Washington was the first state to propose implementation legislation for 988, the three-digit number for behavioral health emergencies that must be available nationwide on July 16, 2022. Suicidologist Jennifer Stuber, Ph.D., helped craft it.
She first heard of 988 on the news. “Just like everyone else,” she says. “I thought, ‘I sure hope there’s funding coming to support the Lifeline centers that are already underfunded in Washington state.’” Dr. Stuber is a professor and co-founder of Forefront Suicide Prevention at the University of Washington. She lost her husband, Matt Adler, to suicide a decade ago and changed her research focus because of that life-altering event. “My career and research focused on healthcare and mental health policy, yet I didn’t know how to support my husband,” she says with dismay. “I knew I had to get him into care, but beyond that, I had no idea what to do.”
Many healthcare experts, including those in mental health, don’t know a lot about suicide prevention. Dr. Stuber points out that the default is to tell people to take their loved ones to an emergency room. In other instances, the confidentiality curtain is drawn, and families don’t know they’re on the precipice of tragedy. In the case of Dr. Stuber’s husband, it was the latter. After his death, she discovered that five months prior, he’d told a mental health professional he was thinking of jumping off a bridge. It was a critical moment where assessment and intervention, like safety planning that engages familial supports and suicide-specific psychotherapy, could have potentially saved her husband’s life.
Dr. Stuber has since worked tirelessly in Washington to reduce suicide and improve public health policy. A gap, she says, that needs to be filled. “Within the suicide prevention field, policy hasn’t been a big focus,” she points out. Thirteen months after her husband died, Gov. Christine Gregoire signed into law the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012. Under the act, named after Dr. Stuber’s husband, mental health professionals licensed in Washington must complete a six-hour course in suicide prevention at least once every six years.
Training is only one part of the solution. Mental health professionals in Washington don’t just default to the emergency room because of insufficient training on suicide, says Dr. Stuber, but also “because of gaps in crisis services.”
That’s why she’s excited about 988. All phone service carriers must start directing 988 calls to the existing SAMHSA-funded National Suicide Prevention Lifeline (NSPL) by July 16, 2022. “It’s an opportunity,” Dr. Stuber points out, “to build a more comprehensive and integrated system.” Still, she worries how the much-needed policy shift will affect call-volume for Washington’s NSPL accredited call centers. She’d already been on the front lines advocating for them to get more money because of low response rates before 988 was even a whisper.
“I’m worried about capacity issues,” she says, “and what funding is going to look like.”
Vibrant Emotional Health, the nonprofit organization that runs the NSPL, has a planning grant to work with accredited call centers to perform landscape analysis of the existing behavioral health crisis system and ensure they’re prepared for increased call volume. There’s no precise estimate, but experts calculate that the 988 call volume could be upward of 40 million nationwide once those now calling 911 for mental health, substance use, and suicide crises ultimately make the switch.
Also, Dr. Stuber points out there isn’t much time. Many state senate and house sessions meet at the beginning of the calendar year to create new laws, change existing laws, and enact state budgets. Others, like Texas, don’t meet every year but every two years. In Washington, regular sessions begin on the second Monday of January each year.
“There isn’t a lot of time left,” she says, “to develop a well-functioning behavioral health crisis system and then implement it.”
Knowing how much has to be done and quickly, Dr. Stuber and her colleagues hit the ground running in September, meeting with legislators like Rep. Tina Orwall, Rep. Lauren Davis, and Sen. Manka Dhingra so they could introduce a 988 implementation bill in January.
Being the first state to propose 988 legislation hasn’t been easy, says Dr. Stuber. Much of the guidance for 988 has yet to be created or came out after the Washington bill was introduced, but waiting until the next legislative session, she notes, would have been an even bigger challenge than operating with imperfect information now. As guidance has come out, the sponsors have rapidly updated the bill language. It’s now on its second substitute.
In the 988 implementation bill, legislators propose Washington go beyond merely expanding the call center response to the accredited NSPL lines by building the state’s crisis system’s much-needed infrastructure. This is because, notes Dr. Stuber, just like in many other states, Washingtonians in crisis and their families have to navigate convoluted, fragmented systems to get their behavioral healthcare.
Abraham Dairi, whose wife Holly Deierling died of suicide in September, knows this firsthand. In January, the Seattle resident testified before the Senate Behavioral Health Committee that navigating Washington’s crisis system revealed failures at every turn. “For those who think the existing system works,” he said, “I’m going to tell you why it doesn’t.” “We touched the system at every point, and it failed Holly, and it failed our entire family.”
Between July and August 2020, Holly made three suicide attempts. Each time, Abraham called the Lifeline (1-800-273-TALK), the NSPL hotline number. He said the call counselor instructed him to take her to the emergency room, which he did. The problem is that each trip resulted in the hospital refusing to admit Holly, saying she didn’t meet the minimum requirement to hold her.
On the last night of her life, Abraham called 911. Two officers arrived. “They ripped her out of the door,” he said, “threw her to the ground, strapped her to a stretcher, put her in an ambulance in front of our neighbors [and] our community.”
When she arrived at the hospital, Holly told staff she’d kill herself when released. They released her. Abraham said, “The thought of Holly’s last night being one like that—in the hospital alone—is something I’ll have to live with for the rest of my life.”
After Holly’s first suicide attempt in 2015, she was taken to Harborview Medical Center in Seattle, where she was strapped to a bed and left in a hallway overnight. She later told him that that moment was the most traumatic experience of her life.
In 2014, the Washington State Supreme Court held psychiatric boarding unlawful, ruling that the state’s Involuntary Treatment Act “does not authorize psychiatric boarding as a method to avoid overcrowding certified evaluation and treatment facilities.” Four years later, the Washington State Hospital Association did a snapshot of psychiatric boarding during a single month, finding 155 patients held in emergency or acute care departments.
Dr. Stuber says the shortage of mobile crisis teams and crisis stabilization facilities contributes to emergency room overcrowding and psychiatric boarding. “If we don’t fill these gaps,” she says, “we’re going to end up with the same situation where those in crisis have no alternatives but to go to the emergency room.”
Washington is also missing the technology to allow call centers to coordinate crisis services, make same-day routine or urgent appointments, or see what beds are available. “We don’t have resource mapping, integration, or a bed tracker,” she says. “And without adequate data tracking, it’s even unclear exactly how much the state is spending on crisis services.” She says the state needs foundational reform and greater accountability for how state general fund dollars are being spent on behavioral health.
The 988 implementation bill aims to enhance and expand behavioral health crisis response services. It draws from the Crisis Now model seen in Arizona and Georgia and SAMHSA’s National Guidelines for Behavioral Health Crisis Care: A Best Practice Toolkit. The bill calls for high-tech crisis call center hubs to triage calls and link people to care. It also calls for planning to expand mobile rapid response crisis teams and crisis stabilization services, with peers threaded throughout the crisis care system.
It includes 23-hour stabilization units based on the living room model, crisis stabilization centers, short-term respite facilities, peer-operated respite services, and behavioral health walk-in urgent care centers. It also adopts no wrong door, accepting all walk-ins and first responder drop-offs.
Transforming state crisis systems to prepare for 988 will require funding. That’s no less true for Washington. The National Suicide Hotline Designation Act allows states to implement a monthly telecom customer service fee to pay for 988-related services. The fee can cover costs attributed to (a) ensure efficient and effective 988 call routing to an appropriate crisis center and (b) personnel and providing acute mental health, crisis outreach, and stabilization services by directly responding to the 988 hotline.
Washington’s 988 implementation bill includes its telecom customer service fee through a line tax on the use of all radio access lines, including wireless, wireline (landlines), and VoIP services. The tax will increase from 30 cents to 75 cents per month for each radio access line between October 1, 2021, and July 1, 2024. Despite the state’s authority to impose the fee, Dr. Stuber says that CTIA, a trade association representing the United States wireless communications industry, has pushed against the proposed tax.
Gerard Keegan, vice president of State Legislative Affairs at CTIA, testified before the Washington House Committee on Health Care and Wellness in January that wireless consumers in the state have the third-highest wireless tax burden in the nation, “so it’s important that fees be kept as low as possible.” He also said allowable use of the 988 funds should be to cover direct costs for the call centers: 988 call-taking equipment, call routing and communications, and call center personnel costs related to taking and routing 988 calls.
Dr. Stuber says that while the tax is necessary to ensure that 988 calls route rapidly and effectively, it should also, as allowed by the act, support critical underfunded components of the integrated crisis network like rapid mobile response teams. “The call centers will be the central coordination hub for crisis care,” she says. “They must have standardized and available mobile crisis teams to dispatch.”
The pushback from CTIA is, in part, because 911 service fee funds—Washington’s combined state and county E911 tax rate is 95 cents—are limited to their call centers (called public safety answering points or PSAPs for short). The funds don’t pay for services outside of answering and routing calls like law enforcement or EMS personnel. “It’s a false equivalency,” says Stuber. Relying on the counties to make up the difference for 988 will be rife with disparity, making it impossible to build an equitable crisis care infrastructure.
While discussions with telecom providers are ongoing, Dr. Stuber says that T-Mobile, headquartered in Bellevue, already absorbs the 911 service tax and “has mentioned doing the same with the 988 tax in Washington.” T-Mobile made 988 available to its customers nationwide on November 20.
Dr. Stuber says getting people up to speed on 988 has been an uphill battle, including those in behavioral health. She points out that while people in the crisis sphere were aware of each step the FCC took regarding the three-digit number, that wasn’t true for others in mental health, including suicidologists. “This is the most important policy on the table right now because of its potential impact on suicide,” she says. “Yet, many of us don’t know what’s going on.”
Like her, members of local advocacy chapters in Washington first heard about 988 on the news. And when the bill dropped in early January, she says it took the entire system by surprise. It left Dr. Stuber and others who support the bill to explain 988 to the many system players, including how the NSPL works. “We’ve had to explain how calls route to accredited call centers by the caller’s area code,” she says. “People don’t understand why only accredited lines can answer the calls or what the implications are for local county lines.”
Dr. Stuber says what states need is coordinated technical assistance, with access to experts who can provide in-depth factsheets on the NSPL and talking points for how to engage hospitals to take part in bed registries, counter telecom who want narrow tax usage, and discuss with counties the problem of implementing their own tax for crisis services. “There was a coordinated effort among leading behavioral health organizations and agencies to make 988 a reality on the federal level,” says Dr. Stuber. “Their attention now needs to shift to the states.”