PAP Therapy Rejection and the Role of Emotion: Social Emotions (Part II)

In the previous post, we talked about fear, which usually arises during the development of an externally perceived threat, for example, when the mask feels like it is compromising your breathing. As we now move to the “social” emotions, the threat remains external, but it takes the form of another person’s response (or your imagined understanding of the response) when you put on the mask or start up the pressurized airflow. That’s the reason for using the term social emotions as it refers to shame, embarrassment, or guilt—feelings we almost always generate in relationship to another person or a memory of an event with another person.

In general one of these social emotions will surface because you believe you are doing something (using PAP) that creates a negative interaction between you and the other person, the latter usually being a spouse, another loved one, a roommate, etc. The most commonly reported scenario would be where the use of the device annoys the other person or tangibly interferes with the other person’s sleep. At that point, the interaction may evoke feelings of embarrassment, shame or guilt, because you have caused a problem for the other individual.

Although the example above is clear-cut in terms of cause and effect, social emotions are usually more complex or subtle in the way they manifest, such that it may prove very difficult for sleep technologists or sleep physicians to connect the dots and recognize this problem before it overwhelms the patient. This confusion arises, because many patients will never tell us about these negative responses from the other person in the equation. Instead, it would be more common to hear the patient describing lots of hassle factors about using the device, which for whatever reasons never quite seem to resolve to the satisfaction of the patient—not that the patient could not also experience a higher sensitivity to the adjustments required to gain comfort with pressure and masks. In fact, such a patient may be that much more on edge and therefore develop a hypersensitive response when trying to adapt to the device equipment from headgear to mask to cushions to tube placement to pressurized air. Still, the deeper issue may often simply be the patient’s own awareness of the other person’s inevitable negative response, which inexorably steers this patient away from wanting to use the device. The patient knows full well that when the moment of truth arrives in the bedroom, embarrassment will surface as soon as the bedpartner scowls. Like so many negatively-perceived emotions, who would want to feel shame, embarrassment or guilt? If you don’t want to feel these feelings, it’s easy, don’t use PAP. 

Again, these emotional issues usually run still deeper. After all, while it makes some sense that someone else can experience unpleasantness when you are using the PAP device, chances are high these issues could be solved. The other person could use earplugs or the bedroom furniture can be rearranged accordingly. Some people do need to switch to separate beds and rarely some switch to separate bedrooms, but in the big picture, isn’t it worth reducing your daytime sleepiness, getting your blood pressure under better control, reducing the number of trips to the bathroom at night, and overall decreasing your risks for cardiac problems?

This question goes to the heart of the matter, because if the shame is so great the individual would forego treatment just to prevent the unpleasantness or awkwardness in the relationship, then it suggests the emotional distress is not only much deeper but also more likely to be more entrenched in the psyche of the individual rejecting PAP therapy. Think about it. If your blood pressure were blatantly out of control and medications were no longer working optimally and your doctor advised you of your skyrocketing risks for a stroke, what on earth would stop you from using a device with a strong potential to lower your blood pressure? The answer should be nothing on earth would stop you, right?

However, if deep within your mental landscape, so to speak, the person is really dealing with very weak emotional coping skills or perhaps more accurately stated, poorly developed emotional coping skills, then this individual is most likely feeling shame at a much higher level and from OTHER THINGS that occurred much earlier in his or her life. These other things are likely to be numerous or recurrent experiences in the life history of this individual including examples such as: a highly chaotic, joyless and unpleasant childhood; a painful adolescence filled rejections, heartbreaks, and failures; and very commonly, difficulties in identity formation to gain a normal sense of integrity about self. Worst of all, for some people, it could involve specific life episodes of a traumatic nature where the individual would naturally feel ashamed about something they did wrong or was made to feel ashamed by someone transferring the blame. For so many reasons and invariably unique to each person, in the former instance the individual never learns how to work through this shame to attain the necessary state of forgiveness, which may include atonement involving the injured party or resolution from within. In the latter instance, the individual may never realize or believe the fault lay elsewhere. Most of us can recall accidents that occurred in childhood or adolescence in which someone was injured by unintentional albeit reckless or inattentive actions of another. These actions led the person to feel shame about the hurt caused to another as most people do feel embarrassment, shame or guilt (if not all three) in such circumstances, and yet most people generally find a way move on.

It is highly likely that an encounter with a patient who rejects PAP do to embarrassment or shame or guilt is really dealing with underlying issues from any or all these social emotions. Like fear, it may be impossible to help this patient, until there is a willingness to dig deeper to find out why he or she places his or her own health status below that of someone sleeping in the same bedroom.

There are myriad ways in which the superficial complaints proffered by the patient about attempting PAP use can actually represent deeper issues the patient chooses not to discuss openly. The person who reports feeling embarrassed about putting on the mask in front of the bedpartner or trying to sleep in the same bed may in truth have deep concerns about a fragile romantic relationship. While PAP therapy is not advertised as a sex toy, it will improve one’s energy level and may increase libido. Yet, PAP is certainly not a cosmetic enhancement, and I’m not suggesting you need to find kinky ways in which to incorporate the device into your sex life (though I wish you good fortune in your efforts!). Truth be told, you can make love before you go to sleep, and you can also make love any time during the night by removing the mask. All these things are possible and most likely engaged in by regular users of PAP devices. But, for the person who cannot tap into the deeper concerns about the embarrassment felt in the bedroom environment, odds are very high PAP will be used minimally at best.

Guilt is its own special affair; if your device disrupts sleep through noise or blowing air into your bedpartner’s face, then you not only damaged his or her slumber, but also you affected how he or she functions the next day. If you hurt someone in this manner, you would usually feel remorse or guilt and apologize for your actions. Unfortunately, if this sequence repeats itself every night, then it’s a nonstarter that you would apologize every night and every morning.   Instead, as above, you would need to switch to another bed or bedroom. But, then of course, you might feel guilty if your lover felt abandoned by you, and you might feel lonely, not to mention embarrassed or ashamed or guilty again about your abandonment of your bedpartner.

What to do? It is not surprising but it is true that many patients will not avail themselves of brief marital therapy, which would likely overcome those issues directly relating to the use of PAP therapy in the bedroom. That so few patients take this step suggest many sleep professionals do not make such referrals, or more likely, most patients do not follow this advice. Occasionally, we persuade the patient to come to an appointment as a couple so that some degree of dialogue can be generated on the topic at hand. These folks may benefit from such discussions, but as above, when the issues involved are much deeper both on the personal level for the patient and perhaps more so in terms of marital relationships, then unquestionably longer term psychotherapy may be the best hope for helping this patient.

During a few of these encounters, I have seen patients release a great deal of emotional tension, usually with crying but sometimes with an angry outburst. In many such instances, there is a type of sadness or grief that appears to go to the heart of the matter. We’ll discuss those scenarios next.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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