Orlando, Florida-based therapist Janera Echeverría was not surprised to see an upsurge in the number of Hurricane Maria refugees arriving from the island seeking treatment for anxiety, depression, and stress. After any disaster, the counselor explained, it's par for the course. In the area, groups and agencies are helping provide services to those who fled the monster storm and its devastating aftermath.
"Even if you were unharmed and your house was okay, living an experience like this is emotionally traumatizing," said Echeverría of the hurricane that hit Puerto Rico on September 20th. "In one way or another, after a disaster — manmade or natural — it is expected that people will suffer some kind of post traumatic stress."
However, what has alarmed Echeverría, a twenty year veteran in the field of mental health, is how deeply the hurricane's aftermath has hit islanders who live outside of Puerto Rico.
"I have a client, a 60-year-old grandmother, who stopped eating because she feels guilty that members of her family might be going hungry," Echeverria said. "I have another client, a woman in her 40's, who is sleeping on the floor because she says that her sisters lost everything so she is in some form of solidarity with them. She has a perfectly comfortable bed but prefers to suffer and sleep on the cold concrete floor -it's a form of flagellation."
These reactions may seem illogical to some, but for people who are not mentally resilient, it's the only way they know how to cope with stress. Technically it's a form of survivor's guilt, she explained.
"They say things like, "if my sister lost everything, I just can't be living comfortably here," she said.
Nearly sixty days after the category five storm landed, millions are still without electricity and desperate for basic necessities such as warm food, water, and shelter. In Echeverría's downtown Orlando practice, she has begun seeing the toll such images are taking on the mental health of Central Floridians.
"We're feeling all kinds of emotions," she said. "It's difficult to see any human suffering, but when it's your cousin, aunt, and extended community, it hits you more directly."
Echeverría, who was born and raised in the western Puerto Rican town of San Germán, has seen the strain in her inner circle. Discussions around the dinner table revolve around the latest news from the island. Family members and friends discuss having trouble sleeping, experiencing fears about the future of the island, sadness, and some, say they are unable to fully focus as they watch the latest news and hear from family members having a rough time.
The most vulnerable populations after disasters are children, who don't have the capacity to understand the scope of the devastation. Echevarría also sees it in women, mostly mothers and grandmothers, who suffer doubly because they are not on the island to do what Puerto Rican mothers do best — nurture their loved ones.
Brain experts say that even witnessing images destruction from afar, such as scenes of strangers' lives ruined, wound the brain. But if it's extended family, the wound is deeper.
According to U.S Census figures, there are 5.4 million Puerto Ricans living in the 50 states. Migration has increased by the hundreds of thousands in the last decade due to an unrelenting recession that began in 2006. In 2015 alone, Census numbers show that 89,000 islanders migrated to Texas, Pennsylvania, Ohio,and Connecticut.
Florida, which already had one million Puerto Ricans, received the bulk of the migrants. In the last decade alone, Central Florida has received more Puerto Rican nationals than any other region in the country, according to local government figures. In 2015, nearly 56,000 islanders moved to the Orlando area. In 2016, the numbers shot up to 89,000.
Since Hurricane Maria, about 139,000 Puerto Ricans have arrived in Florida, according to state figures, at least for temporary lodging while the island grapples with a lack of basic necessities.
But hundreds of thousands of Floridians have called the Sunshine State home all their lives and have close relatives on the island and closely follow news of the relief and recovery efforts. For them, the hurricane is very personal.
"This is a community that has been doubly hit with two back-to-back major disasters," said Nancy Rosado, 60, a retired NYPD sergeant who moved to Central Florida ten years ago.
A year ago, a lone gunman opened fire in Pulse nightclub killing 49, and the majority of the victims were Puerto Ricans.
"It's like we recover from one tragedy only to be hit with another," said Rosado.
Rosado is a veteran of disasters. She was in charge of a mental health unit helping NYPD officers cope with the aftermath of 911. She was already in Florida when the nightclub massacre happened.
"I am a first responder by nature and by training," she said.
During the massacre, Rosado said she that she helped provide culturally competent training for local officials. Everyone grieves and mourns differently and Puerto Ricans are no exception.
"It was important to let officials understand that culturally, we see loss and grieve in a unique way. Our language is different, even the forms of mourning expressions are unique," she explained.
This time around, Rosado said she took a step back from the disaster, because she said that "even those trained to help others are also affected."
Rosado, who was born and raised in the Bronx, decided to travel to the Caribbean island of her parents' birth to distribute goods. She said being on the ground has helped her tremendously.
"You get to directly touch lives," she said. "Even a hug in times of stress is just as important as a meal."
Rosado is planning a second trip in December and is in the middle of collecting funds to buy solar lights.
"Island life is very stressful now," she said. "The darkness is driving people mad, not to mention the hard and loud sounds of generators running all night that keeping people from a good night's rest. And then she said, "there's burning diesel—the smell of diesel is disgusting."
Experts say that directly helping others is one of the ways to cope with stress. Another way is to take a break from the news cycle, as images do cause harm and humans are not built to take in so much suffering at once.
One of the most important ways to handle stress is to talk about it.
"It's important to recognize the feelings," Rosado explained. She said for cops it was vital to talk about what they witnessed with friends and family, and in many cases, with professionals.
"For Puerto Ricans, therapy is not the norm," the mental health professional explained. "We are used to staying in the family. But this is something catastrophic and we have to be able to open up. My suggestion is that if you feel like you can't handle seeing so much loss, to get help from a culturally competent professional."
"It's important for anyone suffering from afar to now that they are not alone," said Rosado. "Others are feeling the same way."