The man had a gun in one hand and his dog at his feet. He made one last call, dialing the National Suicide Prevention Lifeline to relay his final messages. To his girlfriend, just a goodbye. To his brother, a request to look after the dog.
Two hours later, the man was still on the line — and starting to reconsider pulling the trigger.
“I basically walked him to the edge of the cliff and back,” crisis counselor Chris Niles said. “What it boiled down to was him feeling like nobody cared.”
Niles and his colleagues — five counselors per shift staffing the Baltimore Crisis Response‘s Here2Help Hotline around the clock — spend their working hours fighting to save the lives of strangers. They receive about 3,500 calls per month.
That number could increase thanks to a pilot program the city started in the summer of 2021 to send more 911 calls to the 988 suicide hotline, instead of automatically dispatching Baltimore police officers to people experiencing mental health crises.
The program comes amid a nationwide push to limit the role of police, allowing officers to focus on reducing violent crime and leaving medical, behavioral health and other calls to professionals in those fields. Experts hope the shift will reduce encounters between citizens and police — which too often turn deadly for people with severe mental illness — and save time and money as law enforcement agencies face deepening officer shortages and recruiting challenges.
In Baltimore, the program aligns with a requirement under a federal consent decree implemented in 2017 after U.S. Justice Department investigators found a pattern of unconstitutional policing by city police. The agreement instructed the city to address gaps in behavioral health services, among many other changes.
“We need to stop looking at our police officers as a solution for all of our problems,” Democratic Mayor Brandon Scott said in June as he marked a year since the 911 diversion program started. “They are not trained for this work and their time is better spent doing what our residents actually need them to do — proactively policing and catching violent criminals.”
With mental health concerns rising during the pandemic, making services more robust and accessible is more important than ever, experts said.
In July, the Biden administration rolled out a 988 suicide hotline, which replaced a 10-digit number. The federal initiative also funded local call centers and created a regional structure for 988 calls. That means most people in the Baltimore area who dial 988 get routed to the Here2Help Hotline. Previously, Baltimore hotline counselors sometimes would receive calls from across the country because their center served as a backup for other jurisdictions.
For example, the man who wanted to relay final messages — to his girlfriend and his brother — called from Texas.
Being able to help people thousands of miles away brought challenges and rewards, Niles said. But focusing on local calls allows counselors to connect people more easily with nearby services, including inpatient slots for detox and psychiatric stabilization at the Baltimore Crisis Response center in Southwest Baltimore.
The diversion program is being developed to best take advantage of the resources available in and around Baltimore, said Kerry Graves, executive director of the local affiliate of the National Alliance on Mental Illness, NAMI Metropolitan Baltimore. The organization provided training to dispatchers before the program launched last year.
“Ultimately, what I see is a better-resourced behavioral health system that’s easier to navigate,” Graves said. “But this is not a simple Band-Aid solution. It’s going to take time because there is so much nuance to this work.”
The first year
The Baltimore 911 system receives roughly 13,000 calls a year about people experiencing a mental health or substance use crisis. People often call 911 out of habit, or because they don’t know where else to turn, officials said.
Some of those calls could — and should — be resolved without police. The challenge is figuring out which ones. That’s because they rarely fit easily into specific categories.
When the 911 diversion program began, dispatchers were instructed to divert two call types away from police: behavioral health concerns not involving violence (for example, panic attacks or substance use issues) and suicidal ideations without violence, meaning a caller was considering suicide, but hadn’t developed a plan for their death. In April, officials began also routing to the hotline calls from people with specific threats or plans regarding taking their lives.
The city has sent more than 380 calls for police to the hotline, according to data it posts online. Nearly 60% were resolved there. The rest were sent back to 911, either because the caller refused to speak with a crisis counselor or the counselor decided a police or an emergency medical response was appropriate.
An additional 261 calls triggered a joint response by mental health professionals and first responders, according to the data as of Sept. 19.
The diversions have saved an estimated 372 crew hours for Baltimore police, firefighters and medics, according to the data.
While the numbers are relatively small, officials said they deliberately chose a limited approach using existing funding and staff, with plans to scale up the program over time.
“It was a really small universe of possible calls that could be diverted,” said Adrienne Breidenstine, vice president of policy and communications for the Behavioral Health System Baltimore, which oversees the local behavioral health system.
They plan to add more call types, though officials have not specified which ones, and place a mental health clinician inside the Baltimore 911 call center to help dispatchers assess incoming calls.
Officials also plan to expand the program to children, a group Baltimore Crisis Response can’t currently engage because its counselors aren’t trained to work with kids. That part of the expansion will include assembling a mobile crisis team to respond to situations involving children.
The city recently received $2 million in federal funding and additional money from local hospitals to pay for the expansions. City officials also recently allocated $1.5 million to Baltimore Crisis Response.
On a recent afternoon in the Here2Help Hotline office — a small, nondescript second-floor room inside the Baltimore Crisis Response center with cubicles lining the walls and sunlight filtering in through large, curtained windows — crisis counselor Alana Purnell received a call through the 911 diversion program.
A mother said her daughter, who is younger than 18 and lives in Baltimore, recently attempted suicide. Now, she wouldn’t go to a follow-up appointment or take medication.
Purnell explained that police and medics were already responding to the call because the child was considered a potential danger to herself or others. But Purnell worked to help the mother feel calmer. She also referred her to the Baltimore City Child and Adolescent Response System, which provides comprehensive mental health services for children, to provide continuity of care and long-term treatment options.
‘A service of last resort’
Niles, the crisis counselor, worked in private practice in Louisiana before moving back to Maryland and joining Baltimore Crisis Response three years ago. He said crisis counseling can be incredibly rewarding because of the potential for immediate, profound impacts — a result of what he called “being a service of last resort.”
The job requires two underlying qualities, hotline staff said: empathy and coolness under pressure. In addition to a degree in psychology or a related field, prospective counselors complete specialized training.
Each person has their own style, and their approaches often vary depending on the call, said Quinita Garrett, the agency’s director of call center and system coordination. Counselors sometimes use humor to connect with callers. They often convey extreme compassion and always provide a listening ear.
When a caller describes suicidal ideations, Niles said, sometimes it helps to confront those ideas. Some people are taken aback by the approach, because their loved ones typically have tried to steer conversations away from suicide, he said. But speaking this way with a trained counselor can help people distinguish between fantasies and real intentions.
He gave an example of a woman who said she planned to kill herself by taking pills. She mentioned cleaning her apartment beforehand, making sure everything was in order. Niles said he could tell appearance mattered to her, so he asked whether she had ever seen a dead person — how would it look and smell when someone discovered her body?
She told him nobody had ever talked to her that way, Niles said, and decided to rethink her decision.
By their very nature, most of the calls from people threatening suicide are from people who aren’t quite ready to give up, staff members said. The challenge is finding that spark of hope.
“Essentially, this person is fighting for their life, and you’re fighting with them,” Purnell said.
Even when the immediate focus is keeping a caller alive for minutes or hours, counselors work to connect people with long-term mental health services.
When appropriate, they send a team of clinicians — most often a licensed social worker and a nurse — to meet with the caller, conduct a clinical assessment and develop a care plan.
‘You got this’
Every call is different and many of the complaints are messy, often involving multiple layers of needed assistance, counselors said. Maybe a caller reports chest pain, which means EMTs need to respond. Or maybe a suicidal person has access to a gun and threatens to use it. That would mean police must respond, potentially alongside mental health professionals. While simple in theory, the diversion process is complicated in practice.
Sometimes, hotline counselors said, they have to send police to address a public safety risk even when the caller doesn’t want a law enforcement response. In those cases, having officers who are well-trained in dealing with people experiencing a psychiatric crisis can make a huge difference.
Kathleen McAdam, a hotline shift supervisor, said she vividly remembers a particularly horrific call from a man who called the national suicide helpline after drinking two fifths of Jameson whiskey. A military veteran, he described an arsenal of guns in his home — what he called his “sniper nest” — and was adamantly opposed to police coming there.
McAdam said she was obligated to send both medics and officers because the man was displaying volatile behavior while armed. Unfortunately, police showed up before the ambulance.
Breaking News Alerts
Still, the man remained on the phone with McAdam while three squad cars pulled up and officers banged on the door. As a standoff developed, she tried to reason with him, even as he threatened repeatedly to shoot the police. He eventually agreed to get help.
McAdam, who worked as an EMT in the past, said the call highlights the complexities of crisis response work.
On the other hand, counselors said, a lot of the calls are from people who aren’t actively suicidal, just seeking information about mental health resources. Those calls increased significantly during the pandemic.
During a recent shift, Niles answered a call from one of his regulars, a man who recently got out of prison and was struggling to distance himself from negative influences.
“Anxiety? What got you going today?” Niles asked, his tone gentle. “You got a job? Now it’s just the game of keeping it. One step at a time.”
Niles spoke to the man like an old friend, reminding him to tune out unfair criticism and focus inward.
“You got this. You’re a strong guy,” he said. “You know you can always call — anytime you need, man, just call me.”