Bruce Hubbard, PhD

Cognitive Behavioral Therapy (CBT) is widely recognized as the most researched, clinically-proven approach to tinnitus. The goal is not to change tinnitus sounds themselves, but to change how tinnitus is perceived and experienced. This can help to reduce distress, increase functioning, and promote habituation. 

CBT is a set of principles and skills used to change your emotional response to tinnitus. CBT skills are learned, practiced, then applied throughout the day, especially during periods of stress. To benefit from CBT, the exercises must be practiced and applied consistently. A comprehensive CBT program for tinnitus includes:  careful thinking, mindfulness, courageous action, relaxation, background sound, and hearing conservation. 

If you or someone you know is challenged by tinnitus, the following CBT tips might help. Additional CBT self-help resources are listed at the end of this post. 

Careful Thinking: Taking a Recovery Perspective on Tinnitus

Your thoughts have power over how you feel and act. The gloom and doom thinking common to tinnitus, while understandable, fuels distress and maintains your negative focus on tinnitus. The following strategies can help replace negative thinking with pro-recovery thinking:

Learn the Facts About Tinnitus and Habituation

  • Contrary to what you may have heard, tinnitus is not a progressive condition. That means tinnitus does not inevitably get worse over time.
  • While one in three people are initially stressed by tinnitus, the vast majority—98%— are eventually not bothered because they have habituated. The tinnitus is still there, but they rarely notice it, and when they do, it carries little or no emotional weight. 
  • Habituation is a natural process through which the brain screens out of awareness unimportant sounds and sensations. The sound is still present, but it is not noticed, perceived or thought about. During habituation, it’s as if tinnitus doesn’t exist. 
  • Habituation happens in all five senses. It’s why you’re not distracted by the pressure of your feet on the floor, the scent of your aftershave or perfume, the frames of your glasses. It’s what enables people to live near train tracks, airports, even fire stations, and not be bothered by the noise. For all its bluster, tinnitus is just another unimportant sound your brain can learn to screen out and forget. 
  • Habituation occurs gradually, over about 6 to 18 months, as the emotional (limbic) brain comes to view tinnitus sounds as unimportant, that is, offering no harm or benefit. You can promote habituation by developing a neutral, dismissive response to tinnitus. 

So, even if your tinnitus doesn’t go away, there is a strong probability you will gradually habituate and resume your prior life.

Careful Thinking

Now that you know the facts, you can practice applying them through a CBT strategy called Careful Thinking (or cognitive restructuring):

  1. First, write down a few of your most upsetting thoughts about tinnitus
  2. Next, take a careful look at these thoughts. How do they compare to the facts about tinnitus and habituation? Have you noticed any evidence of habituation in your own experience, moments, however brief, that you were not aware of tinnitus? Have you coped with similar difficulties before? How did you handle them then? What would you tell a friend struggling with this or a similar problem? 
  3. Based on your evaluation, what are some more reasonable, effective (pro-recovery) ways to think and talk to yourself and others about tinnitus? 
  4. Finally, write a Recovery Statement that captures your New Perspective on tinnitus: a collection of helpful, reasonable thoughts that give you hope and direction for living with tinnitus and getting your life back. Your recovery statement is a tool to apply throughout the day, particularly, at times of stress.

Mindfulness: Acknowledge, Let Go, Redirect

Humans are generally good at changing things we don’t like. But when faced with unwanted circumstances that cannot be readily changed, our abilities diminish. Mindfulness can help you adapt to unwanted, uncontrollable events like tinnitus. Mindfulness won’t change tinnitus, but it can help soften your experience of the sounds, get control over how and where you direct your attention, and promote habituation.
Mindfulness is defined as present-centered, nonjudgmental attention. This means paying attention to things exactly as they are, even if it’s not how you want them. Mindful is simple, but as you might imagine, it is not easy. It takes effort, patience, and a good dose of courage. 

There are many ways to learn mindfulness. Popular apps, such as “Calm” and “Headspace,” can get you started. Once you understand the basics, you can apply them to tinnitus. The following tips might help:

  • It’s hard not to hear your tinnitus. Fortunately, it’s not hearing tinnitus but how you hear tinnitus that affects recovery. Practice mindfully listening to internal sound (AKA “tinnitus”), and hearing tinnitus against a background of external sound. 
  • When practicing mindfulness with tinnitus, it may help to play soothing background sound (see below). Mindfully observing tinnitus against a background can help soften your experience, and make it easier to hear your tinnitus. You’ll practice noticing internal sound (tinnitus) along with other external, ambient sounds. 
  • When hearing tinnitus, the mindfulness skill “noting” may help. That means describing (to yourself) tinnitus in a neutral, objective manner. For example, instead of “This abominable noise is ripping me apart!” you’d say, “A high pitched tone is present on the right side,” or “a modulated whooshing is present,” or “a buzz is arising” and so on.   
  • Along with mindfulness of sound, practice mindfulness of your emotional experience of tinnitus, especially, the spontaneous, gloom and doom thoughts that arise around tinnitus. This means noticing thoughts and feelings without being hijacked by them, allowing them to be present in the same neutral, objective way you attend to the sound(s) of tinnitus. 
  • As with all CBT skills, mindfulness is meant to be practiced and then applied, for example, at times when you can’t avoid hearing tinnitus—when masking fails, when concentrating, when falling asleep.

Relaxation: Learn to Recognize and Release Tension

Stress makes tinnitus seem louder and more intrusive. Relaxing mental and physical tension associated with tinnitus can go a long way to soothing distress and promoting recovery. Relaxation strategies used in CBT include "abdominal breathing" (also called “diaphragmatic” or “belly” breathing) and "progressive muscle relaxation" (PMR). You can find basic instruction on YouTube. Relaxation exercises that employ soothing imagery are also available.

Background Sound (AKA Partial Masking)

Deliberate use of background sound is the oldest, most intuitive method for tinnitus relief. Most tinnitus sounds will blend into a carefully selected background. While tinnitus itself won’t change, your subjective perception of tinnitus may soften considerably. This can offer a much-needed break from the noise and make it easier to redirect your attention away from tinnitus. 

There are many ways to create background sound for tinnitus. In-ear noise generators are available through some audiologists. However, there’s a lot you can do on your own, at a much lower price-point, to craft a sound background that works for you. It can be as simple as turning on a fan, some music, or the radio. Smart phone apps, such as “Sleep” and “White Noise”, provide a wide range of sounds that can be used to help with tinnitus. 

While it may be tempting to “drown out” your tinnitus completely (full masking), it is strongly recommended that you adjust the background volume a bit lower than the volume of your tinnitus, a procedure called partial masking. Partial masking may reduce the emotional impact of tinnitus, while providing the tinnitus exposure needed for your brain to habituate over time. 
In CBT, background sound is used as needed, not “round-the-clock” as in some other approaches. Background sound may be most helpful during periods of concentration, relaxation and sleep. 

Taking Courageous Action

People bothered by tinnitus tend to withdraw from activities that bring value to their lives. The best way to promote habituation is to get active again. Fight the urge to avoid, escape, and generally drop out, and instead, whenever possible, choose to engage. Keep a copy of your Recovery Statement on hand, apply background sound as needed, stay in the moment, let go of negative thinking, and start living! 

Hearing Conservation: Noise exposure is one of the few scientifically documented causes of tinnitus. Getting back to living fully with tinnitus means learning proper use of hearing protection. This can help you reenter life without fear of making your tinnitus worse. A variety of over-the-counter earplugs are available. Custom-fit earplugs can be purchased through an audiologist. And over-ear, noise-cancellation headphones make music and spoken word safer in loud settings. 

Graded Desensitization: Some people with tinnitus develop an exaggerated fear of sound called phonophobia. They give in to irrational impulses to avoid even safe levels of sound, fearing it will make their tinnitus worse. Phonophobia can greatly contribute to avoidance and withdrawal, maintain tinnitus distress, and block habituation. 
To address phonophobia, Cognitive Behavior Therapists use a strategy called graded desensitization, or exposure. Armed with careful thinking, mindfulness and, when appropriate, proper hearing protection, you approach avoided settings a little at a time, building confidence at one level before moving on to the next. In this way, you can gradually regain comfort in the full range of settings. 

Sleeping with Tinnitus

Sleep is the number one tinnitus complaint. Once you habituate, sleeping with tinnitus won’t be a problem. But in the meantime, a disrupted sleep cycle can make everything harder. Studies show that CBT for insomnia is as effective as sleep medications like Ambien. An internet search on “CBT for Insomnia” will yield practical advice. These tinnitus-specific sleep tips might also help: 

  • Sleep is the area most often addressed with background sound. Table-top sound machines can help, but won’t address tinnitus in the ear that rests against your pillow. For this, you can try: 
    • Sound Pillow has a speaker in the pillow, which can be supplemented with a table top unit for the exposed ear. 
    • Sleep headphones are a soft, elastic headband with miniature speakers that fit over your ears. Some sleep headphones allow streaming, so you won’t have a wire attached to your device. 
  • Even with background sound, it can be hard to completely avoid tinnitus when falling asleep.  Here’s where your new CBT skills come into play: Remind yourself of your new perspective on tinnitus (that is, even if tinnitus doesn’t go away, you can eventually adapt and habituate), practice mindfulness of sound, breath, and the feeling of your body against the mattress and bed sheets. Practice relaxing, letting go, and not getting caught up in negative thinking.

CBT Self Help Resources

The most up-to-date, comprehensive source on CBT for tinnitus is my video available on YouTube. You can access the video by clicking here, by searching YouTube for “CBT for tinnitus”, or cutting and pasting this link:  https://www.youtube.com/watch?v=fVaac8TNoAs&t=118s

CBT for Tinnitus Self Help books are also available. (Note: These books do not cover mindfulness for tinnitus): 

  • Living with Tinnitus & Hyperacusis (2010), by Lawrence McKenna, David Baguley, Don McFerran.
  • Tinnitus: A Self-Management Guide to the Ringing in Your Ears (2001), by Jane Henry & Peter Wilson. Currently out of print. Used copies available.
  • Tinnitus: Living with the Ringing in Your Ears (1989), by Richard Hallam. Currently out of print. Used copies available.