Natural Disasters and Mental Health: Lessons Learned in Puerto Rico

Natural Disasters and Mental Health: Lessons Learned in Puerto Rico

In September 2017, Puerto Rico was battered by Hurricane Irma and Hurricane María, the latter being the strongest hurricane to ever hit the island. The United States government’s double standard in handling relief efforts on the mainland versus those on the island exposed Puerto Rico’s status as a colony. Puerto Ricans were – and continue to be – left at the mercy of a government that lacks meaningful representation and voting power in Congress to approve the necessary aid. The aftermath of Hurricane María is emblematic of the urgent needto develop a more in-depth, specific continuity plan to prepare for proper mental health care in the wake of future storms.  

In the aftermath of these disasters, Puerto Ricans will facesignificant infrastructure damage affecting roads, drinking water, electricity, cellular networks, and access to medical care. The 2017 storms submerged the island’s 3.4 million citizensin a humanitarian crisis that accompanied an already existing economic one. María was the third costliest tropical cyclone in United States history, with estimates showing thousands displaced from their homes, seeking shelter elsewhere in Puerto Rico or in the mainland United States. Surveillance is critical to understanding the impact of deaths, injuries, and displacements on communities. However, officials lack reliable data, which distorts not only immediate responses, but also future steps for preparedness, risk-reduction, and planning. Six months after the storm, many neighborhoods still lack electricity without indications of when it will return. The winds also took away the mantle from the “commonwealth,” a euphemism used to describe the island’s political relationship with the United States. 

The Caribbean islands face hurricanes every seasonand generally know how to prepare. However, this catastrophe represents much more than just an extension of past storms. The island has lost life, potable water, power, communication, infrastructure, freedom of movement, security, predictability, and above all, social and government services—the foundation of effective relief efforts. As a result, since the storm, the island has seen increased mortality rates and high rural displacement rates.

Currently, warning signs of a full-fledged mental health crisis exist, with many people exhibiting post-traumatic stress symptoms. This ongoing crisis, not visible in a wound or a downed power line, has placed significant strain on citizens' mental health

Immediately after a natural disaster, many typically experience fear, anxiety, sadness or shock. However, if symptoms continue for weeks or months following the event, they may indicate a more serious psychological issue. Post-traumatic stress disorder (PTSD) is one of the most commonly studied mental health disorders, which can occur after frightening events that threaten one’s own life or those of family and friends. Common responses to disasters also include substance abuse and domestic violence. While many survivors show resilience, studies indicate that mental and behavioral health issues can crop up weeks, months, and even years later. Length of exposure to trauma is an important variable for PTSD development, and many Puerto Ricans face months of suffering.

The multi-agency disaster response and recovery network, currently consisting of the Federal Emergency Management Agency (FEMA) and the Red Cross, should also include public and mental health agencies, schools, local government, social services, businesses or workforce development, and the media. After Hurricane María, responders could not reach suicidal patients on the telephone coaching crisis line for days following the storm. Disaster response programs should include resources intended to help women and families experiencing domestic violence, depression, and PTSD.

Communities should also prepare to reconnect disaster survivors to friends, family, and temporary housing locations. For instance, my team of clinical psychology doctoral students from Albizu University—along with the Army Special Forces and Facebook personnel—used gas stations as message boards for families. Separately, with the help of antennas installed in the mountains, we allowed families to access wireless internet to inform their loved ones that they were alive after the hurricane. These simple steps serve as mental health prevention that other agencies should replicate. 

Many businesses, like insurance companies, also faced the challenge of proper crisis response. Following an incident that disrupts business operations, companies need resources to carry out recovery strategies and restore normal operations. Thus, mental health clinics and agencies require more than just emergency protocols. A continuity plan detailing what to do or where to go if communication or power goes down can be delivered through special programming and other communication interventions. 

The clinic at Albizu University utilizes a Dialectical Behavioral Therapy (DBT) program to work with Borderline Personality Disorder and crisis or suicide prone patients. Before the hurricane, we identified skills that our patients used regularly and adapted them for the post-hurricane reality. For example, if someone regulated emotions by watching TV or holding ice cubes, they would require alternative methods during a blackout. As few anticipated that the suffering would last so long, the staff prepared patients to expect outages for a week, rather than the prolonged six months that has been seen. Thus, many faced crises without the usual support of their therapist, medication, telephone coaching, or available mental health clinics. This disaster taught that all mental health clinics need long-term continuity plans.

Rural areas experience even greater logistical challenges in receiving supplies or psychological first aid. Destroyed roads and impassable roads prevented people from accessing the few supplies that did arrive. Without infrastructure for an extended period, it is imperative that people and professionals know what to do and where to go. The following policy suggestions represent a “business continuity” plan in the case of a future crisis: 

1.     Develop alternative means to restore hospitals operations to a minimum acceptable level, prioritizing the data obtained from studies after Hurricane María. Plans should account for damage to facilities or medical machinery and the potential failure to deliver supplies or information.  

2.     Reform shelters (often public schools) to serve a double purpose as community health centers as well. Officials should station pre-assigned mental health workers, volunteer physicians, and professionals from health agencies at each location.

3.     Perform Secondary Preventive PTSD assessments in communities with the longest exposure to suffering and displacement. Multidisciplinary teams should implement evidenced-based prevention and remediation interventions among children.

4.     Simultaneously, set up regional mental health clinics in all areas exposed to suffering (e.g. flooding, landslides, blackouts, no running water) for more than four consecutive months.

5.     Review all emergency protocols in communities and schools to ensure that they include immediate and ongoing recovery that agencies can activate before the onset of disaster. Schools should receive children in stages as soon as possible to begin preventative PTSD assessments. 

6.     Appoint community leaders to meet two days after the disaster in a predetermined safe place after screening their community for people in need. This measure will allow officials to report issues and direct emergency services more effectively and immediately. 

7.     Establish education on sustainable community energy programs where power restoration is a real challenge. Implement solar energy and community water filtration systems in these regions.  

8.     Strengthen the relationship, communication, and coordination between the Office for Emergency Management and FEMA.

9.     Ensure that an emergency management plan exists, as envisioned in Law #20 (Catastrophe Plan, Natural Disasters Plan, Operations Continuity Plan, and Mitigation Plan), taking into consideration the experience from María. 

Poverty and social inequality existed before María, but this disaster has exacerbated them. To reduce these vulnerabilities, Puerto Rico should develop its social capital and foster unity between social classes in the face of disaster. These steps will create a more resilient nation and help lessen vulnerability in the potential development of a mental health crisis.


Dr. Domingo J. Marqués-Reyes is an Associate Professor in the clinical psychology Psy.D program at Carlos Albizu University (CAU), San Juan campus. Currently, he is the Director of the Dialectical Behavioral Therapy and Research Program at CAU. Furthermore, he is part of the editorial staff of the Puerto Rican Journal of Psychology, a member of the editorial board for the Interamerican Journal of Psychologyand of the editorial committee for Psychology for Latin America Journal. He is currently the primary investigator in studies regarding psychotherapy for Borderline Personality Disorder, self-harming behaviors, and mortality rate and suffering from natural disasters.