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.

Virna Little, Chief Operating Officer & Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers, trumpets the importance of preventing suicide in primary care.

Research shows that about 84 percent of people who die by suicide, and 92 percent of those who attempt suicide, had a healthcare visit within a year of their acts, Little said in her presentation, “Best Practices for Primary Care,”at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

Little also cited recent research indicating that people who died by suicide had suddenly resurfaced in primary care and became active on their healthcare portals within a month of their deaths.

Little spoke of her experience in conducting Zero Suicide trainings for 3,000 primary care providers in 27 states. She found that while 95 percent of the providers considered suicide prevention as part of their role, many of them were not trained either in their current positions or in their previous education. She found that many felt they did not have the knowledge or time to assess and intervene with an individual at risk of suicide.

She added that more than half of the behavioral health providers in these primary care settings did not feel comfortable or confident to care for someone at risk for suicide. She found that some people in her trainings were not familiar with the standard Patient Health Questionnaire that includes a key screening question about self-harm (PHQ-9).

Part 5 in a Series about the Zero Suicide Model for Healthcare

Little reported that many providers who had received traditional suicide prevention training did not feel it was helpful due to the trainers’ lack of understanding of how primary care practices operate.

“There are all kinds of places in primary care where people can fall through the cracks,” she said. “What I wanted to do was bring the idea of Zero Suicide and suicide safer care right to the front line, to make sure that we were doing something that would change what was happening in the primary care visit for people that were at risk for suicide.”

In her experience engaging primary care providers, Little said, they could easily identify their population of patients who suffered from diabetes but were usually silent when asked about how many of their patients were at risk for suicide.

Little felt that pediatric providers don’t really understand the extent of the problem of youth suicide. She cited data from the 2019 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention indicating that 8.9 percent of high school students in the survey had attempted suicide in the past year, and 18.8 percent had seriously considered taking their own lives.

In her training, Little urges primary care providers to adopt the seven core elements of the Zero Suicide Model, to bring a systemic approach to suicide care into their practices. Little stressed the importance of engaging everyone in a primary care practice, whether physicians and nurses or front desk and billing staff, in the process of suicide care.

“I often give an example of a practice where somebody cancelled three appointments within a very close time frame, and died by suicide,” Little said. “Nobody who answered the phone knew that she was at risk for suicide to do anything different. There was no process in place to catch that.”

Little’s training takes providers through the Zero Suicide protocols: effective screening procedures, speaking directly with patients identified as at risk, safety plans for patients, referrals to behavioral health specialists, and follow-up caring contacts.

She advises primary care providers to include suicidality on their patient problem lists, which provide immediately accessible structured data on their patients’ most important illnesses, diseases, injuries, or other health issues. “Imagine telling your primary care provider something really important, and then the next time you came in nobody even remembered,” she said.

Little said she also speaks with primary care providers about creating “pathways” of care for suicidal patients within their practice, and thinking about appropriate levels of  care so that suicidal patients are not automatically dispatched to hospital emergency departments.

“For example, everybody that comes in with chest pains, we would probably do an EKG, not everybody would go to the emergency room,” she said. “Not everybody who is asthmatic goes to the emergency room. So, one of our jobs in primary care is to make sure that people get the appropriate level of care.”

Little said that she found suicide care became more relatable when the primary care providers understood how discussing a patient’s suicidal thoughts with them and making referrals was little different than the usual workflows they use for patients with other issues like high blood pressure or asthma.

“Making those comparisons for primary care providers was incredibly helpful because it really helped them say, ‘Wait a minute you know what? I actually do this.’ I would remind them that, yeah, we shift gears all day long in primary care. It would be a beautiful day in primary care if somebody came in and they just had one thing going on and it was the actual thing that was the most urgent. If you’re going to engage primary care providers in this work, you have to speak primary care.”

She also said it was useful to provide primary care practices with role modeling for visits by individuals at risk for suicide, and to share storage statements with them that can be used to speak with such patients. She takes primary care providers through a role play of getting an at-risk individual to put the National Suicide Prevention Lifeline number in their phone contacts, or to access www.nowmattersnow.org, a website that shares stories of how people have coped with and survived painful emotions.

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.