As Hurricane Rita bore down on the bayous of southeastern Texas in 2005, Caitlin Eaves’s family made the wrenching decision to evacuate and leave their longtime home to an uncertain fate. After they returned, they spent several months sleeping on what was left of their floor and repairing the extensively flood-damaged house bit by bit, hampered in part by the long delay in restoring power. The storm also destroyed the local high school, leaving then-16-year-old Eaves and her peers in their 200-person rice-farming community without any formal schooling for weeks.
When Hurricane Harvey barreled toward the same area in 2017, Eaves’s parents and her then 91-year-old grandmother opted to stay put based on the forecasts. But the storm stalled over the region, inundating some areas with more than 60 inches of rain. The resulting floods trapped her family in their home. Eaves, by then grown and living elsewhere, frantically called local high school friends. Within minutes they rushed to successfully rescue the family by airboat.
The experiences exacted a mental toll on the family. “These kinds of things keep happening over and over, and I think my parents are finally getting worn down with everything they have to do,” Eaves says. But people such as her parents can’t just sell a house in small-town Texas for enough to buy a home farther inland, away from the danger of future storms. Their story is one of thousands of similar accounts among hurricane survivors. Almost 300 hurricane-related disasters have struck the U.S. since 2001, and such events are predicted to become increasingly frequent and ferocious. Two massive storms—Fiona and Ian—recently wrought their damage within days of each other, stressing already stricken places such as Puerto Rico to the breaking point.
Just one major destructive event such as this has immediate and sometimes long-term mental health effects, which can worsen when the disaster and its aftermath are severe and lingering. And research shows that people who are subjected to a conveyor belt of catastrophes are at even greater risk for mental health struggles related to anxiety, post-traumatic stress disorder (PTSD) and mood disorders. The level of support and resources available in an affected location can determine how resilient residents are to these difficulties—and a key strategy may rely on developing what are called “concentric circles of community.” With the individual at the center, family and friends form the closest such circle, followed by neighborhood acquaintances and then the support structures around these communities, from government policies to literal structures that can protect them. “Local government and local organizations need to be active, along with targeted states and national government,” says Sarah Lowe, a social and behavioral scientist at the Yale School of Public Health.
Many people suffer acute stress in the immediate aftermath of a massive disaster, Lowe says. They might have nightmares or want to avoid reality completely, and they can experience a heightened sense of watchfulness that leaves them jumpy and struggling to fall asleep. As a teen, Eaves stopped buying things that wouldn’t fit into her emergency “go bag.” “You catch yourself doing weird things like that,” she says, “and being used to the ongoing inconvenience of it, never feeling stable.”
Other manifestations that connect mental and physical symptoms include backaches, headaches and stomachaches, which all “tend to accompany psychological stress, anxiety and worry about the future,” Lowe says. These reactions can interfere with a person’s ability to cope, causing them to snowball further into depression and despair, she adds. Children might show their own version of anxiety behaviors, such as acting out, separation anxiety or a return to bed-wetting.
Care providers see this clearly play out on the ground. Calls to Puerto Rico’s mental health emergency hotline escalate significantly in the aftermath of hurricanes, says Almarely L. Berríos Negrón, a doctoral student in clinical psychology at Ponce Health Sciences University in Puerto Rico. “This gives us an idea of how impactful disasters like these are for the survivors’ mental health.”
And those who have other health care needs can experience layers of stressors, says Sue Anne Bell, an assistant professor and family nurse practitioner at the University of Michigan School of Nursing. Bell spent several weeks in Puerto Rico after Hurricane Maria hit in 2017. The Category 5 storm killed thousands and knocked out power for up to 11 months in some areas. One of Bell’s first clinical encounters after Maria was with a patient who had dangerously high blood sugar. Unable to access medication and with no food options other than shelf-stable, high-sugar items at the shelter, the patient had resorted to eating doughnuts for breakfast. “Especially for older adults and people with disabilities living with that additional burden of meeting chronic health needs, with the shock of that disruption and living in a disrupted environment, you don’t just go back to your house and pick up where you left off,” Bell says. “It just doesn’t work like that.”
Well after the floodwaters dry up and the debris is collected, the mental effects of a disastrous hurricane can linger. Eaves—who is now an assistant director of administration and finance at the Maryland Language Science Center at the University of Maryland—says the fear of hurricanes has followed her. She and her partner sold their home in Washington, D.C., after its basement flooded because Eaves couldn’t bear how unsafe she felt there. “I remember as a kid I used to love thunderstorms,” she says. “But I haven’t loved the rain in a really long time.”
In a study of 669 residents of New York City and Long Island, N.Y., exposed to Superstorm Sandy in 2012, researchers found that a third of study respondents reported depression years later. Anxiety was likely in almost half, and a fifth had probable post-traumatic stress disorder (PTSD). Increased exposure to Sandy’s effects was tied to increased risk for these outcomes. Another study of the population that lived through Sandy found that people who experienced the specific stresses of personal or property damage were at increased risk for having PTSD.
Existing mental health issues, social isolation, chronic physical health conditions, limited social or economic resources and previous exposure to major stressful traumatic events can all increase the risk of chronic mental health problems after a storm. Fading public awareness can also exacerbate the problem. “A lot of times, people’s needs are longer-term than those that get public attention and support,” Lowe says.
A higher “dose” of trauma—through prolonged exposure to a single event or enduring repeated disasters, as Eaves’s family and the people of Puerto Rico have experienced—also increases the likelihood of chronic distress, Lowe says. Research suggests that people do not “get used to” hurricanes and instead experience escalating erosion of mental health with prolonged storm aftermaths and exposure to multiple severe hurricanes. These cumulative shocks seem to lead to ever more adverse mental health effects. In Puerto Rico, where a relentless chain of disasters has pounded the island, “it almost feels like you’re not able to breathe, to get your head out of the water,” says Edmy Ayala Rosado, community projects manager and science outreach specialist for CienciaPR.
Resource availability also plays a role. Having more money and other supports has been linked to experiencing fewer stressors, and people who suffer the most loss and greatest stressors perhaps not surprisingly have the highest risk for conditions such as PTSD.
The expectation of “resilience,” or the ability and flexibility to recover from setbacks, can add to the pressures people experience. “There is a persistent feeling that if you don’t recover as expected, it is your fault—mostly because you weren’t successful in being ‘resilient,’” Berríos Negrón says, adding that this can cause mental health to decline even further. Such expectations are a bit hard to take, she says, when “to this day, there are communities in Puerto Rico who have not received any resources or support and are still without power or water, which are basic necessities to maintain a healthy mental state.”
Building communities in metaphorical concentric circles, with connections rippling out from the individual to the infrastructure, can help ensure access to essentials such as power and water—and thus support physical and mental recovery from disasters, Bell says. That means such community building is important not only among the people in harm’s way but also at the state and national government levels.
How well people ride out a traumatic event such as a hurricane can be traced in part to the strength of their social connections. Being part of a caring and trusted community is what got Eaves’s parents rescued by airboat during Harvey. What matters is “how connected they are with people they trust and care about to support them in recovery or, at the community level, what community supports are in place,” Bell says. The supports can include faith-based organizations, services such as Meals on Wheels or resources that provide assistance for those navigating the daunting application process for federal emergency aid.
In the immediate aftermath of a disaster, a community needs a “sense of calm and stability to the extent that’s possible,” Lowe says. This means ensuring people have access to temporary but dependable living options, particularly being able to stay with family or friends. “Moving around a lot in the first couple of months is so disruptive that it tends to generate more stress and increase risk over the long term,” she says. Case managers should be available to support survivors in navigating support systems, Lowe adds. “There are so many logistical stressors and deadlines with insurance companies, and trying to get [federal] support can be extremely frustrating,” she says.
During and just after a disaster, more general types of community support can include measures ranging from setting up pet-friendly shelters to ensuring that disaster response teams include behavioral health professionals who can help during the acute phase of a disaster, Bell says. She first encountered pet-friendly shelters when she was deployed in support of evacuees during the 2018 Camp Fire that destroyed the small town of Paradise, Calif. “Pets are so important to people’s health and well-being,” she says.
In Puerto Rico, Ayala Rosado served as project coordinator at Aquí Nos Cuidamos, a series of public services campaigns intended to get the word out about mental health services and supports, including information sent via newsletters that can be useful before, during and after a disaster. The group works with “ambassadors” who serve as support and information nodes in their respective regions of Puerto Rico. “We are facing multiplied and interconnected public health crises,” Ayala Rosado says, and her group works to make tailored resources available to specific populations. “We have a guide, for example, for college students and how they can manage anxiety and stress.”
Making communities more resilient involves thinking ahead well before a disaster strikes or threatens. This includes “preparing to the extent that you have a game plan of where you would go and ideally who you’d stay with—because it’s better to stay in a place that’s comfortable and you know people than being with strangers and being unsafe,” Lowe says. Bell agrees that building community is best done early. “We always say in disaster response that you want to be building those relationships on blue sky days—so that when it’s not a blue sky day, you have those relationships in place.”