Virtualization of psychological emergency care in mental health in the COVID-19 pandemic

Abstract Objective The health and humanitarian emergency caused by the COVID-19 pandemic and the measures of physical distancing and social isolation adopted required new modes of care in mental health. This article aims to define the possibilities and challenges of virtualizing emergency care, specifically psychologist on duty service and psychological first aid. Method An integrative literature review was carried out from 2016 to 2021 in databases. Results A total of thirteen articles were selected, which culminated in the themes: emergency care practices in times of crisis; and implementation of virtualization with its potential and limits. Conclusion One can conclude that virtual care is a way to democratize access to mental health services, but this process has limitations. However, further studies are needed to increase the reach of virtual care in emergency mental health care, in order to allow maximization of the potential of this modality.

Psychological care in emergency mental health care is a topic that has become more prominent in recent decades, especially during crisis such as the current one caused by the Coronavirus Disease 2019 (COVID-19) pandemic (Faro et al., 2020), which demanded from health professionals quick ways to adapt to online interventions.In this article, we consider that psychological emergency care is configured in the following modalities: psychologist on duty service and Psychological First Aid (PFA), which is not an exclusive practice of psychologists (Conselho Federal de Psicologia, 2020; Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020aSaúde, , 2020b)).International studies on the virtualization of psychological care have been published since 1990.The literature on the subject describes that this modality was aimed at filling the gap of the geographical distance between health professionals and patients, as well as allowing the democratization of access to mental health care practices.The main demands met concerned: victims of natural disasters; preventing and combating suicide and patients diagnosed with post-traumatic stress disorder (Silva et al., 2015;Stoll et al., 2020).
With the advance of COVID-19 in Brazil, the Conselho Federal de Psicologia (Federal Council of Psychology) enacted Resolution nº.4/2020 dated March 26, 2020, which allows the provision of psychological services, including emergency services, by means of Information Technologies and Communication, after carrying out the "e-Psi Register".In this resolution, the articles that vetoed the psychologist from attending people and groups virtually in urgent, emergency and disaster situations were suspended, enabling psychologists to act in those situations to seek to minimize the psychological implications present in such frameworks (Conselho Federal de Psicologia, 2020).
In this emergency context, emphasis has been given to mental health as a way of effectively caring for people.Mental health is considered here according to Lancetti and Amarante (2012, p. 669) who define it based on its complexity of meanings, criticisms and ruptures, whose interest is in the person who has the disorder, seen in its entirety as a subject who "demands work, leisure, care, relationships and affections".In this connection, the forms of psychological care highlighted here, aim at acting on an emergency basis in mental health, as they aim to welcome those subjects in their most urgent demand.
One of these care practices in psychological care is the psychologist on duty service, which stands out as an emergency care to attend, in pre-established places, days and time, people who spontaneously seek the service based on an emerging or almost emergent demand experienced (Dutra, 2008;Moreira et al., 2021;Schmidt, 2015;Scorsolini-Comin, 2015;Tassinari & Durange, 2019).
The psychology of emergencies and disasters, another form of care in psychological care, seeks to reduce the impact and the psychological damage in the face of extreme situations, planning interventions articulated with the social context of the region.Within this modality, the PFA stand out, characterized by being a way of attending urgent demands.In such intervention, anyone can volunteer to offer this initial reception (International Federation of Red Cross and Red Crescent Societies, 2020; Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020a).
In this scenario, our study aims to identify, based on current publications, how emergency psychological care, psychologist on duty service and PFA have been performed virtually.

Method
This is an integrative literature review study on the virtualization of care in emergency psychological care.The guiding question of this review was "what has been produced in the literature on emergency psychological care and its relationship with care virtualization"?
The papers were retrieved from PubMed, Periódicos Eletrônicos de Psicologia (PePSIC, Electronic Journals of Psychology), American Psychological Association (APA), PsycNet portals and from the EBSCO platform, through combinations of keywords and their equivalent in English and Portuguese: psychologist on duty, emergencies and disasters, psychological first aid, virtualization and online; based on the Boolean operators "AND" and "OR", aiming to expand the search.
As for the search strategy, the following items were included: 1) articles that contained at least one of the keywords in their titles, abstracts or keywords; 2) research aimed at the virtualization of care in emergency mental health care in psychology; 3) surveys carried out between 2016-2021; 4) written in English or Portuguese.Literature reviews, letters to the editors, book chapters, documentaries, films and any material that was not a primary source were excluded.
In the data retrieved, the following information was gathered from the selected articles: title; authors; country; year of publication; language; journal title; objective, method and results.To establish the final number of articles for review, as shown in Figure 1, two reviewers in parallel evaluated the articles based on the established criteria, following the guidelines and research structure indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).

Results
The search in the databases using the keywords previously informed, yielded 328 articles: PubMed (87.20%),EBSCO (9.45%), APA (3.05%), PePSIC (0.30%).After deduplication, a total of 317 articles were left.Using the search criteria and after reading the abstracts, titles and keywords, we excluded 195 articles, resulting in 122 articles screened.After reading all the surveys, we excluded care practices.Thus, at the end of the process we had selected 13 articles for final review, one from Brazil, written in Portuguese; and the others from different countries, all published in English.
The studies reviewed applied the qualitative approach as a research method in order to investigate the relationship between the use of information technologies and the quality of life of patients treated in emergencies, within the framework of COVID-19.Although data collection aimed to search for articles written between 2016 and 2021, all findings at the time of our research dated from 2020.Table 1 shows the articles used in our research.The findings indicated that the emergency care practices defined in this investigation appeared as highly relevant interventions in the pandemic framework.It was possible to recognize, in the analysis of the selected articles, that the psychologist on duty seems to be a typically national theme, not occurring in the foreign literature surveyed.The PFA, on the other hand, appeared frequently in international articles and were briefly mentioned in the article on the psychologist on duty service, without further in-depth details.
In the US, the literature points out that the level of citizens suffering due to the COVID-19 pandemic was very intense, bringing impacts to mental health such as anxiety, depression and post-traumatic stress (Park et al., 2021); it is thus indicated to seek forms of psychological intervention during the crisis (Feinstein, 2021).Thus, an intervention that proved to be very prominent in this context was constituted by the PFA, used as a means of establishing social support networks (Barbarin et al., 2021;Saltzman, 2020).In addition, the literature highlights the importance of psychological care for health professionals who work on the front line against the virus, given the need for preparation and protection to deal with unhealthy activities in the pandemic framework (Plasse, 2020).In Canada, the development of an online platform and its importance were highlighted.The objectives were to facilitate the registration of patients who urgently needed psychological care, identify the demands of each user and develop faster intervention strategies (Krausz et al, 2020).An example of the implementation of these services was the use of an online platform where patients, in crisis due to alcoholism or other drugs, can contact psychologists through text messages to ask for help for them not to relapse (Agyapong et al., 2020).
In the United Kingdom, for the implementation of virtual emergency care services, some aspects were considered essential, such as initial political support, continuous training of volunteers, promotion of services and the academic curricula of psychologists with courses associated with mental health in a virtual context (Arenliu et al., 2020).Regarding the benefits of using Information Technologies and Communication in emergency mental health care, studies show that it is possible to create support spaces in which people can find connections; develop new relationships and encouraging others and reach people and groups from a wide geographic area including beyond the borders (Usiskin & Lloyd, 2020).
In Croatia, the need for attention to the multiprofessional team that worked on the front line of fighting the virus was highlighted; therefore, rest spaces are necessary for these professionals, as well as their access to PFA.Strategies should also be developed to motivate them to continue dedicating themselves in the emergency context of the pandemic and to recognize the dedication of these health professionals, giving greater meaning to their work and enabling the continuity of their functions (Blake et al., 2020).
In a Chinese study, the conclusions indicated that although face-to-face assessment and intervention are essential for effective online support, first care can effectively extend the scope of care to all patients (Cheng et al., 2020).On the other hand, in Australia, a hybrid service model was implemented which includes the remote and face-to-face modality.In the face-to-face modality, online platforms require consolidated and consistent guidelines to create a system for screening and tracking mental health in populations in general, as well as adapting to the characteristics of underprivileged and vulnerable sub-populations and creating initiatives considering their social context (Balcombe & De Leo, 2020).

Discussion
After an in-depth reading of the 13 selected articles (Minayo, 1998), two categories emerged, based on common themes: 1) Emergency care practices in times of crisis; and 2) Implementation of virtualization with its potential and limits.

Emergency care practices in times of crisis
During the reading of the articles, the theme of the COVID-19 pandemic associated with the need to virtualize emergency care practices emerged as a moment of crisis that generated intense suffering for people.In this section, we will present the psychological implications of this crisis and how psychology can act in an emergency scenario by using the PFA and the psychologist on duty service practices.
Situations involving emergency contexts are quite disruptive to the mental health of those who experience them in epidemics, wars and natural disasters.Individuals, families and entire communities can be affected as they experience grief, adaptations of family routines, and loss of loved ones (Organização Pan-Americana de Saúde & Organização Mundial da Saúde, 2015).
Grief is a process that involves emotions such as sadness, despair, longing, disbelief, anger, guilt, regret, among others; and can trigger physical sensations such as pain, insomnia, muscle tension and panic (Miyazaki & Teodoro, 2020).To be able to reorganize the bereaved in connection with the COVID-19 pandemic, support strategies and emotional support should be offered, such as the strengthening of social networks, the development of alternative rituals that allow this farewell, such as the remote modality, and psychological support in the grieving process (Crepaldi et al., 2020;Fundação Oswaldo Cruz, 2020;Weir, 2020).
Faced with intense suffering in moments of crisis, it is common to feel overwhelmed, confused or disoriented, as well as to experience fear, anxiety or paralysis in the face of the crisis, and this suffering can occur at different levels of severity, depending on the experience of each person (Park et al., 2021; Organização Pan-Americana de Saúde & Organização Mundial da Saúde, 2015).In emergency situations people's basic needs should be met in the first instance as well as the assurance of basic social rights.These are also mental health actions, although not performed exclusively by psychologists, since they constitute policies aimed at mitigating the impacts of an emergency context, such as the pandemic (Weintraub et al., 2015).
Humanitarian crises pose a number of challenges as well as unique opportunities for psychologists.These opportunities are associated with the increase of resources to address and improve mental health services.The challenges include the limited access to specialists and the need to structure an intervention in a contextualized way and articulated with the local mechanisms for managing the crisis (Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020a; Weintraub et al., 2015).Thus, the emergency context required adaptations of health practices, which led to an increase in the offer of online psychological care.In our investigation, as indicated, we list the practices of the first psychological care and the psychologist on duty service as emergency care in mental health.
The COVID-19 pandemic has led to the exploration of options to provide remote mental health interventions and psychosocial support due to the need to maintain physical distancing.Although mental health services need health professionals trained in mental health, due to the emergency framework, it is possible that volunteers, with the proper training and supervision, can offer psychosocial interventions, such as PFA and mutual support (Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020a).These interventions are necessary because social support is essential in the context of a health and humanitarian crisis such as the one caused by COVID-19 and, therefore, it is necessary to think of ways to maintain a healthy relationship between people, which includes the use of technology (Arenliu et al., 2020;Feinstein, 2021;Plasse, 2020;Saltzman et al., 2020).
The PFA act as a form of psychological care in an emergency framework and can be offered voluntarily, free of charge and accessible, with the aim of reaching as many people in danger as possible so that they feel supported enough to better deal with their challenges (Barbarin et al., 2021;Saltzman et al., 2020).The PFA, therefore, is a work to be carried out as a team, with psychologists, psychiatrists and other health professionals trained so that it is possible to take care of as many people as possible (Weintraub et al., 2015).The key principles of PFA include: feeling safe, connected with others, calm and hopeful; having access to social, physical and emotional support; and feel empowered to help oneself as an individual and within the communities (Usiskin & Lloyd, 2020).
In view of the current pandemic scenario, the psychologist on duty stands out as another modality of psychological care aimed at essential mental health care and reception.As an emergency clinic, the psychologist on duty service has been gaining more notoriety in Brazil with the pandemic.Although it has already been widely discussed in our literature, it is considered as a space for listening, welcoming and for intervention that is available at almost at the same time to those who need it urgently (Barcellos et al., 2020;Moreira et al., 2021).
Characterized by the availability for the unexpected, the psychologist on duty service requires the creation of new alternatives for being truly with the patient and not just with the problem that brought the patient to the service (Moreira et al., 2021).Therefore, helping to clarify and confront what emerges (Gonçalves et al., 2016;Morelo et al., 2021;Tassinari & Durange, 2019;Vilela e Souza et al., 2020).Considering the virtual scenario, in order to implement the psychologist on duty service practices, it is important to establish the focus of the intervention based on the demands of the person who sought the service; subsequently, obtain a detailed description of the problem and finally enable the construction of future possibilities through the resources identified in the session (Vilela e Souza et al., 2020).
From the review of the articles retrieved, the psychologist on duty service was evidenced as an eminently national practice, which is not reported in the international literature surveyed.Within the framework of the COVID-19 pandemic and the updated resolution of the Federal Council of Psychology, the psychologist on duty service also began to provide service online, which is quite relevant due to the ability of this modality to act during an emergency and to respond to the demand for expansion of mental health care of the Brazilian population.

The implementation of virtualization with its potential and limits
The possibilities of interventions through online platforms demand strategies that facilitate people's access to on line communication, such as the internet.It is in this context that different proposals arise for the virtualization of care in emergency mental health care (Basheva, 2020;Seddighi & Salmani, 2018).However, most of the studies carried out on the subject have been developed recently, in connection with the physical isolation imposed by the COVID-19 health crisis, which appears as a catalyst for changes in the traditional ways of providing care.The need to create spaces for listening and welcoming online arises from the demands identified in the population.Due to their urgent nature, online and telephone communication platforms began to be developed so that patients can have quick and easy access to qualified professionals (Park et al., 2021;Saltzman et al., 2020).This type of practice became very common in the United States, even before the COVID-19 pandemic.The expansion of this type of service was implemented as a possibility to reduce the stigma of seeking help in times of crisis, besides reaching a portion of the population that is more familiar with technology, such as adolescents and young adults (Silva et al., 2015).
The possibility of online interventions also proved to be effective in psychological emergency care in mental health, especially in cases of natural disasters.Depending on the magnitude of such events, the logistics of health professionals to the accident site are hampered, both for geographic and economic reasons.In these scenarios, it is necessary to plan interventions to reach the people who are in need.However, the implementation of these services involves political issues, especially in the initial phase of implementation of these interventions (Arenliu et al., 2020;Silva et al., 2015).
Without due political recognition of the need to create a system to promote psychological care in the emergency context, it is impossible to develop proposals aimed at reaching a greater portion of the population through the virtualization of care.This political support consists in recognizing the importance of the population's mental health and the need to invest in prevention measures.Those measures consist of prior planning, investment in policies that include emergency mental health care, in addition to preparing online platforms with an easy and fast interface for users to be able to navigate easily, as well as a preparation of health professionals to work within this framework.Such actions make it possible to reduce the suffering and improve the training of teams in the face of health and humanitarian emergencies (Arenliu et al., 2020;Agyapong et al., 2020;Barbarin et al., 2021;Cheng et al., 2020;Park et al., 2021;Schmidt et al., 2020).
In addition, there is a need for qualified people who can be part of this project, hence the requirement for experienced professionals with specific training in the online tools to be used to perform an efficient listening and thus promote health to those individuals suffering who sought the service.The training of these volunteers should be offered by clinical psychologists who already have training in PFA, who must be responsible for supervising the volunteers, allowing them to question and to obtain accurate guidance on what should be done with each patient, as well as providing psychological support for those who are attended (Blake et al., 2020).This planning allows calling people willing to work in this service, so that they can receive the proper training and have access to the basic PFA skills (Arenliu et al., 2020;Balcombe & De Leo, 2020;Cheng et al., 2020).
The virtualization of psychological care allows greater access to a profile of patients who need urgent listening and warm reception, especially in the case of emergencies and disasters.These contexts are important to accelerate the development of platforms and programs that challenge traditional models of therapy, as revealed in the COVID-19 pandemic, in which there was an accelerated migration from face-to-face to virtual care.One of these interventions revealed in this investigation consists of offering applications or websites for patients to report their demands, which then will be forwarded to a qualified professional to tackle their case (Agyapong et al., 2020;Balcombe & De Leo, 2020;Cheng et al., 2020;Krausz et al., 2020).However, the particularities of each social context should be taken into account, as this factor will be decisive for the effectiveness of online assistance in any emergency.
There are difficulties in implementing the virtualization of emergency mental health care.
The adoption of remote care services may not be suitable for all users, as people who use the service may have a disability, which would require specific adaptations, or even reside in a location where there is no privacy necessary for psychological care.Furthermore, depending on the country in which that service should be provided, differences may exist in data privacy laws and considerations (Arenliu et al., 2020;Cheng et al., 2020; Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020b).
Although the importance of online care as a form of mental health care is currently recognized, online care alone may not meet all of a subject's needs.In an exclusively online service model, there may be limitations in diagnosis, adherence and access.The use of a hybrid method in PFA, especially when dealing with the care offered by health professionals in a framework of serious conditions such as the COVID-19 pandemic, can be an alternative for greater care for the mental health of individuals, by including face-to-face support as part of this intervention, given its greater accessibility and effectiveness (Organização Pan-Americana da Saúde & Organização Mundial da Saúde, 2020b; Plasse, 2020).

Conclusion
We may conclude that the virtualization of emergency care occurs through the social characteristics of a population and the demands presented thereby it.Internationally, the implementation of these services took place earlier, which allowed gradual changes and a more accurate monitoring of the aspects that required improvement.In Brazil, the authorization of this type of intervention in an emergency context occurred more recently, after the COVID-19 pandemic, which is the cause of a gap in the relevant studies in Brazil.
Virtual visits can be a great ally for these cases by facilitating access to patients who can not be attended in person or who urgently need professional monitoring, providing a space for listening and reception of their suffering.The psychologist on duty service is a modality that has greater participation in the Brazilian context, being an exclusive intervention of psychologists.On the other hand, the first psychological care has shown to have a wide scope in the international context, and may be offered by anyone who decides to become a volunteer.However, studies point out that volunteers must receive training from mental health professionals -psychologists or psychiatrists.
The difficulties encountered in this type of intervention are in connection with the limitations imposed by the lack of accessibility to the internet and to the devices that allow the users to get in touch with the professional team that can help them.In addition, depending on the case, a hybrid approach would be the most recommended, allowing patients' face-to-face and online consultations.In this connection, further studies are required to deepen the effectiveness of virtual consultations in emergency mental health care, in order to maximize the potential of this modality.

Table 1
Selected articles after applying the inclusion and exclusion criteria