‘911 For the Brain’: Congress and FCC Designate ‘988’ As New National Suicide Prevention Hotline Number, Starting in July 2022
Continuing Education of the Bar / July 28, 2021
In 1968, the first “9-1-1” emergency call was placed in the United States, and since 1999 the Federal Communications Commission (FCC) has designated 911 as the “universal emergency number” for all telephone services, giving callers easy access to Public Safety Answering Points (PSAPs) where trained dispatchers route calls to local emergency medical, fire, and law enforcement agencies.
But what if there were a “911” specific to the brain? This was part of the thinking behind the forthcoming “9-8-8,” an “easy-to-remember, 3-digit hotline” meant to speed-up access to suicide prevention services, and perhaps send the message that mental health crises are of equal importance to medical emergencies.
At the same time, however, the “911” analogy may give short shrift to suicide hotlines and the services they provide.
Dr. Jonathan Goldfinger, CEO of Didi Hirsch Mental Health Services in Los Angeles—the first and largest suicide prevention call center in the United States—explains that “911” for many people “conjures up an image that we’re like the police phone operator who’s on for 20 seconds to triage the call, when really we’re more like the ambulance-over-the-phone, saving lives on 20 minute to 2-hour calls,” he said.
“We’re basically a telehealth service,” Goldfinger added.
Currently, the existing National Suicide Prevention Lifeline (the “Lifeline”)—whose network of call centers Didi Hirsch is a part of—is accessible via a 1-800 number (see more on this below). But thanks to recent Congressional laws, and a final rule by the FCC, phone service providers must direct all “988” calls to Lifeline by July 16, 2022, one year after the release of the FCC’s report.
The need for an easy-access 988-type number was clear: According to the Centers for Disease Control and Prevention (CDC), suicide is the tenth leading cause of death in the U.S. (a fact that has held true since 2008). In 2018, 10.7 million adults in the U.S. seriously considered suicide; 3.3 million made a plan; and 1.4 million attempted it. (The impact on various at-risk populations is even greater. For instance, LGBTQ young adults (ages 18-25) contemplate suicide at rates more than four (4) times higher than heterosexual young adults.) Meanwhile, the impact of the ongoing COVID-19 pandemic has exacerbated suicidality, especially among adolescents, for whom suicide ranks among the top causes of death.
Accordingly:
• Congress passed the National Suicide Hotline Improvement Act of 2018 (“the Act”), amid bipartisan support, to explore simplifying suicide hotline access through studies by specific agencies, including the FCC. See National Suicide Hotline Improvement Act of 2018, Pub. L. No. 115-233, 132 Stat. 2424 (2018).
• Pursuant to the Act, the FCC reported on the feasibility of designating such a number, then unanimously voted to launch a rulemaking proceeding to consider designating “9-8-8” as that number.
• Effective October 2020, the FCC published its final rule requiring all “covered providers” (see below) to implement 988 in their networks by July 16, 2022. See 47 C.F.R. § 52.200.
• Following the FCC’s adoption of its 988 Report and Order, Congress also passed the National Suicide Hotline Designation Act of 2020, making 988 “the universal telephone number within the United States for the purpose of the national suicide prevention and mental health crisis hotline system operating through the National Suicide Prevention Lifeline.” See National Suicide Hotline Designation Act of 2020, Pub. L. No. 116-172, 134 Stat. 832 §§ 2, 3 (2020).
Brief History of the “Lifeline”
Since 2005, the National Suicide Prevention Lifeline (now and until July 16, 2022: 1-800-273-8255, or 1-800 273-“TALK”) has been a toll-free hotline providing 24/7 free mental health and emotional support services to callers in crisis. While this number is arguably cumbersome for somebody in crisis, a 2017 song by the rapper Logic, “1-800-273-8255,” makes it somewhat easier to recall (the official music video now has more than 422 million views).
Contrary to common belief, the Lifeline is not a single, national call center but rather a network of approximately 190 local and state-funded “crisis centers” serving their local communities. (For reference, there are 13 crisis centers in California, including Los Angeles’s Didi Hirsch; and within the first 6 months of 2020, 111,058 calls from California were made to the Lifeline.)
Each “crisis center” is akin to a local safety net (similar to PSAPs for 911), and most centers are nonprofits staffed by trained volunteers and mental health professionals. Calls made to the Lifeline are routed to the closest crisis center based on the caller’s area code, the idea being that local counselors can offer referrals to local services. Further, if a crisis center is overwhelmed by calls or experiences a disruption, the system automatically routes the caller to a “backup” center elsewhere in the U.S.
In 2018, the Lifeline answered a total of 2,205,487 calls nationally, averaging 183,790 calls per month. On occasion, a major public event will prompt a surge of calls, with recent examples including the deaths of Robin Williams, Kate Spade, and Anthony Bourdain, as well as the televised performance of Logic’s aforementioned song. While the Lifeline does not currently offer text services (but see more on this below), it does have a “chat” feature and responded to 102,640 crisis chats in 2018.
A public-private partnership, the Lifeline is partially funded and overseen by the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA). In 2007, adding another layer of crisis support, SAMHSA and the Veterans Health Administration partnered to establish the Veterans Crisis Line, which also uses 1-800-273-TALK as an access point (veterans press “1”).
National Legislation: The Suicide Hotline Improvement Act of 2018
Seeking to simplify the 1-800 number, Congress’s 2018 Act directed the FCC and SAMHSA to report on (1) the efficacy of the existing Lifeline; and (2) the feasibility of a three-digit dialing code. Among the Act’s sponsors were Rep. Chris Stewart and Sen. Orrin Hatch of Utah, a state with one of the highest suicide rates in the nation.
SAMHSA’s report, in short, presented empirical evidence of reduced suicidal ideation among Lifeline callers and concluded that designating an “N11” code for a national suicide prevention hotline could play a key role in improving intervention efforts.
SAMHSA placed arguments in favor of a 3-digit number into two categories:
• A “N11” number would be easier to remember than a 10-digit number, improving accessibility. (Although the SAMHSA Report did not specifically address designating a non-N11 3-digit code, this was the ultimate outcome with the selection of “988,” discussed below.)
• A “911 for the brain,” so to speak, could signal that “mental health crises and suicide prevention are of equivalent importance to medical emergencies [and] would, over time, bring needed parity and could result in additional attention and resources to improve typical local psychiatric crisis services….”
Following SAMHSA’s and the FCC’s respective reports, Congress more recently passed the National Suicide Hotline Designation Act of 2020, statutorily requiring the FCC to designate 9-8-8 as the universal national suicide prevention hotline number, and addressing funding, albeit in a limited manner.
Why “988”?
As mandated by Congress, the FCC along with the North American Numbering Council (NANC) assessed three options for an easier-to-remember hotline number: (1) expanding an existing N11 code (e.g., “211” or “511”), (2) repurposing an existing N11 code, or (3) using a new non-N11 code.
To date, the FCC had assigned six (6) “N11” codes:
• “211” is currently used for community information and referral services;
• “311” for non-emergency police and other governmental services;
• “511” for traveler information services;
• “711” for the Telecommunications Relay Service;
• “811” for notice of excavation activities; and
• “911” for emergencies.
Notably, “411” and “611” have not been permanently assigned by the FCC but are used for directory assistance and wireline and wireless carrier customer service and repair, respectively. The codes “011” and “111” are unavailable because “0” and “1” are used for switching and routing purposes.
NANC’s report explored expanding the “211” code and repurposing the “611” code or the “511” code, the latter of which seems especially outmoded as smartphone apps and in-vehicle navigation systems diminish the need for dial-in travel information.
Expanding 211, however, would require callers in crisis to interact with a convoluted phone tree and responders likely to be untrained for emotional crises. For “511,” NANC recognized that a repurposing would require extensive re-education and costly efforts to update roadway signage where 511 is advertised. Further, re-education efforts could take even longer for “611” calls, which comprised nearly half of all N11 code calls, the NANC report observed. Thus, “611” would need to sit idle for a while to prevent continued customer service and repairs calls from clogging up a suicide line. In other words, repurposing an existing N11 code could take many years to implement.
The FCC’s report to Congress therefore concluded that a unique 3-digit code was better than using an existing N11 code. Moreover, designating a new, non-N11 code would (1) prevent the need to “age” the existing N11 numbers and (2) simplify consumer education campaigns and expedite the hotline rollout.
The NANC explored “988” because it was not assigned as an area code and had fewer Central Office code assignments (also known as the “NXX” code, or the three digits that follow a phone number’s area code) than other NXX codes, minimizing the number of switches that would need development work.
Ultimately, “988” was seen as the quickest path to implementation.
Deadline: July 16, 2022
Pursuant to its order and authority under 47 U.S.C. § 251(e)(1), the FCC ordered all telecommunications carriers, interconnected voice over Internet Protocol (VoIP) providers, and one-way VoIP providers (the “covered providers”) to update their networks to enable users to access the Lifeline via 988 by July 16, 2022.
Since the adoption, several providers, including T-Mobile and Verizon mobile services, have made 988 available to customers ahead of the July 16, 2022 deadline, according to the FCC. (Note: The 1-800 nonetheless remains in effect until the switchover deadline.)
With respect to the existing support network, SAMHSA has awarded its next five-year grant to Vibrant Emotional Health, a New York-based nonprofit that already administers the Lifeline. This next grant cycle will include Vibrant’s implementation of 988.
A Vibrant spokesperson said that Vibrant is working closely with SAMHSA, crisis centers, state mental health agencies, and mental health organizations to plan and carry out the 988 implementation, with the hope of reaching many more people in emotional crisis.
Vibrant has also projected that call volume may double (or more) under “988,” raising questions about call center capacity and funding.
Criticisms and Challenges
Despite bipartisan support and acknowledged need for better mental health infrastructure, the 988 rollout is not without criticism. For example, some have observed that the effort could have done better to target at-risk groups, as well as accommodate those who are deaf and hard of hearing.
Other criticism has observed that phone calls are “old” technology. One commissioner observed that the FCC should have been more “ambitious” by incorporating the ability to “text into” the 988 number, which is especially imperative given the rise in teenage suicides, coupled with the fact that texting is teens’ “primary form of communication.” As it stands, however, the Lifeline currently lacks an integrated text service, although the Veterans Crisis Line does have a chat function (838255), as do non-governmental crisis services (discussed below).
In response to a petition and comments from organizations, the FCC in April 2021 issued a Further Notice of Proposed Rulemaking, proposing comment on requiring covered text providers to support 988 text messaging by routing 988 texts to the Lifeline. The FCC also sought comment on a specific implementation deadline, and whether text providers should be required to send automatic bounce-back messages where the text-to-988 service was unavailable. The FCC held an open meeting and accepted comments (and will accepting “reply comments” through August 10.)
Perhaps most glaringly, the 2018 Act did not authorize additional funding, imposing an unfunded mandate on the covered providers and raising concerns that the Lifeline on both a national and local level may lack capacity to handle the projected influx of calls.
For its part, the FCC observed that funding was beyond its jurisdiction, and that centers will have a year to prepare for the increase. Meantime, President Biden’s FY 2022 budget allots SAMHSA $180 million to fund its suicide prevention programs—a $78 million increase over FY 2021 enacted. Further, Congress’s 2020 legislation called for additional studies, including to address funding avenues for crisis call centers, and it allows states to impose and collect a fee for providing 9-8-8-related services (and the FCC must submit an annual report on state administration of these fees).
Dr. Goldfinger of Los Angeles’s Didi Hirsch Mental Health Services said one of the biggest obstacles to rolling out 988 (now less than a year away) is the “total lack of funding to expand capacity,” which creates risk of “many people calling, chatting, or texting without a response, long wait times, or being sent out of state where [the non-local crisis centers] know less about local resources.”
Goldfinger observes that despite the federal legislation enabling states to pass bills to fund 988, only a few such bills have passed to date, in large part due to telecom industry influence and little to no federal guidance (from SAMHSA, CMS, etc.) on how states could fund 988 call centers using fees and healthcare dollars.
“For a lawyer audience it’s important to realize that this is a moment for states to step up and enforce federal parity and equity law for those with a mental health crisis or suicidal thoughts. Lack of public perception of [the Lifeline]/988 as a healthcare service means the parity and equity lens isn’t likely to be applied by states, payers, and advocates when it should be,” Goldfinger added.
A related concern is a lack of public education about what role Didi Hirch and other crisis centers play and how important their services are, which may perpetuate the lack of funding, Goldfinger said.
Further, even if Didi Hirsch and other crisis centers received the funding needed to enhance capacity, it’s unclear whether they could find and train people to serve as crisis counselors fast enough.
“Right now some of these nonprofits have suffered so financially that they’re losing staff and volunteers, let alone finding ways to grow,” Goldfinger said.
General Takeaways and Attorney-Specific Takeaways
To that end, crisis centers including Didi Hirsch are looking to “staff up,” says Nathan Lichtman, a Training and Volunteer Coordinator for Didi Hirsch’s Suicide Prevention Center.
One of the center’s approaches, Lichtman says, “is to look towards impacted communities, people who may have experienced suicide firsthand or would benefit from getting involved.”
Attorneys are among these groups at greater risk for suicide than the general population, and according to a CNN report based on CDC data, attorneys rank fourth among professions when the proportion of suicides is compared to other occupations (following right behind dentists, pharmacists, and physicians).
“It is crucial that those in the legal profession know that they can always reach out to [the Lifeline] if they themselves, a friend, loved one, or colleague needs support,” Lichtman said. “It would also be great to have their involvement at our crisis line.”
Lastly, it is also imperative to note that despite its 24/7 crisis services, the Lifeline is not the only available resource. “Crisis Text Line” (741741), for one, is a private nonprofit offering similar access to crisis counselors and volunteers, and has exchanged millions of text messages since 2013. Other non-government resources focus on narrower and often at-risk populations, including the The Trevor Project, “the nation’s largest LGBTQ youth suicide prevention and crisis intervention organization,” which responds to thousands of calls, chats, and texts annually; “Teenline,” a nonprofit specializing in call and chat services for youth; the National Domestic Violence Hotline, offering assistance in domestic violence situations; religiously affiliated support lines; and many others.
For attorneys, the State Bar of California also offers counseling services through its Lawyer Assistance Program.
If you or someone you know is contemplating self-harm or suicide, Lifeline services are available 24/7:
Current Lifeline phone number (until July 16, 2022): 1-800-273-TALK