6
Tinnitus Habituation Therapy
The habituation model of tinnitus has been around for over 20 years (Hallam et al, 1984), and although direct proof of its validity is hard to find, it has provided a useful framework for conceptualizing responses to tinnitus treatment. In essence, it suggests that tinnitus can be compared in its effects to an unwanted external sound and that complaints about tinnitus are as much related to psychological and environmental factors as to any underlying dysfunction of the auditory system. For example, tinnitus may not be bothersome when it is masked or partially masked by ambient sounds or when attention is captured by other absorbing activities.
In broad outline, it was proposed that complaints about tinnitus are a consequence of a failure to cease attending to this essentially irrelevant signal. This failure may derive from internal factors that determine readiness to attend (e.g., tonic arousal), from increased salience of the signal (e.g., resulting from learned affective significance), or from the intrinsic novelty of a signal that may be intermittent or may change in quality or intensity. It was suggested that these factors can interact to increase complaints. For example, attending to tinnitus may interrupt the execution of automatic response sequences leading to a change in state or affect. Moreover, the active processing of the negative meaning of the tinnitus following a switch of attention may have similar consequences by eliciting negative emotions or by changing central nervous system arousal. We believe that the interaction of these factors is best conceptualized in terms of feedback loops that lead to “roadblocks” that get in the way of the spontaneous process of habituation of attention. In other words, learning to ignore tinnitus is both a natural and an inevitable process as long as patients (1) are able to learn to view it as a meaningless sound and (2) do not engage in methods of coping that, in opposition to their intention, have maladaptive consequences and serve to maintain attention to it. There are thus several psychological pathways to tinnitus complaint, and in this chapter we identify what they are and suggest some remedies.
The habituation model was based on clinical experience of treating tinnitus patients, factor analytic studies of tinnitus complaint, and empirical outcome studies. Complaints have been grouped into emotional distress, reflecting the affective significance of tinnitus; intrusiveness, reflecting the effects on attentional processes; auditory perceptual difficulties, reflecting associated interference with hearing; and insomnia, which is a common problem for these patients (Hallam, 1996).
It is natural for patients to maintain that tinnitus is a problem because it is loud or has recently become louder. Tinnitus may have a gradual onset, so that it may be several years before an intermittent, low-intensity tinnitus becomes bothersome (Erlandsson et al, 1992). Tinnitus intensity must of course be a factor in complaint, just as it is with external noises that may become difficult to ignore if they get louder. In fact, we have found small but significant correlations between psychoacoustic measures of tinnitus intensity and tinnitus distress (Hallam and Jakes, 1985). However, tinnitus being loud, or louder than it was, does not preclude habituation but only means that the patient may require a longer period of adaptation. It has also been found that tinnitus is rated as more severe when it consists of a complex of different and changing sounds (Dineen et al, 1997; Hallberg and Erlandsson, 1993). It is therefore important that patients are helped to understand the phenomenon of attention and the role that loudness and other psychological factors may play in drawing attention to tinnitus. We deal with this subject in this chapter; see also Hallam (1989a).
Habituation Therapy
Although tinnitus affects a large minority of the population, a much smaller number of people (0.5–1% of the population) are severely affected by it. This chapter mainly concerns those who attend clinics with tinnitus complaints that have persisted for a year or more. It does not consider hearing impairment and its remediation, masking or partial masking devices, or insomnia, which are all dealt with in other chapters. It outlines the chief psychological considerations in assessment and makes recommendations as to the kind of approach to take with different “roadblocks” to habituation. With psychological techniques, there is no expectation that the tinnitus will disappear, but we can claim a “cure” when the patient no longer pays attention to the tinnitus (except perhaps when temporarily stressed or when unoccupied in a very quiet environment). Although research treatment trials often adopt a cookbook approach to tinnitus management, it is important to conduct a careful psychological assessment to identify the factors most likely to be maintaining attention to the problem in each individual case and to tailor therapy accordingly.
This chapter first describes the rationales of attention and relaxation therapies but does not provide details of treatment techniques because these have been discussed in other chapters. Cognitive-behavioral therapy (CBT) may be less familiar to readers and will be discussed more extensively. CBT is based on the flexible use of principles rather than fixed protocols, and we advocate a tailored approach based on a formulation of each patient’s particular needs.
Many recently affected patients who attend a clinic require only reassurance about their health status and good information. Others with a recent onset may in fact be reporting dishabituation brought on by a change in emotional state or a change in ambient sound levels in the home environment or workplace. All patients should be screened at least briefly, so that those who appear to be complaining of tinnitus as a sign of other psychological difficulties can be referred to a more appropriate service. This group will include clinically anxious and depressed patients whose emotional state is primary rather than secondary to tinnitus onset. Treatment of a primary condition may be the most helpful approach, as in the case of the phobic patient treated by Hallam and Jakes (1985).
Roadblocks to Habituation Therapy
Apart from the cases in which tinnitus complaint is secondary to other problems, the following kinds of roadblocks to naturally occurring habituation can be identified:
1. Elevated arousal states in which habituation is slow or nonexistent. It is known that attention narrows to the most salient stimuli as arousal increases (e.g., as in states of fear or anxiety). An alteration in emotional state or the presence of stressors could therefore precipitate complaint about a preexisting and previously habituated tinnitus. Alternatively, a change of arousal may be associated with the emotional consequence of negative beliefs about the significance of tinnitus or result from the way attention to tinnitus interrupts habitual activities, such as conversing or reading, leading to frustration or increased effort.
2. Avoidance of exposure to external noise and/or tinnitus. Paradoxically, habituation requires that a person attend to tinnitus to learn to ignore it. The coping strategy of carrying out attention-absorbing activities (to “avoid” listening to the noise and the tinnitus) may be functional at moderate levels but become maladaptive when the effort required leads to excessive stress or even exhaustion. In the case where external sounds lead to an increase in tinnitus intensity, the person may adopt the reasonable strategy of avoiding them. However, avoiding may become maladaptive if it leads to the restriction of social activities to such an extent that opportunities for enjoyment are excluded.
3. Negative beliefs about tinnitus. Attention to tinnitus is maintained when it becomes meaningful in the negative sense that it represents an irresolvable threat. There are two major types of belief:
• A belief that the tinnitus represents a serious threat to physical or mental welfare and therefore that it would be unsafe to ignore it
• A belief that it is unfair to be afflicted by tinnitus, implying that others are to blame or that there must be a cure for the problem that others are denying them
The following sections address these roadblocks. A very important component of tinnitus counseling is the initial stage of educating the patient about the nature of tinnitus intolerance and explaining how cognitive-behavioral techniques can be of benefit.
Effects of Arousal, Mood, and Attentional Strategies on Tinnitus Habituation
It is convenient to begin by defining a state of habituated tinnitus, which can be likened to the relationship individuals have with the sound of their own breathing. This is clearly audible but, in general, not processed in conscious awareness. We assume that where there is consistent stimulus–response mapping, the sound of breathing is monitored at an unconscious level, and, other things being equal, this automatic monitoring does not affect other psychological processes. The sound of breathing is mapped onto a response signaling that everything is proceeding normally. However, if the auditory stimulus changes, such as when one has a nasal blockage producing a strange sound, the signal is likely to be processed consciously. There may be a momentary switch of attention from another activity to the nasal sound, at which point a readymade interpretation can be assigned and the person may react by, say, blowing the nose. It is generally accepted that the system for attending with awareness has capacity limits. Moreover, the act of switching attention may interrupt other ongoing activities that are fully occupying attentional resources (e.g., a nasal blockage while giving a public lecture). For this reason, the consequences of attending to tinnitus will be context-related. It will be more annoying in some situations than others depending on the nature of competing activities. (The detectibility of tinnitus will also depend on the magnitude of the tinnitus signal relative to the ambient noise level.)
We assume that, because tinnitus is an auditory signal, switching attention to it will be more disruptive when the ongoing activity uses auditory channels or subvocal auditory imagery. This assumption is consistent with the kinds of activities that people choose to compete with attention to their tinnitus (i.e., predominantly visuomotor tasks, e.g., car repairs, walking, and painting.) It is also feasible to speculate that the automatic monitoring of the tinnitus signal out of awareness will interfere more with the conscious (controlled) processing of auditory stimuli than of stimuli in other channels (e.g., the task of piano tuning or composing music), especially when the sounds are similar (Hallam, 1989b).
The ability of tinnitus to demand attention accounts for its intrusiveness (i.e., its being loud, persistent, or impossible to ignore). The development of habituation of attention to tinnitus will depend on a further set of psychological factors, as follows:
1. The degree of stimulus–response mapping. The automatization of tinnitus monitoring will be aided by a consistent meaning analysis of its presence. This may amount to accepting tinnitus in the sense that there are in fact few effective coping responses apart from just acknowledging its presence. Habituation will be delayed by responses such as, What is this? Why have I got this? and What can I do about this? These questions imply no consistent relationship between a stimulus and response.
2. Threat/anger interpretations. If a consistent threatening meaning is assigned to tinnitus, habituation will be delayed because the signal will be processed as too important to ignore. Tinnitus may serve as a reminder of unfinished business (e.g., seeking attention for health care or becoming involved in litigation), which, if not attended to, will intensify its affective significance. Processing this affective information will further deplete attentional resources so that maintenance of attention on primary tasks will be impaired.
3. Self-focused attention. Unlike an external sound, tinnitus is located internally and so is likely to lead to an internal focus of attention on other internal sources of distress that have no intrinsic relationship to it (e.g., self-deprecating thoughts and worries about job or finances; Matthews and Wells, 1996; Newman et al, 1997). These in turn may perpetuate high levels of affective arousal and a negative outlook on life in general.
4. Level of cortical or sympathetic nervous system arousal. We assume that the tendency to become distracted from a primary task and pay attention to tinnitus is related to higher levels of bodily arousal. It follows that habituation will be delayed by any intrinsic or extrinsic source of arousal, such as a mood disorder or environmental stress. Elevation in arousal may also be one of the consequences of paying attention to tinnitus. Temporary changes can be expected to result from the interruption of a primary activity or the processing of threatening information following a shift of attention to the tinnitus noise. Longer-term changes in arousal would be predicted if insomnia is present and leads to persistent sleeplessness.
5. Personality factors. We assume that personality factors play a significant role in tinnitus distress. Ability to hold attention on the primary task and avoid shifting attention to irrelevant channels (attentional focusing; Pines et al, 1989) may predict reduced likelihood of tinnitus distress. Obsessional personality characteristics are correlated with tinnitus complaint (Eriksson-Mangold and Carlsson, 1991). The personality factor of rigidity has been shown to be related to annoyance from external noise (Brand et al, 1995).
Techniques for Modifying Arousal or the Process of Attending in Tinnitus Habituation
The present status of these techniques is one in which a healthy eclecticism holds sway. A variety of strategies for modifying arousal have been tried and found beneficial for some patients at least. Overall, gains have been modest and not always long-lasting. In most cases patients benefit from a combination of techniques, and effectiveness depends on personal preference and the individual characteristics of the patient’s tinnitus. The habituation of attention model is consistent with the findings of empirical research, but given the range of factors it includes, there is no simple way of testing the model’s validity.
A study of coping in tinnitus subjects has found two main types of strategy (Budd and Pugh, 1996). Maladaptive patterns included wishing the tinnitus away and various forms of avoidance and escape. These patterns are likely to lead to roadblocks because, according to our model, it is necessary to acknowledge the presence of tinnitus as a reality and confront it as an object of attention in order for habituation to take place. A second cluster of more effective coping techniques was identified. These included giving full attention to primary tasks in which an external focus of attention is required, the use of distraction, and regarding tinnitus as one of the normal challenges of life. The study underlines the value of a redirection of attention where distraction is used as an aid rather than as a means of escape. For example, listening to background music may help.
Relaxation Training
This approach can be regarded as a solid standby that has most consistently shown benefits in clinical trials. Instructions for training will not be repeated here (see Hallam, 1989a, and Chapter 3), but the following elements are considered to be important.
1. Initial training should be performed with a skilled therapist so that patients learn what relaxation feels like. This may take between one and five sessions, depending on a person’s initial degree of tension and willingness to let go. For a minority of people, the act of letting go is anxiety-provoking in itself and may require separate treatment.
2. Success can only be achieved with adequate practice. For example, it is usual to suggest two 20- to 30-minute daily exercises involving listening to taped instructions (either the therapist’s voice or a suitable commercial tape). Many people find it difficult to arrange the time and comfortable surroundings to practice. It may take 2 to 3 months to learn deep relaxation.
3. In our clinical experience, it is neither advisable nor necessary to use the method of alternate muscle tensing and relaxing. This is especially relevant to elderly patients with joint or muscle problems. The use of suggestion and/or calming imagery should be adequate to induce relaxation.
There are several optional refinements. In applied relaxation, the patient learns a quick relaxation response on cue and applies it when experiencing tense situations. Relaxation exercises may include attentional training or modification of tinnitus imagery (see next section).
According to the habituation of attention model, relaxation should assist people who habitually try to avoid or escape their tinnitus. Instructions can include listening to the tinnitus while relaxed. The patient learns that it is possible to listen with equanimity, and an alternative stimulus–response mapping can be acquired. Relaxation should also lead to lower levels of bodily arousal in which the tendency to switch attention to novel or potentially threatening signals is reduced.
Training in Attentional Control
Adopting the concept of a cognitive skill, Hallam and Jakes (1985) attempted to train tinnitus sufferers, while in a relaxed state, to alternate their attention (every 20–30 seconds) between tinnitus and external background sounds or pleasant mental images. Few participants reported this training to be particularly helpful, and a group that received relaxation alone fared equally well. However, the training was brief, and the sample size was small. Scott and colleagues (1985) provided training in self-control through distraction (in addition to relaxation), and many subsequent studies have incorporated attentional control. Rather than switch to other bodily sensations or external sounds, patients can switch to vivid mental images that incorporate several sensory modalities. Studies by Henry and Wilson (1998) and Eysel-Gosepath et al (2004) provide support for the view that training in switching attention has some promise. Details of techniques can be found in Henry and Wilson (2001), who recommend 10 to 20 minutes of daily practice of the technique.
Attentional training has been advocated in the much broader arena of worry and mental intrusions (see Wells, 2000, pp. 145, 146, for instructions) to refocus attention away from negative self-appraisals onto external stimuli (sounds are used in the training). Wells’s conceptual model provides a framework in which tinnitus treatments could be undertaken on an experimental basis.
Distraction
The aim of distraction is to become involved deliberately in activities that fully occupy attentional resources and thereby minimize the focus on tinnitus. Most tinnitus sufferers spontaneously turn to this technique. As already noted, the distracting activity should be absorbing and preferably use other sensory channels, such as the visual. The technique is not necessarily helpful if it is a form of fearful avoidance of tinnitus. We have encountered patients who exhaust themselves in distracting activities. Nevertheless, it can be a valuable form of relief.
Modification of Tinnitus Imagery
The quality of tinnitus varies enormously, from clicks and buzzes, to hisses and roaring. The associations these sounds conjure up may be highly unpleasant (e.g., a jet plane overhead). The aim of this technique is to develop a pleasant image into which the tinnitus can be incorporated because it can be reinterpreted as similar to a pleasant sound (e.g., a boiling kettle, ocean waves, or wind in the trees). We are not aware of systematic evaluations of this technique, although it is easy to see how it could be included in an overall package of therapy, especially if the patient has good imagery ability. It would presumably facilitate habituation of attention by reducing the threat value of the tinnitus and by setting up a consistent stimulus–response mapping.
Changing Beliefs about Tinnitus: Using Cognitive-Behavioral Principles to Affect Tinnitus Habituation
This section is based on over 20 years’ experience of applying the cognitive-behavioral approach to tinnitus. The basic assumption in the cognitive theory of emotion is that an emotional response to any triggering situation is mediated by a conscious (or potentially conscious) appraisal of that situation. In other words, there is a conscious thought between some event and a subsequent emotional response (Beck, 1976). Emotional responses to tinnitus can also be understood in these terms; that is, there is a conscious thought between the perception of the tinnitus and the subsequent emotional reaction. This formulation may help to make sense of the strength of the reaction that some people have to tinnitus. Given that tinnitus is often matched to relatively quiet external sounds, the level of emotional distress associated with it may seem incongruent unless we understand the individual’s appraisal of the tinnitus and his or her ability to cope with it. The cognitive-behavioral model describes a circular relationship between a person’s thoughts and emotional state such that thoughts become more skewed, or negatively biased, as the emotional state deteriorates, leading to more negative or unhelpful thoughts. In this way, distressing emotions and unhelpful thoughts maintain one another. The cognitive model of emotion suggests that once an event, in this case tinnitus, is perceived as threatening, attention will become fixed on it to the detriment of the sufferer’s ability to process other information. This binding of attention will lead in turn to an increased focus on tinnitus and an increase in distress.
Educating the Patient
To maximize the possible benefits of a psychological approach, it is important to educate patients about the processes involved in their problem as well as about the therapeutic process. Early on in our therapy we educate our patients about tinnitus. This involves telling patients about the epidemiology of tinnitus and in particular that much larger numbers of people have tinnitus than suffer from it. The idea that people usually habituate to tinnitus naturally is stressed, and the process of habituation is described, making clear that habituation will mean that the person will no longer react to tinnitus. Patients sometimes ask if this means that tinnitus will no longer be heard. We answer this by saying that patients who do not react to tinnitus are no longer attending to it, indicating that they are unlikely to be aware of it for much of the time. It is emphasized that the psychophysical parameters of tinnitus are not good predictors of whether or not a person will be distressed by it and do not represent the main roadblocks to habituation. The patient is told instead that the level of stress (or autonomic nervous system) arousal and the negative interpretation that people place on tinnitus represent the main roadblocks. It is made clear to the patient that these factors can be changed. The point is to stress that having tinnitus, even loud tinnitus or tinnitus of a particular quality, does not lead inevitably to suffering. Emphasizing the importance of arousal and interpretation paves the way for the introduction of the therapeutic approaches outlined in this chapter.
Care is needed when educating patients about tinnitus. Instead of being reassured by the information given, some patients become anxious about their ability, or lack of it, to cope with tinnitus. Rather than interpreting the information in terms of the possibility of improvement, they may have thoughts about their own lack of progress (e.g., “If everyone else can come to terms with tinnitus, why can’t I? I must be too weak”). It is therefore important that the therapist seeks feedback from the patient about the information given, is sensitive to the patient’s concerns, and is able to address these therapeutically if necessary.
When done skillfully, assessment and therapy are seamless within cognitive-behavioral therapy. However, it is important, early on in the process, to “socialize” or educate the patient about the cognitive-behavioral model. In essence, this involves helping the patient to see the link between thinking and affect, behavior, or bodily state. This helps the patient and the therapist make sense of the problem, gives coherence to the treatment, and sets the scene for interventions. It is also important to decide whether the therapy will focus primarily on tinnitus in a relatively brief format (5–15 sessions) or deal with broader core beliefs (see later discussion), which may take longer.
There are several suggestions in the literature about how to educate people about the cognitive model of emotion (e.g., Beck, 1995; Padesky and Mooney, 1990). In some cases, additional care and sensitivity may be needed when educating tinnitus patients about this approach, particularly if they do not readily see their problems in psychological terms and are instead seeking a physical cure. Nonetheless, the fundamental principles of CBT remain the same. Metaphors may be used to inform the patient about the CBT model. Illustrations that are based on issues other than tinnitus can be particularly helpful at this stage. One such illustration involves asking the patient to imagine being on a crowded train and being poked in the back by someone’s umbrella. The therapist inquires about the patient’s emotional reaction to this and then about what went through his or her mind about the person with the umbrella. Commonly, people state that they would feel annoyed if they were in that situation and would think of the person with the umbrella as careless or aggressive. Patients are then asked to imagine their likely reaction on discovering that the person with the umbrella is blind and again to say what went through their mind on discovering this. Usually, people report feeling more sympathetic or tolerant toward the blind person and having benign thoughts, such as “The poke in the back was an accident.” Patients are then helped to see the link between the specific thoughts and the emotional states that they described. Alternatively, we may ask patients to reflect on their emotional state and the thoughts they were having while waiting to see the therapist. Whether or not metaphor, or some other illustrative process, is used, it is necessary to help patients make connections between their own thoughts and emotions. To this end care is given to highlighting links between thinking, mood, behavior, and bodily state (including tinnitus) in patients’ account of their own difficulties. It is our practice to provide patients with written material explaining anxiety, depression, and so on, and the assessment and treatment of these problems in terms of the cognitive-behavioral model. Patients and therapists should form an agreed agenda for each session. It is useful to think of the patient–therapist relationship as a joint effort. It is not the therapist’s role to “reform” the patient but rather to work with the patient against “it.”
A typical therapeutic approach that seeks to break the cycle of tinnitus distress will be used to illustrate the various stages of treatment. Albert, a 32-year-old financier, developed tinnitus 6 months prior to seeing the psychologist. A year before his first appointment with the psychologist he had developed a skin disorder and was initially given an alarming diagnosis and pessimistic prognosis. Although the diagnosis proved incorrect and the initial skin problem resolved, Albert became very anxious and experienced prominent physical symptoms of anxiety, including further skin rashes, changes in heart rate, and tightness in his throat. Over the following months he underwent numerous medical investigations, all of which proved to be negative. One of these investigations, a computed tomographic scan, was followed by what he later understood to be a panic attack but which at the time he thought was a physical collapse. His tinnitus emerged shortly after the panic attack. Audiological investigations revealed no other abnormality. His emotional state, as measured by the Beck Anxiety Inventory (Beck and Steer, 1990) and the Beck Depression Inventory (Beck et al, 1996), suggested that he was suffering from a severe degree of anxiety and a mild degree of depression. His responses to a measure of tinnitus complaint (the Tinnitus Questionnaire; Hallam, 1996) indicated that his reaction to tinnitus was severe. When first seen he was on sick leave from work.
Identifying Unhelpful Thoughts
A key element in the cognitive-behavioral management of tinnitus is the identification of unhelpful thoughts. Thoughts about tinnitus, or any other event, are often not well articulated, but occur in a shorthand or telegraphic form. They are not thought to arise in a reasoned way as a result of deliberation or a logical consideration of tinnitus. Rather, it is assumed that the thoughts just happen automatically, without an attempt to initiate them. They are therefore referred to as automatic thoughts. These thoughts are regarded by the patient as plausible even though others may regard them as farfetched and even though they may be contrary to objective evidence. Because they are “automatic,” a person may not be fully aware of his or her thoughts about tinnitus, or any other given situation, unless primed to focus on them. Guidance on how to identify automatic thoughts can be found in the literature (e.g., Beck, 1995; Wells, 1997). A common mistake is to ask people, What do you think about your tinnitus? We try to avoid this because it can lead patients to suppose that they should produce a reasonable, coherent verbal train of thought. What is needed instead is to access the stream of consciousness. It is often useful to recreate a specific, typical incident in which the patient was distressed about tinnitus. An attempt should be made to recall the event in considerable detail and in so doing to recreate a clear memory of the emotion associated with it. When this has been achieved, the patient can be asked to recall what went through his or her mind at the time.
For example, Albert complained of frequently finding his tinnitus highly intrusive. He was asked to describe specific situations in which this happened. Albert began by saying that he experienced more intrusive tinnitus in situations in which there were high levels of everyday noise. When asked to say more about this, he described playing with his children and noticing how loud their laughter and joyful screams were. He also described a time when he used a vacuum cleaner and his tinnitus became louder. When asked to remember each of these situations in detail, he was able to say that the idea went through his mind that the noises would lead to a permanent worsening of his tinnitus and that he would not be able to cope with this; he had an image of himself in the future as a bed-bound invalid. He noted that this image of himself in the future and his strategy of going to bed to avoid noise made his tinnitus worse. He generalized his ideas about noise and tinnitus to almost all loud sounds and as a result adopted an avoidant lifestyle. Albert also described being in a park, watching some older adults playing with their grandchildren, and at the same time becoming anxious and experiencing his tinnitus as more intrusive. After being asked to describe the scene in detail (e.g., the sounds and smells associated with the scene, as well as the visual images), he was able to say that at the time he experienced an image of himself as an old man still plagued by tinnitus and being unable to play with his grandchildren. Such thoughts and avoidance strategies represent roadblocks to habituation.
A patient’s thoughts about tinnitus can also be discovered by asking the person what is going through his or her mind during a change in the patient’s affect, such as when the patient cries; thoughts can be particularly accessible at such times. An alternative to eliciting thoughts in the therapy session is to ask patients to keep a diary of thoughts and emotions. They record situations in which they notice that tinnitus is more intrusive; they note how they felt at the time and also what they were thinking about what was going on. If patients report having no periods of distress or intrusive tinnitus, then they can be asked to enter situations deliberately that they believe may provoke distress. Patients are encouraged to record their thoughts in a verbatim manner rather than to compose perfect prose; this allows useful access to the person’s stream of thought. It is important to note that a patient may have many thoughts about tinnitus and that not all of these will be inaccurate. For example, the thought “My tinnitus will never go away” may not be considered inaccurate. It is therefore important that the therapist does not stop seeking the distressing thoughts at this point but rather seeks the implication of such thoughts (e.g., “Because my tinnitus will never go away, I will never be happy again”). An attempt to address thoughts such as “I have tinnitus; it will never go away” is likely to lead to the therapist and patient being confronted by a therapeutic roadblock. Addressing the implications of such thoughts (e.g., “I will never be happy again”) is likely to offer therapeutic opportunities. For further discussion of this distinction, see Wells (1997) and Moorey and Greer (2002).
Despite considerable emphasis on current events and the way a person thinks about them, the cognitive model of emotion also takes account of “deeper” cognitive processes. These include core beliefs, or assumptions of an absolute nature about the self, others, and the world. These usually derive from early experiences rather than the result of careful reasoning, but are accepted as “just the way things are.” Core beliefs can be positive or negative, but it is the negative aspect that is usually more salient when people are in a state of emotional distress.
Albert had a difficult relationship with his father that dated back to his early childhood. His father wanted Albert to do very well in life and, in an attempt to motivate him, frequently compared Albert unfavorably with other children in the extended family and often rebuked him sternly in public for minor misdemeanors. Albert believed that he could never please his father and developed a core belief that he was “not good enough,” in the sense that he was neither competent nor lovable.
Between core beliefs and thoughts about the current situation are intermediary beliefs, or assumptions. The themes present in automatic thoughts often give a clue to the underlying rules, assumptions, and beliefs. The content of these deeper assumptions and beliefs can be discovered by asking patients about the implications of their automatic thoughts and continuing to ask this question about each belief that is revealed in this way until a “bottom line” is reached. This is known as the vertical arrow technique.
For example, Albert felt particularly distressed following a temporary increase in the intrusiveness of his tinnitus. When asked what was going through his mind, he said that he would be unable to fulfill his usual responsibilities and that he would have to go to bed. When asked “If it is true that you will have to go to bed, what would this mean to you?” he said that he would feel even worse because it would mean that he would be letting people down. When asked again “If it is true that you will be letting people down, what would this mean to you?” he said that he would be out of control of his emotions. When asked again “If this is true, what does it mean to you?” he said: “That’s it, I would be out of control.” This “bottom line” suggested that he held the assumption that if he felt anxious, he would be out of control. Having discovered this, he was asked what his rules for living were, and this question revealed his belief that he should always be competent and in control of his emotions. Further guidance on eliciting rules, assumptions, and deeper beliefs can be found in Beck (1995) and Wells (1997). A person’s assumptions and core beliefs may lead the person to react in a consistent way to situations that outwardly seem different. It may also be the case that a person is particularly distressed by tinnitus because it provokes a reawakening of a negative core belief or assumption or threatens a method of coping linked to an assumption. If core beliefs are thought to play a significant role in tinnitus distress, a brief CBT protocol is unlikely to be effective. The patient may have to be referred for longer therapy unless the therapist has the flexibility and resources to pursue it.
Changing Thoughts
In essence, treatment consists of changing an incorrect belief for a correct one—and the reversal of the exacerbation cycle. Beck (1976) stated the matter succinctly: “By correcting erroneous beliefs, we can damp down or alter excessive, inappropriate emotional reactions” (p. 214) and: “First he [the patient] has to become aware of what he is thinking. Second he needs to recognize what thoughts are awry. Then he has to substitute accurate for inaccurate judgments. Finally he needs feedback to inform him whether his changes are correct” (p. 217). We start this process by developing a formulation of the patient’s difficulties. This is an attempt to match theory to practice in the individual case and so avoid a “one size fits all” approach to treatment. The distinction between theory and formulation is highlighted by Butler (1998): “A theory is the source of general explanation and general hypotheses, whereas a formulation is specific to the person to whom it applies and therefore is the source of more specific explanations and hypotheses … “(p. 4). It involves developing an understanding of a patient’s own thoughts, behaviors, and moods concerning tinnitus, and the links between these factors, within the cognitive-behavioral model of emotion. Constructing a formulation is different from making a diagnosis or categorizing a patient. Allocating a patient to one or another category, particularly on the basis of a checklist approach to categorization, rarely informs the therapist or patient about why that particular patient’s problems have come about. Within CBT it is not enough to know that a patient can be categorized as having tinnitus and as being anxious; it is imperative to know why that particular patient is anxious; that is, what thoughts have led to the anxiety and what mechanisms are maintaining it. It is particularly important to highlight vicious cycles in the system.
In Albert’s case, his belief that everyday noises would permanently worsen his tinnitus led him to avoid noise whenever possible. This in turn led him to become increasingly anxious and increasingly sensitive to sound. His avoidance did not allow him to do things that would disconfirm his beliefs about the relationship between noise and tinnitus; by avoiding noise, his (misguided) logic helped him to maintain his beliefs and the behavior that those beliefs generated. It is best to develop a formulation collaboratively with the patient rather than impose it in an authoritative manner. An explicit understanding of these processes ensures that both patient and therapist can be clear about what needs to change and helps to maintain the patient in a collaborative role within the therapy. Developing a formulation helps patients understand that their problem is one of, say, anxiety about tinnitus as opposed to the simple presence of tinnitus.
Although we have said that the aim of treatment is simply to replace inaccurate or unhelpful beliefs with more accurate or helpful ones, it is important to reiterate the point that in tinnitus management the aim is to modify the person’s appraisal of the consequences, meanings, and implications of tinnitus. There is not a strict procedure for achieving this, and guidance on how to challenge automatic thoughts can be found in the literature (e.g., Beck, 1995; Wells, 1997). The two broad methods of challenging thoughts are through verbal reattribution and through behavioral reattribution. Verbal reattribution can be achieved by techniques such as questioning the evidence supporting negative thoughts. Questions such as, What is the evidence that [a disaster] will happen? and What makes you think that? can be helpful in this respect. Often, however, patients do have some evidence for their beliefs, and it is best not to engage in a head-on confrontation but rather discuss what evidence the patient does have for a given belief and to examine the quality of that evidence. This can be achieved by considering alternative explanations for patients’ observations about what is happening to them and through reviewing counterevidence.
In the case of Albert, two possible explanations were considered for the observation that his tinnitus became more intrusive when he was exposed to everyday loud noises. The first possible explanation was that noises permanently exacerbated his tinnitus; the second possible explanation was that he became anxious when he encountered noise, and that this anxiety made his tinnitus more intrusive. These possible explanations were labeled 1 and 2. Albert was asked to think of evidence in support of explanation 1. He said only that his tinnitus became more intrusive when he was exposed to noises. When asked for evidence in support of explanation 2, he remembered that he did have negative thoughts about noise making his tinnitus permanently worse when in noisy situations, and he had experienced an increase in the intrusiveness of his tinnitus when he became anxious about his tinnitus in the park where the level of ambient noise was not high. He also said that although his tinnitus became more intrusive at times, it always receded again, disproving the “permanent” aspect of his negative thoughts. Albert realized that explanation 2 was much more likely to be the true explanation for his experiences. He found this process of considering a different possible explanation for his experiences helpful and reported a reduction in his anxiety at the time. For Albert this process was important in removing one roadblock to the process of habituation. After reviewing the evidence for and against a particular belief or challenging it in some other way, it is important to conclude by producing a rational response to the negative thought.
Some patients may be reluctant to even engage in cognitive therapy. This may be because they believe it to be an inadequate way of managing tinnitus and instead think that only a medical cure will suffice. For such patients it may be useful to do a cost-benefit analysis (or advantages–disadvantages analysis) of holding such beliefs. The belief is clearly stated, then a two-column table is constructed, with one column labeled “Costs” or “Disadvantages” and the other column labeled “Benefits” or “Advantages.” The patient is then asked to think of ways in which holding the belief is advantageous. For example, it may emerge that the patient holds the belief “Settling for treatment that is not a cure means I will stop fighting tinnitus and I will have lost the battle.” Challenging this belief may allow the person to engage in treatment or become more compliant with it. The second step is to list the disadvantages of holding a particular belief. An effort should be made to generate more disadvantages than advantages, but the advantages and disadvantages may be weighted numerically and the total weight of advantages and disadvantages compared.
Altering patients’ negative automatic thoughts is likely to lead to symptomatic relief. After this has been achieved, it may still be necessary to address the patient’s rules, assumptions, and beliefs. These deeper cognitive structures may be challenged in the same way as negative automatic thoughts. For example, the evidence for and against the beliefs revealed at each stage of the vertical arrow technique can be reviewed. Another technique that was used in Albert’s case was that of constructing a continuum with which to consider his assumption that if he was anxious, he would be out of control, and his corresponding rule that he should always be in control of his emotions. First he was asked to describe the characteristics of someone who was totally out of control of his emotions. He was then asked to describe how a person would be if he were totally in control of his emotions. These descriptions were used to label either end of a continuum. He was then asked to describe the characteristics of people who might fall at intermediary points on the continuum (e.g., at 40% in control and 60% in control). When he did this, he could see that he had most of the qualities of someone who was 60% in control. He also conceded that he did not actually know anyone who was 100% in control of his or her emotions; importantly, he realized that his father certainly did not match that description. He also said that he would not actually wish to be someone who is 100% in control of his emotions because this would mean that he would not be very human and probably not very attractive. Following this, he did not become so anxious about being anxious, and he found it easier to control his reactions to tinnitus.
Behavioral Experiments
There are several ways that behavioral tasks are used in cognitive-behavioral therapy. They may be used to distract the patient from anxiety or to help focus attention away from tinnitus, as described elsewhere in this chapter. They may be used to build up levels of activity in an otherwise inactive patient and in so doing increase the rewards that the person gets from life. This may help combat depression or provide the person with greater resources for coping with tinnitus. One of the most important uses of behavioral tasks, however, is to bring about change in the person’s cognitions. We therefore use behavioral tasks or experiments to challenge patients’ beliefs or test their predictions and to help them adopt more helpful ones.
In Albert’s case, behavioral experiments proved crucial in modifying his beliefs about tinnitus. As noted, he realized that his tinnitus became more intrusive when he became anxious, and that this usually happened at the same time as exposure to environmental noises. This intellectual understanding, however, did not relieve all of his anxiety. His emotional understanding of the point did not match his intellectual understanding of it. An experiment was therefore designed to test the hypothesis that noise exacerbated his tinnitus. It was suggested that when next confronted by everyday loud noise, he would not follow his inclination to escape from the situation but would remain in the situation for a period of at least 5 minutes. Another experiment was designed to test the hypothesis that anxiety, particularly negative thoughts, worsened his tinnitus. It was suggested that he lie on his bed, in the absence of loud noises, worry about his tinnitus, and observe the consequences. It was agreed that he would do the second experiment first, because he regarded the first as risky. Albert observed that worrying about his tinnitus had the effect of making it more intrusive; he also observed that the intrusiveness of the tinnitus subsequently diminished when he became distracted by other events. He realized that negative thoughts were the causal agent because he had controlled the ambient noise levels. He found this very convincing evidence and reorganized the other experiment such that he sought out a noisy situation by going to a movie theater (something he had previously enjoyed but had stopped doing). He observed that his tinnitus became only marginally more intrusive following the movie, and he attributed this to having to monitor its level for the experiment; he again noticed that the intrusiveness quickly diminished. These experiments led Albert to accept hypothesis 2 and reject hypothesis 1. As a result, he quickly became less avoidant and again became involved in his previous activities, eventually returning to work. The process of resuming his usual activities in turn weakened the image of himself as an invalid. These behavioral experiments finally removed the roadblocks to his habituation. According to Wells (1997) and Bennett-Levy et al (2004), the most significant changes in a person’s cognitions are brought about as a result of behavioral experiments. Bennett-Levy et al (2004) give detailed guidance on the design and implementation of behavioral experiments in cognitive therapy.
By the end of therapy, Albert described himself as no longer anxious about his tinnitus and no longer leading an avoidant lifestyle. At that point his scores on the questionnaire measures of emotional state were within normal limits, and his score on the Tinnitus Questionnaire (TQ; Hallam, 1996) reflected a very mild degree of tinnitus complaint. He made a gradual return to work toward the end of therapy.
Conclusion
In this chapter we have placed the cognitive-behavioral approach to tinnitus within the general framework of the habituation model. We advocate a stepped approach to management (i.e., screening/assessment, information/education, brief cognitive-behavioral therapy protocol, and longer cognitive-behavioral therapy). Although the majority of tinnitus patients can be accommodated within a relatively standardized approach, there is a sizeable minority that require careful formulation and a tailoring of techniques to their specific problems. It is desirable that this service be provided within an audiological setting where medical and audiological services and additional rehabilitation techniques are available.
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