by Robert Sweetow, Ph.D.
A variety of tinnitus treatments exist today. These include drug therapy,
masking devices, white noise generators, hearing aids, biofeedback, electrostimulation,
and other medical and surgical procedures. Unfortunately, a proportion
of patients fail to respond to any significant degree to any of the approaches
available today. It is understandable why all tinnitus patients are not
responsive to any single treatment, considering the many possible causes
of tinnitus. Perhaps the most distressing questions regarding the treatment
of tinnitus patients, however, are why so many are unresponsive to any
of the current treatments, and what can we, as professionals, do for these
unfortunate patients while new, and we hope better, treatment plans are
A potential answer to both of these questions can be found by analyzing
the patient's reaction to the tinnitus. I have stated in the past that
it is not the tinnitus itself that presents a problem for the patient.
Rather, it is the patient's adverse, negative reaction to it. For some
patients, the presence of any degree of tinnitus can represent an overwhelming
negative force that prevents them from placing the tinnitus in a background
role in their consciousness. Researchers have suggested that it is not
the loudness or pitch of the tinnitus that is the bothersome aspect. Rather,
it may be its intrusiveness and their lack of control that so psychologically
disables many patients. Because of a cognitive reaction, patients often
modify their thoughts and behaviors in manners that hinder their chances
of success with any tinnitus treatment. Thus one must employ techniques
that assist these patients in altering their negative cognitive reaction.
(Keep in mind that any cognitive reaction is a behavior, and all behaviors
are subject to modification.)
Cognitive and behavioral interventions have proven successful in the
treatment of other noxious stimuli, such as those associated with chronic
pain. The intervention procedures discussed in this article are not intended
to supplant the other treatments, but rather to serve as adjunctive approaches
that might enhance tinnitus-patient management. Note that the term "tinnitus-patient
management" is purposely usedöas opposed to "tinnitus management
or treatment"öbecause these adjunctive approaches are geared toward
an attitudinal adjustment regarding one's reaction to the tinnitus, rather
than toward alleviating the tinnitus itself.
Cognitive/behavioral approaches attempt to modify maladaptive behaviors
by applying systematic, measurable implementation of strategies designed
to alter them. This modification is accomplished through:
direct modification of overt or covert behaviors through the application
of specific behavioral techniques,
manipulation of environmental antecedents or situational demands,
manipulation of environmental consequences.
Interventions therefore can be made in three separate but related domains.
The goal is to make patients reappraise situations they previously perceived
as unmanageable, tension producing, and beyond their control. Interventions
include such strategies as relaxation procedures, hypnosis, thought stopping,
attention diverting, modification of internal dialogue (positive self
statements), minimizing cognitive distortions, reducing positive reinforcement
for maladaptive behavior, stress reduction, activity enhancement, self
recording and monitoring, reinforcement of adaptive responses, assertion
training, and anger control. A pre-packaged treatment intervention is
not imposed on the patient. Rather, the treatment is tailored to the patient's
specific needs, and patients are active participants in the selection
of therapeutic strategies.
It is essential that the patient realize the professional's intentions
from the outset. The patient should be informed that the goal is not to
make the tinnitus disorders, disappearö i.e., it is not curative. It should
be explained that the tinnitus possibly will be present indefinitely.
Success is possible only when the patient accepts this. It is also imperative
that the patient recognize there is no "quick fix " for the
problem. The goal is to make the tinnitus a neutral factor in the patient's
everyday life. The tinnitus needs to be relegated from the foreground
to a background position in the patient's consciousness.
Tinnitus can lead a patient to engage in cognitive disorders, which in
turn can produce maladaptive behaviors, thus impeding progress. The first
step in therapy is the identification of the problem. The problem, of
course, consists of the behavioral and social consequences of the patient's
tinnitus, as well as the patient's (and family's) attitude about it. In
order to adequately define the problem, it needs to be defined in operational
For example, the professional cannot provide optimal counseling to a
patient who complains, "I just can't live with this tinnitus."
Instead, the patient must be encouraged to discuss the problem in specifics,
such as "I cannot fall asleep after being awakened in the middle
of the night by my tinnitus," or the "tinnitus really bothers
me because it prevents me from hearing." It is important to maintain
the distinction between the tinnitus experience and the maladaptive tinnitus
behavior. In other words, the patient needs to recognize that when he
is not thlnking about the tinnitus, it is not a problem. Thus, the time
frame in which the tinnitus truly presents a problem must be carefully
defined. For many patients, that time is limited to quiet periods, such
as when reading or before bedtime. Once the time frame has been established,
it is possible to identify specific problem behaviors that occur during
these periods. Among the most common are: difficulty falling asleep, difficulty
remaining asleep, difficulty concentrating, trouble hearing in crowds,
nervousness, personality changes (such as becoming short tempered), depression,
inability to cope, and strained family relationships.
Essential to the operational definition of the problem is identification
of any cognitive distortions and subsequent maladaptive behaviors. The
most efficient way to do this is via homework assignments that require
the patient to write or chart those cognitive distortions and maladaptive
behaviors. Writing things down not only helps the patient locate his or
her mental errors, but also helps the patient look at the problem objectively.
These homework assignments also are critical in making patients assume
responsibility for their own actions within and outside of the therapeutic
Specific Cognitive Distortions
Cognition refers to the way we perceive and interpret things. When patients
face a difficult course of future actionöe.g., dealing with an unwanted
auditory intruderötheir beliefs might become distorted and not based in
fact. They might begin to view the situation that brought them to seek
professional help as overwhelming. They might begin to engage in one or
more of the following cognitive distortions:
All-or-nothing thinking, e.g., if it isn't perfect, it's worthless.
Overgeneralizing, e.g., one negative event is perceived as a never-ending
pattern of defeat.
Mental filter, e.g., dwelling on a negative event so that all reality
Disqualifying the positive, e.g., positive experiences don't count.
Jumping to conclusions, e.g., by "fortune_telling" or "mind
reading," you decide things are going badly or that persons are
reacting to you negatively, even though you have no evidence to support
Magnification, e.g., exaggerating the importance of things.
"Should" statements, e.g., creating guilt by believing you
"should" have done something differently.
Labeling, e.g., instead of describing the error, you attach a negative
label to yourself.
Personalization, e.g., assuming responsibility for a negative event
when there is no basis for doing so.
Patient must assume responsibility
Cognitive distortions lead to maladaptive and non-productive behaviors.
This is where the "behavior" part of cognitive/behavior theory
comes into effect. All of us have fallen victim to the above mentioned
cognitive distortions. Fortunately, most of us are able to formulate alternative
perceptions. After all, there is always more than one way to analyze a
problem. If our first analysis is negative, most of us will search for
an alternative approach. For many, though, this is not an easy task. Thus,
the patient's reaction, motivation, and attitude about the problem become
essential factors that must be addressed if he or she is to make progress.
The therapist has influence, but not direct control, over the patient's
psychological characteristics. So if a true change is to be made, it must
come from the patient. That is why the patient must be the one to assume
Contrary to popular thought, motivation does not always precede action.
In this therapeutic approach, the patient is forced into action (via charting
procedures) in order to achieve motivation. Motivation is often paralyzed
when the patient perceives the situation as unmanageable and overwhelming.
Therefore, we have the second step in our series of homework assignments,
which is to have the patient (with the therapist's guidance) divide the
problem into smaller, manageable components and tasks. The objective is
to provide the patient with a "taste of success." An example
of using smaller components in tinnitus-patient management is to redirect
the patient's attention away from "conquering" the overall tinnitus
problem and, instead, toward working on areas such as sleep, or concentration
As we divide the overall problem into smaller components, we automatically
identify alternate, desirable behavioral patterns. While doing this we
simultaneously identify alternate thought patterns that must be adopted
if we are to succeed in modifying behavior. A simple, but effective homework
assignment is to have the patient use a two-column table in which he or
she identifies the cognitive distortion or maladaptive behavior) in the
left-hand column, and an alternative thought or behavior in the right-hand
Helpful mini strategies
The professionally directed techniques outlined above are not the only
cognitive/behavioral techniques available to the tinnitus patient. There
also are several mini-strategies that might be useful to patients.
Ten-second mini-relaxation exercises: "Become aware of any tension
(teeth-clenching, neck tightness, sweaty palms). Take a deep breath
and let the tension flow out from the fingertips as your muscles go
limp during the exhale. "
Conditioned stimulus to trigger relaxationöe.g., blue adhesive dot.
Internal cue words, calm or quiet to trigger relaxation response and
when applicable, from patient's family members.
Attention to breathing patterns.
Self hypnosis, enhanced with visualization.
Meditationömultiple repetitions of a given word...or focus with eyes
open on a specific object for 15 minutes. This allows for disengagement
from accumulated stressors and for refocusing on relaxation.
Lifestyle and attitude changes:
plan idle time to do nothing.
increase social interactions.
exercise (however, this sometimes helps and sometimes is deleterious).
develop awareness of things around you.
practice listening, which slows down the "hurry-up disease."
avoid stressors as much as possible.
develop the ability to laugh at yourself.
A recent addition to the strategies of fighting tinnitus is the use of
habituation via a low level white noise generator. Unlike a tinnitus masker,
the noise generated by these wearable devices is designed to be soft enough
so that the brain perceives both the tinnitus and the noise. The theory
behind this technique is that when faced with an abnormal auditory system,
the brain, in an effort to seek out an auditory signal, manufactures tinnitus
by turning up its ãinternalä volume control. By sending a constant low
level signal to the brain, it can, in effect, be ãtrickedä into rewiring
its neural pathways because it thinks it is receiving auditory stimulation.
This technique, known as habituation, can take as long as one to two years.
Furthermore, it is still experimental, but it does deserve further research
to determine whether it helps, when used in conjunction with cognitive
Cognitive/behavioral therapy is an interactive approach requiring full
cooperation between the therapist and patient, and when applicable, from
patient's family members. This technique can be employed both for multiple-session
and for single-session purposes. Its versatility is limited only by the
imagination and flexibility of the therapist and patient.
I hasten to refer the interested reader to two superb sources of information
on cognitive/behavioral therapy, the sources from which most of this material
has been derived. The first is a Signet paperbook that I often lend or
recommend to patients. The book has the not-so-scientific title of Feeling
Good: The New Mood Therapy , by David Burns(1980). But don't make the
cognitive distortion of being fooled by its simplistic title. The book
is excellent and makes for enjoyable reading for both the layperson and
the professional. The second is a book entitled Pain and Behavioral Medicine:
A Cognitive-Behavioral Perspective by Turk, Meichenbaum, and Genest (Guilford