Main Line: 202-559-3900
Donor Help Line: 202-559-3888
Toll Free: 1-888-35PSYCH
Email: [email protected]
988 (previously 1-800-273-TALK) is the new, easier-to-remember national suicide & crisis hotline that provides 24/7 confidential support via call, text, and chat to people experiencing a mental or behavioral health crisis. The hotline officially launched on July 16, 2022, but were states prepared for the rollout? Is 988 really the mental health version of 911? Today, two psychiatrists, Dr. John Palmieri and Dr. Eric Rafla-Yuan, join us to answer these questions and talk about the future of 988.
John Palmieri, MD, MHA, is a Senior Medical Advisor at SAMHSA and currently serving as the Acting Director for the 988 and Behavioral Health Crisis Coordinating Office. Prior to his arrival at SAMHSA, Dr. Palmieri was the Division Chief for Behavioral Healthcare at the Arlington County, Virginia, Department of Human Services. Dr. Palmieri is a licensed physician in the Commonwealth of Virginia and is Board Certified in Adult Psychiatry. He graduated from Brown University Medical School and completed his Adult Psychiatry Residency at Massachusetts General Hospital.
Eric Rafla-Yuan, MD is the 2021 American Psychiatric Association (APA) Jeanne Spurlock Congressional Fellow, and a voluntary assistant clinical professor in the Department of Psychiatry at the University of California San Diego, where he founded and led the psychiatry residency diversity committee. He graduated medical school and completed additional training in bioethics at the Vanderbilt University School of Medicine, and completed residency training at the UC San Diego Community Psychiatry Program. He currently serves on the APA Council of Advocacy and Government Relations, and previously served as the legislative director for the San Diego Psychiatric Society, and as a board trustee for the California State Association of Psychiatrists. His research focuses on policy and structural drivers of health outcomes and his work on clinical crisis services has been published in the New England Journal of Medicine and Health Affairs.
Joy Lloyd-Montgomery: Hello and welcome to Mentally Healthy Nation, a podcast from the American Psychiatric Association Foundation. I'm Joy Lloyd-Montgomery and I'm today's host. Most of us have had the experience of watching TV, and at the beginning or end of an episode, a message shows up on the screen. That message encourages you to call the National Suicide Prevention Lifeline at 1-800-273-TALK if you or someone you love is thinking about suicide. Since the hotline's inception, millions of people in crisis have been helped. And on July 16th, 2022, this 24/7 hotline got a new number, 988. But Lifeline didn't just get a new number.
Joy Lloyd-Montgomery: It also got reframed as the first part of the crisis care continuum. With federal and local funding, our country is striving to transform how we respond to mental and behavioral health crises, so people can have someone to call, someone to respond, and somewhere to go. But it's only the beginning and there's a lot of work that needs to be done to get us there. Stay tuned for my conversation with psychiatrists Dr. John Palmieri and Dr. Eric Rafla-Yuan as they give us the rundown of 988, dispel some common misconceptions, and provide us with insight into the future of mental and behavioral health crisis care in America.
Joy Lloyd-Montgomery: Well, thank you, Dr. Palmieri and Dr. Rafla-Yuan for joining us today. I'm really excited to talk to you about 988. To start out, I would like to talk a little bit about the development of 988. We know that the National Suicide Prevention Lifeline 1-800-273-TALK originally launched in 2005, and it wasn't until 15 years later in 2020 that the FCC designated 988 as a new number for all behavioral and mental health crises. And then I believe it was in October of 2020 that the National Suicide Hotline Designation Act was actually signed into law. I was wondering if both of you could talk a little bit about the significance of this happening in the first place.
Dr. Eric Rafla-Yuan: John, do you want to go first?
Dr. John Palmieri: Yeah, I can start. Thank you for that and for the question. The creation of this easier to remember, easier to access three digit code 988 as a portal into the National Suicide Prevention Lifeline, now known as the Suicide and Crisis Lifeline is historic and intended to make it easier for people to access needed services when they're in crisis, whether that's mental health, suicidal, substance use crisis, or any form of emotional distress, making it an easier to access method to link to trained counselors who can provide ongoing support, hopefully will reduce barriers, decrease stigma, and allow people who have thus far struggled in a system that has been highly fragmented and filled with gaps in terms of accessing services will make it easier for them.
Dr. John Palmieri: I mean, at the end of the day, it also has galvanized a national conversation about crisis services more broadly and the need for transformation and how we're serving individuals in need.
Dr. Eric Rafla-Yuan: I would echo that, especially the part about it really galvanizing momentum around examining how we as a country and how state agencies and local communities respond to individuals in distress who need help. For many, many years, for far too long, the way that our country has responded to people who need immediate mental health assistance by and large has been police and 911. I believe the Suicide Prevention Lifeline that NSPL launched in 2005, and that has been transformative to have a 24/7 available number.
Dr. Eric Rafla-Yuan: But with the move to 988, not only is it now easy to remember and also available not just by calling but by texting and web-based chat, it also has more support for its accessibility in different languages and if you perhaps need an interpreter for American Sign Language. The resources for this have all been greatly increased. I'm sure John will talk a lot about that because he's managing a lot of that work. But one of, I think, the most exciting things about the change to 988 is the fact that we are now giving mental health emergencies and substance use crises the same level of respect and care that they deserve, which is just like what you'd have for other types of emergencies.
Joy Lloyd-Montgomery: What did it take for that to happen in the first place, for this act to pass so we can give it the respect that it deserves?
Dr. Eric Rafla-Yuan: It took a lot of work and continues to take a lot of work. 988 itself is just the first step, and then now implementation is likely to be an ongoing process. It began like as a lot of good ideas at the grassroots level. In different states, there are a lot of different local crisis line numbers and also great variability in terms of their availability and how accessible they are and things like this. The move, originally the idea was to, can we just make this easier to remember? As that idea grew and gained legs, the idea of, well, can we make this more than just a suicide prevention number, but can we do more with it to be a broader response to individuals who are in a mental health crisis?
Joy Lloyd-Montgomery: You talked about the implementation, so I want to talk about that a little bit more. We know hundreds of millions of dollars in federal funding have been put towards supporting the implementation of 988. Dr. Palmieri, can you talk a little more about what that funding is actually going towards?
Dr. John Palmieri: Yeah, sure, happy to. In FY '22, there has been unprecedented federal investment in the Lifeline system at a total of $432 million. And just as a point of comparison, looking at FY '21 budget for the Lifeline, that was at around $21 million. You can see there's been really exponential increase in investment to support the Lifeline Network and expansion. As Eric pointed out, I think historically it's been well-documented that the system has struggled with resource challenges. The result of that being that people in crisis haven't easily been able to access care, often leading to the default response, which has unfortunately in many communities been 911 or law enforcement.
Dr. John Palmieri: The $432 million includes $177 million that was provided to the Lifeline Network Administrator. That organization is Vibrant Emotional Health, and that funding went to support a number of key functions to support Lifeline capacity, including infrastructure, technology training, standard setting. The Lifeline Network Administrator also oversees some key national backup functions, including text and chat currently, the backup call centers, and the Spanish subnetwork.
Dr. John Palmieri: And then, importantly, there was $105 million that was awarded to states and territories as part of a new cooperative agreement opportunity with the intent of supporting states' territories in building local capacity to respond to 988 contacts and ultimately link to other services in the crisis continuum. We think it's extremely important to build out that local capacity, because at the end of the day, for the person who's in crisis, it's going to be critically important for them to be linked to local resources in their local service network to provide the wraparound and supportive services that they're going to need on an ongoing basis.
Dr. John Palmieri: And then more recently, there's been $150 million that's been allocated to the Suicide and Crisis Lifeline through the Safer Communities Act, and we are currently flushing out the spending plan for that. But much of it will continue to be focused on expansion of services, both for the national backup function and for the local capacity, as well as driving forward ongoing work in collaborating with 911 to promote diversion opportunities and also to make sure that we're continuing to expand services for Spanish speakers and other populations as well.
Joy Lloyd-Montgomery: I want to echo what you said about the importance of the local support and mentioning that for the people who are the callers, I also thought about the counselors, those answering the lines. Just so you all know, I'm actually a former Lifeline counselor, so this is something I'm particularly interested in. I'm sure you know a lot of the counselors across the country are volunteers. The culture tends to be when you have a really tough call, we are here for you as your fellow counselors, but I'm wondering if there's any funding for supporting the mental health of these hotline counselors or if this is something that more local organizations and states can advocate for.
Dr. Eric Rafla-Yuan: As far as I know, no congressional funds have been specifically designated for that purpose. I will say that there has been a huge issue of we just don't have enough counselors to respond to the number of calls or centers are rapidly trying to hire more counselors. There are funds that have been allocated to support some of that workforce development. I think making sure that we have enough counselors and that counselors get the training that they need to feel comfortable handling calls as well.
Dr. Eric Rafla-Yuan: Because something else that has come up is sometimes counselors feel that they might not have the support that they need in handling some of these really kind of serious and sometimes life or death situations. Making sure that they feel that they have the adequate support and training to respond to that and that they have supervisors or other individuals they can rely on when things get more difficult.
Dr. John Palmieri: And just to build upon that, wanting to acknowledge the tremendous work that crisis counselors are providing and investing in the mental health and well-being of the nation and extremely appreciative of everything that they do on a daily basis to support individuals in crisis. One of the pieces that the investments have gone to support has been to make sure that we're paying counselors appropriate wages to support the work that they're doing, recognizing that volunteers are always going to continue to be important and very appreciative of volunteers.
Dr. John Palmieri: But this is a system that has had historically relied extensively on volunteers to provide the network response and wanting to create a system where there's still obviously opportunities for volunteers who bring lots of value to the system and at the same time making sure that we're paying people decent living wages to be able to provide the service in a way that doesn't create more strain and stress for them because of their own personal circumstances. And that the overall health and well-being of this field is critically important, and that comes through cultural changes at the organizational level in terms of how staff are supported, the development of supervision and other resiliency supports.
Dr. John Palmieri: There has been funding at the federal level that has gone to HRSA that has been focused on resiliency and well-being among healthcare workers and first responders more broadly. Some of that does include standing up technical assistance opportunities to support resiliency and well-being among workers. That's an area that we will continue to collaborate with them on and continue to build out. Workforce, as Eric said, is a huge challenge. We recognize that retention and recruitment are challenging.
Dr. John Palmieri: We need to make sure that these are positions where people feel well supported, that have sufficient flexibility and where we're lifting up the mission, because I think that the mission of the work is something that resonates strongly with people as an appealing element of the work to attract workers. We are working to engage community colleges, colleges, other institutions in the education system to think about how we're developing pathways and providing opportunities for young people to identify crisis counseling as a reasonable career path.
Joy Lloyd-Montgomery: Yeah, I wouldn't even have known about it had I not been recruited in college. I was a psychology major and they came into one of my psych classes and told us about it.
Dr. John Palmieri: I would like to hear about that experience more so that we could think about replicating that.
Joy Lloyd-Montgomery: Yeah, offline we could definitely talk about it. We had a pretty good pipeline, I guess you could say, of counselors, the call center I worked at in Florida. I was there as a volunteer and then ended up getting hired later and answered multiple lines, but Lifeline being one of them. I definitely hear you about the mission resonating with folks. It was kind of a no-brainer after I heard about it. So, I'm glad to hear that there are conversations and efforts in the works to support these counselors.
Joy Lloyd-Montgomery: It's also great to hear about the funding that's going towards this because how can you really... Not this in particular, but this effort of 988 in general because how can you really say that you care about this without putting your money where your mouth is, I guess. In that same vein, I know there's a lot of money going towards it right now, but is there a plan for continuous federal funding to support the sustainability of 988, or is it going to be more the state's responsibility in the future?
Dr. Eric Rafla-Yuan: This is an area of ongoing work. I will say that. I will also take a minute to talk about what I want to call the crisis continuum of care, which 988 is the first piece of. Historically, there has been congressional funding for the National Suicide Prevention Lifeline, but historically, there has not been congressional funding for the regional call centers. And historically, there has not been funding just because it hasn't existed for the crisis continuum of care. I'm sure we'll talk about this more later, but briefly, it is having someone to call, which being 988, and then the large majority of calls are able to be resolved over the phone.
Dr. Eric Rafla-Yuan: But for the smaller percentage that aren't be able to, having an in-person response with a mobile crisis team. Importantly, that's generally not law enforcement. Instead, it's mental health professionals who may be assisted by nurses, medics or peer specialists. And then the large majority of incidents that field-based team is able to handle if it's on the street or at the person's home, at the school, wherever the situation is. If they're not able to handle there, then there's somewhere to go. Just like for other types of medical emergencies, you call 911 and an ambulance comes and they have EMTs and paramedics, and then they can perhaps resolve the situation there.
Dr. Eric Rafla-Yuan: And if not, then get you to an emergency room. Having that full continuum of care is something that's still in process and each piece of the continuum, the funding source is different. But to put it simply, we have done a great job investing in the initial investments in terms of what it was before. President Biden's budget request for 988 and crisis continuum of care this year has been roughly around $700 million. I'm happy to say that both the House and the Senate appropriations bills at this point in time do respond to that request in full.
Dr. Eric Rafla-Yuan: Still remains to be seen, how these bills will move forward and what will ultimately pass, but making sure that both the 988 itself is funded, as well as the different steps of the continuum of care. Still work remains to be done and advocacy to make sure that this happens.
Dr. John Palmieri: I would add to your question that there is an important piece of partnership here with states territories as well that I think is critically important around the sustainability piece. As Eric pointed out, there has been a lot of positive movement at the federal level in terms of funding and important signaling about potential resources to come to support 988 services and ultimately a strong desire to link that to the broader crisis continuum.
Dr. John Palmieri: There are other federal resources that do exist to support crisis services, including the Mental Health Block Grant prices set aside as one example that has existed even prior to this recent allocation of funding specifically for 988. That can help states and territories support service expansion along the crisis continuum. At the same time, we recognize that there is an important role for states to play in helping to build out local capacity. Some states have passed legislation for fees attached to cell phones as permitted in the Hotline Designation Act.
Dr. John Palmieri: There are four states that have done that. Other states have allocated funds in a separate manner to support 988. Many states have formed commissions. Some states are leveraging Medicaid resources to support 988 and crisis services. It's going to take all of those efforts combined to continue to work in concert to get to the place that we need to be with respect to that full continuum of crisis services.
Joy Lloyd-Montgomery: How much time do you think that'll take for us to really build out this full crisis care continuum?
Dr. John Palmieri: I do think it's going to take time. I think even with respect to 988 capacity and local capacity for 988, so really focusing on that first component of the crisis continuum, that in and of itself is going to take time. We have consistently described this as a transformative journey and very much believe that this is a journey. We have made huge progress over the past year in supporting expansion of 988 and certainly even local capacity for answering calls. One of the things that we track as part of our metrics is in-state response rates for 988 calls, and that continues to move in a positive direction. We ultimately want texts and chats to be answered at the local level as well.There's a lot of work to be done there.
Dr. John Palmieri: We have set some benchmarks in time for what we would like to see in terms of movement for access to mobile crisis services and crisis stabilization services over the coming years. Ultimately, we want to get to a system where there's 100% access across the board as there is for many medical conditions to make sure that we have a system that's fully built up. But we do think that that's going to take time to get to that place, but hoping and actually seeing encouraging signs of progress along the way. There are some communities now that have a very well integrated continuum of crisis services that can serve as a beacon for amplification for the rest of the country.
Joy Lloyd-Montgomery: Are there examples that you all know of that you could share of states or local organizations or territories that are leading the way in this effort?
Dr. Eric Rafla-Yuan: There are a number and some of these actually predated 988. Perhaps one of the most commonly referenced one is called CAHOOTS. This was from Eugene, Oregon. That was one of the most early kind of widespread models. There has been some federal programs that use the CAHOOTS name. However, something that was an issue was a lot of these were smaller pilot programs and they served a single city or a single area. It wasn't something that was a reliable thing for everyone in that community or that larger state to access. What we began to see was a pattern of more urban areas or areas that had more political will or more resources to invest in these.
Dr. Eric Rafla-Yuan: It's been exciting to see now with the support that 988 is getting at the federal and state level, that there's more thought happening with the leadership in terms of how can we make this accessible for everyone in our state and our community. There have been movement at this. Arizona is another example I'll put out, which at the state level has had great leadership in terms of investing in infrastructure. That's broadly available for residents of the state.
Dr. Eric Rafla-Yuan: Some other good leadership is happening in LA County, which has really also been at the forefront of looking at some of how does 988 interact with 911 and how can we really reduce reliance on police and 911 for mental health and shift this over to 988. Part of that is making sure that the 988 mobile crisis response is reliable. There's been a lot of work there. I think as we move forward and as people get to know 988 more and come to assume that 988 will be reliable or have good experiences with 988, that it'll continue to move in this direction.
Joy Lloyd-Montgomery: For those of us who are not in an area like LA County or Arizona that have a more built-out system, what should someone expect right now if they call 988?
Dr. Eric Rafla-Yuan: That's really a challenge. That's something that we've gotten a lot of questions on. The difficult and complicated answer is it depends on where you live. In some places, it will depend on what's your city lines or county lines or state lines. If you called 988 anywhere in the country and in four US territories, in all 50 states, four US territories, you'll get connected to 988 Lifeline counselors. However, the rest of the continuum of care will be variable depending on where you live. Would you say that's accurate, John?
Dr. John Palmieri: I think that's entirely accurate. I think there's a lot of still variability across the country, across states, localities. I think that experience of care, which ultimately we want to lift up to a standard expectation for what people should expect when they contact 988, there's still variability about what happens after that 988 contact. As Eric said, there is standardization in terms of what people should expect when they contact 988 in terms of the connection to the counselor, but what happens after that will depend a bit on one's location.
Joy Lloyd-Montgomery: Is there anything that can be done right now to help ensure that people who call 988 who aren't a part of that 80% and their call gets resolved that they can get the help that they need? Are there advocacy efforts that we can get involved in and things like that?
Dr. Eric Rafla-Yuan: I love advocacy.
Joy Lloyd-Montgomery: It seems like it.
Dr. Eric Rafla-Yuan: The senator from New Jersey I think is a great quote, "Change doesn't come from Washington. Change comes to Washington." I think that's really true. I think if people want to advocate, that there is a great need for it at all levels. I think John did an excellent job of explaining 988. There's federal leadership, there's state leadership, and there's local community city county level leadership. We need advocacy at all those levels to keep those leaders both accountable and also helping educate them on why this is important in those communities. I think we'll see more of this as we go forward.
Dr. Eric Rafla-Yuan: Because right now if a state decided, well, in our state, we just don't really prioritize ambulances. If you call 911, we just don't have ambulances. Residents of the state probably wouldn't take that for an acceptable answer. I'm hoping to get to a place with 988 and mobile crisis response and things like this where it becomes an expected thing that people believe this is an important service to have in their community. It will take advocacy at those different levels to move us there.
Joy Lloyd-Montgomery: I want to talk about 988 awareness. I think the last poll I saw showed that less than 15% of the public or something knew about 988, and I know a lot of healthcare professionals aren't aware either. How is educating the public about 988 being managed, especially in areas that aren't prepared we just talked about?
Dr. John Palmieri: Yeah, it's a great question. We have been spending a lot of time working through communications planning around 988 and believe completely the public awareness and expanded public awareness around 988 and the lifesaving services that it provides is critical across the nation. It's one of the reasons that we at SAMHSA have been working closely with partners both to develop a messaging framework around 988 and to build out a partner toolkit, which includes a number of products, downloadable materials, social charitables, FAQs, radio scripts and so forth to support aligned and coordinated messaging around 988 with the idea that these would be materials that could be disseminated by our partners to support broader public awareness of 988.
Dr. John Palmieri: Having said that, two of the limiting factors at the moment are, one, we don't have funding at the moment for a large-scale national 988 campaign, but expect fully that that will happen and it will be critically important that it does happen. We're building some foundations for that campaign right now, which I can speak to a little bit more. And then the other piece around messaging, understanding that as we've provided a framework, as we've built out a toolkit to help partners disseminate messaging, how they do that in their states and localities is going to depend a little bit on the circumstances that are unique to that location based upon the resources that are available, what somebody might expect when they call 988, for example.
Dr. John Palmieri: Because there's still a fair amount of variability as we talked about, there's going to need to be some nuancing at the local level about the extent to which the messaging is going on and what people are actually saying about what's going to happen when people contact 988. Ultimately, we are moving to a place where there will be standard, hopefully, expectations and experience of care, but we're not there yet. We do recognize that there's going to need to be some local variation in the degree and the volume, the titration of what that messaging will be.
Dr. John Palmieri: At the same time, while we're thinking about this broader public awareness campaign, one of the key underlying drivers of that is making sure that we are having reach and impact particularly for populations that we know to be at higher risk of suicide and populations that we know have faced inequities and burdened with inequities either in access or outcomes from a fragmented system.
Dr. John Palmieri: We're engaged now in some foundational work looking at some of those populations, understanding better their knowledge, attitudes, beliefs about help-seeking behavior, who their influences are, what are their preferred channels of communication to make sure that as we ultimately, hopefully, have resources to build out a national behavior change campaign, we're focused specifically on those populations that we know to be at higher risk.
Dr. Eric Rafla-Yuan: I'll add a couple things. I think part of the beauty of 988 is that it's so easy to remember. Probably most of the listeners, if this is their first time hearing 988, they've already got it. They've already know that 988 is already with them. It's easy to remember. There's two areas in that are related, which think I think actually have more concerns about. One is making sure that there's a reliable response when people call 988, that they get the response that they find supportive and is timely and it is what they expect, and that they find it supportive to their situation. That's one, because I think that's critical.
Dr. Eric Rafla-Yuan: Because if someone calls 988 and their state, city, county has really not decided to invest much in this and there's a really long wait time or there is not the connection to services that they were expecting, I think that that's really disappointing. They'll tell their friends and family, "I had a not good encounter with 988." Whereas if it was a good encounter, I think it'll really go the other direction in terms of spreading awareness. And then the other piece that I've seen, and John's agency is probably working on this as well, is there's a decent amount of misinformation and just confusion and mistrust floating around about what 988 is and what it isn't.
Dr. Eric Rafla-Yuan: For example, there's these media posts that's been shared a lot on social media that basically says that 988 is tracking you if you call. People I think have concerns. Making sure that when people do have contact with 988 that it's reliable and timely and supportive, and then dispelling some of the misinformation that's out there.
Dr. John Palmieri: I think, Eric, that public trust component is extremely important that we're making sure that we're building trust in the system, both through the response and making sure that the system has the capacity to respond to individuals and also providing accurate information about what people can expect when they call 988 and making corrections to inaccuracies when they arise about the tracking conversation that you're having or some communications that I've seen in social media about the degree to which police response accompanies 988, which has been misleading and not accurate in line with the statistics that we have been tracking.
Dr. John Palmieri: I think those things are critically important, particularly for communities that may already be mistrustful of the system or have had particular experiences with 911 or other systems that have been launched at the national level that make them already hesitant to seek supports through 988. We have to make sure that we're providing accurate information, that we're building capacity, that we make sure that we're communicating with the system is for them as well. And then again, we're looking back at how we're messaging to make sure that we're communicating in a way that resonates for them.
Joy Lloyd-Montgomery: I really appreciate both of you bringing up that point. Obviously, misinformation tends to be an issue across fields, but in terms of it serving as a barrier to people getting care is really unfortunate. I'm glad that both of you and SAMHSA and other folks are actively working to dispel those myths. The framing is so important too, because like you said, Dr. Palmieri, there are a lot of folks who have not had a good experience with 911. For people to say that 988 is like the new 911 but for mental health might not be the best thing to say for some communities to build that trust.
Joy Lloyd-Montgomery: If you're talking to black and other minoritized communities, they're probably not going to be particularly compelled to call 988 after hearing those comparisons. I really appreciate both of you talking about that.
Dr. John Palmieri: Thank you for that comment because it is one of the things that makes me wince often when people say 988 is the 911 for mental health crises because I think that that comparison is misleading and is harmful in some ways, particularly for communities that have had those negative experiences with the 911 system. And they're very, very different systems. I think that is important to understand. 988, as Eric pointed out earlier, is an intervention in and of itself.
Dr. John Palmieri: The vast majority of people who contact 988 get what they need from that 988 contact, stabilizing their particular situation, deescalating a crisis, providing linkage to ongoing supports. 911 is largely a dispatch service where somebody is dispatched because of a public safety concern. 988 is largely not a dispatch service, most of those services and in that moment on that particular contact with a follow-up plan developed afterwards. They're very, very, very different systems.
Joy Lloyd-Montgomery: I guess, maybe because of the nature of the system, and this is part of the reason why we have 988 now, but there are a lot of folks experiencing a mental or behavioral health crisis that they call 911 or somebody calls 911 for them and they often don't want them to get arrested or anything, but they end up being put in jail instead of connected to the care that they need. We don't want that to continue to happen.
Joy Lloyd-Montgomery: So, what strategies are being implemented to really make sure that we're preventing these outcomes for folks that call 988 and how are we going to ensure that there are equitable responses across communities so it's not just in an affluent community. You'll have have a mobile crisis team and you'll be able to go to a center if you need to and all of that. But in the more under-resourced areas, how do we know that it won't just end up being kind of a replication of 911?
Dr. John Palmieri: I think the importance of building out the flow crisis continuum so that it's accessible equitably is critically important so that there are opportunities when people call 988 and they might need mobile crisis or same-day services from a behavioral health professional that those are accessible to those individuals no matter where they happen to be. That's very much important. There's a huge piece here around data, because we need to be able to look at data to inform and improve equities and how the system is performing. We do need to understand who's calling into 988, what the disposition of those contacts is in what communities, where there are communities that are not contacting 988.
Dr. John Palmieri: We need to be able to disaggregate all that data to be able to make informed decisions about where we need to be focusing our resource efforts, where we need to be focusing our communication efforts, where we need to be focusing our performance improvement efforts. I think there's also another critical piece in addition that's related to communications, which is also recognizing that we need to be sure that other partners who are involved in these responses are aware of 988 and what the options are for diversion away from law enforcement. That does include police. It does include emergency medical providers. It does include 911 centers. We're doing a lot of work with partners across the federal government to make sure that there's broad awareness of 988 services in those communities as well because they are, in some cases, still the first point of contact for individuals in crisis. They need to be aware just as the behavioral health community needs to be aware that 988 is an option and there are opportunities at every point along the way to divert people away from law enforcement response and the criminal justice system.
Joy Lloyd-Montgomery: Yeah, The Sequential Intercept Model.
Dr. John Palmieri: The Sequential Intercept Model. Exactly.
Dr. Eric Rafla-Yuan: Couple things I'll add. One, I think that the continued federal, state, local partnerships are needed to make sure that this is really accessible everywhere, because there's been even right now uneven uptake or implementation across the country. I think part of that is just in what states have the leaders who are invested in this and what states there have a lot of advocates for this. I think we're seeing the result of that and implementation. I think we will see a general move towards this as there's more implementation across the board, but I think it's going to continue to be uneven and it's really going to need to be those advocates that help move this along so that it continues to remain a priority.
Dr. Eric Rafla-Yuan: One of the things I'm a little bit worried about is 988 in itself is an intervention and I think it's an amazing step, but to make sure that the momentum continues behind 988 around the rest of the implementation of the crisis care continuum. I've been talking about July 16th, 2022 for a long time. I don't have a new marker date, but the continuing to after that July launched our transition period, hoping to see the momentum continue forward on this implementation across the board.
Joy Lloyd-Montgomery: When this episode airs, 988 will have been live for a little over a month I believe. Are there any updates that you can share with us maybe, Dr. Palmieri, during these first couple of weeks or the month when that will have passed when this episode airs that you think will be relevant to share with listeners?
Dr. John Palmieri: Sure. A couple of things and our plan, just for your awareness and for listener's awareness as well, is to promote more transparency in how the system is performing moving forward so that they'll be broader public awareness of response rates and time to response so that we're all collectively looking at the performance of the system and all working to improve the performance of the system. We expect that that moving forward will be something that will be more accessible so that there's easier public awareness and consumption of that information. I will say since the 16th, the transition date, overall I would say the transition has gone successfully and gone smoothly.
Dr. John Palmieri: Certainly from a technology perspective, from a security perspective, that has gone very well and there's been a lot of planning behind the scenes to make sure that the system is prepared for that transition date. I feel like that has gone very well. There has been significant increase in volume as you might expect with this transition. Even though there hasn't been, perhaps to your point, full awareness and visibility into 988, there has been a lot of media coverage around 988 and awareness certainly among our partners around 988.
Dr. John Palmieri: There has been a significant increase in volume to the tune of approximately 45% increase from the week during the transition as opposed to the week prior, and that translated to about 23,000 more people who are able to be supported through the Lifeline through call, chat and text that week of the transition compared to the week prior. We also are noting that there has been significant improvement in response at the local level. We are feeling like our engagement with states and territories, both through appropriations and through ongoing partnership, is starting to pay dividends in terms of local response.
Dr. John Palmieri: Not most importantly, but certainly importantly, our response for text and chat, which still currently are by and large a national service, are still handled at the national level. We had flagged in our reports to Congress and public reports that text and chat in particular were areas where the system was underperforming, which is, of course, concerning because of preferences largely by youth populations to use text and chat and understanding that some of those populations are among the highest risk for suicide. Text and chat response capacity has improved tremendously in the past month with respect to 988 and is a reflection of a lot of the investments at the federal level that have supported that.
Dr. John Palmieri: So, we're very encouraged in particular by chat and text response. Again, we will be coming out with more granular data to back up what I'm saying here. But overall, I think there are a lot of encouraging signs in the performance of the system and improving access for those individuals in crisis.
Joy Lloyd-Montgomery: Are there other plans other than what we've already talked about for the future of 988 in the next few years? What would you like to see?
Dr. Eric Rafla-Yuan: One piece, which I think is of great interest to a lot of advocates and to a lot of the state partners, as well as SAMHSA, is the issue of making sure that when someone calls, that their call is routed to the call center that's geographically closest to them. The importance of this is that it's connected to someone who works and lives in that community and who can importantly connect them to the resources in that community. Right now, 911 has basically special privileges, special technology that no other number has and one of those is basically geolocation-based routing.
Dr. Eric Rafla-Yuan: One of the issues right now is that if you call 988 and you have an area code, it will go to the call center that's in that area code. For example, I have a California area code. Even though I'm in Washington, DC my call will go to somewhere in Northern California, in the Bay Area because that's what my area code is. And that it'll be very difficult or not happen at all to connect me to crisis resources here in DC should I need them. That is I think one of the next major challenges.
Joy Lloyd-Montgomery: Earlier on in our conversation, you talked about how with geolocation people are really afraid of being tracked. You're saying it could actually be a good thing.
Dr. Eric Rafla-Yuan: This paradox of that we need more specificity in where you are to have less law enforcement response. Because part of the issue is 911 has special privileges. And if 988 doesn't get some privileges as well, we're just going to have to continue to rely on 911 for some of those needs. And then I'll also point out that there's a difference between the actual physical GPS coordinates of someone and the routing to have their call go by geographic proximity rather than area code.
Joy Lloyd-Montgomery: Right, absolutely. But how do you communicate this nuance to folks?
Dr. Eric Rafla-Yuan: That's been challenging, and I think I'll hand it over to John because it's something that they're actively working on right now.
Dr. John Palmieri: There is a lot of work happening in this space. Some of it falls squarely within the domain of the FCC, but we have been doing a lot of work in collaboration with them. The FCC issued a report back in 2021 recommending an advisory group to look at the issue, the issues around geolocation. We recently had a convening in May of this year with the VA and the FCC to further that conversation both around geolocation and around some of what Eric is talking about in terms of geo routing, which may be something that provides less precise location data, but would route you to a local center based upon where you are through other mechanisms.
Dr. John Palmieri: That conversation continued to further awareness and discussion around the need for balancing both the safety and the local integration of service needs that come with people in crisis and I think a lot of legitimate privacy concerns that people have as well around geolocation. The FCC is taking all of that information back from this most recent convening, deliberating on next steps and recommendations. But I think that there are some options here between what we have now and full on geolocation that could potentially provide a balance of some of the safety and the privacy issues that people are raising.
Joy Lloyd-Montgomery: Dr. Rafla-Yuan, earlier you emphasized the importance of advocacy. I would love for both of you to talk a bit more about what we can do to contribute to the successful implementation of 988 and the whole crisis care continuum from mental health professionals and clinicians, like both of you, to policymakers and even just the general public. What can we do to support it?
Dr. Eric Rafla-Yuan: I think advocacy for some people is a scary word and big fancy buildings and really serious intense meetings, but it really depends on what someone's strengths are. There is legislative advocacy where you do meet with your elected officials and regulators for either education or telling them what the priorities of you and your community members are. But there's also advocacy in terms of just spreading the awareness among your friends and families and circles and networks about the importance of 988 and making sure that everyone is educated about these life-saving services and so that they in turn can help continue to spread the word.
Dr. Eric Rafla-Yuan: If someone is more invested and wants to do what you did in terms of volunteering and being part of that crisis center community, then that's another way. For professionals, I think there's a big need as well to help educate patients, as well as how mental health professionals and other medical professionals as well can rely or know how 988 will integrate into their practice or how they speak to patients about things. For a lot of mental health clinicians, there's a standard line of if you're having thoughts of suicide or feel unsafe, call 911 or the National Suicide Profession Lifeline, which is the national number or the local number that you have.
Dr. Eric Rafla-Yuan: 988 is now going to be a part of that script and knowing what's active and available in your community and if there are efforts that you can do to help strengthen these or push for their implementation. I think there are a lot of different things to do, but one of the first pieces for any of that is to make sure that you yourself are educated on what 988 is and how to operate in your local area.
Dr. John Palmieri: Yeah, agree completely with everything that Eric said. I think from the federal level, certainly continuing to work with states and other partners around public awareness, around this broader national campaign to drive change in help-seeking behaviors for people with respect to 988. We want to make sure that we're continuing to provide ongoing technical assistance and support around implementation challenges, that we're partnering with states around creative financing and workforce solutions to continue to build out crisis system capacity, that the provider community is aligned on what 988 is and providing consistent messaging around that.
Dr. John Palmieri: I think Eric highlighted some ways that people can look at some of their internal organizational practices around voicemail messaging or discharge summaries or other ways that people can be informed of the availability of 988 as opposed to contacting 911 as the default response. And then I think for the general public, amplifying the conversation and awareness around 988. I think every time that we can do that, we're working to erode stigma. I think one of the tremendous benefits of 988 is that it has amplified a national conversation around mental health and substance use needs.
Dr. John Palmieri: This has happened from the White House on down. I think it's really important that for individuals in their communities to continue to amplify awareness and visibility in 988, because it will facilitate help-seeking behaviors and decrease stigma for individuals who may be struggling.
Joy Lloyd-Montgomery: I agree. So, obviously we know there's a lot of work to be done and I appreciate the transparency that both of you shared during this conversation today. But like you said, Dr. Palmieri, 988 is a step in the right direction. The communication that is surrounding it and the conversation about mental health I really think is playing a role in decreasing stigma. I mean, I am steeped into mental health every day in my job, but I have seen much more of a national conversation about it. It's great to see that momentum finally. I am hopeful, honestly, about the direction and attention that mental health will get in the future and that it's getting now. Before we go, I would love to hear what else makes you too hopeful?
Dr. Eric Rafla-Yuan: One thing I think a lot of people don't know as fact is 911 has not been part of the fabric of the United States for the majority of our country's existence. It's somewhat recent phenomenon in terms of 50 or 60 years ago, if you had a heart attack or you had a stroke, where it what was increasingly happening at that time, if you were in a car accident on one of these new highways, you had called your local emergency services provider number, that infrastructure wasn't really there. What happened was local law enforcement would ferry you in the back of their police car. There were some other private individuals or corporations that did a little bit of this work, but mostly it's police.
Dr. Eric Rafla-Yuan: They take that person with that medical emergency and take them to a hospital room. There were not really widespread emergency rooms for EMTs. 50, 60, 70 years later, we are now just taking that step for mental health and substance use crises. We're still where the rest of healthcare and medicine was 50, 60, 70 years ago and now making these changes. But if you talk to most Americans on the street and you ask them, what happens when you call 911, everywhere across the country, they can give you a pretty standard and reliable response.
Dr. Eric Rafla-Yuan: I'm hoping that as we move forward, 988 gives us the footing and the mechanism to have this reliable response for the seriousness and respect, timeliness in services that mental health and substance use crisis deserve and need.
Joy Lloyd-Montgomery: I appreciate that historical context too, because I don't think a lot of people know about the history of 911 and how recent it really is, especially the younger generations.
Dr. Eric Rafla-Yuan: 911 originally was just policing too and it wasn't until federal legislation in 1973 with the EMS Systems Act that passed Congress where the widespread... EMS systems that we have at the county and state level across the country are now pretty standard, but that as well took time.
Dr. John Palmieri: Agree with that. I think what gives me hope is part of what we talked about just a few moments ago, which is the conversation that's happening at the national stage. I would say that there is tremendous engagement and enthusiasm and motivation to take advantage of this opportunity that is presented with 988 to build out a more just and equitable crisis system for individuals in need. The level of enthusiasm and engagement is huge and palpable really in just about every meeting that I've been involved in recently. We need to continue to build upon that. And it's also extremely encouraging that with investments that have come this year, there has already been meaningful impact.
Dr. John Palmieri: That tells me that if we can continue to build out those investments, there's a lot more that we can do to provide support for those individuals in need. I feel very encouraged by the early signs of yield on investment. I feel extremely encouraged by the level of engagement in the conversation, and I think that there is tremendous opportunity to move forward. I appreciate Eric's context about 911. It will take time. It is going to be a journey, and I think that we can accelerate that progress continuing on the path that we're on.
Joy Lloyd-Montgomery: Well, that's a beautiful note to end on. But before we go, I just want to lay out the carpet for both of you if there are any words of wisdom or things that you would like to share with the audience before we go here. Please feel free.
Dr. Eric Rafla-Yuan: I think going back to the crisis continuum of care piece, I think this is the part that I think needs the most advocacy going forward. I think it has tremendous opportunity to really transform how we respond to mental and behavioral distress in the United States. This ranges not just from someone having an immediate mental health crisis, but something as well where we can develop wraparound supports, where we can support kids in school, and really move towards community-based programs where we can support people in need. I think that 988 gives us a lever, momentum mechanism to connect to some of these things.
Dr. Eric Rafla-Yuan: One of those things that it provides is easy to remember, easy to access, universally available point of contact that only really has existed for 911 before. Just like 911, well, originally it was law enforcement, but now it's fire and now it's police and EMS, emergency medical services. This is the first time where we now have the opportunity to connect some of these other pieces as well.
Dr. John Palmieri: And also really focusing in on the importance of coverage for mental health and substance use services. We haven't talked a lot about parity in this conversation, but I think it is an important piece that will be a sustaining factor as we think about the crisis continuum. Making sure that we are continuing to have conversations about the health benefit need for payers to be able to be at that table and at that conversation to support the sustainability of these services.
Joy Lloyd-Montgomery: Very important piece. Thank you for adding that before we go. Well, thank you Dr. John Palmieri and Dr. Eric Rafla-Yuan for joining us today on Mentally Healthy Nation. It was a really fruitful conversation, and I even learned some more things too. I really appreciate it and thank you.
Dr. John Palmieri: Thank you all so much.
Dr. Eric Rafla-Yuan: Thanks.
Joy Lloyd-Montgomery: Dr. John Palmieri is a Senior Medical Advisor at the Substance Abuse and Mental Health Services Administration, also known as SAMHSA, and currently serves as the acting director for the 988 and Behavioral Health Crisis Coordinating Office. Prior to his arrival at SAMHSA, Dr. John Palmieri was the division chief for behavioral healthcare at the Arlington County Virginia Department of Human Services Service. Dr. Palmieri is a licensed physician in the Commonwealth of Virginia and is board certified in adult psychiatry. He graduated from Brown University Medical School and completed his adult psychiatry residency at Massachusetts General Hospital.
Joy Lloyd-Montgomery: Dr. Eric Rafla-Yuan was the 2021 American Psychiatric Association Jeanne Spurlock Congressional Fellow. He currently serves on the APA Council of Advocacy and Government Relations and previously served as a legislative director for the San Diego Psychiatric Society. He graduated medical school and completed additional training in bioethics at the Vanderbilt University School of Medicine and completed residency training at the UC San Diego Community Psychiatry Program. His research focuses on policy and structural drivers of health outcomes and his work on clinical crisis services has been published in The New England Journal of Medicine and Health Affairs.
Joy Lloyd-Montgomery: Thank you so much to our listeners for joining us. If you want to learn more about the work being done at the APA Foundation, you can visit apafdn.org. If you enjoyed what you heard today, please share this episode with a friend, family member, or colleague. I'm Joy Lloyd-Montgomery. Take care.
Disclosure: The views and opinions expressed in this podcast are those of the individual speakers in their personal capacity only and do not necessarily represent the views of the American Psychiatric Association Foundation or the views, official policy, or position of the institutions and organizations with which the speakers are affiliated. The content of this podcast is provided for general information purposes only and does not offer medical or any other type of professional advice. If you're having a medical emergency, please contact your local emergency response number.