Mental health support can’t keep up with wildfires or hurricanes

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A small amount of help

FEMA’s crisis counseling program was made for disaster survivors who want help. But some say they never got it.

Established in the 1980s as a short-term disaster relief grant, the program funds free emotional help for anyone affected by a major disaster. It’s been used in every state, plus Puerto Rico and other territories, for more than 400 traumatic events in all.

States with some of the most damaging climate-related catastrophes in the past decade said they rely largely — often entirely — on the program’s funding to support disaster survivors’ mental health. That typically includes state hotlines and crisis counselors who, until the pandemic hit, would go into communities and offer help in person, sometimes door to door. After floods and hurricanes in South Carolina, for instance, counselors showed up to town halls, local meetings, even Christmas parades.

States are required to plan for the mental health consequences of disasters. Officials said they’re grateful when they get CCP funding and appreciate the flexibility to plan the response they think will suit their communities best. But the way the program works can also impede efforts to help.

Carlene Anders, mayor of Pateros, previously led the Okanogan County Long Term Recovery Group. (Marcy Stamper for the Methow Valley News)

Wildfires often aren’t deemed large enough to qualify for a federal emergency declaration and the support that such a declarati“on makes available. A Government Accountability Office report said “wildfire disasters are generally a small proportion of the major disaster declarations FEMA supports,” but notes that climate change may boost future demand for the agency’s help. 

When events do pass the unspoken threshold, states must complete long applications justifying the need. Iowa’s most recent request, for instance, ran 168 pages. And states must fill out two applications if they want to access the full program because FEMA splits it into “immediate” and “regular” phases. The second application can take months to be approved.

The agency’s reasoning is that states should receive assistance only if the event would overwhelm existing mental health services. But that’s almost always the case for major disasters, said Karen Hyatt, emergency mental health specialist with the Iowa Department of Human Services.

“Even when … other FEMA programs are up and running, crisis counseling program administrators are still writing the grant,” she said.

In wildfire-prone California, where counties provide much of the mental health response to disasters, local officials have found the federal program difficult to manage in part because they were on the hook to pay upfront. “It took a long time for them to get reimbursed,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

Then there’s the problem of how long funding lasts. The program typically ends after a year, even though studies show that emotional burdens can persist far longer.

“When you’re talking about mental health, recovery takes years,” said Dr. Karen G. Martínez, director of the University of Puerto Rico’s Center for the Study and Treatment of Fear and Anxiety. “Disaster programs don’t really address that.”

Of the nearly 200 survivors who responded to the survey by Public Integrity, Columbia Journalism Investigations, InvestigateWest and other partner newsrooms, a third still reported five or more types of emotional struggles today — at least three years post-disaster in many cases. Meanwhile, 70% of survivors said they didn’t get mental health services after their experience, for reasons ranging from cost to their belief that they didn’t need help. Yet the struggles they linked to the disaster — from anxiety and depression to trouble sleeping — suggest that many could have benefited from the support.

Over 60% of survivors reported five or more types of emotional challenges in the first year after the disaster. Though people across the country participated, the survey isn’t nationally representative, and it may have drawn respondents more affected by disasters than average.

But reports of lingering emotional struggles echo earlier research. Epidemiological studies have found emotional disturbances three years after Superstorm Sandy, which occurred in 2012. One study of low-income mothers affected by Hurricane Katrina in 2005 discovered one in six had post-traumatic symptoms 12 years after the storm.

And the new reality of back-to-back disasters gives people little time to heal, said Amber Twitchell, associate director at On The Move, a social-services organization in California’s Bay Area. Since the Sonoma Complex Fires in October 2017, she said, “We have been in a constant state of disaster response.” 

Public Integrity and Columbia Journalsim Investigations reviewed the FEMA crisis counseling program response to six major disasters: floods in Missouri and Iowa; the Camp Fire in California; and Hurricanes Harvey, Maria and Florence in Texas, Puerto Rico and South Carolina, respectively. The program’s reach varied but was small compared with the scale of the disasters, according to federal data obtained through a Freedom of Information Act request.

Puerto Rico’s CCP, which was extended beyond two years to accommodate the high level of need, reached the most people. Of the island’s 3.2 million residents, 580,000 met with counselors for sessions lasting longer than 15 minutes. Yet even there, some areas appear underserved. In Ponce, 35% of residents applied for FEMA financial aid — one indication of how many people were affected — and only 7% received counseling sessions.

Texas has relied on the CCP for 35 disasters, some simultaneously — more than any other state or territory. “Responding to multiple disasters is nothing new for our program and for the state,” said Chance Freeman, director of Disaster Behavioral Health Services at the Texas Health and Human Services Commission.

In many ways — in part because of the repeated poundings — the state has one of the most advanced disaster mental health systems. Yet a review of its Harvey response in Houston shows that even there, the federally funded counseling program reaches relatively few suvivors.

Roughly 22,000 Houston residents received individual, family or group counseling within the 14 months the program was active, according to the Public Integrity and Columbia Journalism Investigations review. At the same time, about 341,000 people there applied for housing or property aid from FEMA.

Freeman said the state used that list of applicants to help identify the hardest-hit areas.

But in the nine Houston ZIP codes with the highest per-capita share of FEMA applicants — all lower-income, majority Black and Hispanic areas — 1% of the population received counseling. That’s about the same level of help provided in some higher-income, majority-white ZIP codes, even though a smaller percentage of residents there applied for aid.

Dr. Annelle Primm, chair of the All Healers Mental Health Alliance, a group that taps volunteers to fill gaps in the government response to disaster-struck communities of color, is not surprised by the data. The unequal distribution of assistance she sees in Black neighborhoods in particular, from food to disaster loans, adds to the emotional toll for residents.

“In this country, the response seems to assume that the people who are affected are middle-class white folks,” Primm said. “They really aren’t thinking about, well, what if the community that is affected was already behind the eight ball, or had preexisting challenges, which the disaster just made … that much worse?”

Presented with Public Integrity and Columbia Journalism Investigations’ findings, a FEMA spokesperson said the program supplements local mental health services, so “there is no universal ideal or adequate level of counseling post-disaster — it varies not only by locality but also by disaster.” The agency added that crisis counseling is available to all U.S. residents through the federal Disaster Distress Helpline.

The Harris Center for Mental Health and IDD (intellectual and developmental disabilities), which ran the CCP in Houston after Harvey, said the findings don’t include other forms of support beyond counseling. The agency led educational sessions with thousands of residents that, it said, could inform and motivate survivors to seek help from other mental health organizations, religious groups, family and friends.

The Texas health department’s Freeman, said the program serves all survivors equally. Among the 16,000 who received individual counseling in Houston, 38% were Black, 30% were Hispanic and 18% were white, according to the counselors’ observations.

“More time would be great and more resources would be great,” he said, but “we’re not there to create a need that doesn’t exist. Communities are resilient.”

Stigma around mental health care and people’s desire to be self-reliant both make it difficult to know when a community no longer needs aid, experts caution. After Katrina, teams dispatched to hard-hit communities found that no one stopped to talk if they set up a table with a “free crisis counseling” sign. “But when we began posting ‘tell us your hurricane story,’ people stopped,” said Danita LeBlanc, manager of Louisiana Spirit, that state’s crisis counseling program.

When Texas reached the end of its Harvey counseling program, 40% of the grant was unspent. Positions were never filled and some staff, including counselors, left before their contract was up. “This is not uncommon, given the temporary nature of the program,” a state health department spokesperson said in an email.

The agency didn’t directly address a question about whether thousands more people could have been counseled with the unused funds. It said it exceeded its goals and got a commendation from the federal government. The money, $5.6 million, went back to FEMA.

The long, uneven road to recovery

How well or quickly someone recovers emotionally from a disaster can depend on how well and quickly they recover in other, more tangible ways.

“It’s not just initial exposure” to a flood or wildfire, said Sarah Lowe, a psychologist and professor at Yale School of Public Health. “It’s more than that: dealing with bureaucracies, finding someplace else to live, financial impacts.”

One example of those traumatic ripple effects: Major disasters worsen homelessness.

In the 2017-2018 school year — marked by Hurricanes Harvey, Irma and Maria — the number of homeless students jumped 57% in districts where a hurricane, flood, coastal storm or wildfire damaged property, according to a Public Integrity and Columbia Journalism Investigations analysis of federal data.

A crew of volunteers from California looks for items that survived the fire in the Methow Valley, hoping to give homeowners some closure. (Marcy Stamper for the Methow Valley News)

In unscathed school districts that year, student homelessness was virtually unchanged.

The longer the recovery takes, the worse that mental health outcomes can get. This was clear, experts said, from Louisiana after Katrina, where many lived in damaged homes for years and felt forgotten.

Recovery efforts after Harvey were widely applauded by both government officials and emergency management experts. But even in Houston, thousands of low-income homeowners are still seeking aid to repair hurricane damage to their homes, according to the city. Recent analyses show that part of the reason may be the unequal way the federal government distributes aid.

In one study, researchers at the University of Colorado Boulder and the Federal Reserve Bank of St. Louis found that bankruptcy rates in Houston after Harvey rose nearly 30% for flooded low-income households while remaining flat — or even declining — for flooded higher-income households. Emily Gallagher, a finance professor who co-authored the study, attributed that to how those same low-income areas — as well as majority Black and Hispanic neighborhoods — were also less likely to secure federal disaster aid.

In majority-white Houston neighborhoods like Greater Heights, for instance, the rate of approval for FEMA housing aid was 20%. In the Fifth Ward, a majority-Black neighborhood, the rate of approval dropped to 15.5%. This pattern was consistent throughout the city.

“It isn’t because there was less damage in minority areas,” said Gallagher, whose study controlled for that. Her conclusion wasn’t that FEMA is actively discriminating, but that the agency may not be accounting for the way that race in America, after decades of systemic discrimination, is linked “with factors that make it harder to get a grant.”

FEMA’s case workers do their best to help all people struck by disaster, regardless of their background, an agency spokesperson said.

Nationally, other studies have shown differences in aid. Nearly 60% of requests for federal disaster loans were denied from 2001 to 2018, and tens of thousands of other applicants were kicked out of the process before a decision was made, according to a Public Integrity investigation. Ninety percent of denials were attributed to “lack of repayment ability” or “unsatisfactory credit history,” one way that lower-income disaster survivors get shut out of recovery help.

‘Such a betrayal’

Few Americans are protected from disaster-related stress this year. As COVID-19 exacts collective trauma, more than 40 states and territories so far have launched federally funded crisis counseling programs in response.

But the need to stay physically distanced upends the way disaster counseling usually operates. States scrambled to organize video calls and are relying more on hotlines. Unable to send people door to door, they’re hoping that online announcements, posters in stores or pamphlets with food aid will get the word out that help is available. In the midst of all this, some officials are also trying to support the mental health of people who survived extreme weather before the pandemic hit — and they’re bracing for more climate disasters.

“Just being able to reach out … has been a challenge,” said Garcia Bodley, director of the Louisiana Department of Health’s crisis counseling program. “We’re missing that connectivity we’ve had in the past.”

For the survivors of recent wildfires, hurricanes and floods, the coronavirus represents yet another weight. About three-quarters of those who took the Public Integrity and Columbia Journalism Investigations survey said the pandemic is compounding their previous disaster experience, from piling on more stress to further eroding their finances.

Many of the survey respondents are profoundly anxious about the future. Nearly all were concerned that their community will be hit by more disasters; two-thirds were very concerned. A few had already moved at least in part for that reason.

And they’re deeply frustrated about the government’s preparedness for and response to disaster. Two-thirds rated it “poor.” Only 12% said it was “good” or “great.”

The problems they identified ranged from scant rebuilding help to local development decisions that worsen flooding, a problem so common that the flood-survivor organization Higher Ground now has more than 50 chapters in the U.S. And then there’s the halting, often nonexistent response to the warming climate supercharging storms and fires.

“After a disaster, if the government does not declare a climate emergency and start acting like it, it’s just such a betrayal,” said Margaret Klein Salamon, a psychologist who started the advocacy group The Climate Mobilization after living through Superstorm Sandy. Providing mental health support to survivors even as elected officials fail to rein in global warming “is like a Band-Aid. How can we trust a government that does so little to protect us?”

Even when it’s working well, crisis counseling may be only the start of what survivors need. Counselors try to connect people with longer-lasting services when required — that’s the logic for why the program ends after a year. But America’s fragmented system of mental health care is strapped at the best of times.

Almost a quarter of all U.S. adults with a mental illness reported that they were unable to get the treatment they needed, according to the advocacy group Mental Health America. Some of the most common reasons: lack of insurance, lack of providers, an inability to cover copays.

Asked how the country should change its response to psychological damage in an era of worsening disasters, FEMA said: “There is a need for investment in mental health services at every level, but especially at the local, state, tribal and territorial levels. Survivors will always receive the best, most appropriate services from those who live in their own community.”

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