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Behavioral Therapies
Behavioral TherapiesTinnitus can trigger strong, negative emotions, including anxiety, depression, and anger. Patients can learn to control their emotional reactions and thereby disassociate tinnitus from burdensome negative behavioral responses.
Cognitive (adj. form of cognition) — involving or related to the functions of attention, knowledge, memory, judgement, reason, and decision-making
Behavioral — involving or related to physical, emotional, and psychological action
Behavioral therapies, which focus on the patient’s emotional reaction to tinnitus, are among the best established and most effective treatments for burdensome tinnitus. These approaches have consistently been shown to reduce tinnitus-related distress, anxiety, and depression, and to improve the overall quality of life for patients.
The rationale of behavioral treatments is that “severe” tinnitus is defined by its emotional toll, not its acoustic characteristics. (Research shows that there is little correlation between tinnitus loudness/pitch and patient-reported distress.) What makes the condition truly burdensome are the negative psychological and cognitive reactions patients have in response to tinnitus. In other words, the patient’s emotional response is the key factor in whether the tinnitus is perceived as bothersome or non-affective, deeply distressing or a minor annoyance. The goal of behavioral therapies is to help patients control their reactions to tinnitus, and thereby reduce the perceived impact of the condition.
Patients who pay close attention to their tinnitus and who lack emotional coping techniques are generally more depressed, more distressed, and have higher perceived handicaps related to their condition. Behavioral therapies provide skills to reduce attention to tinnitus, improve coping, and devise alternative thinking and behavior patterns that help patients alleviate the negative impact of tinnitus on day-to-day living. The overall objective of therapy is to increase pleasant activities, learn relaxation techniques, reduce monitoring of tinnitus, and build cognitive skills that replace negative (or unhelpful) thinking.
Therapy can be delivered individually, in group-settings, online, or through teletherapy sessions. There is growing evidence that therapy delivered through virtual conferencing, online, or on the telephone is as effective as in-person; but it depends on the patient and his/her needs. From an accessibility standpoint, telehealth makes it easier to access help. However, not all insurance plans cover it.
The outcomes evidence for behavioral tinnitus therapies are robust. A 2010 meta-analysis of eight research studies showed significant improvement in self-reported depression and quality of life for patients completing a therapy program. A 2014 review of research literature showed that these treatments consistently and significantly decreased tinnitus severity and impairment, reduced tinnitus-related fear, and lowered general depression and anxiety. Moreover, the patient improvements after psychological therapy were found to be stable and long lasting — with benefits continuing as long as 15 years after the end of treatment.
On this page, we are using “behavioral therapy” as an umbrella term for a variety of different tinnitus treatments. While these individual practices may have slight variations (depending on the protocol or even individual clinician) they all generally include: patient education, analysis of emotional triggers, exploration of the patient’s thoughts and beliefs about tinnitus, applied relaxation techniques, investigation of the patient’s emotional reactions to tinnitus, and an assessment of the patient’s avoidance behaviors.
Cognitive Behavioral Therapy (CBT)
This is the generalized treatment term used to address a variety of issues, including the negative emotions associated with tinnitus. Many clinicians, particularly those who do not explicitly specialize in tinnitus management, may use this general term. However, even as a general practice, CBT has been shown to significantly help many patients struggling with tinnitus.
Here are links to a webinar and a podcast by Dr. Bruce Hubbard, a leading CBT and tinnitus specialist, on how CBT can help those with tinnitus.
Podcast:
Webinar:
Here is a wonderful webinar by Dr. Bruce Hubbard, Director of the Cognitive Health Group on CBT and how it can help those with tinnitus.
Mindfulness-Based Stress Reduction (MBSR)
A therapy that emphasizes “mindfulness” — an acute and non-judgemental awareness of one’s physical sensations, sensory perceptions, emotional reactions and cognitive processes. Rather than struggling (often in vain) to ignore tinnitus, MBSR teaches patients to wholly accept, embrace, and control their experience. In doing so, patients put themselves in a better position to manage their condition. It can also addresses negative feelings of anger and apathy that so often accompany tinnitus.
Acceptance and Commitment Therapy (ACT)
Like other mindful-based approaches, ACT emphasizes the need to reduce experiential avoidance of tinnitus. Patients are taught to fully experience thoughts, perceptions, and emotions in a direct, non-judgemental way. By fully accepting even negative thoughts and feelings, patients can find greater control over those reactions.
Tinnitus Activities Treatment (TAT)
A variation of CBT that focuses specifically on tinnitus management. TAT follows an incremental learning-based approach to explore four impact areas of tinnitus: thoughts and emotions, hearing and communication, sleep, and concentration. The process also generally uses low-level supplemental sound therapy for masking purposes.
University of Iowa's Tinnitus Activities Treatment Materials
Attached below is a PowerPoint presentation of the University of Iowa's Tinnitus Activities Treatment (TAT).
Iowa's Tinnitus Activities Treatment Summary.pptx
Also, here is an interview from Spring 2018 about TAT from a clinician's perspective with Shelley Witt, AuD, a research audiologist in the Department of Otolaryngology — Head and Neck Surgery at the University of Iowa. Witt has treated thousands of patients using TAT.
For more information on using TAT with patients, contact Rich Tyler, PhD, at the University of Iowa via email: rich-tyler@uiowa.edu.
Tinnitus Retraining Therapy (TRT)
A treatment regimen that combines the use of traditional CBT counseling with supplemental sound masking to habituate patients to tinnitus. The counseling component aims to demystify tinnitus and help patients reclassify tinnitus as an emotionally neutral signal. Constant low-level broadband sound is used to habituate the patient to tinnitus.
Progressive Tinnitus Management (PTM)
Developed by the U.S. Veterans Administration’s National Center for Rehabilitative Audio Research, PTM is an incremental approach to tinnitus treatment that involves comprehensive patient education, behavioral therapy, and when appropriate, supplemental sound therapy. To access the FREE digital version of the Progressive Tinnitus Management workbook and other materials, click here.
Considerations
Multidisciplinary Healthcare: Behavioral therapies for tinnitus typically require patients to see a behavioral health specialist in addition to a hearing health professional. It may also require coordinating care across multiple doctors, increasing the complexity and cost of treatment.
Time and Effort: Behavioral therapies also tend to involve multiple clinical sessions over the course of several months to several years, depending on the patient. Results are cumulative, and successful treatment often requires the full completion of therapy sessions.
Commitment: All tinnitus management programs require that the patient embraces the treatment protocol with an open mind and positive expectations. This may be particularly true for behavioral treatments that rely heavily on active and transparent patient involvement.
References
Cima, R., Andersson, G., Schmidt, CJ, and Henry, J. (2014) “Cognitive-Behavioral Treatments for Tinnitus: A Review of the Literature.” Journal of the American Academy of Audiology, 25: 29-61.
Gans, J. (2014) “Mindfulness: Changing the Brain to Change our Perception of Tinnitus.” Tinnitus Today, 39,1: 24-25.
Jastreboff, P. and Jastreboff, M. (2000) “Tinnitus Retraining Therapy: An Update.” Hearing Review, Available at: http://www.audiologyonline.com/articles/tinnitus-retraining-therapy-an-update-1286 (Accessed March 11, 2015.)
Martinez-Devesa, P., Perera, R., Theodoulou, M. and Waddell, A.. (2010) “Cognitive Behavioural Therapy for Tinnitus.” Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD005233. DOI: 10.1002/14651858.CD005233.pub3.
Robinson, S. (2005) “Cognitive Behavioral Therapy - The Basics.” Tinnitus Today, 30,3: 11-12.
Tyler, R.S., Gogel, S.A.. and Gehringer, A.K.. (2007) “Tinnitus Activities Treatment.” Progress in Brain Research,166:425-34.