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The Suicide and Crisis Lifeline, previously better known as the National Suicide Prevention Lifeline, but most commonly referred to as "the 9-8-8 hotline" or just 9-8-8, has now been around for quite a few years. As we near the five-year anniversary of the FCC's choice of the 9-8-8 code and a little over 21⁄2 years since the code became active, I thought I would reflect a little bit on how the service has evolved, some of the problems it created, and current barriers that prevent 9-8-8 from being more useful.
9-8-8 was only officially launched in July 2022, but planning for it had been in the works for several years prior. In 2018, Congress passed the National Suicide Hotline Improvement Act of 2018, which required the Federal Communications Commission (FCC) to, among other things, "[examine] the feasibility of designating a three-digit dialing code (N11 dialing code) for a national suicide prevention and mental health crisis hotline system". For a couple years, there considerable debate within the FCC and outside as well about which code would be assigned. Of the N11 service codes, 2-1-1 was the most seriously entertained, though ultimately, the FCC decided to go with a 9-8-8, which isn't an N11 code at all. Its rationale was that repurposing any of the existing N11 codes, which are all being used to varying extents throughout the North American Numbering Plan (NANP), would face challenges, and a previously unassigned code would fare better. The FCC also acknowledged some of the more controversial impacts of this decision, namely that 988 is a valid NXX (prefix) in many NPAs (numbering plan areas, or area codes) today.
Their solution to this problem was to force everyone in all the impacted area codes (88 of them, originally, though North Dakota returned 904-988 to the number pool instead, so only 87 in the end) to adopt mandatory 10-digit dialing so that 9-8-8 could be dialed prefix-free. Technically, this is not a requirement of telephone switching systems today, which happily handle many code assignments that may not be prefix-free (a good example is the Speed Calling feature, which makes use of the codes 2 through 9 and 20 through 49, all of which may prefix valid telephone numbers). However, the FCC felt that calls to 9-8-8 completing immediately was important enough to warrant this decision.
The FCC's decision to adopt 9-8-8 was not without controversy, largely due to the mandate to adopt 10-digit dialing in, ultimately, 87 area codes. With a single unprecedented order, the FCC reshaped the NANP more swiftly and dramatically than perhaps any other changes to the NANP since its inception, including the decision to allow non-NNX prefixes (NXX codes). While a preference for area code overlays, rather than splits, started gaining ground in the 1990s (today, splits are largely obsolete), these decisions were made locally by state public service commissions, often with input from the public. In many cases, splits were preferred by the public due to the convenience of being able to retain 7-digit dialing.
In contrast, with a single order, the FCC unilaterally wielded a hammer and shattered a good chunk of whatever design and elegance still remained in the NANP. While North Dakota avoided this fate for the 904 NPA by giving up 904-988, no other area code with an assigned 988 prefix was spared this fate. This was not for lack of ideas. At the time, I personally drafted and presented some proposals to several states to avoid this - I had a pleasant exchange with the head of the Wisconsin Public Service Commission, but in the end, the Wisconsin PSC declined to devote any resources to 9-8-8 mitigations due to lack of staff. Ultimately, millions of people are now forced to dial three extra digits for all their local calls. This begs the question — was it worth it?
Choosing A Number
The principled — indeed, expected — answer here is that, yes, of course it was worth it — any measure to save lives is worth inconveniencing millions of people. I don't say this caustically — in society, we have made the decision in many cases to give up a little bit of convenience for some safety (reasonable people can, of course, debate the merit of any particular case, as we will do here). However, I think this is a cop out answer. Critics of 9-8-8 have been accused of being unempathetic towards those in crisis which may have a legitimate need for the service. However, I think reasonable people can and should discuss the merits of 9-8-8 insofar as technical implementation. That is what I do here.
First, it's worth remembering that 9-8-8 did not itself create a new service. Rather, it created a new 3-digit code that simply redirects to the Suicide Hotline's existing toll-free number, (800) 273-TALK, which dates back to 2005. And by redirect, I mean that literally — the implementation of 9-8-8 in switches today is literally a translation that maps to this number. There is no "special" 9-8-8 service that is different from the 800 number. In other words, 9-8-8 was less the launch of new services or resources for those in need than it was a rebranding to make it easier to remember. This differs from services like 9-1-1, which typically do not just map to a 10-digit phone number, but generally go over special types of trunks from the switch to the PSAP (Public Service Answering Point).
Regardless, in 2018, Congress came to the conclusion that a toll-free number was insufficient and tasks the FCC with appropriating a 3-digit code. In fact, if you pay attention to the verbiage of the bill, Congress specifically requested an "N11 dialing code" in the parenthetical to three-digit dialing code. (Apparently, the FCC either ignored the parenthetical or believed it to be optional, as it passed on all the N11 codes and came up with 9-8-8. Perhaps Congress never expected the FCC to come to such an absurd conclusion?) Had the FCC been forced to reappropriate an N11 code, I believe it would have picked either 211 or 311. All the other N11 codes from 411 on up are pretty widely used. 311 may be widely used in communities where it exists, but the number is not in use everywhere either. 211 typically goes to the United Way or a similar service that exists in the state. I think this would have been the most logical choice, as suicide prevention fits in pretty nicely with the existing goals of the 211 number, typically to provide community services for people that need them. Given the existence of an already dedicated toll-free number, a simple option to connect to the Lifeline from 211 would have been very logical.
While 211 may connect to the Lifeline in a parallel universe, in this one, it's the separate 988 number that does so. As a result, millions of people are now required to dial the area code before calls that never required one before. While this has happened before whenever area code overlays were introduced, the scope of the 988 order was truly unprecedented. Many area codes that previously, thanks to lack of significant population growth, had not needed to worry about overlays, nonetheless ended up with one anyways. It really was decimation of the NANP on a massive scale — the methodical, planned out numbering plan that the Bell System designed in the 1940s is largely history. Thanks to area code overlays, wireless roaming, number portability, non-NNX prefixes, and now 988, the numbers we dial more often lack the meaning they originally had, and what is more, we are dialing more numbers (digits) altogether.
Knowledge and Awareness
The choice of the 9-8-8 number itself was calamitous for the NANP, but enough about dialing purity. At least with a 3-digit code, one might assume that at least awareness of the service has increased — perhaps not on par with 911, but to a respectable number. Here, you will be disappointed. In 2023, more than a year after 988 was actually launched, a survey by the Annenberg Public Policy Center found that just about ten percent of the general public knew about the 988 Lifeline. More than a year later, this number went up, but barely, from 11% to a measly 15%, despite an eight-month paid marketing campaign promoting the number!
Of course, awareness will likely continue to grow slowly for some time. Although the first 911 call was placed in 1968, it took decades before 911 was universally available and universally understood to be "the" emergency number (even in the 1970s, it was still very common to dial "0" and ask the operator for the police, and the Bell System's own educational videos still trained children to dial "0" in emergencies). On the other hand, near-universal access to 988 was brought about in months, rather than years or decades. One would expect awareness of 988 to accordingly increase at a much faster clip. While usage of the Lifeline has increased since the launch of 988, for all the upheaval caused by the 988 implementation, awareness of 988 itself is far from stellar, making it reasonable to question whether this increase can be attributed to 988 itself or all the marketing efforts for the Lifeline in general that have accompanied its launch.
Training Children
I believe one reason for the slow uptick in awareness of 988 is that, unlike 911, the Suicide Lifeline is not considered to be critical life-or-death information instilled in the populous from a young age. Suppose, for instance, that you are a parent. It is easy to imagine that, as soon as a child is taught to use the telephone, the child should be taught how to dial 911 in an emergency. So when ought a child be instructed to dial 988? At a young age, children are not likely to understand the concept of suicide, and parents may not want to cross this bridge until a later point. Even if this occurs later in childhood, it's still likely to be an awkward conversation at best and potentially seed unwanted thoughts at worst:
(Hypothetical conversation between parent and child) Parent: Mary, you already know that in an emergency, you should dial 911. Child: Of course, Mom, duh! Parent: But if you ever think about killing yourself, there's a separate number for that, 988. Child: Why would I want to kill myself? Parent: I don't know, but if you do, promise me you'll call 988 first. Child: Okay, Mom. (Eyeroll)
Now that 988 exists and, for better or worse, is here to stay, it would certainly be prudent to ensure that everyone is made aware of it at some point. Nonetheless, it is not inconceivable that many parents, beliving their children to be too innocent and outside the reach of the Grim Reaper, may forgo the conversation (along with certain other topics to protect the innocent). More likely is that awareness will need to be built in schools or other public exposure. Here, it is less clear that this is actually happening en masse. There has been some traction; for example, Missouri has published a "988 Guide for Schools", complete with infographics. Even more "in your face", in Virginia, student ID cards are now required to advertise the number — admittedly slightly bizarre, but certainly not ineffective.
Rail Suicide
Outside of targeted campaigns such as these, public awareness today is typically greatest at train stations. In the past few years, signs advertising 988 have become commonplace on transit, from local subways to commuter rail.
The particular emphasis on 988 awareness near rail transit is understandable — hundreds of people die or are injured annually each year due to rail suicide attempts in the U.S. alone. However, there is a major problem with these kinds of awareness campaigns. Typically, where these kinds of signs have been rolled out in rail transit, they are posted in isolation. Knowing about 988 is great, but how to actually call it? Unfortunately, fewer and fewer transit stations have payphones or other public phones easily accessible these days, and I seldom see 988 posters near any kind of phone — I think I've seen one emergency phone that happened to be near a poster, but the placement there may have been merely incidental. Either way, I don't count it, as it's unlikely an emergency phone would connect directly to 988, of all things, and given the FCC ruled out leveraging 911 or 211 for fielding suicidal callers, this would fall short of what the FCC would consider to be an adequate mechanism to reach the Lifeline.
This is a big problem for a few reasons. First, not everyone has a mobile phone. While some people choose not to use them for personal, societal, or environmental reasons, others may be unable to use them due to disability (e.g. health reasons) or they may be unable to afford one. And even if you do have one, it could be broken, battery depleted, lost, stolen, etc. It shouldn't need to be stated, but society should not expect that everyone in crisis is carrying a working mobile phone with them at all times. All lives should and must be valued, not just the lives of people that have a smartphone in their pocket at all times.
Even setting this aside, this is still problematic for people that do own a mobile phone. The Federal Railroad Administration (FRA) produced a report in 2014 titled "Countermeasures to Mitigate Intentional Deaths on Railroad Rights-of-Way: Lessons Learned and Next Steps". In it, they specifically addressed the practice of posting signage on railroads encouraging suicidal individuals to call a crisis center (of course, this predated the 988 number, but the National Lifeline and others were being advertised). The FRA stated:
If signage campaigns are implemented, railroads must decide whether a dedicated phone line should also be included. Although no research exists to address the necessity of a dedicated phone line with signage in the railroad environment, one investigation found that fewer than 5 of the 29 decedents included in their study were in possession of a cell phone at the time of death (Berman, et al., 2013). Although this is a small sample, it raises the question of whether the availability of a public telephone is necessary for this signage to be effective. Some may argue that a telephone is not necessary because individuals who attempt suicide on the railroad right-of-way may visit the site prior to the actual incident and therefore have an opportunity to see the number in advance. More research is needed to understand how individuals contact crisis center hotlines after reading railway station signage.
Although this report is now a decade old, mobile phone usage has not increased exponentially during that time - it was already 91% in 2014 and is now 98%. If 91% of people had a mobile phone at the time and less than 20% of them brought it to their suicide spot, it's reasonable to conclude the majority of would-be suicide victims don't have a device with them when planning to carry out the act.
While more research certainly could be helpful, frankly, I don't think it's necessary. 988 signs without a mechanism to call 988 from a place of crisis are an edict without any mechanism to facilitate it. If someone sees a 988 poster, considers calling 988, and isn't able to call it — either because he or she doesn't have a mobile phone or left it at home — it's certainly possible s/he might decide to take a deep breath, go home, call the number and work things out.
It's also possible that, being already in crisis, and frustrated at not being able to call the number the damn sign is yelling about, he or she just says "screw it" and jumps in front of the train anyways.
This is not just a small oversight, it's a systemic failure in the way that the Lifeline is being promoted in many places, particularly transit stations.
Payphone Problems
Lack of phones to call 988 in places where they are most needed is certainly a problem. Unfortunately, even if there happened to be a payphone near the platform where our hypothetical friend is debating whether to take his own life (which is quite unlikely; most payphones left in the transit system in the U.S. are in the main station, not on platforms themselves), it's unlikely it would be very helpful in this scenario. Most payphones today are COCOTs (customer-owned coin-operated telephones), payphones with custom circuit boards in them for handling call rating and which plug into a normal phone line, as opposed to a traditional coin line, as used to be common. The majority of COCOTs remaining today are owned by PTS (Pacific Telemanagement Services). While they do still service many of their phones, particularly high-traffic or higher-margin ones, they are not always on top of maintenance issues for all their phones, and stale programming can linger for years. Even today, on many COCOTs, dialing an 833 number may prompt for a coin deposit, even though it's supposed to be toll-free. 833, the newest toll-free area code, went into service in 2017, meaning that the programming for some payphones may go years without seeing an update. I've personally found that even on phones where 833 is recognized as toll-free, dialing 988 can be hit or miss on PTS phones. Earlier this month, I did a test in Philadelphia's Suburban Station, where none of the payphones allowed dialing 988, instead failing with a cryptic numeric "error" message in Protel's best semi-robotic lady voice. If our friend in need had decided to pick up this phone and tried dialing 988, only to receive an error message, it's now more likely he would have ended up dead on the tracks.
To be clear, this is a problem specific to the 988 code. Had our friend dialed (800) 273-TALK instead, he would have been connected and perhaps decided against jumping in front of the train. In this situation, ironically, the 988 number actively did more harm than good.
Needed Improvements
The implementation of 988 was not without problems, and unfortunately, 10-digit dialing is relatively permanent, so it's unlikely we'll be able to solve the problems it's already created. The past is the past, and crying about 10-digit dialing won't fix anything. However, the rollout of 988 is effectively still ongoing, and there are still serious problems with the way that 988 is expected to be accessed today that reduce its effectiveness. Fortunately, there are a few simple steps that would significantly increase its utility:
- Ensure that a phone (whether a payphone, emergency call box, or other public phone) is installed on all high-traffic rail platforms with 988 signage. Any 988 sign in a busy area should be close to a phone — ideally, next to it.
- Payphone compliance with 988 requirements needs to be more strictly monitored. Providers should report their 988 compliance and any noncompliance should be reportable by the public with consequences for the provider. Although I mentioned PTS by name, they are not unique; payphones historically have lagged behind on allowing free calls to newer toll-free area codes, and because 988 is a new code that never existed before, many payphones today simply aren't programmed to allow it at all.
- On any fixed signage advertising 988, the full toll-free number should also be posted (perhaps in smaller print). This way, even if a phone can't call 988 for whatever reason, a user can still dial the Lifeline directly.
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