Decriminalizing Mental Health Crises – The Health Care Blog


By BEN WHEATLEY

Effective July 2022, a new three-digit telephone number (988) will become the number to call in the case of mental health emergencies. Currently, 911 serves as the default number for people to call, placing the acutely mentally ill on a direct track toward police involvement. The new system is meant to ensure that every person experiencing a mental health crisis will receive a mental health response instead—help, not handcuffs.

In November 2021, 15 prominent organizations including NAMI (the National Alliance on Mental Illness) and Well Being Trust joined together to reimagine what a crisis response system might look like. Their Consensus Approach included the response to mental health crises, cases of suicidal behavior, and instances of substance use disorder. They argued that “Without a systems approach to transformation, simply implementing a new number to call will have little impact on those who are in need.” 

The Consensus Approach detailed seven critical pillars upon which a new crisis response system could be based, including Equity and Inclusion, Integration and Partnership, and Standards for Care. Pillar #4 stated that “Law enforcement should take a secondary role in crisis response.” This, they said, would be “a paradigm shift” that recognizes mental health conditions as “matters of health care, not criminal justice.” 

Three of the seven pillars alluded to the intersection of 911 and 988. Pillar #2 said that “Planning efforts must include how 911 and 988 responses will interact to ensure the two systems operate in a complementary fashion, not as parallel or exclusive systems.” Pillar #4 said that “Planning efforts [should] encompass the overlapping of 911 and 988 responses to encourage clarity of roles and protocols for cross-system referrals.” Pillar #3 noted that we should “Reject artificial distinctions for who can be served with crisis services, e.g., ‘violent’ versus ‘non-violent.’”

This last point deserves more attention. In a previous blog, I discussed the case of Miles Hall, a 23-year-old Black man who was shot and killed by police during a mental health emergency. 911 had received numerous calls regarding his behavior, including by family members who said that he was acting violently. He had broken a sliding glass door to his parents’ home with a 5-foot crowbar that he thought had been gifted to him by God. Neighbors called 911 to say they had heard arguing and what sounded like a gunshot. Police arrived on the scene with these warnings in mind. 

Though there were perceived threats to public safety, Miles Hall was also clearly in the midst of a mental health crisis. When we say (convincingly) that every mental health crisis deserves a mental health response, this is an example of one that we mean. In fact, the legislation supporting 988 in California is entitled Assembly Bill 988 – The Miles Hall Lifeline Act. The key legislative sponsor of the act has reiterated that “Mental illness is a health condition, not a crime, and health practitioners should respond to crisis calls, not law enforcement.”

But this is where the line between 988 and 911 becomes unclear. AB 988 requires that “any call made to 911 pertaining to a clearly articulated suicidal or behavioral health crisis shall be transferred to a 988 center unless both of the following conditions are met:” (1) “The situation cannot be reasonably managed without law enforcement, medical [emergency medical services], or fire assistance” and (2) the “911 operator has reason to believe there is a medical emergency,…the person is threatening others’ personal safety, or there are reported conditions where law enforcement is mandated to investigate a potential crime or crimes, by federal or state statute.”

In the case of Miles Hall, there are several reasons to suspect that the calls placed to 911 would not have been transferred to 988. First, 911 operators may not have agreed that this was a “clearly articulated” mental health crisis. Though the family members who called 911 articulated that Miles was having a mental health crisis, they also said that he was being threatened and acting violently. Second, the neighbors who placed calls to 911 only reported that Miles was acting menacingly, they may not have known of his mental health condition. And third, there were potential weapons involved—the 5-foot long metal crowbar, and the (falsely) reported gun.

For these reasons, it seems clear that even when 988 is up and running, 911 dispatch and the police will continue to maintain primary responsibility in a case such as Miles Hall’s. In other words, a mental health crisis such as his will not receive a mental health response. And, police-involved shootings of the mentally ill will remain a serious possibility. As a result, key steps still need to be taken to fully reimagine our crisis response system. Specifically, we will need to determine how to accommodate mental health crises that also have a public safety component. 

Existing Infrastructure

911 call centers (called public safety answering points, or PSAPs) receive an estimated 240 million calls per year in the United States. There are more than 5,000 separate 911 call centers, each with its own standards for training staff, call-handling and dispatch protocols, and data management and reporting systems. In a survey, about two-thirds of responding call centers said their call-takers and dispatchers had not received any specialized behavioral health crisis training. In California, Assembly Bill 680 was under consideration to increase training requirements for emergency dispatchers. The goal was to make sure that those answering and responding to emergency calls knew more about crisis intervention and mental health identification. According to its author, “When implemented, California will be the first state in the country to provide this level of training to all 911 dispatchers as part of their basic training course curriculum.” However, the bill failed due to cost pressures.

The 988 call centers will build upon the National Suicide Prevention Lifeline infrastructure, a national network of approximately 170 local- and state-funded crisis centers. It remains to be seen how these crisis centers will interact with 911 systems. This is part of what needs to be built upon between now and July 2022. It may be that some 988 call takers will be housed within 911 call centers to help with hand-offs between the two. 

The End Goal

At each step in the new crisis response system, the end goal will be to divert those experiencing mental health crises away from criminal justice response. More emergency calls will be directed to 988 rather than 911; the on-site response will be handled by mobile health crisis teams rather than police officers, and those in crisis will be directed to stabilization units rather than emergency departments or police stations. 

Part of the reason this represents a difficult paradigm shift is that in many cases—as in the case of Miles Hall—the mental health crisis also includes a public safety component. This is a nuance that needs to be addressed, otherwise, people will continue to talk past each other—some focused on the needs of the mentally ill, others focused on the need for public safety. As an example, the city of Walnut Creek, California awarded a $4 million settlement to the family of Miles Hall after a period of litigation. However, the city “did not admit fault by any of the officers who responded or other city employees involved in the incident.” 

Another example illustrates the difficulty of our current situation. In Antioch, California, the family of Angelo Quinto, a 30-year-old Navy veteran who suffered from anxiety and paranoia called 911 because they were worried about the safety of his mother. The police who responded acted forcefully to restrain Quinto and he subsequently died. Quinto’s sister “asked the detectives if there was another number I should have called, and they told me that there wasn’t and that I did the right thing.” But she replied, “the right thing would not have killed my brother.” This case is also undergoing litigation, pitting the family of a mentally ill person against the criminal justice system. 

At the end of the day, fully reimagining our crisis response system will have to address the public safety threats perceived by police and others, but also the basic care needs of people in crisis. In short, it will require that those in crisis receive both care and containment. 988 and 911.

Ben Wheatley has 25 years of experience working in health policy with organizations including AcademyHealth, the Institute of Medicine, and Kaiser Permanente.



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