Kelly Livingston/ABC News

(NEW YORK) -- For Belinda Mosby, the nightmares started in March.

Mosby had been working at Carelon Behavioral Health, one of the new 988 Suicide and Crisis Lifeline hotline centers in New Hampshire, for two months. When Mosby started the job in January 2023, she said she was enthusiastic. After 25 years working in the mental health industry as a prison behavioral health specialist, substance abuse counselor and mobile crisis responder, she knew how dire the crisis was. She also said she knew she could help.

"I'm 25 years of preparing for this," Mosby told ABC News of her thinking at the time.

But quickly, she said she felt overwhelmed. Callers were in such severe distress, she told ABC News. Call after call, Mosby said she began to feel a discomfort set in that she couldn't shake.

First came the anxiety, Mosby said. Then, the nightmares, followed by panic attacks. The attacks grew so severe that even imagining another call could set the chain in motion, Mosby said.

Part of Mosby liked the job, she said: the ability to help people at a critical moment in their mental health crisis. But she said part of her also worried about how the work was impacting her own health.

"Just the thought of the job -- that's how bad it was," Mosby said.

In July 2022, amid historic rates of mental health illness, the Biden administration launched 988 -- the new national suicide prevention hotline -- to reinvigorate the country's previous, antiquated network. Since its launch, the White House has invested nearly $1 billion into 988, and the hotline has served more than seven million Americans, Danielle Bennett, a spokesperson for the Substance Abuse and Mental Health Services Administration (SAMHSA), told ABC News.

That figure -- which is a group of people almost double the entire population of Los Angeles -- is 40% more than were served over the same period before the hotline's launch in 2022, according to SAMHSA data.

The federal government has also developed community-centered sub-networks for veterans, LGBTQ+ individuals, Spanish speakers and the hard of hearing to meet each group's distinct needs. The company Vibrant Emotional Health has the contract to administer the hotline, and the hotline is overseen by SAMHSA.

But now, some 988 workers such as Mosby -- who were already in significant shortage -- say they're burning out and leaving the job. Data obtained by ABC News found that, in some states such as Oklahoma and Colorado, more than one-third of employees left within months of taking their first call. In addition, turnover rates continue to increase across the United States. In Washington, for example, state data shows attrition rates increased 1.5 times between 2022 and 2023.

As calls to 988 balloon with ever-higher demand, and as the line continues to provide much-needed services at a pressing time, officials are expressing concern about what the burnout trends among employees mean for the hotline.

"Staff burnout is high," Tia Dole, the chief 988 officer at Vibrant Emotional Health, the organization appointed by the federal government to oversee the line, told ABC News.

In some cases, the job is putting workers' own mental health in jeopardy, too, Dole said.

"It is hard to answer calls all day when you're going through things yourself," Dole added. "The people answering calls are people, too."

High pressure, low bandwidth

For Chantel Aaron, operating the Carelon hotline was the culmination of her own journey of struggling with mental health challenges. Including hotlines she'd tried calling -- hotlines that provided little relief at the time, Aaron said.

"I've always been a person who, if I don't like something, I change it," Aaron told ABC News.

Her first day working at the hotline was in January 2023, and Aaron said she remembers it vividly. "I got thrown in," she said. The first contact was a repeat caller, she said, someone who's chronically grappled with mental illness and the kind of patient the hotlines have struggled to care for.

The caller "was very belligerent and aggressive" and "didn't want to hear solutions," Aaron said.

In the weeks and months that followed, that kind of call was not a rare occurrence, Aaron said. And as she got further into her time with the hotline, she said she also noticed a parallel, growing challenge: Her colleagues were showing up less and less. Sometimes, even at peak hours, the only staff on the line would be Aaron and a colleague, she said. Shifts originally scheduled for eight hours became 12; Aaron said she picked up more night and weekend shifts.

"It was killing my spirit," Aaron said.

Aaron's experience is not unique. Since the earliest days of 988's launch, centers around the country have faced major hurdles in hiring amid what the U.S. Government Accountability Office says are shortages in the behavioral health workforce.

Data obtained by ABC News from Nebraska's Department of Health and Human Services showed that in 12 of 16 months since the hotline's June 2022 rollout, there have been more vacancies than employed staff. In West Virginia, during those same six quarters, staffing has not once met the levels required by federal and state grants, according to data from the state obtained by ABC News.

There's also growing turnover among the staff that centers are, in fact, able to hire.

In Washington, 988 staff attrition rates increased from 19% in 2022 to 30% in 2023, state data shows. In Oklahoma, more than one-third of 988 staff have turned over since July 2022, according to state data. In Colorado, turnover rates of employees who'd been on the job for more than three months reached 40%, according to state data. In those working for less than three months, the rates shot up to 60%, state data shows.

Other states have been more successful in terms of hiring and retention. For example, in Oklahoma, turnover rates dropped between 2022 and 2023, state data showed. In West Virginia, head count has steadily climbed every quarter: As of September 2023, vacancies were the lowest on record, and turnover had stabilized, according to state data.

But even standouts like these states haven’t been able to overcome broader headwinds facing the industry. State data shows West Virginia still has 20% less staff than required by the federal government. Oklahoma still has turnover rates that exceed 30%, according to state data.

Shortages and turnover are a major problem for the mental health workforce overall, according to a 2022 SAMHSA report. They can jeopardize care for patients and call operators alike, the report states.

"Burnout is one of the biggest workforce challenges we're facing," Monica Johnson, SAMHSA's 988 director, wrote to ABC News.

Undertrained and overwhelmed

One major contributor to burnout in the mental health workforce, according to the 2022 SAMHSA report, is a "feelin[g] of inefficacy." One of the major determinants of efficacy, some 988 operators told ABC News, was whether they felt they had the tools to handle calls.

All 988 hotline workers undergo basic training developed by Vibrant, the company that administers the hotline, while more in-depth training is left up to the discretion of individual states, Vibrant's Dole said. This allows states to adopt their own standards customized to their specific constituents, she added.

Vibrant doesn't claim its training can stand on its own.

"988 Lifeline-provided training resources are intended to offer a foundation that supplements the local training that crisis centers in the network provide," Divendra Jaffar, a Vibrant spokesperson, told ABC News.

SAMHSA doesn't have specific guidelines for what 988 crisis hotline operator training should include.

"There is not one standard nationwide crisis center training program for contact centers in the network, and that training can and does vary across the contact centers," Bennett, at SAMHSA, said.

But the agency does discuss key elements for crisis care in 2020 guidance on best practice care. Some of those elements are not covered in the Vibrant training, according to Anthony Cava, a spokesperson for the California Department of Health Care Services.

For example, SAMHSA says in its guidance that crisis care staff should have training on "trauma-informed care" during orientation. Cava told ABC News the Vibrant modules don't include instruction on "trauma-informed care," and that California added a module to cover it. The SAMHSA guidelines also say crisis care staff should be prepared to handle substance abuse issues, but the Vibrant training doesn't include modules on substance use, Cava told ABC News.

Vibrant did not comment specifically to ABC News about inconsistencies between its training and SAMHSA's recommendations.

Beyond the Vibrant training, centers "are required to be certified by an independent accreditation authority," Bennett at SAMHSA said -- a process that Vibrant oversees. However, these accreditation authorities' standards can vary widely. For example, the American Association of Suicidology only requires 30 hours of training. In other cases, according to Vibrant documents, no certification or licensure is required for 988 centers "assuming there is a demonstrable need for a center in that area." There are seven centers that have had provisional acceptance, and these centers are expected to pursue accreditation following their admittance to the network, Jaffar added.

In New Hampshire, where Carelon Behavioral Health is located, "staff training varies depending on the role the provider fills and their level of education," Jennifer O'Higgins, a senior policy analyst for the state's Department of Health and Human Services, told ABC News. The state didn't provide any other details on its training requirements or whether they added modules on top of the Vibrant training.

Soon after Clara Rodriguez started taking calls for Carelon in June 2023, Rodriguez said she started doubting whether she was prepared to handle the workload.

Rodriguez said she was taking calls with people who ran the gamut of mental illness: adults and children, all with diverse gender, racial and ethnic backgrounds. People who were struggling with hallucinations and delusions, Rodriguez said; people who were actively suicidal or homicidal.

It didn't take long before Rodriguez said she felt overwhelmed. Rodriguez had no behavioral health experience before joining the line and said she only received two weeks of training, mostly via 45-minute online modules, before starting at the hotline. According to Johnson at SAMHSA, there are no strict credentialing requirements for call operators, so long as these operators receive high-quality training during their onboarding process.

But Rodriguez said she felt these didn't meet what she would consider a high-quality standard.

"Those [were] intro courses, like me reading something online," she said. "I found myself undertrained."

"We take the training, supervision and support of our staff seriously," Tina Gaines, a Carelon spokesperson, wrote to ABC News in response to the allegations of Rodriguez and others.

The feeling of being undertrained weighed heavily on Rodriguez, she said.

"Answering a call where someone says they're tired and had a bad day is very different from answering a call with someone who says they have a gun to their head," she said. "I don't have the experience to de-escalate a situation like that."

Although not specifically addressing Carelon, Vibrant acknowledged the impact a lack of training might have on 988 centers.

"If there is a lack of training, there is absolutely a possibility of organizational disintegration," David Obergfell, Vibrant's assistant vice president of 988 center engagement, told ABC News.

Rodriguez said the limited training and long hours weighed on her. Even after months on the line, she said questioned her abilities.

"Am I capable," Rodriguez said she would ask herself. "Am I competent?"

According to the 2022 SAMHSA report, a "sense of failure" is also commonly associated with burnout. For Rodriguez, at a certain point, she said these concerns became personal.

"I [started] feeling like if my parents called, or if someone else I loved called, I would be highly upset if I found out someone answering on the end of the call has not been trained properly to do the job," Rodriguez said.

"They're calling a line for hope"

For Mosby, Rodriguez and Aaron, their feelings of inadequate training combined with the pressures of the job gradually caught up.

Rodriguez, like Mosby, said she's been fighting overwhelming anxiety, panic attacks and nightmares. Aaron said she also, at times, has had a difficult time coping with situations that are deeply triggering.

According to SAMHSA, burnout has close and potentially long-lasting ties to one's one well-being.

"Helping people in crisis can take a toll," SAMHSA's Johnson wrote to ABC News. "In many cases, [988 operators are] talking to people on the worst days of their lives."

Rodriguez said she eventually mustered the courage, for her sake, to air these challenges to a supervisor. She's been struggling, she told them, as have her colleagues, and she thought that was a reason some were choosing to leave.

But, in contrast to SAMHSA's 2020 guidance, Rodriguez said her supervisor responded by saying that "some people just weren't meant for the job."

"[We] consistently uphold the standards and training at our call centers," Gaines, at Carelon, wrote to ABC News.

In January, Vibrant and Carelon parted ways after failing to agree on the terms of contract renewal. Carelon continues to provide services to a handful of state partners.

"Vibrant Emotional Health is well-equipped to manage natural evolution within the 988 Lifeline network," Jaffar, at Vibrant, wrote to ABC News.

Experienced altogether, the challenges faced by hotline workers have forced a reckoning among people such as Mosby, Rodriguez and Aaron.

Mosby left the job in September. She said she doesn't know if, or when, she'll reenter behavioral health work.

Given how much working the line has impacted her own well-being, Rodriguez said she also struggled. In October, Rodriguez said she'd ideally like to find another job sooner rather than later.

"If I could leave tomorrow," she said at the time, "I would."

Rodriguez recently told ABC News she left her job by early January.

Still, 988 continues to fill a critical void in providing mental health services, she said. Over and over, Rodriguez said she's witnessed firsthand how much the line can help people. Rodriguez said she also continues to encourage people to call 988, especially given how few other options may be available for so many.

"They're calling a line for hope," Rodriguez said.

If you or a loved one is struggling with a mental health crisis or considering suicide, call or text 988.

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