In the year and a half since its launch, 988 — the country's easy-to-remember, three-digit suicide and crisis hotline — has received about 8.1 million calls, texts, and chats. While much attention has been focused on who is reaching out and whether the shortened number has accomplished its goal of making services more accessible to people in emotional distress, curiosity is growing about the people taking those calls.
An estimated 10,000 to 11,000 counselors work at more than 200 call centers nationwide, fielding calls from people experiencing anxiety, depression, or suicidal thoughts.
A newly released report, based on responses from 47 crisis counselors, explored variations in their training and work experiences. The survey "is not large enough to support conclusions" about all 988 staffers, said Dan Fichter, the report's author and a former program manager for the Substance Abuse and Mental Health Services Administration's 988 team. Still, the first-of-its-kind survey — published by Crisis Crowd, a new noncommercial project focused on raising the voices of 988's workforce — surfaced interesting snapshots.
For instance, counselors who responded noted wide variations in training, from four days or less to two weeks.
"We know that there are significant workforce challenges for 988 including staffing shortages and burnout, like much of the health care industry is experiencing today," Monica Johnson, director of SAMHSA's 988 & Behavioral Health Crisis Coordinating Office, wrote in a statement. "Ensuring that 988 crisis counselors are properly trained and supported to do this life-saving work is critical."
Different training approaches emerged as one of the report's central themes. Most counselors who responded said they were trained in four weeks or less and didn't consider it adequate.
"I understand that even with about 120 hours of training, we can't get through all the nuances that boost confidence," said one anonymous survey response.
Some counselors said they had received training only in talking to people experiencing suicidal thoughts and not how to deal with other mental health issues, such as anxiety attacks, substance intoxication and withdrawal, and mood disorders. They said they had not been prepared for the wide range of calls of varying levels of intensity they would face.
"There could have been more emphasis on how different each convo would be," noted one.
Some also suggested that opportunities to listen to 988 calls or sessions that used role-playing exercises to practice handling calls would have been helpful.
The risks of counselors not being properly trained are high, said Eric Rafla-Yuan, a member of the California Governor's Office of Emergency Services' 9-8-8 Technical Advisory Board and a psychiatrist at San Diego County Psychiatric Hospital. He said it is concerning that some callers may not "feel that they have the support that they need" when reaching out to 988, and "may not call again in the future." The situation could possibly "cause more stress rather than support," he added.
Hannah Wesolowski, chief advocacy officer of the National Alliance on Mental Illness, said these differences were not a surprise since 988 brought together a patchwork of local and state efforts to provide a hotline specifically for mental health emergencies. In addition, Fichter said, centers' different training approaches and time frames may "have to do with funding differences that there are between some centers."
The survey also found that crisis counselors have different expectations for how long they should stay on the phone with callers.
Some counselors, for instance, said they were expected to end conversations with first-time callers and texters who didn't have immediate plans of suicide within 15 minutes. Others reported limits of up to an hour.
Wesolowski said this issue stood out to her. "That's certainly not in the spirit of what 988 stands for because there is no exact time that's perfect to address a crisis," she said. "Every crisis is unique; every situation, every health seeker is unique."
The report also noted that centers have different policies on whether counselors should inform callers with imminent plans of suicide or those who are actively attempting suicide that first responders are being dispatched.
Involuntary intervention is used as a last resort to keep someone safe, but some centers believe that telling a caller that police are on their way may lead them to hang up the call, Fichter said. Other centers allow counselors to be transparent with callers about interventions and help callers prepare for the police.
Efforts to make improvements to the hotline's operations are underway. For example, Vibrant Emotional Health, the company that administers 988, recently created online, self-paced training courses for crisis counselors, according to Tia Dole, Vibrant Emotional Health's chief 988 Suicide & Crisis Lifeline officer. These classes, she said, are designed to "assist local centers in delivering training and supporting crisis counselor skill development." She added that these courses are intended to supplement the training local centers already do.
"The success of 988 hinges on those vital people answering calls, texts, and chats every single day," Wesolowski said of crisis counselors. "They are the heart of this system, and we have to value them. We have to invest in them and give them what they need to be successful."
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 This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF - the independent source for health policy research, polling, and journalism.
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