The mental health response to Hurricane Fiona

In the wake of yet another deadly hurricane hitting Puerto Rico, psychologists are in triage mode, working to reach those with the greatest needs first. Psychologists are a key part of the effort to deliver food, water, supplies, and emotional support to residents in the hardest-hit areas since Fiona hit Puerto Rico on September 18. Teachers, counselors, graduate students studying psychology, and volunteers trained in psychological first aid are fanning out across the island to help.

On September 23, psychologist Eduardo Lugo-Hernández, PhD, visited a family who “lost practically everything” when a river flooded their home, and helped them find food, water, and shelter nearby. Meanwhile, Frances Boulon, PhD, a psychology professor at the University of Puerto Rico at Rio Piedras and past president of Puerto Rico Psychological Associationopens in new window (APPR), met with a group that ensures people with disabilities and special needs are cared for during emergencies.

They are also assessing the damage and planning next steps to ensure that responders maximize their impact and avoid duplicating one another’s efforts. Mariveliz Cabán, PhD, assistant faculty in psychology at Ana G. Méndez University, Cupey Campus and coordinator of emergency response efforts for APPR, spent much of the first several days after Hurricane Fiona hit calling nongovernmental organizations (NGOs) to determine what sort of supplies and psychological first aid their constituents most need right now.

“Unlike five years ago, we have people on the ground, ready, who know how to help,” said Rosaura Orengo-Aguayo, PhD, an associate professor at the Medical University of South Carolina (MUSC) and director of the Puerto Rican Center for Intervention and Training in Traumaopens in new window, who has co-led post-Maria efforts to train first responders on the island. “It’s a very community-based, participatory approach.”

Immediately after Hurricane Fiona hit, Orengo-Aguayo and her team based at Albizu University, Mayaguez created “booster” tools in Spanish—including an eight-minute videoopens in new window and a tip sheet highlighting four key steps—to refresh trainees on disaster response protocols and express solidarity with first responders. Among their tips: First, check in with yourself and the people you live with. Are basic needs (food, water, safety) being met? If not, start there. Next, join a coordinated response through a community organization—the safest and most efficient way to help.

Third, focus on immediate needs. This isn’t the time to deliver therapy, but rather to connect people to basic support and resources. And it’s important to remember that the norm is distress. “If you see people crying, desperate, and anxious, that is a normal response to a traumatic event,” said Orengo-Aguayo, who also co-directs the Telehealth Outreach Programopens in new window for Traumatic Stress in Puerto Rico with Regan Stewart, PhD, of MUSC.

Finally, they provided several concrete tips about what to do if someone is in crisis in front of you—how to remain calm, use grounding techniques, and ask pointed questions that assess safety. Connect the individual with a professional trained to manage a mental health emergency (if needed, dial 988opens in new window to access the federal suicide crisis line).

Responders are also seeking help from the Red Cross’s Integrated Care Condolence Teams, who are trained in bereavement, to provide emotional support if a death has occurred. But for the most part, volunteers are there to help residents identify sources of strength and support within themselves, their families and peer groups, and their communities.

“People always tell me that they start receiving food, water, and basic supplies, but the emotional support is hardest to get,” Cabán said. “It’s critical that they get at least some basic emotional support in order to prevent further trauma.”

Five years ago, another hurricane–Maria–hit Puerto Rico. The storm killed around 3,000 people, plunged the entire island into darkness—some areas had no power for an entire year—and left behind widespread mental health issues, including posttraumatic stress disorder (PTSD), depression, and high rates of suicidality (JAMA Network Open, Vol. 2, No. 4, 2019opens in new window).

Now, Hurricane Fiona, which made landfall on September 18, has again destroyed entire towns, torn apart families, and left many on the island without power, water, or basic supplies. It has also left psychologists bracing for another surge of mental health concerns.

“People are really struggling,” said Cabán, the emergency response coordinator for APPR. “Whenever people think things have gotten a little bit better, something happens. The earth shakes for them, metaphorically or literally.”

Some residents who rebuilt their homes after Maria, for instance, lost them again during the earthquakes that struck in 2019 and 2020. Since 2019, Puerto Ricans have also faced Hurricane Irma, the Zika epidemic and covid-19 pandemic, economic austerity measures, and ongoing problems with the electrical grid and other infrastructure.

One upside of all the upheaval is that the island is more prepared for Fiona than it was for Maria, largely thanks to training and coordination by NGOs, community groups, and professional associations such as the APPR. A large network of volunteers, as well as designated emergency management centers, are facilitating a more efficient response this time around.

But those involved in such efforts, in Puerto Rico and beyond, are also concerned about future disasters that may further strain resources at the local, national, and international levels. The typhoon that struck Alaska on September 17opens in new window, as well as hurricanes, wildfires, and other climate-related disasters, all threaten to inflict more physical damage—as well as mental health fallout that can take months or years to address.

“We are at a moment where we desperately need to rethink the way we provide mental health services, in Puerto Rico, but also in other places that are heavily impacted by the climate crisis,” said Lugo-Hernández, who is an associate professor of psychology at the University of Puerto Rico, Mayaguez Campus and a leader of grassroots and community-based efforts on the island. “The climate crisis is here to stay—and we need to change with the times.”

As much as first responders have trained and prepared for this moment, many still feel like they’re swimming upstream. Most are working without power, juggling the delivery of psychological first aid with the need to charge their devices and tend to their own families’ needs after the storm.

“Community leaders can’t turn the power on,” Boulon said. “The reality is that [our efforts] are limited for reasons that have nothing to do with our skills or training.”

Most of the psychologists and other workers engaged in the relief effort also have full-time jobs. Donating their time and energy to help others, one disaster after the next, is taking its toll.

“We’ve been burned out for a while already, because we have been giving that first response, but we haven’t received any aid or relief from the government,” said Patricia Landers, PsyD, an associate professor of school psychology at the Pontifical Catholic University of Puerto Rico and president-elect of APPR. “There’s a sense of hopelessness among many mental health providers.”

Even outside the bounds of disaster response, mental health providers are feeling the strain of Puerto Rico’s economic troubles. Many clinical psychologists have stopped accepting insurance due to low fees, late payments, and other problems, Landers said. As a result, wait times for intake appointments average between two to three months.

The difficulty of accessing services, combined with the cumulative effect of “living in a state of emergency for five or more years” had left many mental health providers feeling frustrated, indignant, and concerned about the future, Orengo-Aguayo said.

However they choose to contribute, psychologists will continue to be central to the recovery effort.

“Psychologists have an important role to play in helping Puerto Ricans respond to Hurricane Fiona, not just with regard to the immediate impact of this storm, but also with regard to Hurricane Maria and its aftermath,” said APA President Frank C. Worrell, PhD. “It is important for us to view the current work in the context of sustained trauma.”

One of the most important things psychologists can do right now is support their colleagues in Puerto Rico. If you know someone affected by the storm, reach out, said Lugo-Hernández.

“People like me who are on the ground have very few outlets to process everything that we’re seeing and doing,” he said. “We need allies and spaces for conversation to relieve the pressures we’re facing, because we’ve been affected by this, too.”

Avoid what Orengo-Aguayo calls “performative allyship”—posting solidarity on topics you’re not familiar with or sharing resources you’ve never read. Instead, reach out to those affected and tell them you’re thinking of them and that what’s happening is not OK.

Many community leaders agree that at this time, “we do not urgently need mental health professionals and psychologists to come to the island to assist with the response,” said Boulon, because of Puerto Rico’s extensive network of professionals and trained volunteers. “What we do need are financial donations that may arrive to the communities more quickly than federal aid.”

Those donations can be used to buy supplies such as solar lamps and first aid kits or to cover meals and expenses for volunteers (see below for more information).

• Brigada Solidaria del Oesteopens in new window is a mutual support network accepting donations via PayPal (brigadasolidariaoeste@gmail.com) in order to purchase and distribute water purification tablets, water filters, solar lamps, and first aid kits.
• escape Family Strengthening Centeropens in new window is a nonprofit focused on crisis intervention and the prevention of child abuse. Donate to their relief effort through PayPal (escape@escapepr.org).
• The Puerto Rico Psychological Associationopens in new window is also accepting donations via PayPal (pagos@asppr.net; include “Fiona donation” in the description), which they will distribute to their community partner organizations.
• The American Red Crossopens in new window is also aiding the response in Puerto Rico. Follow the instructions on this pageopens in new window to donate directly to Hurricane Fiona relief efforts.