key: cord-0816758-ol1tz5r6
authors: Hüfner, Katharina; Hofer, Alex; Sperner-Unterweger, Barbara
title: On the difficulties of building therapeutic relationships when wearing face masks
date: 2020-08-26
journal: J Psychosom Res
DOI: 10.1016/j.jpsychores.2020.110226
sha: e237382cae3279c28c3884f62207926350b53573
doc_id: 816758
cord_uid: ol1tz5r6

nan

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 J o u r n a l P r e -p r o o f 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 facial 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. 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.

J o u r n a l P r e -p r o o f

Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism

An investigation of affective theory of mind ability and its relation to neuropsychological functions in Alzheimer's disease

A meta-analysis of mentalizing impairments in adults with schizophrenia and autism spectrum disorder

Theory of mind and emotional awareness deficits in patients with somatoform disorders

Enhanced 'Reading the Mind in the Eyes' in borderline personality disorder compared to healthy controls

Childhood Adversity Impairs Theory of Mind Abilities in Adult Patients With Major Depressive Disorder

Emotional processing subtypes in bipolar disorder: A cluster analysis

Moving Personal Protective Equipment Into the Community: Face Shields and Containment of COVID-19