Counselling and Psycho-Education for Tinnitus Treatment and Management

Article about counselling and psycho-education for tinnitus treatment and management.

Keypoints

  1. Tinnitus is a dysfunction of the auditory system that has proven to be highly resistant to a wide variety of treatments (Laryngoscope 109:1202–1211, 1999) making it a difficult condition to treat and to live with (The psychological management of chronic tinnitus: a cognitive-behavioral approach. Allyn & Bacon: Boston, 2001).
  2. As there are no easy cures for tinnitus, the tinnitus patient has to adjust to not only the perception of internal noise but also to the often negative beliefs and consequences that accompany it (Psychological aspects of tinnitus, in Contributions to medical psychology. Pergamon: New York, 1984).
  3. Some of the difficulties that tinnitus patients encounter include high levels of emotional distress, sleep difficulties, loss of concentration, attention problems, and disruption to their personal, occupational, and social lives (J Speech Hear Disord 48:150–154, 1983).
  4. The need to address these “psychological” aspects of tinnitus has been known for many years (Lancet 36:828–829, 1841) but has only recently been given adequate consideration.
  5. Fundamentally, the goal of tinnitus treatment is to reduce the negative impact this condition has on the patient’s life. To facilitate this, counselling helps individuals understand their tinnitus, which can reduce the occurrence and level of distress.
  6. Providing patients with education about what their tinnitus is, and what it is not, helps to demystify the condition, which can greatly change how they perceive and respond to their tinnitus.
  7. This article focuses on one counselling approach and provides resource materials that will enable specialists and therapists to provide support for their patients’ efforts to reduce tinnitus distress.

Introduction

Men are disturbed not by things, but by the view which they take of them.

(Greek philosopher Epictetus)

To help people cope with their tinnitus and its consequences, counselling is recognized as a vital component of virtually all tinnitus management options [6]. Yet despite the important role that counselling plays, it can be difficult to ensure that this aspect of tinnitus management is undertaken. Non-psychologists often feel uncomfortable in their role as a patient’s counsellor, frequently feeling uncertain as to how far their counselling efforts should patients’ efforts to reduce tinnitus distress. go [7]. It is therefore the intent of this chapter to clarify the need to provide counselling for tinnitus patients, the role of counselling, and who should deliver this very important component of a tinnitus treatment program.

What is Counselling?

For the purpose of the chapter, we define counselling as the process of facilitating change by informing, advising, and empowering individuals who need support. To help patients understand tinnitus and facilitate their coping with the condition, clinical approaches to the management of tinnitus include the use of education, psychological interventions, and counselling approaches. As the term “counselling” has many connotations and is used by many professionals, it is important to be clear what “counselling” refers to, what role it has in the management of tinnitus, and who should be providing the counselling. Just as the term “counselling” can cover a variety of topics, those who undertake counselling can include a wide range of professionals including psychologists, audiologists, counsellors, social workers, general physicians, nurses, and medical specialists. In this chapter, we refer to counselling in the broad psycho-educational context that can be provided by any number of health professions.

With regard to its role in tinnitus, it has been said that counselling is the single most important component in the management of tinnitus [6]. Virtually, all treatment strategies incorporate some form of counselling. These treatments include the use of hearing aids [8] tinnitus retraining therapy [9], tinnitus masking [10], and cognitive behavioral therapy [11]. The importance of counselling was emphasized by Tyler [12], who encouraged all sound-based therapies to go hand-in-hand with counselling. The rationale and the form of counselling may differ across treatments [13], but regardless of which strategy is employed, it is necessary to help the patient understand and learn to cope with their tinnitus [6].

Tinnitus is a Complex Condition: Why is Counselling Needed?

Tinnitus is the involuntary perception of sound originating in the head (or ears) [14]. Tinnitus is experienced as an occasional slight irritation by the majority of the population [8, 14]. Between 6 and 17% of the population have tinnitus to a significant degree, with 0.5–2% reporting tinnitus that produces sufficient annoyance to interfere with day-to-day activities and quality of life [15–17]. To date, there is no cure for tinnitus. However, there are ways of minimizing the effects of tinnitus on the patient’s life [18]. While today it is accepted that tinnitus can impact the patient’s life in many ways, awareness of the broad-ranging consequences and potential contributors to distress caused by tinnitus was facilitated by studies designed to assess how tinnitus patients experienced this condition.

One of the early attempts to investigate the problems experienced by tinnitus patients was undertaken by Tyler and Baker [4], who asked tinnitus sufferers in a self-help group to list the difficulties they experienced as a consequence of their tinnitus. The primary problems reported included negative effects on lifestyle (93%), general health (55.6%), hearing (52.7%), and emotional problems (69.4%). Participants particularly noted difficulties with the persistence of tinnitus (48.6%), and sleep (56.9%) [4]. Further demonstrating the distress that tinnitus can cause the patient, 6.9% of the respondents in Tyler and Baker’s [4] study had considered suicide. The findings of this study (i.e., the potentially negative impact that tinnitus can have on the patient’s life) have been confirmed in other studies, which have reported that severe tinnitus is often associated with depression [19] and, rarely, suicide [20, 21]. Clearly, tinnitus has widespread effects on the lives of those with this condition, which would normally require a multidisciplinary approach to manage it. Consideration must therefore be given to both the physiological aspects of this condition and the psychological factors that can impact the experience of the disorder and, hence, the level of distress it creates for the patient.

When considering how people react to tinnitus, people with tinnitus generally fall within two distinct groups: those who have marked distress or handicap associated with their tinnitus and those who do not [22]. Why this difference occurs between patients is not always clear. For example, vulnerable people exposed to significant stressful events, such as war and accidents, may suffer tinnitus related to post traumatic stress disorder [23]. Also, personality traits may play a significant role in tinnitus [24]. For those working with tinnitus, it is important to appreciate the influence of factors that can impact on the experience of tinnitus, as these factors can increase the level of distress caused by the tinnitus as well as the patient’s ability to benefit from treatment (see Picture 1).

Tinnitus treatment picture: the effects of counselling on tinnitus annoyance

Picture 1: The effect of counselling on tinnitus annoyance. (a) Distress caused by tinnitus is greatest when a person has high stress levels; mental health issues (anxiety, depression) poor coping strategies and little support. (b) counselling can break a cycle of distress and provide the patient with the resources to accommodate the tinnitus

 

Of those who experience distress and disability related to their tinnitus, there is considerable variability regarding the nature and extent of the psychological distress they experience [4, 25]. It is therefore essential that the difficulties experienced by those tinnitus, patients negatively affected by their tinnitus, be carefully assessed in order to determine the factors that may cause and/or maintain their difficulties [2]. When assessing the impact of tinnitus on the patient’s life, it is important to realize that how, and why, a person experiences distress is variable and may not relate to the more “obvious” elements of their condition. For example, it may appear obvious that the loudness of the tinnitus is the factor most likely to influence the degree of distress experienced by a person with tinnitus [2], yet this is not always the case. Several studies have considered features of tinnitus such as loudness and unpleasantness and have found that the loudness of tinnitus (either self-rated or determined by loudness matching) was unrelated to complaint dimensions [26–28]. This highlights the importance of understanding that the perception of tinnitus is only one dimension of tinnitus and it is the psychological dimension that leads to the emergence of tinnitus related distress [2].

Although tinnitus is a sensory experience, how individuals respond to their tinnitus tends to be more multidimensional, involving their perceptual, attentional, and emotional processes [29]. In describing the impact of psychological factors on tinnitus, Hallam and colleagues [3] proposed a psychological model based on the process of habituation. They suggested that the distress caused by tinnitus is due to an individual’s inability to habituate to the signal, which should occur as it does to any other constant stimulus that does not present as something harmful to the individual [30]. The significance associated to the signal or any arousal-elevating condition can be influenced by the person’s emotional state and/or personality, slowing the natural progression of habituation [3]. For example, if the person is someone who experiences negative thinking, this can overlay all processing of incoming sensations. Such persons may perceive the tinnitus as distressing, harmful, and something that they will be unable to cope with. The importance of understanding how people interpret their situation is eloquently summarized by the Greek philosopher Epictetus’ quote at the beginning of this chapter. It is, after all, the person’s perceived disability that is going to have the greatest impact on their life.

The treatment of tinnitus patients can be further complicated by a delay in patients seeking medical attention from the onset of their tinnitus. It is not always clear why the person has not sought help for their tinnitus earlier and why their tinnitus has now become distressing [18]. The delay in seeking assistance may be due to people’s developing strategies to distract themselves from their tinnitus to help them cope with the condition [18]. Alternatively it may be that their resources to endure and manage their tinnitus become weakened over time, and as the condition persists, they require assistance in adapting or strengthening their resources. Furthermore, patients often report difficulties in accessing appropriate information and referral to specialist services for tinnitus.

The negative consequences of tinnitus may include emotional states such as depression, anger, and anxiety, resulting in sleep disturbance, concentration difficulties, and interference with personal and social activities [4, 29, 30, 31]. Accordingly, psychological treatments aim to reduce the negative impact of tinnitus; often through the use of cognitive behavioral therapy (CBT see Chap. 21). CBT attempts to address the negative or unhelpful thought patterns and consequential behavioral problems accompanying tinnitus. The therapeutic approach of CBT has been shown to be effective in reducing the negative impact of tinnitus (i.e., distress and tinnitus annoyance) [32, 33] through cognitive restructuring and behavioral modification [34]. While CBT has been shown to be an effective treatment approach for tinnitus, some of the techniques are considered beyond the scope of practice for non-psychologists; a more general approach is required for those who are working with tinnitus patients, but are not trained in CBT.

The Role of Counselling in Tinnitus Treatment

The goal of tinnitus management is the reduction of either the tinnitus itself or the patient’s perception of the annoyance related to the tinnitus [7]. As reactions to tinnitus and the ability to cope with this condition vary from person to person, tinnitus is a complex condition to treat. Counselling should be the cornerstone of all tinnitus consultations. To facilitate the treatment of tinnitus, the practitioner must work toward establishing as in-depth an assessment of the individual’s complaints as possible, including a thorough tinnitus interview as well as assessment measures. The assessment allows better understanding of the person’s experience of their tinnitus, the impact it has on their life, and their ability to cope [12]. Patient’s perception of their tinnitus, their ability to cope with their tinnitus, their overall level of disability, and their ability to benefit from treatment interventions should be evaluated. As tinnitus can be associated with psychological distress from anxiety and/or depression, it is appropriate that an initial assessment determines their presence. The Beck Depression Inventory [35] and State-Trait Anxiety Inventory [36] have been used to assess baseline states of anxiety and depression. A useful alternative measure of the presence of psychological distress is the Hospital Anxiety and Depression Scale [37], which provides an easy to administer and well-validated measure of psychological distress in physical health conditions and is suggested as a crucial first step in identifying when to refer patients for psychological assessment [38].

The strong relationship between psychological symptoms (e.g., distress, depression, and anxiety) and tinnitus means that psychological approaches have been included in the treatment of tinnitus. There are many approaches to treating complex health conditions such as tinnitus [4]. Which psychological approaches are incorporated into the treatment of tinnitus will reflect a variety of factors, including the resources available to provide the patient and the training of the clinician. Common elements of a management approach include providing education and means to cope with the tinnitus and its effects. How these are provided to the patient varies considerably between programs and practices (again due to resources, practitioner experience, and practicality of program delivery). For those that do not have access to a multidimensional team approach, there is still a great deal that can be offered to the tinnitus patient in terms of tools to help them to understand and cope with their tinnitus.

Who Should Provide Tinnitus Counselling?

There is an opinion that interventions involving psychological therapy for tinnitus should include qualified psychologists [39]. It is also argued that an complicated by a considerable delay in patients audiologist may be satisfactorily skilled to provide the CBT for patients with problematic tinnitus [34]. There are differences across country borders as to whom and how tinnitus management is provided. It is our opinion that provision of good counselling is important no matter the professional and that all clinicians should be aware of their own limitations and establish appropriate collegial networks. As the role of counselling and its definition will differ across professional groups, the varied background of participants in the counselling process will inevitably require that their expertise be used in different ways. Knowledge and training will determine to some extent the amount of, and style of, counselling. How the counselling is provided will also be determined by the environment (i.e., physical location, resources, type of patients, support networks, and referral options). For example, an otolaryngologist in a small rural center may be required to undertake greater counselling across a broader scope of practice than a clinician based in a large urban hospital working as part of a multidisciplinary team. While it is ideal for tinnitus patients to have access to a professional trained in the psychological management of this condition, it is not always possible or practical, as many practices do not have the resources or funding to provide such treatment. It is, however, possible to provide tinnitus patients with effective approaches to manage their condition, as audiologists or other tinnitus specialists can provide professional counselling [18] by familiarizing themselves with general counselling skills and principles (good basic texts exist for this purpose [7]).

Due to the chronic and distressing nature of the condition, tinnitus patients require engagement at a greater level than many other otologic or audiologic problems; as a consequence, clinicians should be prepared for an ongoing relationship with the patient. It is important that the professional be knowledgeable in their area of speciality, be sympathetic and caring for the patient, and demonstrate an understanding of the patient’s problem [13]. The professional also needs to provide a clear therapy plan and express their belief in the chosen treatment [13]. Clear communication processes need to be established about when and how patients can contact the clinician (e.g., email, telephone, consultation). It is important not to foster dependence on the clinician but still maintain an easy means for the parties to communicate.

Counselling Approaches for the Treatment of Tinnitus

As a chronic condition, a primary focus in counselling and psychological approaches to the management of tinnitus is to reduce the distress caused by the tinnitus and the impact the condition has on the person’s life. That is to say that tinnitus is a persistent condition with no easy cure and the focus of interventions therefore are to alter any negative thoughts the person has about the condition and its impact on their life, as this will decrease the role that tinnitus plays in their life.

Counselling interventions can range from simply providing information [29, 40] or educational sessions [41, 42] to psychologically influenced techniques such as relaxation training (e.g., [43]), attention control training (e.g., [44]), and sleep hygiene (e.g., [45]). Some counselling-based therapies include sound therapy as important elements. These approaches include masking and partial masking [2], tinnitus retraining therapy [46], tinnitus activities treatment [47], and audiological tinnitus management [48]. Counselling is the critical component in these therapies [49].

The Psycho-Educational Approach

Psycho-education is a patient-focused approach based on the premise that the more knowledgeable the patients are about their condition, the better the therapeutic outcome [50]. Readers are referred to Lukens and McFarlane [50] for a review of the effectiveness of psycho-education in health care. Providing information is considered by many to be a critical part of tinnitus management [29, 40, 51]. It has been suggested that an educational approach be the first step in tinnitus treatment before additional intervention is ventured into [39]. This helps with correcting the maladaptive thoughts and behaviors that can develop from false beliefs about tinnitus, which would be counterproductive to any accompanying management strategy [13]. Educating the patient about tinnitus and peoples’ responses to this condition enables both the patient and the clinician to explore the problem and clarify the purpose and expected outcomes of subsequent interventions [41]. During the education sessions, it is important that there is opportunity for sufficient feedback and participation by the patient, as this will allow them to express any uncertainties and demonstrate any problematic patterns of thinking that could be a barrier to the success of any treatments offered (e.g., negative thinking about possible sinister causes of the tinnitus).

Counselling Content and Context

Tinnitus treatments use either group or individual sessions, but sometimes both have been applied. The integration of both contact styles has been effective in tinnitus management [52]. From a clinician’s perspective, group therapy is a more cost- and time-effective method; it allows for the presentation of information to more patients in less time [52]. Individuals in a group may be role models to each other, which helps with the realization that there are others in similar situations [52, 53]. Another benefit of the group educational approach is its abilities to attract those who are not drawn to counselling, per se, due to the stigma and uncertainty attached to nonmedical or psychological approaches [54]. However, a disadvantage of the group session is the lack of an one-on-one relationship between the patient and the clinician [52]. Also, unless sessions are well managed, outgoing individuals may dominate discussions to the detriment of more reserved participants. Additionally, within the group format, the observation of another group member’s success might evoke envy or confirm the uniqueness and difficulty of one’s problem [55], making the person feel more distressed. In contrast to group therapy, individual sessions allow for specific issues pertaining to each individual patient to be addressed, which might be necessary for some. The decision to provide group or individual counselling depends on factors such as the availability of groups (this is not always feasible for some practices) and the patient’s preference [56].

With regard to the content of the counselling, in an individual setting, it should be adjusted to suit each individual because a patient’s lack of understanding will be a barrier, thereby defeating therapeutic interventions [8]. In a group setting, the content should be broadly based to encompass the essential elements applicable to most patients. It has been suggested that successful counselling programs include: the capability to change the way patients think about tinnitus; the ability to alter their behavioral or emotional reactions toward tinnitus; and an understanding of each patient’s needs [8]. Shorter term counselling interventions have become increasingly favorable in a variety of clinical settings and are usually designed to be part of an overall management plan [42]. Topics usually covered include: the hearing system and hearing loss, the epidemiology and causes of tinnitus, perception (including habituation and attention), and treatment options [13]. In the following sections, we will briefly outline the main contents of one approach to counselling and the rationale for using them. Effective counselling on this basis requires that the clinician has good working knowledge of the physiology of the auditory system, as well as the mechanism and management of tinnitus and be able to convey this information in layman’s terms to de-medicalize the condition.

Counselling Topics

Although for presentation purposes, the topics are presented here in a linear fashion (2 follows 1, etc.), the person providing counselling should be prepared to take a very nonlinear approach – the clinician should guide and react to patient responses, rather than follow a script. The elements that the authors believe are important to convey to the patient are:

  1. Needs and goal setting
  2. Anatomy/neurophysiology of the ear
  3. Results of audiological assessment
  4. Perception of sound and tinnitus
  5. Habituation
  6. Attention
  7. Treatment approaches
  8. Self-management/coping strategies
  9. Referral
  10. Relapse prevention
  11. Hyperacusis
  12. Homework

Needs and Goal Setting

A technique commonly used in counselling of chronic conditions such as tinnitus is goal setting, as it is an important skill to help patients work toward, achieve, and maintain treatment success [12]. Research has shown the importance of goals in improving self-efficacy and performance; it has been reported that the enthusiasm to match performance to goals derives from an anticipated increase in self-satisfaction [57]. Goal setting is said to positively impact an individual’s performance through a self-regulatory process. These processes include enabling the individual to focus their attention, promote effort, and initiate task-related strategies [58]. While there are many ways to set goals, one of the most successful methods is setting S.M.A.R.T goals, which require the person to make their goals specific, measurable, achievable, realistic, and time bound [59]. The clinician’s role is to help patients identify the areas they want to change and then guide them in ways to achieve these goals.

The purpose of using a goal setting technique is to help the patient focus on ways to move themselves forward, thereby reducing their focus on the negative and distressing aspects of their tinnitus. The use of the motivational effects of goal setting in the acquisition of new skills has been demonstrated in various fields (e.g., [58, 60]). It is necessary to ensure that the goals are adequately difficult to motivate, but not so difficult to discourage an individual from achieving them [61– 63]. Several studies [57, 61] also emphasize the need to have explicit performance levels, including concrete and quantifiable outcomes. Regardless of the nature of an assignment, a person is usually advised to set shortterm goals, as this increases their motivation and expectations toward the task at hand [64].

An important aspect of helping patients’ progress through treatment is determining their needs (i.e., what they want/expect from treatment). Many audiologists will be familiar with the Client Orientated Scale of Improvement (COSI, [65]). This tool is used to determine specific hearing needs and the extent to which they are achieved following the fitting of hearing aids. A slight modification of this scale can also be applied to help determine needs and set goals for tinnitus management [8]. Using the Client Orientated Scale of Improvement in Tinnitus (COSIT), the clinician and patient identify specific situations in which tinnitus is bothersome (e.g., “Tinnitus affects my ability to concentrate at work”) and discuss ways of reducing tinnitus in these situations (e.g., “Amplify sound to reduce tinnitus audibility”). At stages throughout the tinnitus rehabilitation process, the problems identified using the COSIT are re-examined and in each situation, the degree of tinnitus improvement is determined. If improvement is not shown, appropriate steps (change in strategy, different techniques, or referral) are undertaken to address the problem until realistic goals are achieved.

Anatomy/Neurophysiology of the Ear

Counselling based on neurophysiology will commonly attempt to explain, in some detail, the normal and abnormal physiology of the auditory system and related neural networks. In so doing, the aims are to provide knowledge of the processes occurring in the generation of tinnitus and eliminate unfounded fears or presumptions as to the underlying causes [46]. It is also vital that misconceptions are corrected and patients are given sufficient reassurance that tinnitus is not a life-threatening injury or a psychiatric disease.

The elements of anatomy/physiology of the ear thought to be important for discussion (using diagrams and scripts similar to Appendix 1 as a starting point) are outlined below. It is important to pitch the amount of detail to the perceived level of the patient’s understanding. Starting simple is best, but allow the patient to guide you as to the depth of their understanding through questions and answers. It is better that a patient leaves their consultation with a firm grasp of basic concepts, than a collection of confusing neuroanatomical nomenclature. Examples:

1. Outer and middle ear are responsible for conduction and amplification of sounds to the inner ear. The Eustachian tube is a source of repetitive sounds during swallowing.

Specialists demonstrate and say to patients: Although swallowing is louder than your tinnitus, it is not perceived. The brain is able to filter sound, when it has no “importance.”

2. Inner ear: hair cells, possible pathologies (e.g., noise trauma, ototoxicity) (Picture 2 below).

3. Auditory nerve ruling out possibility of acoustic neuroma (assuming investigation has been undertaken).

4. Brainstem: reaction to sound when detecting danger and provoking a strong and subconscious reaction. Tinnitus as a new signal to the brain creating arousal, fear, and threat-related reaction.

Specialists explain to patients: Our reactions to tinnitus are a consequence of hearing a new and unknown annoying sound; they are not signs of mental illness.

5. Midbrain and cortex: addition of emotions and complex association of the sound to templates of normal sounds and depending on the subconscious evaluation we may focus even more on the tinnitus sound.

tinnitus treatment picture: the anatomy and physiology of the ear

Picture 2: For counselling about the anatomy and physiology of the ear. (a) Discuss role of outer, middle, and inner ear and transduction of sound from physical vibrations to electrical discharge of nerve. (b) Explain role of structures of the organ of Corti and relate patient’s audiometric results to likely source of cochlear injury (e.g., outer hair cells). Discuss the stria vascularis as the battery of the inner ear, outer hair cells (OHCs) as amplifiers (relate to OAE results) inner hair cells (IHCs) as switches to send information via the auditory nerve.

Specialists say to patients: Tinnitus sound can be “stored” and become longer lasting the more you are focused on it.

and

It is thought that tinnitus becomes magnified because of how the brain analyses tinnitus and how we think about it. Tinnitus happens because the brain misunderstands information from the inner ear. The inner ear sends nerves (think of these as wires in an electrical circuit) to information centers in the brain. When damage occurs to a specific region of the ear, there is less activity from the ear; the brain reacts to this over time creating new activity.

and

People react to tinnitus in different ways. Tinnitus usually begins following ear injury, even small amounts of damage can start tinnitus (we relate the patient’s tinnitus to audiometry and discuss different measures such as otoacoustic emissions (OAEs)). But the parts of the brain involved in hearing and emotion are also involved downstream from the ear. Most of the “wiring” of the auditory system is involved in the development and appearance of tinnitus itself (see Picture 3 below for illustration of the nonauditory centers, which explains that the limbic and autonomic nervous systems are primarily responsible to a large extent for tinnitus annoyance).

tinnitus treatment picture: brain anatomy and physiology

 

Picture 3: For counselling of brain anatomy and physiology. Follow on from explanation of cochlear physiology. (a) Explain to patient the various sections and orientation of the brain. (b) Discuss neurons as the wiring of the brain relaying information (c). Sound (1) travels from the cochlea (2) (discuss using analogy with light switch), auditory nerve (wiring) via auditory nuclei (3) (junction boxes) to auditory cortex (4) (light bulb – light goes on – we hear). Adjust detail according to patient knowledge. (c) Modelled on figure of the auditory pathway

Results of Audiological Assessment

The first step in the evaluation of tinnitus, and then its management, is a comprehensive case history including questions of onset, description of the tinnitus “sound,” location, possible cause (noise, medications, stress), and severity. If the tinnitus is objective, pulsatile, unilateral, or associated with a tempromandibular joint complaint, referral to an otolaryngologist or other specialist is recommended to the patient. Specialists explain that the underlying cause in these cases may possibly be medically treatable, and are careful not to build expectations of a cure, nor are they pessimistic as to the potential for an effective intervention. Specialists also explain that while there is currently no objective measure of tinnitus, psychoacoustical assessments of tinnitus qualities (pitch and loudness) and psychometric evaluations of tinnitus severity are often used by clinicians to characterize tinnitus.

Perception of Sound and Tinnitus

Tinnitus does not obey the normal rules which apply to sound perception [66]. For example, tinnitus intensity matches are out of step with its perceived loudness – tinnitus may subjectively match to a quiet external sound but be perceived by the sufferer as being extremely loud, e.g., “as loud as a train.” Although tinnitus may have a low-intensity match, it can be difficult to mask – even when using high intensity frequency-matched sounds. Also, tinnitus does not have an external source or object to relate to. One reason for the annoyance and “strangeness” of tinnitus could be its conflict with normal Auditory Scene Analysis (ASA) [66, 67] (Picture 4 below).

tinnitus treatment picture: illustration of perception of sound as a process of sound

Picture 4: For counselling about sound perception processes. Describe perception of sound as a process of sound (e.g., xylophone and rain) being broken into elements before being reassembled by the brain as an object. Relate to the anatomy in  Picture 3. Contrast this with tinnitus perception where no auditory object is present but a similar process of constructing the image of sound must occur. Use this to explain the unusual nature of tinnitus and how it differs from sound, with regard to tinnitus assessment and attempts to interfere with the tinnitus using sound. For a patient with a good understanding of physiology explanation of the various processes within the cochlear nucleus (CN) superior olivary complex (SOC), inferior colliculus (IC), medial geniculate body (MGB), and auditory cortex (AC) can be provided. Otherwise, these can be described as “Junction” or “decision” boxes

 

Using Picture 5a (below), specialists address the perception principle that describes the mind’s tendency to seek figure and ground distinctions (e.g., Rubin’s figure ground vase) and how the brain extracts important features. They also use visual analogs to explain phantom perceptions (such as lateral inhibition, Picture 5b).

treatment of tinnitus picture: tinnitus counselling - using visual analogs

Picture 5: For counselling about tinnitus perception – using visual analogs. (a) Rubin’s vase can be used to demonstrate the concept of figure ground. Tinnitus can be viewed as an auditory object standing out from the background. By shifting attention from the faces to the vase, the patient can be informed about the use of attention strategies to focus less on tinnitus than background sound. (b) Visual analog of lateral inhibition. Have the patient stare at the center of the crosses, they should notice the emergence of gray spots at the intersections of the lines. Explain that the brain is tricked into seeing something that actually is not there. Relate this to tinnitus by explaining that the white lines depict activity – normal hearing, while the black squares depict absent activity – hearing loss. The area between the activity and nonactivity has created a phantom image. This diagram can be useful to explain how ear damage might result in activity in the CNS and how the fitting of hearing aids might “remove” areas of decreased acuity

 

Specialists say to patients:

In our daily activities we are able to listen to one sound of interest, such as a friends voice buried in a background of competing noise. To do this we must categorize sound features occurring simultaneously (e.g., pitch and loudness) to the correct source. Tinnitus disobeys rules we would normally apply when listening to real sounds.

Feldmann [68] eloquently described that the natural reaction of people to tinnitus onset is to search for it and place it in context of a sound in the environment. With true sounds, we can localize them to something we can see, touch, and sometimes even smell. Multisensory recognition of objects is normal, tinnitus lacks this sense of reality, making it difficult to ignore.

Specialists say to patients:

One of the reasons tinnitus is so annoying is that we hear it, but can’t see it or find where it is coming from. Imagine for a moment that tinnitus comes from this pen instead of your ears. If it was from the pen it would appear real, and be easier to ignore. It is natural for us to want to find and identify the source of sounds, when we can’t it becomes frustrating (e.g., finding the source of a dripping sound in the house, is it a water leak?)

The above examples help to relate the tinnitus sufferer’s experiences within a simple philosophical framework that can be adjusted to suit the patient and the therapeutic approaches described in the following sections.

Habituation

A decline in behavioral responses to a sound signal due to repeated exposure is known as auditory habituation [69]. It appears that habituation is not caused just by the repetition of the sound but by the meaning or association the stimulus holds in the particular situation [69]. A lack of habituation was possibly first postulated by Hallam et al. [3] to play an important role in tinnitus persistence and annoyance. Habituation has become a common feature of most counselling and sound therapy practice [46, 47].

Specialists say:

If a person moves from the country to the city often they become annoyed by the noise of city traffic. Sometimes the noise keeps them awake and is a great irritation. Usually this annoyance reduces and the person becomes less and less aware of the city noise with time. They – automatically – learn to ignore the noise, as it is not an important sound. The sound becomes classified as unimportant by the brain. It is as if the sound is no longer there. The same thing can happen with your tinnitus, we need to find ways to help your hearing system treat the tinnitus as an unimportant background “sound.”

Attention

Attention may play a large role in tinnitus annoyance and should be addressed in counselling [12]. Tinnitus can often become the main focus in a person’s life, consuming their attention resources and ability to concentrate in other tasks. Tinnitus can become the dominant element in a person’s awareness. The acquisition of attention control skills, such as distraction, allows a person to shift their attention to and from tinnitus during stressful situations [13, 43]. These techniques may provide the individual with some sense of control over their tinnitus and the related distressing experiences [29, 44]. Apparently, it is the assumed uncontrollability of the tinnitus sensation which plays a key role in tinnitus being aversively interpreted [27, 68].

Attention control techniques aim to help listeners learn strategies to switch focus of attention from one thing to another, so that attention can be brought under voluntary control to direct thought to and from one’s tinnitus. Henry and Wilson [2] suggest that by exerting control over attention, tinnitus-related distress will be reduced. Their technique can be used to alternate attention from tinnitus to others sounds and is consistent with the process of ASA discussed with patients:

Specialists say:

We need to teach your hearing system to pay less attention to the unnatural sound of tinnitus and instead listen more to other “real” sounds. Use your ears like a search light – listen for sounds around you, what do you hear? Where is it coming from? Can you tell me more about the sound? When you were listening for the sound – were you aware of the tinnitus – possibly not as the other sound was competing for attention against the tinnitus, we can’t hear everything around us all at once, we must pick and choose. Let’s practice

and

Focus your awareness on the noises in your head – tune into the noises. What can you hear? Now quickly redirect your attention. Focus on external noises in the room and outside…notice you can only focus on one thing at a time.

(see Henry and Wilson page 106 [2] for complete dialog)

Treatment Approaches

The different treatment types can be discussed in lay person’s terms to facilitate the patient’s understanding of their tinnitus and the role that different treatment approaches can play in the management process. Specialists provide the following simple information to patients about treatments.

Hearing Aids

It is likely that tinnitus is the response of the hearing system to altered output of the inner ear following hearing loss. One treatment approach is to identify any underlying reasons for the hearing system being overly active and to interfere with how the brain analyses the tinnitus. When hearing loss accompanies tinnitus, this would involve the fitting of hearing aids to the injured ears in an attempt to normalize activity. There are a number of ways the fitting of appropriate hearing aids can help in reducing tinnitus [8]:

  • Psychological benefit from reducing hearing handicap
  • By reducing the attention being paid to hearing and consequently tinnitus
  • Modification of neural networks responsible for tinnitus
  • Amplified sound can partially mask the tinnitus

Masking

Masking is the process of covering, usually partially, the tinnitus with an external sound. The sound used does not appear to be crucial, but should be less bothersome than the tinnitus. Masking often allows the tinnitus sufferer to gain control over their tinnitus by determining when they do not wish to hear it. Long-term use of partial masking, along with counselling, may lead to tinnitus habituation. Some idea of the potential benefit of masking can be assessed in the clinic by listening to an assortment of sounds over headphones.

Habituation Therapy

If the patient has no reason to attend to tinnitus, they should get used (habituate) to it. Even loud sounds can be habituated to if they are non-threatening, for example, people living near railroad tracks seem unaware of the sound of trains passing. The difference between a person who experiences tinnitus and one who “suffers” from it may be the person’s ability to habituate to the tinnitus. Habituation therapies sometimes combine sound therapy with counselling. Hearing aids, broadband noise generators, and devices combining both amplification and generation of sound (combination aids) are used to reduce tinnitus audibility to facilitate the habituation of tinnitus. The sound therapy is thought to help by allowing the patient to become used to tinnitus as the sound fades into the background.

Cognitive Behavioral Therapy (CBT)

Psychologists often use CBT. They teach strategies and techniques to enable patients to cope with tinnitus. This therapy enables sufferers to change the way they think about their tinnitus. By minimizing the impact of unhelpful or negative thoughts about tinnitus, through challenging and changing responses, tinnitus annoyance can be reduced.

Self-Management/Coping Strategies

It has been shown that a person vulnerable to stress is more likely to experience tinnitus distress, whereas a more stress-tolerant or resilient person might be able to handle a greater degree of tinnitus before seeking help [70]. Although tinnitus and its associated symptoms can be a frequent source of stress and distress, stress in return can often exacerbate the existing effects of tinnitus. Therefore, managing stress and learning to relax helps reduce the effects of tinnitus and prevent further aggravation. As a stress-reduction technique, relaxation training enables an individual to become calmer and less reactive, hopefully reducing tinnitus perception [40]. As a first step, relaxation exercises such as progressive muscular relaxation and abdominal breathing [2] are potentially helpful. Patients can be informed about relaxation and be provided with resources for undertaking it (Appendix 1 below).

Improving Sleep

A very common complaint amongst tinnitus sufferers is difficulty in sleeping [4, 12, 15, 27]. Sleep problems may include regularly waking during the night and difficulty in falling asleep [72]. It is possible that tinnitus seems louder and more noticeable at bedtime due to the decrease in ambient noise at night [72]. Improving the quality and ability of individuals to sleep may reduce the adverse effects of tinnitus.

Sleep hygiene is a treatment tool for insomnia which involves behavioral practices that promote good sleep [45]. Patients should be asked about their bedtime routines and sleep patterns. There are different treatment versions of sleep hygiene [73, 74]. However, they all generally involve learning about sleep scheduling, attitudes and feelings that affect sleep, appropriate prebedtime activities, maintaining a good sleep environment, and the importance of daytime behavior [74]. Caffeine and nicotine both have stimulating effects, and intake should thus be regulated [53]. Regular exercise promotes sleep, but should not be carried out close to bedtime [53]. The use of sleep hygiene alone has produced variable success; however, when applied with other forms of intervention (for instance, relaxation exercises or cognitive behavioral treatment) greater improvement in tinnitus symptoms has been observed [75].

Music

One easily implemented self-help sound therapy measure is the use of low-level music played in the background in quiet situations to draw attention away from the tinnitus.

For best results, the following has been recommended to patients [76]:

  • Listening to music or background sound that induces positive feelings.
  • Music without vocals.
  • Music without pronounced bass beat.
  • Music should be pleasant but not too interesting.
  • For short-term relief, when tinnitus is severe, attention capturing music can be beneficial.
  • For long-term tinnitus, habituation music which induces relaxation while reducing tinnitus audibility.
  • Music should be played at a low level, ideally where the music blends with the tinnitus.

Extra stimulation could be provided at night by a bedside sound generator or compact discs (CDs) designed to interfere with tinnitus detection [77]. This could involve the use of a pillow speaker in combination with a pre-existing CD or MP3 player. If these are not available, purchase of a purpose-built bedside sound generator or tinnitus reduction CD could be considered (the clinic could have these available or a source for clients to obtain them).

Referring to Clinical Psychology

On the basis of cost-effectiveness, it is proposed that combining education and self-help advice should produce significant tinnitus reducing benefits when used as routine treatment. Those patients not profiting from the use of the minimal-contact approach could be offered CBT [78] or another psychological intervention. A common reason why tinnitus becomes stressful and disabling relates to the persons’ perception of the auditory stimuli in terms of what could be causing the sensation and their ability to cope with it. Psychological therapy is therefore an appropriate treatment approach for tinnitus, as psychological techniques, including CBT, aim to change how a person thinks about something that will then impact how they react to that situation, stimulus, or event. Within a tinnitus management program, the intent is therefore to change how the person perceives and responds to their tinnitus, so that they are not as negatively impacted by the condition.

Relapse Prevention

Once made aware of potential triggers and means to manage them, the patient should be able to identify signs that a previously compensated tinnitus may re-emerge. New stressors, anxieties, and life events could retrigger tinnitus onset. Reassurance that the re-emerged tinnitus is likely a consequence of these events and that management of these issues should again reduce the salience of tinnitus is important. Changes in hearing could also trigger a resumption of tinnitus. As noise is the primary cause of tinnitus related ear injury, it warrants attention. Hearing conservation should be addressed with caution. Care should be taken to distinguish damaging from helpful sound. An over emphasis on hearing protection may lead to an auditory deprivation effect – potentially reactive plasticity and tinnitus [79] and hyperacusis. At the same time, patients should be made aware of dangerous sounds and how to avoid further injury [80]. One method to avoid resumption of annoying tinnitus is for the individual to be equipped to manage any re-emergence. Written materials to refer to can be useful, “The Consumer Handbook of Tinnitus” [81] and “Tinnitus. A Self-Management Guide for the Ringing in Your Ears” [82] being examples. Another way is to have access to homework tools that can be used independent of the clinician.

Hyperacusis

Although this chapter focuses on counselling for tinnitus, the underlying counselling principles can be applied to other symptoms of auditory injury such as hyperacusis. Care should be taken to explain the concept of hypersensitized auditory pathways, hearing protection vs. hearing isolation, and the importance of sound exposure to achieve some degree of normal tolerance to sound.

Homework

Homework permits the practitioner to use the time between sessions effectively by engaging the patient in tasks aimed toward the therapy goals [83]. Although homework assignments are not commonly applied as part of a tinnitus intervention plan, research on home work in other disorders has demonstrated improved treatment outcomes [84]. One of the primary benefits of using homework is that the techniques learned during the intervention are practised outside the session [83]. CBT [11, 29], cognitive therapies [85, 86], and rational-emotive therapy [87] have all incorporated homework as part of their therapy plans. Anxiety disorders [88] and certain phobias [89] are examples of clinical conditions that have been aided by homework activities. As part of a SMART approach, homework need not be complex or onerous, but it should encourage participation and ownership of the problem by the patient.

The benefits of the inclusion of homework assignments into therapies can be seen through such effects as significantly improving treatment outcomes [84] and modifying behavior without supervision of a clinician [90]. It is important to note, however, that the benefits a person gains from the homework assigned depends on the clarity of its description and rationale, as well as the degree of patient involvement and level of compliance [84]. Kong [56] investigated the effectiveness of two CBT-based homework exercises alongside group-based information sessions to manage tinnitus. Simple, stand-alone take-home tasks were specifically designed, so that they could be provided to participants without needing to have a psychologist involved in their delivery. Two experimental groups, ACTIVE and PASSIVE, received identical educational sessions, once a week, for five consecutive weeks. All participants were given information sheets with general instructions to carry out the homework tasks that were meant to help in areas of difficulty caused by tinnitus. Additionally, the ACTIVE group participants received detailed and specific assignments to complete during the week. The majority of participants tended to benefit from the participant education sessions. A slightly greater reduction in tinnitus effect was recorded for the ACTIVE group participants at the end of this study when compared to the participants in the PASSIVE group. It was concluded that group-based information sessions including specific “active” homework assignments have the potential to be used alongside audiological management to reduce tinnitus impact [56]. The decision for the weekly topics was based on areas of difficulty frequently experienced by people with tinnitus, which were identified in previous research [4, 11, 30]. Kong [56] compiled the self-help strategies presented in Appendix 1 from various psychological management publications (e.g., [29, 91, 92]).

Resources

The approach recommended by specialists is as follows. They recommend that it is useful for the clinician to have charts of the ear and the central nervous system, and cartoons/schematic diagrams of perceptual principles available. In this chapter, we have provided some examples that we, as clinicians, have found useful. Pubmed is a great source for up-to-date information on tinnitus, while hearing aid manufacturers often have excellent anatomy charts. In addition, clinicians have offered helpful counselling tools in print [92] and on the internet Patients should be guided in how to undertake internet searches for tinnitus information and informed of the frequency of poor quality information and misinformation on the World Wide Web.

Summary

Education alone can be a sufficient intervention for some patients [43, 78, 93]. Due to the complexity and multiple factors which impact upon the emotional well-being of an individual, a multidisciplinary team approach is best when treating a patient with complex tinnitus [52, 94]. However, circumstances will determine which professionals will be providing counselling within different settings. We have suggested a method that works in our clinic practices. We have found the education approach a very useful counselling method to empower patients to de-attend and habituate to tinnitus. Clinicians will have their own counselling “tricks” and methods, but the essence of approaches will likely be similar, to make the patient feel less fearful of their tinnitus and provide tools to minimize and, hopefully, eradicate any negative effects from the perception of tinnitus. 

Appendix 1: Homework

The following homework exercises were compiled and trialled by Kong [56] on the basis of several previous studies [including: 2, 27, 92]. They are presented here in a format for clinicians to provide to patients.

Topics for Take-Home Tasks

  1. Goal-setting; S.M.A.R.T goal-setting strategy
  2. Sleep hygiene; Going to bed strategies; Falling asleep strategies; Sleeping environment; Daytime habits
  3. Relaxation techniques; Progressive muscle relaxation; Deep breathing exercises
  4. Attention control; Attention control techniques; Distraction
  5. Communication strategies (when tinnitus accompanies hearing loss); Communication tips

Task 1 Goal Setting

Background for Clinician

Tinnitus may result in a withdrawal from work and social activities that might normally provide a sense of achievement and enjoyment. The loss of these positive feelings, along with isolation, may lead to the person strongly attending to their tinnitus. Goal setting is about identifying and then overcoming barriers to participation and activity.

For Person with Tinnitus

Goal setting is the process of determining what your goals are, and making plans to achieve them. The goalsetting strategy explained here is known by the acronym S.M.A.R.T. This strategy has five components:

Goals need to be Specific, Measurable, Attainable, Realistic, and Timely.

Specific: Goals need to be specific in order to make reaching them easier. Specific goals have a much greater chance of being accomplished than do broad and general ones.

For example, a specific goal, “to be able to read without becoming annoyed by tinnitus,” is easier to reach, make a plan for, measure progress, and to know when it is achieved than a general goal of, “I want the tinnitus to be gone.”

Answering these questions can help to ensure a goal is a specific one:

  • Who is involved?
  • What do I want to accomplish?
  • Where am I going to do this?
  • When will this occur?
  • Why do I want to accomplish this goal?

Measurable: Goals need to be measurable. This way you will be able to see the progress you are making, will know when your goal is reached, and will know when it is time to celebrate! Celebrating your success is an important part of goal setting.

To determine if your goal is measurable, ask questions such as:

  • How much?
  • How often?
  • How will I know that I have reached my goal?
  • How will I know that I am making progress towards my goal?

For an example of a measurable goal, let us say your goal is to read in the evening without becoming annoyed by tinnitus. When you have achieved this, you will know that you have reached your goal. You can set mini-goals along the way of reading for 10 min at a time. Each time you reach one of these mini-goals you know that you are making good progress towards your overall goal. This allows you to monitor progress – and to have mini-celebrations along the way!

Attainable: The goals you set for yourself need to be achievable. The goals also need to be important for you so as to encourage you to make the commitment and put the effort in to reaching them. While goals should challenge you slightly, it is important to set goals which you are likely to achieve. This will set you up for success. Succeeding will encourage you, help to keep you motivated, and give you confidence to set and achieve further goals.

For example, setting a goal of reading an entire book without being annoyed by the tinnitus may not be feasible, whereas reading several chapters may be.

Realistic: Goals need to be realistic. Realistic does not mean easy, but it does mean do-able. The goals you set need to be reachable, relevant, and meaningful to you. You will need to devise a plan that makes reaching your goal a realistic proposition.

Timely: Put a timeframe on your goal. Setting an endpoint for your goal gives you a clear target to work towards and helps to encourage you to put in a consistent effort. Look for signposts along the way indicating progress towards your goal. Include these mini-goals in your time frame. Without a time frame in which to accomplish your goals, the commitment to achieving them becomes too vague.

TIPS: Telling others about your goals may provide you with support and encouragement.

Take the time to look back, notice the progress you have made, and celebrate your successes!

Use these SMART strategies to get you where you want to be. Identify what you want to do. Set your goals and GO FOR IT!

Task 2 Sleep Hygiene

Background for Clinician

One of the most common tinnitus complaints is poor sleep. Good sleep practices along with relaxation exercises may improve the amount or quality of sleep.

For Person with Tinnitus

Using a number of strategies and forming new sleeping habits can improve quality of sleep. These strategies are commonly referred to as “sleep hygiene.” Good sleep refers not only to quantity of sleep, but also quality of sleep. We want to make sure you get enough, and that what you get is refreshing. In practice, this means getting to sleep and not waking until fully rested!

People tend not to spend a lot of time thinking about their sleeping habits. You might have your dinner, do whatever it is that you normally do, and then just go to bed for the night. However, there are often things that we can do to make a good night’s sleep more likely.

The quality and quantity of our sleep can be much improved by changing some of our habits!

Good sleep hygiene includes the following:

Going to Bed Strategies
  • Maintain a routine. Try to go to bed and wake up at the same time every day, even on the weekends. Keeping a regular schedule will help your body expect sleep at the same time each day.
  • Use bedtime rituals. Doing regular things before sleep tells your body that it’s time to slow down and a general goal of, “I want the tinnitus to be gone.” begin to prepare for sleep (e.g., a warm bath each night before bed).
  • Relax for a while before going to bed. Some quiet time can make falling asleep easier. Try relaxation techniques.
  • Write down all of your concerns and worries. Write down your worries and possible solutions before you go to bed so you don’t need to dwell on them in the middle of the night. This allows you to put away your concerns until the next day.
  • Go to sleep when you are sleepy. When you feel tired at night, go to bed.
  • Don’t nap through the day. If you find you have to, limit naps to 30 min, as daytime sleep can upset your body clock for sleeping at night.
Falling Asleep (or Getting Back to Sleep) Strategies
  • Practice your attention control techniques. This will help to keep your mind occupied, will increase your relaxation, and help you to fall back to sleep.
  • Get out of bed if unable to sleep. Don’t lie in bed awake. Go into another room and do something relaxing until you feel sleepy. Worrying about falling asleep actually keeps many people awake.
  • Don’t do anything stimulating. Don’t read or watch a stimulating TV program (as the brain receives a mixed message of having to pay attention to something and yet wanting to go to sleep). Don’t expose yourself to bright light. The light gives cues to your brain that it is time to wake up.
  • Drink some warm milk. Milk may help create feelings of sleepiness.
  • Consider changing your bedtime. If you are frequently experiencing sleeplessness, think about going to bed later so that the time you spend in bed is spent sleeping.
Sleeping Environment
  • Make sure your bed is large enough and comfortable.
  • Make your bedroom primarily a place for sleeping. Use your bed for sleeping or intimacy only. Help your body recognize that your bedroom is primarily a place for rest.
  • Keep your bedroom peaceful and comfortable. Make sure your room is well ventilated and the temperature is fairly constant. You could use a fan or a bedside sound conditioner to help reduce attention to tinnitus.
  • Hide your clock. A highly visible clock may cause you to focus on the time and make you feel stressed and anxious. Place your clock so you can’t see the time when you are in bed.
Daytime Habits
  • Limit caffeine and alcohol. Avoid drinking caffeinated or alcoholic beverages for several hours before bedtime.
  • Expose yourself to bright light/sunlight soon after awakening. This will help to regulate your body’s natural biological clock. Likewise, try to keep your bedroom dark while you are sleeping so that the light will not interfere with your rest.
  • Exercise early in the day. Twenty to thirty minutes of exercise every day can help you sleep, but be sure to exercise in the morning or afternoon, not evening. Exercise stimulates the body and aerobic activity before bedtime may make falling asleep more difficult.
  • Check your iron level. Iron deficient women tend to have more problems sleeping so if your blood is iron poor, a supplement might help your health and your ability to sleep. Check with your doctor as to whether this is a concern for you.

Establishing good sleeping habits will have many positive benefits for you. Remember to give yourself and your body time to adjust to your new sleeping routine. Some of the strategies will be of more use to you than others. The “going to bed” and “falling asleep” strategies may be the ones that create the biggest change in your quality of sleep, so focus on establishing these first.

Here’s wishing you many nights of great sleep!

Task 3 Relaxation

Background for Clinician

Tinnitus can be increased with stress and tension. Relaxation is one strategy toward overcoming the negative consequences of stress and alleviating some tinnitus effects.

For Person with Tinnitus

By relaxing and becoming more calm, the stress driving your tinnitus, or resulting from tinnitus, may be reduced. This may have a positive effect on your mood and reduction in tinnitus annoyance.

Abbreviated Progressive Relaxation

After learning the skill of relaxation, this can be quickly tapped into at times of stress.

This exercise involves four muscle groups. You can modify this exercise if needed, simply be sure to include the areas listed below. Follow the principals of holding a muscle tense for 10–20 s and releasing, then relaxing for 15–20 s before moving on to tensing the next muscle.

  1. Hands, forearms and biceps
  2. Head, face, throat and shoulders, including concentration on forehead, cheeks nose, eyes, jaws, lips, tongue and neck
  3. Chest, stomach and lower back
  4. Thighs, buttocks, calves and feet

Find a quiet, comfortable place to sit where there are minimal distractions. Use a squeeze ball while doing these muscle-relaxing exercises, as it a useful aid to help a person to identify when a muscle is being tensed and when it is relaxed.

To begin:

  1. Curl both fists
  2. Tighten the upper arm and forearms as tight as possible
  3. Hold them for 10–20 seconds and then relax them (this is the same for every part that follows)
  4. Next wrinkle up the forehead. Simultaneously, press your head back as far as possible and roll it in a clockwise fashion. Then reverse the head roll
  5. Now wrinkle up the muscles of your face like a walnut, and then relax them
  6. Arch your back (but be careful if you have a bad back) and take a deep breath. Press out your stomach and relax.
  7. Put both feet flat on the floor and now pull your toes back toward your face as far as possible. Tighten your shins; now your calves, thighs, and buttocks; now relax them. Don’t stand up in a hurry after finishing – take a few deep breaths and stand up slowly to give your body a chance to re-orientate itself.

Deep Breathing Exercises

Another form of relaxation is deep breathing. This is a simple exercise that does not take a lot of time. Slow deep abdominal breathing is a useful method of reducing anxiety and causing relaxation. Abdominal breathing expands the belly as it expands the lungs. Chest breathing is shallower and does not provide the relaxation that comes with abdominal breathing.

To begin:

  1. Close your eyes.
  2. Focus on your breathing.
  3. Place your hand flat on your stomach.
  4. Take slow deep breaths, breathing in through your nose to a count of 1-2-3-4.
  5. As you breathe in, feel your stomach rise under your hand. If you cannot feel your stomach rise under your hand keep practicing to learn the technique – you will know when it is right because you will feel your stomach rise under your hand. Sometimes it can feel awkward to have your stomach go out when you breathe in. To help learn this technique, imagine that when you take a breath in you are inflating a balloon in your stomach – deep breathing inflates the balloon and your stomach goes out and exhaling deflates the balloon and your stomach goes in.
  6. Pause.
  7. Exhale slowly through your nose (or mouth if you prefer) and count down 4-3-2-1.
  8. Repeat this breathing technique.
  9. After a few minutes of breathing like this, as you breathe in, think of the work “relax” and as you breathe out say the words “let go”.

Task 4 Attention Control

Background for Clinician

People may experience tinnitus as intrusive, constantly on their mind and in their thoughts. It can become the unwanted over riding focus of their attention and make it difficult to think about anything else. This constant awareness can be overwhelming and the cause of much distress. Simple attention control exercises can be useful to shift attention from tinnitus to more useful perceptions. See also Henry and Wilson [2].

For Person with Tinnitus

How much of your time and attention does your tinnitus take from you? The answer is quite likely “Too much!” One of the most common complaints amongst those with bothersome tinnitus is that it is always on their mind. It takes up too much of their attention. But – it doesn’t need to be this way! Although we are not always aware of it, we have some control over what we pay attention to – and we make these decisions many times a day. For example, we might be working on a crossword puzzle while others are watching TV. In that situation there are a number of things competing for our attention, but we are able to choose to pay more attention to one (e.g., doing our crossword puzzle) and less to the other (e.g., watching TV). With practice, it is possible to take that same control over the attention that you give to your tinnitus.

Learning this skill of attention control means you will be able to give less consideration to your tinnitus. It won’t be constantly on your mind and in your thoughts. You will be able to better manage your tinnitus and to reduce the associated distress. You may even be able to do more of the things that you enjoy!

With tinnitus (or anything else really!) it is impossible to simply choose not to think about it anymore. But we can control where we focus our attention. We can redirect the focus of our attention from the tinnitus to something else; with practice this can become nearly second nature! There are a number of strategies that can help you learn how to direct the focus of your attention. These include attention control, imagery, and distraction. Without consciously thinking about it, you probably use some of these techniques already. You can use these very same techniques to manage your tinnitus. The aim of all of these techniques is to learn how to control the focus of your attention – to be able to direct your attention from one thing to another at will. The idea is that you will learn how to direct your attention, to and from, the tinnitus under your own control.

Attention Control Techniques

A characteristic of human behavior is that we can really only concentrate on one thing at a time. As we focus on a particular thing, other things become less of the focus of our attention and recede into the background of our mind. We can work this to your advantage, with tinnitus becoming less the center of attention and receding into the background of your awareness. The following are two examples of attention control techniques simplified from a self-help book “Tinnitus. A self-help management guide for the ringing in your ears” by Drs’ Henry and Wilson (2002) which you might find useful. Modify them to suit you, and practice making up your own.

Example 1: Focus on your breathing. Breathe in and out. Think about breathing in through your nose and out through your mouth. Breathe slowly, deeply. Become aware of each breath. As you focus on your breathing, notice that you have been less aware of other parts of your body. Gently shift the focus of attention from your breathing to your feet. Without moving your feet become aware of any sensations they are feeling. Become aware of each toe. Picture them in your mind. How do they feel? Are they warm, cold? Can you feel your toes resting next to each other? As you focus your mind on your feet, notice that you have become less aware of your breathing. Gently shift the focus of your attention back to your breathing. As before, think about breathing in through your nose, out through your mouth. Become aware of each breath.

Practice switching your attention from your breathing to your hands. Focus on the details of each hand. Then practice directing your attention back to your breathing. Do this with different parts of your body, going back to your breathing in between. Notice how you can control where you focus your attention. Notice that as you focus your attention on one thing, other things fade into the background.

Example 2: Find a comfortable place to sit. Ask yourself “Where is my attention now?” Is it focused on a thought, a feeling, or a noise outside? Now change your focus to the physical sensations of your body. Does your skin feel cool or warm? Become aware of any other sensations in your body. Spend some time exploring these. Now refocus your attention to the noises around you. Try to identify what they are. Perhaps you can hear traffic outside, birds chirping, or people talking. Now refocus again, focusing your attention to your hands, picturing each one in your mind. Notice that you can become aware of where your attention is and that you can change the focus of your attention. You are able to deliberately change your attention from one thing to another.

Distraction

Distraction can be helpful in taking your mind off what is causing you distress or worry. You probably have some distraction techniques that you already use. These might include going for a walk, watching TV, or reading a book. Here are some others that you could try. Some will suit you more than others – try them all and see!

  • Make a list of five things you enjoy doing most
  • Listen to some nice music
  • Take a walk
  • Play a computer game
  • In your mind, run through the alphabet backwards from Z to A
  • Count backwards from 100 subtracting 6 at a time
  • Search for a movie you would like to see
  • Plan a shopping list
  • Do something nice – for yourself or for somebody else!
  • Make a list of other possible distraction techniques you could use

Task 5 Communication

Background for Clinician

Tinnitus and accompanying hearing loss can lead to communication difficulties. Communication is such an important activity we seldom think of the detrimental effects of being unable to effectively communicate. Reduced communication can lead to isolation and miscommunication can lead to negative consequences for relationships with family and friends.

For person with tinnitus and hearing loss

  • Let other people know you have difficulties hearing. Tell them what they can do to help make things easier. Be specific. Let them know that you need their help because you value what they have to say.
  • Place your back to the main source of background noise and face the speaker.
  • Ask people to get your attention before they start talking to you.
  • Face the person you are talking to so their gestures and facial expressions will help you understand what they’re saying.
  • Try to choose a place that is well lit, so it is easy to see the target speaker.
  • Try to keep calm and don’t panic. If you become anxious or flustered, it might be harder for you to follow what’s being said.
  • Have patience, good humor, and be understanding with yourself.
  • If your hearing is not the same in both ears, try turning your better side towards the person speaking to you.
  • If you don’t catch what someone says, don’t be afraid to ask him or her to repeat it or say it in a different way. If necessary, ask people to slow down and speak more clearly.
  • Don’t be too hard on yourself. No one hears correctly all the time!

References

1. Dobie RA (1999) A review of randomized clinical trials in tinnitus. Laryngoscope 109:1202–11.

2. Henry J and P Wilson (2001) The psychological management of chronic tinnitus: a cognitive-behavioral approach. Allyn & Bacon: Boston.

3. Hallam R, S Rachman and R Hinchcliffe, (1984) Psychological aspects of tinnitus, in Contributions to medical psychology, S Rachman, Editor. 1984, Pergamon Press: New York. 31–53.

4. Tyler RS and LJ Baker (1983) Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 48:150–4.

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