An unfamiliar therapist

During the Covid-19 pandemic, mental health professionals are conducting diagnostic examination and therapeutic intervention under conditions that are unprecedented: by wearing surgical, plastic or black masks, mental health professionals' facial expressions and emotions are much less visible to their patients. These important protective measures are accepted by many patients, but for some, masks can affect communication with their therapists. I have found that my patients with Capgras delusion are likely to have extreme emotional and behavioural reactions.

Capgras delusion, sometimes known as Impostor Syndrome, is a very rare disorder in which a patient begins to believe that one of their significant others, usually a family member, has been kidnapped and/or replaced with an identical person [1, 2]. This delusion can occur among patients with a psychotic disorder, although it sometimes occurs in patients with prosopagnosia, dementia or after trauma to brain neurons [3]. Possible aetiological factors are dopamine imbalance, lesions in the prefrontal cortex or in the connection of the optic nerve with the amygdala, and the reduced function of the right cerebral hemisphere [4–6]. All proposed psychotherapeutic approaches are built within a supportive framework, where feelings of panic and suspicion are reduced, and individuals feel safe. These approaches become more difficult when the therapist is wearing personal protective equipment (PPE), as I have discovered during the pandemic.

When a patient with Capgras delusion sees their mental health professional with a different appearance – their face and hands covered – but in the same environment that they always meet, the patient is convinced that their anxiety concerns the professional (and not themselves). The patient experiences a conflict in the perception of the therapist's body image, and by not having clear self-boundaries (between the inner experience and the external reality), is convinced that the person opposite is an identical imposter who has replaced the therapist [7–9].

Suspicion, mistrust, irritability and aggression can result from the confusion that accompanies a psychotic disorder [10, 11], which is reinforced by a body image of a therapist who looks unfamiliar, causing a rupture in the therapeutic alliance. The lack of connection between the inner experience and the outside reality (thought disorder), if not due to brain damage or a degenerative disorder (e.g. Parkinson's or Alzheimer's  disease), often characterises psychotic disorders [12, 13], as there are no associative chains that allow the external environment to connect with the internal conflicts the patient experiences. The PPE now worn by mental health professionals appears to act as a further disruption that enhances the destructiveness of Capgras delusion, resulting in a more severe relapse of the patient's symptoms. 

The therapist and family members try to persuade the patient to work with an 'identical-looking imposter' [14]. At this point, the patient's aggression can be transferred from the therapist to their family members, disrupting the existing supportive emotional connections [15]. This makes the patient even more vulnerable, and the literature suggests that professionals should not oppose and correct the patient, but better recognise and focus on their feelings, in order to stop the vicious circle of anxiety, the derealisation and depersonalisation [16–18].

The violation of a mental health professional's body image boundaries reduces the patient's ability to connect inner experiences with external reality [19]. In order to prevent the patient's deconstruction of boundaries, the therapist's body needs to regain its lost image, and its therapeutic unity. The therapist's form and content appear to be levers that help patients to regain their own lost unity. 

Mental health professionals should communicate with patients before the therapy session, explaining the necessary use of PPE during the pandemic, thus reducing patients' confusion and surprise, while preventing conflicts that may harm the therapeutic relationship. This communication can enhance the link between inside and out, preventing further thought disorders. 

Where strong suspicion is detected regarding the replacement of the therapist with an identical-looking imposter, an online video meeting could be arranged. The therapist would have no medical equipment, revealing their face and smile, as well as their optimism regarding the course of treatment. The psychotherapeutic techniques or changes in pharmacotherapy proposed should be more readily accepted by the patient under these conditions, enhancing adherence to the treatment. 

Modern challenges in clinical practice observed in unprecedented global phenomena such as the Covid-19 pandemic can only be addressed if mental health professionals formulate case studies of their current patients and make them available to the general scientific community. 

-       Charalambos Costeris, MSc, MA, PhD, is a Clinical and Health Psychologist, and a Research Associate at the Integrative Behavioral Health Research Institute, Pasadena, CA

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