From The Texas Tribune:
Thousands of Texans in need are abandoning the state’s suicide hotline mid-call every month as call centers struggle under a $7 million funding deficit and a growing suicide rate statewide.
The 988 number — a federally mandated, state-run service that connects callers to crisis counselors — fills an essential niche in the behavioral health care system because it gives catered mental health services in an emergency where 911 might not be appropriate. The hotline has been used thousands of times in two years, but its federal funding is declining, and with a workforce shortage, the system is starting to bend under the demand.
“To be very clear, we’re doing way more work than we’ve ever been able to do,” said Jennifer Battle, supervisor of the 988 system at the Harris Center for Mental Health and IDD. “If you want us actually to meet the volume of Texas, then somebody’s got to decide to increase the resources that are made available to centers so that we can increase the number of people we serve.”
Since launching in 2022, Texas’ five centers that answer calls to the 988 suicide hotline have received more than 380,000 calls, the second highest call volume in the nation, according to the National Alliance on Mental Illness Texas. One-third of them occurred from January to June of this year.
Currently, less than 85% of calls in Texas are answered in-state, with some 200 other centers across the nation serving as backup. Although much improved from the 40% in-state answer rate in 2021, the year before the state’s crisis hotline was integrated into the federally-mandated 988 hotline, Texas’ latest rate falls short of the 90% standard set by the national 988 administrator Vibrant Emotional Health.
The more a caller is transferred in and out of state, the more likely he or she will hang up before reaching a crisis counselor. Between January and August, 18,500 calls to Texas’ 988 system were abandoned. In August, the most recent data available through the 988 website, more than 12% — or 2,446 — of received 988 calls in the state were abandoned, tying Texas with Tennessee for the fifth highest rate in the nation.
Across the five Texas call centers, 166 staff members are responsible for responding to 988 calls, texts and chats through the 988 website. In May, this equated to an average of 95 calls per person with most calls lasting about 15 minutes, according to the mental health alliance.
To fully implement the text and chat component into the state’s 988, the state would need to at least double the number of crisis counselors across the entire system. It also needs an additional $7 million — the projected cost in 2023 to operate the state’s five call centers was $21 million, but the state only allocated $14 million in fiscal year 2024, according to the mental health alliance.
In 2022, Texas Health and Human Services Commission also recommended more resources for the state’s crisis call centers. In 2023, Texas lawmakers did not address developing the 988 call center capacity.
In the upcoming legislative session that begins Jan. 14, Sen. José Menéndez, D-San Antonio, has filed Senate Bill 188, which would create a more reliable and robust funding source for the 988 hotline — a state trust fund, similar to how 911 is helped funded. The 988 trust fund would be supported by a surcharge collected from cellphone bills, allowing call centers to expand capacity, increase counselor pay and ensure that technology like text and chat is always available, Galvan said.
“Nationwide, there are currently 20 states that have already passed some type of legislation related to 988 funding,” Galvan said. “This trust fund aims to put 988 in parity with the 911 funding mechanism and ensure we treat all emergency services the same.”
Florida has 13 call centers handling 988 calls, compared to Texas’ five.
These tightened resources are occurring as Texas’ suicide rate has jumped 37% from 2000 to 2022.
“It’s time for Texas to step up and ensure that when a fellow neighbor faces a mental health crisis, help is ready and waiting for them,” Galvan said.
Life and death conversation
“Hello, this is 988. How can I help you?”
For some people, this simple question starts the most important conversation of their lives.
“‘Are you thinking about suicide today?’ ‘Are you thinking about killing yourself right now?’ That’s a severe question, and it’s possible that we could be the first person ever to ask that question,” said Battle, a social worker who has worked at crisis lines for more than 20 years. “Sometimes you’ll hear people pause or take a breath because they haven’t had the opportunity yet to answer that question honestly and vulnerably. We train what to do during that breath.”
When people call a 988 call center, they first hear an electronic greeting that will give them a series of choices, including for Spanish speakers, veterans, and LGBTQI-plus youth. Depending on what callers select, the system could transfer them to an organization that fits their needs, including the Trevor Project and the Veterans Crisis Line.
If callers do not pick any of these options, they are usually transferred to their closest 988 call center and if nobody is available there, they are transferred to another until they reach a crisis counselor, sometimes out of state. It is during these multiple transfers when people often hang up.
If a call is connected, crisis counselors ask a series of questions to gauge the risk level of the caller to hurt themselves or others. Counselors must try to be empathetic and nonjudgmental while casually talking the caller through breathing exercises and anti-anxiety measures over the phone.
“Most of our callers have had some thoughts of suicide, off and on, but don’t have a plan or don’t have access to anything that can harm them, but they feel overwhelmed, and sometimes, and some days, it feels like life would be easier if they weren’t here,” Battle said. “This is our moment to enter into a conversation with them.”
More than 80% of the time the caller is not in an active crisis situation, Battle said, but he or she just needs someone to speak with for a few minutes. She said an additional 10% of calls require services like mobile crisis referral and then there are 1% to 2% of calls where law enforcement needs to get involved because the caller or someone else is in imminent danger.
Sometimes a call ends without a resolution, which can wear on a crisis counselor, who has to be ready for the next call.
Battle remembers picking up the phone at the Houston crisis call center before 988 was created, and what awaited her was a disoriented, suicidal person who was standing on train tracks in an unknown area.
“I had years and years experience, and I was [still] feeling kind of scared and overwhelmed,” Battle said. “I could hear the train, and they were still pretty intent on dying.”
In the span of a few minutes, Battle was able to talk the person off the railroad tracks just as she heard the train whistle by on the phone.
“They were still on the phone. After the call was over and they found them, all I could do was breathe. And then get ready for the next one,” Battle said.
Battle said experiences like this have taught her to ensure that her staff, which experiences high turnover akin to what other behavioral health positions experience statewide, have resources that include being available to conduct debriefs with crisis counselors after calls or to regularly check in with them to see how they are doing. Crisis counselors are also allowed to work from home to help balance stress levels.
“There are all kinds of different things that we do as an agency to try to wrap around our amazing crisis line counselors to try and help with the natural levels of stress that they’re going to feel doing a highly impactful job,” Battle said.
Battle’s center covers 59 Texas counties including those in Houston and Dallas and has a monthly average call volume of 6,000. While the center’s answer rate for calls is 80%, it struggles with text messages — the center could only respond to 335 of the 7,427 texts received in September. The rest were handled by backup call centers.
“The state wants us to meet all these targets, and absolutely, we want to do that. But ultimately, if you’re only funding half of what we need to make it happen, we are still over-performing for what we’ve been provided,” Battle said.
Funding and parity
While 911 has been in place for decades, with dedicated funding and trained health care personnel available 24/7, the 988 hotline infrastructure is still in its early stages.
Emergency medical services for other types of health crises are routinely reimbursed by Medicare, Medicaid and private insurance. Still, Texas has not allowed Medicaid to cover crisis intervention services, such as 988.
Texas mental health advocacy organizations support adding these services to Medicaid, similar to what 23 other states have done.
Due to the lack of Medicaid reimbursement, 988 call centers in Texas rely on federal funding.
The federal government directed nearly $1 billion through the American Rescue Plan to launch the 988 hotline. However, with that money running out this year and until the federal government decides whether they will continue funding 988, states will need to pick up the tab for the call centers.
