Tinnitus - Tinnitus Treatment
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 being formulated
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 usedas opposed to "tinnitus management or treatment"because 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, and
- 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, disappear 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 terms.
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 sessions.
Specific Cognitive Distortions
Cognition refers to the way we perceive and interpret things. When patients face a difficult course of future actione.g., dealing with an unwanted auditory intrudertheir 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 becomes clouded.
- 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 this conclusion.
- 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 responsibility.
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 while reading.
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 column.
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 relaxatione.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.
- Meditationmultiple 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 "internal" volume control. By sending a constant low level signal to the brain, it can, in effect, be "tricked" 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 behavioral counseling.
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 press, 1983).