The contents of the Federal Public Law 116-172 establish the 988-telephone system through the Federal Communications Commission (FCC), describing the line as it relates to suicide and its creation in coordination with the currently existing National Suicide Prevention Lifeline (NSPL). The 988-phone system is one of the core elements of the newly proposed community crisis response system outlined in the SAMHSA document and includes regional or statewide call centers coordinating in real-time; centrally deployed, 24/7 mobile crisis response; 23-hour crisis receiving and stabilization programs; and essential crises care principles and practices (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020).
Unfortunately, the funding for this project was obviously under-estimated. A new bill before Congress is currently asking for BILLIONS in taxpayer funds to pay for this system.
This plan falls short in several areas. First, there are currently 180 crisis centers in the nation which are in the NSPL network – staffing in the individual centers is unknown. The SPL indicates that the line received over 1 million calls in 2021 (this is approximately 5,700 per center, per year – 32 calls per day, per center, 1.3 calls per hour, per center, every day of the year). Recall that the NSPL is intended for suicide, not other crisis situations as proposed by 988.
Additionally, there only six crisis center locations located in Illinois. According to the National Suicide Prevention Lifeline. In 2021 there were 84,974 calls to the NSPL originating in Illinois. The in-state centers answered just 20% of those calls in-state. The remaining 80% were transferred out of state. This begs the question, what percentage will be answered in Illinois when all crisis situations are added? How will calls be screened to ensure the most in jeopardy callers are given the help they need? How much funding will be required to make this a sustainable reality?
Unfortunately, the clinical staffing mentioned in the SAMHSA document seems unlikely due to current and future shortages of mental health clinical practitioners nationwide. Under the best of conditions, U.S. Department of Health and Human Services projections indicate 2025 shortages of 16,940 mental health and substance abuse social workers; 13,740 school counselors; 8,220 clinical, counseling, and school psychologists; 6,080 psychiatrists; and 2,440 marriage and family therapists (U.S. Department of Health and Human Services [US HHS], 2016). This totals over 47,000 clinicians of different specialties and these numbers were published in 2016, long before COVID-19 and the increased presence of mental health awareness within our communities. To wit, it is clear that a planned large-scale clinical presence at these call centers is not likely to be successful.
Another severe issue with this plan is the ability for the crisis line to have rapid enough contact with emergency 911 call centers to request response of emergency personnel to scenes of mental health and crisis scenes which may be law enforcement or medical calls. Of substantial concern is the potential medical aspect of some of these calls. It is well known that various physical health issues and mental health issues may present similar symptomologies or may co-occur with them. Examples of this are difficulty in breathing, chest pain, abdominal pain, dizziness, nausea, lightheadedness, and a host of other issues. The clinical responders used in the proposed crisis line will presumably not be trained to assess a patient medically. This may delay recognition of potentially serious medical issues and increase the response time of emergency medical services (EMS), potentially resulting in tragic consequences.
Finally, it seems as if the 988 system will be parallel to the 911 system, a system that has proven itself over decades of use, managing 240 million calls in the US annually. This parallel nature will cause delays in service, confusion and may result in negative impacts on patients during emergencies.
The call center concept includes a crisis line that is available 24/7 and clinically staffed. The SAMHSA document details that the crisis line must meet the National Suicide Prevention Lifeline Standards; to include a brief suicide assessment, an imminent risk policy, and appropriate follow-up (SAMHSA, 2020; National Suicide Prevention Lifeline [NSPL], n.d.). The current plan includes rebranding the National Suicide Prevention Lifeline to the 988-Suicide Prevention and Crisis Response Hotline but retains its core element of suicide prevention and does not explain how the system will become a crisis line (which includes much more than suicide). They do, however make sure they discuss, in detail how to tax this service.
We agree that a crisis phone line is a critical component of this program. We recommend, however, that the program be integrated within the current 911 communication system, which has successfully dispatched emergency personnel to events for decades. The development of a new 988 system will only add to the confusion and potential for tragic events to occur due to lost calls, improper categorization of calls, and improper resources sent.
In Joliet, this addition would include a trained crisis line operator within the 911 dispatch center. This crisis operator will be cross trained as an emergency medical dispatcher (EMD) and can work within or near the same workspace as 911 dispatchers, reducing the potential for missed opportunities for care. Further, the dispatchers will be trained in basic methods of crisis first aid, using the Crisis First Aid for Paramedics algorithm adapted for dispatchers. Licensed clinicians are not necessary to perform crisis intervention.
The history of the 911 system is a long one. The first line was created in the 1960s and has taken over 50 years to become a standard for emergency response – it is now part of the fabric of America. Currently, 96% of the land area of the United States is covered by trained 911 dispatchers and many by Enhanced 911 systems, which includes other services. This system currently manages 240 million calls per year nation-wide and is known to the general public. 50 ILCS 750, the Emergency Telephone System Act, states that 911 will be established as the “primary emergency telephone number” in Illinois to allow quick response to those “seeking police, fire, medical, rescue, and other emergency services.” One could make the argument that crisis intervention falls into the other emergency services category and should be serviced by 911. Section 4 of the law indicates that 911 shall include police, fire, and ambulance, but may also include other emergencies as well. The law already provides for safeties, redundancies, and other reliability assurances to ensure the system maintains reliable service and keeps pace with emerging technologies.
The State of Illinois, has a post consolidation total of 394 active dispatch centers for emergency response (FCC). The 84,974 calls placed in Illinois to the NSPL (mentioned earlier) would translate into an average of 216 calls per year to each of the existing dispatch centers, less than one additional call per day, per center (0.59 calls). Also, with shored staffing and brief crisis training, dispatch center personnel are well suited to perform professional crisis intervention on the telephone – it is a natural fit for them. The 988-system transferal is duplicative and uses valuable resources that may be better used elsewhere. Unfortunately, dispatch centers were not considered stakeholders when 988 legislation was considered and passed. Finally, many behavioral health patients, their families, and bystanders already call 911 when behavioral issues occur. People in most areas are familiar with the 911 system and it may be their default resource in behavioral events.
The SAMHSA document also describes the mobile crisis teams as being able to reach any person in the service area at their home, workplace, or any other community-based location in a timely manner (SAMHSA, 2020). The term timely is not defined. These mobile crisis teams include a licensed and/or credentialed clinician who will respond to the person’s location and connect individuals to facility-based care as needed through warm handoffs. According to the SAMHSA document, best practices for the Mobile Crisis Teams include incorporating trained peers (those with lived experience), responding without law enforcement presence (unless special circumstances warrant), real-time GPS and geolocation technology in partnership with the region’s crisis call center, and the ability to schedule outpatient follow-up appointments in a manner synonymous with a warm handoff.
The challenges with this plan are many, and some may be life-threateningly dangerous. First, as we discussed earlier, the severe national shortage of clinical care professionals for mental health issues will be a major obstacle in staffing these units. Second, the areas and populations involved to be covered can be quite large, and response times may be very high. An example of this can be found in Will County, Illinois. According to census documents, the land area of Will County, Illinois, exceeds 800 mi.², and the population is just under 700,000 (US Census Bureau, 2020). As a point of comparison, the entire state of Rhode Island is just over 1500 mi.², and the population of the State of Wyoming is under 600,000 (US Census Bureau, 2020). Next, the definition of timely is quite important, especially when the potential exists for the patient to be experiencing a physical and possibly life-threatening issue such as stroke, heart attack, or other issue. It is clear that substantial delays in response may occur, which may result in police and EMS response to these calls. Importantly, this as of yet unavailable credentialed clinician will ostensibly respond to the scene (person’s home, work, etc.) and perform crisis intervention. It seems clear in the SAMHSA document that the person they are performing crisis intervention with will not become a long-term client of the responder. This proposed process poses several challenges including the safety of the responders and makes certain assumptions about the location of the person being conducive to crisis intervention.
This is further complicated by the desire to remove police presence from the response is a recipe for disaster. Many of the crisis response units will be unfamiliar with the various areas to which they respond. This includes high crime areas and other potentially dangerous environments with which police, fire, and ambulance crews are familiar. The SAMHSA document discusses the coordination with emergency responders as necessary; however, this is much easier said than done in the real world. Many first responder agencies have unique communication methods that do not transfer over municipal or town boundaries, leaving the mental health units unable to communicate their needs rapidly, especially in an emergency.
We also agree that initial crisis care is critical to the well-being of our citizens. Instead, however of creating another structure in the form of Mobile Crisis Response units, using clinicians which it has been shown do not and will not exist to handle calls for service, a program is far more likely to be successful if a functioning system and personnel are already in place. This system is made up of local fire departments. According to the US Fire Administration and the National Fire Protection Association, there are over 1,100 registered fire departments in Illinois and 38 in Will County alone, including the Joliet Fire Department (JFD). Of the 1,100 fire departments in Illinois, 80% provide basic life support (BLS) or advanced life support (ALS) care using EMT-B and Paramedic personnel. Nationally, there are 1.15 million active firefighters.
In our area, these facilities do not exist and there is no provision for funding them. Currently, the City of Joliet is completing negotiations with Thriveworks, a company with contracted mental health professional services which offers quick clinical appointment times. They have access to 3,500 clinical care professionals. The City of Joliet is considering entering into an agreement with them to provide clinical care for residents in need, including those uninsured or underinsured who may have difficulty securing services). This will enable those without clinical care or those unhappy with their current clinical care to seek out new clinical professionals and connect with them within 48 hours (in both in-person and telehealth formats). The paramedic can help the patient make appointments with the clinician of their choice within the system
They do it. Every. Single. Day.
Essential crises care principles and practices are a critical component of the National Guidelines document, but principles and practices are not explained to any great degree. This becomes important when determining which agencies may perform crisis care in the field.
Many formulae exist for crisis management. Slaikeu (Comprehensive Model for Crisis Intervention), Flannery and Everly (, Aguilera, James and Gilliand, Greenstone and Leviton, and Kanel (A-B-C Model), and Cavaiola and Clifford (L-A-P-C Model) have all put forth crisis intervention models at some point. Robert’s Seven-Stage Crisis Intervention Model is arguably the best known of several crisis intervention models that describe the needs of those experiencing crisis. The seven stages include:
1. Crisis Assessment: Stressors, coping skills, available resources.
2. Establish Rapport: Supportive relationship.
3. Identify issues: Gain information about the cause of the crisis.
4. Deal with feelings: Active, supportive listening.
5. Explore alternatives: Previous, new coping.
6. Create a plan: May include many components from referrals to hospitals.
7. Follow-up: Check-in for status (Roberts & Ottens, 2005).
The members of the Joliet Fire Department are trained in Crisis First Aid for Paramedics.
One does not have to be a clinician to do this. In fact, there are many programs out there that teach this process to the general public.
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