CBT related resources for Tinnitus Distress

CBT is the most researched, evidence-based program for tinnitus distress. However, very few cognitive behavior therapists have ever heard of tinnitus! This makes it very difficult to access the right treatment. The problem is compounded by the fact that many mental health professionals and some audiologists falsely claim expertise in CBT in order to draw business to their practices. You will recognize true CBT for tinnitus as it involves cognitive, behavioral, and mindfulness strategies, written materials, worksheets, and weekly homework! Your options for accessing help are:

  1. Use the resources recommended below to familiarize yourself with CBT for tinnitus. CBT is essentially a self-help approach taught by a qualified therapist. Following the steps laid out in the self-help resources may be sufficient without the therapist.

  2. Find a local therapist who claims expertise in CBT. Familiarizing yourself with the program through my webinar and the self-help books below will help you determine that you are getting the real thing. Local therapists can be found at:

    1. Association for Behavioral and Cognitive Therapies (ABCT)

    2. Anxiety and Depression Association of America (ADAA)

    3. Psychology Today


CBT for Tinnitus Webinar

Dr. Hubbard’s CBT for Tinnitus Webinar is the most up-to-date self-help resource as it describes mindfulness as well as cognitive and behavioral strategies. Sponsored by the Anxiety and Depression Association of America, this is a 90 minute explanation of how people become trapped by tinnitus and how to break out with CBT.


STAGES OF TINNITUS HABITUATION

Habituation to tinnitus is a gradual process that occurs over weeks, months and years. In his book “Tinnitus: Living with the Ringing in Your Ears”, psychologist Richard Hallam has broken it down into four stages. Hallam’s stages provide an invaluable overview of the course of habituation. They help you know what to expect and provide a yardstick to gauge your progress.

Stage One

  • Persistent awareness of noises except during sleep and masking by louder sounds.

  • Frequent worrying and depressing thoughts about tinnitus.

  • Concentration on mental tasks difficult to sustain for more than a few minutes.

  • Attention is either on tinnitus, and worries about tinnitus, or is divided between tinnitus/worries and other activities

  • Absorbing activities provide only slight distraction.

  • Insomnia severe (if present). Cumulative sleep loss in some cases necessitating medication.

Stage Two

  • Intermittent awareness of tinnitus developing – especially during absorbing activities. There are moments when you are aware that you have not been aware of tinnitus.

  • Improvement in concentration reflected in increasing engagement in usual activities, as the portion of attention allotted to tinnitus begins to diminish.

  • Beginnings of emotional acceptance; the implications of the noises no longer seem catastrophic

  • Gradual return to normal sleep pattern (if disturbed).

Stage Three

  • Awareness mainly limited to periods of fatigue, stress or quiet.

  • Tinnitus intrudes mainly when listening and mental concentration are important

  • Tinnitus is annoying rather than emotionally distressing

Stage Four

  • Attention rarely given to tinnitus. Attention limited to periods when tinnitus is louder than usual or you are reminded of it.

  • Tinnitus does not intrude into normal activities.

  • Emotional acceptance achieved – tinnitus is truly neutral, neither pleasant nor unpleasant


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CBT for Tinnitus Self-Help Books

Living with Tinnitus & Hyperacusis. By Lawrence McKenna, David Baguley, Don McFerran
An excellent how-to on traditional CBT for tinnitus. Does not cover acceptance and mindfulness.

Tinnitus: A Self-Management Guide to the Ringing in Your Ears. Jane Henry & Peter Wilson
Very thorough how-to on traditional CBT for tinnitus. Does not cover acceptance and mindfulness. This book is currently out of print and is available used (though the price can be high).  Dr. Stephen Nagler has graciously made the book available in PDF form through this link.

Tinnitus: Living with the Ringing in Your Ears.   By Richard Hallam
Available used (Out of Print). First self-help book for tinnitus. An early how-to resource for traditional CBT for tinnitus. Does not cover acceptance and mindfulness. 

How to Manage Your Tinnitus: A Step-by-Step Workbook. By Henry, Zaugg, Myers & Kendall. Concise self-help manual based on Veteran’s Administration program of Progressive Tinnitus Management. Includes basic CBT, as well as an excellent “how to” on self-guided sound therapy

Mind and Emotion. By Matthew McKay, Patrick Fanning, Patricia Zurita-Ona
General review of the emotion regulation model used in much of contemporary CBT. Includes description of numerous emotion regulation skills used in CBT for tinnitus, including acceptance, mindfulness, careful thinking, and graded exposure


Mindfulness Training

Dr Hubbard’s Mindfulness of Tinnitus, Sound and Breath, is a 10 minute guided exercise to get you started. A background in basic mindfulness will help you apply this exercise. Such training is available through the apps “10% Happier”, “Calm”, and “Headspace.” For more in depth mindfulness study, consider a course in Mindfulness-Based Cognitive Therapy (MBCT), an approach integrating mindfulness and CBT which has been shown to significantly reduce tinnitus distress. The website of the Center for Mindfulness at the University of Massachusetts Medical School offers information about Mindfulness-Based Cognitive Therapy, a directory of certified teachers and access to online courses.


Acceptance & Commitment Therapy (ACT)

ACT is a type of CBT which is focused on accepting hardships like tinnitus and redirecting your focus to the actions needed to rebuild a life worth living. Behavioral, motivational, acceptance and mindfulness strategies are emphasized. One study study found that people who show higher tinnitus acceptance tend to have lower distress, whereas low tinnitus acceptance was associated with higher distress. Another study found Acceptance and Commitment Therapy was effective in reducing tinnitus distress. ACT founder, Steven Hayes, writes about his personal experience with tinnitus and his recovery using ACT strategies.



Tinnitus Distress References

CBT for Tinnitus Self-Help

CBT

  • Hallam, Richard (1989). Tinnitus: Living with the ringing in your ears. Thorsons: London.

  • Henry, J.L. & Wilson, P.H. (2002) Tinnitus: A Self-Management Guide for the Ringing in Your Ears. Allyn & Bacon: Boston

  • McKenna, L Baguley, D, & McFerran, D & (2010). Living with Tinnitus and Hyperacusis. Sheldon Press: London.

Mindfulness

  • Teasdale, J Williams, M, Segal, Z. (2014). The Mindful Way Workbook. Guilford: New York.

Acceptance & Commitment Therapy (ACT)

  • Hayes, S. & Smith, S. (2005). Get out of Your Mind and Into Your Life. New Harbinger: Oakland

  • Strosahl, K & Robinson, P (2017). The Mindfulness and Acceptance Workbook for Depression: Using Acceptance and Commitment Therapy to Move Through Depression and Create a Life Worth Living. New Harbinger: Oakland


Evidence that it’s not Tinnitus but the Response that keeps you trapped

  • Andersson, G (2002) Psychological aspects of tinnitus and the application of Cognitive–behavioral therapy Clinical Psychology Review 22 (2002) 977–990.

  • Andersson, G & Westin, V (2008) Understanding tinnitus distress: Introducing the concepts of moderators and mediators. International Journal of Audiology, 47(1) 106-111.


Evidence for CBT

  • Cima, R, Andersson, G, Schmidt, C & Henry, J.A. (2014). Cognitive-Behavioral Treatments for Tinnitus: A Review of the Literature. J of Amer Acad of Audiology, 25:29-61.

  • Cima RF, Maes IH (2012). Specialized Treatment Based on Cognitive Behavior Therapy versus Usual Care for Tinnitus: A Randomized Controlled Trial et al Lancet 379(9830):1951.

  • Martinez Devesa P, Waddell A, Perera R, Theodoulou M (2008). Cognitive behavioural therapy for tinnitus (Review) Copyright (2008). Cochrane Data Base Syst Rev (1):CD005233.

  • Hiller, W, Haerkotter, C (2005) Does sound stimulation have additive effects on cognitive behavioral treatment of chronic tinnitus? Behaviour Research and Therapy 43:595–612.

Ear-Nose-Throat Doctor Guidelines: Doctors “should recommend CBT for persistent, bothersome tinnitus.”

  • Tunkel, DE, Bauer, CA, Sun, GH et al (2014). Clinical Practice Guideline: Tinnitus. American Academy of Otolaryngology-Head and Neck Surgery, 151(25) S1-S40.


CBT Model

  • Cima RF (2016). Managing Tinnitus in Adults: Psychological Strategies. In: Tinnitus: Clinical and Research Perspectives, by Baguley, D. & Fagelson, M. Plural: San Diego.

  • Hallam R & McKenna L. (2006). Tinnitus Habituation Therapy. In: Tinnitus Treatment: Clinical Protocols, by Richard Tyler, New York: Thieme.


Evidence for Acceptance & Mindfulness

  • Hesser, H., Westin, V., Hayes, S. C., & Andersson, G. (2009). Clients’ in-session acceptance and cognitive defusion behaviours in acceptance-based treatment of tinnitus distress. Behaviour Research and Therapy, 47: 523‑528.

  • McKenna, L, Marks, E, Hallsworth, C, Roland, S. (2017). Mindfulness-Based Cognitive Therapy as a Treatment for Chronic Tinnitus: A Randomized Controlled Trial. Psychotherapy and Psychosomatics 86:351-361.

  • Philippot, P, Nef, F, Clauw, L, Romrée, M & Segal, Z (2012) A Randomized Controlled Trial of Mindfulness‐Based Cognitive Therapy for Treating Tinnitus. Clinical Psychology and Psychotherapy, 19:411–419

  • Westin, V.Z., Schulin, M., Hesser, H., Karlsson, M., Zare Noe, R., Olofsson,U., Stalby, M., Wisung, G., & Andersson, G. (2011). Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus distress: a randomized controlled trial. Behaviour Research and Therapy, 49:737‑747.

  • Westin, V., Hayes, S. C., & Andersson, G. (2008). Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact. Behaviour Research and Therapy, 46:1259‑1265.

  • Westin, V., Östergren, R., & Andersson, G. (2008). The effects of acceptance versus thought suppression for dealing with the intrusiveness of tinnitus. International Journal of Audiology, 47: 112‑118.


Therapist Manual – Traditional Cognitive-Behavior Therapy

  • Henry, J.L. & Wilson, P.H. (2001). The Psychological Management of Chronic Tinnitus: A Cognitive-Behavioral Approach. Allyn & Bacon: Boston


CBT for Hyeracusis

  • Baguley, DM & Andersson, G (2007) Hyperacusis: Mechanisms, Diagnosis, and Therapies. Plural: San Diego.

  • Juris, L., Andersson, G, Larsen, H.C., Ekselius, L. (2014). Cognitive behavioural therapy for hyperacusis: A randomized controlled trial. Behaviour Research and Therapy 54:30-37.

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