Trust comes from the quality of services, says Dr. Monserrate Allende Santos. “When someone calls our crisis line, we respond immediately, utilizing all our strategies and sharing every resource we have. If the person needs more, we go directly to the community to provide services face-to-face.” Dr. Allende Santos is the director of Puerto Rico’s La Línea Primera Ayuda Psicosocial (Línea PAS) and project director of the island’s 988 system. She shares how the island’s implementation of 988 has built on its existing crisis call line (800-981-0023) and other crisis support services. “PAS” translates to “The Psychosocial First Aid Line.”
Línea PAS has been operational since September 13, 2001. As Puerto Rico’s only crisis contact center, it covers its 78 municipalities, providing an integrated program for crisis intervention, including phone, chat, mobile crisis teams, education, and community outreach. “If there is a crisis, people in the community know to call Línea PAS and that we will come to attend to and provide organization for the situation,” shares Dr. Allende Santos. Línea PAS is a 24/7 service, with calls answered by masters- and doctoral-level clinicians in mental health-related specialties. Beyond their academic and clinical preparation, the workforce is trained specifically in crisis response to offer high-quality services.
Fostering close relationships and collaboration with providers across Puerto Rico has paid off—Línea PAS can quickly connect callers to mental health and substance use services in real time. If mobile crisis services need to be activated, a team goes to stabilize the person, identify their support network, encourage voluntary care if needed, and provide continuity of services in the community. “There is continuous follow-up until the person begins their process of recovery,” explains Dr. Allende Santos. “If the person has a social network, but those individuals are feeling exhausted, the staff works to stabilize and educate the support network so they can support the client.”
Every caller receives follow-up by phone from Línea PAS crisis counselors, and outreach will continue based on the needs of the individual. The mobile crisis team offers six in-person follow-ups in the community, with the option for additional follow-ups as needed. Línea PAS supports clients’ coordination with different service providers and assists the person in that process until they can empower themselves in their own stabilization. Follow-up and connecting to the community are key elements of Línea PAS’ crisis intervention and stabilization approach, utilizing existing support systems to help individuals begin a sustainable path to recovery.
In addition to connecting people to the community, Línea PAS educates the community about mental health using outreach teams. These groups travel throughout the island offering Mental Health First Aid training and identifying, stabilizing, and referring anyone with service needs to Línea PAS to access resources.
On March 1, 2022, in preparation for the launch of 988 on July 16, 2022, Línea PAS joined the 988 Suicide & Crisis Lifeline network. As the administrator of the 988 Suicide & Crisis Lifeline (988 Lifeline), Vibrant Emotional Health (Vibrant) collaborated with Línea PAS to ensure seamless integration to 988 for residents of Puerto Rico. Dr. Allende Santos shares, “988 was a blessing because it finally makes a statement about the importance of mental health on a national level and establishes a unique and easy-to-remember number just for mental health.”
Puerto Rico began promoting 988 through the communications office of their department of mental health, la Administración de Servicios de Salud y Contra la Adicción (ASSMCA). Using Vibrant’s and SAMHSA’s education and outreach materials, the office launched a social media campaign in tandem with 988 going live to inform the public and media outlets about the new three-digit number for suicide and crisis services.
“We also have an ongoing free public awareness campaign,” notes Dr. Allende Santos. Information about Línea PAS is consistently shared in the news when a crisis happens, and through artists on the island who promote the line. In addition, since mental health providers, businesses, and the media already know and trust Línea PAS, she shares that they are happy to promote 988 for all mental health crises.
Staff at Línea PAS are excited to be a part of the 988 network. With new grant funding from SAMHSA and Vibrant, they were able to hire additional staff, including five crisis managers. ASSMCA also increased funding for Línea PA, enabling them to hire another 10 staff members who solely respond to 988 calls.
Since 988 doesn’t have geolocation capabilities, a person with a Puerto Rico area code—787 or 939—living outside the territory is routed to Línea PAS. The contact center delivers its usual services to these callers. If the person is in immediate risk, their initial action is to identify a support network to be with the person. If a mobile response is needed, they will either begin the stabilization process while doing a warm transfer to the crisis contact center in the 988 network closest to the individual or stay on the line while the local PSAP (public-safety answering point) responders are activated. In either case, the Línea PAS crisis counselor stays on the line with the caller until the situation is stabilized.
988 Suicide & Crisis Lifeline Spanish Subnetwork
In the United States, the U.S. Census Bureau reports that roughly 41 million are native Spanish speakers—more than in any other country where Spanish isn’t the official language. The U.S. Centers for Disease Control and Prevention reports that 4,905 Hispanic/Latino individuals died by suicide in 2021, about a 4 percent increase from 2020.
Spanish speakers calling the 988 Crisis Lifeline can press 2 to connect to the 988 Lifeline’s subnetwork of Spanish-speaking crisis counselors. According to Vibrant, the Spanish Subnetwork received almost 67,000 callers in 2022—a 17.2 percent increase in call volume demand for Spanish-speaking 988 Lifeline services over 2021. Since the launch of 988 in July, the Spanish Subnetwork has experienced a 50 percent increase in call volume. With the growing call volume demand for the Subnetwork, Vibrant recognized the significant need to address the rising volume of Spanish-speaking callers. On November 1, 2022, Línea PAS joined Vibrant’s national Spanish Subnetwork for 988 calls as one of four crisis contact centers that respond to 988 callers who press 2 for Spanish.
Línea PAS has been integral in helping to meet the growing needs of 988 Spanish-speaking callers. This role means that Línea PAS answers callers from all different nationalities whose native language is Spanish using the same protocols regardless of their location. In terms of chat and text, Línea PAS currently answers chat and text through their local line. Vibrant is in the development stage of launching Spanish chat and text services, recognizing that Spanish speakers in crisis may prefer to connect via text or chat instead of by phone. Línea PAS is excited about the prospect of a Spanish 988 text and chat in hopes that more Spanish-speaking individuals will reach out for crisis support.
“People from many different Latin American countries live in Puerto Rico,” explains Dr. Allende Santos. “We are very active in cultural competency and familiar with supporting people from different cultures.” Social connections and cultural characteristics are critical protective factors to understand when supporting the mental health and crisis needs of Latinos. There is an additional fragility to the mental health of people who are somewhere that’s not their native home and language, sometimes without significant social support. “We can empathize with the 988 caller and build trust.”
As 988 use increases, Línea PAS continues to provide and build trusted, comprehensive, and culturally and linguistically competent services to residents of Puerto Rico as well as Spanish speakers across the U.S.
Christine Malik, MSW, is the project director for the National Association of State Mental Health Program Directors (NASMHPD). She oversees and manages several federally sponsored contracts related to suicide prevention, crisis services, 988 implementation, clinical care delivery systems, and older adult behavioral health.
Nili Ezekiel is a technical assistant and research associate at the National Association of State Mental Health Program Directors (NASMHPD), providing customized technical assistance, conducting research, and developing materials on a range of behavioral health topics.