INTRODUCTION

The World Health Organization (WHO) defines mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community"¹. Consequently, mental health is a construct composed of psychological, emotional, social and environmental issues which includes a person's ability to function under adversity and also to adapt to changes around them.

Mental health allows individuals to maintain control over their tension and anxiety, find more satisfaction in giving than receiving, show consideration for others, curb feelings of hate and guilt, and love others. In addition, mentally healthy people have been described as individuals who are accepting, understanding, honest, frank, hopeful, sensitive, loving, optimistic, self-controlled, self-aware, caring, and realistic.

In contrast with the characteristics listed above, poor mental health is associated with rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, human rights violations, and physical ill-health. Each of these factors negatively impact on a person's ability to perform their daily activities. Not surprising, the WHO's comprehensive Mental Health Action Plan for 2013-2020 is designed to prevent mental disorders, enhance recovery and promote mental well-being among others (WHO, 2020a). The plan is designed to promote mental health everywhere and at all times, however, it does not directly address humanitarian crisis situations. A second document, Mental Health and Psychological Support in Emergencies (WHO, 2020b) indicates that the prevalence of mental disorders including depression, anxiety, sadness, hopelessness, irritability, anger, and aches and pains tend to more than double during emergencies and that while most people will return to normal over time, interventions must be available to assist those experiencing crisis during crisis situations.

The WHO suggests that we must understand mental health in more positive and broader terms: it is not about the satisfactory functioning of the individual; it is a basic character of human relations that defines the possibilities of humanization that open up to the members of each society and group. In fact, mental health is a dimension of relationships between people and groups rather than an individual state. It is not a matter of simplifying a problem as complex as that of MH (mental health) by denying their personal roots and by avoiding individual reductionism, incurring social reductionism "(Martin-Baro, 1990).

Mental health issues must be located in the historical context where each individual elaborates and realizes his existence in the cobwebs of social relations (Martin-Baro, 1980). According to the authors, "... the group that should most demand our attention is that of children, those who are building their identity and their life horizon in the fabric of our current social relations." Mental health professionals must ensure that children do not structure their personality by learning about violence, irrationality and lies.

MENTAL HEALTH ISSUES IN CRISIS SITUATIONS

Crisis situations are characterized by a disruption or a breakdown in an individual's normal or usual pattern of functioning (Zamoum & Serra Gorpe, 2018) and have five distinct phases (Table 1). A crisis cannot be resolved by a person's customary problem-solving resources/skills. Therefore, crises are by definition stressful, difficult to cope with, and require adequate timing. Mental health professionals can learn a lot from experiences lived by different groups in different crisis situations.

Table 1 Stages of Crises 

Source: Catholic Charities - Crisis Intervention, nd.

In psychological terms, trauma refers to those psychic problems originated by the impact that a certain experience or experience has on a person. It is an abrupt experience, which usually occurs unexpectedly and, in any case, has a pathogenic nature, generating psychic damage.

The implicit assumption of the individuality of the traumatic experience can lead to misleading conclusions. Current models -- including diagnostic tools promoted by the American Psychiatric Association (2014) in DSM 5 -- suggest understanding psychic trauma in a similar way as we understand organic trauma: by examining the affected individual's wound or individual injury. This is the so-called "medical model" that misses key issues experienced during crisis situations which can result in Post Traumatic Stress Disorder (PTSD).

A disorder that arises as a late or delayed response to a stressful event or to a situation (brief or lasting) of an exceptionally threatening or catastrophic nature can cause widespread discomfort in almost everyone. The typical characteristics of PTSD: repeated episodes of re-experiencing the trauma in the form of reviviscences or dreams that take place against a persistent background of a feeling of "numbness" and emotional dullness, detachment from others, lack of ability to response to the environment, anhedonia and avoidance of activities and situations reminiscent of trauma. Situations that recall or suggest trauma are often feared, and even avoided. Rarely, dramatic and sharp bursts of fear, panic, or aggressiveness can occur, triggered by stimuli that evoke a sudden memory, an update of the trauma or the original reaction to it, or both at the same time. Usually, there is a state of vegetative hyperactivity with hypervigilance, an increased startle reaction, and insomnia. Symptoms are accompanied by anxiety and depression, and suicidal ideations are not uncommon. Excessive consumption of psychotropic substances or alcohol can be an aggravating factor. The course is fluctuating, but recovery can be expected in most cases.

Martin-Baro (1990) suggested that although it seems paradoxical, not all the effects of social strive such as war are negative. The literature suggests that periods of social crisis trigger favorable reactions in certain sectors of the population, in other words, faced with "extreme situations", there are those who bring up resources of which they themselves were not aware or rethink their existence in the face of a new, more realistic and humanizing horizon.

CRISIS SITUATION: COVID19

At the present time, we are experiencing a health emergency, unprecedented in the modern era. This unique situation prevents us from fully understanding and measuring the psychosocial impact on individuals around the world. In recent days, health experts make the United States visible as the epicenter of the Pandemic. On March 23, 2020, the WHO announced that the number of cases of coronavirus around the world had exceed 300,000. More alarmingly, the WHO reported that while it took almost sixty days to reach the first 100,000 cases around the world, it only took 11 days to reach 200,000, and even more alarmingly only four days to reach 300,000 (WHO, 2020c).

In response, many governments around the world have imposed unpreceded measures to curb the spread of the disease. In the United States, COVID 19 has revealed significant gaps in the health care infrastructure and public health measures such as lockdown and social distancing are exacting their toll on the health status of US residents. Other countries and governments have enacted their own responses to the evolving pandemic as shown in Table 2.

Table 2 Selected Government Responses to the Evolving COVID-19 Pandemic 

Source: Perez, Cesar Cano, Alonso, y Chacon Andrade, 2020.

STRATEGIES FOR ADDRESSING MENTAL HEALTH DURING CRISIS SITUATIONS

As we review the present condition and project ourselves into the future, we can identify several mental health issues resulting from the coronavirus or COVID-19 pandemic. Currently, in the Americas, news reports are generating panic about the accelerated growth of the Pandemic vis-á-vis the number of infected and deceased. This situation is exacerbated by false information, misinformation on social networks, and why not also say it? over information or saturation from daily news.

In addition to panic, confinement conditions and mobility restrictions in many countries, and last but not least, uncertainty and hopelessness on a personal, social and family level, seeing the closure of businesses and sources of employment, and the consequent looming economic crisis all present a danger to the mental health of individuals.

Even more worrisome are the statements made on a television newscast made on March 23, 2020, by US President Donald Trump, when he stated that "that the medicine could be worse than the disease", hinting that the economy of the world cannot be paralyzed as a result of quarentine orders around the world. In his speech, he urged Americans to restart their work on April 14 and he added, how serious it would be if there were numerous deaths and massive suicides as a result of the global recession. He has since rescinded the ideas of re-opening certain sections of the US economy. The changing nature and increasing volumes of information makes one thing certain: we do not know with certainty the impact the Pandemic will have, but what we can be sure of is that there is an uncertainty and worrying about the future. In fact, the fear of an unknown future is very real. In some cases, after the effects of the Pandemic, we will see reactions of anxiety, panic, aggressiveness, depression and hopelessness.

In the context of crisis situations, "psychology plays a substantial role in providing an opportunity for a different understanding that gives meaning to the lived experience, for those who participate accompanying, but above all for those who are protagonists of that experience, the population affected" (Berinstain, 2000). In fact, Martin-Baro identified that there are two main types of traumatic experiences:

a) the experience of acts of violence and destruction, often steeped in cruelty and horror,

b) the experience of physical and personal separations.

As previously mentioned in the approach of trauma by Martin-Baro, referring to a traumatic experience or experience that affects in such a way that it leaves a permanent residue. In psychosocial terms, it implies a dialectical (individual-social) character of the wound (Martin-Baro, I. 1988) that in disasters entails both an individual and a social cause and experience, given the collective nature of a disaster.

Crisis interventions seek to identify factors that lead to the crisis, relieve symptoms, restore equilibrium, and development of coping strategies. Mental health professionals are suddenly dealing with unprecedented issues related to anxiety about the unknown, adaptations to new work environments, possible unemployment, modifications to roles such as becoming teachers to students who suddenly have to stay home, and mental noise which prevents people from listening to messages as they are too stressed from the ever-changing situation they experience.

Two classic approaches to dealing with mental health issues are cognitive behavioral interventions and interpersonal therapy. In cognitive behavioral interventions individuals examine their thoughts and emotions, and with the assistance of a professional, employ strategies to control the intensity of those factors (Kendall, 2013). In interpersonal therapy, psychotherapists seek to restore mental health by focusing on the impact of relationships on psychological problems (Weissman, Markowitz, & Klerman, 2017).

Unfortunately, these methods are not always feasible during crisis situations given burden on mental health system and or lack of enough mental health professionals. The following recommendations have been provided for addressing mental health issues during crisis situations (Miaoudakis, Petroulakis, Kastanis, & Askoxylakis, 2014). Table 3 shows six different general activity categories to help maintain mental health during a crisis situation.

Table 3 Maintaining Mental Health in Crisis Situations 

Sources: Epping-Jordan, Harris, Brown, 2016; Tol, Leku, Lakin, 2020

MAINTAINING GOOD MENTAL HEALTH DURING THE PANDEMIC

Every crisis brings opportunities and creative ways of coping. The following recommendations are provided from an interdisciplinary and multidisciplinary way to assist people maintain their mental health:

For work adjustment:

For personal adjustment:

Comprehensive mental health care in adverse situations requires the implementation of care models aimed at the prevention of risk factors, promotion of protective factors, and adequate care for mental disorders. This implies an accompaniment process for the recovery of mental health, as a permanent task that only varies its characteristics in emergency conditions. Comprehensive training for mental health work during emergencies should also be included in the university curriculum. Self-care of mental health personnel should be regularly institutionalized. However, it is recognized that there are advances in the recognition of the benefits and the need to avoid emotional burnout, known as the burn outsyndrome.

CONCLUSION

The lessons we have learned from the coronavirus pandemic allow us to conclude that while it is a biological disease, mental health professionals play a key role in maintaining the health status of individuals. Psychologists not only restricted to providing psychological counseling or psychotherapeutic support, but they themselves are the patients along with their relatives and the teams of doctors and nurses who intervene in the front line.

The role of the psychologist goes beyond psychosocial intervention at the first level of primary health care. As a mental health expert, the psychologist must provide transparent information about the true causes of the coronavirus, as well as the means of transmission and its consequences, facing disinformation and / or distortion of the existing information, which could increase the level of anxiety and stress of people, the same that can reach levels of collective panic.

An important task for mental health professionals in cases of an epidemic such as the coronavirus is to guide and advise individuals and families so that they can develop resiliency behaviors that allow them to creatively and assertively handle psychosocial situations such as quarantine and social isolation. We know that as we continue to face confinement in our homes, subjected to conditions of uncertainty and stress due to the lack of knowledge of how long this situation will continue, whether or not they will get food to face the quarantine, as well as the fear of possible contagion from family members and from information from the media mental issues will continue to increase.

But, without a doubt, the main role that the mental health professional has in the face of the current coronavirus epidemic is to strengthen the "feeling of security" in people, for which transparent management of information is essential, guiding and recommending the population to inform themselves through official sources, to avoid spreading the rumor, advising against receiving news from "unreliable" sources.

In addition to the above, it is essential that the psychologist develops natural resilience behaviors in the population, allowing the person to face the various types of stressful life situations.

In summary, the psychologist must take into account the differences in the psychological characteristics of each person, so that once the quarantine and / or social isolation has been overcome, these people can be prevented from suffering from depression, as well as post-traumatic stress as there have been similar cases in situations of isolation caused by other epidemics.