Alana Casanova-Burgess: Hi, everyone. This is The Takeaway. I'm Alana Casanova-Burgess from WNYC, host of the La Brega podcast in for Melissa Harris-Perry. Just a heads up. We're going to be talking about some difficult mental health issues today. Difficult, but essential.

911 Operator: 911, what is your emergency?

Alana Casanova-Burgess: Since the late 1960s, 911 has been the all encompassing number we're told to call in an emergency, an easy to remember code that was also easy to dial on a rotary phone. 911 calls typically dispatch law enforcement, paramedics or firefighters, but a study put out earlier this year by the criminal justice reform nonprofit, Vera, looked at nine major cities over two years and found that nearly 20% of 911 calls were related to mental health. Experts have long said that these types of calls do not require a police response. An estimated 52 million Americans are thought to be living with some form of mental illness. That's about 1/5 of all US adults.

Since 2005, the National Suicide Prevention Lifeline has been one option for people in crisis. The number 800-273-Talk has connected callers to a network of 200 local call centers, but it's a long number. It's clunky, it's hard to remember and it's specifically tied to suicide prevention. In 2020, Congress unanimously passed legislation to mandate a new three digit number, 988, a nationwide lifeline to provide support for people struggling with mental health, substance abuse and suicidal crisis.

Here's former US House representative and current Montana Governor Greg Gianforte, who was part of a bipartisan group, which introduced the legislation to create 988.

Greg Gianforte: No matter where you are in the country, just like when you call 911, when you call 988, you'll be connected to mental health resources.

Alana Casanova-Burgess: Now, two years later, 988 is about to come online. On July 16th, this Saturday, it'll go live.

Hannah Wesolowski: When somebody's experiencing a mental health crisis, they're feeling paranoia, they are conducting self harm, they are experiencing suicidal ideation or they're in any range of emotional distress, 988 is going to be a resource for them.

Alana Casanova-Burgess: Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness says the number will be key.

Hannah Wesolowski: When someone dials 988, they will be connected to trained crisis counselors who are there to listen, to provide support, to deescalate the situation.

Tonja Myles: I'm a three-time suicide attempt survivor.

Alana Casanova-Burgess: Tonja Myles, a peer support specialist and community activist testified before the House of Representatives in 2021.

Tonja Myles: For over 28 years, I've been blessed to wake up every day on a mission to push hope for those who suffer from addiction, mental illness, individuals incarcerated and formerly incarcerated.

Alana Casanova-Burgess: We reached out to Tonja. She told us that she had dealt firsthand with police coming to the scene in response to a mental health concern.

Tonja Myles: When I had my crisis, the only choice that my family had was to call 911. There were two law enforcement officers that came on the scene. One treated me like I was in crisis, the other treated me like I was a criminal.

Alana Casanova-Burgess: Her own experience underlines the risks of sending officers with little training to deal with someone in crisis.

Tonja Myles: They're already confused and they're concerned and in a place of trauma, and so when someone who is not trained to know how to deescalate, to talk to someone that's in a crisis, then that crisis can become something that nobody wants to see. It can become now, that person who's in crisis is now handcuffed, maybe going to jail, so we want to avoid that.

Alana Casanova-Burgess: Here's the vision for 988. Calls and texts will be routed to local crisis centers or to the National Suicide Prevention Lifeline to provide immediate access to trained professionals. Here's Hannah Wesolowski again.

Hannah Wesolowski: It's trained crisis counselors answering the phone and they can help anywhere from 80% to 95% of people that call and resolve that crisis on the phone. Anyone, no matter where they live, can dial 988 and they will be connected to the national 988 Suicide & Crisis Lifeline network. That's about 200 call centers across the country. Ideally, those calls will be answered locally, but if the local call center doesn't have capacity, there are national backup centers that can pick up that excess demand. No matter where you call from and what your state may have available, you will be able to talk to a trained crisis counselor.

Anna Sale: Can you talk me through when you're answering calls, what is the experience of the caller and then when did they connect with you and what do you see?

Alana Casanova-Burgess: Anna Sale, the host of Death, Sex & Money, which is also produced by WNYC Studios recently visited a call center in Wyoming and spoke with one of the trained crisis counselors on the other end of these calls.

Crisis Counselor: If a call comes in, there'll be a little flag here. I will click, pick up the phone and then I will hear press one to accept this lifeline call. We press one and then we're connected. Then here we have the suicide risk assessment section.

Anna Sale: There's this little dial on the side of the screen that guides what the lifeline staff do next.

Crisis Counselor: When it gets to the red, then we're really in. We have somebody who is at immediate risk.

Alana Casanova-Burgess: In March call center hours went to seven days a week in anticipation of the launch of 988. By June, they had set a monthly record for total calls.

Tonja Myles: We have to make a difference, so we can change lives.

Alana Casanova-Burgess: Tonja Myles, who we heard from earlier emphasized to Congress the need for states to build up the mental health resources and infrastructure to handle crisis response needs. In addition to her spoken testimony, she submitted a statement that read, "It will do little good to have a fully staffed regional crisis call center to accept 988 calls without a fully functioning comprehensive crisis system. With the launch just two days away, there are fears that many states do not have the infrastructure fully in place."

For more on all of this, I spoke with Dan Gorenstein, the executive editor and host of the health policy podcast Tradeoffs. Dan's show has produced a series reporting on the 988 rollout. Here's a clip from the podcast.

Dan Gorenstein: In 2020, the current suicide lifeline got roughly 3 million calls and texts. As many as 12 million may come through this wider 988 door starting in July. As mental health advocates see it, that's 12 million opportunities to greet people with better, safer crisis services than they've had before.

Alana Casanova-Burgess: That sounds great, but as one mental healthcare professional in Iowa told you.

Healthcare Professional: Brilliant idea, logistical nightmare.

Alana Casanova-Burgess: Dan, talk about the potential of 988.

Dan Gorenstein: The potential is awesome. It really is on paper, this front door to all kinds of mental health and behavioral health services. People who are struggling with things like suicide, addictions, schizophrenia, depression and it's a way to get these essential services. 988 represents this opportunity to make it a three-digit phone call away from getting those services.

Alana Casanova-Burgess: Yet, there's the logistical nightmare part of it. How is it going to work and what makes it a nightmare?

Dan Gorenstein: I wonder if nightmare is too strong, honestly, but at the same time, there are very real questions. I think the real questions are simple. Who's going to answer the call, are there going to be people who can show up to your home if you need services, and if you need services beyond someone showing up at your home and you actually need to go somewhere to some inpatient treatment facility or you even need weekly counseling, are those services available and accessible to you?

Alana Casanova-Burgess: If we're thinking that this is going to expand the availability of trained counselors who can help people, where are those trained counselors coming from?

Dan Gorenstein: It's really clear from the reporting that we've done and we've talked to a dozen crisis call centers around the country, most centers are not fully staffed up. This line goes live on July 16th and there just aren't going to be enough people to answer these calls. You've got these call center operators who are literally having the nightmares, pulling their hair out, whatever cliche you want to use, but they're really all trying to figure out how do we staff up and they're limited by a couple of big things.

One of the big things is money. I talked with one Iowa call center who was saying to me, just yesterday, she was telling me that they can pay their starting salaries $17.50 an hour. She's competing with the Targets and the Walmarts, and this job answering call after call after call of people who are potentially in crisis, literally, sometimes people who are standing on a bridge or people who have a gun across their lap. You're going to be get paid $17.50 an hour to answer a call like that, compared to work in a cash register or restocking a shelf. How do you convince people to take this job?

Alana Casanova-Burgess: But it's not like there isn't a hotline now, what's new is this simpler 988 number that people can remember instead of the old 10-digit number. What exactly is different that makes the demand for trained counselors greater now?

Dan Gorenstein: That's an excellent question. I think this is been a bit confusing on some level because 988 is replacing the National Suicide Prevention Lifeline, which is this 10-digit number. As that name suggests, it really is a call predominantly for people who are thinking about harming themselves in some way.

988 is bigger than that, it is broader, it is more than just people who are struggling with suicide. It is, in fact, people struggling with all sorts of mental health crises, whether that is schizophrenia, depression, rates of depression in the pandemic have gone way up in the United States. Then, of course, there are all the behavioral health crises that people experienced, struggling with addiction in one form or another, whether that's alcohol or substance use, opioid use. This is really a way for people not just who are thinking about suicide, but people in crisis.

Alana Casanova-Burgess: There's polling from the National Alliance on Mental Illness that shows that the public doesn't really know about the number 988 yet. One poll showed that around 77% of those surveyed had never heard of it. What are the issues as far as making people aware of the 988 number leading up to its launch?

Dan Gorenstein: Everybody knows 988, just not ready for primetime. The infrastructure is not there. You don't have enough people to answer the calls. There's not necessarily the great protocols for how people should show up at someone's home. The coordination between law enforcement and social service providers, is just in its early nascent stage. There are not necessarily facilities and treatment beds and places to take people if they need more serious help.

The question is, how do you both promote this new service and also, knowing that it's not quite ready for prime time? People want folks to start calling 988, but they're afraid that demand is going to overwhelm supply and that will somehow be ruinous and taint the reputation of 988, like, "988 it's a joke. I'm not going to call 988. I'm not going to get any service from there." It's really this difficult balance, one that folks are really trying to hold and there are no easy answers. The line is going live, whether people are ready for it or not and so there's going to be collateral damage. I think anybody who's reported on this, and anybody who's working in this field, understand collateral damage can be a matter of life or death.

Alana Casanova-Burgess: We have to take a quick break, more on the rollout of 988 right when we come back on the Takeaway. I'm Alana Casanova-Burgess, in for Melissa Harris-Perry. We've been speaking about 988, a new federally mandated mental health and substance abuse crisis hotline number set to go live in just a couple of days, on July 16. It's also seen as a way to get trained professionals to handle these crisis situations, instead of law enforcement.

According to a stat from the Washington Post, nearly one in four people killed by police suffer from mental illness. That's 1,500 In the past six years. I asked Dan Gorenstein, the executive editor and host of the podcast Tradeoffs, the ways in which 988 tries to address the issues of that other three-digit number 911.

Dan Gorenstein: 988 truly, in theory, represents a genuine alternative to law enforcement showing up. We know that when law enforcement shows up, it can be deadly, particularly for people of color in a mental health crisis. The fact that this is an alternative is something that is one reason why there's so much enthusiasm behind this new line. One of the reasons why there's so much gnashing of teeth and nervousness, is because it doesn't seem like it's ready for prime time and people might call 988 and law enforcement shows up anyway. Then that's almost a poison pill of like, "Wait a minute, I thought this was an alternative. It's not the cops are still at my door. What's up with this?"

Alana Casanova-Burgess: What are the lessons that 988 could learn from 911?

Dan Gorenstein: The first is that it took 911, which I think came out in the late '60s, a while to find its footing. It's going to take 988 some time, there's no question about that. I think we need to be honest about that in trying to set expectations. I also think that 911, over time, ultimately figured out how to come up with a sustainable source of funding. Most places have some kind of fee tacked on to our cellphone bills. The question, when Congress adopted and passed this law creating 988, it gave states the authority to do that.

There are a small handful of states that have done that four-ish so far, but will we see more states begin to adopt a steady, reliable, sustainable stream of funding for 988? Looking to 911, history can perhaps be instructive there.

Third, I think we need to think about the 911 workforce itself. The 911 workforce based on the best evidence we have, can be in pretty rough shape. It's been a staff long overworked, the average call taker makes about $47,000 a year. People are working 8 to 12-hour shifts at a desk, listening to people describe shooting, suicides, child abuse. One of the stats that really jumped out at me, was that nearly a quarter of the call takers suffer from PTSD symptoms, like nightmares, and distracting thoughts and that makes it hard for them to work and live.

This is another way of thinking about the stress and the toll that's going to be wrought upon these people who are taking 988 calls. We are asking a lot of this 988 workforce, and can the 988 service providers really look to the challenges 911 workforce has faced and try to make sure the staff is taken care of and supported both in terms of how much they're paid, the services they have, the time off they get. All those sorts of things.

Alana Casanova-Burgess: In your series, you do focus on a number of different states and municipalities around the country that are experimenting with other alternatives to providing mental health care. Do you want to just shine a spotlight on one example that you really learned something from?

Dan Gorenstein: Yes. In Texas, for example, we talked with one woman who runs 988 services there. She has worked with state officials to change the educational requirements. Anyone with a bachelor's degree could work there, instead of that person needing a degree in psychology, sociology, or social work. We've talked to people in different states who are offering bonuses, increasing pay. The woman in Texas has managed to increase starting salary from $42,000, a year to $51,000 a year.

I was talking with somebody in Iowa who's saying, one of the ways they're trying to sell the job is by focusing on benefits, including pet benefits, and a good insurance plan. I think one of the things that you see also is in this post-pandemic era, if you want to call it post-pandemic, you see a lot more people saying, you don't have to work in the office, you can be virtual. In fact, there's one crisis center, we talked to, based in Washington state that hired someone in Virginia to actually answer calls for them. I think more of this is going to be remote work.

Alana Casanova-Burgess: Even in this conversation with you, I'm thinking, wow, I really want listeners to the takeaway to know about 988, whether they're in a crisis themselves or they see someone in a crisis, a loved one, someone in their household. At the same time, I want to make sure that we are thinking about this rollout and I don't want to give people the impression that they shouldn't call because it won't work and they won't get help. There's a tension there as well.

Dan Gorenstein: Absolutely, that's really well said, I think. The cliched expression, don't let perfect be the enemy of the good, comes to mind. I think we need to acknowledge that something is better than nothing. I think the folks who are doing this work 988 understand what is at stake. That's why they want it to be so good from day one. Unfortunately, in most instances, that's not going to be the case, but there will be some people who call 988 and instead of having law enforcement answer that, instead of having a 911 call taker answer that, it will be somebody from 988. It will be somebody trained in helping people deal with a behavioral health crisis or a mental health crisis, and that is progress.

It's inadequate. It's in Complete. There's so much more that could be done, but it's still progress.

Alana Casanova-Burgess: Dan Gorenstein is executive editor and host of the health policy podcast Tradeoffs. They have a series, it's great on this 988 rollout. Dan, thank you so much for your time today.

Dan Gorenstein: Alana, thank you so much. Really glad you're doing a story about something so critical as this.

Alana Casanova-Burgess: For much more on the rollout of 988 checkouts, Death, Sex & Money & Tredeoffs. They're both available now wherever you get your podcasts. If you or someone you know is in need of help, call the National Suicide Prevention Lifeline at 800-273-8255. It's available 24 /7. 988 will begin its rollout this weekend.

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