Relaxation is relatively easy to learn, and it can be meaningful to learn this skill apart from the effects related to tinnitus. Thus applied relaxation can be helpful for dealing with stress and tension, working on other tinnitus-related issues such as insomnia, and confronting problems less related to tinnitus such as headache and back pain. However, although applied relaxation can be beneficial in many circumstances, there are some caveats. First, there are some people for which relaxation, at least initially, can be a very terrifying experience. Examples of relaxation-induced panic have been reported in the literature (Heide and Borcovec, 1983). Fortunately, this is very rare. We inform our patients about the potential adverse sensation they might experience, so that feelings of elevated anxiety will not come as a surprise. In addition, we know from the literature that it can be a bad idea to try to relax under severe stress because the opposite may occur: the patient may feel more tense than when he or she started (Wegner et al, 1997). The solution lies in gradually approaching difficult situations and learning first to relax under easier conditions. In this context the therapist needs to be attentive to motivating factors because the patient may find that there is no need to practice relaxation when he or she feels relaxed. Here, the therapist may find it useful to compare relaxation with the effects of exercise, where it is important to start gradually to build up physical strength, and where it s not useful to begin exercising by running a marathon.

There are, of course, indications when applied relaxation is more or less likely to lead to an improvement (Linton, 1982). For patients with signs of stress, muscular tension, and anxiety, applied relaxation is likely to be of help, but then resting and a change of environment also are beneficial. Also, some patients, despite being given a rationale for this treatment, may search for an alternative treatment, believing that tinnitus will disappear, and that applied relaxation is therefore not needed to make a difference.

This chapter presents an overview of our CBT program. There are several components to it, but the focus here is on applied relaxation.

Cognitive-Behavioral Approach to Tinnitus

The cognitive-behavioral approach to tinnitus management is based on certain premises derived from CBT for other conditions, such as anxiety and depression (Persons et al, 2001), as well as research conducted with patients afflicted with somatic conditions, such as chronic pain (Philips and Rachman, 1996) and insomnia (Morin, 1993).

The following basic assumptions guide our practice and the treatment protocol described in this chapter.

Tinnitus can be viewed, at least partly, in terms borrowed from learning theory. Hallam et al’s (1984) psychological model of tinnitus suggested that the natural history of tinnitus is characterized by the process of habituation (a learning theory term). Hence factors that impede habituation (e.g., arousal and novelty) are important to investigate to understand tinnitus. More recently, Jastreboff (2000) developed a theory that relies on classical conditioning, (the notion being that tinnitus can be conditioned (associated) with fear (and other negative emotions), and that this conditioning does not necessarily need to occur on a conscious level.

The severity of tinnitus can be understood within a stress-diathesis model (Andersson and McKenna, 1998; Schulman, 1995). This model assumes that a “vulnerable” person may develop tinnitus distress following the onset of relatively soft tinnitus. A more stress-tolerant person may bear higher degrees of tinnitus before seeking help. It is necessary to point out that vulnerability does not necessarily connote “psychiatric disturbances.” In fact, in the clinic we sometimes meet highly successful individuals with remarkable achievements in life, and without any pretinnitus psychiatric or somatic problems, for whom tinnitus becomes the major stressor initiating problems at work and in the family.

Finally, an important assumption is the simple notion that what is good for life in general is usually good for coping with tinnitus. This includes living a healthy life with respect to food, exercise, social contacts, and so on. One related aspect is that it may be important for the tinnitus patient to establish regular routines in life. Before the onset of tinnitus, it might have been possible to have irregular working hours and sleep patterns, but often adaptation to tinnitus requires regular habits, in particular when it comes to sleep.

In the context of changing beliefs and thoughts, it is important to work toward acceptance of tinnitus and to foster the idea that tinnitus is not worth all the attention it gets. The idea that acceptance of tinnitus is something to work for is not easy to convey. Some patients have had the bad experience of health care personnel telling them that tinnitus is something they have to learn to live with. For many patients this is true when it comes to the sensation of tinnitus, but it is not true when it comes to the accompanying annoyance and distress. What we tell our patients is that we want to give them tools to deal with the consequences of tinnitus and that this is a way to be able to accept that tinnitus seldom disappears by itself. We need to help our patients distinguish between useless attempts to try to control something that cannot be controlled (as often is the case with loud tinnitus), and successful ways of controlling their reactions and emotions when faced with difficulties (in this context, the consequences of tinnitus). So far, the notion of acceptance of tinnitus has received little attention in the literature, but in the day-to-day clinical practice this is something many of us work for. Some work has been done in the field of chronic pain, an area bearing several resemblances to tinnitus (Møller, 1997). For example, McCracken (1998) found that greater acceptance of pain was associated with reports of lower pain intensity, less pain-related anxiety and avoidance, and several other indicators of well-being in relation to chronic pain, and this was not a function of pain intensity. Experimental studies seem to support this notion (Hayes et al, 1999a). According to this way of thinking, acceptance of tinnitus can be defined as acknowledging that one has tinnitus, giving up unproductive attempts to control it, acting as if tinnitus does not necessarily imply disability, and being able to commit one’s effort toward living a satisfying life despite the problem (adapted from McCracken, 1998). According to Hayes et al (1999b), acceptance is often interpreted by the patient to mean tolerance, which is an entirely different thing, or resignation, in which the client accepts defeat. Acceptance has more to do with choosing the direction in one’s life.

Treatment Protocol

Structured Interview and Questionnaires

Once the decision has been made to start treatment, the patient is given a questionnaire as the first homework assignment for the next session. Questionnaires can be divided into tinnitus-specific or more global devices, including those aimed at assessing psychological well-being and cognitive functioning. In this context, it is important to be aware of the special needs and circumstances surrounding the tinnitus patient that may affect the ability to complete an assessment. The most obvious example is hearing impairment, but there are other less conspicuous problems, such as fatigue, lack of motivation, and litigation status, that may affect the result. The psychological dimensions of tinnitus complaints are usually measured with self-report instruments specifically developed for use with tinnitus patients (Noble, 2000; Tyler, 1993). Validated measures of depression and anxiety can be useful when one is planning and evaluating the treatment (e.g., Beck et al, 1961; Zigmond and Snaith, 1983).

Daily diaries can be used in clinical practice to collect data on the characteristics of tinnitus. Tinnitus often fluctuates, sometimes even within a day, and occasionally this aspect of tinnitus is not clear to the patient. Daily diaries need to be easily comprehended and unobtrusive while still providing usable data. One alternative is the Visual Analogue Scale (VAS), which is a straight line, the end anchors of which are labeled as the extreme boundaries of the sensation, feeling, or response being measured (Wewers and Lowe, 1990).

Tinnitus Education

Information about tinnitus and a proper examination of potential causes and moderating factors are crucial. This should be familiar to all clinicians dealing with tinnitus, but lately it has become even more relevant, given the abundance of information about tinnitus provided by mass media and the Internet. Hence patients sometimes do not need more information, but rather advice regarding what information they should trust. Unfortunately, given the lack of knowledge regarding tinnitus (e.g., regarding prognosis), it is often difficult to give the patient definite answers (and if there are no answers, none should be given). CBT for tinnitus includes presenting information to the patient in a gentle and pedagogic manner. Early in the treatment many patients need help to sort out the different problems they experience, which may require different solutions. For example, hearing impairment is not caused by tinnitus, and it needs separate attention.

TREATMENT RATIONALE

Figure 8–1 Heuristic model of the consequences of tinnitus (tinnitus today) and the way treatment may decrease the area in life devoted to tinnitus (what we want to achieve). The actual tinnitus sound is illustrated as being of similar proportions (same size of the boxes) before and after treatment.

A mountain metaphor can be used to describe how the treatment comes into the patient’s life: At first, treatment is like climbing up a mountain, with all the patient’s problems, seemingly insurmountable, ahead, but perhaps this is the only way to leave the mountain behind. Or perhaps the patient could try an alternative strategy and walk around the mountain. The point, though, is, whether it is scaled or walked around, the mountain is there.

Applied Relaxation

TREATMENT RATIONALE

The rationale for applied relaxation includes, but is not restricted to, the following information (adapted from Öst, 1987). The text that is set in italics can be used as a training manual or patient handout to introduce the patient to the treatment/training protocol and to guide the patient in practicing at home.

Tinnitus is often associated with increased bodily tension, not the least because of how one reacts to tinnitus. There are also studies suggesting that muscular tension can be associated with increased loudness of tinnitus. Relaxation can make tinnitus more tolerable, decrease tension, and increase general well-being. Moreover, it can be a way to handle some of the consequences of tinnitus (e.g., irritation) and lead to increased control. Applied relaxation is a self-control technique in four steps, with each step building on previous skills obtained. The aim of the technique is to learn the skill of relaxation, which can be applied very rapidly and in practically any situation. This skill can be compared with any other learned skill (e.g., learning to swim, ride a bike, or drive a car), in that it takes time and practice to learn, but once you have mastered it, you can use it anywhere. You should not become restricted to the calm and nonstressful situation in this office or your own home.

The goal is to be able to relax in 20 to 30 seconds and to use this skill to counteract the physiological and mental reactions you may have in relation to tinnitus and other stressors in life. To achieve this goal, we will go through a step-by-step process, starting with tensing and relaxing different muscle groups. This will take about 15 minutes, and you will practice this twice a day. Next, we reduce the time by taking the tensing exercise away, just relaxing, which will take about 5 to 7 minutes, but we will add an exercise involving imagery techniques, which will take about 2 to 3 minutes. The next step teaches you to connect a self-instruction to the bodily and mental state of relaxation. We will then introduce rapid relaxation, which you will practice many times in nonstressful situations. In the last step, you will learn to apply the relaxation skill in more difficult situations related to your tinnitus.

The aim is not to reduce tinnitus per se, but to control its effects. However, you should not be surprised if you come to perceive your tinnitus as decreased. The goal of applied relaxation is to obtain a balanced state of mind. It is the average level of tension during the day that is important to decrease, not only those occasions when you feel especially tense. In fact, individuals who do not feel particularly tense also benefit from applied relaxation. In association with the relaxation training imagery, techniques will be introduced (e.g., imagining a beach) that are useful for coping with tinnitus. Numerous research studies have found that applied relaxation has positive effects on medical conditions (e.g., pain), but it’s also beneficial for healthy individuals who come to feel less stressed and more efficient in their daily life. Moreover, applied relaxation is a skill that most people can acquire with the right instructions and a lot of practice. It is a portable skill that can be used in almost any situation, not only directly linked to tinnitus, but also for problems like falling asleep.

Rarely, relaxation may feel strange and odd, and even cause anxiety If so, stop and try again later. Do not expect immediate effects. Leave time during the day for practicing relaxation. Do not practice when you are short of time or tired.

Finally, applied relaxation is not something you use to get rid of tinnitus, but rather something you apply to make you stronger to deal with tinnitus. The time you devote to applied relaxation is well spent.

INSTRUCTIONS FOR APPLIED RELAXATION

In the following, the instructions for applied relaxation will be presented. Preferably, the therapist should model some of the tensing-relaxing exercises, as modeling facilitates proper understanding. For example, we always point out that it is not good to tense the muscles too much. For some patients it can be necessary to start by using some background sound (e.g., a radio playing soft music). As we will return to later, it is always crucial not to mask the tinnitus, as this can interfere with our goal to habituate thepatient to the tinnitus.

Step 1. Progressive Relaxation The important thing here is to learn to feel the difference between tensed and relaxed muscles. To do this, we tense the muscle for 5 seconds, then relax it for 10 to 15 seconds and notice the difference. You also become aware of the location of different muscles. Many people regard it as easier to relax a muscle if they have tensed it first, as the contraction of the muscle automatically leads to resting. The point, again, is to become more aware of your body, and not to obtain a perfectly relaxed state.

The following guidelines are recommended:

• Practice twice daily, preferably the same time every day (e.g., at 10:00 A.M. and 6:00 P.M.).

• Practice alone and be sure that nobody interrupts you.

• Find a quiet place to do the relaxation exercises.

• Avoid being too stressed or tired when doing the relaxation exercises.

• Wear comfortable clothes.

• Sit comfortably, straight and symmetrical.

• Use a chair with neck support, but do not lean backward during the relaxation exercises.

• Place your feet on the floor without pressing them down (you may need to have something under your feet).

• Your head should not fall forward or backward. Hold it straight in relation to your shoulders.

• Place your hands in your lap. Do not clutch them.

Write down the time you start the exercises, and rate your level of tension on a scale of 0 to 100. Do the same thing once you have finished the exercises.

Start by sitting comfortably and close your eyes. Tense (5 seconds) and relax (10 seconds) in this order:

• Right hand (make a fist)

• Left hand

• Both hands

• Upper arm (press your elbows toward your body)

• Eyebrows (raise and lower your eyebrows)

• Eyelids

• Jaws (gently open and close your mouth)

• Tongue (press your tongue up then down)

• Lips (press your lips together)

• Neck front (lower your chin toward your chest, but do not bend your head forward)

• Neck back (press your head against the neck support)

• Shoulders (raise your shoulders upward)

• Take a deep breath, then release the air slowly.

Do these exercises twice day. I will ask you to register in a daily diary each time you do these relaxation exercises. Each occasion will take about 10 to 15 minutes to complete. It is important that you can practice these exercises undisturbed by the telephone, family members, work, or anything else. If you feel that you do not have enough time, it is better to postpone the exercises than to do them in a hurry. A good idea is to have set times and places where you do the applied relaxation training (e.g., 9:00 A.M. at work in your office). In addition, it is preferable that you space the exercise sessions so that you have at least 1 to 2 hours between them. Keep in mind that it is better to practice regularly than to be perfect each time you practice. In fact, 14 moderate exercises during a week are better than 3 perfect ones.

Step 2. Short Progressive Relaxation The purpose of this step is to reduce the time it takes to become relaxed and to introduce some imagery techniques. In this step you will learn to relax without first tensing the muscles. This will reduce the time needed for doing the relaxation training (5–7 minutes), and you will become more relaxed, as the tensing exercises can interfere with the relaxation. Again, you will need to practice at least twice daily over the next week. The idea is to focus on the same muscles as in the first step and to relax as much as possible. You will also be asked to focus on your breathing. Again, the positive effect of applied relaxation may not be immediately noticeable, and you need to be persistent in your training. Remember that applied relaxation training is most time consuming during the early stages of the treatment. If you should forget the order of relaxing the muscles or how you should do the exercises exactly, do not stop, but continue the exercises. You could always repeat the order before the next session. If you should experience any adverse effects, remember that these are of a temporary nature. Actually, negative reactions can be better than no reactions at all, as it tells us that the relaxation is tapping the processes involved in your problems. Practice will solve this. Do not practice if you are tired, do not have enough time, or are feeling particularly stressed. Also, make sure that you are undisturbed. If you have a problem relaxing any particular muscle, do not give up. Instead, stay focused for a while. Try to visualize the muscle as soft and loose. Continue with the exercise after you have done this. If you still feel that the muscle is not relaxed, you can tense it briefly or move it a bit and then relax. It is common in the beginning of this step to have some problems relaxing muscles without tensing them first. One way to solve this is to shift between steps 1 and 2 for a period.

Although the recommended time for doing this exercise is 5 to 7 minutes, it is up to you to set the pace. If you do not feel sufficiently relaxed, repeat the exercises when you have the time. You can also choose to go over the rest of the muscles in the body.

Write down the time you start the exercises, and rate your level of tension on a scale from 0 to 100. Do the same thing once you have finished the exercises.

In association with the relaxation training, imagery techniques are introduced (e.g., imagining a beach; see section on cognitive techniques).

First, make sure you breathe deeply from your abdomen. You can check for this by holding one hand on your chest and the other on your abdomen. Then place your hands in your lap, close your eyes, and follow these instructions.

You will relax now. Concentrate and relax all your muscles. Let your body rest. … Begin by checking that your forehead is relaxed … your eyebrows … your eyelids. … Continue with your temples … tongue … lips … and jaw …

Relax your neck and throat… shoulders … down the arms and out your hands … to your fingertips …

Let the relaxation spread to your stomach … your back … now the lower parts of your body … your legs … your feet… out to your toes. Feel relaxed all over your body.

Continue to relax in your whole body. Monitor your breathing… only your breathing.

Take a deep breath, hold it, and release. RELAX. Think “RELAX” each time you breathe, so that the word becomes a cue for deeper and deeper relaxation. Feel how easy it is to breathe and that you have become relaxed. End by taking a deep breath. Go back to breathing normally. Check that you are relaxed. If not, go back and try again.

If you find the word relax unsuitable as an instruction, you can switch to another word or a short sentence, for example, “Calm down.” However, it is a good idea to stick with the word or phrase you start practicing with now.

Step 3. Cue-Controlled Relaxation (Controlled Breathing) The purpose of cue-controlled relaxation is to link your cue word to a calm, smooth breathing pattern. Controlled breathing is an easy way to become relaxed, and the cue word relax serves as an instruction to you and your body. Given proper practice, the process of relaxing to the cue word will become automatic. The controlled breathing and your cue word will make you able to relax within 2 to 4 minutes, which is faster than that achieved in the earlier exercises. However, when starting these exercises, you may need some more time to become fully relaxed. When you have completed these exercises, I will ask you to use your positive image (see Instructions for Positive Imagery). It is good if you can practice 2 to 5 times daily for the next week.

Common Problems Most people are not used to breathing from their abdomen, and they have devoted little or no thought to their breathing. Usually we breathe more rapidly and from the chest, so it takes some concentration to adjust your breathing so that you are filling your lungs fully. To do these exercises, make sure your clothes are comfortable. It is a challenge to relax in such a short time. If you find it too hard, go back to step 2; that is, review each of your muscles, and when you feel sufficiently relaxed, you can begin doing step 3 exercises.

Write down the time you start the exercises, and rate your level of tension on a scale from 0 to 100. Do the same thing once you have finished these exercises, and comment on the use of the positive image.

1. Close your eyes. Take a deep breath. Release the air slowly and think “RELAX.” Do not push your breath.

2. Breathe with calm, regular breaths. Do not overdo it. Think “RELAX” each time you breathe out. Breathe in at your own pace. Feel that your body is becoming more and more relaxed. Keep this up for 1or 2 minutes. (One way to do this exercise is to count when you breathe in: 1-relax, 2-relax, 3-relax, etc.)

3. Take a deep breath, release the air slowly, and think “RELAX,” then go back to breathing normally.

Check your body for signs of tension from the head downward, and feel that you are relaxed properly. If not, go back to step 2.

4. Use a positive image in which you are not disturbed by anything. Visualize the seashore, a garden—anything that gives you a sense of ease and peace. Investigate this image with all your senses: sights, odors, sounds, any sensations. Concentrate on this image for a few minutes.

Step 4. Rapid Relaxation—First Session This exercise has two purposes: to be able to relax in natural nonstressful situations and to further reduce the time it takes to get relaxed, with the goal of being able to relax in 30 to 60 seconds. The exercise can be described as a mini-break or micro-pause from your ongoing activities and thoughts. Let the first exercises take longer, then gradually reduce the time. You need to do this exercise 10 to 20 times each day for it to have a good effect. The reason you keep your eyes open is to learn to use relaxation in everyday settings when it is not possible to keep your eyes closed. Because you will need to do this exercise often and regularly, it can be helpful to plan in advance the situations and places when you can practice. Preferably, these situations will work as cues for you to do the rapid relaxation. Moreover, when you start practice you need to begin with easy situations in which you do not feel tense or nervous. To achieve this, you can think over how your day usually goes and from that plan the situations in which you can do the rapid relaxation. Examples can be in the car, when talking on the phone, when you look at your watch, when you turn on your computer, before eating and coffee breaks, and so on. Write down a list of all the situations and read it through to facilitate remembering the situations. Another method is to write notes to yourself and place them so that you will be reminded (e.g., on the refrigerator). Yet another way is to use small colored stickers and place them where you want to be reminded to do the rapid relaxation. Follow these instructions:

1. Focus your attention on your breathing. Fixate on one point in space and look at it for the whole exercise.

2. Take a deep breath from your abdomen. Release the air slowly and think “RELAX” (or your own cue word).

3. Relax in all of your muscles, throughout your body, from your forehead down to your toes. Feel the relaxation spread in your body.

4. Continue to breathe from your abdomen at your own pace, without exaggerating your breathing. Scan your body for tension.

5. Continue with what you did before the exercise and stop fixating on the point in space.

Step 5. Rapid Relaxation—Second Session The exercise for this week is identical to the rapid relaxation you did last week, but this week you will use rapid relaxation in stressful situations and when you are disturbed by your tinnitus. Examples can be when you concentrate on something, when you are attempting to sleep, in noisy environments, when you are problem solving, when you face obstacles, and when your tinnitus sounds loud. It is advisable to apply the relaxation techniques as soon as you feel any tension, as it is more difficult, even impossible, to relax if you are too stressed. Keep in mind that you use these relaxation techniques to feel well overall, and not to ward off tinnitus. Therefore, it is crucial that you apply rapid relaxation in different situations so that it is not linked in your mind to bad experiences. If that happens, rapid relaxation may be a reminder that you have problems, and this is not want we want to achieve.

Cognitive Techniques

There are two main cognitive components in the program. The first deals with attention-diversion techniques, use of “inner picture” imagery, and exercises directly aimed at reinterpreting tinnitus as something less painful (see Hallam, 1989; Henry and Wilson, 2001), then applying those skills in real-life settings. The latter involves exposure techniques inspired by the principles used in the treatment of phobias. These techniques are beginning to be applied with chronic pain patients (Vlaeyen et al, 2001), and our experience is that they are applicable for a proportion of tinnitus patients.

The following is an example of the use of positive imagery. Occasionally, the therapist can skip aspects relating to sounds in the instruction (at least the first time), and ask patients afterward if they were aware of tinnitus during the exercise. Often, patients report that they forgot their tinnitus while focusing on the image.

INSTRUCTIONS FOR POSITIVE IMAGERY

There are many advantages to being able to use positive imagery: (1) it can help you maintain a relaxed state; (2) the positive image can become the mental equivalent of your bodily relaxation; (3) your mental abilities and focusing skills are maintained; (4) it can increase general well-being. The following suggestions are given.

1. Choose a mental image unrelated to your tinnitus. It can be something from nature or wildlife. One example is picturing yourself standing on the beach and looking out at the sea. You can choose something you have seen in real life, but it is better not to include other people in your image. Also, your image should not be associated with any problem solving, work, or other effort. It is good to involve several senses, includ ing vision, hearing, and smell.

2. Use your relaxation exercises from steps 1 through 4, then start focusing on your positive image.

3. Imagine that you are exploring that image. For example, you can look out over the sea, to the right, to the left, perhaps see a boat… look at the beach … smell the salty air and feel the sand under your feet … feel the wind blowing … hear the waves … notice other details.

4. Let go of your positive image and slowly open your eyes. Do not stay too long with your image so that tinnitus takes over. If that happens, focus again on your positive image. Stop if you lose your concentration. Start by doing small exercises, so as not to overdo it.

Hearing Tactics

Sleep Management

Sleep hygiene, bedtime and worry-time restriction, relaxation, and cognitive restructuring can be helpful for patients with sleep problems (McKenna, 2000). These methods are tailored according to the special needs of the tinnitus patient.

Relapse Prevention

In brief, this includes a proper discussion of risk factors for developing more severe tinnitus and hearing loss, then devising a plan for what to do should the tinnitus become worse (Henry and Wilson, 2001). This can include returning to the relaxation training and to the sound-enrichment strategies.

As part of the secondary prevention part, the importance of regular exercise is covered. The word exercise is usually associated with hard work, sweat, and muscles. The exercise we often forget is the one we can get naturally, for example, by cycling or walking instead of taking the car or bus for short distances. Taking the stairs instead of the elevator is another example. Instead of a coffee break, a walk in the park could be beneficial. Several research studies show that exercise can alleviate and even prevent depression, insomnia, and stress (Gullette and Blumenthal, 1996), and some preliminary evidence suggests that exercise is good for tinnitus too. The effects of exercise are similar to the effects of relaxation; that is, physical and mental balance, but the approach is different. A combination of the two is likely to have beneficial effects.

During exercise or immediately after, tinnitus can become temporarily louder and more noticeable. However, this is often temporary, and the beneficial effects of exercise always outweigh the small fluctuation in loudness the patient may perceive. On the contrary, most people find that tinnitus disturbs them less when they exercise. The patient is instructed not to be too ambitious and to gradually extend the time he or she devotes to exercise. Almost all activity can be regarded as exercise.

Cautions for the Cognitive-Behavioral Approach

Psychopathology and Tinnitus

When Applied Relaxation Should Not Be Used

The first example of when relaxation should not be used is when a patient is clinically depressed and shows clear signs of psychomotor retardation. It is evident that a patient who can hardly stand up because of fatigue and malaise should not be instructed to relax more. Instead, behavioral activation should be recommended. There are other precautions to consider when a patient is on medication or is suffering from a medical condition when the effects of relaxation should be specifically targeted for that condition. An example is asthma. It is not that relaxation is counterproductive in the case of the asthma patient; rather, it is that it cannot be presented in isolation. As already mentioned, applied relaxation can be used as an avoidant strategy instead of an approaching strategy, and that is why the reasons for doing relaxation always should be discussed and monitored.

Groups versus Individual Treatment

Conclusion

The protocol described in this chapter has been evaluated in a series of studies conducted in Uppsala (for a review, see Andersson et al, 1995a). The effects of psychological treatment have been reviewed, most recently in a meta-analysis (Andersson and Lyttkens, 1999). Overall, the effects are well established, and although the strongest effects have been found immediately following treatment, there is evidence that positive treatment effects are maintained at follow-up. However, the effects are mostly seen with regard to tinnitus annoyance and to a lesser extent the perceived loudness of tinnitus. In a majority of studies on the effects of cognitive-behavioral therapy for tinnitus, psychologists have served as therapists, and it is now appropriate that the methods are adapted for use by a broader range of professionals such as hearing therapists and audiologists.

Applied relaxation, used in conjunction with other CBT techniques, represents a useful treatment for tinnitus. The method is easy to learn and has beneficial effects overall, not just on tinnitus distress.

Acknowledgments

Berit Scott, Per Lindberg, Lennart Melin, and Leif Lyttkens are gratefully acknowledged for their work in developing an earlier version of this program and for evaluating it in controlled studies.

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