EXECUTIVE SUMMARY 

THE CHALLENGE 

There is broad recognition that behavioral health crises have reached epidemic proportion, with drug overdoses and suicides having overtaken traffic accidents as the two leading causes of death among young Americans ages 25-44. The COVID-19 pandemic has further underscored the dramatic need for behavioral health services, including crisis services. Yet very few communities in the United States have a behavioral health crisis system that would be considered excellent, let alone ideal. 

In most American communities today, the behavioral health crisis system isn’t really a system at all, but a combination of services provided by law enforcement and hospital emergency rooms that are typically not designed to meet the needs of individuals in the midst of behavioral health crises. Often the only treatment options for individuals in behavioral health crises are in settings that do not adequately meet their needs despite being extremely costly, such as emergency rooms and inpatient psychiatric units. Further, lack of appropriate and accessible behavioral health crisis response too frequently results in law enforcement being the only available first responders, which may lead to an increase in unnecessary arrest and incarceration for people with acute behavioral health needs. 

Thankfully, this situation is changing, as there is growing recognition that behavioral crisis needs special attention to ensure appropriate response for everyone, on par with that provided for medical crises, disaster response, fire response and public safety. Table 1 lists a series of reports over the past decade that describe various components of state-of-the art behavioral health crisis services. Among the most recent is a toolkit from the Substance Abuse and Mental Health Services Administration (SAMHSA) that proposes national guidelines for crisis services (SAMHSA, 2020). Another important driver has emerged from work on reducing inappropriate criminal justice involvement, recognizing the need for focus on “Intercept 0” (an effective community crisis system) in the Sequential Intercept Mapping process (Bonfine, 2019) so that law enforcement involvement in behavioral health crises is minimized. Even more important, federal legislation (National Suicide Prevention Hotline Improvement Act) has led to the initiation of implementation of a national suicide prevention and behavioral health crisis line number – 988 – that is intended to go live nationally by 2022. This major initiative provides an opportunity for the creation of high-quality community crisis response systems that approximate the level of response that we have grown to expect from medical, fire and public safety emergency response since the implementation of 911 several decades ago. 

For communities to respond to the need for effective behavioral health crisis response and to implement successful 988 response systems, significant guidance will be needed. Existing reports, such as the SAMHSA guidelines, provide helpful direction for making progress but do not address all the essential elements of a behavioral health crisis system or measurable standards and implementational strategies for communities. Consequently, communities (as well as counties and states) have inadequate guidance regarding the development, implementation and maintenance of behavioral health crisis systems that effectively meet their specific population needs. 

The purpose of this report is to fill that gap. This report provides a detailed guide for communities to use to create a vision and direction for their behavioral health crisis systems, to evaluate their current behavioral health crisis capacities and to operationalize a strategy for implementing structures, services and processes that move toward an ideal crisis system. 

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