Crisis Line 988 Callback Puzzle
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Crisis Line 988 Callback Puzzle

  • Crisis Line 988 Callback Puzzle

    Russell Copelan is a retired emergency department psychiatrist who graduated from UCLA Medical School and completed his internship and fellowship training in emergency department psychiatry at UC Irvine and CU Denver.

“At every step we should think ahead and consider every possible eventuality, not just the normal course of events.” – Lucius Annaeus Seneca

The launch of the 988 Suicide & Crisis Lifeline in July 2022 is a reminder of the urgency of mental health crisis care. As a physician-scientist who has practiced psychiatry in the emergency department for decades, I am interested in knowing what is really happening in those brief, highly sensitive moments immediately before and during crisis calls. While this new entry point has the potential to advance the field, concerns about the training and effectiveness of this new “comprehensive” crisis service continue to be raised and are likely justified.

Further research is needed beyond general acceptance, case reports, some favorable numbers, and anecdotal clinical literature. Improvements to the Lifeline are necessary to better understand local mental health needs, assess the clinical expectations of admissions counselors, increase the visibility of existing resources, and improve access where clear and compelling pathology rather than social factors is the primary barrier.

For example, there is no evidence of bias-free validity to demonstrate the hypothesized effectiveness of the crisis line in high-risk encounters. High-quality evidence of the effectiveness of the crisis line in cases of immediate suicide risk is limited. In addition, concerns about the accuracy of specific risk assessments by crisis call counselors using the Applied Suicide Intervention Skills Training (ASIST) are significant.

On the one hand, ASIST states that it develops a “non-judgmental attitude” and “…does not focus on the complexity of suicide and its causes, but on a simple concept and an achievable goal of safety for now.” However, in this prehospital setting, acuity must be determined by the patient’s complaints at the level of the admission dispatcher. When 988 aides receive calls, they should not only determine the patient’s acuity level based on the patient’s complaints, predominant symptoms, and comorbidities, but also route the call appropriately.

While 988 advisors can urgently answer high-volume calls, contact non-emergency customers using multiple communication preferences and help develop a safety plan, prioritizing calls and callbacks to address those with the most urgent needs is especially important. Without knowing what happens during these calls or if there is some sort of triage protocol, I don’t know if this resource is being implemented appropriately.


Callbacks must be made within a specific time frame, based on an initial assessment of the individual’s complaint.

For example, crisis counselors should recognize that some nonurgent callers who need help in times of crisis may not return calls in a timely manner due to fear of police contact, stigmatization, involuntary hospitalization, or other serious personal or financial consequences of the call. In situations where individuals need immediate attention, the call should be immediately transferred to specially trained triage counselors. This allows for appropriate levels of care to be tailored. Unfortunately, in some stress-induced, rapidly progressing, often nonobvious suicidal states, destructive behavior may occur during the crisis call itself or before the call is returned.

Certain immediate, real traumatic events, imagined or threatened with exceptional personal clarity or vulnerability, may expose individuals to a single and particularly life-threatening event for which ASIST is not helpful—regardless of how the 988 helpline is currently used. This is descriptively termed extrapyramidal or autonomic suicide with both motor and psychiatric symptoms, and is often characterized by the person believing that they are in the process of dying (Latin: ματικος … anger = anxiety, animi = animated).

This dynamics angry anime is equivalent to near death, acute myocardial infarction, shortness of breath and poor clinical condition requiring heroic intervention. In the period before irreversible slowing of reaction time, difficulty in initiating and prioritizing tasks and internal preoccupation there is a therapeutic window through which the person can still be psychologically available and reachable by phone. However, it will close quickly. Immediate transfer to specially trained triage advisors or a quick call back is essential here.

Lumped factors

Short of randomized trials or nonrandomized designs with some form of control to identify best assessment practices, only focused factors that influence crisis interview outcomes will begin to improve crisis care. Assessment of focused risk factors is complex but essential. Observational studies should also be conducted to examine effectiveness.

What constitutes a focused, good fit factor of meaning and survival in those highly sensitive moments immediately before and during a crisis call? It is the early identification of an acquired neurocognitive ability characterized by inhibition or loss of verbal or symbolic fluency, i.e., phonological recoding to connect letters and numbers.

Mysteriously, it is the 988 number sequence itself. Here is why it is important. During a psychological crisis, cognitive functions can be significantly affected. Acute stress can lead to mental slowing, impaired task switching, difficulty concentrating, decreased processing speed, and decreased comprehension.

Therefore, for some, during a disruptive crisis, the digital dialing code 988 may not be easy to remember. Those most in need may not be able to cognitively access it at some point in their crisis. Therefore, influencing the accuracy of current, phenotype-specific training and risk assessment becomes essential because of the clear index of suspicion for atypical high-risk cases.

I understand the challenge and complexity. Recognizing cognitive impairment is one thing, but considering potential etiologies and intervening is another.


It should be obvious by now that determining suicide risk requires examining complex sensory processing. What is the process required? Simply put, these findings speak to the importance of crisis counselors, during the initial call and timely return call, suspecting and understanding the rapidly changing and autonomous probabilities of suicide. Counselors need to assess neurocognitive functioning, independent of ideation, early and early in these crisis encounters. Well-designed tests of executive function, such as the 1-Minute Alphanumeric Phonetic Test, are additional, easy-to-learn, and easy-to-administer tools for identifying risk acuity in a distribution of high-risk callers.

Future training efforts and implementation of 988 must focus on improving the consistency and effectiveness of currently inadequate ASIST-type risk assessments. In-depth training on focused factors, clinical guidelines, and suicide prevention strategies should be based on emerging high-quality evidence on clinical utility. This should include empirical decision trees and differential diagnosis of extreme risk distribution phenotypes with complex probability models.