Update - Positional Sleep Apnea Therapy

[ems]

Hi NightMonkey

Withholding therapy because someone will not do what the therapist suggests is only to be used when the client is using their time with the therapist to serve a purpose unconnected with the stated aim of the therapy, and, by choice, continually sabotages the therapy.

Precisely.

[VVV]

I have a friend who has been a mental health counselor for years and another friend whose wife is a mental health counselor.

They both have told me that they have discontinued therapy to some patients. The cases I remember are:

- A lady was recommended to talk to some of her relatives who were involved with her in a traumatic event. She was urged to do this over several months and never did it. The therapist finally told her she could no longer help the patient. The end of the story was happy because the patient later called the therapist back and said she had long conversations with her relatives and was feeling much better.

- The other counselor told me that with some patients he gets quickly to the point where the spouse needs to attend the sessions. Sometimes the spouse refuses. The counselor has discontinued treatment in a number of cases for this reason. Followup has been mixed - some patients worked out the problem and other patients he never heard from again.

Both related some other cases where they discontinued treatment but I don't remember the details.

With my experience with sleep apnea and CPAP, if I were a mental health counselor, I could not in good conscience sit and talk to a patient and take their money if I thought they had a sleep disorder. You could say I would not discontinue treatment but I would transfer the treatment to an appropriate practitioner - a sleep doctor.

For those of you who think discontinuing treatment is wrong, let me ask you something. If you were having your back treated by a chiropractor and he began to suspect you had a cancerous tumor would you not expect him to stop treating you and insist you visit an oncologist? Even if you objected?

Something has gotten badly off track in this thread. That therapist failed in his duty by failing to get the lady to a sleep doc. I don't see how costs are an objection because 18 months of unproductive talk therapy is expense with no return. Apply the money to a sleep study up front instead of 18 months later.

[Cuda]

Maybe you need to be someone that pays for it all like I have to. 18 months of talk therapy is much easier to handle than a sleep study and the gear to treat it. Others are scared because once you have OSA on your record kiss getting private insurance goodbye if you are self employed (which in turn can mean losing your entire life savings if some other illness befalls you thus lowering the standard of living of your whole family). Of course cost should not be a factor, then again those saying that have insurance so cost is not a factor. Maybe you need to realize your situation is not everyones situation.

A therapist that gets you to do something by removing all help will have to live with what that actually means, possibly pushing the patient into a situation where they think all hope is lost. Any idea what people tend to do when all hope seems lost?

I'll give you a hint, its worse than anything else that can happen.

[jnk]

It can sometimes be good when therapists admit to a patient their own limitations and inablility to find a way a way to be helpful when that is the case. That way a patient has the opportunity to find someone who can help him without dictating to him his every decision in life.

. . . if I were a mental health counselor, I could not in good conscience sit and talk to a patient and take their money if I thought they had a sleep disorder. . . .

It is good for all of us to recognize our limitations as to what we could or could not do. That saves us from entering a field we are not cut out for.

. . . That therapist failed in his duty by failing to get the lady to a sleep doc. . . .

Docs, let alone non-docs, are never responsible for forcing people into elective medical therapies. So, by your measure, as I read it, everyone on the planet who obeys the law is a failure.

A parent may have a right to force a minor to get a sleep study. Other than that, other people do what they do, and the rest of us try to be helpful any way we can. We give them information then let them make decisions according to their conscience, not ours. If I chose only to be helpful to human beings who conform to my thoughts on what they should do medically, I would consider myself a failure as a human being. But hey, that's just me.

That said, I agree fully that when a therapist recognizes he has nothing helpful to say, he is being helpful to admit that to the patient so that the patient can find someone more helpful than he. But when someone is in pain (emotionally or physically, either one), you don't create a hostage situation by denying them pain-relief until they decide to start handling their other medical decisions in harmony with your ideals.

For example, what if someone insisted on positional therapy alone to treat documented OSA, despite, in my view, of its obvious limitations compared to PAP therapy? Would I still try to be helpful to that person in other ways? (See, I'm almost on topic here for a second!)

Just my opinionated 2 cents. I respect your views, VVV.

[VVV]

Maybe you need to be someone that pays for it all like I have to. 18 months of talk therapy is much easier to handle than a sleep study and the gear to treat it.

You make some assumptions about me to bolster your argument, but it is an invalid argument. In any case, my insurance will not pay for a sleep study and will not pay for any CPAP equipment. It will also not pay for mental health counseling.

A therapist that gets you to do something by removing all help will have to live with what that actually means, possibly pushing the patient into a situation where they think all hope is lost. Any idea what people tend to do when all hope seems lost?

I'll give you a hint, its worse than anything else that can happen.

Why hint about it? Why not say "suicide"? That is my concern also. I think what you are arguing for will more likely lead to "loss of all hope". I can only imagine someone with sleep apnea going to a therapist for 18 months and not treating the sleep apnea. They are not getting better during that 18 months because their sleep apnea is untreated. At what point do they say, "I have seen this therapist over and over. We have talked about all details over and ove. I am still very ill. It will never work. All hope is lost."

Cuda, That seems to me to be the case you are defending.

Now you talk about costs for someone without insurance. The patient has wasted 18 months of counseling fees and still has to be able to afford sleep studies and CPAP equipment.

The logic of those who defend the reported course of treatment escapes me.

I will repeat myself. That therapist failed in his duty by failing to get the lady to a sleep doc early in the treatment process.

You can parse my post, pick at individual sentences, make assumptions to bolster invented arguments, say you respect my views, but it does not change the fact that the therapist failed to adequately address the fundamental problem for 18 months. My expectations of medical care are much higher than that.

[mars]

I have a friend who has been a mental health counselor for years and another friend whose wife is a mental health counselor.

They both have told me that they have discontinued therapy to some patients. The cases I remember are:

- A lady was recommended to talk to some of her relatives who were involved with her in a traumatic event. She was urged to do this over several months and never did it. The therapist finally told her she could no longer help the patient. The end of the story was happy because the patient later called the therapist back and said she had long conversations with her relatives and was feeling much better.

- The other counselor told me that with some patients he gets quickly to the point where the spouse needs to attend the sessions. Sometimes the spouse refuses. The counselor has discontinued treatment in a number of cases for this reason. Followup has been mixed - some patients worked out the problem and other patients he never heard from again.

Both related some other cases where they discontinued treatment but I don't remember the details.

With my experience with sleep apnea and CPAP, if I were a mental health counselor, I could not in good conscience sit and talk to a patient and take their money if I thought they had a sleep disorder. You could say I would not discontinue treatment but I would transfer the treatment to an appropriate practitioner - a sleep doctor.

For those of you who think discontinuing treatment is wrong, let me ask you something. If you were having your back treated by a chiropractor and he began to suspect you had a cancerous tumor would you not expect him to stop treating you and insist you visit an oncologist? Even if you objected?

Something has gotten badly off track in this thread. That therapist failed in his duty by failing to get the lady to a sleep doc. I don't see how costs are an objection because 18 months of unproductive talk therapy is expense with no return. Apply the money to a sleep study up front instead of 18 months later.

VVV

Well, at least we can be thankful you are not a Mental Health Therapist. I have never heard such ignorant garbage in all my life ! And I am not impressed by what you say about your 2nd example, but I think it likely you have misunderstood, as you have everything else about the practise of therapy.

Here is how you want it -

Client: I really feel like going out and shooting somebody

Therapist: And how do you sleep at night ?

Client: What !

Therapist: How do you sleep at night ?

Client: Look, I sleep pretty good but wake up tired. now, about me wanting to shoot someone

Therapist: Sorry, before we go any further you must have a sleep study because you might have sleep apnea.

Client: Never heard of it, and I'm not here about sleep, I'm here about my wanting to shoot someone

Therapist: Sorry, I cannot help you, you must have a sleep study.

Client walks out in a rage, comes back with a gun and shoots the Therapist

And who can blame him

As for example -

If you were having your back treated by a chiropractor and he began to suspect you had a cancerous tumor would you not expect him to stop treating you and insist you visit an oncologist? Even if you objected?

I would expect him to continue treating me for the reason I was there, and to refer me if he thought that was needed. You seem to totally ignore that a person who might need a sleep study does not have to stop everything else, but can continue with all other treatment. Those of us with sleep apnea are not stupid, and can benefit from counselling and therapy like anyone else.

and

That therapist failed in his duty by failing to get the lady to a sleep doc.

More nonsense from someone who has not a clue about what they are spouting off about. And how is the Therapist supposed to get the lady to a Sleep Doc. Kidnap her perhaps. "Failing in his duty" indeed - arrant rubbish.

You do realise that you are inciting all therapists to commit a crime, don't you. As well as totally disrespecting their clients.

(Edited to remove unnecessary offensive remarks, the necessary one's I have left in )

Mars

[ems]

More nonsense from someone who has not a clue about what they are spouting off about. And how is the Therapist supposed to get the lady to a Sleep Doc. Kidnap her perhaps. "Failing in his duty" indeed - arrant rubbish.

Of course! He thought perhaps I "might" have sleep apnea... he didn't know I had sleep apnea. He suggested that perhaps a sleep study might give us both more ideas about why I had little energy or motivation and was tired all the time. He suggested other things during our sessions, a sleep study was just one of them. Whether or not I decided to have a sleep study or do any of the things he suggested from time to time, was entirely up to ME! For him to tell me he wouldn't see me unless I did everything he suggested is so ridiculous it's beyond the beyond.

Again, if he said he would no longer see me unless I did everything he suggested, I would have laughed in his face. I may have even shot him!

[jnk]

shot

Would you like to talk about how it made you feel to say that, ems?

Oh, wait, the other line is ringing, just a second . . .

. . . It's the Feds. They would like to speak to someone in this thread about all the talk of kidnapping and shooting and hanging upside down and stuff.

Mars, would you like to take that call?

[ems]

shot

Would you like to talk about how it made you feel to say that, ems?

He is a very nice person and a great therapist. Others I may consider shooting tho!

[mars]

shot

Would you like to talk about how it made you feel to say that, ems?

Oh, wait, the other line is ringing, just a second . . .

. . . It's the Feds. They would like to speak to someone in this thread about all the talk of kidnapping and shooting and hanging upside down and stuff.

Mars, would you like to take that call?

Hi JNK

Are you implying the FBI don't know what they are doing ?

After all - they called you, not me

And we all know they don't hassle innocent people. Besides, there is less paperwork if they go after you

Your friend

Mars

PS - Obviously positional sleep apnea therapy is a dangerous subject on a cpap forum .

[JonnyH]

I suspect my wife as positional apnea. She snores a lot on her back. If I can get her to sleep in a recliner chair, do you think that will work to fix it?

[Julie]

Well, it might help, but really you can't just fling something at it and cross your fingers - you need to have some structure so you know what is happening (as you would with the software), and only a proper (even an at-home one) study could do that... If you can get hold of an apap machine and some decent advice on how to use it (with a comfortable and well fitted mask) you might be able to titrate her over time, at least find out if it helps, but 'just' trying a recliner out of the box is not sufficient.

What you could do is help in keeping her off her back at night - people even use tennis balls sewn into pajama top backs, but foam bolsters are a good start - until you can get a better test.

[jamiswolf]

JohnnyH wrote: I suspect my wife as positional apnea. She snores a lot on her back. If I can get her to sleep in a recliner chair, do you think that will work to fix it?

That's usually recomended for people who sleep better with there head elevated. She would still be on her back.

Multiple pillows or a large wedge pillow can prop her up on her side.

I

nk wrote: A home oximeter tells us nothing about how well we sleep and how many arousals we have that may be ruining our sleep. Treating SDB is about sleep, not just O2 saturation.

I hesitated responding to this since it might end up triggering more nonsense.

But this is serious mis-information. Sleep doctors use oximetry to guage effectiveness of therapy...or at least mine does.

Apneas cause desats which show up on oximetry.

But if Ink says it has nothing to do with sleep quality...well it must be true.
Jamis

[jnk]

A home oximeter tells us nothing about how well we sleep and how many arousals we have that may be ruining our sleep. Treating SDB is about sleep, not just O2 saturation. . . .

I hesitated responding to this since it might end up triggering more nonsense.

Nonsense? From whom?

I am glad you responded. It is a key point of mine that I end up having to make a lot.

But this is serious mis-information. Sleep doctors use oximetry to guage effectiveness of therapy...or at least mine does.

Apneas cause desats which show up on oximetry.

But if jnk says it has nothing to do with sleep quality...well it must be true.
Jamis

Not necessarily. I am wrong a lot.

But I would ask that you read my statement carefully. I am not saying that O2 is unimportant. O2 saturation is one thing that PAP improves, but it is not the ONLY goal of PAP therapy.

That is why checking one's own sustained O2 saturation might be useful, but it is not, by any stretch, the final measure of sleep quality.

That is because it is possible for us to self-titrate pressure high enough to stop low overall O2 but still not have pressure high enough to stop all the disturbance of sleep. And disturbance of sleep can do a lot of damage physically, mentally, and emotionally--EVEN WHEN O2 saturation looks fine on a home oximeter.

The oximeters used in a sleep study are used to identify the quick desats that help to identify events. But few home oximeters are that sensitive. And a full lab/center PSG monitors arousals, not just desats.

That is why I feel it necessary to point out to the home-oximeter obsessed that . . .

A home oximeter tells us nothing about how well we sleep and how many arousals we have that may be ruining our sleep. Treating SDB is about sleep, not just O2 saturation. . . .

The point is that oximeters measure O2, not arousals.

To sum up, you can have arousals without having any desats show up on your home pulse-ox. Those arousals can disturb the quality of our sleep in significant, but silent, insidious ways. That is why a good sustained O2 level, as important as that is, does NOT prove you are sleeping well. It only proves you are breathing well enough to keep your O2 levels from dropping. And that is not necessarily good enough. And that is why real sleep studies glue wires to our heads and all that other cool stuff and hook us up to a sensitive, calibrated, accurate oximeter that catches the quick dips that can indicate significant events, instead of just plucking a $100 Chinese home pulse ox on the end of our fingers that mostly only catches sustained drops, and then calling that good.

Hope that wasn't too nonsensical. I'm actually a pretty serious guy when it comes to the sleep stuff. And I have a few home pulse-oxes that I occasionally use during sleep. I just think it is important to know what the info from our home oximeters does, and does not, tell us, so we can make decisions that are more fully informed than: "Hey we can all prove what we're doing is effective by simply checking what our home pulse-oxes tell us!"

[ems]

Not "nonsensical" in the least. Even I understood it, and I'm still very much a newbie.