Harnessing Hope for Tinnitus Recovery

Empowering Providers and People Struggling With Tinnitus

By Brittany Grayless, AuD

I once had two patients who were both very bothered by their tinnitus. They had very similar scores on the Tinnitus Reaction Questionnaire indicating severe distress from their tinnitus and they both presented with mild depression.1 Additionally, both patients pursued Tinnitus Activities Treatment, which is a therapy that involves components of cognitive behavioral therapy (CBT) focused on tinnitus management.2 Where these two patients differed, however, was in how successful they were in utilizing the techniques they were taught during the therapeutic process.

These patients had very different outcomes; one was motivated to complete the homework throughout therapy and implement the coping strategies and in the end exhibited a successful reduction in tinnitus distress and acceptance of the tinnitus. The other patient did not show gains in tinnitus distress reduction, lacked the motivation to complete the homework throughout therapy, and implemented about half of the suggested coping strategies. This made me ponder what the difference between these two patients could be attributed to and led me to investigate levels of hope in the tinnitus population.

Hope Theory

Hope is defined by the Merriam Webster’s dictionary as a “desire accompanied by expectation of or belief in fulfillment.” But hope is a little more complex than that. Hope Theory describes hope as a “positive motivational state that is based on an interactively derived sense of successful agency (goal-directed energy) and pathways (planning to meet goals).”3 To explain this further, creating and setting goals provides the anchor of Hope Theory, and the type of goal matters. Some goals are made with 100 percent certainty of success; these goals do not involve hopefulness because an individual knows that they will achieve it; therefore, hope is not necessary. Other goals can be unrealistic, with 0 percent probability of success; these goals are counterproductive and set an individual up for failure. The goals that induce hopefulness occur somewhere in the middle.4

Once an individual sets a goal, two components of hope are put to work, pathways thinking and agency thinking. The perceived ability to create a route or direction to get to that goal is called pathways thinking, developing a plan or “path” to reach the goal. The belief that an individual can travel along that imagined path toward their goal is called agency thinking, the desire and motivation to implement the plan.4 As you can see, both the agency and pathways elements are equally important in developing and achieving hopeful goals.

Then there are barriers.… Barriers are referred to as ‘goal blockages’4 and prevent an individual from reaching their goal using the original plan. This is where a person’s ability to create alternative routes (pathways thinking) and muster the motivation to pursue those alternative routes (agency thinking) becomes very important. Barriers can cause individuals to have negative emotional reactions, which is not a surprise, because we all want to reach our goal with the original plan and are disappointed when we don’t. The interesting piece is that high-hope compared to low-hope people react differently to barriers. High-hope individuals often have more-positive responses to barriers, perhaps because of their ability to create different paths to reach goals.5

Knowing this information, one can envision how hope can relate to tinnitus distress. An example is an individual who has worked in a fast-paced environment for years and perceives themself as highly successful. They experience a traumatic brain injury that results in debilitating tinnitus, and they can no longer function in their work environment. In this scenario, their ongoing goal is a successful career, and their primary barrier is the tinnitus. Their pathway and agency thinking abilities will determine whether their emotional reactions are more positive or negative.

Research on Hope

In the field of psychology, studies have shown correlations between levels of hope and depression,6 and have identified hope as an important factor to measure and potentially focus on to obtain the best treatment outcomes. Research on the effects of the first pre-therapy diagnostic appointment, prior to any intervention, has found that the appointment itself resulted in significant client improvement.7 Basically, simply knowing that you are taking steps to improve your situation (creating a plan and moving toward that plan) can result in higher levels of hope. Additionally, when a patient receives a logical explanation for how the goal of symptom relief may be attained, they will sustain hopeful motivation during the early treatment stages.8

Hope and the Placebo Effect

Hope and the placebo effect overlap. A placebo is not intended to produce therapeutic effect, although in many studies the “placebo effect” indicates that participants taking a sham treatment (perhaps a sugar pill) experience symptom reduction. The placebo effect is the belief that the treatment will work. Previous research on the placebo effect has shown that treatment should trigger “hope for relief.”9,10 Though it may seem like everyone would naturally have hope for relief from an illness, these studies explain that the illness itself elicits suffering, making it difficult for a person to believe that relief is possible. It “takes the intervention of an authoritative figure to promote hope and expectation for relief,” which then leads to the placebo effect.10

Hope and Tinnitus Distress

Our most recent study investigating levels of hope and tinnitus distress found a negative correlation between the Tinnitus Reaction Questionnaire and the Herth Hope Scale, indicating that higher levels of tinnitus distress were associated with lower levels of hopefulness.11 We selected the Herth Hope Scale as the measurement for hope because it comprises three domains:

  • Temporality and Future: The perception that a positive outcome is realistically probable in the future.
  • Positive Readiness and Expectancy: A feeling of confidence with initiation of plans to effect the desired outcome.
  • Interconnectedness: The recognition of interdependence and an interconnectedness of self and others and self and spirit.12

Investigations of these domains revealed the first domain—temporality and future—to be a predictor of tinnitus disturbance. This highlights the need for individuals suffering from tinnitus to be given research-based information regarding tinnitus management options. Receiving this information from an experienced provider would likely facilitate hope for the future.

Conclusion

With this information, I hope to educate healthcare professionals on the importance of providing hope for the future and setting positive patient expectations in the clinical setting for patients struggling with tinnitus distress. Tinnitus can become a barrier to the expectations we have of our future.

If you are a person experiencing tinnitus distress, scheduling an appointment with a healthcare provider skilled in tinnitus evaluation and management is the first step. By making this choice to consult a medical provider, you are taking a step toward your goal of tinnitus relief, and by attending your appointment, you are moving along your path toward that goal. Your healthcare provider will help you develop your own plan to reach an individualized goal by providing you with the data and research supporting the different treatment options for tinnitus management. Together, we can find hope.

Brittany Grayless, AuD, is an associate professor at the University of Tennessee Health Science Center in Knoxville, Tenn. She completed her training at the University of Tennessee Health Science Center with a residency at Duke Medical Center. She has been with UT since 2014 and provides services to adults and adolescents with tinnitus and hyperacusis. She is currently pursuing her doctorate in hearing sciences and her research efforts are primarily focused on the psychological aspects of these clinical populations. She is eager to contribute to tinnitus research by providing clinically applicable information that clinicians can utilize to provide individualized patient-centered care.

References
1. P. Wilson, J. Henry, M. Bowen, & G. Haralambous. (1991). Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Journal of Speech, Language, and Hearing Research, 34, 197–201.
2. R. S. Tyler, S. A. Gogel, & A. K. Gehringer. (2007). Tinnitus activities treatment. Progress in Brain Research, 166, 425–434. https://doi.org/10.1016/ S0079-6123(07)66041-5
3. C. R. Snyder, L. Irving, & J. R. Anderson. (1991). Hope and health: Measuring the will and the ways. In C. R. Snyder & D. R. Forsyth (Eds.), Handbook of social and clinical psychology: The health perspective (pp. 285–305). Pergamon Press.
4. C. R. Snyder. (2000). Hypothesis: There is hope. In C. R. Snyder (Ed.), Handbook of hope theory, measures, and applications (pp. 3–21). Academic Press.
5. C. R. Snyder. (1994). Hope and optimism. In V. S. Ramachandren (Ed.), Encyclopedia of human behavior (Vol. 2, pp. 535–542). Academic Press.
6. A. Leite, A. G. A. P. de Medeiros, C. Rolim, et al. (2019). Hope theory and its relation to depression: A systematic review. Annals of Psychiatry and Clinical Neuroscience, 2(2), 1014.
7. C. R. Snyder & J. Tayler. (2000). Hope as a common factor across psychotherapy approaches: A lesson from DoDo’s verdict. In C. R. Snyder (Ed.), Handbook of hope theory, measures, and applications (pp. 89–108). Academic Press.
8. J. D. Frank & J. B. Frank. (1991). Persuasion and healing. Johns Hopkins University Press.
9. N. Humphrey. (2002). Great expectations: The evolutionary psychology of faith healing and the placebo effect. In N. Humphrey (Ed.), The mind made flesh: Frontiers of psychology and evolution. Oxford University Press.
10. F. G. Miller, L. Colloca, & T. J. Kaptchuk. (2009). The placebo effect: Illness and interpersonal healing. Perspectives in Biology and Medicine, 52(4), 518–539. https://doi.org/10.1353/pbm.0.0115
11. B. Grayless, J. Combs, J. Hausladen, & M. Hedrick. (forthcoming). The effect of perceived tinnitus disturbance on hope. American Journal of Audiology.
12. K. Herth. (1991). Development and refinement of an instrument to measure hope. Scholarly Inquiry for Nursing Practice, 5(1), 39–51.