Emerson M. Wickwire, PhD, ABPP, CBSM

Imagine you’ve never run a day in your life, except in middle school gym class because you had no choice. And you hated it. Now today your doctor is telling you that you have a new sleeping disease, and the best treatment is running. Not walking or yoga or lifting weights—only running. In fact, you’ll have to run every day for the rest of your life. He proceeds to explain about recent advances in running shoe technology and how much quieter, more comfortable, and more effective these new shoes will be at protecting your joints. Yet even as you agree with the request to order your new shoes right away, you remain unconvinced.

In much the same way, many OSA patients feel ambivalent about initiating PAP therapy. They lack the knowledge, confidence, or motivation necessary to implement a lasting behavior change such as adapting to PAP. As a result, sleep medicine professionals have become increasingly interested in the psychological aspects of PAP adherence. A 2012 editorial in The Journal of Clinical Sleep Medicine noted that “any improvement in PAP adherence rates will more likely occur by addressing social and psychological obstacles to usage rather than newer technical innovations in PAP delivery or interface design.”1

In a recent article in this journal,2 I reviewed an emerging but solid evidence base supporting cognitive behavioral treatments (CBTs) for PAP. For example, psychological variables measured pretitration have identified eventual PAP nonadherers with 86% accuracy.3 Four randomized controlled trials support CBTs for PAP,4-8 more than any other PAP adherence intervention to date. Further, CBTs can serve as a cornerstone of an evidence-based PAP adherence program. In our center, benefits of our comprehensive PAP Success program have included:

  1. Near-universal willingness among patients to complete PAP titrations and PAP adherence well above published averages.
  2. High patient satisfaction and patient-to-patient referrals.
  3. Increased recognition as a preferred center in our area.
  4. Marketplace differentiation and increased referrals as a result of our behavioral sleep program.
  5. Excellent evaluation during our AASM accreditation site visit (no provisos).
  6. Emerging relationships with entities that outsource sleep medicine care.

Non-CBT practitioners can improve patient care by considering PAP adherence in its proper behavioral context, exploring CBT-based recommendations to maximize PAP adherence, and learning from successful CBT program case examples. These CBT-based suggestions will benefit sleep medicine clinicians, PAP equipment providers, and anyone involved in OSA patient care.


Figure 1. Social cognitive theory as applied to positive airway pressure adherence.

A number of high-quality reviews document the myriad of patient-reported barriers that contribute to overall adherence rates in the range of 40% to 50%. The most common complaints include side effects such as nasal dryness, mask discomfort, machine noise, skin abrasion, and so on. Yet these concerns are typically relatively straightforward to resolve. Further, in spite of stunning advancements in PAP technologies during the past two decades, adherence rates have remained relatively stable. Why?


Even under ideal circumstances including sufficient disease knowledge, technical competence, minimal side effects, and high motivation, PAP users are required to develop new behavioral routines. They will perform new tasks including wearing PAP nightly, cleaning PAP most days, replacing filters monthly, attending clinical follow-up appointments, working with a durable medical equipment (DME) provider, and so on. By any standard, acclimating to PAP requires a lifestyle change. With this in mind, let’s consider the psychological aspects of PAP success.


As in other fields of medicine, a number of theoretical frameworks have been proposed to predict and enhance PAP adherence. The most parsimonious and extensively researched psychological framework for predicting and enhancing PAP adherence is social cognitive theory (SCT).9 (See reference 10 for a review of SCT variables and PAP.) SCT postulates that behavior is influenced by three core constructs: perceived environment, outcome expectancies, and self-efficacy. Perceived environment variables include perceptions of social models and vicarious experience, such as bed partner attitudes or social support for PAP. Outcome expectancies include the perceived costs and benefits of using PAP as well as of not using PAP, as well as perceptions of OSA risk. These variables have been consistently related to PAP use. Indeed, perceived benefit of PAP has been consistently identified as the single most robust predictor of PAP use. The final component of SCT is self-efficacy, including both perceived ability to use PAP as well as overall personal self-efficacy and active coping skills. Self-efficacy has strong empirical support as an important and modifiable factor related to PAP adherence. Figure 1 depicts SCT as applied to PAP adherence.

Figure 2. Transtheoretical Model.

For the clinician, the SCT model provides an easy framework to guide inquiry into potential barriers to PAP adjustment as well as to identify resources to facilitate PAP adherence. Even a single question to assess each of these domains can provide powerful insight to develop a personalized treatment plan. For example:

  • Do you know anyone who has used PAP successfully? Who do you know who might support you in this transition?
  • What do you know about obstructive sleep apnea? About PAP? What are your expectations?
  • Has there ever been a time when you changed a habit or learned a new skill? How were you able to do that?

Although these represent only a small sample of possible angles, asking the right questions is the most efficient way to develop a patient-centered treatment plan. The keys are to know which areas to assess and to know when to listen more than speak.


From a motivational perspective, patient readiness is a prerequisite for long-term success in any change effort. Patients who feel rushed may resist or abandon PAP whereas patients who have self-selected PAP as their preferred treatment are most likely to persevere and become long-term PAP users. It is thus incumbent upon the sleep medicine clinician to assess current readiness, resolve ambivalence, and increase buy-in to PAP.

To feel ready, patients must perceive both that using PAP is important and also that they possess the skills and abilities to use PAP successfully. One of the most efficient ways to assess perceived importance and perceived self-efficacy is to ask the patient directly by using a “readiness ruler”:

  • On a scale of 1-10, how important do you think it is for you to use PAP?
  • On a scale of 1-10, how confident are you in your ability to use PAP from now until the next time we meet?

Table 1. Wickwire’s Three Levels of Learning

My rule of thumb is to aim for a rating of 8 or greater on a 10-point scale before advancing. If a patient reports a lower score, then I ask, “What might make that number higher?” Depending on patient response, we might lower the bar (shoot for 2 hours nightly use instead of 8), recruit social support from the patient’s network, or implement a creative reward system. Regardless which techniques you employ, collaborating to set realistic goals will help maximize patient buy-in. Similarly, explicitly reinforcing all patient self-care will help maintain behavioral momentum.

Another cornerstone CBT tool for increasing motivation is the decisional balance exercise. This in-depth exploration of patient perceptions regarding pros and cons of PAP can provide a powerful catalyst to move patients from precontemplation to contemplation, action, and beyond (see Figure 2).11 When identifying pros of PAP, it can be especially helpful to identify important life goals and personal values that might be supported by PAP. For example, if a patient would be better able to spend time with loved ones were she less sleepy during the day, then this can be a powerful motivator to use PAP. In addition, patients are asked to explore the pros and cons of not using PAP. Although this may initially seem counterintuitive, some of patients’ greatest aha moments take place when they first realize the benefits of the status quo. They are thus empowered to choose consciously a new future of self-care.


Once patients are ready to initiate PAP, we use specific goal-setting strategies based in the sport and performance literature. Patients clarify behavioral objectives under their control that are specific, motivational, assessable, realistic, and time-based. As part of this exercise, patients identify potential barriers to PAP and how they will overcome them, as well as individuals who can support them during the transition to PAP. A final component of the goal-setting process is to incorporate rewards for adherence. Patients leave each CBT encounter with specific action steps, contingency plans, social support, and meaningful rewards in place.


At the Center for Sleep Disorders at Pulmonary Disease and Critical Care Associates, we employ a team approach to maximizing PAP adherence. Everyone from front desk staff to sleep physicians understands and can respond to patient queries regarding our comprehensive model, PAP initiation, CBT, and other components of the program. To present a unified front, we provide in-service training to encourage consistent and supportive language regarding PAP.

In our practice, a behavioral sleep specialist administers all CBT for PAP. During assessment, patients complete validated measures assessing perceived costs and benefits of PAP, perceived self-efficacy to use PAP, insomnia, and so on. These results are reviewed with the patient, and provider and patient collaborate to develop a personalized treatment plan. Patients are instructed what to expect at each stage of the process. In developing our model, the original manual of Aloia et al4 was an invaluable guide.

Treatment session 1 focuses on the three levels of PAP learning (Table 1) and concludes with initiation of the decisional balance exercise. Session 2 expands upon the decisional balance exercise and emphasizes self-management approaches for long-term success. During either visit 1 or visit 2, a guided imagery/PAP desensitization exercise is administered, and patients are provided a take-home CD for daily practice. Any subsequent CBT sessions focus on troubleshooting and maintaining gains. For an uncomplicated patient newly prescribed PAP, a typical course of treatment lasts two to three visits. Combined CBT for PAP and CBT for insomnia may take four to eight visits.


The field of sleep medicine has entered a transition phase of increased attention to cost-effectiveness and measurable patient outcomes. Thus, maximizing PAP adherence is an important goal shared by all in our field. Clinicians and researchers have sought to emulate other, well-established chronic disease models and have thus become increasingly interested in the psychological aspects of PAP success. CBT for PAP is a promising intervention with consistent empirical support. More important, adopting a behavioral perspective and incorporating the CBT principles presented in this article will help maximize treatment buy-in and PAP adherence among your patients. In future articles, we will consider strategies for program expansion such as clarifying your vision, training requirements, staffing needs, and leveraging technology for online or remote administration of CBT.

No matter how high-tech running shoes might become, the shoes will never run themselves. Every morning, the runner will still have to decide to pull on his socks, tie his laces, and choose to get moving. As providers, it is our job to ensure the runner possesses the knowledge, skills, motivation, and support to maintain long-term success.

Emerson M. Wickwire, PhD, ABPP, CBSM, is sleep medicine program director at Pulmonary Disease and Critical Care Associates in Columbia, Md, and assistant professor, part-time, at Johns Hopkins School of Medicine. He serves on the Education Committees of the American Academy of Sleep Medicine and the National Sleep Foundation. He encourages questions and can be reached at [email protected].

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