MONTEVERDE, COSTA RICA — The kids are, most decidedly, not OK. 

Costa Rica ranked first on the Happy Planet Index in 2021. But for Sati Alfaro Navarro, 15, this ranking falsely represents Ticos’ true happiness. Alfaro said Costa Rican culture means avoiding difficult but vital conversations about mental health to preserve false societal perceptions. 

“Everybody wants ‘perfect,’” Alfaro said. “And in a sense if it’s not perfect, then it doesn’t exist.”

The insidiousness of mental illness is how its lack of physical symptoms makes it “invisible.” Dr. Adania Martinez Safrián is a licensed psychologist. She provides care in the Monteverde, Jaco, Quepos and Chomes areas when a clinic’s primary psychologist is away. During the week of Semana Santa she worked at Santa Elena’s public clinic. Dr. Safrián said if people are unwell on an emotional level, it will also affect their physical wellness. Brailyn Brenes Solano, 17, said physical pain typically receives more attention than mental anguish.

“Let's say, if you are sick, I can notice that you are physically sick,” Brenes said. “We would say mental health — we would say intellectual, emotional health — it is something that is not seen, and I think that this idea has been formed that if it is not seen, it is not something that we have to give importance to.”

Additionally, Monteverde lacks free, centralized places for young people to hang out. As much as Jackson Smith, 16, hates to admit it, he said lots of his peers “just do drugs all the time, party every night” while others stay inside all day. Dr. Safrián said child abuse, eating disorders and people’s use of illicit substances are Monteverde’s three primary mental health problems. 

A receptionist at Santa Elena’s public clinic estimated wait times for psychological consultations range from 15 days to two months. Although the Ministerio de Educación Pública, the Patronato Nacional de la Infancia and the Instituto Nacional de las Mujeres provide some additional support for patients, residents may have to go to Puntarenas to access these resources. Further, people who want a private psychologist must travel out of town or rely on virtual options. 

“Obviously there are many people who find it difficult to travel to Puntarenas due to the economy,” Dr. Safrián said. “It does seem very important to me that perhaps at the local level we [better] promote … the consolidation of these organizations.”

Monteverde’s economy depends on tourism, which some residents view as a factor for why the area lacks spaces for young people to spend time. Alfaro said if tourists don’t demand change, then there’s no incentive for the municipality to invest in mental health resources or community infrastructure. 

All the while adolescents’ mental health continues to fracture. 

Despite Monteverde’s flaws, María José Jiménez, 17, loves her town. She’s lived in both Monteverde and Nicoya and said young people in Monteverde can be “more free” since they can watch the sunset, chill with friends, get a job and walk alone without fear of being assaulted.

“I’m sacrificing my mental health [going to school in Nicoya], but I think this is something that would have happened when I got to college,” Jiménez said. “I’m just choosing to live this [a] few years before, I guess.”

Sometimes the world gets to be too much, and young adults may end up acting as peer-therapists, holding each other’s sanity together with metaphorical duct tape and chewing gum. In Dr. Safraín’s experience, it is common for adolescents to turn to peers before speaking with adults because “at this time their circle of friends is more important than their own family.” Smith said when he’s in “a really bad spot,” he’s more likely to talk to his friends before going to an adult for help, even though “older people have a lot more experience.” 

When the COVID-19 pandemic brought life to a stand-still, Smith’s mental wellness rapidly declined. Smith said he was inside on his computer all day, every day. He lacked the motivation to do online school and started feeling like there wasn’t any hope.

“It’s such a weird feeling to always feel like you’re going down. You feel like you’re just sinking, and no matter what you do you’re never going back,” Smith said. “I would wake up feeling like shit every single day, even if I had no reason to feel bad, right? That’s just what I thought was normal.”

Approximately 280 million people world-wide suffer from depression, according to the World Health Organization. Depression doesn’t mean someone can never be happy, Smith explained, but “there’s always this feeling [of judgment toward yourself] in the back of your head.” With the support of his friends, girlfriend and family, Smith took control of his own mental wellness. He still has his ups and downs, but when a down comes he no longer feels like he will fall forever.

“No one can guarantee that they can help, but they can at least be there,” Smith said, “and that’s a lot more than a lot of people do.”

With his guy friends, Smith said they sometimes have trouble with their mental health because they feel like they “can’t” or aren’t “supposed to” be emotionally vulnerable. Brenes has also noticed a “belief that men cannot talk about their feelings and emotions.” He said men are taught from a young age that they shouldn’t talk about how they feel and must instead be confident, strong leaders with no self-doubt.

“All people — regardless of gender, entity, orientation, religion — we are people of mind, soul and body,” Brenes said. “We are people who are constantly thinking and feeling, and socially we have been taught that these things are not talked about, that repressing an emotion [is normal]. … Everyone in this life has received a comment of, ‘Oh, don't cry; don't cry. You don't have to cry.’ So I question that so much because why can't I cry? Why can't we be human beings and be able to allow ourselves to feel that sadness?”

It is important to normalize feeling a variety of emotions, Dr. Safraín said, because “we all have problems [and] difficulties.” She said normalizing healthy emotional communication is a good place to start. For some people, family members may be their biggest source of love and encouragement, but Jiménez said others her age don’t have parental support. When Jiménez spoke with her parents about the problems she was having with obsessive-compulsive tendencies, there was a gap in understanding. 

“I told my mom, ‘Hey, Mom. I have OCD,’ and she was like, ‘Oh, that’s not real. That’s in your mind. That’s not real.’” Jimenez said of her OCD, which the Mayo Clinic described as a mental illness where one experiences “unwanted thoughts and fears” that lead to repetitive behaviors. “Well, it is. It’s actually in my mind, and it is actually real.”

Dr. Safrarín said simultaneously providing parents and children tools to handle mental health crises is extremely important. When parents work all day then come home tired, they may not be aware their child is suffering, local physician Dr. Kristinne Bellorín said. Once a child’s struggle appears on a parent’s radar, then the family can move forward together.

“I think, on behalf of the family, it could be not to want to recognize that there is a problem in the family,” Dr. Bellorín said. “And when they [have open conversations] and they realize there is a problem, they start allowing help.”

A variety of stigmas exist surrounding mental illness, especially when one seeks out professional help. In Jiménez’s experience some of these stereotypes include people from older generations saying, “When I was your age I didn’t have time to be anxious,” or, “When I was your age, those [kinds] of problems didn’t exist.” She also said some people will think individuals are exaggerating or lying about the severity of their anxiety or depression. Dr. Safarín is no stranger to these taboos. She said instead that for her some common misconceptions about therapy include people not healing, that it is only for “crazy” people, or that others will judge them for taking advantage of professional help. 

“[Psychotherapy] is not something without evidence. It is a science,” Dr. Safarín said. “I don't attend to any crazy person at all. I take care of people with problems because we all have problems. I take care of people here who have those problems and want to solve those problems.”

No two individuals’ experience with mental health is identical. Alfaro described their mental health journey as “going rafting without knowing how to swim” or “driving without knowing how a car works.” Monteverde’s limited resources means teens are left on their own to navigate the fast-moving waters and winding roads of young adulthood. 

“For a long time I felt really lonely and alone in every sense of the word,” Alfaro said. “For a long time I had a problem with food, so, like, I couldn’t eat at all. And I still feel guilty sometimes about eating, but it’s fine.”

Eating disorders are serious mental disorders characterized by disturbances in thoughts, behaviors and attitudes to “food, eating and body weight or shape,” according to the National Eating Disorders Collaboration. Alfaro’s relationship with food is improving—they’ve “learned the wondrous world of sushi and other foods”—but they remain aware of how the COVID-19 pandemic affected their generation’s mental wellness. Alfaro said they know students at Santa Elena’s public high school who frequently self-harm. When people self-medicate or self-harm, Alfaro said, it isn’t because they want attention or pity: they see it as the only option. 

Alfaro wants to talk about mental health in health classes and learn the warning signs of self-harm, as well as how it’s addictive and permanent. Nonsuicidal self-injury can be a precursor for suicidal behaviors, according to the American Academy of Pediatricas, so early identification and treatment helps prevent negative health outcomes. When patients feel depressed or anxious, Dr. Bellorín encourages them to look at their situation from a different point of view and remember how capable their bodies are of surviving and healing.

“[Educators] taught us to trust in governments, to trust in medicines and the treatment that the doctors give, but to trust yourself? They don’t teach you that,” Dr. Bellorín said. “That doesn’t exist.”

People rely on various coping mechanisms as they move through life. When Smith’s doing activities he enjoys — like skating, biking, gaming or art — his mental state improves. Additionally, by focusing on his hobbies and not his anxieties, Smith finds his flow: a state where he feels connected to himself and effortlessly in control. 

“At first I wanted to be really good at art,” Smith said, “but I think now that I’ve just gotten a lot more relaxed with it. I think that art is just a good way of releasing built up stuff, just releasing your creativity.”

In fact the American Public Health Association found creative expression has “significantly positive effects on health.” The American Psychological Association recommends routine exercise to treat mood disorders and anxiety. This year Jiménez is making time for her passion, classical ballet, which she did for eight years while living in Monteverde. When she can’t dance, however, she turns to one of her many other coping strategies.

“I really love watching sunsets,” Jiménez said. “I also love journaling. I love baking. I love cycling. I love exercising. Just like any physical thing, you know.”

Similarly, Brenes realized he could change habits that were harming him. In 2016, Brenes said he was relatively disconnected from technology, but in 2017 he started to use Instagram, YouTube and TikTok. It didn’t take long for him to notice the negative effects of constantly consuming superficial, dramatized content.

“There was a time when I felt that social networks were a competition where I had to show myself as always the best, as always the most perfect person, the most beautiful person,” Brenes said. “And when I saw the other people who were having what I perhaps interpreted as perfect and that I did not have it, that made me feel very envious and … [I had] emotions and feelings of anger, fear, anxiety, negative emotions. So of course I know what it's like to feel that your social networks go from being a friend to an enemy.”

Before the COVID-19 pandemic, Brenes said he wasn’t well-informed about mental health. Then, in 2020 and the beginning of 2021, he changed his social media consumption habits to emphasize self-education. Instead of passively scrolling on TikTok and Instagram, Brenes sought out pages and content creators from whom he could learn. 

“I would invite you first to recognize that you are perfect just the way you are, that you do not need anything that you are looking for outside. All the answers are with you,” Brenes said. “After that, very small changes can be to stop following accounts that do not make you feel good, or [asking yourself,] ‘Do I want to consume the content or information of this account?’”

For all the potential connectivity social networks provide, they also contribute to teens’ fear of missing out, poor sleep and increased loneliness. Dr. Bellorín said phones have become a go-to distraction, which allows young people to avoid interacting with one another.

Building and maintaining mental health is a slow and arduous process. But with consistent support and a personalized treatment plan, healing is possible. So far Jiménez, who started therapy earlier this year, has had two sessions with a psychologist. These appointments gave her a space to vent without burdening her friends or family. In addition to processing her emotions with a professional, she’s also learned better strategies to organize upcoming tasks so she isn’t overwhelmed.

“I feel that when I talk to family members or friends or people I love they’re just like, ‘Oh, my God, here she goes again.’ So I didn’t want to feel like this anymore,” Jiménez said. “So if I need to pay for someone to listen, for a professional to listen to me, then I’d rather do that.”

Jiménez’s family can afford her twice-monthly therapy, but she’s well aware not everyone has the same economic possibilities. Public health services in Monteverde are “quite saturated,” Dr. Safrain said, and COVID-19 patients receive priority because of the pandemic. She said to meet this heightened demand for care, some patients’ treatment had to be stopped, which brought their progress to a halt.

“Patients who have the possibility of seeking some private care would be ideal because, in my opinion, mental health cannot be postponed,” Dr. Safraín said.

In Jiménez’s experience, mental health isn’t linear. She compared it to Monteverde itself: full of twists, turns and unexpected potholes. As a psychotherapist, Dr. Safraín is well-versed in handling the ups and downs of the human mind. With the COVID-19 pandemic the clinic offers in-person and virtual therapeutic services. Some people prefer to have face-to-face conversations while others elect to to take advantage of these alternative options. Regardless of the medium, Dr. Safraín’s first priority is caring for her patients.

“For me, it is very important to commit to the patient at least for the time that I am here. … I do have a commitment to the patient, directly with the patient,” Dr. Safraín said. “For example, if a patient comes who is not scheduled and comes in crisis and needs my attention, for me there is no problem in attending him during my lunch hour or leaving later to give him that attention because … as a professional [I understand] that many times you can't say you feel bad one day or, 'I woke up wanting to feel bad.'"

Instead of mental health meaning someone’s happy constantly, Jiménez views it as having the ability to properly manage one’s emotions, time and relationships. For those seeking out non-psychotherapeutic mental support, a few options include reading self-help books or relying on peers, according to the UK-based mental health charity Mind. Alfaro said they can help themselves, but they still struggle to support their friends. 

“I genuinely want to help others and make sure people around me are OK too, and I don’t know how to do that,” Alfaro said. “But I will learn one day. It’ll be really fucking cool.”

As social creatures, people are built to help and support one another. When people take time to listen and can give advice, Smith said they generally feel good about themselves. To normalize vulnerability and encourage empathy, Smith pushes himself to have uncomfortable conversations about his mental health and personal struggles.

“There’s still a lot of stuff that’s hard for me to talk about,” Smith said, “but the more I do it, the more I can say it and the more open I become. I feel like I grow as a person.”

Looking to the future, Smith’s ideal Monteverde would be “a community that cares more about its people than tourism.” He wants there to be free, public spaces for people with different interests to meet and pursue hobbies together. 

But as Monteverde’s own mountain shows, socializing and green space alone can’t heal a community’s mental health. Dr. Safraín said she wishes there would be “more policy drives that directly prioritize mental health” at a national level so psychologists can give patients the time and attention they deserve. She also wants society to view mental health as a priority and allow professionals to work in different institutions to assist people of all ages. For Alfaro and their peers, it’s imperative Costa Ricans in Monteverde and across the country receive consistent access to diverse, high-quality, confidential mental health services. 

“You can ask for help,” Alfaro said. “You’re never alone on anything. There always has to be someone [who can help].”

Author's Note: The Monteverde News, the publication in which this story first published, no longer exists, so this story is no longer accessible online.