Cognitive behavioral therapy (CBT) for tinnitus has become increasingly popular following the publication of US and European clinical guidelines which designate CBT the only recommended treatment for tinnitus. As an experienced, board-certified, cognitive behavioral psychologist who has tinnitus, I am heartened by this trend. However, I have concerns about how CBT is understood and applied in the tinnitus community.
1990s CBT for Tinnitus
The version of CBT typically offered to the tinnitus community is one that was popular in the 1990s, when CBT for tinnitus was first introduced. Originally called “cognitive therapy,” now called “traditional” or “second-wave” CBT, the older version can be easily identified by its adherence to the “cognitive model.”
The cognitive model assumed “thoughts cause feelings and behaviors, so, the solution to complex emotional problems like anxiety, depression and tinnitus distress, was to change our thinking.” Accordingly, treatment consisted of “cognitive restructuring,” a time-consuming process of tracking automatic negative thoughts, identifying cognitive distortions, and correcting them with more accurate, positive thoughts. Behavioral skills emphasized relaxation and engaging in pleasant events.
Despite its intuitive appeal, the cognitive model was never more than a guiding theory, and considerable subsequent research has cast doubt on its validity. While cognitive change can be helpful, it is one of several important psychological processes that work together to resolve problems like tinnitus distress. There is no justification for basing a treatment program for tinnitus on cognitive change.
Today’s CBT for Tinnitus
Developments in biopsychosocial science over the past twenty years led to third-wave CBT, which has many advantages over the older approach. In place of changing our thinking, third-wave CBT emphasizes acceptance, mindfulness, and values-directed action. We can think of third-wave CBT as a set of tools for accepting and diminishing the negative impact of unwanted realities like tinnitus, and redirecting attention to living full, valued lives. Acceptance and Commitment Therapy and Mindfulness-Based Cognitive Therapy are third wave CBT approaches that have been shown to significantly reduce tinnitus distress. A best practice CBT for tinnitus then must incorporate third-wave CBT advances not available in treatment programs based on older, cognitive model CBT.
Best Practice CBT for Tinnitus Distress
If you are a person struggling with tinnitus, a loved one of that person, or a professional who wants to learn more, here’s what I recommend:
Promote Tinnitus Habituation
How is it that someone can have the same tinnitus that brought me to my knees and not be bothered? How could someone, like me, who suffered greatly, get to a point where their tinnitus hasn’t changed but they couldn’t care less? People who aren’t bothered by their tinnitus have achieved a high level of habituation—the natural, neurological process through which the brain gradually reduces its emotional reaction and attention to tinnitus.
Habituation makes it easier—typically a lot easier—to live with tinnitus. In the absence of a cure, the greatest reduction in tinnitus suffering worldwide happens through habituation. When done correctly, CBT does more than just “manage” and “cope” with tinnitus. CBT shows us how to promote and maintain tinnitus habituation.
Acceptance versus Change
Third wave CBT begins with a careful assessment of which problem aspects can be changed, reduced and removed, and which problem aspects are best addressed through acceptance.
By tinnitus acceptance we don’t mean embracing tinnitus, making friends with tinnitus, resigning to a future of suffering with tinnitus. We are simply acknowledging the fact that we probably cannot, as our doctors said, gain control over the sounds of tinnitus, and instead commit our efforts to adapting, coexisting, and moving on. We can be grateful that of all the hardships that can befall a person, tinnitus is rarely dangerous, is not physically painful, and is subject to habituation. Tinnitus acceptance then is a practical decision that helps us move forward with recovery.
Therapeutic Exposure to Promote Confidence and Habituation
Therapeutic exposure has replaced cognitive restructuring as the backbone of modern CBT. Exposure is used to reverse patterns of avoidance that commonly drive tinnitus distress and to promote functioning and habituation
The exposure strategy in CBT is based on age-old wisdom: face your fears to overcome them; turn avoidance into approach. As awful as tinnitus feels, we can be grateful that tinnitus is rarely dangerous, is not physically painful, and is subject to habituation. It may be emotionally uncomfortable, but it is not dangerous to hear our tinnitus.
Rather than hiding from tinnitus and letting tinnitus control our lives, we can practice allowing tinnitus to exist, moving toward avoided areas, accepting uncomfortable feelings, while keeping our attention connected to what is important in the present moment (mindfulness), taking courageous action to fully rejoin our lives.
Mindfulness of Sound: the Practice of Tinnitus Acceptance
Mindfulness is an ancient meditation technique that has become an integral part of modern, third-wave CBT. Many people are now familiar with app versions of mindfulness, where it is promoted as a method to relax, calm down, and get some space. This view is misleading. Mindfulness can help us calm down, but more important, mindfulness is used to accept and coexist with aspects of our experience that are desperately unwanted but cannot be changed. Examples include chronic pain, recurrent illness, strong emotion, and several studies have found that mindfulness significantly reduces distress caused by tinnitus.
In mindfulness, we practice allowing our experience to be exactly as it is without trying to change it—and here’s the catch—even if we don’t like how it feels! We accomplish this feat by developing the skill of paying attention to our experience in the present moment, without being driven by thoughts and judgments. Through mindfulness, we can get better at experiencing unwanted, unavoidable aspects of life, such as tinnitus and uncomfortable emotions, without freaking out!
To get the most out of mindfulness for tinnitus, practice mindfulness of sound. For those of you familiar with mindfulness, this is equivalent to the “body scan” used to help us accept and adapt to physical pain. Listening to our tinnitus in this manner promotes therapeutic exposure to tinnitus. Through mindfulness of sound, we come to hear our tinnitus effectively, without making it the center of attention, and without getting pulled into gloom-and-doom thinking. Tinnitus becomes less threatening, more familiar, easier to ignore.
Flexible Thinking
In third-wave CBT, flexible thinking has replaced cognitive restructuring as the primary cognitive skill. In flexible thinking, we are not “correcting distortions.” We practice viewing problems from different perspectives and choosing the one that best fits. With tinnitus, there are two main perspectives: control and recovery.
The control perspective views tinnitus as the problem, so the only way to feel better is to reduce or remove tinnitus. This keeps us focused on tinnitus, fuels distress, and blocks habituation.
The recovery perspective views the distress reaction to tinnitus as the problem, so even if tinnitus doesn’t go way, even if it gets worse, we can be okay because we can learn to reduce tinnitus distress by coping and promoting habituation. The recovery perspective redirects our focus from controlling tinnitus to adapting, habituating, and moving on.
Values-Directed (Committed) Action (Behavior)
Values-directed committed action is the heart of modern, third wave CBT for tinnitus. Values-directed action has replaced relaxation and pleasurable activities, like massage, yoga, movies, as the primary behavioral component of CBT. Here’s where we apply our new skills—mindful acceptance, flexible thinking—and promote therapeutic exposure by leaning into our new lives with tinnitus.
In taking action to change your response to tinnitus, I recommend you first clarify your values. What’s most important to you in life? What brings you the most meaning? As you begin the process of reengaging in life, you will choose behaviors that are meaningful but may not be pleasurable, and in fact, may at times be uncomfortable. But here is where you’ll get the most bang for your buck!
A father, for example, may gain greater long-term relief from attending his daughter’s middle-school concert, facing the uncomfortable feeling that his tinnitus may get louder, than by taking a walk through a favored park. A woman may choose to work late instead of getting a massage, so that she is better prepared for an important presentation the next day. By accepting some discomfort in service of the greater goal, tinnitus takes a back seat, loses its importance. Tinnitus no longer controls our decisions and actions, we do. And through consistently taking these courageous steps, we gradually rebuild lives worth living.
Conclusion
Cognitive behavior therapy (CBT) for tinnitus must be updated to incorporate important advances made over the past 25 years. We need less emphasis on correcting cognitive distortions, relaxing, and engaging in pleasurable events. We need greater emphasis on developing a recovery perspective on tinnitus, ignoring unhelpful thoughts, mindfully accepting tinnitus, and committing to the courageous, values-directed action necessary to be ourselves again. When done correctly, cognitive behavioral therapy for tinnitus is an effective, efficient method for getting out of our ears and back into our lives!
Dr. Hubbard’s Tinnitus Website
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