Puerto Rico’s crisis hotline has seen exponential growth in demand over the past two years, reaching over 900,000 calls in 2020, compared to 170,000 in 2019, according to news organization Noticel.

Since Hurricane María struck the island in 2017, leaving parts of the island without power for up to a year, and causing massive economic and health consequences, Puerto Ricans have faced a number of back-to-back emergencies: earthquakes, flooding, the Covid-19 pandemic, and most recently, Hurricane Fiona.

These events have resulted in what experts describe as a severe mental health crisis, including mounting cases of post-traumatic stress disorder, anxiety, substance use disorder, and depression.

But even before the hurricane, there weren’t enough mental health providers, and an exodus of physicians and clinical therapists from the island took place in its aftermath.

“People are looking for services, but are not finding them. We have a demand crisis,” said Dr. Karen Martínez, a psychiatrist and director of the University of Puerto Rico’s Center for Study and Treatment of Fear and Anxiety.

As clinicians struggle to meet the growing need, appointment wait times have stretched – up to seven months, in some cases. Even in her private practice, Martínez and her colleagues cannot take on new patients.

Amid the rising need and shrinking pool of providers, local nonprofits are stepping up to provide essential mental health services.

Over the last four years, Direct Relief has supported 13 local groups focused on mental health, thanks to a $50 million donation from global biopharmaceutical company AbbVie. To bridge gaps in access and provide targeted mental health services to vulnerable populations, projects include telepsychiatry sessions, school-based healing programs, psychosocial support for patients with chronic conditions, grief counseling, and counseling for communities embattled by violence.

“You belong here”

One of those groups is the Stefano Steenbakker Foundation, a nonprofit providing grief counseling for bereaved families. The group was formed after the tragic death of a teenage boy killed in a carjacking, and the organization receives mental health referrals from the state crisis hotline and the Puerto Rico Department of Justice. The founder of the organization – and mother of Stefano – Zorimar Betancourt, explained that the foundation provides “psychological help, social work, support groups, and healing workshops.”

With a Direct Relief grant of $107,000, the Stefano Steenbacker’s Foundation has expanded its scope of services to include social workers, psychologists, and thanatology specialists – who focus on the loss created by death – as well as conducting support groups for victims of loss experiencing complicated grief.

The foundation complements services with art and dance classes, field trips, and concerts, and encourages participants to offer workshops to their peers. Social workers and psychologists are involved in these activities to provide support. “People are happy, they feel as if they are family. They know that we offer a safe space,” said Betancourt.

Tina Terado, a psychologist at the organization, said it provides a feeling of belonging that separates it from traditional mental health services. “Validating their emotions and saying to them, ‘You belong here,’” is vital to the process, she explained.

If the Stefano Steenbakker Foundation didn’t provide these services, Tirado said, “there would be around 500 people without specialized help with their grieving process, and who would not find the necessary tools to manage their loss in a healthy way.”

Play Time

After Hurricane María, Fundación Atención Atención, a nonprofit organization that received funds from Direct Relief, tailored their artistic programs to develop and teach healthy coping skills to children. This approach aims to prevent the negative effects that such a traumatic event can have on children’s lives.

Paula Rivera, the group’s executive director, explained that they must work in settings where children can receive regular, uninterrupted care. “That is why we like working with schools because it’s a way of involving social workers and school psychologists to follow up on things our psychologist has identified.”

Fundación Atención Atención received a $180,000 grant to implement their “Play Time” initiative across 30 schools and communities in Puerto Rico. They’re using play and dance as therapeutic tools to help children cope, as well as offering meditation, breathing, and socialization skills.”

Their project, “La Hora del Juego,” which translates to “Play Time,” provides crisis management tools taught through song and play for children and their parents, as well as teachers and other adults within the schools and communities they serve.

Caonabo Canales, a child psychologist from Fundación Atención Atención, said the group also trains parents, teachers and community leaders on how to identify and manage emotions. “We recognize that both adults and children carry emotions that must be managed,” he said. The idea is to teach both to learn when emotions “present as a risk factor causing stress or anxiety attacks that [they] can’t manage, and what strategies we can integrate to avoid that.”

He recalled when, days after the hurricane, the organization visited a community in the municipality of Yabucoa, which didn’t have water or power to implement Play Time. “I received a boy who wasn’t more than seven years old, and every time he lost, he would become very aggressive. The effect that Play Time had on him was incredible: He developed empathy, emotion management skills, and adequate communication skills,” Canales said.

“We get old because we stopped playing”

Both organizations have taken traditional mental health services and combined them with hands-on holistic practices. Betancourt, who experienced the sudden death of her 17-year-old son, explained that during her grieving process, “I realized that it is not only just going to the psychologist…You also need holistic healing in your life to be able to face the big trauma of losing a child.”

“The way to approach mental health with children is through play, through healthy socialization, providing safety, that is what all pedagogues will tell you,” Rivera said.

She had an additional piece of wisdom to offer for the adults with whom her organization works: “We must help adults remember that we don’t stop playing because we get old; we get old because we stopped playing. If we can understand that, we will have happier children.”