It Starts with One.

The only journey is the journey within.

– Rainer Maria Rilke

I often wonder: how many whispers does it collectively take to make a resounding roar? What is the tipping point that moves one from awareness to action? What is the change agent that elicits movement toward something better?

As a part of health communication theory, scholars teach what is (more or less) commonly known as The Transtheoretical Model (TTM), to more acutely depict the stages of behavior change that take place in cases of intervention. These are perhaps the steps that move someone from awareness of the need for health-risk behavior change to actual change itself. These stages include:

1. Precontemplation: No intent to take action within the next 6 months.
2. Contemplation: Intends to take action within the next 6 months.
3. Preparation: Intends to take action within the next 30 days and has taken some behavioral steps in that direction.
4. Action: Changed overt behavior for less than 6 months.
5. Maintenance: Changed overt behavior for more than 6 months.
6. Termination: No temptation to relapse and 100% confidence.

While TTM is often associated with health communication messaging as it applies to the persuasion of smoking cessation, alcohol abstinence and a lengthy list of potential health behavior-changes, it seems this could apply to changing more broad-stroked social ideologies and norms as well. To move a society — one by one — from passive thought to passionate action. To reflect on new laws, regulations and resources that foster hope for a society. How do we move a national conglomerate through these stages to a place where mental health is destigmatized, options are readily available, and the awareness and recognition of the ever-present danger has gained momentum that brings it to the forefront… and is recognized for much longer than when immediate or personal crisis occurs?

Today, NPR published a story, “Rural Areas Across the Country Face Drastic Shortage of Mental Health Care,” sharing news of a man from International Falls, Minn., who completed a meaningful, successful career in psychiatry, then retired. As a result, this small town (with a population of approximately 6,000) lost it’s only dedicated mental health care provider within over 100 miles to treat anxiety, depression, schizophrenia, bi-polar disorder, and many other mental health conditions. Patients who previously received care were left with even fewer resources than they had before… and real conditions that still deserved immediate, specialized care.

As NPR states, “More than 90 percent of psychiatrists limit their work to urban areas, even though more than 20 percent of the population lives outside of cities.” As a result of these absent services, many patients are forced to receive care from general practitioners who may not have the dedicated mental health training necessary to provide the proper support, or perhaps end up in the hospital emergency room when their situations are severe enough. Then, the practitioners who saw them find themselves desperately in search of beds that may or (in many cases) may not exist for the mental health patient. Commonly, the facilities are already full — for weeks or months. And so continues the cycle of illness that needs to be treated… and the deficiency of resources to treat it.

In an effort to carry the baton of advocate rather than second-hand victim (as I believe no positive change can come from the latter), I assert that there are some immediate resources that are available to those who need immediate care: ‘911’ (in emergency situations, of course), the NAMI Helpline, the Substance Abuse and Mental Health Services Administration (SAMHSA) Helpline, Psychology Today’s treatment center resource site, and the National Suicide Prevention Lifeline, amongst others. They’re crisis resources — timely, and they provide effective support to the extend they’re able. But, it’s often that patients are directed from these hotlines to local care centers, where beds are once again unavailable and providers are variably low in-count compared to the population in need. It’s not that they don’t do their very best, it’s simply that the demand of need is much higher than the supply of help. And this is where change can occur.

In a return to TTM, I wonder when we — as a society — are going to move from a place of precontemplation, contemplation, or perhaps preparation, to a place of unsubdued action, maintenance and termination of the crisis at-hand. When people in need of mental health care will receive treatment regardless of location, situation or diagnosis. When the whispers will turn to resounding roars, and we will break down the obstacles that stand between a healthy society and a desperately hurting one. Recent news indicates that we’ve perhaps move to the “preparation phase,” as we see the timely approval by the FCC of ‘988’ as the new, 3-digit number for suicide prevention to “help increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.” It’s a valiant first-step in a series that must take place, noting that “…suicide rates have increased across the U.S., over the past two decades, and dramatically so — by more than 30% — in half of U.S. states, according to the Centers for Disease Control and Prevention.” But, as we wait for this new resource to take effect, perhaps we must also consider forward-thought. What happens after the number is called? What happens before a person gets to the state where they need to call it? How do we prevent rather than simply react? How do we get the proper resources to those requiring it in a timely, cost-effective and manageable fashion before we enter the crisis phase?

It starts with one small voice moving through the phases of contemplation to action. Make a phone call to check up on a friend or family member who may be struggling. Know what resources exist in your area — and which ones don’t. Advocate for new resources through your local authorities. Talk about it openly with others so the unnecessary shame dissipates. And, if we all raise them, perhaps we’ll find ourselves in movement toward termination. But it takes all of us, demanding recognition, restructuring and newfound support from the inside of a fragmented system, to the outside of it… one person at a time.