As calls to mental health line rise in Missouri, some worry about long-term funding
If you’re in eastern Missouri and call 988, you may end up talking to crisis intervention clinician Jennifer Brown.
Brown answers calls for Behavioral Health Response, the crisis response line for the St. Louis region and other parts of the state.
“Many people are simply calling because they don’t know what to do with those feelings, with the energy they’re feeling outside their bodies. They’re looking for hope and help,” she said.
In July, Missouri officials debuted 988, an emergency mental health hotline that connects callers to dozens of organizations around the country based on the caller’s area code. During the hotline’s first month of service, calls to Missouri mental health centers increased 30%.
It’s not just people who are thinking of suicide who call the hotline, Brown said. Sometimes, it’s those just feeling lost or helpless.
“I really want them to feel a connection when they call in,” she said. “It’s a real person on the other end of the line.”
Advocates of 988 say the easy-to-remember number will connect more people to professionals like Brown when they need it the most: when they or someone they know is in a mental health crisis or thinking of killing themselves.
A workforce on the line
The hotline’s overhaul means crisis response organizations need more workers and money to pay them. Advocates are concerned that the state has not committed to funding the hotline for the long term.
The Missouri Department of Mental Health received $16.7 million in state funding and block grants to support calls for the first fiscal year of 988, department officials said. But the Missouri legislature hasn’t produced a law that secures continual funding, and the hotline doesn’t have a guaranteed money source for years to come.
“It’s a fear of mine,” said Casey Muckler, who leads the 988 system for the department. “How we can make this a sustainable effort and keep this going long term — that has kept me up at night pretty much since I started.”
State health officials expect a surge in callers as more people learn about the new number. Department of Mental Health officials estimate the service will receive 172,000 calls in the first year of the service alone, not including texts and chat messages or follow-up calls.
That’s more than four times the number of calls that Missouri Suicide Prevention Lifeline networks received in 2020, Muckler said.
To absorb that new volume, the state’s response organizations will likely need to hire dozens of additional employees.
Even though the hotline was a national initiative, the federal government isn’t providing full funding, Muckler said.
“It’s really up to the state to fund 988 at the state level,” she said. “We’ve been looking for any possible funding that we can find for well over a year."
A handful of states have enacted laws that place a surcharge on phone bills to pay for the line, but Missouri has not taken that approach.
“I can't say I know for sure or can even lean one way or another on whether or not this will be sustainable with the governor's office,” Muckler said. “But we sure are hoping so.”
Backers of the 988 line say that once state officials see how effective the service is, they’ll be eager to fund it in perpetuity.
“I think we’ll be in a good place after this first year to really say, ‘This has been working and we need more funding to make sure we can continue this important service,’” Muckler said.
A special job
Unlike 911 dispatchers, the call center workers are also providing care and can stay on the line for a long time, said Behavioral Health Response Director Bart Andrews.
“It’s really creating a system that meets people’s needs, in the moment, where they are, and lowering the barriers to access mental health services,” Andrews said.
Even with new funding, recruiting and training people to work the specialized and sometimes traumatic and taxing job is a big task, Andrews said.
Behavioral Health Response is planning to use the first year of government funding to hire about 60 staffers to meet the new patient load, he said.
“There’s going to be a huge hiring binge across the entire state of Missouri,” Andrews said. “Missouri will be in excellent shape for 988.”
To hire more workers, Missouri and other states changed the qualifications needed to work for the line.
“We used to only hire master's-level clinicians. We’re never going to have enough master-level clinicians to handle the capacity that we really need, the volume that’s going to be coming in."
He says being good at this job is less about education and more about experience and training. Behavioral Health Response crisis workers need to have three weeks' training before they even take their first practice call.
New (and old) problems
Another way the 988 line is different from 911 is that the hotline routes calls based on a phone’s area code, not on its location.
That could cause problems for connecting people with local services, Andrews said.
“In metropolitan areas, up to almost 50% of people have out-of-area cellphones,” he said. “Many people have gotten rid of their landlines. So we have a problem.”
Crisis clinicians say they can still transfer calls to local response centers or dispatch teams to people in crisis wherever they are in the country, but they hope the line can soon route calls based on the caller’s location.
There’s also the issue of follow-up care. In addition to giving someone a listening ear, 988 clinicians can connect people in distress to services or in-person help.
“The important thing is not just to answer,” said Gena Terlizzi, National Alliance on Mental Illness Missouri executive director. “But to know how to connect individuals with any immediate needs, referrals of follow-up care they may need.”
But depending on where someone lives, it may be expensive or logistically difficult to, for example, schedule an appointment with a psychiatrist, she said. According to the Rural Health Information Hub, which compiles federal HRSA data, all but two of Missouri’s 114 counties have professional mental health shortages. If someone is uninsured, it can take even longer to get an appointment with a therapist or psychiatrist.
“If you are able to meet that No. 1 goal … and keep that person from taking that action, we still need to make sure that they are getting the treatment and services they need in the future,” Terlizzi said. “It’s not a one-time thing. It’s a long-term commitment to trying to improve the mental health of society.”
What callers want
Andrews said research shows many people who call the lifeline actually don’t want follow-up services.
“They just want to be able to call the lifeline when they’re struggling, when they want help, when they need to talk to somebody,” he said. “We’re actually making it easier for people to get the services they want, in the way they want it.”
Jennifer Brown, the crisis call worker, said some callers just want to talk.
“Oftentimes, when people are at their lowest, the thing you need is a connection with someone, someone they can trust and to feel safe,” she said.
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