Why I Won’t (Yet) Recommend 988 as a Crisis and Suicide Prevention Resource
A lot of people might be surprised to hear that I am not recommending 988, the newly implemented “mental health 911” number, as a resource for people who are experiencing emotional distress or thoughts of suicide. After all, I’ve spent the past several years as a peer support worker, using my own lived experience of healing from trauma as a way to connect with and support people coping with emotional distress. I regularly talk with people who are contemplating suicide, recovering from traumatic events, and working through emotional crisis. Why would I not be excited to promote a new resource for people to access mental health support?
For those unfamiliar, 988 is replacing the National Suicide Prevention Lifeline and is also meant to divert crisis calls away from 911 so that, in theory, a person in emotional crisis can receive the support they need by trained mental health workers. This is, in theory, a good and noble idea. And, as currently managed and implemented, 988 is not a resource I can endorse. How do I know? I spent many hours over the past couple of years attending 988 task force meetings, reading, and learning what I could about the implementation plans. What I’ve learned has left me feeling very worried about the potential for emotional and physical harm to the most vulnerable and historically marginalized. This includes Black, Indigenous, and people of color, the LGBTQIA+ community, people healing from traumatizing police interactions, and people at risk of forced psychiatric interventions.
Simply put, 988 is not trauma-informed. A 2014 document published by the Substance Abuse and Mental Health Services Administration (SAMHSA), “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach,” details trauma-informed program implementation, and notes that “A program, organization, or system that is trauma-informed… responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”
The current rollout of 988 is carrying over the same harmful protocols and practices of the Lifeline it is replacing, and is not taking the needed steps to actively resist traumatization and re-traumatization. Below are the principles of a trauma informed approach as outlined in the SAMHSA document, and the ways in which 988 is not yet able to measure up. (All quotes taken from “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.”)
1. Safety
“Understanding safety as defined by those served is a high priority”
988 does not currently prioritize asking the person in distress what they need and want in order to feel safe. Rather, the typical protocol is to use a standardized risk assessment (that is not scientifically valid) in which the hotline worker makes a subjective determination of what they think safety should be for the person in distress. This can lead to interventions that the caller is not wanting, including forced psychiatric hospitalization. Psychiatric hospitalization can actually increase suicidality. People who have found themselves locked in a psych ward (myself included) often note that they felt the opposite of safe in facilities like this.
2. Trustworthiness and Transparency
“…decisions are conducted with transparency with the goal of building and maintaining trust”
People who experienced harm from calling the Lifeline often speak about interventions taking place without their knowledge and consent, such as their location being traced without their consent, and with no communication from the crisis worker that emergency first responders (and police) were being dispatched to their location. This lack of transparency is a deep breach of trust and often results in a person further isolating themselves from seeking out support in the future. Most 988 call centers will continue this practice, and the possibilities for geolocation without the consent of the caller will likely increase with the 988 rollout. This is especially concerning for communities that have experienced excessive police presence, who might experience law enforcement showing up unannounced to their home as re-traumatizing due to past experiences of harmful police interactions and the history of police killing people during a wellness check. If there are not assurances that police will not be dispatched without the expressed consent of the caller, trust will continue to erode and 988 will not be safe number to call.
3. Peer Support
“mutual self-help” from “individuals with lived experiences of trauma”
Those of us who have lived through our own experiences with wanting to die and other deep emotional distress are uniquely positioned to provide guidance for creating effective support. Many of us have created our own crisis support models in the form of warmlines, peer-run respite houses, and identity-specific crisis alternatives. Yet throughout the planning for 988 implementation, the wisdom and expertise of lived experience was routinely ignored or sidelined. While some 988 call centers will meaningfully integrate peer support and peer support values into their infrastructure, the vast majority of 988 centers will be staffed by people who do not have this important perspective and ability to provide this form of mutual support. In addition, while many 988 call centers are seeking to hire peer support workers to take these calls, current protocol expectations will likely place peer support workers in the difficult ethical position of going against peer support best practices of voluntary, transparent, mutual support in order to keep their jobs at 988 call centers.
4. Collaboration and Mutuality
“…meaningful sharing of power and decision-making”
5. Empowerment, Voice and Choice
“…shared decision-making, choice, and goal setting to determine the plan of action they need to heal and move forward.”
I want to pause here to note here that there are indeed many people who have called the Lifeline and other crisis lines and found them to be an effective and even healing experience. The same will be true for 988. My guess is that the reason for those good experiences included the above listed elements of collaboration, mutuality, empowerment, voice, and choice. The callers felt heard, they were given options, and they were offered opportunities to choose how they wanted to proceed in navigating their distress. That should be the goal for all calls to 988. Until this is the universal experience of all callers to 988, we must continue to advocate for changes that will make it more likely that everyone experiences this level of trauma-informed support that prioritizes self-determination.
6. Cultural, Historical, and Gender Issues
“…access to gender responsive services; leverages the healing value of traditional cultural connections; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.”
The rush to implement 988 has led to important program elements not getting the attention they deserve. Most notable is the lack of time and funding to recruit and train diverse call center workers who can respond to 988 calls with cultural humility and even shared cultural understanding. In my experience as a peer support worker, I have heard many stories from people who no longer call crisis lines like the Lifeline/988 because they experienced racial microaggressions, harmful comments about their gender or sexuality, and a lack of understanding about how oppression contributed to their emotional distress. In the scramble to just get enough people hired to take the expected influx of calls to 988, I fear that more of this harm will continue.
As currently structured, 988 is not equipped to meet the standards of trauma-informed best practices, and callers who engage with the service may experience harm. This is particularly true for people from marginalized identities. Until this risk of harm is significantly minimized, I will not be able to confidently recommend 988 as a resource.
What else to offer
The Bazelon Center for Mental Health Law published a report that includes their recommendations for a better implementation of 988 and other crisis interventions. They highlight the need for truly confidential services, with no geolocation and risk of police intervention, better funding for community-based supports, and increased reliance on peer to peer supports driven by people with shared lived experience, cultural awareness, and shared identities.
Alternatives to 988 exist, and they need funding and support to succeed as trauma-informed answers to the current 988 model. Do a search for peer-run warmlines in your area that are committed to truly confidential, trauma informed support. Promote and support the development of community-based supports that do not rely on force or coercion.
I also encourage people to learn skills based on the peer support model for providing emotional support to your loved ones. The more we can learn how to offer support to one another during hard times, the less need there will be for outsourced crisis interventions. I highly recommend trainings like Intentional Peer Support, Alternatives to Suicide/When Conversations Turn to Suicide, and other peer and survivor led models of support.
If you are part of a workplace or agency that is promoting the use of 988, please practice informed consent: provide sufficient information about both the potential risks and potential benefits of calling 988 or any other crisis line. This is especially important if you are part of a peer-run or survivor-led organization. Research where 988 calls will be routed to in your region. Find out the policies of those call centers, particularly around geolocation (call tracing), police involvement, confidentiality, and culturally responsive training. Communicate those details if you offer 988 as a potential resource. Informed consent is a hallmark of ethical medical care, and should also extend to mental health support.
