This story is a partnership between Inside Climate News and Honolulu Civil Beat.

Nancy Sidun has been counseling disaster survivors at a state-run mental health clinic in Lahaina, Hawaii, since just after the devastating wildfires in August 2023. Now, it’s her last week—and she wishes it hadn’t come to this.

For two and a half years, she and other clinic staff have served Maui residents dealing with displacement, grief, depression, anxiety, suicidal ideation and more, an ongoing mental health crisis. But Sidun and her colleagues have faced their own stress and anxiety over their jobs for months.

Counselors and caseworkers at the clinic are on temporary contracts that had been slated to end this week. Last fall, Hawaii’s Department of Health told them to apply for permanent state positions. But after months of what some described as shifting messaging and unanswered questions, they found out last week that their contracts had been extended for another six months without explanation.

This upheaval, which three of the staffers described in interviews and documented with emails and text messages, played out as some colleagues took big pay cuts.

“I’m very proud of our state trying to take care of our survivors,” said Sidun, a psychologist. “Unfortunately, they’ve done a very poor job taking care of their providers.”

When Sidun found out that part-timers like herself might not be eligible for state positions, she reached out to the Department of Health for clarity but said she received no response for months. Worried her job might end abruptly and her patients would be left without help, she decided to leave the clinic for private practice, taking as many of her patients with her as she could. That has brought insurance complications and stress for everyone involved.

“It’s really been quite anxiety-provoking, both for the patients and myself,” Sidun said.

The state Department of Health, which runs the Maui County Certified Community Behavioral Health Clinic with federal funding, confirmed that staffers’ contracts were extended for six months. An agency spokesperson wrote in an emailed statement that the department “remains committed to ensuring continuity of care for Maui residents, including those impacted by the wildfires, and will continue working closely with partners to support a stable and sustainable behavioral health workforce.”

The agency said its approach has been informed by community input.

“Creating new positions takes more time and strategic planning than simply filling existing positions, but the result should be a solid, sustainable base for long-term recovery,” the agency wrote.

One week before the contract extension was announced, Trever Davis, the Maui behavioral health wildfire response project director at the agency, told Inside Climate News that he was aware of staff concerns.

“There has been some concern because that April 2nd date has been looming, and I think there’s just some worry about that, but it’s getting taken care of with the state positions, and anything else that we need to do contract-wise is going to get worked out,” Davis said.

About 40 people work at the two Maui clinics. Although Davis said the department is working to transition them to state positions with benefits and expressed confidence that full-time staff would be kept on, he was not sure what will happen to the handful of part-timers. They will not be eligible for state positions, Davis said; some may be covered by grant funding.

“We’re just kind of working that through case by case,” Davis said.

The disruption is an example of the challenges facing states as climate change amps up major disasters. Interventions for public health, including mental health, are an often overlooked but crucial part of recovery.

The two clinic locations on Maui offer free services to all residents. According to the Department of Health, they have provided ongoing mental health services to more than 1,800 people over the past year alone.

“These services were created through the work of the dedicated professionals and DOH’s commitment to the Maui recovery,” a department spokesperson wrote in an email. “We wish to continue this work by building sustainable, high-quality programs that will help for as long as they are needed.”

The initial development of the Maui clinic was funded by a federal grant in 2022, and the state planned to begin operations in 2024. Then the fires hit in August 2023. Hawaii moved fast to open the Lahaina location that month and the Kahului clinic in January, both ahead of schedule.

That was the initial reason for temporary contracts: The health department wanted to get therapy and case management staff already doing emergency-response work on the ground—sometimes as volunteers—into the clinic as quickly as possible, Davis said.

The transition to the next phase is where things got bumpy.

When Sidun received her contract extension on March 25, she said she was told it would come with stipulations, including a requirement to take on new patients and a minimum number of weekly hours, but she wasn’t told the specifics of those requirements.

“I think it’s just horrific,” Sidun said. “A week before the contract is finished, they’re coming back and saying they’re extending it with stipulations, but they can’t tell you what the stipulations are other than the broad category?”

A spokesperson for the Department of Health wrote in an email that part-time staffing was always intended to be temporary, and that the priority is to hire full-time, on-island staff. Part-time staffers continuing under the new contract extension have been asked to meet some of the same requirements as full-time staff to improve timeliness and monitoring of case loads, the agency added.

“We expect this will result in higher quality of care and long-term sustainability,” the agency wrote.

Christopher Knightsbridge, a full-time mental health provider at the clinic, put in his two-week notice last week. Like other staffers, he described local clinic leadership as excellent, but the Department of Health’s handling of the contracts was too much for him to bear. He’ll be moving to Maui Healing, a group practice focused on culturally responsive therapy.

Knightsbridge has more than 100 wildfire survivors on his patient caseload, about half of whom are active, he said. Like Sidun, he’s taking any patients who want to follow him, but he said the uncertainty around the contract has been a major source of stress and frustration.

Knightsbridge’s patients are still dealing with displacement, trauma, job loss and, in some cases, severe mental illness tied to the fires. The recent weather also took an emotional toll, he said. Back-to-back Kona low storms, a seasonal subtropical weather system, set off the worst flooding the state has seen in decades. In Lahaina, floodwaters swept along the burn scars of the 2023 fires.

“My patients traumatized by fire are now traumatized by water,” Knightsbridge wrote to Inside Climate News. “They cant catch a freaking break.”

Unanswered Questions

Sidun’s mounting frustration is clear in her emails to the Department of Health, which she shared with Inside Climate News.

“Given that more than a month has passed, I feel it is important to respectfully note that I do deserve a reply,” Sidun wrote to Davis after the winter holidays, following up on an email she sent Nov. 24.

“The issues I raised are significant and time sensitive,” she continued. “They directly affect my ability to continue providing ethical, consistent care to Lahaina wildfire survivors—a community I have served continuously since the week following the August 2023 fire.”

Knightsbridge said he also reached out to the agency multiple times since January, with no response.

Davis said he’s been in regular contact with the clinic site supervisors and said he isn’t aware that staff messages went unanswered.

“I can understand a perception that they’re not getting the information they’re looking for, but I’m concerned to hear they’re saying they’re not getting responded to, because I don’t feel like that’s accurate,” Davis said. “That doesn’t align with my experience of it.”

Davis sent a group email to clinic staff on Feb. 13 saying that the department intended to move quickly to finalize state positions. But a month later the contracts were simply extended, and staff told Inside Climate News that they still have no update on the state jobs.

A Department of Health spokesperson wrote in an email that the agency updates staff regularly.

“As we have provided updates, we have tried to avoid giving timelines, as we are not in full control of the hiring process,” the spokesperson wrote.

The uncertainty was made more challenging by pay cuts in November for some roles, including both Knightsbridge’s and Sidun’s.

The Department of Health said some pay cuts occurred to align staff salaries with state rates, but the majority of staff maintained their rates.

Matthew Prentiss, a case manager at the clinic, said the six-month extension last week, after months of not knowing whether his job would be secure, was bittersweet. He’d applied to the state for a permanent position when the option came up last fall, but like his colleagues, he still hasn’t heard back.

“This whole thing has been weighing on all of us for a very long time now,” Prentiss said. “Finally, they said we have an update, and the update really isn’t much of an update.”

Since the fires, Prentiss has been a case manager, an expansive role in a community in crisis. He’s helped survivors move, get to doctor’s appointments, navigate complicated state and federal housing programs and more. A few weeks ago, he designed safety plans for six wildfire survivors experiencing suicidal ideation, he said.

He’s happy the contract extension lets him continue serving survivors. “My people aren’t finished recovering,” he said.

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Still, he is now coming up on three years without a raise, paid time off or sick leave, Prentiss said. Doctor’s appointments, the flu, his six-day hospitalization for a heart condition: Each lost him wages.

Learning From Maui

After the fires in 2023, people on Maui mobilized rapidly to help their neighbors.

“There was no red tape holding us back from helping everybody,” said Kainoa Correa, a licensed clinical social worker at Maui Healing. “It was all hands on deck.”

External aid to disaster-struck communities inevitably slows over time. But the needs in Lahaina remain acute.

“They’re still struggling with the loss and the grief and the pain,” Correa said.

About half of Maui’s wildfire survivors have experienced depression since the disaster, often tied to an ongoing lack of housing and employment, according to research from the University of Hawaii. Strong winds and tsunami warnings are scary triggers for the many here with post-traumatic stress disorder, Correa said, and loneliness and isolation are rampant.

Compounding that, Maui faces a shortage of mental health providers, part of the broader provider shortage suffered by the entire state. Marion Hart, the office and billing administrator at Maui Healing, said that waitlists for therapy at private practices can often be six to 10 months long.

Having continuity of care and local therapists who understand cultural nuances is especially important, Correa said.

Today, Sidun has nine wildfire-survivor patients, most over 70 years old, eight of whom lost their homes in the fires and one who had to evacuate from a workplace in the burn zone. Several have needed cancer treatment since the fires while dealing with the relentless upheaval of multiple moves between temporary housing. All have lost community and stability, and most do not have family nearby, she said.

One of her patients can’t switch insurance to continue seeing her, Sidun said, and although the patient will likely be referred to another provider at the clinic, Sidun said it’s unclear when the transition will occur.

The situation illustrates how crises compound: provider shortages, insurance struggles and climate disasters intersecting to leave survivors without options.

Davis, with the health department, said the clinic will fill staffing gaps left by part-time staff that the state can’t keep on. Recovery will take years, so setting up enduring systems is crucial, he added.

“I think for the long term, when we look at sustainability, there’s still some more work that we need to do to make sure that it lasts,” Davis added, speaking of clinic funding.

State Rep. Della Au Belatti of Oahu said Hawaii has learned crucial lessons on disaster preparedness and response from Maui. Among them: Get mental health resources on the ground immediately and connect survivors with people who can help navigate the disaster-help bureaucracy. That’s playing out on Oahu now, as Waialua on the island’s North Shore deals with devastating floods triggered by the Kona lows.

“We’re seeing increasing frequencies of these kinds of unusual weather patterns that are going to become more and more usual,” said Belatti, a Democrat, pointing to climate change. “We need to deal with it, as government.”

Part of that is focusing on mental health. Belatti said she applauds the Department of Health for its efforts to sustain the Maui clinic system, but she called the job upheaval “very disconcerting.”

“My hope would be that the Department of Health really gets its act together and not string along the contractors who have already been doing the work and earning the trust of the community,” she said.