Crisis Response
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Our Current Response
Every year, millions of mental health or suicidal crisis calls are made to 911 and local crisis lines. A mental health or suicidal crisis is any situation in which a person’s behavior puts them at risk of hurting themselves or others and/or prevents them from being able to function effectively in the community. For example, a person in crisis may experience one or more of the following: actively thinking about suicide or self-harm; erratic, unusual, risky or harmful behavior; delusions, paranoia or other psychotic symptoms; or extreme withdrawal from everyday life.
Unfortunately, when in-person help is needed, law enforcement — not a mental health professional — is often the only response available. As a result, people in crisis, their families and their communities face avoidable trauma and tragedy.
- Since 2015, about 1 in 5 fatal police shootings have been of people with mental illness (214 killed in 2020 alone), with 1 in 3 being people of color.
- People with mental illness are booked into the nation’s jails around 2 million times every year.
- Over 100,000 people died of a drug overdose in 2021 – a 15% increase from the previous year.
- Over 47,000 people died by suicide in 2021.
It doesn’t have to be this way. We can and we must do better, because a mental health crisis deserves a mental health response.
The Promise of 988
In 2020, Congress took an important step in reimagining crisis response by passing bipartisan legislation, the National Suicide Hotline Designation Act of 2020, to designate 988 as the new nationwide, three-digit number for mental health and suicidal crises.
As of July 16, 2022, people experiencing a mental health, substance use or suicide crisis can call or text 988 or chat with the Lifeline at 988lifeline.org and be connected to trained crisis counselors in the 988 Suicide and Crisis Lifeline network (formerly known as the National Suicide Prevention Lifeline). These crisis counselors are trained to help anyone experiencing a mental health crisis or emotional distress.
This is a great step forward to help people more easily access help during a crisis — but the work is just beginning. Currently, the full system we need to have in place to respond to people in crisis who call 988 is not available in most communities. The additional mental health crisis services for counselors to connect a person to are only available in some communities — and often at insufficient levels to meet the demand.
We Can #ReimagineCrisis
The time is now for federal and state policymakers to reimagine our response to mental health and suicidal crises.
A well-designed crisis response system can be the difference between life and death for people experiencing a psychiatric emergency. There are three core elements of the National Guidelines for Crisis Care:
The 988 Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and administered by Vibrant Emotional Health. The scope of the Lifeline was expanded by Congress to include mental health crises.
When someone contacts 988, their call or text should ideally be answered by a local crisis call center with staff who are well-trained and experienced in responding to a wide range of mental health, substance use and suicidal crises and other types of emotional distress.
These crisis call centers should be able to connect people to local services, including dispatching mobile crisis teams (when needed), scheduling appointments with local community mental health providers and conducting follow-up calls.
For most callers, calling, texting or chatting 988 is the intervention. Crisis counselors will be able to resolve the urgent needs of the majority of callers on the phone or via text or chat, reducing the need for an in-person response overall. Additionally, SAMHSA, which oversees the 988 Suicide and Crisis Lifeline, states, “Currently, fewer than 2% of Lifeline calls require connection to emergency services like 911.”
Most states do not currently have capacity to answer all calls locally, which means that contacts that cannot be answered by an local call center go to a national back-up center. As many calls as possible should be answered by local call centers so they can connect an individual to additional services, like mobile crisis teams. Regardless of whether the contact is answered locally or not, all calls are answered by trained crisis counselors able to help.
For someone in crisis who needs more support than can be offered over the phone, mobile crisis teams should be available to de-escalate crisis situations, create rapport with the person in crisis and connect the person to services and supports. Communities that currently have a robust crisis response system estimate that mobile crisis teams are sent to about 10-20 percent of calls.
Mobile crisis teams travel to an individual and provide assessment and stabilization, or they may help an individual go to a place that can offer a higher level of care. Mobile crisis teams should be staffed by behavioral health professionals, including peers with lived experience, and may also include health professionals like nurses or EMTs. Communities with well-established mobile crisis response report that these teams can resolve the immediate crisis in the field for more than two-thirds of dispatches.
Mobile crisis teams should only include law enforcement when absolutely necessary from a public safety perspective. To ensure law enforcement are prepared for any instance where they might come into contact with a person in crisis, we need to continue to train police in de-escalating crisis situations. Local mental health crisis systems should coordinate closely with law enforcement so that law enforcement and 911 may hand off an individual needing mental health crisis services to the crisis system as early as possible.
Unfortunately, too few communities have mobile crisis teams in place. Funding is needed to help create these teams and fill in costs that can’t be billed to Medicaid or other insurers. Mobile crisis teams should be available to every person in crisis if they need it to reduce law enforcement involvement and help individuals get connected more quickly to behavioral health services.
If someone needs intensive care, there must be an alternative to going to the emergency rooms, which in many communities are ill-equipped to support people in crisis. Crisis stabilization options provides that alternative, often in a living room-like setting. Crisis receiving and stabilization facilities provide short-term observation and support services, often for less than 24 hours.
Ideally, strong crisis stabilization programs include peer supports, detox facilities, accept all police referrals with zero rejections and have dedicated areas for first responders to drop off an individual and turn around within 5-10 minutes. They should also accept walk-ins.
Effective crisis stabilization options provide a “warm hand-off” to post-crisis wraparound care, from peer supports to social supports to appointments with providers, that help most individuals treated by these crisis centers remain in the community. For some individuals, more intensive care may be needed, such as inpatient care or connection to short-term crisis facilities and crisis residential care.
Very few communities have access to crisis stabilization options. To make them more widespread, we need to remove barriers to insurance coverage for crisis stabilization services, as well as provide resources to cover infrastructure costs and the needs of uninsured individuals.
By building and providing this continuum of crisis services across the country, we can end the cycle of ER visits, arrests, incarceration and homelessness — and ensure that every person in crisis receives a humane response and is treated with dignity and respect.
Policymakers Must Act Now
It will take federal, state and local action to implement this life-saving system of care in every community and ensure every person in crisis gets the help they need, when they need it.
Federal policymakers should require that crisis services be covered by all health insurers and provide substantial funding to states to cover services and costs that can’t be billed to insurance, like building capacity for the Lifeline and funding start-up costs for mobile crisis teams and crisis stabilization programs. The federal government can do this in a few ways:
- Provide funding to both the national Lifeline network to improve technology and capacity as well as local call centers to increase their ability to answer in-state calls
- Make the 10 percent set-aside for crisis services in the Mental Health Block Grant permanent to help states fill the gaps in needed crisis services
- Fund a new $100 million grant program to help states stand up mobile crisis teams
- Make permanent a new increase to the Medicaid federal matching rate for mobile crisis team response, originally passed in the American Rescue Plan Act in March 2021
- Make Certified Community Behavioral Health Clinics (CCBHCs) available nationwide, as they can provide important crisis services
At the state level, policymakers must pass legislation that sets requirements for 988 call centers and crisis response services, including mobile crisis teams and crisis stabilization programs, that will be available statewide. States must also create oversight for the design and operation of the system, and provide a way to sustainably fund 988 call centers and crisis services.
For the funding piece, Congress provided states with a way to get needed funding, in addition to state appropriations. The Congressional legislation not only put 988 into law, but it also provided a tool—monthly fees on telecommunications bills—to help states build a system that ensures a mental health response to mental health and suicidal crises. These are similar to 911 fees that people across the country already pay on their phone bills. The federal law (P.L. 116-172) specifically allows these fees to pay for the efficient and effective routing of calls, personnel, and the provision of acute mental health crisis outreach and stabilization services.
It’s urgent that policymakers act now, before 988 “goes live” in July, to ensure there’s sufficient statewide capacity to help people experiencing a mental health or suicidal crisis. We cannot wait to #ReimagineCrisis.
Public Opinion on 988 & Crisis Response
Public opinion polling released in June 2022, conducted by Ipsos on behalf of NAMI, finds that people are still largely unaware that this potentially lifesaving resource is on its way. However, while 988 awareness among the public may be low, Americans overwhelmingly favor policies to help build a robust mental health crisis response system that supports people who dial the new number.
- About three-quarters of U.S. adults (77%) still have never heard of 988 — virtually unchanged since October 2021 — and the number who are at least somewhat familiar has not increased over that same period (4% in both polls).
- More than 4 in 5 adults (86%) believe that when someone is in a mental health or suicide crisis, they should receive a mental health response — not a police response.
- People support key pieces that make up a robust crisis response system, such as creating 24/7 crisis call centers (91%) and sending mental health professionals to respond in person to crises (87%). They also agree that there must be an alternative to going to an emergency room during a mental health crisis (89%).
- More than 4 in 5 people support state funding (85%) and federal funding (83%) for 988 call center operations and related crisis response services, with 79% agreeing that more federal funding is needed to support mental health crisis services.
- 88% of Americans support requiring all health insurers to cover mental health crisis services.
- Nearly three-quarters of respondents are willing to pay some amount on their monthly phone bills to sustainably fund their state’s crisis system, similar to how 911 is funded today.
- More than three-quarters (77%) of U.S. adults are not content with the status of mental health treatment in this country.
- About 9 in 10 Americans agree that everyone, regardless of location or income, deserves access to quality mental health care (91%) and mental health crisis response (89%)
- 88% agree that society would be improved if everyone who needed mental health care was able to access it.
When compared to the inaugural NAMI-Ipsos poll in Fall 2021, public opinion around mental health care in the U.S. is unchanged. This is the case when looking at attitudes around mental health, familiarity with the system and the 988 number, and policies they would support.
