Amid the mental health crisis in Puerto Rico, using play, dance and other new solutions

By Anna Umpierre

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

Since Hurricane Mara hit the island in 2017, leaving parts of the island without power for up to a year and causing huge economic and health consequences, Puerto Ricans have faced a series of back-to-back emergencies: earthquakes, floods, the Covid-19 pandemic, and most recently, Hurricane Fiona .

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

But even before the hurricane, there were insufficient mental health providers, and an exodus of doctors and clinical therapists from the island occurred in its aftermath.

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

As clinicians struggle to meet the growing need, wait times for an appointment have lengthened — up to seven months in some cases. Even in their private practice, Martinez and her colleagues cannot accept new patients.

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

Over the past 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 address access gaps and provide targeted mental health services to vulnerable populations, projects include telepsychiatry sessions, school-based treatment programs, psychosocial support for patients with chronic illnesses, grief counseling, and counseling for communities struggling with violence.

“You Belong Here”

One of these groups is the Stefano Steenbakker Foundation, a non-profit organization providing grief counseling for bereaved families. The group was formed after the tragic death of a teenager killed in a carjacking, and the organization received mental health referrals from the state crisis hotline and the Puerto Rico Department of Justice. The founder of the organization – and Stefano’s mother – Zorimar Betancourt, explained that the foundation provides “psychological help, social work, support groups and healing seminars”.

With a $107,000 Direct Aid grant, the Stefano Steenbaker Foundation has expanded its range of services to include social workers, psychologists and thanatologists – who focus on the loss caused by death – as well as holding victim support groups of loss experiencing complex grief.

The foundation supplements the 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 support activities. “People are happy, they feel like family. They know we offer a safe space,” Betancourt said.

Tina Terado, a psychologist at the organization, said it provides a sense of belonging that separates it from traditional mental health services. “Validating their emotions and telling 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 about 500 people without specialized help in their grieving process and who wouldn’t have the tools they need to manage their loss in a healthy way.”

Time to play

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

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

Fundación Atención Atención received a $180,000 grant to implement their Time to Play initiative in 30 schools and communities in Puerto Rico. They use 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 “Playtime,” provides crisis management tools taught through song and play to children and their parents, as well as teachers and other adults in the schools and communities they serve .

Caonabo Canales, a child psychologist at 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 need to 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] we can’t manage and what strategies we can integrate to avoid it.”

He recalled when, days after the hurricane, the organization visited a community in the municipality of Yabucoa that had no water or electricity to run Playtime. “I got a boy who was no more than seven years old and every time he lost he became very aggressive. The effect Play Time had on him was incredible: he developed empathy, emotional management skills and adequate communication skills,” Canales said.

“We grow old because we stopped playing”

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

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

She had additional wisdom to offer the seniors her organization works with: “We need to help seniors remember that we don’t stop playing because we get old; we grow old because we have stopped playing. If we can figure that out, we’ll have happier kids.”

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