SAMHSA Pushes All Non-988 Crisis Lines To Support Call Tracing

And the public comment period on SAMHSA's draft plan is (was?) painfully short

Near the end of November, the Substance Abuse and Mental Health Services Administration (SAMHSA), as part of its development of a 988-centric crisis system, released a document obtusely titled, “Model Behavioral Health Crisis Services Definitions.” The first giveaway that this was about something more important than obscure “definitional” discussions was that the document was 94 pages long and SAMHSA was allowing public comments for only 14 days—which included the Thanksgiving long weekend. The people behind this document were, if anything, hoping to squelch, not invite, public discussion.

It quickly became clear why.

The document states that SAMHSA—one of America’s main federal funders of mental health supports and services—is working to establish “consistency across services” and “alignment of services” that will determine “payer coverage.” Essentially, this draft document appears to represent an effort to categorize and define which types of facilities and services—not only among crisis lines but across the entire continuum of behavioral crisis care—will get funded moving ahead. That’s bound to be controversial—especially if, say, you want to quietly target certain types of facilities and services for loss of funding and support unless they reshape themselves to play by your “definitional” rules. Which is, in part, what SAMHSA appears to be doing…

Most concerning from the PsychForce Report perspective are the parts of this draft model where SAMHSA targets those facilities or services currently operating as alternatives to the involuntary commitment and social-control aspects of the mental health system.

How important or influential will this “model” ultimately be in the grand scheme of federal and state funders of mental health supports and services? It’s difficult to know—but we do know that 988 is widely characterized by governments as the first step in revamping the entire crisis care system. So if you care about crisis hotline practices, or indeed about any aspect of the crisis care system in the United States, especially non-clinical and peer-run services, then read on. The public has only until Thursday, December 5th at midnight to submit comments on this new “model.” I encourage you to submit your thoughts to SAMHSA! Here—admittedly in some haste—I’ll discuss the main problems I’m seeing in this draft model, point to other areas worth closer review, and summarize my own planned comments.

Key missing principles

The first section of SAMHSA’s document outlines the proposed “Overarching Principles” of its “model” crisis care system. Many are vague, innocuous-sounding principles like “Crisis Services Should Prioritize Quality and Effectiveness” and “Crisis Services Should Be Evidence-Based, Evidence-Informed, and/or Reflect Promising and Emerging Practices.”

Across thirteen pages of such principles, most notable is what’s missing.

There is no overarching principle about proactive public transparency of policies and practices—even though the SAMHSA writers acknowledge that widespread confusion about policies, practices, and available services is a reason for their own efforts to nail these definitions down.

There’s also no overarching principle supporting robust complaint-resolution processes in crisis services, even though it’s difficult to find any experienced or knowledgeable person who doesn’t describe the nation’s mental health system as “broken”—and its perceived brokenness is the primary reason for SAMHSA’s effort to create this new model.

“I can’t hear anyone, even me!”

There’s also no overarching principle about reporting key data on involuntary crisis interventions or working to reduce involuntary interventions. This, even though involuntary interventions are one of the most controversial and problematic aspects of the crisis care system and, as I examine in my book, the tracking and public reporting on involuntary psychiatric detentions is abysmally poor.

And there’s no overarching principle about protecting people’s privacy—the word “privacy” doesn’t appear anywhere in the document, even as revelations have emerged about widespread, arguably illegal recording and sharing of confidential conversations by 988 call centers.

Call 988—or else

In its second section, the SAMHSA document reviews the main types of services that are available to people experiencing behavioral or mental-emotional crises, under categories of “Someone to Contact” (e.g. crisis hotlines), “Someone to Respond” (e.g. mobile crisis teams) and “A Safe Place for Help” (e.g. hospitals, peer respites).

The third category is the most expansive, and anyone who works in crisis services— especially those run by non-clinicians or peers with lived experience—may especially wish to review it. My own primary focus here will be on the “Someone to Contact” group: crisis lines. But problematic issues relevant to the second and third categories quickly become apparent. (Wildflower Alliance, a supporter of the launch of PsychForce Report, has recently posted comments on these other categories as well.)

I’ve reported extensively on how 988’s secretive call-tracing and policing practices lead to callers getting subjected to dangerous law-enforcement encounters, psychiatric incarcerations, and traumatizing forced treatment. As Vic Welle has explained eloquently, SAMHSA and Vibrant Emotional Health’s 988 hotline does not even meet SAMHSA’s own criteria for trauma-informed practices.

This SAMHSA model document itself acknowledges “the iatrogenic trauma of coercive treatment on individuals with mental health and [substance use disorders] and the historical and cultural trauma of marginalized communities who have been exposed to the disproportionate use of force.”

Callers who become aware of these practices are consequently increasingly searching for those non-988 call centers and peer-run warmlines that don’t trace calls. And rather than change its policies or risk the popular failure of 988, SAMHSA’s “solution” appears to be to work to eliminate these alternatives.

Basically, in its model, SAMHSA strongly recommends, or seemingly defines as required, that all crisis lines will contact 911 or 988 in situations when callers are perceived to be at “imminent risk” of suicide or other future harms, so that policing interventions can be initiated with or without caller consent.

For example, according to the SAMHSA draft model, all non-988 crisis hotlines should “[t]riage/screen each caller for suicide (ideally following 988 Lifeline Guidelines training)” and should “[i]nitiate transfer to 988 or 911 if there is an imminent safety concern.”

Similarly, for “Peer-Operated Warmlines,” SAMHSA repeatedly advises that these should “[c]ollaborate with the local 988 centers” and “[i]n cases of imminent risk that cannot be addressed through collaborative safety planning, refer to 988.”

And even at phone lines simply offering non-crisis “emotional support,” SAMHSA again repeatedly declares that all call-attendants should screen for imminent risk and “discern when to transfer to 988… for more intensive intervention” and “[i]n cases of imminent risk that cannot be addressed through collaborative safety planning, refer to 988.”

SAMHSA knows how controversial this is. So, is SAMHSA’s intention that crisis line operators who decline to channel any callers to 911 or 988 might eventually cease to get SAMHSA funding or accredited recognition by other federal and state agencies? This question is especially sensitive for non-988 crisis hotlines and warmlines already threatened by the 988 state-tax funding model which excludes non-988 crisis lines. The SAMHSA web page inviting public comments includes an email address for questions. Last week, and again this week, I emailed a request for clarification. SAMHSA has not replied.

So if you’re concerned about the crisis care system in America, you may want to read SAMHSA’s Model Behavioral Health Crisis Services Definitions and submit comments there before the Thursday, December 5 midnight deadline.

Here is a summary of my own thoughts, which anyone is welcome to include or adapt in their own submission:

1) An overarching principle should be, “Crisis services should provide proactive public transparency about all policies and practices.”

2) Overarching principles should be, “Crisis services should track and publicly report on involuntary interventions” and “Crisis services should work to reduce and eliminate involuntary interventions.” Aggregated data on involuntary interventions, involuntary holds, and involuntary psychiatric commitments should include reasons for interventions and detailed demographic information to help better understand and improve practices.

3) All crisis services should have clear policies and practices for receiving and responding to complaints from patients, external parties, volunteers, and staff, for retaining neutral third parties for dealing with unresolved complaints, and for issuing annual, anonymized summaries of complaints and resolutions.

4) All crisis lines should be proactively publicly transparent about their policies and practices of collecting and sharing of personal data, including recorded conversations and transcripts of conversations—which should be recognized as confidential personal health information even when stripped of names and contact numbers. There should be clear opt-in and opt-out procedures available.

5) All crisis lines or peer-run warmlines that do not engage in non-consensual interventions should be supported as vital alternatives to 988.