On the early morning of Sept. 20, 2017, psychologist Frances Boulon, PhD, was listening to her battery-powered radio when the newscaster made a panicked announcement: "We need to leave." The station went off the air. Shortly after, at 6:20 a.m., Hurricane Maria made landfall.

"It ripped the roof off the radio station," says Boulon, who teaches in the psychology department at the University of Puerto Rico at Rio Piedras. Maria, a Category-5 storm and perhaps the worst natural disaster in Puerto Rico’s history, with winds of more than 160 miles per hour, uprooted trees and power lines, and cut off electricity to more than 3.3 million people—the island’s entire population. Bridges collapsed, homes tumbled down cliffs, and mudslides and debris made roads impassable. Officially, 64 people were reported killed in the storm, although The New York Times and other news outlets estimate the number to be well over a thousand.

"Nobody experienced anything like this unless they had been in a war zone," Boulon says.

Maria struck just two weeks after Hurricane Irma, another Category-5 storm that knocked out power to more than a million Puerto Ricans and destroyed dozens of homes. The back-to-back disasters overwhelmed the island’s already strained infrastructure. According to local media, three weeks after Maria, only 30 percent of hospitals could provide services, while 93.5 percent of the island lacked power, 48 percent lacked cellphone service and 43 percent lacked potable water.

The U.S. government was widely criticized for its delayed response on the island. Criticism was especially harsh given that only weeks earlier, thousands of engineers had been sent to Texas and Florida to help those states recover from Hurricanes Harvey and Irma, respectively. And just two weeks after Harvey made landfall in Houston, President Trump signed a $15 billion relief package for that area, while at press time, no decision had been reached on whether Puerto Rico’s $4.9 billion loan would be forgiven, as is customary for U.S. loans granted after natural disasters.

Activists protesting lack of aid to Puerto Rico.Alongside this humanitarian crisis, Puerto Rico’s psychologists also worried about a possible mental health crisis. Many pharmacies were closed, meaning antidepressants, antipsychotics and other medications were unavailable. Treatments were disrupted, and doctors couldn’t be reached since cellphone and internet service were down. Some remote mountain towns were essentially quarantined by blocked roads.

"People who were fragile before the storm went over the brink," Boulon says. And a small army of psychologists, disaster relief workers and volunteers worked desperately to pull them back.

They’ve succeeded in averting a widespread mental health breakdown, although reports of increasing suicide rates concern the island’s psychologists. And while metro areas such as San Juan have mostly recovered, outlying towns and mountain hamlets are still plagued by rolling blackouts, polluted water, high unemployment due to shuttered businesses, and out-migration.

Unprepared for disaster

Zahira González, PhD, who was then president of the Puerto Rico Psychology Association (APPR), had disaster in mind when she began planning an emergency mental health network in early 2017.

The APPR’s emergency mental health network wasn’t fully trained yet when Hurricane Irma hit, but members scrambled to collect food and clothing for affected people on Culebra and Vieques, small islands off Puerto Rico’s east coast that are part of the commonwealth. González’s team also arranged two free sessions of psychological first-aid training for APPR members and interested volunteers. The two-hour sessions attracted more than 100 people.

Then came Maria.

The damage was catastrophic, and few on the island were prepared. In Gurabo, an eastern city not far from El Yunque National Forest, counseling psychologist Silma Quiñones, PhD, recalls television antennae flying through the air and downed trees everywhere. According to the town’s mayor, Rosachely Rivera, 700 homes lost their roofs, all schools and parks were closed, and her own office was flooded.

The immediate concern was the town’s approximately 260 bedridden residents. In the first week after Hurricane Maria, Rivera tasked social workers with creating a census of those who were housebound, were physically or mentally ill or had a history of violence if not medicated. Makeshift centers were set up in those communities to provide insulin, medication, ice and other services.

"We needed to do triage," Quiñones says.

Meanwhile, a community leader who knew about Boulon’s work with the APPR asked her to help facilitate psychological first aid elsewhere on the island. Boulon charged her cellphone in her car since the power was still out. "I made 30 calls and reached one psychologist," she says.

Schools were turned into emergency shelters. Boulon was struck by the variety of socioeconomic backgrounds that co-existed. Homeless people slept next to middle-class couples who were worried about the fate of the Victorian furniture they’d left behind. People with addiction issues and criminal records slept next to families. Still, one thing united them: their need to talk. "The main duty of volunteers was to listen to the story of the night of the storm over and over again," Boulon says. Indeed, listening was one of these psychologists’ most critical tools. "We learned that the psychology of disasters doesn’t look like clinical therapy," González says. "It’s more about being there with someone, not diagnostics. It’s about managing a crisis." She adds that while it’s too soon to see evidence of post-traumatic stress disorder, psychologists expect to see many such cases in the coming years.

APPR members and volunteers advised those they spoke with to focus on new possibilities rather than on what they’d lost. They also shared techniques for how to regulate emotions and communicate proactively with each other. More strategically, the APPR created a tiered disaster response schedule. In the first 30 days after the storms, members visited displaced persons and provided emotional support. Sixty days after, they distributed food, water, clothing and other supplies, and 90 days after, they began documenting and reflecting on what they learned to help refine their emergency mental health network in the future.

"We weren’t in a condition to be very precise," Boulon says about the days after the storm.

Scenes of resilience and dispair

The crisis was especially intense in Puerto Rico’s mountains and rural towns. Valerie Cole, PhD, manager of individual disaster care for the American Red Cross, arrived 10 days after Hurricane Maria made landfall. The organization dispatched teams of three to six people to search remote areas and confirm families’ well-being. "It took all day just to staff the teams," Cole says. And since cellphone networks were down, there was no communication once teams drove off into the mountains. "They took food and water with them, but we never knew if it was going to be enough," she says.

Teams discovered vivid scenes of resilience and despair: a blind woman who lived alone; a woman whose husband was killed during the storm when a metal panel slammed into his head. Quiñones mentions a family who buried a loved one in their patio because they were isolated and the body was starting to decompose.

Neighbors helped each other. Those lucky enough to get a cellphone signal shared their phones. People ran errands for those who couldn’t. Volunteers from the APPR and the Red Cross relied on local communities to help identify at-risk people. González says that children who weren’t traumatized by the storms enjoyed the unusual freedom that the hurricanes brought. "There was no school, no phones, no computers, so for them it was an opportunity to make new friends."

For others, including APPR members and relief workers, the threat of burnout was constant. Psychologists who’d lost their homes had to suppress their own grief and counsel people experiencing the same shock and depression. "Some psychologists felt overloaded just trying to provide the right words," González says.

Adding to Puerto Ricans’ distress was the bungled response from the U.S. government. "Something is not working well when they can go into the deserts of Africa or the Middle East but they can’t get to a mountain on an island that’s 100 miles by 35 miles," Boulon says, summing up the attitudes of many Puerto Ricans. She compares the relief efforts to "spontaneous combustion" because random, sometimes disproportionate, outreach replaced a systematic plan. In Gurabo, Rivera has nothing negative to say about the Federal Emergency Management Agency (FEMA) or the U.S. Army Corps of Engineers, although she notes that language and other barriers complicated an already precarious situation.

"FEMA came to the shelters and said they’d help fill out requests for funding, but some FEMA people weren’t bilingual, and some of our people aren’t techies," she says. "We had no internet, no computers, but everything had to be done online. It was a crisis within a crisis."

As of February, Mayor Rivera had spent more than $246,000 to purchase electric poles and cables to help restore power in Gurabo—a significant sum for a small city. One bright spot came when APA sent $5,000 to the APPR for basic needs such as water and toilet paper, and later earmarked more than $20,000 for post-disaster mental health recovery. According to Amanda Clinton, PhD, senior director of APA’s Office of International Affairs, the funding is modeled on APA’s response to Nepal’s crippling earthquake in 2015, when the association sent more than $20,000 to help a U.S. expert train local psychologists. The difference, in this case, is that well over 200 trained, licensed and doctoral-level psychologists live in Puerto Rico, so they’re expected to take the lead in capacity building efforts with funding from APA. Nonetheless, having lived on the island for a decade (she is now based in the United States), Clinton knows firsthand that psychologists there are desperate for help.

"Trauma is more significant over the long term when people are re-traumatized," she says. "This recovery has taken months, so it’s re-traumatizing already vulnerable people."

A need continues

Today, more than eight months after the hurricanes, Puerto Rico is still struggling. González says that about 30 percent of the island still has no power. In Gurabo, four schools remain closed, and the mayor’s office is so flood-damaged that it’s unusable. Six thousand residents have left the town of 30,000, migrating either to San Juan, where the recovery has been faster, or to the United States. Some businesses have closed permanently, while others have threatened to pull up stakes. Unemployment rates are higher, and so, too, are suicide rates. In February, El Nuevo Día, the island’s largest newspaper, reported a 29 percent increase in suicides after the storms, although there’s been no official investigation to correlate the two.

"How many people died is a big question mark," Quiñones says. Puerto Rico’s government has yet to release a centralized evaluation of the hurricanes or their aftermath. Coordination is still haphazard, too. Since October, Boulon has attended several meetings with leaders from FEMA, the Red Cross, Puerto Rico’s Substance Abuse and Mental Health Services Administration and local agencies, but says it’s still unclear to her where the most urgent needs are.

González hopes that people on the U.S. mainland continue to talk about and publicize Puerto Rico’s ongoing recovery. "If others pay attention to what’s happening here, the government also pays attention," she says.

Quiñones also urges psychologists to investigate resilience in Puerto Rico.

"It’s a special place to look at how communities are strengthened, how people survive catastrophic events and how to provide psychological help with limited resources," she says. Beyond that, she invites anyone who is interested to come to Puerto Rico and help the island rebuild. "Even painting houses makes a psychological difference for us," she says.

For those interested in helping, contact the American Red Cross at www.redcross.org.