Half of the Face Is Covered by Official Order – Thoughts on the Isolation of Communication.
After the Chinese province of Guangdong introduced compulsory masks wearing on 26 January 2020, Vietnam was the first country to follow suit nationwide on 16 March. Venezuela followed one day later. Shortly afterwards, the first country in Europe – the Czech Republic – introduced compulsory nose and mouth masks on 18 March. This was followed by Slovakia (25 March) and Bosnia (29 March). At the beginning of April, the Latin American countries Colombia, Cuba and Ecuador followed, as well as the United Arab Emirates, Turkey and Morocco – as the first African country to do so.
Austria was the first country in Central Europe to introduce the obligation on 1 April. Today, more than 130 countries prescribe the wearing of masks in public. In 42 countries (including Switzerland) only a recommendation or partial mask obligation applies.
However, many citizens in countries without strict regulations wear the mask anyway to protect themselves and others from infection with the coronavirus. Moreover, in many countries, especially in Asia, wearing masks – for example to protect against air pollution – is already the norm.
This has become a worldwide standard: where it is impossible to keep a distance, it is advisable to wear face masks. Half of the face is thus covered by official order.
How do we now deal with such limited forms of communication?
Changed Facial Expressions
Normally, we are used to being able to understand other people quickly thanks to their facial expressions and to being able to assess them – at least to some extent. If a mask covers the face, an important means of communication is lost: the mouth image, an important part of facial expressions.
If the mouth and parts of the nose are covered, reactions such as a smile can no longer be perceived. (1)
Green and Phillips showed that both the eye and mouth regions are typically scanned to determine facial expressions. (2) Hidden mouths can be problematic for two reasons: The lack of muscle activation around the mouth, which provides a more obvious emotional message (e.g. smiling, grimacing, etc.), also leads to less reliable and/or authentic signals. In addition, although the area around the eyes conveys a more nuanced affect, it can also be more difficult to “read” it with certainty, as highlighted by Fox and Damjanovic (3) and Baron-Cohen et al. (4). This can be further affected by a protective visor.
But also the sound waves are no longer optimally distributed as a result of the masking and the tendency is to speak louder and with more air and to articulate more clearly. The focus of communication thus shifts from facial expressions to the voice.
People are used to reading the facial expressions of others. This ability may have given us an evolutionary advantage, as Charles Darwin noted in his 1872 book “The Expression of the Emotions in Man and Animals”. (5) Meanwhile, extensive literature and research testify to the dominant role of non-verbal signals in human communication. This includes reading emotions from a face; it promotes social interaction and reduces misunderstandings. The elimination of facial expressions is therefore not insignificant. With gestures, facial expressions, body movement and posture as well as the use of voice, we transmit far more information to other people than with speech.
The Allensbach Institute gives more precise values in a study from 2016: For example, gestures and facial expressions alone already account for 55% of communication, 26% is accounted for by the non-verbal part of the voice (sound, intonation, etc.) and only 19% by the technical content we express when speaking. (6)
Face Masks Hide What Words Cannot Say
Masks may save lives, but they also create social challenges and frictional losses. “Words alone are not enough to convey our attitudes, our feelings, our thoughts and all the other things that are important for creating social and emotional bonds between people,” says David Matsumoto, professor of psychology at San Francisco State University and founder of Humintell, a research and training company specializing in non-verbal communication. (7)
When it comes to examining faces, the eyes and mouth are the most informative regions because they are usually the most expressive. We can control the mouth better than the rest of our face. Masks cover the mouth and reduce the effective signalling of essential non-verbal cues.
We unconsciously analyse the combined movements of the visual field to find out what someone is trying to tell us. Nevertheless, each feature itself can also convey certain emotions particularly well. The mouth region in particular is well suited to express feelings of happiness. Concealing this area can be problematic if you want to appear accessible and friendly – which could explain why a number of frontline healthcare professionals have begun to put smiling pictures of themselves on their medical gowns to relieve patients’ anxiety.
Mask and the Doctor-Patient Relationship
The emotional aspect of a doctor-patient relationship is largely determined by non-verbal communication. Non-verbal behaviour plays a significant role in the quality and satisfaction of this relationship, which in turn influences adherence and clinical outcomes. (8) Both doctors and patients must be able to explore and recognise each other’s non-verbal cues. The ability to read facial expressions (such as smiles, nods, frowning) is therefore fundamental to the relationship between patients, doctors and nurses. (9)
Communication skills and the relationship between doctors and patients are therefore essential in primary care consultations and correlate with compliance with medical advice and medication, patient satisfaction and positive clinical outcomes.
Research confirms this: A study conducted in 2013 at a hospital in Buffalo, NY, found that patients found doctors who wore masks to be less caring and empathetic. In a time of widespread worry and tension, hiding a social smile behind masks can contribute to feelings of danger, isolation or paranoia. (10)
Wearing face masks can lead to a “masking effect” of non-verbal communication. In a randomised controlled trial in Hong Kong, doctors wearing face masks had a significant negative effect on patients’ perceptions of empathy. (11) Surprisingly, the effect was even worse in an established doctor-patient relationship. The latter is particularly important in the care of the chronically ill. (12)
The question remains open as to what happens when both doctors and patients wear face masks (“dual masking”). Although there is little literature on this, it is possible that the doctors’ perception of the patients’ empathy is also affected. Perceived empathy is one of the key components of therapeutic relationships. During the Covid-19 pandemic, where “double masking” is a common scenario, negative effects on mutual feelings of empathy, trust and the whole doctor-patient relationship seem plausible.
Collateral Damage in Communication
Numerous measures to limit the spread of Covid-19 are very incisive in terms of communication and affect people in their everyday communication needs. However, people in social institutions, with cognitive or complex disabilities or with sensory impairments are particularly affected. (13) In addition to the oldest groups of people, such as those in care homes and nursing homes, these include the youngest in day-care centres and kindergartens (14), people with hearing problems, people with dementia or people with an autistic spectrum.
People with Hearing Problems
For people with hearing problems, keeping their mouths covered is still a major obstacle. At least 5% of the world’s population is hard of hearing, and reading a person’s lips and facial expressions can be an important part of communication, even for those who use sign language.
Mouth masks are problematic for deaf people. In order to understand other people, they read lips (see this blog post by Danja Rachel Leimgruber). If a protective mask covers the face, this is impossible. Chris Frith, professor emeritus of neuropsychology at University College London says that people might misunderstand what others are saying if they cannot see how their mouth moves when they speak. (15) And this is especially true for people who are hard of hearing.
Non-verbal Communication and Dementia
As their disease progresses, people with dementia find it increasingly difficult to express themselves verbally. Their non-verbal skills, on the other hand, remain intact for a long time. However, the current protective measures around corona make non-verbal communication more difficult.
For many people, non-verbal communication is considered the most effective element of communication to connect with a person suffering from dementia.
People with dementia increasingly lose the ability to communicate verbally, but in the vast majority of dementias, body language skills are retained longer than verbal skills. People with dementia are usually able to interpret facial signals correctly: They interpret a smile as a sign of joy and compressed lips as a sign of anger. They can tell from the sound of our voice, our posture and our speed whether we are relaxed or stressed, in a good mood or angry. Much of this is missing right now – which their surroundings often do not even notice.
Duty to wear masks massively impairs facial expressions in communication and generates collateral effects which have hardly been addressed in accordance with their importance.
The question therefore arises as to how society as a whole not only handles such communicative restrictions, but also discusses and contextualises them. It is noticeable that the communicative consequences of compulsory masks have so far only been discussed in care homes or within the framework of specialist agencies. (The consequences of being “locked up” in one’s own home – as a further communicative restriction – are not even mentioned here).
The politically decreted measures always invoke the value of “responsibility” or “self-responsibility” and their legitimation is guided by a narrowly defined scientific discipline, that of virology, to the exclusion of all other social knowledge. This is happening at a time of considerable social, economic and cultural disruption.
In this sense, the isolation of communication is only a small but very significant example of the current social situation in dealing with Covid-19. And the use of new vaccines will not change this.
(2) Green, M. J., Phillips, M. L. (2004). Social threat perception and the evolution of paranoia. Neuroscience and Biobehavioral Reviews, 28(3), 333–342. doi:10.1016/j.neubiorev.2004.03.006.
(3) Fox E., Damjanovic L. (2006). The eyes are sufficient to produce a threat superiority effect; DOI: 10.1037/1528-35126.96.36.1994 https://pubmed.ncbi.nlm.nih.gov/16938095/
(4) Baron-Cohen S., Wheelwright S., Hill J., Raste Y, Plumb I. (2001). The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism, In: J Child Psychol Psychiatry. 2002 Feb, 42 (2): 241-51. https://pubmed.ncbi.nlm.nih.gov/11280420/
(5) Darwin C. (2000). The expression of the emotions in humans and animals. Critical edition, introduction, afterword and commentary by Paul Ekman. Translated by Julius Victor Carus and Ulrich Enderwitz. 1st edition. Eichborn Verlag, Frankfurt am Main 2000, p. IX.
For the extensive literature on non-verbal communication see: Argyle M. (2013). Körpersprache und Kommunikation; Junfermann, Paderborn.
(7) Matsumoto D. et al. (2013). Nonverbal Communication: Science and Applications, SAGE, Los Angeles. https://books.google.ch/booksid=PeOeu3qFFTIC&pg=PT3&hl=de&source=gbs_selected_pages&cad=2#v=onepage&q&f=false
(8) Silverman J., Kinnersley P. (2010). Doctors’non-verbal behaviour in consultations: look at the patient before you look at the computer; doi: 10.3399/bjgp10X482293
(9) Sharif S. P., Blagrove E. (2020). Covid-19, masks and communication in the operating theatre: the importance of face value; Psychological Medicine 1–1. https://doi.org/10.1017/S0033291720003669
Frank M.G., professor and chair of the Department of Communication at the
(10) Wong C. et al. (2013). Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879648/
(11) Wong C. K., Yip B. H., Mercer S. et al. (2013). Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. BMC Fam Pract; 14: 200.
(12) Ghosh A., Sharma K., Choudhury S. (2020.) COVID-19 and physician–patient relationship: potential effects of ‘masking’, ‘distancing’ and ‘others’. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543553/
“This includes in particular touching. This represents a form of non-verbal communication and encounter with another person. Touch can be used to express affection, appreciation and sympathy. The physical and psychological well-being can be positively influenced by this. Refraining from touching also impairs the quality of the accompaniment, which can lead to moral stress for the staff.”
(14) See, for example, the recommendations of the “Marie Meierhofer Institute for the Child”: ”Infants have elementary relationship and communication needs. They orient themselves towards facial expressions, gestures, language, posture. The mouth area of the person opposite does not play the only role, but an important one, especially for language acquisition. Small children need a counterpart regularly and for a certain time during their waking hours, who is in dialogue with them even without a covered face.” https://www.mmi.ch/files/downloads/1f095c8e718db99e89f7b026be438b47/201020_FAQ_Masken_FIN.pdf
(15) Frith C. (2009). Role of facial expressions in social interactions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781887/