Progress and Pain Points in National Crisis Line’s First Year

Dan Gorenstein: There are a lot of words to describe the first year of America’s new mental health crisis line: 988.

Courtney Gallo Hunter: Revolutionary
Olka Forster: Complicated
Monica Johnson: Transformative
Deborah Turner: Exhilarating
Hannah Wesolowski: Roller coaster

DG: In July 2022, 988 replaced the 10-digit National Suicide Prevention Lifeline. The goal: create a new national front door for people struggling with all sorts of problems — depression, substance use, suicidal thoughts. Over the last year, outreach to 988 has grown by more than a third. Wait times have plummeted. And many people reaching out are not suicidal, but they really need someone to talk to. Yet, challenges remain. Today, a look at 988 by the numbers: what’s working, what’s not, and where the line goes from here. 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: We kick off today’s episode with a big number…one that captures how quickly crisis response is changing in this country: 71,067. That’s the number of text messages sent to 988 in just one month, May 2023. One year ago, the old 10-digit line received about 8,000 texts, a 750% spike.

Naomi: I’m 24 and I’m a recent graduate with a masters in marine biology.

DG: This is a woman we are calling Naomi to protect her privacy. Naomi — one of the people fueling this growth in crisis texting — reached out to 988 late last year. She was spending her final semester of grad school in Hawaii conducting research for her thesis.

Naomi: I got to scuba dive 3 to 5 days a week. And I got to see the most incredible creatures — dolphins jumping above my head.

DG: Naomi’s worked in aquariums, swam with sharks, and hopes to use her new masters to research fish behavior.

Naomi: When you’re underwater, everything is so different. Just the way things move, the way that light looks. Everything’s so quiet. It’s like awe.

DG: But one Saturday morning last December, a familiar feeling began to creep in. It was the day before Naomi’s 24th birthday. She was in her favorite cafe in Honolulu drinking coffee, lost in her laptop.

Naomi: I just felt like doom. I don’t know how else to describe it. I just felt like everything was kind of imploding in on itself all at once.

DG: Naomi recognized this feeling. She’d been dealing with it for about a decade. A psychologist had diagnosed Naomi with what’s known as complex PTSD, the result of a three-year relationship with an abusive boyfriend in high school. Since then Naomi has struggled with bouts of depression, anxiety and panic attacks. Ironically, one of Naomi’s triggers is when things seem to be going well.

Naomi: I’m like constantly looking for what’s going to hurt me next. And when I finally have something good, I feel like there has to be something wrong.

DG: Naomi decided to leave the cafe for home, try to shake off the spiral she felt coming. She turned on some Phoebe Bridgers — go-to music when she’s feeling down. 

ICU by Phoebe Bridgers

Naomi: But the more I walk, it feels like I’m walking away from the music in a way. Like it starts to sound very distant. 

DG: By the time she reached her apartment, things had gotten worse.

Naomi: I just remember shaking and being on the floor. And not knowing how to get my soul back to my body.

DG: Naomi was experiencing dissociation, where you feel disconnected from your body — a byproduct of complex PTSD. 

Naomi: I can’t think of anything that I’ve ever done. I looked at myself in the mirror and it didn’t seem like that was me. And I couldn’t speak. I would open my mouth and try to say something. And I just like nothing would come out. And all I could feel is fear.

DG: Some part of her remembered her therapist had told her about 988 earlier in the week. So she pulled out her phone and started typing.

Naomi: Hello. I have PTSD and I’ve been dissociating for the past 4 hours and it won’t stop.

DG: The ability for people like Naomi to text when in a crisis is still new. The 10-digit National Suicide Prevention Lifeline only added text in 2020. About half of texts went unanswered, and even when they were, it took an average of 15 to 30 minutes for someone to respond. Federal officials knew 988 had to be better.

Monica Johnson: We know that young people, and I say young people, I’m 49 years old and I would much rather text you than call you.

DG: Monica Johnson is the director of 988 at the federal Substance Abuse and Mental Health Services Administration or SAMHSA.

MJ: If we do not have robust infrastructure that connects you locally for chat and text, we’re not keeping up with the times and we are not reaching some of the key target populations.

DG: But that infrastructure is far from complete. Responding to texts requires additional staff, new trainings and a special tech platform new to most centers. At least 29 states do have local call centers answering 988 texts, while the other states rely on national backup centers. It’s clear to 988 frontline staff that texting is critical to the line’s success. 

Shawn Kinney: A lot of people would not reach out if it wasn’t for that option.

DG: Shawn Kinney has been answering 988 texts for First Choice Services in West Virginia since last summer. In that time, he says he’s learned something important: A lot of people are more comfortable texting. More willing to type out traumas and fears than talk them out over the phone. And he’s responded to texts in moments when a call would’ve been impossible.

SK: They could be in a public place, you know, on a bus. In the home with their abuser, the person who’s making them feel like they need to reach out is sitting right next to them. A kid was at school and they were being bullied right now hiding in the bathroom, they text in.

DG: A foundational goal of 988 is to make it easier for people to get help. Texting makes that possible by allowing someone in crisis to seek help safely regardless of where they are and who they’re with.

That early morning of her 24th birthday in Honolulu, Naomi texted because she could barely form words. After a few automated questions, the line connected her to Jess.

Jess VO: I am so sorry you’re struggling with this tonight.

Naomi: She was just like that sounds so scary. I’m so sorry you’re going through that right now.

Jess VO: I know it can be really frustrating and upsetting so I’m glad you reached out.

DG: Jess asked Naomi about her life, what she’d experienced, how things were with her family. Jess told Naomi that she also had PTSD and suggested how to reignite her senses and find her way back to herself.

Naomi: She encouraged me to do something with my hand to kind of ground myself in the feeling. So I made hot chocolate for myself.

DG: The text thread felt natural — full of emojis, smiley faces and exclamation points on both sides.

Naomi: I can tell that she’s older because she did use periods, and she did capitalize her sentences. But she was writing with her speaking voice. It was just like she was talking to me.

DG: An hour in, Naomi started to feel a bit better.

Naomi: I was still shaking and sweating and I felt panicked still, but I felt like myself again.

DG: Naomi sent Jess a final text.

Naomi: Heart heart heart. Hee hee hee. Thank you so much. I think I’ll really be able to sleep now. I’m so grateful for you.

DG: Normally, it would take Naomi a few days after an episode like this to do anything beyond the basics of school and work. But this time was different. Naomi had a special birthday scuba dive scheduled for later that morning. She thought about canceling, but then she re-read several of Jess’ messages. 

Jess VO: You are such a strong, amazing person, Naomi.

You definitely aren’t crazy or alone, I promise.

DG: Naomi decided to go on the dive.

Naomi: I think she just kind of stopped me from sabotaging that moment for myself. 

DG: This is how 988 is supposed to work. People in crisis can get help from a trained professional and move on. 

Naomi: During the first dive, I remember floating there watching the shark like slowly swim away from me. And I was looking around, and I saw so many fish, so many corals. The light was like trickling through. And I was just overwhelmed. I was like, wow, I’m so grateful that I’m alive right now and I’m so grateful that I’m looking at this. 

DG: Naomi is home in New York now looking for jobs to take her back to the ocean. Several times, she’s re-read her conversation with Jess, glad to know 988 is there if she needs it again.

When we come back, we look at three more numbers to see how 988 is doing in its first year.

MIDROLL

DG: Welcome back.

To fully evaluate an ambitious and complex system like 988, we’re going to need a lot more than a few data points from a single year. But early numbers can be a useful barometer on the progress or lack thereof the system is making. Like the number 48. That’s how many states still have job openings for their 988 call centers, highlighting why workforce remains a major concern. Another major concern? Money. Only eight states have dedicated cell phone fees to fund their 988 programs. Every other state is counting on unpredictable federal and state funding. Joining us now to talk about some more numbers is Tradeoffs producer Ryan Levi. Ryan, how ya doing?

Ryan Levi: Doing great, Dan.

DG: We focused on texting in the first half of the show, but we’re going to zoom back out to the entire 988 system — calls, chats, texts. And, Ryan, you have got three numbers you think give us a good window into the progress the line has made so far.

RL: Yes, and there’s a theme here, Dan. These numbers are all about how the people running 988 are trying to strike the right balance on some really tricky issues as this massive system gets off the ground.

DG: Got it. Good. Hit me with the first one. 

RL: So the first number I want to talk about is 6-1-2, as in my area code.

DG: That’s Minneapolis, Minnesota. You know I lived in St. Paul, Ryan, which I prefer. So I’ve got a preference. 651 is really where I go to.

RL: Fair enough. To each their own. I was born and raised in Minneapolis, and that’s where I got my first phone too. But I live in Washington DC now, and if I call or text 988, the system is going to connect me with a call center in Minnesota based on my area code.

DG: Even though you would be calling from Washington DC?

RL: Yes. Regardless of where I am, if I call from a Minnesota area code I will be directed to a Minnesota center. 

DG: That seems like a real problem, Ryan. If you need treatment or any other kind of in-person services, obviously that person in Minnesota’s not going to know what the options are in DC.

RL: So this is exactly what leaders are trying to balance, Dan. On one hand, just like you are saying, they want people who contact 988 to connect with someone nearby who can point them immediately to local resources. But there’s also a strong desire to protect people’s privacy and not give 988 too much information about vulnerable people’s exact locations.

DG: That seems like a difficult problem to navigate. Ryan, any sense how often this happens when someone’s area code gets them plugged in to a 988 center far away?

RL: No hard numbers, but I talked with nine different call centers, and they told me it’s common and a major source of frustration. Deborah Turner runs a 988 center in Rochester, New York, and she told me it’s really hard to tell someone who’s reaching out for help that they need to go somewhere else.

Deborah Turner: To make them have to call yet another number and repeat themselves, that burns them out and can make them feel more hopeless.

RL: If someone is in the process of attempting suicide, Dan, talking to some faraway 988 center makes it that much harder to get care quickly. It’s dangerous. I even talked to one center in Texas that still encourages folks to call their local 10-digit crisis number instead of 988 because it’s the only way they can guarantee that they’ll get a local response.

DG: Wow, that’s the antithesis for what people want for 988, which is to make this easy, to remember the three digits, not the 10-digit number. How’s the line trying to deal with this?

RL: Hannah Wesolowski with the National Alliance on Mental Illness told me call centers are lobbying the federal government to find a middle ground between local help and privacy.

Hannah Wesolowski: How do we better route calls based on a generalized area, finding the nearest call center, but not a person’s exact location.

RL: What Hannah’s talking about is called georouting. And it’s the same technology that lots of 911 centers use.

DG: So this “georouting” would make it easier to connect people to a center physically near them, but still keep their precise location hidden.

RL: Exactly. This compromise means 988 still couldn’t send a police officer to your door, but they would have more information about resources nearby. Now, to do georouting for 988, the Federal Communications Commission has to get involved. And last month FCC Chairwoman Jessica Rosenworcel told a congressional committee that her agency is working to make that happen. 

Jessica Rosenworcel: It’s my hope we’re going to have an announcement or a pilot, try to find a way forward so that wherever you are when you reach out for help, we can send resources to you because who you’ll be talking to will be somebody who is nearby.

RL: She told lawmakers technologically, this is easy. The challenge is trying to do it while also protecting some people’s desire for privacy.

DG: Alright, Ryan. Keep us posted on any updates. What’s your next number?

RL: 13%, Dan. This comes from a Pew survey released in May that found that only 13% of U.S. adults had heard of 988 and knew what it was for. 

DG: I know that sounds low, Ryan, but I also know from our reporting last year that 988 wanted to keep a bit of a low profile in the early going because centers were having a very hard time hiring people. So this is a bit by design, right?

RL: Absolutely, Dan. There’s been this push and pull between letting call centers get up to speed and helping as many people as possible. So far, national 988 leaders have erred on the side of giving centers more time. So, you’re right, the low awareness numbers, definitely expected, even though some states have gone ahead with their own high-profile messaging.

Oklahoma PSA: Everyone knows you cry yourself to sleep. Boink!

RL: Oklahoma, for example, hired Broadway star Kristin Chenoweth to appear in a Super Bowl commercial.

Oklahoma PSA: We all have our burdens. Call or text 988 to get yours off your back.

RL: The call centers I talked to definitely appreciated the time to staff up, but with 12 months of experience under their belts at this point, leadership has seen the value of 988, how it’s helped people like Naomi. The prevailing theme I heard from folks, Dan, was, “It’s go time.”

DG: And what about the workforce challenges, Ryan. Like we said, there are still job openings in 48 states.

RL: Yes, workforce is definitely still a top concern, but staffing levels are better than last year. Several 988 leaders said that spreading the word is much higher on their priority list at this point. This fall, 988 is launching its first national awareness campaign.  Deborah Turner who runs the Rochester center said she hopes this big publicity blitz will give people running 988 a better handle on the resources it needs to meet the true demand.

DT: Those floodgates, in a sense, have to be open so we can understand those true baselines of what is our new normal going to look like.

RL: Bottom line, Dan: After a year, there’s a sense across 988 that people are ready for the training wheels to come off.

DG: OK, two numbers down, Ryan. One to go. 

RL: My third number, believe it or not, is three.

DG: Oh the symmetry, Mr. Levi, oh the symmetry. Go on.  

RL: Well, when you call 988, Dan, the first thing you hear is an automated menu.

988 Intro: You’ve reached the 988 Suicide and Crisis Lifeline…

RL: You can press 1 to connect to a special veteran’s lifeline. Two gets you help in Spanish. And then last September, 988 added a new “press 3” option.

988 Intro: To connect to specialized support for LGBTQ+ people under the age of 25, press 3…

RL: Dan, 41% of LGBTQ+ youth seriously considered attempting suicide in the past year. And the legislation that created 988 specifically called out the need for services catered to young queer and transgender people. Federal officials spent $7 million piloting this “press 3” option to direct people to a special line run by the Trevor Project, a nonprofit that’s been running its own crisis line for LGBTQ+ young people since the late 1990s.

Tia Dole: We turned it on and it was like, holy smokes, right? Look at all these kids who are reaching out to us.

RL: Tia Dole is the Chief 988 Officer at Vibrant Emotional Health, the nonprofit that runs 988. Since September, Dan, 6% of all 988 calls and 17% of texts have gone to this special pilot line. And earlier this month, the press 3 pilot became a permanent part of 988, with $40 million in federal funding and six more call centers around the country answering these contacts. Tia says serving the LGBTQ+ community has been one of the biggest successes in 988’s first year. But a lot of people I talked to said there’s still more to be done. 

Kellan Baker: There’s a lot of perceptions in queer and trans communities that calling 988 is a shortcut to getting the police involved.

RL: Kellan Baker is the executive director of the Whitman-Walker Institute, an LGBTQ+ research and advocacy organization. Here’s the issue, Dan. 988 says its number 1 concern is keeping people alive, and sometimes that requires working with 911 to dispatch an ambulance or police even if they’re unwanted. But Kellan and some other trans advocates argue this approach increases the risk that a trans person in the middle of a crisis will have a dangerous interaction with paramedics or law enforcement. They say if someone says don’t send help, that should be honored, full stop.

DG: And, Ryan, this is one of 988’s biggest balancing acts, overall. 988 is seen by many as this chance for the country to move away from law enforcement responding to mental health crises especially since those interactions can often be deadly particularly for people of color. But in many places, as you know, police are the only option.

RL: Right, and we are starting to see more so-called mobile crisis teams that include mental health professionals instead of or in addition to police. But only about half of states have those available statewide right now.

DG: Going into this, many 988 leaders knew about this tension. So after a year, how is 988 trying to help marginalized groups like trans folks while also making sure they feel safe reaching out?

RL: Well Tia Dole, who actually helped run the Trevor Project’s crisis line before she came to Vibrant, says transparency is the key.

TD: It’s not like we’re going to say, “Oh, don’t worry, we’re not going to call emergency services.” Because that’s not true. But what we will say is, yes, we do this and this is what it looks like and this is how we do this. And this is how many times this happens. Let’s talk.

RL: Several trans advocates I talked with said this kind of transparency is critical. But they also said some trans folks may still just contact the Trans Lifeline, which is staffed by trans people and never sends police or paramedics without a callers’ consent. Kellan Baker at Whitman-Walker also said that given the recent wave of anti-trans legislation like bans on gender-affirming care, there’s a lot of mistrust in the trans community that goes beyond 988.

KB: It’s a terrible environment to try to be making the argument that the government is here to help.

RL: It’s a good reminder, Dan, that how people feel about 988 and whether they even use it may depend on factors outside the control of the people running the line.

DG: So as we know 988 remains a work in progress. But what I’m hearing from you, Ryan, is that people feel some positive momentum out there. Is that right?

RL: Absolutely. I heard a real sense of accomplishment from folks on the ground. But there’s also a clear understanding of what’s left to be done: What happens after someone calls or texts 988? Are there enough mobile crisis teams to respond? And are there places for people to go if they’re not safe at home? I think Hannah Wesolowski at the National Alliance on Mental Illness captures the urgency people feel.

HW: Everyone always talks about it took decades to build the 911 system, and it did. But if we take decades to build this system, we’re going to lose a lot of lives.

RL: The point Hannah is making here, Dan, to me, is that for as much progress as has been made, it’s not enough. In some ways, it can never be enough or happen fast enough. Everyone has to keep their foot on the gas to make sure this entire system works well and works for everybody.

DG: And we are a long way from that place. Tradeoffs producer Ryan Levi, thanks so much.

RL: Anytime, Dan.

DG: I’m Dan Gorenstein, this is Tradeoffs.