This story is the first in a series we are publishing in collaboration with the Center for Public Integrity, Columbia Journalism Investigations, California Health Report, and newsrooms across the country, in which we asked people affected by hurricanes, floods and wildfires — and the professionals helping such survivors — to share their experiences in an online survey, which you can fill out here. Read more about the project here.
Erin Bennett couldn’t sleep.
For months, the nurse and mother of two from Kelseyville had been on constant alert. Three times that summer, she and her family had fled their home as wildfires — including the monstrous 2018 Mendocino Complex Fire — threatened to engulf their small community. On the most recent occasion, she’d opened her front door to a wall of white smoke from a brush fire sparked accidentally by a neighbor using a power tool. Her husband, a real estate agent, worked with local firefighters into the night to fight back the blaze.
Now, Bennett couldn’t close her eyes for more than an hour at a time. Throughout the night, she’d jump out of bed and throw open the window, looking for signs of flames in the distance, sniffing the air for wildfire smoke. Then she’d hurry over to check on her kids, ages 6 and 8, asleep in their bedrooms.
“The repetitive fires … the fear that came with gathering your belongings and leaving because you’re no longer safe — that was the beginning of the PTSD,” she said. “My body was in this constant state of shock and reaction … I started to devolve.”
Emotional distress is common following natural disasters, and the psychological toll can linger for years, studies suggest. In California, where the state is in the midst of yet another highly destructive wildfire season, published research on the prevalence of mental health impacts among wildfire survivors in the state is scarce. However, a preliminary study by researchers at UC Davis found that around one in five people reported significant symptoms of anxiety and post-traumatic stress up to 10 months after the 2017 North Bay wildfires. The region is once again under siege as firefighters struggle to contain more than 600 fires across the state — including in Lake County where Bennett lives — raising the likelihood of further mental anguish for those affected.
Wildfires, along with other natural disasters such as hurricanes and floods, are intensifying as climate change accelerates. Already, the U.S. has faced nearly 40 such events costing at least a billion dollars each in the past decade, more than any period previously recorded. Mental health experts worry the psychological toll from these increasingly common cataclysms — with a pandemic now overlaid on top — could be unprecedented.
The nation isn’t ready.
The country’s primary aid for mental health after disasters is the Crisis Counseling Assistance and Training Program, run by the Federal Emergency Management Agency and the Substance Abuse and Mental Health Services Administration. Every year, the program distributes an average of $24 million, or 1 percent of FEMA’s annual total relief fund, to send mental-health workers into disaster-stricken communities and provide other support. But the Center for Public Integrity and Columbia Journalism Investigations found that this help usually lasts about a year, even though the psychological effects can linger for many more, and reaches only a fraction of survivors.
After Hurricane Maria struck Puerto Rico, for instance, 18 percent of the island received counseling paid for by the program even though many more were affected. In Houston, where Harvey’s flooding was widespread, less than 1 percent of residents saw counseling.
The FEMA-funded program has given out $867 million nationwide in its more than three decades of existence — just slightly more than the money one Defense Department agency lost track of in a single year.
Long after the fires, anxiety can linger
Studies show other forms of federal assistance, like housing aid, are distributed unevenly, exacerbating inequalities and drawing out recovery for communities of color and people with less money. This, in turn, compounds the trauma and emotional burdens of a disaster.
The Substance Abuse and Mental Health Services Administration referred questions to FEMA, which funds the effort. FEMA said its program, often shortened to CCP, provided counseling to 1.4 million people in the past five years and gave brief help to several million more.
“The toll that disasters put on mental health is well documented and part of the reason FEMA funds the CCP,” a spokesperson wrote in an email. The program, however, “exists to supplement, not supplant, state, local, tribal, and/or territorial resources.”
In California, counties play a larger role in providing mental health care after disasters than in many other states, and some wildfires don’t qualify for FEMA funding to help survivors. California counties are required by state law to provide mental health services in the wake of a wildfire or other emergency event, but only to the extent their resources allow. Many poorer, rural counties – which are often those most impacted by wildfires – just don’t have the money or resources to provide this type of mental health assistance, said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.
“The ability to be organized and have an organized response is very localized,” she said. “There’s really no guidance from the state of California about what this (mental health) response should look like.”
Yet more Americans are affected by climate-driven disasters every year, with serious emotional consequences. Even with FEMA aid, state and local resources aren’t enough.
Public Integrity, CJI, California Health Report, The Mendocino Voice, and newsrooms across the country asked people affected by hurricanes, floods and wildfires — and the professionals helping such survivors — to share their experiences. More than 230 responded to the online survey, most from regions repeatedly hit by disasters in the last decade. That ranged from Puerto Rico, struck by seven major storms, to some Northern California communities fighting wildfires every year.
Seventy percent of the survivors said they did not get mental-health services after their experience, for reasons ranging from cost to their belief that they didn’t need help. But 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 percent of survivors reported five or more types of emotional challenges in the first year after the disaster.
In Magalia, California, Mickey Dukes, 65, lost her job as a medical technologist when the 2018 Camp Fire — the state’s deadliest and most destructive wildfire — burned through her town. The hospital where she worked closed and many of her friends moved away. “The feeling of loneliness is overwhelming,” said Dukes, but “we don’t really have very good mental-health services.”
Don Allcock, 70, wrestled with crippling anxiety for more than a year after he and his wife lost their Santa Rosa home and all their possessions in the 2017 Tubbs Fire. FEMA offered the couple financial assistance but no mental health support, he said. For 15 months Allcock said he tried to suppress his anxiety, convinced he could muscle through. Men don’t go to counseling, he thought. But “there was that lingering thing in there like a thorn in your foot that just won’t go away,” he said. Eventually he was able to enroll in therapy through Medicare.
In Naguabo, Puerto Rico, Jonathan Alverio Rivera started having flashbacks after Maria slammed into the island in 2017. He lost power for three months, reliving the terror in the dark. Alverio Rivera, now a 29-year-old medical student, says he needed mental-health aid but couldn’t find any. “I didn’t see any ads or anything saying, ‘If you need help, call this number,’” he said.
And in the rural Midwest, where those services are often spare to nonexistent, punishing floods in recent years have sowed trauma. Sharon Stewart’s community of Pacific Junction, Iowa, was largely wiped out by 2019 flooding. “We’ve had a really, really, really rough year since then,” she said. “There’s so many people that went through so much.”
Irva Hertz-Picciotto, director of the Environmental Health Sciences Core Center at UC Davis, who is overseeing the research on the mental health impacts of the North Bay wildfires and now other wildfires, said she hopes it will help health and government officials better meet the mental health needs of those affected by these disasters. These include people choking on smoke-clogged air, those forced to evacuate, and residents who lose homes or family members.
“There are real needs that people have for mental health services,” she said. “It’s not their weakness that they’re overwhelmed. The circumstances really are traumatic.”
Constantly on the run
As scientists warn that the warming climate will keep adding fuel to extreme heat, droughts and wildfires, California is a bellwether. Ten of the state’s most destructive wildfires have occurred in the past five years, and 2020 looks likely to set new records. One of the grimmest fire years was 2018. That’s when the Camp Fire burned more than 150,000 acres in Butte County, destroying the town of Paradise and killing 85 people. Thousands more were displaced. That same November, the Woolsey Fire swept through 97,000 acres in Ventura and Los Angeles counties burning 1,500 structures and prompting the evacuation of more than 250,000 people.
Meanwhile, the Mendocino Complex Fires roared across almost 460,000 acres in Colusa, Lake, Mendocino and Glenn counties in July, 2018, becoming the largest wildfire in California history.
That was the year Bennett and her family experienced five wildfires in a row. It came on the heels of three unusually active wildfire seasons, starting with the Valley fire in 2015 in which several of her friends lost their homes.
By 2018, Bennett felt like she was constantly on the run from fires. She and her husband didn’t even bother to unpack their belongings from the RV anymore, certain it was only a matter of time before they’d have to evacuate again.
Bennett kept going to work at Sutter Lakeside Hospital in Lakeport, but she felt herself starting to unravel. Her normal, happy self was gone. In its place was a frazzled, sleep-deprived woman who looked like she was about to cry.
“I was constantly on edge. I had given up coffee because I just couldn’t handle any more heart palpitations,” she said. “My biggest fear was I was going to be at work taking care of patients, and something was going to happen, and my husband was going to have to evacuate our home.”
It didn’t occur to Bennett to ask for help. After all, everyone else around her had gone through the fires as well, and some had lost their homes. Surely her suffering, she thought, paled in comparison.
A small amount of help
FEMA’s Crisis Counseling Program was made for survivors of these types of large-scale natural disasters. But many say they haven’t received support.
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 last 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.
Though disasters always impact mental health, states don’t automatically get the funding. Wildfires often aren’t deemed large enough to qualify, despite the widespread devastation they can cause. A 2019 federal report noted that “wildfire disasters are generally a small proportion of the major disaster declarations FEMA supports,” but suggested that climate change may amp up needs as wildfires worsen.
When events do pass the magic 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 only receive assistance 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 for 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.
‘A constant state of disaster response’
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,” Cabrera said.
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, CJI and partner newsrooms, a third were still reporting five or more types of emotional struggles today — at least three years post-disaster, in many cases. Though people across the country participated, the survey isn’t nationally representative, and it may have drawn respondents who are more affected by disasters than average.
But this finding echoes earlier research: Epidemiological studies found emotional disturbances three years after Superstorm Sandy in 2012. One study of low-income mothers affected by Hurricane Katrina in 2005 discovered one in six with 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 CJI reviewed the 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 to 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 percent of residents applied for FEMA financial aid — one indication of how many people were affected — and only 7 percent received counseling sessions.
Not enough aid to communities of color
California has relied on CCP for more than 30 disasters, second only to Texas. Yet a review of its response to 2018’s Camp fire in Butte County and Woolsey fire in Ventura County shows that even there, only a limited number of survivors were reached by the federally funded counseling program.
In Butte County after the Camp Fire, 15 percent of residents received counseling paid for by the CCP. In Ventura County, where the Woolsey Fire’s destruction was widespread, just 77 people saw counseling.
The state was awarded $3.2 million for CCP response to Camp and Woolsey.
Following the Mendocino Complex Fire, 22 percent of residents received some form of group counseling or public mental health education, although just 118 people — less than 6 percent of the population — received individual counseling, FEMA data shows. The proportion was much higher in Shasta County following the 2018 Carr Fire, where more than a third of residents got individual mental health support.
In some cases, communities of color received less mental health support, data shows. In Butte County, for example, which has a 17 percent Hispanic population, counselors reported that only 8 percent of those receiving individual counseling through CCP were non-white Hispanics.
In the nine Houston ZIP codes with the highest per-capita share of FEMA applicants after Hurricane Harvey — all lower-income, majority Black and Hispanic areas — 1 percent 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 communities of color, 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 CJI’s 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.
Regarding the apparent disparities in Butte County in California, another FEMA spokesman said the agency does not base disaster assistance on race, color, sex, political affiliation, religion, national origin, age, disability, language proficiency, education level or economic status.
“To imply that FEMA does not or would not grant assistance to any survivor in need is grossly inaccurate, misleading and disturbing,” the agency said in a statement.
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 percent 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 percent in districts where a hurricane, flood, coastal storm or wildfire damaged property, according to a Public Integrity/CJI analysis of federal data.
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 percent 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 the fact that 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 percent. In the Fifth Ward, a majority-Black neighborhood, the rate of approval dropped to 15.5 percent. 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 percent 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 due 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, including California, 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 hurricanes, floods and wildfires, the coronavirus represents yet another weight. About three-quarters of those who took the Public Integrity/CJI 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 percent 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.”
Using data from FEMA and the Centers for Disease Control and Prevention, Public Integrity and CJI identified 178 U.S. counties or municipalities predisposed to disaster-driven mental illness, including Lake County in California. All have vulnerable populations that were hit by multiple, property-damaging hurricanes, floods or wildfires in the last 10 years. At least a quarter of those places have poor access to psychological care, according to County Health Rankings.
Evacuation plans, again
Lake County is one of the poorest counties in California and ranks at the bottom when it comes to health. After the spate of wildfires in 2018, Bennett said multiple patients arrived at her hospital suffering from mental distress and its effects – insomnia, inability to properly care for themselves, increased drug and alcohol abuse, domestic violence. Although some emergency mental health care was available in the community for people evacuated and displaced from their homes, services dwindled soon after the disaster, she said.
Three weeks after Bennett faced the blaze right outside her home, she arrived at work with numb arms and chest pain. A coworker wheeled her over to her hospital’s emergency room. Although she thankfully wasn’t having a heart attack, lab results showed Bennett’s stress hormone levels were so high she was on the verge of developing a serious condition known as Cushing’s disease.
Unlike many of her patients, Bennett had access to good health insurance through her work and as a health care professional she understood how to obtain mental health treatment. She received two sessions of cognitive behavioral therapy followed by several weeks of Eye Movement Desensitization and Reprocessing therapy.
“I started feeling human again,” she said. “I didn’t feel like a scared animal who was fleeing for my life.”
At night, she was finally able to sleep.
But on Monday, Bennett and her family were once again making preparations to evacuate should the giant LNU Complex Fire — now the second largest in California’s history — move closer to their home. (LNU stands for Cal Fire’s Sonoma-Lake-Napa Unit.) The fire was burning in southern Lake County, and had not reached Kelseyville, as of Monday afternoon. Still, Bennett said she could see fire plumes to the north, south and east of her house. The air was heavy with smoke.
Bennett said she could feel the stress hormones pumping through her body again. But she also felt mentally stronger than after the 2018 fires, thanks to the therapy.
“This time I’m more prepared,” she said.
Kio Herrera and Chris Zubak-Skees contributed to this article. Dean Russell is a reporting fellow for Columbia Journalism Investigations, an investigative reporting unit at the Columbia Journalism School. Funding for CJI comes from the school’s Investigative Reporting Resource and the Energy Foundation. Jamie Smith Hopkins is a senior reporter with the Center for Public Integrity, a nonprofit investigative newsroom in Washington, D.C.