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Friday, July 15, 2022

The Problems with 988

A lot of reporting has been done on the purported boons of the new national 988 mental health crisis line. It promises to reduce the number of 911 calls on those experiencing internal distress, and, it is hoped, thereby reduce the number of people sent to jail inappropriately or traumatized or shot by cops showing up for a crisis instead of more helpful mental health professionals. The idea is that people experiencing extreme states of mind or psychological crises will “get the help they need” instead of criminal records and go on to lead fulfilling, productive lives.

There are numerous problems with this assumption. Let’s start at the point of crisis and go from there.

1. Calling 988 does not guarantee that a mental health professional will show up at your door.

That would only be the case in communities with an available crisis response team (CRT), which, geographically speaking, is a small fraction of the nation at this time (see The Takeaway podcast below), and even then, there’s no guarantee they meet national standards. In communities so served, CRTs may or may not be adequate in number or staffing to meet the needs of every 988 call deemed a true crisis. The trigger is generally “threat to self or others,” as determined by the 988 staff member who takes the call. Ideally, most calls will not result in a crisis being determined, and people will be referred to other services—a representative from NAMI, speaking recently on The Takeaway, estimates that 95% of callers will not be deemed to be in crisis, though it’s unclear where she got this statistic; a federal survey suggests 61% of crisis call outcomes were voluntary/collaborative.

However, if a CRT is not available, cops will show up, just like in the bad old days before 988, and it’s possible they will (re)traumatize you by tackling you, tasing you, handcuffing you, or, determining that you’re a threat to them, shooting you. This is more likely if you’re a person of color.

The way the members of this team treat you may or may not be appropriate for your situation or helpful to you: some CRTs may include, for example, a peer support worker, who is likely to understand what you’re going through, having experienced something similar. However, as someone who used to train peer support workers and support peer-to-peer program implementation, I can say that peer support workers are often dismissed by their co-workers and their opinions or actions overridden by mental health professionals who assume, by virtue of superior education or sane status, to know better. Even if your CRT has a peer support worker, there’s a good chance they won’t be allowed to do their job.

Indeed, crisis response is often an opportunity for coercion in the mental health field, and coercion generally just makes the problem worse. As the Intentional Peer Support model points out, it’s often better to take a non-coercive approach to crisis situations. But in the US, we’re stuck in an action-hero mindset that we must save people with direct action, even if we destroy half of Gotham in the process.

2. Often, people in crisis have been “get[ting] the help they need,” and it hasn’t helped. In fact, the help sometimes foments the crisis.

I read about mental health systems in which CBT, DBT, and other therapies are available, but I live in Kansas, and I don’t see that, except for privately insured people who are good at self-advocacy. What I do see in the public system are infantilizing and insulting psychosocial education groups and possibly helpful supported education and supported employment programs. Above all, though, what I see are psych meds—lots and lots of psych meds—a panoply of psychoactive substances doled out in massive doses and with almost ubiquitous polypharmacy.

These meds, while sometimes helpful, often have low efficacy (sometimes little better than placebo), and often have devastating and sometimes permanent side-effects. Switching meds when one doesn’t work for you is difficult, if not impossible for many: a person for whom I provide informal peer support was threatened by per prescriber with involuntary commitment to a state hospital if she didn’t stop asking for a change in medications, even though the side-effects of the ones she was on made it impossible for her work. (She was literally falling asleep on her feet at her retail job.) And this did not happen to her in the bad old days of Cuckoo’s Nest-level maltreatment. This happened last year, in 2021.

Side effects and few options, then, often lead people to stop taking their meds or to reject treatment to the degree they can; often people quit cold turkey. Or their prescibers actually listen to them but take them off of meds too quickly. Quitting or switching psych meds is always a perilous time, with withdrawal effects sometimes mimicking the very symptoms that got the person the diagnosis to begin with, and with others ranging from nausea and dissociation to “brain zaps,” which can last for weeks or months. In other words, the med merry-go-round can lead directly to, you guessed it, a mental health crisis.

988 advocates are relying on the very system that may have played a part in creating the crisis to fix the crisis. They are also assuming the appropriateness of crisis “care.”

3. Crisis “care” is often the source of trauma or retraumatization.

A few communities have short-term crisis centers. In Kansas, the three major metropolitan centers—Wichita, Topeka, and the Kansas City metro area—have short term crisis centers where people can cool off and get support and services for the 24-48 hours a mental health crisis generally lasts. These centers are much less coercive than traditional residential treatment (aka “psychiatric incarceration” to its critics) and tend to cost less and be preferred by users.

They’re also almost always full.

A handful of communities in the US are served by peer-run respite centers that house people for a week or more, and even fewer have short-to-medium-term residences run on the Soteria model.

Most places in the US have none of these things, which means a trip to the psych ward of the local hospital or to a state psychiatric hospital. In Kansas, you have two options for the latter, Osawatomie or Larned, and, as above, they are mostly full most of the time.

Based on my work in them, there you’ll find a situation little different from the way things were 45 or 50 years ago, only now you’ll stay for a few weeks instead of a few years. But it’s still involuntary commitment: you can’t leave until they say you can, and forced medication, seclusion, and physical restraint are common. And a trip to the state hospital is incredibly disruptive to a person’s life. If you’re single and live alone, as is the case with many who have long-term mental health challenges, during the weeks you’re there, you may lose your job, fall behind on rent and lose your housing, and lose any romantic relationships you may have formed. Your pets may die or be taken away, and if you have kids, they may be taken into the foster care system.

Recall that the peer I described above was threatened with a trip to the state hospital? All this is why. Mental health providers know the problems these facilities create, and they use the fear of them as leverage.

Further, there’s growing evidence that involuntary commitment in residential facilities actually increases suicidality, even when the severity of people’s distress is taken into account.

In other words, a call to 988 may not be preventing a suicide; it may merely be delaying one. And it may make one more likely.

As an alternative to hospitalization, many communities have implemented assisted outpatient treatment (AOT) or assertive community treatment (ACT) programs. But as these Orwellian titles suggest, these schemes merely bring the hospital into the community; they are sentences, not services, as the people involved have no choice but to participate (or the choice is these programs or the state hospital—which isn’t really much of a choice at all). These programs may be less acutely traumatizing, but they are still coercive by nature, and they rely on the “meds first and meds mostly” approach that has been the mainstay of mental health treatment for the past 40 years. The point is to keep you in the community and on your meds—to “stabilize” you and reduce your symptoms—not to foster actual recovery or return you to the driver’s seat of your life’s direction.

I am not saying that 988 is a bad idea; I am saying that it is attached to a set of mental health systems that are fundamentally and philosophically ill-equipped to actually help people (re)gain control over their lives and their life trajectories after a mental health crisis. 988 may appear to solve problems for the worried families and friends of suffering people and to those interested in “cleaning up” the places where people in frequent crisis end up—homeless encampments, shelters, local jails. But it won’t reform the system itself, the very system that has been failing these same suffering people over and over again.