SEATTLE — A green light blinks quietly on an office phone monitor. A volunteer named Mark McAllister quickly transfers the call to his direct line. A soft voice comes through his headset: "I've been feeling a little bit sad lately."
McAllister shifts in his chair, his glasses bobbing as he nods along. To his right, two other volunteers take calls. One listens to a teary 17-year-old who recently fought with her mother. Another call is from a woman worried about her brother who's experiencing symptoms of severe mental illness; he's refusing treatment and she doesn't know what to do.
Every day at this inconspicuous office a couple of blocks from the Space Needle, dozens of volunteers and staff answer crisis calls and monitor the suicide hotline for King County and large parts of Washington state.
In less than 100 days, this place will add dozens of new staffers for the rollout of 988, a nationwide crisis phone line that's set to debut in mid-July. The goal is to consolidate various hotlines and phone services for youth, veterans, people seeking substance use treatment and any caller who just needs a kind listener or resources for their mental health.
The challenge is this: consolidating a patchwork of crisis response systems across police, fire and mobile crisis teams, and across state agencies, county and tribal lines. Those building the hotline hope it will eventually connect to a robust behavioral health system that can provide next-day crisis appointments and support families with resources and treatment options. That system doesn't fully exist today — and won't for years, if ever — but those implementing 988 see the hotline as the first milestone.
Others, though, worry about launching 988 without a full infrastructure behind it. Ben Miller, CEO of the mental health advocacy nonprofit Well-Being Trust, warns that much of the U.S. is not ready: Workforce shortages in the mental health sector are dire, and in Washington the number of beds for crisis stabilization is limited.
"Hope is not a strategy," said Miller, who is also a clinical psychologist based in Tennessee. "We're going to have people call a new number and we're going to get the same response [as they did before the hotline]. Or even worse, my biggest fear is that they call the new number [and] they get a police response."
Encounters between police and people with mental illnesses can have tragic results: People with mental illnesses are 16 times more likely to be killed in a police shooting than the general population, according to the Treatment Advocacy Center.
The stakes for 988 are high, Miller cautioned: "We run the risk of losing the trust of the public by not being prepared."
How does 988 work?
In 2020, Congress passed the National Suicide Hotline Designation Act as a complement to the current 911 emergency line, requiring states to launch the new 988 number by July 16. The following year, the Washington state legislature passed House Bill 1477 to further develop the plan and partially fund the service through a tax on phone and internet lines (24 cents per month, then 40 cents starting next year).
Three nonprofits that already operate local crisis hotlines — Frontier Behavioral Health, Crisis Connections and Volunteers of America — are set to host the 988 line across Washington, with the majority of Washington's calls monitored by Volunteers of America. Crisis Connections serves King County, the most populous and busiest part of the state for crisis calls. They receive about 282 calls a day on the current King County hotline, and hundreds more through programs like Teen Link, a call and text service for youth; a service for veterans; and another called the WA Warmline, hosted by peers who have direct experience with emotional or mental health challenges.
While Crisis Connections has a volunteer program for its other hotlines, the 988 line will rely on 35 paid staff counselors who can provide crisis intervention and crisis counseling services around the clock, as well as referrals to local resources and a mobile crisis team when needed. Volunteers of America says it's bringing on 50 additional staff members.
Administrators expect about 128,000 statewide calls in the first year of the new line, but it's hard to know how fast demand for services will grow. So far, the state has allocated over $27 million.
"We don't want to overpromise to the community," cautioned Michelle McDaniels, CEO of Crisis Connections and a member of the Crisis Response Improvement Strategy Committee, a group of state leaders tasked with planning the rollout.
"This is not going to be a massive reform on July 16, that we absolutely have a system that's in place."
At first, both local county hotlines and the 988 line will be active — something that some staff worry could be confusing for the public.
Some staff also worry about the complications of transferring calls coming from three different dispatch centers: former county hotlines, the new 988 state line, and traditional 911 police and fire lines.
"We don't want (a caller) to have to tell their story over and over again," said Joe Avalos, the chief operating officer of Thurston-Mason Behavioral Health Administrative Service Organization.
At best, the caller is frustrated and at worst, Avalos explains, the dispatch loses the caller — which means losing the chance for early intervention, a key part of crisis cases.
The 988 vision
State officials and local leaders see the 988 federal rollout as an opportunity to leverage funding and energy to revitalize Washington's system of crisis care.
A draft operational plan submitted to the Washington Legislature at the start of the year envisions two new technical systems to go along with 988 and help streamline communication between agencies: an integrated referral system and a crisis call center hub system. The federal government has selected contractors to build these tools, but the state has not yet decided whether to use those vendors or build a different system altogether.
The referral system would include a provider directory for the public, as well as an electronic health record system that would allow dispatchers to see mental health advance directives (a legal document that describes the kind of services an individual wants in case their mental health problems become so severe they need help). Crisis workers would also see real-time availability of beds in their region — additions that would greatly connect the crisis system that is currently siloed among many networks.
The call center hub would connect the various hotlines, tribal lines and emergency services dispatch centers into one platform that is cohesive and can easily transfer people. That flexibility would be helpful, since not all emergencies are created equally.
"The caller can start the call requesting one thing and then it becomes apparent over the course of that call that there's a crisis occurring there," said Jessica Shook, the president of the Washington Association of Designated Crisis Responders. "But it is not the crisis that they initially called with."
A crisis might initially be called in as a welfare check or a domestic violence situation among family members, for example. Depending on each case, a dispatcher may send police, fire, EMTs, a mobile crisis team, designated crisis responders or a combination of the above.
In theory, the new 988 system and the accompanying tools will connect the dots and help people in need of mental health services get diverted from the police and even get follow-up care.
The Seattle Police Department has a specialized crisis response team — which pairs an officer with a mental health professional — to respond to some nonemergency crisis calls. But there currently are only nine people on the team, and SPD has received over 2,900 crisis calls this year already. (Some other officers have crisis intervention training, a 40-hour course that teaches them about mental health and de-escalation, and provides resources to share with the community.)
Altogether, the department struggles to keep up with demand and is hopeful 988 will lighten the load. After the rollout, however, law enforcement is still going to respond to some calls. Depending on the situation, officers may need to be dispatched if someone is physically violent or has a weapon, or if social workers need assistance detaining and transporting someone to a hospital.
Evergreen challenges
The state still faces huge challenges before 988 can be part of a truly comprehensive mental health system.
Washington, like many states, faces a shortage of mental health workers. Across the board, health care and mental health care organizations have struggled to retain staff and hire new workers. Many mental health professionals are facing burnout after two years of the COVID-19 pandemic. Salaries in clinics that serve low-income people are not nearly as competitive as in private practice, and to enter the behavioral fields, workers often need a bachelor's or master's degree on top of work experience, often leaving them with debt.
Advocates point to a peer model — where people who have experienced mental health challenges can help others — as a possible way to boost the workforce. But the state's current peer program is limited to patients on Medicaid, and unlike designated crisis responders or higher-level providers, peer advocates are limited in their legal capacity to provide care.
Another big challenge is where to take people who are in crisis. Almost everyone agrees that emergency rooms are not the solution, but most regions in the state have a shortage of crisis stabilization beds.
Those beds are meant for a short-term stay for people who need help but are not immediately a threat to themselves or others. People must go voluntarily and they typically stay less than a day, unlike inpatient facilities where people cannot check out and initially spend 72 hours.
King County currently has 46 short-term crisis beds for its 2.2 million residents through the Downtown Emergency Services Center. A 2016 report from the Washington State Institute for Public Policy estimates there are 175 crisis beds across the entire state. For the people Avalos serves in Thurston and Mason counties, there are none.
Some progress on adding beds is being made. For example, the Washington State Department of Commerce is working to get two additional crisis stabilization facilities licensed in King County.
Still for people who are in crisis now, the wait is hard, and the current alternatives are often jail or homelessness.
Shook, from the Washington Association of Designated Crisis Responders, is hopeful for the start of 988 because it could be a first step to a full crisis care system that includes prevention, early intervention and a place for people in crisis to go to.
"I would love to have the capability for a 24/7 crisis team," she said. "I would love to have the capability to be staffed up to respond like firefighters and just be able to hit the ground running and go out the door.
"This is the first time we've had this much attention and focus on (crisis response) and that can't help but lead to improvements and changes to the system."
