Emergency interventions, lack of consent raised as issues with 988 in national study

The 988 Suicide and Crisis Lifeline is the largest hotline network in the country. A national study from Trans Lifeline raises concerns about 988’s practices on consent, transparency, safety and the disclosure of emergency intervention data.

Researchers said one of the major issues study participants highlighted was the lack of informed consent in emergency interventions after interacting with 988.

Olka Forster, one of the researchers, said nonconsensual interventions can include instances where the helpseeker is unaware the crisis center may involve police or use geo-tracking services. While 988 does not have geolocation capability, the researcher said crisis centers connect with 911 call centers which do have the ability to track location, which is not communicated to people seeking help.

“These interventions can traumatize and discourage people from reaching out for help, and that is the opposite of what we want,” Forster said.

Forster said the possibility of incarceration and forced hospitalization can also affect trust in hotlines — especially for people of color, people with disabilities, and the LGBTQIA+ community.

“In fact, nonconsensual interventions are considered violations of human rights and the right to health by the UN, the WHO and several other global human rights organizations,” Forster said.

Forster said even when emergency interventions start out with consent, they can become nonconsensual “as dynamics of race, gender perception of risk play out between emergency responders and the people who are experiencing crisis.”

Nemu HJ, another researcher, said 988 does not disclose the possibility of nonconsensual emergency interventions in its advertising or during calls, text conversations and chats. They said it takes navigating multiple pages into the website to locate information on emergency interventions.

The 988 website says it “recommends counselors contact emergency services (911, police, sheriff) for assistance only in cases where risk of harm to self or others is imminent or in progress, and when a less invasive plan for the caller/texter’s safety cannot be collaborated on with the individual.”

HJ said the team that compiled the report found that it isn’t just recommended.

“It is a policy to issue emergency interventions in these imminent risk situations,” HJ said.

But how imminent risk is determined is also a problem, according to Forster. They said while 988 calls them “safety assessments,” the tool used to determine risk is based on suicide risk assessments.

“In a meta analysis of 50 years of research on risk assessments, suicide risk assessments conducted by a trained health professional were shown to be no more accurate at predicting suicide than random guessing or by someone with no training or by flipping a coin,” Forster said.

The 988 website says less than 2 percent of calls result in emergency intervention.

HJ said 988 has “refused transparency” about the total number of emergency interventions initiated, the demographics of who those interventions were initiated for.

“We can use this information to better understand what’s happening at a systemic level and how we can hold it and other hotlines accountable for harm and push for change,” HJ said.

HJ said it has also refused to disclose if these interventions are nonconsensual, and the outcomes of these interventions such as police interaction or hospitalization.

“For help seekers, the transparency of this information is crucial for us to make informed decisions about if or when or how we use 988 or other hotline services,” HJ said.

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HJ said 988 hasn’t taken action to ensure their initiation of emergency interventions are transparent, safe and consensual.

Nearly 90 percent of study participants said they did not want to interact with emergency services, including police — and 80 percent said they didn’t want to be hospitalized.

“It’s interesting that there are so many people who actually are willing to talk about their problems or their issues or their crises,” Forster said. “And what’s going to stop them is this possibility of harm from these emergency interventions.”

Researchers said some participants described unpleasant and violent interactions with police, including among other things threats of violence, homophobic and transphobic language, and sexual assault.

“Even when participants did not experience physical violence or harm from law enforcement, many described their interactions with police as coercive and threatening,” Forster said.

Forster added that even participants who did not report any kind of negative interaction with law enforcement said they would prefer “not to experience a police-based response at all.”

The bill that made 988 possible specifically tasked the hotline with providing support and resources to underserved communities. However, researchers at Trans Lifeline said some of 988’s practices actually put those communities in harm’s way.

HJ said interventions like law enforcement and forced hospitalization can be dangerous for vulnerable communities — and can actually lead to bigger problems.

“A history of involuntary psychiatric hospitalization can actually be used to deny trans people the ability to give informed consent for trans-affirming surgery or hormones in the future,” HJ said. “A history of hospitalization is allowed to be weaponized, to deny a trans person the validity of being trans and is used to question their sanity.”

HJ said denying gender-affirming care can lead to psychological harm, including thoughts of suicide.

They also said forced hospitalization can also lead to large hospital bills that can also worsen crisis situations. They said hotlines need to end practices that create harm and provide little benefit to people who seek help.

The researchers made a series of recommendations for improving the 988 hotline, including centering informed-consent practices and being transparent with how often they initiate emergency intervention.

They also recommend hotlines create and implement training protocols based on recommendations from “hotline users, suicide attempt survivors, and psychiatric survivors, especially those from marginalized groups.”

Abigail is our health reporter. Contact them at aruhman@wboi.org.