The Eyes Have It: Psychotherapy in the Era of Masks

Abstract

Nonverbal communication is integral to the success of psychotherapy and facial expression is an important component of nonverbal communication. The SARS CoV-2 pandemic has caused alterations in how psychotherapy services are provided. In this paper, potential issues that may arise from conducting psychotherapy when both the patient and therapist are wearing masks are explored. These include higher likelihood of misidentifying facial expression, especially when expression is incongruent with body language, and when the lower face is more important for correct identification of emotion. These issues may be particularly problematic for patient populations for whom emotion recognition may be a problem at baseline, or for those more prone to biases in emotional recognition. Suggestions are made for therapists to consider when seeing patients in-person when masks are necessary.

The role of face masks within in-patient psychotherapy: Results of a survey among inpatients and healthcare professionals

“…Especially in group therapy, with patients from other cultural backgrounds and when assistance is needed (e.g., impaired hearing) or in cases of profound mental illness, non-verbal gestures, and body language should be matched to the intended emotional expression. Mitzkovitz et al (2022) have compiled suggestions for conducting masked psychotherapy in their review article.…”

“…The pandemic has also led to changes in the provision of psychotherapeutic services: while psychotherapy has partly been conducted using telephone or videoconferencing throughout the pandemic, face-to-face psychotherapy continued to be offered, especially for severely ill patients in day-patient and inpatient settings (Zipfel et al, 2020). Among many benefits of telemedicine and telepsychotherapy (Poletti et al, 2021;Lin et al, 2022) challenges remain, such as a "lack of control over the patient's environment, " reduced privacy and confidentiality, and possibly limited assessment of treatment progress and difficulties in establishing a therapeutic relationship without face-to-face contact (Cataldo et al, 2021;Mitzkovitz et al, 2022).…”

“…Among many benefits of telemedicine and telepsychotherapy ( Poletti et al, 2021 ; Lin et al, 2022 ) challenges remain, such as a “lack of control over the patient’s environment,” reduced privacy and confidentiality, and possibly limited assessment of treatment progress and difficulties in establishing a therapeutic relationship without face-to-face contact ( Cataldo et al, 2021 ; Mitzkovitz et al, 2022 ).…”

“…On the one hand, masks carry the risk of misrecognizing facial expressions, especially if the expression does not match the corresponding body language. This is particularly relevant for patient groups for whom emotion recognition is a problem, or who are more susceptible to emotion recognition bias (e.g., Mitzkovitz et al, 2022 ). Based on previous research on the perception of masks among individuals suffering from health anxiety ( Cannito et al, 2020 ), an attentional bias toward virus-relevant stimuli (i.e., face masks) and thus interactionally disruptive effects on psychotherapy may be assumed.…”

Mask wearing provides psychological ease but does not affect facial expression intensity estimation

“…After the pandemic, several global researchers have investigated the impact of mask-wearing on cognition, especially regarding face perception and emotion processing. Observers struggle to accurately perceive the facial expressions of mask wearers in terms of both valence and intensity due to mask interference [15][16][17], which can lead to miscommunication in clinical settings [18]. Conversely, mask-wearing also affects the wearer.…”