The coronavirus pandemic has deprived us of the closeness we are biologically programmed to seek when we are vulnerable, lonely or fearful -- exactly when we need it the most. Face masks, video chats and personal protective equipment make it harder to see facial expressions and body movements, while social distancing forces us to be unnaturally apart and the invisible presence of a virus has infused touch with a sense of danger.
Health workers rely on positive non-verbal communication to show care for their patients: close physical proximity, touch, head nodding, smiling, open body language and a focused eye gaze. It’s such an important part of the work they do, that the world’s largest nursing body, the UK’s Royal College of Nursing, has a section of its website dedicated to the importance of body language.
The six universal expressions
Humans use facial features to convey several basic emotions. Researchers working on automatic expression detection study this range of movements, including raised eyebrows, tightened lips and clenched jaws.
Surprised expressions are highly distinctive and are usually formed of elevated brows and a raised upper lip.
Happiness can be communicated by a single facial movement, which occurs when the corners of the lips are pulled into a smile.
Researchers believe that pressed and tightened lips are the essential signifiers of anger.
Fear is formed of subtler facial movements and is often communicated by the movement of eyebrows.
Sadness can be shown by a combination of eyebrow movement, depressed lip corners and a partial deepening of the nasolabial furrow, also known as smile lines.
Either a wrinkled nose or a raised upper lip can signify an expression of disgust.
A doctor or nurse’s body language sets the trajectory for treatment from the moment the patient first sees them. Positive non-verbal communication has been shown to decrease patient anxiety and give better outcomes. And it gives the patient confidence that a physician is sensitive and understanding. As a result, the patient is more trusting and communicative.
Even with pain, patients who get high non-verbal support from their physicians show increased tolerance. Doctors’ detachment and distancing behavior -- such as the absence of smiling and direct eye-gaze -- has the opposite effect and is linked to worse patient outcomes. A recent study of 719 patients with the common cold found that the more empathic they perceived their doctor to be -- the faster they recovered. Each patient was asked to score the doctor for empathy shown to them on a 1-10 scale. Those who scored the doctor a perfect 10 (around a third of patients) had reduced severity of symptoms, recovered faster and also had higher immune function, about 50% better than others.
How masks disrupt communication
Face coverings significantly limit a doctor’s ability to gauge a patient’s emotions. The masks can hamper health care workers’ attempts to provide non-verbal support to people in their care.
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Wearing a mask further neutralizes a person's expression and poses practical difficulties for doctors as they can muffle speech.
Happiness is often conveyed when the corners of the lips rise, a movement hidden when wearing a mask.
Source: SensorSpot/Getty Images/CNN Illustration
Author and scientist David Hamilton, who studies empathy, says that with Covid-19, it’s been an uphill battle with hospitalized patients.
“If you are going into hospital, the system and brain are stressed and scared, which can have a dampening effect on immune response. So you need greater reassurance to bring the body back to a baseline,” he told CNN.
“The more empathy the patient feels the better their potential immune response.”
According to Hamilton, the behavior of health care staff has a powerful role because “we catch the other person’s emotions.”
“The more expressive someone is -- facially -- the greater the degree of emotional contagion,” he added. “If someone is showing you compassion, kindness and empathy you feel a sense of connection which causes chemical changes in the brain which have a powerful anti-inflammatory effect and a positive effect on the cardiovascular and immune system.”
The key chemical at play is oxytocin, which Hamilton calls the “kindness hormone.”
“The more empathy the patient feels the better their potential immune response,” he added.
Why masks make it so hard for us to express how we feel
Emergency room doctor Ara Suppiah, who is working on a Covid-19 ward in Florida, says he acutely feels the barriers to communication.
“Masks on both sides significantly limits our ability to interpret emotions and a patient’s feelings. Not hearing each other through layers is frustrating. Expressing feelings with masks, goggles, face shield and gowns is seriously challenging, but rewarding,” Suppiah told CNN.
Suppiah is doing what many health workers are doing, including Welsh doctor Sharan Chugani.
“I write my name on my gown and draw a smiling face,” Chugani told CNN. “It makes a difference in that people like putting a face to a name and them being able to see you smile makes a big difference with trust and reassurance.
“It definitely has been a challenge, probably the hardest being unable to use your smile or laughter to comfort people and make them feel more at ease.”
Hamilton says that just seeing a smiley face drawn on a gown would help because the patient can recognize the effort to make the connection. It also activates the same mirror neurons in our brains that a real smile does, just to a lesser extent, so helps to build rapport, he added.
Distance and personal space
You don’t need a scientist to tell you that when you’re separated from your nearest and dearest by more than 6 feet you yearn to be closer -- and when someone you don’t know, or dislike is within touching distance you feel that forcefield being invaded.
Personal space is akin to a bubble surrounding a person which they regard as psychologically theirs -- almost like an extension of their body. When someone gets this close, the part of our brain that deals with emotional responses automatically reacts -- it's being put on flight or fight mode to scan for a survival threat. If someone is accepted in our inner circle -- we enjoy the intimacy, but if the presence is unwanted, we will feel the urge to repulse the space violation. Physical proximity reflects emotional proximity to others.
Being able to flit back and forth between distances is a key part of developing relationships because it provides opportunities to test the reciprocity of the desire to deepen a friendship, build intimacy or develop romance. Now governments and scientists are prescribing the distance we keep. Even as lockdowns ease, social distancing remains the new normal before a vaccine or effective treatment is found.
How interpersonal distances vary by relationship
Social distancing 6 feet apart has shattered our notions of personal space and disrupted relationships.
Public space: 12 to 25 feet.
The distance maintained between a speaker and an audience.
Social space: 5 to 12 feet.
Used for communication among business associates and earliest conversations with strangers.
Personal space: 2 to 5 feet.
Space for friends and family members.
Intimate space: 0 to 2 feet.
Whispering and embracing happens here. It’s the space reserved only for the most trusted and loved in our social circles.
The physical dance of dating and the fluidity of friendship forming have become clunky and difficult. Creating new relationships face-to-face will take more effort. Not only to abide by the guidelines, but also because socializing will require deeper trust. Everyone will know they are responsible for their closest friends and family members through their own social choices.
Twenty-eight-year-old Dave, who preferred not to give his last name for fear of embarrassing his date, went on a socially-distanced first meeting with a woman he’d been messaging for a couple of weeks. They met in a park in London, he said “awkward” was the only way to describe it.
“I couldn’t kiss her on the cheek, or even shake her hand when we met. It felt like being so hyper-aware was creating even more distance between us,” he said.
“The conversation was nice but all the romance was killed. I didn’t realize how much greeting a date warmly breaks the ice.”
How interpersonal distances vary around the world
Our preferred physical proximity to others varies by culture. These instinctive boundaries shape even the closest of relationships.
Evidence suggests that human behavior adapts in epidemics and that we have been shaped by the parasites and diseases we have encountered in the past.
Research from evolutionary and cultural psychologists Mark Schaller and Damian Murray, indicates that people living in regions that have historically suffered from high levels of infectious diseases are less extroverted, exhibit higher levels of social conformity, use less physical contact and like to keep further apart.
By contrast countries which have historically lower levels of disease, exhibit more deviation from social norms, individualism and higher levels of social extraversion.
How exposure to disease affects culture
Societies tend towards becoming more introverted if they are exposed to pandemic diseases throughout their history. Here we use research from 2005 to see how the two figures correlate.
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1How sociable different cultures are Researchers used the NEO-PI-R scale to score levels of extraversion. The scale is used by researchers to study personality traits.
2Past cultural exposure to disease To measure how societies were shaped by past infection outbreaks, researchers use a numerical index based on disease prevalence data.
3The trend line approximates the relationship between how sociable different cultures are and past cultural exposure to disease.
Murray, of Tulane University, researches the cultural consequences of disease threat. He told CNN that in response to the coronavirus pandemic we might see “more wariness of strangers and outsiders” and “lower levels of sociability and extraversion in general.”
“Societies that have had higher levels of pathogen prevalence have more restrictions on civil liberties and higher levels of authoritarian-type governance and conformity in society”
“We will probably see a resurgence of traditionalism, more emphasis on conforming to established norms in the coming years and, not surprisingly, lower levels of physical contact in greetings,” he added.
Murray pointed to studies showing that where “disease threat is higher, you are less likely to see a hug or a kiss or even a handshake as a cultural greeting but more likely to see a bow or something like that.”
He said that the effect goes beyond individual and social behavior.
“Societies that have had higher levels of pathogen prevalence have more restrictions on civil liberties and higher levels of authoritarian-type governance and conformity in society,” Murray added.
There are many reasons some societies will find observing social distancing more unnatural than others. Our preferred distance from strangers already varies between cultures, gender, environment and personal preferences.
One study conducted by the University of Warwick found that the preferred distance for talking to strangers was the largest in Romania, Hungary, Saudi Arabia and Turkey and almost half the distance in Argentina, Peru, Bulgaria and Ukraine. Cultural practices in the US and northern and central European regions involve minimal body contact -- often a handshake. Whereas Mediterranean societies prefer closer and more tactile greetings.
Touch and virtual connection
From before birth to our last moments we need human touch. It is the earliest sense developed in the fetus. Skin-to-skin contact builds trust between child and parent in the early years. Nurturing touch is essential to the development of a child’s physical and cognitive abilities and overall wellbeing. Later it becomes the foundation for forming strong attachments in life.
When we are stressed, fearful or unwell at any age -- touch helps. It produces oxytocin which slows down the release of stress hormones and boosts the immune system.
Prolonged touch -- like massage -- decreases the stress hormone cortisol and increases serotonin and dopamine, which are important for mood regulation and well-being. And in patients with depression, auto-immune disease and HIV it has shown to give our system an even bigger boost.
The benefits of touch go both ways too -- giving, as well as receiving touch has physical and psychological benefits.
Humans need touch, especially when we grieve
Touch or skin hunger is well documented. Distinct from loneliness, it’s a physical need for skin to be stimulated, which is why phone calls or video chat won’t take the feeling away.
Professor Tiffany Field, who works with the Touch Research Institute at the University of Miami, suggests that people who are isolated, engage in more physical exercise -- walking, brushing of hair, yoga and stretching. Any activity which physically moves the skin will help alleviate the yearning.
“Touch is necessary for immune function. Stimulating pressure receptors under the skin slows the nervous system down and halts the release of stress hormones,” Field told CNN.
The benefits of touch
Touching people can be vital when they are unwell. A small touch can release oxytocin which slows down the release of stress hormones and boosts the immune system. A lack of touch can lead to depression, anxiety and stress.
An extended touch can lower stress hormone levels. It can also boost the amount of serotonin and dopamine in the body, which helps regulate mood. These interactions are particularly important for the development of young children.
The comfort of human touch is deeply embedded, which is why we also ache to hug or comfort others when they are suffering.
Nowhere is the lack of ability to soothe the suffering more difficult to bear than when a patient dies without family by their bedside. It deepens the despair of life’s darkest moments.
Fiona Boardman, whose mother died in a care home in England in early April of presumed coronavirus, told CNN that the lack of touch during their final visit with her was the hardest.
“(The) doctor brought us in. We were standing nowhere near her. We didn’t want to say we’ve come to say goodbye, so we said we just wanted to say we were thinking of her, loving her and praying for her,” Boardman said.
“We couldn’t hold her hand and say our goodbyes. You’re just sliding a bit of love under the radar and you hope that it was better than nothing.”
“We couldn’t hold her hand and say our goodbyes. You’re just sliding a bit of love under the radar and you hope that it was better than nothing.”
David Kessler is an author and grief expert who says the need to be with loved ones when they die is one of the greatest challenges that society is currently facing.
“It’s very rare in history that we have had these moments where we are isolated physically from one another,” he told CNN.
“When we are in deep grief we long for physical connections. Our loved one has been physically ripped away from us. So we at least want the others who are alive to be with us, to be holding out hands, to be touching us,” Kessler added.
“You know many times when we are alone, we miss being touched. So just missing that person, holding your hand as you cry, makes all the difference in the world. So that’s why it’s so devastating for people right now.”
Kessler applauds the efforts of health care staff to hold up phones so families can video call during a relative’s final moments.
“It is important we find ways to connect, and when someone dies we still have to grieve in real time,” he said.
But he says video calls can only go so far.
“Virtual connection is never going to make up for real touch, for real presence, but it’s the best thing we have right now,” he said. “So it’s so important to do something, instead of nothing.”
Something, instead of nothing, is a popular refrain these days. The richness and depth of interaction has been replaced with necessary -- but empty -- substitutes. A smiley face is not a smile and pixels don’t evoke proximity -- physically, emotionally or biochemically.
The coronavirus pandemic has stolen lives and the ways we comfort each other at the most profoundly human level. The behaviors that would help alleviate suffering -- showing empathy through body language, being physically close to those we care about and the healing power of touch -- have been taken from us because of the nature of the disease.
The absence of the simplest of all human behaviors has reminded us why they are the most precious and hardest to replace.