Cognitive Behavioral Therapy Versus Tinnitus Retraining Therapy: Similarities and Differences

By James A. Henry, PhD

Cognitive behavioral therapy (CBT) and Tinnitus Retraining Therapy (TRT) are perhaps the two best-known and studied methods of tinnitus management around the world. According to systematic reviews of the scientific literature, CBT is generally considered the method with the strongest research evidence, based mainly on randomized controlled trials.1,2 TRT is not ranked as highly, but several studies have demonstrated its efficacy.3–5 Both CBT and TRT have credibility for tinnitus management, but people often misunderstand and are confused about what they involve, how they should be conducted, and which practitioners are qualified to offer the methods. This article aims to bring some clarity to how the methods differ.

orange gearsBrief Overview of CBT

The use of CBT for tinnitus was adapted from the prior use of CBT for pain, anxiety, depression, and insomnia.6–8 As its name implies, there are “cognitive” and “behavioral” aspects of CBT. In a nutshell, the cognitive goal is to identify unhelpful thoughts and beliefs and to replace them with more constructive alternatives; the behavioral goal is to acquire certain coping skills for self-managing any effects of tinnitus on the person’s life.9 Accomplishing these goals involves numerous components of therapy.10 Components of CBT specific to tinnitus typically include relaxation techniques, activities for distraction, changing thoughts about tinnitus (“cognitive restructuring”), and education about health, sleep hygiene, and the auditory system.

Brief Overview of TRT

The goal of TRT is for patients to be aware of their tinnitus only occasionally and for it to have no impact on their lives.11 The intervention, which involves counseling and sound therapy, is designed to facilitate the learning process known as “habituation”—both to any reactions to tinnitus and to the awareness of tinnitus. The counseling, which is very structured and detailed, is the most important component. For sound therapy, patients “enrich their sound environment” and they often use ear-level devices (sound generators) that produce broadband noise, which is adjusted according to a specific protocol. The entire program is based on the “neurophysiological model of tinnitus.”11

Who Provides These Therapies?

blue head CBT

Most commonly, CBT is conducted by clinical psychologists but also by providers of behavioral or mental health services (advanced nurse practitioners, clinical social workers, professional counselors, psychiatrists).12 These providers often have expertise in CBT, but very few are trained in delivering CBT for the management of tinnitus.13 Hence, a conundrum: CBT is considered to have the strongest research evidence for tinnitus intervention, and yet very few behavioral health providers offer CBT specifically for tinnitus.14 This conundrum has been addressed by tinnitus researchers and clinicians.12,14 They point out that non-behavioral health providers have delivered CBT successfully for panic disorder, social anxiety disorder, depression, and generalized anxiety disorder. It could therefore be argued that audiologists, who are typically the primary point of contact for individuals seeking clinical services for tinnitus, could administer CBT for tinnitus. It was stated, “It seems evident that audiologists can at least provide certain components of CBT without extensive training…. Audiologists can offer a viable pathway for expanding tinnitus management services in populations in which behavioral health providers are not readily available.”12

Although audiologists (or any non-behavioral health provider) should not perform CBT without the necessary training and supervision, they could learn to teach the behavioral components of CBT, which require much less training than the cognitive components.12 The behavioral components mostly involve relaxation and distraction techniques. If non-behavioral health providers, especially audiologists, were to learn these behavioral components, patients would have much greater access to research-based tinnitus intervention.

TRT

The clinical implementation of TRT is mostly within the scope of practice for audiologists. As described in a previous issue of Tinnitus Today, “Audiologists are hearing healthcare specialists who hold an Audiology Doctorate (AuD) degree, which is the current requirement, or a master’s degree in audiology, which was the previous requirement…. Audiologists are trained to conduct diagnostic evaluations of the entire auditory system (outer ear to brain).”15

Audiologists have extensive training in diagnosing disorders of the auditory system, and in providing hearing aids to address hearing loss.15 Roughly 75 AuD training programs in the U.S. are accredited by the American Speech Language-Hearing Association (ASHA). An informal survey was completed by 32 (43 percent) of these programs, and all of the respondents reported that they provide training in tinnitus management.16 Most of these 32 programs (97 percent) reported that they provide training in methods of sound therapy, and 91 percent said they teach TRT.

heads

It therefore appears some percentage of audiologists receive training in TRT during their AuD program. What is unknown is the extent of that training and the level of competency they achieve in administering TRT in the clinic. A website exists that lists practitioners who have met certain requirements to be included in the “TRT Association” (www.tinnitus-pjj.com). One of those requirements is that they have completed independent TRT training, which has been offered periodically by Drs. Pawel Jastreboff and Margaret Jastreboff. It should be noted that the website states, “The list is based on the statements of members and is not further verified. Consequently, it is not equivalent to certification and should not be treated as a referral list.” TRT practitioners are usually audiologists, but they can have doctorates other than the AuD (i.e., PhD or EdD). They may even be physicians (MD). Some examples of these nonaudiologist TRT practitioners can be seen on the TRT Association website. TRT providers may also be all types of behavioral health providers, which were listed earlier.

Clinical Assessment

Clinical management of tinnitus involves two phases: assessment and intervention. Assessment means testing and obtaining measures to diagnose the condition and make recommendations concerning the potential need for further services. Intervention is the “treatment” phase, which involves the delivery of some therapy that is intended to improve the condition. Improvement would be documented by repeating some of the assessment following the intervention and comparing the before and after results (i.e., outcome assessment).

blue gearsCBT

CBT is described as an intervention. That is, CBT is therapy only. Some type of assessment is essential, however, to determine whether a patient might benefit from CBT, and, if so, how to tailor the intervention to address the patient’s individual needs. The assessment should include baseline measures that can be repeated during and following the intervention to determine whether the program is beneficial.

Most publications about CBT for tinnitus include recommendations for conducting an assessment. For example, one group recommends assessing for auditory functioning (a hearing test), impact of tinnitus, functioning in daily life, cognitive ability, and emotional distress.10 A recent book titled Cognitive Behavioral Therapy for Tinnitus devotes a whole section (pp. 36–42) to describing an initial assessment and monitoring outcomes of the intervention.14

Another group recommends an examination by an otolaryngologist and audiology testing that includes tinnitus matching tests and tinnitus minimum masking level evaluation.17 This would be followed by an interview with a psychologist focusing on history and characteristics of the tinnitus, effects of tinnitus on the person’s life(sleep, concentration, etc.), things that make the tinnitus better or worse, related symptoms, and any previous treatments for tinnitus. This evaluation establishes the therapeutic relationship and determines whether the patient is a suitable candidate for CBT. It is clear there is no one “right” way to perform an assessment for CBT for tinnitus. Certain types of measures, however, are considered essential.10,14,17

In our lab, we conducted a study comparing outcomes between CBT and a specific method of sound therapy.18 Portions of the assessment applied to both methods and started with screening to identify eligible candidates for intervention using the Tinnitus Screener19 and the Tinnitus and Hearing Survey.20 Then we performed an audiologic assessment (hearing test) and questioned candidates to determine whether they were eligible to participate, including their ability to complete all study procedures. For example, candidates were excluded from participation if they were suspected of having secondary tinnitus (such as pulsatile/pulsing tinnitus) that would indicate a possible underlying medical condition1 or if they had recently used medications that are known to be associated with tinnitus. The Tinnitus Questionnaire (TQ) was selected as the main outcome measure for the trial because the TQ is capable of evaluating psychological interventions for tinnitus—such as CBT.21 The type of assessment used for this trial might be appropriate for any patient being considered for CBT. It is clear, however, that specific assessment methods would differ for different CBT practitioners.

TRT

Clinical assessment for TRT has been described in detail by the founders of TRT.22–25 It has also been reviewed in various other publications.26–28 The purpose of the assessment is to diagnose and distinguish among the conditions of hearing loss, tinnitus, and decreased sound tolerance.24 An audiologic evaluation is recommended to determine hearing ability, and includes threshold testing with pure tones up through 12,000 Hz to obtain an audiogram and speech discrimination testing.11 Loudness discomfort levels (LDLs) are obtained using pure tones at the same audiogram frequencies. Results of LDL testing are essential to assess for a loudness tolerance problem. Additional testing includes distortion product otoacoustic emissions (DPOAE), tinnitus loudness and pitch matching, and minimum masking levels. The parameters for the DPOAE testing are specified and results are important for counseling purposes.

The patient assessment provides the essential information to place patients into one of the five TRT treatment categories: 0, 1, 2, 3, or 4. Determining the category for an individual patient requires answering four questions: (1) How much does the tinnitus impact the person’s life? (2) How does the person perceive the significance of any hearing loss? (3) Does the person have decreased sound tolerance, and if so, how much of a problem is it? (4) Is there prolonged worsening of the person’s condition (tinnitus and/or hyperacusis) following exposure to moderate levels of sound?29

Category 0 patients are only minimally bothered by their tinnitus, or they have had their tinnitus for a short period of time.11,29 They receive an abbreviated version of the TRT counseling, which focuses on learning to think about (reclassify) tinnitus as a benign/meaningless stimulus, along with advice to “enrich the sound environment” to optimize habituation to the tinnitus. Ear-level sound generators are not normally recommended.

Category 1 includes patients who have a significant problem with tinnitus.11 They receive the full TRT counseling and are recommended to wear ear-level sound generators.

Category 2 patients are the same as Category 1 except they also have significant hearing difficulties. In addition to the full TRT counseling, they wear hearing aids that have a built-in sound generator.

Category 3 patients have hyperacusis as their primary complaint. Prior to any intervention for tinnitus, the hyperacusis is treated, which involves a modified version of the TRT counseling along with wearing ear-level sound generators. If the patient also has hearing difficulties, then hearing aids with a built-in sound generator are used.

Category 4 patients have prolonged worsening (exacerbation) of their tinnitus and/or their hyperacusis that is caused by exposure to certain sounds. By definition, the worsening lasts until at least the next morning. If hyperacusis is the main problem, then the hyperacusis treatment is used as for Category 3 patients. Otherwise, treatment focuses on tinnitus as for Category 2 patients. Category 4 patients may be the most difficult to treat successfully.30,31

Clinical Intervention

CBT

CBT takes a “whole health” perspective, meaning a person’s global well-being is the overall objective.13 An assumption is, “What is good for life in general is usually good for coping with tinnitus. This includes living a healthy life with respect to food, exercise, social contacts, and so on.”17 The basic premise underlying CBT is that thoughts, emotions, and behaviors are all interconnected, and changing any one of these tends to change the others.14 Most generally, intervention with CBT is designed to change thoughts and behaviors in such a way as to decrease emotional reactions to tinnitus and increase the ability to function normally in life (with respect to sleep, concentration, etc.).

red headThe practice of CBT can involve a number of therapeutic components— each of which involves a different path to achieve the overall objectives. These components generally include learning relaxation techniques, making constructive behavioral changes, changing thoughts about tinnitus, and applying lifestyle recommendations to improve sleep, health, and the auditory system. There is no agreement on which components are the most beneficial for improving a person’s tinnitus condition.10

The cognitive part of CBT focuses on learning to avoid negative thoughts and to make them more constructive and helpful in reducing effects of tinnitus.14 What people think affects how they feel.32 We react to people and events according to what we think about them. And our feelings affect our health.28 For these reasons, it is important to assess any thoughts about tinnitus and to determine whether they are contributing to the tinnitus problem. Such unhelpful thoughts have been referred to as “thought errors.”33 Twelve common thought errors have been described along with how they pertain to tinnitus.32

Common behavioral components of CBT for tinnitus include practicing relaxation exercises and increasing pleasant activities.32 Additional behavioral components include enriching the sound environment and addressing sleep problems.14 All of the behavioral components of CBT are intended to promote participation in more positive and pleasant activities, to shift attention away from the tinnitus when it is bothersome, and to employ stress-reduction techniques. Patients are also educated about tinnitus (types, causes, effects, etc.) and hearing loss.

What different CBT providers teach varies considerably. Not only can multiple therapeutic components be used with CBT, but also some providers are integrating CBT with other forms of psychological treatment, namely, mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT).10

In addition, the format for the clinical delivery of CBT can vary.10,17 The number of treatment sessions can be as few as three or as many as 20, and the length of each session can differ. The CBT sessions can be conducted individually or in groups. CBT has also been delivered as an online/internet program with beneficial results.34,35

CBT Self-Help Resources

Self-help resources are available for people to learn these different techniques:

  • A step-by-step approach to self-management with CBT is available online (www.ncrar. research.va.gov/Documents/ HowToManageYourTinnitus.pdf),32 which includes changing thoughts (pp. 54–60), learning relaxation exercises (deep breathing and imagery; pp. 38–43), and planning pleasant activities to “help you enjoy life and pay less attention to your tinnitus” (pp. 44–47).
  • Videos are available online that teach deep breathing, imagery, planning pleasant activities, and changing thoughts (https://www. ncrar.research.va.gov/Tinnitus/TinnitusPatientResources.asp).
  • The book Tinnitus Treatment: Clinical Protocols describes applied relaxation in detail “to guide the patient in practicing at home” (pp. 105–110).17 • The recent book Cognitive Behavioral Therapy for Tinnitus is written in such a manner that the entire book can be used as a self-help guide.14
  • Another book, Tinnitus: A Self Management Guide for the Ringing in Your Ears, has been available for over 20 years and covers CBT in detail and how to self-manage tinnitus using the CBT techniques.36
  • A number of online CBT training programs are available.37 Some even offer support from a tinnitus therapist.14

TRT

This section draws from a previous article published in Tinnitus Today,38 updated with information from more recent sources.11,22,28 Clinical intervention with TRT is based upon Dr. Pawel (pronounced PAH-vul) Jastreboff’s “neurophysiological model” of tinnitus. Counseling is essential for all patients, and involves “intensive teaching about mechanisms of the tinnitus origin and its benign nature (as perception), which nevertheless may evoke strong negative reactions affecting patients’ lives. Patients typically have many incorrect concepts about tinnitus and, at the same time, tinnitus remains a mystery for them. Therefore, demystification of tinnitus and providing patients with solid knowledge is important.”11 The counseling is minimal for Category 0 patients, and comprehensive for all other categories. Category 3 and Category 4 patients require specific modifications to the counseling.11,22,28

Neurophysiological Model

The neurophysiological model explains bothersome tinnitus as involving three interacting brain systems: (1) The auditory nervous system processes neural signals transmitted from the ear to the brain, which is how we hear and comprehend sounds. It is also the system that generates and perceives tinnitus. (If the tinnitus is not bothersome, then the tinnitus neural activity is generally confined to the auditory nervous system.) (2) Some sounds, including tinnitus, can cause emotional reactions, which results from activation of the limbic system. (3) Activation of the limbic system by any stimulus that has negative associations causes activity in the sympathetic portions of the autonomic nervous system. If the sympathetic activity is extreme, the body prepares for fight-or-flight mode. If the activity is less than extreme but sustained over time, then the same reactions will occur but to a lesser degree (stress!).

The subconscious (lower) part of the auditory nervous system works like a computer to sort, organize, and route the incoming signals from the cochlea. This filtering process gives awareness about information important for survival and well-being to the conscious (upper) part of the auditory nervous system. Unimportant information, such as the sound of an air conditioner or refrigerator, is filtered out and blocked from reaching awareness. Habituation means the brain and nervous system have learned to block sounds that are unimportant. For TRT, the main goal is habituation of reactions to tinnitus. When that goal is achieved, habituation of tinnitus perception follows automatically.

Plasticity refers to the brain’s ability to “rewire” itself based on changes (positive or negative) in how it functions. The brain is rewired or “retrained” as it learns to habituate the tinnitus signal—hence the name tinnitus retraining therapy. To promote habituation, TRT uses its unique counseling combined with sound therapy.

TRT Counseling

The counseling is designed to educate patients as to how the different brain systems are involved in tinnitus and to remove any fears or anxieties patients may have about their tinnitus. The counseling is repeated at each appointment, generally over a period of six to 18 months.

Sound Therapy

The purpose of sound therapy is to “enrich” the patient’s sound environment to facilitate the process of tinnitus habituation. For more severe cases, sound therapy is accomplished with wearable ear-level sound generators or, in cases of significant hearing loss, hearing aids that have a built-in sound generator.

Rationale for Sound Therapy

Every nerve fiber in the body is active, even when not stimulated. Each fiber “fires” (or discharges) on its own many times per second. The “spontaneous firing rate” for nerve fibers in the auditory nervous system is typically 50 to 100 per second. Ear-level sound generators deliver a controlled and low level of sound directly to the ears. This causes nerve fibers in the auditory nervous system to fire at higher rates than they would in quiet conditions. The effect of this heightened neural activity is to reduce the contrast between the tinnitus and the background sound, which causes the tinnitus signal to be less “detectable” within the auditory nervous system.

To optimize success with TRT:

1. Meet with a competent, experienced provider.
2. Learn the neurophysiological model of tinnitus and apply its principles.
3. Enrich your sound environment 24/7 (and avoid silence). Maintain a constant background of sound, even when sleeping. The sound should be low-level, comfortable, and non-annoying.
4. If you are fit with ear-level sound generators:

  • Wear them during all waking hours.
  • Adjust them to just below the “mixing point.” Do this at the start of the day. Gradually turn up the volume of the noise, and note that the quality/spectrum of the tinnitus starts to change at some point—that point is the mixing point. Then turn the volume down slightly. The intent is to hear (and habituate to) your “usual” tinnitus while also hearing the constant background sound.
  • Do not readjust them. Think “set and forget.” Adjust them at the start of the day, then leave them alone. Doing this minimizes paying attention to the tinnitus.

5. Attend all follow-up appointments. Learn and relearn the counseling information.

TRT Self-Help Resources

Resources are available to learn about TRT (note: the present author receives no book royalties): • Any YouTube or other video from Pawel Jastreboff. • Official websites for Pawel Jastreboff and Jonathan Hazell. • The original book about TRT: Tinnitus Retraining Therapy: Implementing the Neurophysiological Model— written for the professional but loaded with information.22 • A lay-language script that models the TRT counseling.28 The scripted counseling is based directly on the material contained in the original book about TRT.22 A companion flip-chart counseling book corresponds directly with the lay-language script.39

Similarities and Differences of CBT and TRT

Assessment
For any method of tinnitus management, patients must be evaluated to determine the extent of the problem and which, if any, clinical services are warranted. Although both CBT and TRT patients require assessment, it is somewhat loosely defined for CBT and very specific for TRT.

Counseling
It has long been recognized that counseling is the single most important component for the clinical management of tinnitus.11,40 Although CBT and TRT utilize completely different forms of counseling, it is the essential component of intervention in each case.

Sound Therapy
For TRT, sound therapy is essential for all patients. For CBT, the use of sound in managing tinnitus is often/ usually recommended but may not be considered essential—depending on the practitioner.

Habituation
The intended outcome of intervention with CBT and TRT is essentially the same, despite the use of different terminology to describe it. TRT is known for its goal of habituation, which is usually not stated as the goal of CBT. Prior to TRT, however, a psychological model based on habituation was proposed to describe the impact of psychological factors on tinnitus.21,41 “The CBT strategies provided intend to promote habituation.”14 Habituation is therefore considered a goal of CBT.14,42

Conclusion

Methods of tinnitus management are intended to reduce or eliminate any adverse effects of tinnitus on a person’s life. Until a cure is discovered, these methods can be key to living a normal life in spite of experiencing chronic tinnitus. Both CBT and TRT are well known to be beneficial for accomplishing these objectives. Although CBT has the stronger evidence base in the scientific literature, it cannot be assumed that CBT is generally more effective than TRT. There are just too many factors to consider when comparing methods to reach such a definitive conclusion.

It is important for readers struggling with tinnitus and seeking professional help to be educated about methods that have research evidence supporting them, which most certainly includes CBT and TRT. Provided the methodology is performed appropriately by a skilled provider, either of these methods should be helpful. A caveat is to always be vigilant not to invest in expensive therapies until or unless less expensive therapies have been attempted and ruled out. Other comprehensive evidence-based methods to consider are Progressive Tinnitus Management (PTM)43 and Tinnitus Activities Treatment (TAT).44

James A. Henry, PhD, is a certified and licensed audiologist with a doctorate in behavioral neuroscience. He recently retired from the Veterans Affairs (VA) Rehabilitation, Research & Development (RR&D) Senior Research Career Scientist at the VA RR&D National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. For more than 25 years, he devoted his career to tinnitus research. His overall goals were to develop and validate clinical methodology for effectively helping individuals with bothersome tinnitus and to increase accessibility to evidence-based tinnitus care.

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4 J. A. Henry, C. Loovis, M. Montero, et al. (2007). Randomized clinical trial: Group counseling based on tinnitus retraining therapy. Journal of Rehabilitation Research and Development, 44(1), 21–32.

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19 J. A. Henry, S. Griest, D. Austin, et al. (2016). Tinnitus Screener: Results from the first 100 participants in an epidemiology study. American Journal of Audiology, 25(2), 153–160.

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32 J. A. Henry, T. L. Zaugg, P. J. Myers, & C. J. Kendall (Schmidt). (2010). How to manage your tinnitus: A step-by-step workbook (3rd ed., pp. 50–53). Plural Publishing.

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38 J. A. Henry. (2002). Optimizing tinnitus retraining therapy success. Tinnitus Today, 27, 16–17.

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