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With three digits and a cell phone tax, 988 seeks to transform crisis response

Despite hotline’s planned overhaul, some fear service gaps will handcuff success
State Rep. Tawna Sanchez, D-Portland, chatting before a session of the Oregon House on March 21, 2023. Sanchez sponsored the bill that will expand the 988 hotline's services. | JAKE THOMAS/THE LUND REPORT
June 29, 2023

On the final day of the 2023 legislative session, lawmakers passed a tax intended to flesh out Oregon’s 988 suicide and crisis hotline.

Now the question is: Will it work?  

The federally mandated three-digit number went live last-year, connecting callers experiencing a mental or behavioral health crisis with a trained counselor. The program, authorized in the 2021 Legislature, hired two nonprofits to answer calls — operating like “air traffic control for behavioral health,” said Dwight Holton, the CEO of Lines for Life, one of the two groups. 

Thanks to House Bill 2757, the hotline is about to take on an expanded role.  

The Legislature approved adding a 40-cent monthly tax to most people’s cell phone bills that is expected to generate nearly $33 million in Oregon’s upcoming two-year budget and $54 million in the budget after that. Holton told The Lund Report that the money will help stand up a “three-legged stool of care.” That stool includes 988 call centers, trained workers that will be dispatched to people in crisis, in addition to facilities where they can be stabilized. 

Holton said that the 988 system will help transform Oregon’s behavioral health system, which is widely viewed as inadequate for the state’s prevalence of mental and substance use disorders. 

“This is a comprehensive approach to building healthier communities by having effective crisis intervention,” he said. “It starts with a kind of core recognition that everybody struggles. It is OK to struggle. It is not something to be embarrassed about. It’s not something to ignore.”

Despite lawmakers’ support for the new tax, Kevin Fitts, executive director of the Oregon Mental Health Consumers Association and longtime mental health advocate, told The Lund Report the crisis line is a gateway that will continue to lead to Oregon’s dysfunctional and fragmented behavioral health system. 

“I don’t think people understood what’s on the other side of it and the lack of choices and options.”

“I don’t think people understood what’s on the other side of it and the lack of choices and options,” he said. 

Fitts said he also shares concerns of other mental health activists that some people may be involuntarily committed after calling 988. 

With funding secured, Oregon will begin building out the 988 system while determining what it looks like along the way. 

Chris Bouneff, the executive director of the National Alliance on Mental Illness Oregon, told The Lund Report that the state has a chance to build a new coordinated behavioral health system.

“We’re trying to do something and create something that doesn’t exist in our state,” Chris Bouneff, the executive director of the National Alliance on Mental Illness Oregon, told The Lund Report. “That means there are problems we know we have to solve, and there are problems that are going to arise.”

A lot can be taken care of on the phone 

Boosters of the easy-to-remember new line say it will prevent callers from having their problems spiral into a situation requiring hospitalization, residential care or jail. Trained workers staffing 988 call centers refer callers to services in their area, help them talk through how to resolve a difficult situation or just offer a sympathetic ear. 

The three-digit line grew out of a Congressionally mandated overhaul of the National Suicide Prevention Hotline that began in 2017. The federal government initially offered states money to help states set up 988 networks with the expectation they would provide ongoing funding for the network. 

Oregon contracted with two nonprofits to operate 988. Salem-based Northwest Human Services answers calls in Marion and Polk counties. Lines for Life covers the rest of the state, responding to the vast majority of calls. 

Since launching 988 in Oregon, Lines for Life has seen its monthly calls jump from around 2,000 in July 2022 to 3,500 by the end of the year. 

Holton said 988 expands the National Suicide Prevention Hotline from a suicide crisis line to a behavioral health crisis line. When someone calls 988, they’re connected with a trained crisis intervention specialist, or “call counselor,” said Holton. 

If the caller expresses suicidal thoughts, said Holton, the first priority is establishing a safety plan. He said that can range from the caller agreeing to eat or shower and call 988 back. More urgent calls might involve planning an emergency room visit, he said. 

Call counselors also hear frequently from people who need help with substance use and are worried about family or friends, said Holton. With those calls, Holton said counselors will walk callers through what services are available and will do a warm handoff when possible. 

Lines for Life data submitted to a legislative committee shows that 97% of calls are categorized as “resolved,” meaning the caller said their issue had been addressed. Holton said it’s surprising that so many calls can be resolved by calling 988.

He said 988 will connect callers with a school counselor, their own insurance or employee assistance program or a list of mental health providers. Other times just talking with friends or family will resolve the crisis. 

“It’s about getting them on the path to recovery and support,” he said. 

As states prepared to implement 988, the federal Substance Abuse and Mental Health Services Administration released a report in December 2021 suggesting that many crisis calls could be resolved over the phone. The report found that a crisis system already in place for southern Arizona was able to resolve 80% of calls without dispatching mobile crisis teams, law enforcement or emergency medical services. 

Seventy-one percent of calls that did require a mobile response team response were resolved, the report found. Of those that required a mobile crisis unit or facility, 68% of callers did not need another department visit or hospitalization within 45 days. 

“Effectively responding to people in crisis who are experiencing a behavioral health emergency has three main components as outlined in SAMHSA’s National Guidelines for Behavioral Health Crisis Care: providing someone to talk to, providing in-person response, and providing a place to go,” reads the report. “Implementing 988 successfully will be a critical first step in evolving the broader crisis continuum.”

Oregon lacks key requirements for 988 success

A different Substance Abuse and Mental Health Services Administration report concluded that the new system requires “timely access to services” and “a strong behavioral health workforce.”

Currently, Oregon has neither. 

A 2022 report from Oregon Health and Science University researchers found that nearly a third of the state had an anxiety or depressive disorder. But the report found there are only enough mental health workers to meet the needs of about a quarter of the state’s population. 

Fitts said people may call 988 for emotional support and a referral for services. But he said they may soon become frustrated when they can’t find a counselor, particularly those in rural areas. 

“You’re referring people to a broken product that’s deteriorated and demoralized and not linked together,” Fitts, the mental health advocate, said. 

Holton acknowledged there is a lack of treatment options for people with substance use disorder and said there are discussions underway about building a database that shows which programs have room at any moment. He said that residential treatment “is where we’re most pinched” but many don’t require that level of care. 

“There are definitely times when the call counselor is not going to be enough,” he said. 

He said in those situations 988 can dispatch a mobile crisis unit through the county mental health programs. While some counties have developed mobile response units, notably CAHOOTS in Eugene and the Portland Street Response, he said this component of the system “needs a lot of help and support.”

Cherryl Ramirez, executive director of the Association of Community Mental Health Providers, told The Lund Report every corner of the state has a mobile crisis unit but their staffing levels vary. 

“On average, we need to double the number of mobile crisis responders that we have,” she said. 

The 988 funding bill prioritizes the crisis call centers and Ramirez said local programs are counting on enhanced Medicaid matching rates and additional state funds to expand mobile crisis units. 

Holton said another component planned for the 988 system is crisis stabilization centers that provide short-term treatment for people that don’t require hospitalization or residential care. But he said these centers aren’t available in all communities and will be costly. 

Once Oregon has a fleshed-out system in place, Holton said the state will move from relying on law enforcement to respond to people in crisis to more directly putting people on the path to recovery. 

“There’s a beginning of an infrastructure, we just need to grow it.”

“There’s a beginning of an infrastructure, we just need to grow it,” he said. 

Ramirez said crisis stabilization centers need the most development but the 988 funding bill doesn’t earmark any of the new tax revenue for them. She said there are currently just a handful of crisis stabilization centers in Oregon, including in Deschutes, Marion, Washington and Clackamas counties. 

The Oregon Health Authority requested funding to build a crisis stabilization center in every county. But Ramirez said the Legislature didn’t fund the request. 

The Legislature’s end-of-session “Christmas tree” spending bill did include $5 million for a crisis center in Lane County, $2 million for one in Polk County and $5.4 million in Benton County. 

Ramirez said the state is still figuring out what the crisis stabilization centers will look like and how they will serve very remote areas of the state. The health authority has convened a group that includes representatives from the judicial system, mobile crisis units, 988 and others. 

“We are all in it together,” she said. “This will help us all and we all need to be working on this.”

Calling 911

As lawmakers gave final approval to the 988 funding bill, state Rep. Tawna Sanchez, D-Portland, described on the House floor how families struggle with how to respond to a loved one in crisis. 

“They don’t know what to do,” said Sanchez, who sponsored the bill. So the first thing they do (is) call 911 because we’ve been taught that when we need help we call 911.”

But she said that “unfortunately, the response sometimes hasn’t gone well,” referring to high-profile events where police use force on someone in crisis. 

Holton said it’s rare for 988 to involve emergency services in a call, but there are situations that require it. For example, if someone called and was actively planning to commit suicide by ingesting pills, 988 would involve emergency services. 

Nationally, fewer than 2% of 988 calls are referred to emergency services, such as 911, according to Substance Abuse and Mental Health Services Administration. 

But Fitts said he’s worried about the potential for calls to be referred to emergency services. He pointed to reporting describing the disruptive experiences of people who were involuntarily committed after calling 988.  

“This is coercion,” he said, adding that involuntary commitment undermines the “therapeutic bond” between the caller and 988.

Bouneff agrees that the issue is important. He said the bill created a committee that can explore ways to address it. He said the goal is to help people before the situation involves police.

“988 gave us the opening to really help people much earlier and much closer to the onset of their symptoms and during their first crisis, not their 50th crisis,” he said. 

You can reach Jake Thomas at [email protected] or via Twitter @jakethomas2009.