Crisis decision tree: 988 vs 911 vs mobile crisis vs ER

The second time I called for help, I called a different number. The first time I had called 911 because that is what you do when something is wrong, and what happened next is the reason I spent the next year learning the difference between four phone numbers that all answer when you are scared. The difference is not academic. The first call put my son face-down on a kitchen floor. The second call put a clinician at my kitchen table. The kid did not change. The door did.

This is the post I wish someone had handed me ten years ago. There are four crisis pathways in this country. Three of them are not 911. Most autism families do not learn the other three until after they have been through 911 once and decided never again. We can do better than that.

The four pathways, plainly

988 is the National Suicide and Crisis Lifeline. Three digits. Live since July 2022. You call or text 988 and a trained crisis counselor answers, typically within thirty to ninety seconds. 988 counselors are good at talking. They are not at your door. They can warm-transfer you to your local mobile crisis team, schedule a callback, or stay on the phone while you ride it out. 988 does not dispatch police as a default. That matters.

Mobile crisis teams are the door most families do not know exists. A mobile crisis unit is one or two people, typically a licensed clinician paired with a peer specialist or a community health worker, who come to your home, your job, the parking lot of the grocery store, wherever the crisis is. They drive an unmarked car. They wear normal clothes. They arrive in twenty to ninety minutes depending on your county. They sit with your person, de-escalate, develop a safety plan, and either stabilize on the spot or warm-transfer to inpatient care if that is what is truly needed. Mobile crisis is the single best-kept secret in adult disability services in the United States.

911 dispatches armed officers, paramedics, or both, depending on your description of the call. 911 is the right answer when there is imminent physical danger that requires medical or law enforcement response: a stabbing, a fire, an overdose with unconscious patient, a person actively trying to harm someone. 911 is the wrong answer for most autism crises, because most autism crises are dysregulation, not danger, and dysregulation under armed response gets worse.

The emergency room is where you go for medical stabilization and for involuntary psychiatric assessment under your state’s emergency hold statute. ERs do this badly for autistic adults. The fluorescent lights, the four hour waits, the rotating cast of strangers in scrubs asking sensory-overload questions in escalating volumes. Use the ER when there is a medical reason. Avoid using it as the front door for behavioral health, because the front door for behavioral health is usually somewhere else.

What the data say about why this matters

The data on autistic adults and mental health are sobering. Hirvikoski and colleagues, in the British Journal of Psychiatry in 2016, reported that autistic adults without intellectual disability were more than nine times more likely to die by suicide than the general population. Croen and colleagues, in Autism in 2015, documented elevated rates of depression, anxiety, and crisis encounters across the autistic adult lifespan. The Centers for Medicare and Medicaid Services has acknowledged, in successive State Medicaid Director Letters since 2018, that crisis service infrastructure for adults with intellectual and developmental disabilities is underdeveloped in most states.

Federal policy is finally catching up. SAMHSA’s 988 implementation, the Crisis Now framework’s “three core elements” (someone to talk to, someone to respond, somewhere to go), and the national Mobile Crisis Intervention Services Medicaid option created by the American Rescue Plan Act of 2021 have meaningfully expanded the non-police crisis infrastructure. But the rollout is uneven. Some counties have well-staffed mobile crisis units. Some counties still have one social worker who covers from Tuesday to Thursday. Your job tonight is to find out which county you live in.

How to make the call

Open with the door. “I need mobile crisis.” Or “I need 988.” Or “I need an ambulance.” Name the door first because the dispatcher is making routing decisions in real time and the first sentence does most of the routing work.

State the disability. “My adult is autistic. He is in a mental health crisis.” Use the word autism explicitly. Do not assume the dispatcher will infer it from the behaviors you describe. They will not.

State whether there is imminent danger and to whom. The dispatcher needs to know whether to send anyone armed. “He is not violent. He is dysregulated. He has not threatened anyone” tells them mobile crisis or 988 is appropriate. “He is holding a knife and threatening to use it on himself” tells them an armed unit may be required for safety, and even then you ask for a CIT-trained officer.

State the address with the floor and the room. Responders show up faster when they know where to walk after they park.

State the request explicitly. “Send mental health response. No lights and sirens. Plain clothes if possible. He has a history of restraint trauma.” You will not always get what you ask for. You will sometimes. You will never if you do not ask.

The crisis card

The crisis card is a 4 by 6 inch laminated card, one or two pages, that lives in three places: your wallet, the kitchen cabinet next to the spice rack, and your adult’s go-bag. The card contains the information a clinician needs to deliver the right intervention in the first ten minutes without having to ask you while you are crying.

On the front: photo, name, date of birth, autism diagnosis with support level, address, three emergency contacts with relationship and 24 hour numbers, primary psychiatrist, primary care, and case manager. On the back: communication style (verbal, AAC, gestural, written only), current medications with dosing and last dose time, sensory triggers, known calming inputs, three phrases that have worked in past crises, past restraint trauma or holds to avoid, hospital preference and reason. Reprint the card every time a medication changes. Date the bottom.

What to do while you wait

You picked the door. You made the call. The unit is on the way. The next twenty to ninety minutes are yours.

Lower the lights. Turn off the television. Open a window. Bring the sensory comforts your adult uses: the weighted blanket, the chewy, the noise-canceling headphones, the favorite song queued and paused. Do not chase the dysregulation. Sit nearby and breathe loudly enough that your adult can hear you. Mirror the breath. Wait.

Do not corner. Do not touch unless you know touch is welcome. Do not ask questions that require words right now, because the brain that is melting down does not have words. Yes-or-no is sometimes possible. Choices between two specific things are sometimes possible. Open-ended questions are not.

When the responders arrive, meet them at the door. Hand them the crisis card before they cross the threshold. Walk them through the medications. Tell them what works. Then step back and let them work. You have done your part.

After the crisis

The first 24 hours after a crisis are when the system is most willing to listen. Use them. Call your case manager. Update your psychiatrist. Request a debrief from the mobile crisis team if they offer one. Write down what worked, what did not, and what you would do differently next time. Add the lesson to your crisis card.

Then, in the next week, take a walk with your adult. Not as therapy, not as a debrief. As a return to the rhythm of your life together. Crises are not the story. The way you both come back from them is the story. The card you printed tonight is the reason next year’s crisis ends at the kitchen table instead of in the ER.

Jim Palasty is the founder of OASIS for Autism and a single father of an adult autistic daughter in Michigan.