Dan Gorenstein: July 16th is going to be a big day. 

After nearly two years of planning … a new mental health crisis line will launch nationwide … 9-8-8.

The 3-digit number is supposed to make it easy for people dealing with addiction, mental illness or suicide to get help fast. 

But with just hours to go before the line goes live … there are still a lot of unanswered questions.

Today … in Part 3 of our special series “Answering the Call” … we’ll introduce you to three people working in their communities trying to address those questions.

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

*****

DG: We’re going to be doing something a little different this episode.

Throughout the show, I’ll be joined by three reporters from our partner Side Effects Public Media.

They’ve been on the ground talking to sources … and they’re going to help us think about three fundamental challenges facing 988:

Natalie: A place to call.

Christine: Someone to respond.

Carter: A place to go.

DG: But first… some 988 basics.

In October 2020 … Congress passed legislation converting the 10-digit National Suicide Prevention Lifeline into an easy-to-remember 3-digit hotline — 988.

The goal: create a front door for the more than 50 million Americans with some kind of mental illness … most who go untreated.

This Saturday … July 16 … more than 200 state and local Lifeline centers will start taking 988 calls, chats and texts.

Federal officials say 988 could receive up to 12M calls in its first year…that’s quadruple what the Lifeline gets.

Some people in crisis will just need a person to talk to….others will need an in-person response … and some of those folks…will need additional treatment and services.

DG: Experts in the field call this the “crisis care continuum” … 

This is where the three Side Effects reporters come in.… with their help…we’ll introduce you to one person at each step of that continuum.

First up, Side Effects reporter, Natalie Krebs from Iowa Public Radio.

Hi, Natalie.

NK: Hi, Dan.

DG: So you’ve been reporting on this first, most basic step — a place to call.

And – based on your reporting – there are going to be two 988 call centers in the state…one in Cedar Rapids, the other in Iowa City. 

Natalie – where’s Iowa at with launching the line?

NK: Well, the state has allocated just under $3 million dollars to fund this work for the first year of 988.

The state has split that money about evenly between the two centers.

That’s about $1.5 million short of what the call centers will need according to Vibrant Emotional Health.

Vibrant is the nonprofit hired by the federal government to run 988 and currently oversees the National Suicide Prevention Lifeline.

DG: What does the state think of that estimate?

NK: I spoke with state officials from the Department of Human Services, Dan, they say they talked to Vibrant about its estimate…and they’re confident the two centers have enough money.

But they also told me that after the line goes live if the centers need more they can ask.

One final note  – like many states Iowa is only using federal dollars to fund 988 over the first two years…no state money.

Department says they are planning to evaluate 988’s costs and financial needs over the next two years.

DG: Ok, so from the get-go, based on Vibrant’s estimate, I’m guessing the state’s two 988 call centers already are feeling financially squeezed?

NK: That’s right.

I’ve interviewed Emily Blomme. She’s the CEO of Foundation 2 Crisis Services, the center in Cedar Rapids.

Here’s what she thinks about 988 in a nutshell.

NK: What she’s saying is she really doesn’t have the money she needs, Dan.

The clearest example is hiring.

As the Center switches from running the Lifeline to running 988, her biggest need is crisis counselors.

These are the people who answer the calls and either provide direct counseling or direct folks to other services.

So far, Emily’s hired six people. She needs 12 more.

And given her funding from the state, she’s limited in what she can pay.

Blomme: It’s really hard to say hi, you need to have a bachelor’s degree and two years of experience, and I’m going to pay you $17 an hour.

NK: And remember, Dan, this is a tough job. Emily’s competing with other employers who pay the same wage for a much less taxing job.

Blomme: To sit with someone while they’re suffering. It’s just not a – it’s not an easy thing to do. And to do that for an eight hour shift, you know, five days a week. It just – it wears on our teams quite a bit.

DG: Right. We’ve heard from 998 centers around the country…hiring is one of the biggest challenges facing 988 as it goes live.

There’s some creative moves people are pulling to make it easier to recruit…like boosting salaries, changing educational requirements…one call center in Washington state has hired people from Virginia to answer calls.

How’s Emily trying to work around her cash crunch?

NK: She’s trying to work with the resources she has.

Emily’s pulled from the organization’s reserve funds to pad salaries and offer signing bonuses up to $1500.

They’re pushing the benefits they offer down to pet insurance and paid parental leave.

What Emily is doing a hard sell on is the value of the job and Foundation 2 is a great place to work.

Blomme: What we have found is that work satisfaction, And having a place where counselors feel supported, and feel confident, well trained and confident to do the work is the, is the best retention tool we have.

NK: She also says they’ve opened up the search beyond Cedar Rapids – which she says has helped.

DG: And what about going back to the state – saying she already needs more money…is that on the table?

NK: It is.

Vibrant has estimated that the entire state will get 70,000 calls, texts and online chat requests during its first year.

Blomme: If the call volume matches the estimates that Vibrant sent, we’ll be severely understaffed. And I’ll go back to DHS and say, ‘Hi, we’re severely understaffed. We can’t keep up with calls, and hopefully they will find us money.’ I mean, that’s, that’s the best I can do.

NK: So as people start calling the new hotline…Emily is stressed…knowing she does not have the staff she thinks she’s going to need.

And what worries her is the potential fallout.

Blomme: I can tell you what keeps me up at night, the idea that someone’s going to call and no one’s going to answer and it’s going to bounce around until it lands somewhere where someone in another state tries to provide quality services. I worry that more people are going to die by suicide, because this line will have been marketed as the lifesaver that it can be that it has the potential to be that but people might not get what they need right away out of the gate. And that worries me.

NK: Emily says she wants to see the state establish long-term, sustainable funding for 988 as soon as possible.

Final point here, Dan. Iowa is like most states.

Despite Congress granting states the power to fund 988 by putting surcharges on cell phones, most states have yet to do that.

DG: Natalie Krebs – thanks so much for your reporting on this.

That’s Natalie Krebs with Iowa Public Radio and Side Effects Public Media.

*****

DG: Research suggests the vast majority of 988 calls … around 80% … will be resolved on the phone.

But everybody else – they’re gonna need someone to show up.

Who shows up will be determined, in part, by who answers these calls.

A new survey from the National Alliance on Mental Illness shows nearly 80 percent of people have never heard of 988. 

Chances are 911 will keep getting plenty of mental health calls… until word gets out about 988. 

That makes coordination between the two hotlines incredibly important.

To learn more about this, I’m joined by Christine Herman from Side Effects Public Media. Thanks for being here.

CH: Thanks Dan.

DG: Christine – One reason some are really excited about 988 is that it gives people in crisis an alternative to 911.

The last thing lots of people want is a police officer showing up in the middle of a mental health emergency.

CH: Right, Dan. There are way too many examples of how wrong this can go.

I think of Daniel Prude in Rochester, NY.

In 2020, he’d just been released from the hospital and was suffering a mental health crisis when police encountered him. Officers restrained him and placed a hood over his head. He suffocated and died a week later. Just a tragic example of how dialing 9-1-1 can be dangerous – even deadly – and that’s especially true for people of color, who are more likely to be killed by police.

And to be clear… sometimes you want the police there, if there are weapons involved, for example. But lots of times, it’s trained mental health professionals who you want showing up. They’re in plain clothes, and unmarked vehicles. It’s less stigmatizing that way. And more helpful to the person in crisis.

DG: Christine, you’ve been doing some reporting out of Kentucky. Looking at how 911 and 988 are trying to work together. What’s happening out there?

CH: I’ve been talking with this guy Mike Sunseri with the Kentucky 9-1-1 Services Board. He’s spent the past couple years trying to make sure that 911 and 988 can, essentially, talk to each other.

Thing is, there are way more call centers for 911 than 988. Like, order of magnitude. Kentucky’s got 120 counties – and a 911 call center in virtually every county. But they’ve only got about a dozen call centers for 988. And while 911 calls are routed based on a person’s physical location, 988 routes calls based on area code. So… just a bunch of logistical challenges there.

Mike is pretty focused on one thing: He needs to figure out how to make sure that all these 911 call centers, when they get mental health calls coming in, are able to do a warm handoff to the folks over at the nearest 988 center.

Sunseri: So what we’ve been trying to do with our colleagues in 988, is help establish a set of guidelines. So essentially, like a phone tree, if a caller calls with this situation, and this action happens, then is it appropriate to continue the call with 911? Or would the call be better served with 988? 

CH: People who answer 9-1-1 calls are used to thinking in terms of three buckets: fire, ambulance, or police. The new protocols will add a fourth bucket: mental health.

DG: That sounds pretty straight-forward. Ideally, how is this going to work? 

CH: Yeah Dan, so Mike’s got his eyes on California, which he says is a few steps ahead of the game in this kind of work. And places like Austin, Texas, where they’ve figured out how to route calls seamlessly without putting people on hold.  Which is super important in a moment that could be life or death.

That kind of seamless coordination of 911 and 988 may be more feasible in larger cities with more resources. There are at least a few places in Kentucky – cities like Owensboro and Louisville – taking steps in that direction. It’s gonna be trickier to pull off in some of the more rural parts of the state.

DG: What else does Mike think is gonna get in the way of getting 9-1-1 and 9-8-8 to talk to each other?

CH: Mike says there’s also questions about liability. If 911 passes a call off to 988 and loses knowledge of what happens to the caller and there’s a bad outcome… that’s a huge concern.

Sunseri: So what’s one of the things Kentucky’s looking at is what kind of exchange of information can we have after the call is transferred either direction to find out how the call was treated and ultimately resourced.

CH: Another factor is money. Many places, including Kentucky, have yet to set up a sustainable funding source for 988, like 911 has. Let alone have extra cash for technology upgrades that might help with some of this.

And Mike said this really interesting thing about funding. 911 is working on certain upgrades that will help them, for example, more precisely locate where calls are coming from. So… 988 certainly needs more money. But so does 911 – 

Sunseri: That’s going to involve discussion with the General Assembly about additional funding. So it creates a somewhat of a conflict between making sure that 988 stays 988. And any discussion about fees on the 911 side are unique to 911. It’s an aside and a tangent but it’s all part of that same equation.”

Basically, Mike wants to make sure that through all this, it’s clear that 911 is separate from 988… so that they can also get the resources they need to do the work they do.

DG: Christine, based on your reporting, this is technical, there’s a lot of money involved, potentially there’s a turf war that you’re alluding to right there. Do you get the sense whether Kentucky is going to be able to pull off this kind of cohesion between 911 and 988? 

CH: It’s hard to know. The good news is that Kentucky is doing something that other states are struggling with. ….. State officials are confident they’ve got the capacity to answer all or most of the calls that are gonna come in.

Mike says the coordination of 911 and 988 has been part of 988 preparations in Kentucky from the very beginning…and some of it is starting to happen.

That said, Dan, there is no formal timetable and it’s clear this will not be up and running across the entire state by the time the line goes live. 

DG: Thanks so much, Christine, I really appreciate your reporting on this.

CH: Thanks Dan.

DG: Christine Herman is the Managing Editor of Side Effects Public Media.

DG: When we come back, we look at the third and final step of the crisis care continuum: a place to go.

*****

DG: Welcome back.

As we’ve said about 20% of people who call 988 will need more than someone to talk to.

Some of those callers can have their needs met with an at-home visit…but some people will need additional services. 

America’s default treatment facilities for people experiencing mental health crises often are jails and emergency rooms.

The facilities that do exist can struggle with long waitlists and workforce shortages.

So where will people go.

Looking into that…is Side Effects’ Carter Barrett.

Carter, so glad you’re here.

CB: Thanks for having me, Dan.

DG: Tradeoffs has done a little bit of reporting on this program called “Living Rooms”. You’ve been looking into Living Rooms a lot, Carter. What are they, how do they work? 

CB: Yes, so in Illinois there’s a network of these facilities called “Living Rooms”. Which are designed to serve as an alternative to the ER for people having suicidal or homicidal thoughts, panic attacks, severe depression, or struggling with substance use.

The idea is to be a comfortable place to go, where people can meet with peer support counselors. And anyone can just walk-in, no referral or doctor’s note needed. And it’s free. 

Sometimes these are called “crisis stabilization centers,” or “peer respites,” but each model can be slightly different  — some of these offer overnight stays, others  24/7 availability, a lot of them in Illinois close each night.

Nationwide, we’re seeing this type of model pop up in more than half a dozen states including Arizona, Tennessee and Georgia.

Right now, there’s at least 21 of these facilities across Illinois. 

DG: I know these Living Rooms have only been around for about ten years, Carter. But we really always try to focus on data as much as we can at Tradeoffs. Is there much evidence behind how well these Living Rooms work?

CB: So there’s a little evidence out there.

In one very small study, of a single living room in Illinois researchers found of the 200 people that went there 93 percent had their crisis resolved without needing to go to the ER.

A majority of the people surveyed said that the most helpful thing was just having a place to talk and solve problems. 

And Dan, there’s also a federal report that said overall peer-crisis services need further study, but that the research so far has been promising. Like, one crisis center found that for every dollar invested into its program there was a return of $2.16. 

DG: And I know as part of your reporting you talked with someone who used one of the Living Rooms. What was the experience actually like?

CB: Yeah, so in May of this year, Benjamin Kowalczyk said he was feeling really lost after a bad breakup. He said he felt like everything was crumbling around him. He had dropped out of college,  and was getting angry with his family members.  Afraid of doing something drastic, he knew he needed immediate help. 

Kowalczyk: I had fallen into a bad depression state. I mean, I’ve been, you know, kind of struggling with depression my whole life, you know, losing my mom at six years old, recently losing someone important to me, at that point, I realized, like, I need to get back into therapy. And I need to do something about my mental health because it’s declining very quickly.

CB: Ben worried it would take too long to connect with his old therapist. So he and his adoptive mom started calling around and were told about the Living Room, Forever Hope. 

It’s in Chicago about 30 minutes from his house. 

Kowalczyk: And then you walk in and there’s this gigantic room with so much space. And there there’s chairs and like there’s comfortable seating and there’s desks and computers and people with just smiling faces.

CB: A counselor helped connect him to a therapist and psychiatrist.

And it was just such an experience going there for the first time it made me feel like I actually had somewhere safe to go.

DG: Would Ben go back? 

CB: Well, Ben still goes to Forever Hope, when he needs to. He really connects with the people there. 

Kowalczyk: I feel like personally going to therapy is a little bit different because, you know, therapy appointments usually scheduled and, you know, you make a set time and place…  But when you go into threshold, it’s kind of like what is on your mind? What do you need to talk about? Is there anything else you need to talk about? Which I really love about threshold.

CB: Ben’s good, he’s appreciative of the care he’s gotten, and he posts about it on social media.

DG: Using Ben’s experience as an example, Carter, what problem are these Living Rooms trying to solve, Carter?

CB: So, Living Rooms are trying to keep people like Ben out of the emergency department.

And they’re trying to provide people with better help and save money.  Let’s take these one at a time, Dan. 

Living rooms are designed to be calm spaces, where people can drop in, whenever and talk to a professional counselor. 

Sometimes when a patient in crisis has to go to the ER, they may wait for hours or even days. 

And in terms of money, emergency rooms visits can cost thousands of dollars. One estimate put the cost of a living room at $269.  

DG: Final question, Carter. As the line goes live, is there going to be some race to Living Rooms in Illinois?

CB: No, and I think that’s because we’re expecting the 988 rollout to be slow. As Tradeoffs has reported, the marketing of 988 has been tamped WAY down.

So a lot of everyday folks have never heard of this new phone number. Even if people are calling 988, it’s unclear if call takers even know about Living Rooms. 

So based on the conversations with Living Room operators I’ve had, it’s a wait and see. 

DG: Thanks so much, Carter, really appreciate the time.

CB: Thank you, Dan.

DG: That’s Carter Barrett, reporter with Side Effects Public Media. She brought us this story on Living Rooms, a program that aims to provide an alternative to the ER for people experiencing a mental health crisis. 

I’m Dan Gorenstein, this is Tradeoffs. 

Tradeoffs’ coverage of 988 is supported, in part, by the Sozosei Foundation.