How a 988 Crisis Center Helps People With Mental and Behavioral Health Emergencies

On July 14, the National Suicide Prevention Lifeline became reachable through a short, three-digit dialing code: 988. The easy-to-remember number is designed to ensure that people experiencing suicidal crises and behavioral health emergencies can get quick and simple access to care.

State and local governments have been largely responsible for building the infrastructure needed to strengthen and expand the lifeline; since 988 went live, 23 states have enacted legislation to support the new number.

Maryland, for instance, is considering legislation that establishes a funding stream to implement 988. In Columbia, Maryland—about halfway between Baltimore and Washington, D.C.—the nonprofit Grassroots Crisis Intervention Center offers 24/7 suicide prevention, behavioral health, shelter, and housing support services. In addition to responding to 988 calls, Grassroots houses a walk-in counseling program and operates a mobile crisis team to respond to behavioral health emergencies.

Dr. Mariana Izraelson, Grassroots’ executive director, is a licensed clinical alcohol and drug counselor with several decades of experience in nonprofit management in health care settings.

This interview with her has been edited for length and clarity.

How has your call volume changed since 988 launched?

It’s increased gradually, to 30% higher now than it was pre-988. The biggest volume increase has been in the text and chat functions; we’re finding that the younger generation uses those functions more. Young people seem to perceive a level of confidentiality in text or chat that they don’t feel from picking up the phone.

On our end, it has been a matter of making sure we have the appropriate staffing in order to answer the calls.

What types of calls are you getting?

The majority of our calls are from people thinking about suicide. We’ve also had a lot of third-party callers, such as concerned family members who want to know how 988 works and how to connect a loved one with us. And we have more health care providers calling 988 than before, looking for assistance for their clients or patients.

There’s also a significant number of people who call 988 regularly for support—and were doing so even before we transitioned to 988. And since last year, we’ve had a partnership with Howard County’s police department so that any calls the department gets about nonemergency mental health issues can be dispatched to our counselors.

At its core, 988 is a support line. The idea is that the counselor will work with you to help resolve your crisis or anxiety, so then you can go on with your day.

Can you walk us through a typical call?

First, we would say, “Hi. Thank you for calling 988,” and then we’d ask, “How are you doing today?” Then we get into a normal rhythm of a conversation, with the counselor focusing on the caller and their needs. We also try to gather demographics in an empathetic way, to give us a little more insight on how to be helpful and thoughtful in discussing the caller’s crisis.

When it comes to suicidality—a term that encompasses suicidal thoughts, plans, deliberate self-harm, and suicide attempts—we focus on the crisis at hand. We ask the caller what thoughts they’re having and if something happened during the day that impacted their feelings. Counselors try to give them time and space to explain and help navigate their feelings. The hope is that by providing that release, the caller won’t engage in any dangerous behavior. Counselors aim to help bring the caller’s anxiety down and stabilize the person so they feel heard and understood.

Some of the calls we get are from people struggling with grief, loneliness, or heartbreak. There’s this misunderstanding sometimes that only those who have a mental health condition call the hotline, but suicidality can be a separate issue. For example, you can be heartbroken and experience feelings of sadness that may lead to suicidal thoughts.

How are staff trained to respond to someone experiencing thoughts of suicide?

Our center is accredited by the American Association of Suicidology, whose specific trainings we follow. We require that new hires undergo 40 hours of training—both in person and online. After they pass practice exercises, they’re qualified to begin shadowing a counselor for three weeks.

During the shadowing process, a new hire will pick up calls, and the supervisor will listen in and evaluate their progress.

We also require all employees to complete a crisis counselor certification within a year of employment. In addition, we can never have one person alone staffing 988; there must be two people plus a supervisor available at all times.

What do your crisis counselors do to make callers feel cared for?

The key is to make people feel listened to. Our crisis counselors listen to callers and validate their emotions, and help them work through what they’re feeling. We let them express their feelings without judgment or criticism.

Counselors also make sure a caller is safe before they disconnect the line. They do that by checking what other connections or resources—whether family, friends, or a therapist—are available to the caller to help them feel better. Counselors will also ask if they can do a follow-up phone check with the caller the next day. And if a caller expressed thoughts of suicide, we follow up within 24 hours to check on whether they’ve connected with a mental health provider or gotten in touch with a loved one.

Do you coordinate with 911 when needed?

We have very specific, detailed protocols. We use a short questionnaire called the Columbia Suicide Severity Rating Scale—which is endorsed by the Substance Abuse and Mental Health Services Administration—to assess suicide risk. If a counselor determines that the caller can’t be stabilized over the phone and appears to have access to a weapon or other lethal means, that call gets escalated to 911.

What happens then?

The counselor remains on the line throughout the entire 988 call. If a person is attempting to die by suicide and has access to a weapon or lethal means, we call the police. If the person is not actively planning suicide and is willing to participate in safety planning, we send out a mobile crisis team—made up of mental health professionals—to talk to the caller face-to-face and de-escalate the situation.

But an “active rescue” component, where we call law enforcement or send out the mobile crisis team, happens rarely—only about 7% of our calls. Most of the time, we’re able to resolve situations over the phone.

How do you count a call as “resolved”?

A successful call is where we can de-escalate the situation to the point that the level of anxiety has decreased drastically; the person is no longer having active suicidal thoughts and is safe.

Normally, when the crisis is reduced, the caller doesn’t want to talk anymore. They would rather go on with their day and hang up. For us, there’s a sense that the person felt heard and that they’re comfortable with the resources at hand to help them.

Have you experienced any challenges since the 988 launch?

Our most pressing challenge is staffing. I have adequate funding; but I don’t have adequate staff, even though we’ve increased counselors’ salaries by at least 40% in the past two years. We can’t compete with some other industries. And to be a counselor at Grassroots, we require a bachelor’s degree.

Plus, it takes a certain type of person to want to do this job. Counselors are mostly talking to individuals who are unhappy, and while there’s a satisfaction in the resolution of the call, most calls are difficult. We recognize that we need to take care of our counselors. We offer a licensed clinical counselor or social worker for them to consult during particularly difficult calls, which is one of the ways we create a supportive environment.