f0rmer math teacher, would be proud — tells me that’s more than a 20% bump.

Has that helped?

RL: Jennifer says it’s too soon to know.

Several other crisis lines told me they’re boosting salaries, too.

But the thing a lot of them are hoping will do the most to bring in more applicants is allowing people to work these jobs from home.

JB: Maybe there’s people that would love to do this, but they didn’t know that this was available because they wouldn’t have never looked at the Harris Center’s website.

RL: Jennifer is only looking at people in Texas for now, but I talked with one center, Dan, that’s hiring people in Virginia to answer 988 calls in Washington state.

DG: That is crazy. That is definitely the definition of casting a wide net. 

Going back to Jennifer, though, Ryan, does she think these changes will get her the 25 new people she needs by July?

RL: No. She doesn’t.

Crisis center folks have spent the last 18 months being creative, Dan. Lobbying their bosses, state lawmakers, private donors for more money to fill these jobs, and they’re still coming up short.

It seems pretty clear to me that 988 is going to go live on July 16 with a lot of these roles still open.

And that means folks are going to call and there won’t be enough people to help.

But there is a plan. 

JB: It’s not like July the 17th, we’re going to go from 30,000 calls to 90,000 calls. So that’s also helpful to me. And on the days where I feel a little panicky about it, I keep reminding myself of that.

RL: Federal health officials know the call centers will be understaffed on Day 1.

So they’re holding off on a big 988 awareness campaign until next year, crossing their fingers that that’ll be enough time to fill the jobs. 

DG: Okay, thanks for that, Ryan. So let’s move onto the next issue Rebecca Neusteter raised: training.

Rebecca told us in 911 centers, training is super varied. 

And I know from our first story, that’s also true with 988. 

RL: That’s right, Dan.

Vibrant Emotional Health, which is the nonprofit hired by the federal government to administer the National Suicide Prevention Line and 988, they’ve always let each center design their own trainings. 

Now, some states require specific trainings.

But that just adds to this patchwork and raises questions for some about quality.

And yet the 988 centers I talked to were all really confident in their training.

DG: Why?

I mean, it seems really hard to train people to handle calls on suicide, addiction and severe mental illness.

RL: I think some skepticism is fair here, Dan.

As we’ve said, the stakes of this can be high, literally life or death.

But here’s why they’re confident.

First, a lot of these centers use trainings that have been studied and found to be effective by independent researchers and government agencies.

And second, there’s additional peer-reviewed research showing that when people call the National Suicide Prevention Lifeline, they are less likely to die by suicide.

DG: So I think what you’re saying is people look at those results and say if we’re meeting our end goal then whatever training we’re doing must be working too.

RL: Exactly.

That’s not to say that everyone everywhere is satisfied with their training.

Lata Menon: I would say that it was my primary concern.

RL: Lata Menon is the CEO of First Choice Services, which will be West Virginia’s only 988 center.

When Lata started in 2019, she saw big gaps in how the staff there were trained.  

She remembers chatting with a counselor the morning after they’d taken some calls overnight.

LM: This particular staff of ours said I had to kind of help this woman understand that her problems weren’t that big. There are other people who have much worse problems.

RL: Lata froze when she heard this because she instantly knew this counselor could have hurt that caller.

To Lata this captured why her team needed more help.

But until 988 came along, her annual budget ran less than $200k, enough to cover one week of training.

LM: There’s been so much attention because of this big 988 movement, and that has also created a lot of funding where there was very little funding before.

RL: Now, to be clear, Dan, overall, most of the 988 centers I spoke with say even with new money for 988, funding is still really tight.

But for a small center like Lata’s, a little goes a long way.

West Virginia lawmakers boosted her annual sustained budget to around $2 million.

DG: And how has this windfall helped her with training?

RL: It’s allowed her to more than triple her budget on this.

New hires now go through two full weeks of training and a week of shadowing before they start answering calls on their own.

And she’s been able to hire a training director to oversee it all and provide ongoing support for the call-takers.

LM: It’s been a game changer for us, honestly.

DG: This sounds like a real win for Lata, but we’ve still got the patchwork problem that Rebecca talked about with 911. 

Is there any move to standardize training, potentially save some money so places like Lata’s don’t have to build something from scratch? 

RL: There is.

Vibrant — again, that’s the nonprofit that will manage 988 — they’re working on a mandatory curriculum for all 988 call-takers, which will start rolling out this fall.

And you know, Dan, this training question had me thinking about something we talked about in our first episode in the series, this idea that 988 is simultaneously a huge opportunity and a massive challenge.

Getting this workforce off the ground and prepared to handle what’s coming is going to take a lot of work.

But as we see in West Virginia and with this new national training plan, it’s also pushing the 988 world to fill in some big gaps.

DG: So that’s training.

That leaves us with the third and final concern: supporting the mental health of call takers.

And thinking back to Rita Salazar’s story, this feels super important because if crisis centers fail to support people like Rita, everyone suffers — the call-taker and the people on the other end of the line.

RL: Yeah, that’s a huge concern. 

I talked with Courtney Colwell. She’s the 988 program manager at Volunteers of America, Western Washington.

She worked the overnight shift as a call-taker for a few years, so she knows the importance of supporting her counselors.

Courtney Colwell: I was very susceptible to feeling the burnout and having it come through where I end a chat with a client and I think that just wasn’t my best work. And it was just true burnout seeping through and impacting the work.

DG: So what’s Courtney doing to help people not get burned out like she did, Ryan?

RL: She’s doing a lot of things, Dan.

She’s setting up fun virtual and in-person events, team-building stuff.

She’s added more managers to handle tough calls or jump in if someone needs a break.

She’s soliciting feedback from frontline staff and involving them in policy decisions.

And I heard similar things from other centers as well.

But then Courtney said something that caught me off guard.

CC: Sharing uplifting and funny memes. It’s probably our number one get-through-the-day thing.

RL: Now Courtney is clear: Memes are something that help the staff take the edge off a little, help them laugh a little. This is not some formal policy.

CC: I think it’s just a way to be human together. You’re not just a colleague to me. I care about you more than that. Which, I don’t know, sounds kind of silly, but we definitely see a lot of positive impact.

RL: You know, Dan, a lot of 988 folks actually mentioned memes and goofy Slack channels.

I mean, who doesn’t love a good meme, right?

But 911 researcher Michelle Lilly says there’s a danger to relying on them too much, and she’s seen this approach bite some 911 centers.

ML: If you try to do those things in an environment where people are feeling like their fundamental needs are not being met, it actually just makes them angry. You’re not listening to me and seeing the things that are most important to me and the ways in which I’m suffering. But instead you’re bringing me treats and sending me funny memes.

RL: Michelle said the more concrete support steps Courtney is taking like adding more supervisors, listening to her staff, she’s seen those be really successful in 911 centers.

DG: You know, Ryan, listening to you lay all this out makes me feel like there’s one big difference between 911 and 988 worth flagging. 

911 has operated under this “suck it up, buttercup” mentality Rita Salazar talked about for a long time and only in the last few years are they really trying to focus on investing and protecting workers’ mental health. 

But with 988, that seems built in from Day 1.

RL: I think that’s right.

Rita and Michelle both talked about the huge shift they’ve seen in people’s attitudes.

When Michelle started presenting her research at 911 conferences a decade ago, she would literally have people corner her in the hallway and tell her that it was impossible for 911 call-takers to get PTSD.

ML: If you go to a 911 conference now, there’s often an entire section devoted to mental health and wellness and more and more people talking about this very real problem.

RL: Now, Michelle says more 911 centers are offering mindfulness and resilience training for staff.

They’re investing in peer support programs, putting a therapist on retainer. 

And these are the kinds of things she says 988 centers should consider too.

But hands down, Dan, my personal favorite mental health support was one Rita told me about.

RS: So we have miniature horses that come in. I cannot tell you, you should see the look on people’s faces when the horses come in.

DG: Horses? Are you serious?

RL: Not just horses, Dan. Miniature horses!

And I know some people might think it’s silly or even ridiculous, but these horses really seem to do the trick for Rita.

RS: It’s so amazing. I used to have a horse and it makes me so fucking happy. And I’m like, when are the horses coming? Everybody’s face just lights up. You hear these little horses clip cloppin in there with their special shoes, and then you’re happy for the rest of the day. It’s fucking awesome.

DG: Pulling it back, Ryan, where does this all leave us.

Do you think 988 is on the path to avoiding the workforce mistakes of 911?

RL: I think when it comes to supporting and valuing their call-takers, 988 is leaps and bounds ahead.

988 centers see these folks as first-responders, and they know they have to protect their mental health.

Now making sure there are enough of them? That’s a lot harder.

Some centers are trying to make the job more attractive — raising wages and offering remote work.

But at the end of the day, this is a really hard job, that’s not going to pay super well, and we need a lot more people doing it than we have right now.

DG: Which, as we’ve said, will mean some callers will fall through the cracks when 988 launches. 

RL: And the workforce, too. The people doing the job are going to have to shoulder a heavier burden.

The centers I talked with are confident they will get enough people eventually.

What they don’t know, Dan, is how long that will take and how many people will suffer until it happens.

DG: Ryan Levi, thanks so much for your reporting.

RL: Anytime, Dan.

DG: Remember, this is the second episode in our special series on the launch of 988, “Answering the Call.”

If you haven’t yet, be sure to go back and listen to the first and make sure you’re subscribed to Tradeoffs so you catch the next installment.

I’m Dan Gorenstein, and this is Tradeoffs.

This story was updated on July 11, 2022, to clarify how much funding the Biden administration has put toward 988. It’s $282 million, not around $400 million as originally stated.

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