Zero Suicide: Crisis Care for Everyone, Everywhere, Every Time

David W. Covington, member of the Executive Committee of National Action Alliance for Suicide Prevention, begins a call for upgrading mental health crisis response systems in America with an analogy to a 2010 accident at a gold and copper mine near Copiapó, Chile.

Thirty-three miners became trapped nearly a half mile underground, but were brought safely to the surface after 69 days through an intense international rescue effort, Covington recalled in his presentation, “The Promise of 988: Crisis Care for Everyone, Everywhere, Every Time,” to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

“That obvious, caring, engaging, supporting, global collective impact and outreach has not been what we’ve seen for those whose darkness is not being trapped in a mine but having some kind of a mental health, substance use, or suicidal crisis,” Covington said. “For those individuals, it’s been far different.”

Covington’s presentation outlined the new vision for crisis care—“for anyone, anywhere, anytime”—that includes the introduction of the easy-to-remember 9-8-8 national phone number for the National Suicide Prevention Lifeline to assist people experiencing a mental health or suicidal crisis. Congress passed the National Suicide Hotline Designation Act in 2020 and the 9-8-8 number officially goes into effect in July 2022.

Part 7 in a Series about the Zero Suicide Model for Healthcare

The new vision for crisis care is reflected in the the National Guidelines for Behavioral Health Crisis Care issued in 2020 by the Substance Abuse and Mental Health Services Administration, Covington said. The guidelines, he added, stemmed from many efforts including the Crisis Now project of the National Association of State Mental Health Program Directors, developed with the National Action Alliance for Suicide Prevention.

Covington said the new model involves handling mental health crises with a minimum or total absence of police and hospital involvement—which the National Alliance on Mental Illness calls the “revolving door of ER visits, arrests, incarceration, and homelessness.” Rather, services are provided by mobile crisis response teams and non-hospital crisis care facilities.

Funding remains a major challenge for scaling up the new model of crisis care, Covington noted, with Congress looking to states to fund upgraded crisis services.

Covington said the new model for crisis care is in line with, and related to, the “extremely bold aspiration” of the Zero Suicide Model for healthcare, and is backed by a growing national momentum. “Let’s talk about how we might dare a much mightier system of care, and think about the way that we responded to those Chilean miners, without judgment, without shame. Instead, with an all-on full effort, an integrated and collective effort, to save their lives and support them, get them back to their lives,” he said.

The new model addresses what Covington called the “two sins” traditionally committed in crisis response.

The first, he said, is the message that reaching out for help leads to “punishment” in the form of a response by armed police officers. “Imagine that the darkness that you’re experiencing isn’t in a Chilean mine but in your living room in your apartment, and the response is law enforcement cars in the driveway, lights flashing,” he said. “About 70 percent of the time they’re handcuffed and placed in the back of the patrol car and transported to to a facility. While they may not in fact be arrested, it certainly feels like an arrest to the individual who’s in pain.”

The second sin, according to Covington, is “warehousing” individuals in a hospital emergency department as a way of handling individuals in crisis. He cited a 2013 Seattle Times report that found that in Washington State people in crisis arriving at hospital emergency departments were put into psychiatric boarding for an average of three days before getting access to mental health treatment. Some, the newspaper reported, waited for months.

“This is really hard for us to get our heads around, that this is the way we respond to people in a psychiatric emergency, in deep emotional pain, feeling suicidal,” he said. “We land up detaining them without real active care treatment for days, while they face the gauntlet of trying to get into a service. Many land up just falling through the bottom, falling through the cracks.”

Covington said the 9-8-8 hotline is an important step forward, likening it to the narrow opening that was drilled to make contact with the Chilean miners, to check if they were alive, and send them basic food and water supplies.

But, he said, “if 9-8-8 is all we do, then it’s going to be equivalent to those Chilean miners where we dig the four-inch diameter hole but we don’t actually get them out of that crisis, we don’t get them out of that hole. Many, many individuals will be supported through 9-8-8 and they won’t need more intensive services. But for those who need something more, making the connection is not enough.”

Covington said the new crisis care model envisions intermediate levels of support instead of the “red-light, green-light” approach that either directed patients toward the highest level of acute care or outpatient behavioral health care or follow-up care. He pointed to a flagship crisis response system in Arizona equipped with mobile crisis response teams and crisis care facilities.

“What a difference it makes when you have that approach,” he said. “Thousands of individuals are going directly into crisis care, and we’re reducing law enforcement engagement. You’ll see a much stronger fit of the level of service matching the clinical care they need. We haven’t eliminated psychiatric boarding in the Phoenix area, but we’ve reduced it by a staggering amount.”

Moreover, Covington added, “there’s a very significant reduction in overall healthcare spend as well as reductions in the exposure for hospitals. It’s an approach where care is much more like care than punishment.” The 9-8-8 number, providing an alternative for mental health crises to the 9-1-1 national emergency number in use since 1968, is an opportunity to reduce the involvement of police in the front end of a mental health crisis where there isn’t an explicit threat to public safety, he said.

Covington said the Community Mental Health Act of 1963, which provided federal funding for community mental health centers, never realized its promise.

“The challenges we face today as a result of the lack of that crisis system, the lack of that concerted engagement and outreach for those who are in pain or in darkness, are the extremely long waits in the emergency department, the extremely costly way that we go about this, concerns about the public safety of not having these systems in place, and far too many deaths that have occurred not only from suicide but from opioid overdoses, from alcohol related deaths, and other deaths that could have been avoided,” he said.

Covington said that innovations in crisis care began more than 60 years ago, with the first suicide crisis call center established in Los Angeles in 1958 leading eventually to the National Suicide Prevention Lifeline 1-800-273-8255 in 2005. He pointed to efforts in various states such as Georgia, Arizona, and Colorado to create unified systems of crisis response and care prior to the 2020 SAMHSA guidelines.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.