The "mind" behind the "mask": Assessing mental states and creating therapeutic alliance amidst COVID-19.

Dear Editor.

““Face is the index of mind” - if the face is masked, how will I read the mind?”

With recommendations for the universal wearing of face-masks in hospitals (Klompas et al., 2020) and the community (Leung et al., 2020) amidst the coronavirus disease 2019 (COVID-19) era, ‘masked’ clinician-patient communications will be the new norm – at least in the immediate future. While it is known that the surgeon's mask might interfere with the communication to the patient (Wittum et al., 2013), this ‘new norm’ is likely to impact the clinical assessments in general and perhaps with unique challenges for psychiatry in particular.

The art of empathic communication is the cornerstone for an effective “Mental Status Examination” to understand the patient's psychopathology and subjective emotional states (Akiskal and Akiskal, 1994). Communication is dependent on two critically complementary components – verbal and non-verbal (Green et al., 2015); a mask can interfere affect both. Relying on both these aspects of communication becomes even more critical especially when patients are cognitively impaired, perplexed, or cannot talk much.

Besides, communication is bidirectional; hence the impact of a patient's mask on a psychiatrist's assessment of mental status can at times be more profound. Assessment of thought and mood is contingent upon the understanding we derive from the Gestalt view of the whole person in front of us (Martin, 1990). Patients in turn present with a broad range of social communication difficulties – while individuals with schizophrenia may not be able to read emotions very well and thus perceive threat easily, persons with depression may not say much, but the face will reveal a depressed affect. In contrast, for someone who has gone through trauma, a trustworthy and empathic face of the psychiatrist and appropriate verbal messages breaks the barrier. It is also well documented that individuals with mental health difficulties have specific preferences to professional attire, but without the white coats that doctors generally wear (Long et al., 2017).

Interviewing children would pose a unique set of challenges. Younger children may not completely understand the gravity of the situation and may perceive the context as a playful activity. In their curiosity and distractibility, they may want to come closer and touch the masks of the clinician or pose repeated questions about the mask during the interview. In this regard, it is critical to establish a context for the current pandemic scenario and the importance of covering one's face in an age-appropriate manner.

Insights anchored on social-neuroscience may offer innovative solutions to these impediments. In parallel to motoric and proprioceptive contributions to ataxia, socio-emotive incoordination (difficulties in expressing and perceiving emotions and mental states in others) can involve expressive and receptive components. For instance, access to a select set of non-verbal cues (i.e. expression of emotions exclusively through eyes) as well as altered verbal communication (muffled voice) can potentially breed ambiguity and hence accentuate biased inference of other's mental state in both the psychiatrist and the patient. Indeed, veiled faces have been shown to bias the perceptual inference toward more negative and less positive emotions (Fischer et al., 2012). Moreover, wearing a face-mask can alter the sensory feedback of the motoric gesture as we communicate. We may hear our voices as muffled, or may not be able to make the full range of facial expressions. Studies from individuals receiving botulinum toxin treatment of the facial musculature (and impaired feedback systems thereof) report facial emotion recognition difficulties, based on the theory of embodied emotions (Lewis, 2018). Together, these receptive and expressive impairments can critically impair efficient social reciprocity, which is rooted in moment-to-moment appraisals of social cues within a transactional framework between two individuals. Ambiguous social cues can break this rather smooth and reflexive synchronous process driven by the early responsivity of the mirror neuron system (Mehta et al., 2019). This, in turn, might lead to a shift in communication-based on mirror neuron-driven, faster, reflexive brain to the mentalization-driven, slower, reflective brain (Lieberman, 2007).

Such neuroscientific insights predict greater challenges especially for emergency room psychiatrists who are in personal protective gear and seem even more unapproachable. Therefore, psychiatrists may need to learn new ways of communicating and assessing emotions during clinical encounters. To begin with, making the patient and the mental health professional wear transparent masks will overcome not only challenges posed by visual sensory deprivation but also help us interpret what the other person is speaking more efficiently (Atcherson et al., 2017). Using the eyes, eyebrows, hand gestures and appropriate body posture to more effectively communicate will help to improve the patient's comprehension of what we want to communicate. Taking time to understand the information in its entirety and then responding or moving ahead in the conversation will enable tapping into the mentalizing brain and facilitate better interpretation of the patient's mental state. Having fewer mental health professionals communicating with the patient (preferably one-to-one) so that the patient does not have to switch between team members and understand different levels of muffling voices. When appropriate, harnessing digital technology-based virtual assessments or electronic expressions (emojis) may circumvent some of the challenges. Undergoing training from speech and language therapists specifically to use the right intonation and prosody to speak clearly through a mask may yield additional benefits.

On a different note, a Panglossian perspective may provoke a view that masks may indeed make certain patients (the ones worried about scrutiny of their facial expressions and similar others) comfortable. Nonetheless, the bottom line is that a clinician-patient relationship is built on mutual trust and a warm and caring environment beyond the interview room. Taking adequate steps to ensure this environment will also go a long way in overcoming this unique challenge we are faced with today. To surmise, the “obstacle” of the “mask” may very well be the “path” to re-discover the value of “personalized, empathic communication” which, unfortunately, has been gradually fading in contemporary psychiatry.

Contributors

PSC conceptualized the paper, UMM drafted the first version, GVS and PSC edited the subsequent versions and provided new ideas to be incorporated into the manuscript.

Declaration of competing interest

UMM receives an honorarium from Elsevier to serve as Associate Editor of Schizophrenia Research. GVS and PSC have no conflicts of interest to report.