On the difficulties of building therapeutic relationships when wearing face masks

As in other European countries face masks were virtually absent in Austria's public until a couple of weeks ago. It is now the law (due to the COVID-19 pandemic) that face masks covering nose and mouth have to be worn in all enclosed public spaces such as transport and shops. In Austrian hospitals, all staff is required to wear face masks while on duty, and in the hospital of Medical University Innsbruck, psychiatrists and psychologists wear large, reusable blue and green cloth masks (except when treating SARS-CoV-2 infected patients when barrier masks with FFP3 certification are worn). Patients are also required to wear face masks when outside their rooms and specifically also in the emergency department.

While it is already a challenge to interact and discuss a patient's case with a familiar colleague when both are wearing such a mask, this poses unprecedented problems when treating patients with psychiatric disorders. Our personal experience shows that while patients with schizophrenia might be bewildered, patients with dementia react with agitation and patients with somatoform disorder with anxiety when interacting with staff wearing such a mask. Patients with borderline personality disorder, on the other hand, are frequently rather amused. The most prominent problems arise in the emergency department when treating agitated patients and those who come for their first psychiatric emergency visit. Individuals with insufficient command of the German language as well as elderly individuals with hearing problems find it almost impossible to communicate their problems to the “masked” staff on duty.

We are now, involuntarily, preforming a quasi live version of the “Reading the mind in the eyes” test on a daily basis. Studies using the traditional version of the test [1] (in "pre-Coronavirus" research) showed that patients with Alzheimer's dementia are impaired in this test [2] as are patients with schizophrenia [3], autism spectrum [3] or somatoform disorders [4], while patients with borderline personality disorder actually outperform controls [5]. Two clusters have been found in bipolar disorder and major depressive disorder with the majority of patients performing similarly to healthy controls [6, 7].

How can we make the best of the current situation of „masked emotions“? We can try to increase emotional awareness in patients with psychiatric disorders (and maybe also in ourselves) by verbalizing the „masked emotions “directly and explicitly. While this will be necessary for patients living with schizophrenia, or dementia to interact successfully with the staff on a daily basis and especially in emergency situations, it can become part of the therapeutic process in patient groups in whom reduced emotional awareness perpetuates the disease process as in somatoform disorders.

A different possibility is to substitute the face masks with a face shield. Their advantage includes that they are “comfortable to wear, protect the portals of viral entry, and reduce the potential for autoinoculation by preventing the wearer from touching their face ….. (while allowing) visibility of facial expressions and lip movements for speech perception” [8]. Only very recently has the management of our hospital given approval to wear face shields instead of masks when interacting with asymptomatic persons and patients. This might in the future be helpful when performing psychotherapeutic interventions on psychosomatic wards. Face shields will definitely make it easier to convey empathy and understanding when deescalating patients in the emergency department. The protective value of cloth masks as well of face shields in preventing COVID-19 spread will have to be further evaluated in the future (Fig. 1).

Fig. 1.

The live situation (author K.H.) and an example from the “reading the mind in the eyes test” reproduced with permission from [1]. Target mental states and distractors where added from the original list.