Cognitive Behavioral

Therapy for Tinnitus

Eldré Beukes _ Gerhard Andersson

Vinaya Manchaiah _ Viktor Kaldo
COGNITIVE BEHAVIORAL
THERAPY FOR TINNITUS
Editor-in-Chief for Audiology
Brad A. Stach, PhD
COGNITIVE BEHAVIORAL
THERAPY FOR TINNITUS

Eldré Beukes, PhD

Gerhard Andersson, PhD
Vinaya Manchaiah, AuD, MBA, PhD
Viktor Kaldo, PhD
5521 Ruffin Road
San Diego, CA 92123

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Library of Congress Cataloging-in-Publication Data:

Names: Beukes, Eldré W., author. | Andersson, Gerhard, author.

Manchaiah, Vinaya, author. | Kaldo, Viktor, author.
Title: Cognitive behavioral therapy for tinnitus / Eldré W. Beukes,
Gerhard Andersson, Vinaya Manchaiah, Viktor Kaldo.
Description: San Diego, CA : Plural Publishing, [2021] | Includes
bibliographical references and index.
Identifiers:LCCN 2020027363 | ISBN 9781635502992 (paperback) | ISBN
1635502993 (paperback) | ISBN 9781635503036 (ebook)
Subjects: MESH: Tinnitus--therapy | Cognitive Behavioral Therapy--methods
Classification: LCC RF293.8 | NLM WV 272 | DDC 617.8--dc23
LC record available at https://lccn.loc.gov/2020027363
 CONTENTS

Foreword vii
Preface ix
Acknowledgments xi
About the Authors xiii

SECTION A. INTRODUCTION TO COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Chapter 1. Cognitive Behavioral Therapy Principles and Applications 3
Chapter 2. Cognitive Behavioral Therapy for Tinnitus 11
Chapter 3. How to Deliver Cognitive Behavioral Therapy for Tinnitus 35

SECTION B. COGNITIVE BEHAVIORAL THERAPY INTERVENTION

(SELF-HELP) MATERIALS FOR TINNITUS

Part I. Overview
Chapter 4. Tackling Tinnitus Program Outline 57
Chapter 5. Tinnitus Overview 67

Part II. Relaxation Guide

Chapter 6. Deep Relaxation 77
Chapter 7. Deep Breathing 85
Chapter 8. Entire Body Relaxation 91
Chapter 9. Frequent Relaxation 95
Chapter 10. Relaxing When Stressed or Upset 101
Chapter 11. Relaxation Routine 105

Part III. Cognitive Behavioral Therapy Techniques

Chapter 12. Positive Imagery 111
Chapter 13. Views of Tinnitus 119

v
vi COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Chapter 14. Shifting Focus 125

Chapter 15. Thought Patterns 131
Chapter 16. Challenging Thoughts 143
Chapter 17. Being Mindful 157
Chapter 18. Listening to Tinnitus 163

Part IV. Dealing With the Effects of Tinnitus

Chapter 19. Sound Enrichment 171
Chapter 20. Sleep Guidelines 177
Chapter 21. Improving Focus 191
Chapter 22. Increasing Sound Tolerance 197
Chapter 23. Listening Tips 207

Part V. Maintaining the Results

Chapter 24. Summary 215
Chapter 25. Future Planning 223

SECTION C. SUPPLEMENTARY MATERIALS FOR MONITORING AND ENGAGEMENT

Chapter 26. Additional Resources 229
Chapter 27. Pre-Intervention Screening Questionnaire 233
Chapter 28. Weekly Monitoring 237
Chapter 29. Providing Guidance 241

Index 253

Tinnitus management continues to challenge patients
and providers as it has for more than 2,000 years.
Tinnitus affects individuals regardless of age, race,
ethnicity, socioeconomic status, geographic loca-
tion, and unexpectedly, hearing status. The relation
between hearing sensitivity and tinnitus severity is
not only weaker than one might expect, but it also
is weaker than the associations between tinnitus
severity and depression or anxiety. Tinnitus is both
a real event, the perception of a sound corroborated
by imaging studies, and an unreal event as it does
not correspond to observable external stimulation.
Its effects suggest that tinnitus may be the arche-
typical psychosomatic experience. Perhaps this is
why the strongest evidence base for effective tinni-
tus management at present, is not hearing aids or
the therapeutic use of sound, but rather Cognitive
Behavioral Therapy (CBT).
Convincing arguments could be advanced sug-
gesting that tinnitus is an audiologic disorder, as it
is perceived by its host as a sound. However, a tin-
nitus sound that does not trigger a psychological or
emotional reckoning of that sound is as bothersome
as other sounds that do not provoke thought or emo-
tion, such as a ventilation system or the sound of
car tires on the road. Humans can coexist easily
with sounds that are understood to have little or no
value. But when a person hears a sound and believes
it to be relevant and important, then coexisting with
that sound may be a less reasonable proposition.
Management of bothersome tinnitus must address
more than the hearing of a sound; it also must con-
sider, and oftentimes modify, the patient’s evalua-
tion of that sound’s value.
The population of individuals with bothersome
tinnitus is heterogeneous, as tinnitus arises from
many potential causes with severity influenced
by many variables. Hence, effective management
requires careful accounting of a patient’s experi-
ence, and intervention flexibility. Fortunately, CBT
FOREWORD
protocols are adaptable and can be tailored to a
variety of applications. The authors provide his-
torical background justifying CBT’s use for tinnitus
management, building upon its effectiveness for
patients suffering from conditions known to influ-
ence tinnitus severity, such as depression and anxi-
ety. CBT may be delivered in a variety of settings,
from face-to-face counseling in a clinic (perhaps
individually, perhaps in groups) to remote interac-
tions between clinicians and patients employing
telemedicine strategies. When people suffer from
tinnitus, it is often because they conceive of tinni-
tus as a portentous event rife with intrusiveness and
negative implications, even though tinnitus in the
vast majority of cases is neither a symptom of sig-
nificant pathology nor an indication of impending
deafness. The long-standing objective of CBT is to
support patients’ coping mechanisms by ensuring
that problems are accurately assessed, and produc-
tive behaviors may be practiced and implemented.
Tinnitus severity may be exacerbated by inaccurate
thoughts that lead to emotional engagement in
response to the sound. If the sound cannot be elimi-
nated, then the emotional response to the sound
must be minimized; and, for decades, health care
providers have employed CBT protocols to that end.
Issues that complicate the delivery of CBT to
patients with bothersome tinnitus involve stake-
holders at many different levels of health care.
Psychologists are the licensed professionals most
equipped to provide CBT; unfortunately, though,
most psychologists do not routinely see patients
specifically requesting tinnitus management, par-
ticularly those lacking a concurrent mental health
diagnosis. Audiologists are most equipped to pro-
vide hearing aids, maskers, assistive devices, and
counseling to support tinnitus management; and
although audiologists routinely employ tenets of
CBT in their rehabilitative endeavors, most would
consider formal CBT to be outside an audiologist’s
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viii COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
scope of practice. Indeed, many audiologists work in
ENT offices that are not likely to offer CBT. However,
the authors of this text address this issue head on, as
their CBT trial in the United Kingdom demonstrates
that audiologists can reasonably support patients
completing Internet-delivered CBT (ICBT). The ques-
tion is not “Should audiologists perform CBT for
their tinnitus patients?” but rather “Can audiolo-
gists refer patients, administer, and support patient
matriculation through a self-paced ICBT protocol
that addresses clinical management of bothersome
tinnitus?” As the authors’ work demonstrates, the
answer, thankfully, is “yes.”
The need to standardize elements of intervention
is obvious. In the United States, patients’ point of
contact in the health care system for tinnitus-related
services include, in no particular order, otolaryngol-
ogists, chiropractors, acupuncturists, audiologists,
herbalists, psychologists, psychiatrists, neurologists,
not to mention the ubiquitous online supplement,
vitamin, and miracle cures; in short, patients who
want to do something about their tinnitus usually
encounter at one time or another healers, wheelers,
and dealers. The ensuing “runaround” creates confu-
sion and frustration, raising the likelihood that needs
remain unmet and hope for improvement fades.
Although it is probable that nearly as many peo-
ple require tinnitus management services as require
hearing aids — many millions in the United States
alone — the number of audiologists providing ser-
vices for tinnitus is a small fraction of those offering
hearing aids. The lack of a simple cure compounds
the lack of providers, particularly outside urban
areas; many patients who would seek services for
tinnitus lack reasonable access. The availability of
CBT for patients with tinnitus is poorer still. A dearth
of providers ensures that barriers such as travel cost,
distance, and physical and mental health conditions
that limit travel have an outsized effect on patient
care. The authors correctly posit that ICBT for tin-
nitus is a logical addition to currently practiced
Internet-based interventions employed in psychol-
ogy and various rehabilitation disciplines. In the
United States, tinnitus intervention using Internet-
delivered Progressive Tinnitus Management is avail-
able to military veterans and reinforces the authors’
experience indicating the viability of remote contact
with patients. The population’s experience with the
COVID-19 virus suggests that health care provided
remotely is likely to increase in the future.
Tinnitus management might not ever conform
to a one-size-fits-all approach for even a plurality
of patients; therefore, flexibility in delivery for the
provider and adaptability to the patient’s particu-
lar needs are crucial requirements for an interven-
tion. The objective of this text, to support the use
of CBT for tinnitus management, offers the means
by which many of the broad spectrum of tinnitus-
related challenges may be addressed. The transfer of
research knowledge to clinical practice suffers when
clinicians do not have access to interventions that
were tested in research. The authors aim to make
intervention materials available to practitioners to
facilitate use of evidence-based materials, with the
hope that, in many cases, tinnitus management
can be delivered using a standardized method.
Their ICBT platform provides for individual differ-
ences throughout a series of modules (presented as
book chapters), mostly organized in a sequential
manner reminiscent of a multi-week CBT protocol.
While sequential modules address well-established
notions of tinnitus mechanisms, effects, and man-
agement, optional modules consider various tinni-
tus symptoms that appear across patients in unique
combinations and levels of severity. The authors’
ongoing work conducting ICBT trials on a grow-
ing and increasingly diverse population of patients
bothered by tinnitus provides the backdrop for this
text, in which they build the case for CBT and its
delivery through an Internet platform. Contents
from the modules are discussed and demonstrate
the intervention’s malleability. This text addresses
a consequential element of tinnitus practice: If the
sound cannot be unequivocally shut off, then any
negative effects of its presence on a patient must be
minimized. Through the diverse inventory of CBT-
related strategies and counseling, the authors offer
a point from which the tinnitus interventionist can
start to provide guidance and the patient can start
to manage their condition.
Marc Fagelson, PhD
Professor of Audiology
East Tennessee State University

Tinnitus is one of the most distressing audiological
conditions. It is a medical enigma as to why some
people with tinnitus are distressed by it whereas
many others are not bothered by hearing these
internally generated sounds. Those who are both-
ered by tinnitus are known to primarily look for its
cure and, after learning that there is no known cure,
either go into despair or start looking for advice by
searching the Internet and other resources. Some
have further diagnostic tests but continue to strug-
gle despite more knowledge about their symptoms.
Others see professionals such as audiologists or psy-
chologists for help but continue to struggle. This
may be partly attributed to a lack of evidence back-
ing some of the management strategies being used.
The approach with the most evidence of effective-
ness in reducing tinnitus distress at present is the
use of Cognitive Behavioral Therapy (CBT; Fuller et
al., 2020; Hesser, Weise, Westin, & Andersson, 2011;
Hoare, Kowalkowski, Kang, & Hall, 2011). CBT also
addresses other comorbidities, such as depression,
anxiety, and sleep problems, and has lasting results.
Its effectiveness is attributed in part to helping indi-
viduals react differently when hearing tinnitus and
providing a range of strategies to better manage the
tinnitus. Despite the evidence backing CBT, it is sel-
dom provided in clinical practice. For instance, a
large-scale survey in the United States showed that
CBT was recommended for 0.2% of the population,
whereas medications were recommended 45% of
the time, despite not having been recommended in
many practice guidelines (Bhatt, Lin, & Bhattacha-
ryya, 2016). These findings suggest the discrepancy
between evidence and practice (Tunkel et al., 2014).
Obstacles preventing delivery of CBT include a
shortage of tinnitus experts and the high costs asso-
ciated with intervention delivery. CBT is generally
provided by psychologists. Audiologists are becom-
ing interested in offering CBT-based counseling for
people with tinnitus, although no formal training is
PREFAC E
provided on this in the audiological curriculum. Var-
ious audiologists and hearing researchers with an
interest in tinnitus across the globe have contacted
us seeking CBT materials for tinnitus. This led us to
create this book with the CBT materials that have
been specifically developed for the management of
tinnitus and thereby to help improve access to tin-
nitus care. We believe this book will help audiolo-
gists, using these evidence-based CBT techniques, to
facilitate habituation in their tinnitus patients.
The materials presented in this book have evolved
over nearly 35 years. The original version of the CBT
materials was developed in Sweden in early 2000
by a few clinical psychologists. The original Swed-
ish version was translated and used in clinical tri-
als in Australia and Germany. The materials were
updated further by Eldré Beukes by incorporating
audiological information and revising the materi-
als based on learning strategies for a clinical trial in
the United Kingdom. More recently, in a National
Institutes of Health (NIH)-funded project, we had the
opportunity to further revise the CBT materials to
ensure that the text is below a U.S. sixth-grade read-
ing level (Beukes et al., 2020). Moreover, various
exercises were developed based on behavior change
principles to ensure user engagement and promote
optimal outcomes.
This book can be used by various stakeholders.
Audiologists can use these materials as clinical
guidelines to offer CBT-based counseling for their
tinnitus patients. Tinnitus researchers can use these
materials in developing evidence-based therapies for
tinnitus suffers. Also, individuals with tinnitus can
use this book as self-help materials to learn effective
strategies in managing their condition. However, we
want to stress that the strategies discussed in this
book are not intended as a replacement for medical
care. A thorough medical and audiological assess-
ment is always recommended to identify the most
appropriate management route to minimizing the
ix
x COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
impact of the tinnitus. Various suggestions are made
as to how this book can be used in various formats
to complement clinical care or to extend care where
this care is not available. We trust this book will
extend access to tinnitus care for many individuals
who are distressed by tinnitus.
Sincerely,
Eldré Beukes,
Gerhard Andersson,
Vinaya Manchaiah, and
Viktor Kaldo
References
Beukes, E. W., Fagelson, M. A., Aronson, E. P., Munoz,
M. F., Andersson, G., & Manchaiah, V. (2020). Read-
ability following cultural and linguistic adaptation of
an Internet-based intervention for tinnitus for use in
the United States. American Journal of Audiology, 29(2),
97–109. https://doi.org/10.1044/2019_AJA-19-00014
Bhatt, J. M., Lin, H. W., & Bhattacharyya, N. (2016). Prev-
alence, severity, exposures, and treatment patterns of
tinnitus in the United States. JAMA Otolaryngology-Head
& Neck Surgery, 142(10), 959–965. https://doi.org/10​
.1001/jamaoto.2016.1700
Fuller, T., Cima, R., Langguth, B., Mazurek, B., Vlaeyen,
J. W. S., & Hoare, D. J. (2020). Cognitive behavioural
therapy for tinnitus. Cochrane Database of Systematic
Reviews, 2020(1). https://doi.org/10.1002/14651858.CD
012614.pub2
Hesser, H., Weise, C., Westin, V. Z., & Andersson, G. (2011).
A systematic review and meta-analysis of randomized
controlled trials of cognitive–behavioral therapy for tin-
nitus distress. Clinical Psychology Review, 31(4), 545–553.
Hoare, D. J., Kowalkowski, V. L., Kang, S., & Hall, D. A.
(2011). Systematic review and meta-analyses of ran-
domized controlled trials examining tinnitus manage-
ment. Laryngoscope, 121(7), 1555–1564. https://doi.org/​
10.1002/lary.21825
Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld, R. M.,
Chandrasekhar, S. S., Cunningham, . . . Whamond E.
J. (2014). Clinical practice guideline: Tinnitus. Otolar-
yngology-Head and Neck Surgery, 151(2 Suppl.), S1–S40.
https://doi.org/10.1177/0194599814545325

We would like to acknowledge the enormous contri-
butions of various clinicians, researchers, and indi-
viduals with tinnitus who all have contributed to
the development and refinement of the materials
presented in this book. In particular, we would like
to acknowledge the staff at the Department of Audi-
ology in Uppsala (Sweden), all students in the clini-
cal psychology program at Uppsala University that
made their master’s theses within tinnitus research
projects, Britt Klein and the late Jeff Richards in
Australia, Cornelia Weise in Germany, David Bagu-
ley and Peter Allen in the United Kingdom, Marc
Fagelson and Elizabeth Parks Aronson in the United
States, and all our students who have worked in the
research trials. A special thanks goes to our web-
masters in the Internet trials, in particular George
Vlaescu. We would like to extend our thanks to the
various study participants who undertook clinical
trials and provided very helpful feedback to improve
these materials. Special thanks to Marc Fagelson,
Professor of Audiology at East Tennessee State Uni-
versity, for writing the foreword to this book. Our
ACKNOWLEDGMENTS
appreciation is extended to Mrs. Patricia Richards
and Ms. Cassy Ford for proofreading and to Ms.
Michelle Lancaster in Graphic Design at Lamar Uni-
versity for designing the figures for this book.
Last, but not least, we are indebted to our fami-
lies for their tolerance and encouragement during
the preparation of this book and the research work
related to this book. Vinaya greatly appreciates his
parents, Manchaiah and Manjula, and his beloved
spouse, Kavya Spandhana. Eldré would like to
extend her appreciation to her mother, husband,
and special daughters, Heidi and Charlotte. Gerhard
thanks his family, patients, and clinical colleagues
over the years. Viktor would like to thank his wife
and coworker, Susanna Jernelöv, who has always
helped to improve the parts related to sleep due to
her expertise, and his sons, Arvid and Volmar.
This work is partly funded by the National Insti-
tute on Deafness and Other Communication Disor-
ders (NIDCD) of the National Institutes of Health
(NIH) under the award number R21DC017214.
xi

Dr. Eldré Beukes, PhD, is the Post-Doctoral Researcher
at the Department of Speech and Hearing Sciences
at Lamar University in Beaumont, Texas, and at
Anglia Ruskin University in Cambridge, United
Kingdom. She received her BSc in South Africa, her
MSc in Audiology from the University of Manches-
ter, and her PhD from Anglia Ruskin University. She
is a clinical scientist in Audiology and was awarded
the Richard May prize following her training. She
received the prestigious Shapiro prize from the Brit-
ish Tinnitus Association for her research for 3 con-
secutive years (2017, 2018, 2019) and the Hallpike
Research Prize (2019) from the British Association
of Audiovestibular Physicians. Her research focus
is on the development and running of clinical
trials to assess the effectiveness of Internet-based
interventions.
Prof. Gerhard Andersson, PhD, is Professor of Clin-
ical Psychology at Linköping University (appointed
2003) in the Department of Behavioural Sciences and
Learning. Prof. Andersson received his education at
Uppsala University, Department of Psychology, and
graduated in 1991 (MSc Clinical Psychology). His
first PhD was in Clinical Psychology (1995), and
his second PhD was in Medicine, Otorhinolaryn-
gology (2000). He did his post-doctoral work in the
Department of Psychology at University College in
London (1996–1997), working with patients with
dizziness and imbalance. In 2010, he completed a
BA in Theology. He was guest professor at Karolin-
ska Institute in the Department of Clinical Neuro-
science, Psychiatry (2007–2012). During his whole
career, Prof. Andersson has worked part-time with
patients, mainly in audiology, but for a period also
in psychiatry. He has a part-time position as a clini-
cal psychologist in the Department of Audiology at
Linköping University Hospital, as a member of the
Tinnitus team. Prof. Andersson is trained as a CBT
therapist and has a license and graduate diploma
ABOUT THE AUTHORS
as a psychotherapist (2005). He has also completed
teaching and supervision training in cognitive and
behavioral psychotherapy (2016). In 2014, he was
awarded the Nordic prize in medicine.
Prof. Vinaya Manchaiah, AuD, MBA, PhD, is Jo
Mayo Endowed Professor of Speech and Hearing
Sciences in the Department of Speech and Hearing
Sciences at Lamar University in Beaumont, Texas.
Prof. Manchaiah received his BSc from All India
Institute of Speech and Hearing at the Univer-
sity of Mysore, India, his MSc from the University
of Southampton in the United Kingdom, and his
PhD from Linköping University in Sweden. He has
worked in various clinical, research, teaching, and
administrative roles, although his current academic
appointment centers predominantly on research.
His research mainly focuses on improving the acces-
sibility, affordability, and outcomes of hearing and
balance disorders by promoting self-management
and using digital technologies. He has published
more than 120 peer-reviewed manuscripts and three
books. He received the prestigious Bharat Samman
Award from the NRI Institute in India in 2017 and
was named a Jerger Future Leader of Audiology by
the American Academy of Audiology in 2016.
Prof. Viktor Kaldo, PhD, is Professor of Clinical
Psychology at Linnaeus University in Växjö, Swe-
den (appointed 2017) in the Department of Psychol-
ogy, and a member of the Faculty of Health and Life
Sciences. Since 2014 he has served as the research
group leader at the Centre for Psychiatry Research
in the Department of Clinical Neuroscience at the
Karolinska Institutet and at the Internet Psychia-
try Clinic, Psychiatry Southwest, Stockholm Health
Care Services. Prof. Kaldo received his MSc in Clini-
cal Psychology in 1999 at Uppsala University. He
then became a pioneer of developing, evaluating,
and implementing Internet-delivered CBT for tinni-
tus distress together with Prof. Andersson. During
xiii
xiv COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

2001–2003, they wrote the self-help manual that were included in Prof. Kaldo’s doctoral thesis (2008).
since has been published as a book (in Swedish) This manual has steadily developed into the current
and evaluated in numerous trials, several of which form presented here.
Section A
INTRODUCTION TO
COGNITIVE BEHAVIORAL
THERAPY FOR TINNITUS
 Chapter
COGNITIVE BEHAVIORAL
THERAPY PRINCIPLES
AND APPLICATIONS
What This Chapter Covers
n An overview of cognitive behavioral therapy
n The uses of cognitive behavioral therapy
n The evidence supporting cognitive behavioral
therapy
Introduction
Coming to terms with a health-related disorder is
always difficult, and more so when the disorder or
its symptoms are chronic or long-term. Depending
on the disorder or problem, symptoms may be alle-
viated through various approaches. In most cases
a medical approach is appropriate, including pre-
scribed medication; however; medical treatments
are not always possible or available, depending on
the stage and type of disorder. Furthermore, because
medical intervention seeks primarily to diagnose
and treat the physical disorder, it does not always
appropriately address the emotional distress associ-
ated with physical illness. Regardless of the medical
approach taken to address the disorder, individu-
als may need other kinds of intervention to come to
terms with the diagnosis, to understand the disorder,
and to learn how to manage symptoms and lessen
their impact on everyday life. Because emotional
distress can negatively impact physical recovery, a
holistic approach — one that combines medical and
psychological treatment — offers a preferable bal-
ance. For these purposes, psychological counseling
can be helpful, either in isolation or together with
medical interventions. A broad range of psychologi-
1
cal counseling-type treatments exist that can be tai-
lored to suit individual medical conditions.
This book focuses on tinnitus and offers Cognitive
Behavioral Therapy (CBT) as a form of counseling
that may help tinnitus sufferers with the emotional
distress accompanying the disorder. Although there
are many forms of counseling, the focus of this book
is on CBT because it is the most clinically evalu-
ated and is regarded as most effective in alleviating
emotional distress in relation to health problems
like tinnitus.
CBT is a type of “problems-focused” and “action-
orientated” psychological intervention that is based
on principles from both behavioral and cognitive
psychology. It helps individuals identify what behav-
iors and emotions are influenced by perceptions of
events (Fenn & Byrne, 2013). In CBT the focus is on
the influence of thought patterns, beliefs, and atti-
tudes on behaviors, feelings, and reactions. Accord-
ing to CBT principles, the way people interpret a
situation influences their emotions rather than just
the situation per se. For instance, those who are
depressed have been reported to have an exces-
sively negative interpretation of situations or events
(Beck, 1976). Another principle in CBT is that the
individual’s own behaviors and their concequences
also influence future behaviors and thoughts; and
together with the first principle, this can create neg-
ative patterns that maintain emotional distress. CBT
is a treatment approach that addresses difficulties
or problems and uses psychological means for the
treatment of emotional and behavioral problems
to improve general functioning and/or symptoms
(Hughes & Pedder, 1979). This chapter provides
greater understanding of CBT.
3
4 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
The History of CBT
CBT originated from cognitive therapy, which was
developed by Aaron Beck in the 1960s (Beck, 1964).
Before the development of cognitive therapy, there
was an emphasis on behavior therapy. Behavior-
ism assumes that behavior is learned and can be
unlearned or learned anew. It is also derived from
the idea that behavior is driven by its consequences
in specific situations, where positive consequences
increase the tendency to repeat the behavior again
in similar situations, while negative consequences
decrease this tendency. Behavior therapy aims to
find out which behavioral patterns need chang-
ing, or how the environment could be changed,
and then focuses on addressing these factors con-
sciously to achieve the desired outcome. Behavioral
approaches have been successful at treating several
problems and are still a fundamental part of CBT;
but CBT developed around an interest in the role of
cognitions in maintaining factors of psychopathol-
ogy. This interest led to an evolved understanding
regarding the role of thoughts and perceptions of a
situation on behaviors.
Following clinical observations and some clinical
studies, Beck (1976) recognized a thinking disorder
at the core of problems such as depression and anxi-
ety. He identified distorted, negative thoughts and
beliefs and a bias in the individual’s interpretation
of particular experiences. He further found that neg-
ative automatic thoughts played a critical part in
maintaining depression due to his patients’ charac-
teristically negative views of themselves, the world,
and the future. He thus, developed cognitive therapy
aimed at problem-solving to propose alternatives
for modifying unhelpful behaviors, thoughts, and
beliefs (Beck, Rush, Shaw, & Emery, 1979).
Pure cognitive therapy is seen as a first-wave
psychological treatment from which CBT, often
described as a second-wave psychological interven-
tion, developed. CBT is a combination of cognitive
and behavioral therapy directed toward altering
problematic behaviors that maintain emotional
distress and changing inaccurate and/or unhelpful
thinking toward problems through behavior modi-
fications. In terms of the focus here on tinnitus, CBT
addresses the long-term emotional reaction to hav-
ing tinnitus and not the sound percept itself. Third-
wave interventions such as mindfulness-based stress
reduction (MBSR; Kabat-Zinn, 1990) and acceptance
and commitment therapy (ACT; Hayes, Strosahl, &
Wilson, 2012) were introduced later.
The Scope of CBT
CBT is based on the basic principle that what we
think, how we feel, and how we behave are all
closely connected, and all these factors have a deci-
sive influence on well-being, as shown in Figure 1–1.
Because of this interconnectedness, addressing the
thoughts and behaviors — the emotional responses
and physical sensations — associated with a disorder
can lead to improvement (Chawathey & Ford, 2016).
CBT helps change how people think (cogni-
tive) and what they do (behavior) in the following
manner.
Focusing on thoughts (i.e., Cognitive tech-
niques): The term cognitive comes from the Latin cog-
noscere, which means “to recognize.” This approach
helps individuals identify distressing beliefs, dys-
functional assumptions, and negative automatic
thoughts. The importance attached to these beliefs is
explored by individuals getting a clear idea of their
own thoughts and beliefs. Examples of negative
thoughts are jumping to exaggerated conclusions,
known as catastrophizing, or having thoughts such
as “my life is over because of this.” Individuals learn
how to replace these negative thought patterns with
more realistic, less harmful thoughts. This replace-
ment is often accomplished by asking Socratic ques-
tions (Beck, 1995) to help individuals challenge the
accuracy and completeness of their thinking. Ques-
tioning helps people to think more clearly and to
have greater control over their thoughts.
Focusing on behaviors (i.e., Behavioral tech-
niques): This approach identifies unhelpful behav-
iors, such as withdrawing, giving up hobbies, or
experiencing high tension due to problems or
medical conditions. When people avoid difficult
situations, they are often creating more fear around
these very situations (Whitfield & Davidson, 2007).
Behavioral therapy includes learning methods to
behave differently in certain situations. This ther-
apy may include changing behaviors to help reduce
tension and find ways of participating, becoming
less isolated, or increasing activeness. Behavioral
activation uses the acronym ACTION (Addis, Jacob-
 CHAPTER 1 COGNITIVE BEHAVIORAL THERAPY PRINCIPLES AND APPLICATIONS 5

Thoughts

What we think
affects how we
feel and act.

CBT
Changing
Emotions Perceptions Behaviors

What we feel What we do

affects how we affects how we
think and act. think and feel.

FIGURE 1–1. The relationship between thoughts, emotions, and

behaviors.

son, & Martell, 2001): Assess mood and behavior;
Choose alternative behaviors; Try out alternatives;
Integrate these changes into life; Observe the results;
Now evaluate.
By following the ACTION steps, a person can
break down difficult situations into different cat-
egories. Thoughts or responses to a situation, not
the situations themselves, are linked to the result-
ing emotions, behaviors, and bodily sensations. This
process can be illustrated by the “hot cross” model
(Mooney & Padesky, 1990). A simplified model is
shown in Figure 1–1.
CBT Principles
The following principles form the basis of CBT and
are adapted depending on the individual and the
disorder.
n Focused on the now: CBT deals with current
problems rather than focusing on issues
from the past. When there is a need for deep
insight into the causes of problems, analytic
psychotherapy is recommended before
starting CBT.
n Short-term treatment for long-term effects:
Therapy generally runs for less than 2 to
4 months in comparison to analytic psycho-
therapy, which can continue for much longer.
The short-term goal is to gain new insights
or perspectives and learn new skills that will
help individuals to maintain their improve-
ments in the long run.
n Problem-solving: CBT is problem-oriented
and looks for practical ways to improve
problems and change behaviors.
n Educational: CBT aims to provide indi-
viduals with new information, knowledge,
and tools to deal with their problems without
the need for continued therapy.
n Collaborative: CBT is a collaborative
approach that is directed by the therapist but
requires commitment from the individual.
The therapist tries to help individuals identify
and address their own negative, automatic
thoughts.
n Structured: There is a clear structure adapted
for different disorders.
n Time-sensitive: CBT is generally time-limited,
with a predefined therapy length.
6 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Goal-oriented: The individual sets goals that
he or she hopes to achieve.
n Clear rationales: The provider identifies
unambiguous explanations and reasons for
the techniques selected.
n Instills hope: CBT aims to provide hope for
improvements in future functioning.
n Practical: Emphasis is on putting into
practice what has been learned. This may be
in the form of homework that aims to create
opportunities for experiences of success and a
sense of mastery.
n Skills training: The effect of therapy is
closely monitored and evaluated to assess
how effective strategies have been. Homework
assignments are normally set. A record of
positive information is also kept to help
disconfirm negative thoughts — for example,
“I managed to go to work despite not sleeping
last night.”
The Components of CBT Therapy
Some key components of CBT therapy include
thought identification, cognitive restructuring, and
exposure therapy. Table 1–1 provides further details
on these components.
The Uses of CBT for Different
Disorders and Its Evidence-Base
CBT is one of the most popular therapeutic approaches
that has been applied to a variety of health problems
and conditions. CBT is commonly used to treat anxi-
ety and depression but is also useful for many other
mental and physical health conditions. A meta-
analysis review performed by Hofmann, Asnaani,
Vonk, Sawyer, and Fang (2012) suggested that CBT
has good research evidence to illustrate its effective-
ness for various conditions, including substance use
disorder, schizophrenia and other psychotic disor-
ders, depression and dysthymia, bipolar disorder,
anxiety disorders, somatoform disorders, eating
disorders, insomnia, personality disorders, anger
and aggression, criminal behaviors, general stress,
distress due to general medical conditions, chronic
pain and fatigue, and distress related to pregnancy
complications and female hormonal conditions.
Moreover, numerous systematic reviews and meta-
analyses have suggested that CBT has been effec-
tively used for many psychological conditions such
as anxiety, depression, and insomnia, as well as for
related conditions such as chronic pain and chronic
health conditions (see systematic reviews by Cuijp-
ers et al., 2013; Hind et al., 2014; Hofmann et al.,
2012; Michail, Birchwood, & Tait, 2017; Trauer, Qian,
Doyle, Rajaratnam, & Cunnington, 2015).
Specific CBT treatments vary significantly for dif-
ferent disorders, as there are characteristic themes
of dysfunctional behavior patterns and cognitive
distortions associated with each disorder. Regard-
less of specific techniques, robust evidence shows
that CBT-based interventions positively impact
psychological and behavioral conditions; the data
include observations of randomized controlled tri-
als (RCTs), uncontrolled trials, case series, and case
studies (Hofmann et al., 2012). Considering this
strong and extensive evidence base supporting
CBT, many health authorities and practice guide-
lines recommend CBT as a treatment option for
specific health conditions. In the United Kingdom,
the National Institute for Health and Clinical Excel-
lence (NICE) guidelines (Clark, 2011) recommended
CBT for panic disorder, generalized anxiety, depres-
sion (mild-to-moderate and severe), and obsessive-
compulsive disorder (mild and moderate).
Ways of Delivering CBT
The use of CBT has flourished, partly due to the evi-
dence base that supports its use. Traditionally, CBT
was offered as a face-to-face treatment by one ther-
apist to one client. This approach emphasizes the
therapist as active and directive. This approach was
largely based on the need for a strong therapeutic
alliance between the therapist and the individual.
More recently, this assumption has been challenged
as the demand for CBT outstrips the capacity for
available therapists. One of the greatest barriers to
obtaining CBT is a shortage of resources, in terms
of both funding and specialists, in delivering these
sessions. Psychological therapies are expensive to
deliver. Furthermore, there are too few CBT thera-
pists. To try to increase the scope of provision, there
 CHAPTER 1 COGNITIVE BEHAVIORAL THERAPY PRINCIPLES AND APPLICATIONS
TABLE 1–1. Key Components of CBT
Concept Explanation
Thought Identifying negative automatic
identification thoughts and cognitive
distortions
Cognitive The process of challenging the
restructuring accuracy and completeness
of thinking and replacing
negative automatic thoughts
with more balanced thoughts
Exposure therapy Graded exposure to feared
situations to habituate to the
situation and diminish the
fear
Behaving “as if” Acting as if there is a favorable
outcome to aid preparation for
the real outcome
Imagery Using mental images that
include all five senses
Behavioral Mapping out behaviors and
analysis their consequences to inform a
plan for behavioral change
Changing the Making adaptions to minimize
environment problems with hearing and
tinnitus
has been increasing evidence to show that CBT n Formulation-driven CBT: This includes
can be applied in a variety of other contexts. These
include group CBT, self-help books, mobile appli-
cations, and Internet-based CBT. These additional
options are often attractive to those that find the
practicalities of regular meetings with a therapist
difficult. These approaches are also useful where
access to a suitable professional is limited.
CBT delivery methods can be broadly classified
into the following four categories (British Association
for Behavioral & Cognitive Psychotherapies, n.d).
7
Example
What is going through your mind?
What are you afraid may happen?
What is the worst that could happen
if it were true?
Sequential thinking such as:
What evidence supports the thought?
What evidence contradicts this
thought?
Is there an alternative explanation?
Becoming involved in activities
that were previously enjoyed by
approaching the fear using small
steps; for example, initially looking
at pictures of the setting, driving past
the setting, staying for a short period
Identifying things required for a
positive outcome and rehearsing
those behaviors
Visualizing a peaceful scene to aid
relaxation, reduce emotional distress,
or imagine an ideal outcome (Homes,
Arntz, & Smucker, 2007)
Activating behaviors to help engage
in more positive activities and be
less hindered by fears and address
avoidance and escape behaviors
Changing the positioning of furniture
to optimize ease of listening and to
increase environmental sounds when
the tinnitus is bothersome
individual or group CBT for a range of
people and problem areas. This method is
appropriate when individuals are not able to
help themselves and seek help from experts
who are trained, licensed CBT therapists. The
relationship between the therapist and indi-
vidual plays an important role. The therapist
first establishes a good therapeutic alliance
with the individual and then collaboratively
conducts the assessment and delivers the
8 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
intervention using various cognitive and/or
behavioral techniques as appropriate for the
individual. The therapist also evaluates the
efficacy of the intervention, comparing the
pre- and post-assessment to make the neces-
sary adaptations to the intervention based on
an individual’s needs.
n CBT approaches specific to a problem
area: This method includes customized
CBT interventions developed for specific
problem areas (e.g., promoting work for those
diagnosed with schizophrenia; specific CBT
intervention for those with depression). This
form of intervention does not require profes-
sionals to formulate and adapt the treatment
uniquely for each individual, but rather
within the limits of a previously evaluated
treatment manual. CBT delivery using this
method can be done easily by someone who
has domain-specific training (e.g., audiolo-
gists trained to provide management for
tinnitus) with some specific training on CBT
intervention specific to the area of practice
and with some supervision from a CBT
psychotherapist.
n Assisted self-help: This method can
include computerized CBT or other self-help
materials presented to a support group or
individuals by health care professionals.
This is a standardized form of psychological
intervention, and health care professionals
offering such an intervention should be clear
that it is not the same thing as meeting with
a highly-trained CBT therapist. However,
it is appropriate to suggest that CBT-based
techniques be provided to clients as self-help
materials, and in that circumstance, the
role of the therapist is to provide minimal
guidance and support as necessary based
on his or her domain-specific training and
experience.
n Self-help: This method of CBT delivery is
through bibliotherapy or web applications,
but without any support from a clinician; it
is thus radically different from the traditional
form of psychotherapy. Moreover, no CBT
skills or training is required by the individual
reading the self-help material.
It is noteworthy that different methods of CBT
delivery require different skills from both the thera-
pist and the individual. For instance, those who are
self-driven and have a good reading ability may be
more suited for using assisted or autonomous self-
help methods. On the other hand, delivering a face-
to-face or group CBT intervention may require more
experience and training from the therapist.
This book can be used as a guide for the latter
three approaches discussed in this section, although
formulation-driven CBT should be offered only by
licensed psychotherapists with specialized CBT train-
ing. Chapter 3 offers further details about how the
materials presented in Section B of this book can be
used to intervene with individuals with tinnitus.
Key Factors Influencing the
Effective Delivery of CBT
Regardless of the method of delivery, certain factors
could influence the effective delivery of CBT, and
these are listed here.
n One of the key elements of CBT is the collabo-
ration between a client and the therapist. This
therapeutic alliance is essential. A cooperative
working relationship is necessary. Hence, it
is important to discuss and agree on roles,
responsibilities, and expectations of both
parties before starting the CBT program.
In particular, it is necessary to ensure the
following:
n There is an equal partnership between
the therapist and individual who each
make contributions to achieve the desired
outcome. The therapist brings knowledge
and skills, whereas the individual brings
his or her own experience and a commit-
ment to learn and practice the techniques.
n Both the therapist and the client avoid
preconceived ideas.
n The therapy is not seen as something
that is done to the individual. Instead it
is the sharing of resources and techniques
that the individual can use to his or her
advantage.
n The therapist develops a formulation (i.e.,
hypothesis about the mechanism causing
 CHAPTER 1 COGNITIVE BEHAVIORAL THERAPY PRINCIPLES AND APPLICATIONS
and maintaining the problems) built on
evidence-based practice and uses it to develop
an individualized treatment plan in collabo-
ration with the client.
n The therapist engages in a cooperative, argu-
mentative dialogue (i.e., Socratic dialogue)
with the individual to stimulate critical
thinking and to draw out ideas and under-
lying presuppositions. This style of dialogue
involves reasoning, thinking, and considering
possibilities to think differently. This dialogue
is essential, as CBT is not about merely
providing knowledge and information, but
also about facilitating so that individuals
can see for themselves (discover) that there
are alternative ways of thinking about their
problems.
n The therapist and the client collaboratively
perform a behavioral analysis to better
understand how the environment and the
consequences of behaviors maintain the
client’s problems and emotional distress. This
process helps them identify what skills the
client could benefit from learning, and what
new behaviors could be tried out to break
dysfunctional patterns.
n Homework (including behavioral experi-
ments) plays an important role in achieving
the optimal outcomes as a result of CBT.
A therapist can develop worksheets at the
end of each session so that the client can try
out things between therapy sessions, putting
what has been learned into practice.
Key Messages
n CBT is based on the basic principle that what
we think, how we feel, and how we behave
are all closely connected, and all these factors
have a decisive influence on well-being.
n The cognitive aspect of the CBT model
hypothesizes that people’s emotions and
behaviors are influenced by their perceptions
of events. In other words, the way people
interpret the situation is what affects their
emotional reactions rather than the situation
per se.
9
n The behavioral part of the CBT model stresses
that learning from experiences is important
both in creating and solving psychological
problems, because behaviors and their
consequences in different situations shape
future behaviors, thoughts, and emotions.
n CBT is commonly used to treat anxiety and
depression, but is also useful for many other
mental and physical health conditions.
n CBT has a strong evidence base supported by
RCTs, uncontrolled trials, case series, and case
studies.
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 Chapter
COGNITIVE BEHAVIORAL
THERAPY FOR TINNITUS
What This Chapter Covers
n An overview of treatment approaches for
tinnitus
n The principles of cognitive behavioral therapy
for tinnitus
n The evidence supporting cognitive behavioral
therapy for tinnitus
Introduction
Tinnitus is a symptom that continues to intrigue and
challenge both health professionals and patients. It
is the conscious perception of unwanted subjective
auditory sensations in the absence of a related exter-
nal stimulus. The nature of the sounds heard varies
among individuals in terms of loudness, pitch, loca-
tion, the number of sounds, and the type of sound. It
is a prevalent condition, affecting 1 in 8 adults and its
incidence is expected to continue to rise due to factors
such as increased life expectancy and recreational
noise exposure (Martinez, Wallenhorst, McFerran,
& Hall, 2015). It is a prevalent condition, affecting
1 in 8 adults and its incidence, it is important to
address and prioritize treatment methods. This chap-
ter outlines tinnitus treatment approaches with an
emphasis on Cognitive Behavioral Therapy (CBT).
Incidence and Prevalence of Tinnitus
Tinnitus is one of the most frequently occurring
chronic conditions; it affects around 10 to 20% of
the adult population across the globe and has been
studied in Europe, the United States of America,
2
Egypt, Japan, Korea, and Nigeria (Bhatt, Lin, and
Bhattacharyya, 2016; Davis & Rafaie, 2000; Dawes
et al., 2014; Fujii et al., 2011; Khedr et al., 2010;
Kim et al., 2017; Lasisi, Abiona, & Gureje, 2010;
Michikawa et al., 2010; Shargorodsky, Curhan, &
Farwell, 2010). Large scale, cross-sectional stud-
ies in the United States have shown that approxi-
mately 50 million American adults (about 15%
of the population) described having intermittent
tinnitus, roughly 16 to 20 million adults (about
5% of the population) described chronic tinnitus,
and about 2 million people had an extreme and
debilitating reaction to tinnitus (Centers for Disease
Control and Prevention, 2013; Shargorodsky et al.,
2010). Determining the exact global tinnitus preva-
lence is, however, hampered by inconsistent defini-
tions and measurements of tinnitus across studies
(McCormack, Edmondson-Jones, Somerset, & Hall,
2016). The prevalence of frequent tinnitus increases
with advancing age, and non-Hispanic whites have
found to have higher odds of frequent tinnitus com-
pared with other racial/ethnic groups (Shargorodsky
et al., 2010). Hypertension, former smoking, loud
leisure-time activities, firearms, and occupational
noise exposure are associated with an increase in
the odds of experiencing frequent tinnitus (Shar-
gorodsky et al., 2010).
Mechanisms of Tinnitus
Initially it was believed that tinnitus was associ-
ated only with the peripheral and central auditory
system. More recently, additional involvement of
nonauditory areas have also been identified, such
as areas associated with awareness and salience
detection. Tinnitus pathophysiology is complex and
11
12 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
multi­factorial. Multiple higher perceptual overlap-
ping networks have been found to be involved in
tinnitus generation and localization, and tinnitus-
related distress (De Ridder et al., 2014).
Considering the heterogeneity of tinnitus, a sin-
gle theory or hypothesis cannot sufficiently explain
the origin of tinnitus. Hence, various theories and
studies have tried to explain the pathophysiology
and mechanism of tinnitus (for review, see Chung &
Lee, 2016; Haider et al., 2018; Henry, Roberts, Cas-
pary, Theodoroff, & Salvi, 2014). A minor change or
more extensive damage to the peripheral auditory
system is one factor known to result in the onset of
tinnitus generation. However, more recent studies
and theories suggest that tinnitus is strongly related
to neuroplasticity changes in the central auditory
system; those changes deprive the brain of its nor-
mal input by the cochlea. Whereas the peripheral
pathology can result in the onset of tinnitus, neural
changes — which are likely to occur at the level of
synapse between inner hair cells and the auditory
nerve as well as within multiple levels of the cen-
tral auditory pathway, are likely to result in more
chronic tinnitus (Henry et al., 2014). Thus, long-
term tinnitus is probably a function of a complex
network of structures involving central auditory
and nonauditory systems. In addition, somatosen-
sory and limbic autonomic nervous systems are also
deeply involved with the pathogenesis of tinnitus.
Due to the complex mechanism of tinnitus and to
not knowing its precise pathophysiology, finding a
cure for tinnitus has been difficult.
Types of Tinnitus
Tinnitus can be broadly classified as either objective
or subjective tinnitus. Objective tinnitus is usually
generated mechanically within the body but may
be heard by both the person with tinnitus and the
examiner. The origin of objective tinnitus can be
linked to vascular, muscular, skeletal, or respiratory
structures (Henry, Dennis, & Schechter, 2005). On
the other hand, subjective tinnitus, which is the per-
ception of sound in the absence of an acoustic stim-
ulus, is heard only by the individual with tinnitus.
Subjective tinnitus occurs much more frequently; it
is associated with a range of possible causes, includ-
ing damage of the auditory system.
Tinnitus is often characterized in terms of its loud-
ness, pitch, spectral qualities, location within the ear
or head, and temporal features (Henry et al., 2014).
Often tinnitus is described as hearing a “ringing”
or “buzzing” sound. However, these are only two
of innumerable forms of tinnitus. Individuals with
tinnitus can hear different pitch sounds, which can
sound like ringing, buzzing, hissing, whistling, hum-
ming, whining, chirping, roaring, clanging, dron-
ing, engine noise, grinding, clicking, or crackling.
Nearly half of those with tinnitus have reported hear-
ing more than one sound. The sound may be differ-
ent in each ear or may be a combination of sounds.
The pitch and the loudness of the tinnitus can vary
over time. In other words, type and noticeability of
sounds are reported to vary within the same day
or different days. Individuals with tinnitus can hear
continuous, intermittent, or pulsatile tinnitus. More-
over, sounds may be heard in the ears, in the head,
or it may be difficult to pinpoint the location.
Consequences and Life Effects of Tinnitus
The range of individual reactions following the
onset of tinnitus is paradoxical (Andersson & Wes-
tin, 2008). Most people with tinnitus do not find it
overly problematic; however, others have strong
reactions (Brüggemann et al., 2016). Results of a
national study in England (n = 48,313) found that
2.8% of people in the total population described
their tinnitus as moderately annoying, 1.6% severely
annoying, and 0.5% were unable to lead a nor-
mal life due to the severity of the tinnitus (Davis
& Rafaie, 2000). Severe tinnitus is often associated
with feelings of hopelessness, irritability, frustra-
tion, anxiety, and depression and disrupts many
aspects of daily life. The presence of insomnia has,
for instance, been found in 25% to 76% of those
with tinnitus (Schecklmann et al., 2015). Difficul-
ties concentrating due to tinnitus can affect cogni-
tive performance, reading competence, and working
memory (Hallam, McKenna, & Shurlock, 2004). In
addition, tinnitus is often accompanied by increased
sound sensitivity (hyperacusis), misophonia (dislike
of certain sounds), and phonophobia (fear of certain
sounds) (Baguley & Andersson, 2008). Hyperacusis
is reported in up to 40% of individuals with tinnitus,
and 86% of those who have hyperacusis also report
 CHAPTER 2 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
tinnitus (Andersson, Lindvall, Hursti, & Carlbring,
2002). These comorbidities increase the burden of
tinnitus and can affect relationships with signifi-
cant others (Granqvist, Lantto, Ortiz, & Andersson,
2001). Tinnitus is consequently more than its psy-
chophysical characteristics, as it is often accompa-
nied by great distress (Probst, Pryss, Langguth, &
Schlee, 2016). Tinnitus is thus a complex percept
encompassing multiple, separable auditory-related,
cognitive, and emotional aspects. These are often
noticeable in people’s descriptions of tinnitus; for
example, “most of the time my tinnitus sounds like
a ringing sound, but sometimes it changes to a rush-
ing low-pitched sound. It drives me slowly crazy and
is really quite depressing. I feel I can’t cope with it.”
Management Approaches for Tinnitus
At the onset of tinnitus, most people search for a
means to permanently alleviate this bothersome
symptom (Fackrell, Hoare, Smith, McCormack, &
Hall, 2012). Finding a way to fully eliminate tin-
nitus is the ultimate goal of tinnitus research.
Although taking a tablet would be the interven-
tion of choice for the majority of those with tinni-
tus, there is currently no licensed pharmacological
drug to eliminate nonpathological tinnitus. This
lack is possibly related to the heterogeneous nature
of tinnitus, its varied clinical presentation, and an
incomplete understanding of how it is generated
(McFerran, Stockdale, Holme, Large, & Baguley,
2019). For those experiencing tinnitus, their hopes
are often shattered following Internet searches or
initial contact with health professionals explaining
that no such cure exists. This often leads to individu-
als reverting to safety or avoidance behaviors, which
are often associated with greater distress and poorer
long-term outcomes (McKenna, Handscomb, Hoare,
& Hall, 2014). People fail to realize that there are
various ways they can manage tinnitus and its asso-
ciated comorbidities. This book aims to provide one
form of help for those with tinnitus, especially for
those who are geographically remote from accessing
suitable professional help.
Tinnitus interventions present a wide array of
challenges (Folmer, Theodoroff, Martin, & Shi, 2014).
The condition itself is complex, making it difficult
for interventions to address its multidimensional
13
nature and its encompassing cognitive and emo-
tional aspects. Most current tinnitus practice guide-
lines recommend interventions with a core of direc-
tive counseling to educate and provide reassurance
(Fuller et al., 2017). For instance, an evidence-based
clinical practice guideline by the American Academy
of Otolaryngology-Head and Neck Surgery (AAO-
HNS) recommended CBT as the preferred man-
agement option for tinnitus (Tunkel et al., 2014).
Although various management strategies exist, many
lack research to back their effectiveness. There are
two main approaches to managing tinnitus: those
that target the tinnitus percept, and methods focus-
ing on reactions to tinnitus. Although the main ap-
proaches are discussed here, often combinations of
these treatments or a stepped-care model is used.
One such stepped-care approach is Progressive
Tinnitus Management (PTM) (also sometimes
referred to as Progressive Audiological Tinnitus
Management or PATM), designed to be maxi-
mally efficient in having the least impact on
clinical resources (Henry, Zaugg, Myers, Kendall,
& Turbin, 2009; Myers et al., 2014). PTM consists
of five levels within a systematic framework for
providing only the required level of services for
the individual patient: Level 1 — Referral; Level 2
— Audiological evaluation; Level 3 — Skills educa-
tion; Level 4 — Interdisciplinary evaluation; and
Level 5 — Individualized support. The central idea
in PTM is that many individuals need only basic
education on how to manage the condition. As the
levels progress, therapy becomes more intensive
and long-term. Those requiring higher levels of care
might use sound generators or other approaches
such as tinnitus-masking or CBT. PTM have been
developed by researchers and clinicians who worked
for the Veterans Health Administration in the United
States, but are adaptable to any clinic that provides
tinnitus services.
Approaches Targeting the Tinnitus Percept
Although there is no known cure for tinnitus, there
are three management approaches that target
the tinnitus percept: medical management, sound
therapy, and the use of hearing devices. Tinnitus
retraining therapy is also discussed here, as its main
component consists of the use of sound therapy
principles.
14 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Medical Management
When there is a medical pathology associated with
tinnitus — such as otosclerosis, conductive hearing
loss, or Ménière’s disease — medical, surgical, or
pharmacological interventions may be indicated
(Soleymani et al., 2011). These interventions may
remove or reduce tinnitus perception, although in
many cases, tinnitus is found to persist despite medi-
cal interventions. For those with no known medical
pathology, pharmaceuticals or herbal supplements
are often prescribed to reduce the effect of tinnitus
and/or its associated comorbidities (Folmer et al.,
2014). Where medical interventions are not appli-
cable or effective, tinnitus must be managed as a
chronic condition. Many nonmedical interventions
are directed toward alleviating or managing the
accompanying symptoms, making the tinnitus less
intrusive or distressing (Hoare, Kowalkowski, Kang,
& Hall, 2011).
Sound Therapy
Sound-based interventions refer to the use of
sound to alter tinnitus perception in a clinically
meaningful way (Hoare, Searchfield, Refaie, &
Henry, 2014). The use of sound can change the
intrusiveness of tinnitus, making it less noticeable,
providing immediate relief, promoting control, lead-
ing to habituation, and shifting attention from the
tinnitus. Various sound therapy devices exist with
the purpose of partially masking the tinnitus by
using sound at a level low enough to distract the
individual from the tinnitus but not completely
mask it (Searchfield, Durai, & Linford, 2017). Both
tabletop and ear-level sound generators can be used
as a means of masking by using sound enrichment.
Various sounds have been suggested, ranging from
white noise to nature sounds and music. Despite
their popularity, little evidence exists for the effi-
cacy of sound-based masking approaches on tinni-
tus exists.
The Use of Hearing Devices
As tinnitus is often accompanied by hearing loss,
the use of hearing devices, such as hearing aids or
hearables, aims to address both the tinnitus and the
hearing loss (Hoare, Edmondon-Jones, Sereda, Ake-
royd, & Hall, 2013; Shekhawat, Searchfield, & Stin-
ear, 2013). These devices amplify external sounds,
thus lowering the contrast between tinnitus percep-
tion and the external sounds and making tinnitus
less noticeable. Moreover, they refocus attention on
sounds that are different from the tinnitus sound.
Additionally, they can improve hearing function,
communication, and help to diminish the effects of
tinnitus. In some cases, the use of hearing devices
may help reduce the impact of tinnitus (Tutaj,
Hoare, & Sereda, 2018), but in other cases, this is
not enough, and further help is required.
Tinnitus Retraining Therapy (TRT)
TRT is a form of habituation therapy that consists of
two components: retraining counseling and sound
therapy (Jastreboff & Hazell, 2004). TRT targets
nonauditory systems (the limbic and autonomic
nervous systems) and thus assumes that tinnitus is
a side-effect of the normal compensatory mecha-
nism in the brain. Taking advantage of the natu-
rally occurring plasticity of the brain, TRT aims to
achieve habituation to physiological reactions to
tinnitus and, subsequently, to achieve habituation
to the very perception of tinnitus and its reinforce-
ment mechanism. Retraining counseling aids tinni-
tus understanding and acceptance. Sound therapy
aims to facilitate habituation at an unconscious
level by decreasing the strength of the signal. It
is suggested that 18 months of TRT is required to
achieve observable and stable effects, although this
treatment may not yield satisfactory results, and the
efficacy remains to be demonstrated conclusively in
meta-analyses (Hoare et al., 2011).
Approaches Targeting
Reactions to Tinnitus
Although tinnitus generation is not fully understood,
current theories associate tinnitus generation with
not only the hearing system, but also non-hearing
pathways. When tinnitus is noticed, it can activate
the emotional centers of the brain. It is thought
that tinnitus is maintained by selective attention to
it and negative appraisal of it as unpleasant. Tin-
nitus distress is heightened due to erroneous beliefs
that it is a threat and that counterproductive safety
behaviors, such as avoiding certain places or activi-
ties, will minimize the perceived threat of altering or
worsening tinnitus (McKenna et al., 2014). Distorted
perceptions of tinnitus and negative automatic
thoughts further add to arousal and distress, and
to selective attention and monitoring, as shown in
Figure 2–1. Reactions to tinnitus are thus not directly
 CHAPTER 2 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS 15

Tinnitus-related neuronal activity

Tinnitus detection

Distorted
perception of Negative automatic thoughts Safety
tinnitus behaviors

Arousal and distress

Beliefs

Selective attention and monitoring

FIGURE 2–1. A cognitive model of tinnitus. Source: Adapted from “A scientific cognitive-
behavioral model of tinnitus: Novel conceptualizations of tinnitus distress,” L. McKenna, L.
Handscomb, D. J. Hoare, & D. A. Hall, 2014, Frontiers in Neurology, 5, 196.

related to the way the tinnitus sounds but to the
interpretation of the tinnitus. This has led to the rise
of psychological interventions that aim to change
reactions to tinnitus. Psychological interventions
were also introduced due to the high prevalence of
psychological distress among those with significant
tinnitus. There are three main approaches in psy-
chological intervention: Mindfulness-Based Stress
Reduction (MBSR), Acceptance and Commitment
Therapy (ACT), and CBT.
Mindfulness-Based Stress Reduction (MBSR)
Mindfulness involves purposefully and nonjudg-
mentally paying attention to the present moment,
relaxing control, tolerating discomfort, and staying
with negative emotions. It is built on the premise
that by allowing feelings to be as they are, the indi-
vidual makes them less threatening and reduces
their impact. Mindfulness can be delivered on its
own or together with other interventions. Initial
studies have indicated its effectiveness for use with
tinnitus, although more research is required to
investigate the long-term effects (Rademaker, Stege-
man, Ho-Kang-You, Stokroos, & Smit, 2019).
Acceptance and Commitment Therapy (ACT)
ACT focuses on the functional usefulness of thoughts
and actions. A key element of ACT is decreasing
avoidance behavior by increasing awareness of how
thoughts and emotions can create distress. Like MBSR,
ACT focuses on awareness of the present moment
and observation in a nonjudgmental way to decrease
worry and contemplation. As ACT has shown prom-
ise in a meta-analysis of various health conditions, it
has also been used for tinnitus (Hesser et al., 2012),
although its use has not been widespread.
Cognitive Behavioral Therapy (CBT)
One of the earliest and most significant contribu-
tions to tinnitus research was the psychological
model (Hallam, Rachman, & Hinchcliffe, 1984).
This model suggested that, like any repetitive stimu-
lus, hearing tinnitus should lose its novelty, which
would lead to a process of habituation, defined as
16 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
a decline in the reactions to, and the perception of,
tinnitus over time. Habituation should occur natu-
rally so that perceiving tinnitus no longer results in
a negative emotional response and does not affect
day-to-day functioning. Habituation may be slowed
by factors such as a high level of arousal and the tin-
nitus acquiring an emotive significance. Habituation
can also be disrupted by factors, such as stress, that
lead to dishabituation. Dishabituation would result
in persistence of tinnitus due to a reduced ability to
filter out and ignore tinnitus-related information. In
these situations, the combined states of high central
and autonomic nervous system arousal lead to emo-
tional significance being associated with perceiving
tinnitus. This results in chronically intrusive tinnitus.
Due to the relationship between tinnitus and psy-
chological distress, CBT has been suggested for the
treatment of tinnitus (Andersson, 2002). It is particu-
larly applied to target the distress caused by tinnitus.
It aims to alter unhelpful thoughts about tinnitus
through behavior modifications that may change
an individual’s reaction toward his or her tinnitus.
It addresses the emotional reaction and problems
related to having tinnitus and not the tinnitus itself.
CBT has been researched over several years in
controlled trials and longitudinal studies and is one
of the management approaches that has a broad
evidence-base for tinnitus (Fuller et al., 2020; Hes-
ser, Weise, Westin, & Andersson, 2011; Hoare et al.,
2011). Collating these results indicates the effective-
ness of CBT for tinnitus (Hesser et at., 2011). CBT has
the most favorable results of all tinnitus treatments
(Hoare et al. 2011). As discussed later in this chapter
in more detail, the results of an extensive range of
studies highlight the effectiveness of CBT in decreas-
ing tinnitus distress, annoyance, and anxiety and
improving daily life functioning. Due to this strong
evidence base, and because current practice guide-
lines (Fuller et al., 2017) globally recommend it for
individuals with tinnitus, the CBT approach is the
focus of this book.
Cognitive Behavioral Therapy
(CBT) for Tinnitus
This section discusses the principles of CBT for tin-
nitus, the components involved, and the research
that has been undertaken to indicate its efficacy for
treating tinnitus.
The Principles of CBT for Tinnitus
CBT is provided as a structured approach incorporat-
ing goal setting, a time frame for completion (gen-
erally 6–10 weeks), active participation, homework
assignments between sessions, and relapse preven-
tion (Beck, 2011). Individuals are generally sup-
ported by a clinician in a collaborative relationship.
Motivation to change habits and alter behavior is
crucial and required for CBT to have an effect. The
CBT strategies provided intend to promote habitua-
tion to and prevent dishabituation to tinnitus.
Components of CBT for Tinnitus
CBT for tinnitus consists of a comprehensive approach
encompassing various components, such as cogni-
tive and behavioral strategies, as shown in Table 2–1.
To reduce physiological arousal associated with
stress, techniques such as relaxation to target the
stress are included. CBT for tinnitus also includes
techniques derived from audiology settings, such
as sound enrichment, although their added effec-
tiveness has been questioned (Hiller & Haerkötter,
2005). Cognitive restructuring strategies are incor-
porated to overcome maladaptive cognitions and
fears related to tinnitus (Dobson & Dobson, 2009).
Habituation is further fostered by gradual exposure
to feared situations — for example, hearing tinnitus
in silence (Henry & Wilson, 2001). CBT for tinnitus
does not represent one form of treatment, but a com-
bination of strategies, some of which can receive a
great emphasis for certain individuals.
CBT thus focuses on both cognitive and behav-
ioral elements. Cognitive therapy focuses on how
one thinks about tinnitus and on the avoidance
of negative ideation. It uses behavioral activation
and exposure to help one engage in more positive
activities and to be less hindered by fears or anxi-
ety. Cognitive therapy involves teaching patients
to cope with their tinnitus by replacing negative
thinking with more positive or neutral reflections.
It includes counseling and cognitive restructur-
ing. Behavioral therapy uses behavioral activation
and exposure to help engagement in more positive
activities and to be less hindered by fears or anxi-
ety. It focuses on positive imagery (i.e., focusing on
something pleasant), attention control (i.e., moving
attention away from the tinnitus when it is both-
 CHAPTER 2 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS 17

TABLE 2–1. Summary of CBT for Tinnitus

CBT Component Description

Information
Functional analysis
Advice regarding hearing
loss
Use of environmental sound
enrichment strategies
Applied relaxation
Cognitive restructuring
Emotional reactions
Avoidance behaviors
Problems with concentration
and sleep
Addressing sleep problems
Relapse prevention
Source: Adapted from “Psychological aspects of tinnitus and the application of cognitive–behavioral therapy,” G. Anders-
son, 2002, Clinical Psychology Review, 22(7), 977–990. https://doi.org/10.1016/S0272-7358(01)00124-6
Knowledge is broadened regarding tinnitus, potential causes, and
moderating factors. Audiometric assessments are also included.
Factors influencing tinnitus annoyance are addressed. These include
medical, as well as behavioral and psychosocial, factors.
This may include referral for amplification as well as behavioral advice
in the form of hearing tactics.
Sound enrichment is used to facilitate habituation to tinnitus. The risks
associated with trying to mask the tinnitus are outlined.
This is a method of gradually being taught to quickly relax and to use
self-control over bodily and mental sensations such as stress. The aim is
not to reduce tinnitus, but to control the effects of tinnitus. The goal is
to obtain a balanced state of mind. In association with the relaxation
training, imagery techniques are introduced.
The individual is helped to identify the content of thoughts and
taught ways to challenge or control those thoughts usually described
as unhelpful or even inaccurate. Reinterpretation of tinnitus into
something more pleasant is furthermore addressed.
Negative emotional reactions related to hearing tinnitus are dealt with
by strategies such as imagery and graded exposure.
Fear and avoidance behaviors are addressed in relation to situations
where tinnitus causes distress, and sound sensitivity is approached
through graded exposure to the feared situations.
Methods for improving concentration, such as taking breaks and
planning, are suggested.
Sleep hygiene, sleep restriction, stimulus control, bedtime, worry-time
restriction, relaxation, and cognitive restructuring to address sleep
problems are introduced.
In the event of a relapse, a plan is devised for what to do should the
tinnitus become worse.

ersome), exposure to anxiety provoking situations
(to decrease the distress they cause), and relaxation
training.
Evidence-Base for CBT in Tinnitus
CBT for tinnitus has been researched over several
years in controlled trials and longitudinal studies
reported by independent research groups. A meta-
analysis on psychological interventions for tinnitus
(18 studies, 700 participants) indicated that the use
of CBT led to the most favorable results in terms
of reducing tinnitus distress (Andersson & Lyttkens,
1999). A further meta-analysis (15 studies, 1,091
participants, conducted by Hesser et al., 2011) and
Cochrane review (8 studies, 468 participants, con-
ducted by Martinez-Devesa, Perera, Theodoulou, &
Waddell, 2010) also indicated the efficacy of CBT
18 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
in reducing tinnitus distress. A comprehensive
Cochrane review by Fuller et al. (2020) included 28
studies (2,733 participants) with psychological CBT-
based interventions including ACT and mindfulness-
based interventions. CBT versus no intervention had
a moderate effect size, CBT versus audiological care
and tinnitus retraining therapy had a large effect,
and CBT versus other active controls had a small
effect, and all favored CBT interventions.
A meta-analysis of Internet-based CBT for tinni-
tus (9 studies, 1,165 participants) indicated the effec-
tiveness of such an approach for reducing tinnitus
distress and secondary effects of anxiety, depression,
and insomnia (Beukes, Manchaiah, Allen, Baguley,
& Andersson, 2019). Quality of life increased, and
results were maintained for 1 year post-intervention.
Results from an extensive range of studies high-
light the effectiveness of CBT at decreasing tinnitus
distress, annoyance, and anxiety and improving
daily life functioning. Study heterogeneity and poor
study quality continue to affect the results of these
meta-analysis. These studies have been either clini-
cian-delivered or clinician-assisted trials. Table 2–2
shows results of randomized studies of clinician-
delivered CBT for tinnitus. Table 2–3 provides results
of randomized studies delivering assisted CBT self-
help for tinnitus. These lists are not exhaustive;
some studies where randomization was not pres-
ent, bias was high, or where participants were reas-
signed (e.g., Kröner-Herwig et al. 1995) have not
been included.
Most of the trials mentioned in Tables 2–2 and
2–3 look at the effects of CBT for tinnitus under ideal
conditions in a clinical trial setup. It is important to
establish whether CBT for tinnitus works in a more
natural setting or when implemented in a clinical
environment. Where implemented, the effectiveness
of such an approach is summarized in Table 2–4.
Ways to Deliver CBT for
Individuals With Tinnitus
Considering the distress often associated with tin-
nitus, appropriate clinical care pathways are cru-
cial. Unfortunately, these are not always available
due to obstacles preventing delivery of appropriate
evidence-based interventions. The main restrictions
include limited access to tinnitus care, sparse provi-
sion of evidence-based interventions such as CBT, a
lack of tinnitus experts, and the high costs associ-
ated with intervention delivery. Access to CBT for
tinnitus seems to be a major issue across the globe.
A large-scale epidemiological study (N = 75,764) ex-
amined the treatment or management options pro-
vided to individuals with tinnitus in the United States
(Bhatt et al., 2016). This study highlighted the para-
dox that medications were the most commonly rec-
ommended treatment option for tinnitus (i.e., 45.5%)
when this approach has the weakest evidence-base,
whereas CBT was the least recommended manage-
ment option (i.e., 0.2%) although it has the stron-
gest evidence-base for tinnitus (Tunkel et al., 2014).
Such access issues have also been reported in
various European countries (Gander, Hoare, Col-
lins, Smith, & Hall, 2011; Hall et al., 2011). This
is because CBT is often provided by psychologists
and psychotherapists who have specialized training
both in CBT as well as tinnitus; however, there is a
shortage of trained specialists who can provide CBT
for tinnitus. Therefore, identifying effective alterna-
tive tinnitus management strategies has been recog-
nized as a priority (Hall, Mohamad, Firkins, Fenton,
& Stockdale, 2013). To increase access to CBT, alter-
native formats have been used. Although individual
treatment is often provided, positive small group
experiences of CBT have been reported. The use of
Internet-based CBT for tinnitus has also been shown
as an effective way of providing care (Beukes et al.,
2019). Approaches that do not have much profes-
sional contact, such as bibliotherapy for tinnitus,
have shown promise (Nyenhuis, Zastrutzki, Weise,
Jäger, & Kröner-Herwig, 2013). There are no clear
differences in efficacy among individual, Internet-
based, and group-based treatments (e.g., Andersson
& Lyttkens, 1999; Kaldo et al., 2008; Nyenhuis et al.,
2013). In a meta-analysis comparing different ways
of delivering CBT, medium effect sizes were found
for individual face-to-face delivery, d = 0.66 [0.22,
0.66]; group-based CBT, d = 0.59 [0.10, 1.07]; and
Internet-based CBT, d = 0.51 [0.09, 0.92]; and small
effect sizes were found for bibliotherapy, d = 0.39
[0.08, 0.86]. It is encouraging that different forms of
CBT delivery can produce favorable results.
Another alternative for improving access to CBT
for tinnitus is for hearing health care professionals to
deliver the CBT program. In general, audiologists and
otolaryngologists tend to be involved in the assess-
ment and management of tinnitus across the globe.
TABLE 2–2. Examples of Randomized Controlled Trials of Clinician-Delivered CBT for Tinnitus

Study and Intervention Tinnitus

Country Groups Description Outcomes Other Outcomes
Davies, 1. Individual cognitive 6 × 1-hour Small effect: Small effect:
McKenna, therapy (n = 16) sessions from a d = 0.12 [0.63; Depression
& Hallam 2. Applied relaxation qualified clinical 0.86] in TEQ d = 0.06 [0.71;
(1995) (n = 16) psychologist Measured: pre, 0.84]
UK 3. Passive relaxation Cognitive therapy post, 1 month, & Anxiety
(n = 13) based on the 4 months post d = 0.18 [0.6; 0.95]
principles of
Rational Emotive
Therapy
Henry and 1. Group cognitive 6 × 1.5-hour Large effect: Small effect:
Wilson (1996) coping skills (n = 22) sessions by d = 0.97 [0.31; Depression
Australia 2. Education only a clinical 1.63] in TRQ d = −0.06 [0.71;
(n = 21) psychologist Measured: pre, 0.84]
3. Waiting list (n = 22) post, 4, 8, & 12 Anxiety
months follow-up d = 0.18 [0; 0.95]
Henry and Total (n = 54) Cognitive Improvement Improvement:
Wilson (1998) 1. Cognitive restructuring in TRQ Depression,
Australia restructuring techniques Cognitions
provided
2. Attention control
and imagery
training
3. Combined treatment
4. Waiting list control
Jakes, Hallam, 1. GCBT (n = 2) 5 sessions in Medium effect: Improvement:
McKenna, & 2. Masking (n = 14) groups of 6 by d = 0.5 [0.4; 1.48] Interference with
Hinchcliffe experienced in TRQ daily activities
(1992) 3. Masking placebo cognitive/
(n = 14) Measured: pre, Loudness
UK behavioral post, & 3 months
4. Waiting list control therapists and tinnitus
follow-up annoyance
(n = 14)
Andersson, 1. GCBT (n = 12) 6 × weekly 2-hour Large effect: Large effect:
Porsaeus, 2. Waiting list (n = 11) sessions in small d = 1.6 [0.63, 2.56] Depression
Wiklund, groups (n = 11) in TRQ d = 0.8 [0.06, 1.64]
Kaldo, &
Larsen (2005) Measured: pre Anxiety
and post d = 1.5 [0.60, 2.46]
Sweden
Robinson 1. GCBT (n = 38) 8 × group sessions Improvement in Improvement:
et al. (2008) 2. Waiting list (n = 27) based on a CBT THI Depression
USA manual for
Measured: Pre,
depression by
post, 2, 4, & 12
a psychiatrist
months follow-up
and doctoral
psychology
students

continues

19
TABLE 2–2. continued

Study and Intervention Tinnitus

Country Groups Description Outcomes Other Outcomes

Cima et al. 1. Individualized CBT CBT together Small effect: Small effect:
(2012) (n = 245) with GCBT where d = 0.32 (3 months) Health related
Netherlands 2. Usual treatment tinnitus was quality of life
d = 0.45 at
(n = 171) severe (3 different d = 0.04
12 months in THI
12-week group
treatment options) Measured: Pre, Depression and
post, 3, 8, & 12 anxiety
months follow-up d = 0.15
Zhong et al. 1. GCBT (n = 89) CBT including Improvement in None
(2014) 2. Masking noise cognitive THI
China (n = 68) restructuring and
Measured: Pre,
sifting attention
post, 2, 6, & 12
Treatment months follow-up
frequency and
duration and
who provided
the therapy not
reported
Malinvaud et 1. Individual CBT 2 × 1-hour CBT Small effect: No effect:
al. (2016) followed by GCBT sessions followed d = −0.01 Depression
France (n = 58) by 8 × 1.5-hour [−0.47,0.44] in d = −0.22
2. Virtual reality GCBT sessions THI Anxiety
comparison (n = 61) provided by a d = −0.17
Measured: Pre,
3. Waiting list control psychologist post, 3, 8, & 12
(n = 39) months follow-up
Martz et al. 1. GCBT (n = 10) 3 x 2-hour Tinnitus distress Small effect:
(2018) 2. GACT (n = 10) sessions for each not measured Coping measured:
USA intervention Pre, post, &
3. Group Coping Coping measured:
provided by a 1month follow-up
effectiveness Pre, post, & 1
psychologist
training (n = 10) month follow-up
4. Waiting list (n = 10)
Schmidt, 1. GCBT (n = 14) Weekly group Within group None
Kerns, Finkel, 2. Audiological tinnitus improvement in
Michaelides, counseling (n = 11) education plus tinnitus distress
& Henry CBT counseling with no between
(2018) provided by group difference
USA a clinical
Measured: Pre,
psychologist
post, 3, 8, & 1
months follow-up
Note. CBT = Cognitive Behavioral Therapy; GCBT = Group Cognitive Behavioral Therapy; F2F = Face-to-face; TEQ =
Tinnitus Effects Questionnaire; TFI = Tinnitus Functional Index; THI = Tinnitus Handicap Inventory; TRQ = Tinnitus
Reaction Questionnaire

20
TABLE 2–3. Examples of Randomized Controlled Trials Delivering Assisted CBT Self-Help Programs
for Tinnitus

Study and Intervention Tinnitus

Country Groups Description Outcomes Other Outcomes
Andersson, 1. ICBT (n = 53) 6 weeks Swedish Small effect: Small effect:
Strömgren, 2. Waiting list (n = 64) self-help CBT d = 0.26 [0.10, Depression
Ström, & manual (Kaldo 0.75]; TRQ d = −0.2[−0.16,
Lyttkens, and Andersson, Measured: Pre, 0.57]
(2002) 2004) guided post, & 1-year Anxiety
Sweden by clinical follow-up d = −0.2 [−0.69,
psychologists 0.35]
Kaldo, Cars, 1. Guided CBT Swedish self-help Small effect: Medium effect:
Rahnert, bibliotherapy CBT manual (Kaldo d = 0.39 [0.08, Depression
Larsen, & (n = 34) and Andersson, 0.86] in TRQ d = 0.20 [0.34,
Andersson 2. Waiting list (n = 38) 2004) guided by Measured: Pre, −0.75]
(2007) 6 × 1-hour group post, & 1-year Anxiety
Sweden supervisions follow-up d = 0.2 [0.33,0.78]
by two licensed
Insomnia
clinical
0.37 [0.14, 0.60]
psychologists
Kaldo et al. 1. ICBT (n = 25) 6 weeks Swedish Within effect size Small effect:
(2008) 2. GCBT (n = 25) self-help CBT for ICBT: Sleep, depression
Sweden manual (Kaldo and d = 0.73 [0.16, 1.3] and anxiety for
Andersson, 2004) within-group
guided by clinical comparisons
psychologists
Abbott et al. 1. ICBT (n = 32) 6 weeks Swedish No effect: No effect:
(2009) 2. Information only self-help CBT d = 0.24 [−0.31, Depression
Australia (n = 24) manual (Kaldo 0.79] in TRQ d = −0.44 [−1.00,
and Andersson, Measured: Pre, 0.89]
2004) guided post, 10 weeks Anxiety
by clinical post, & 1-year d = −0.18 [−0.70,
psychologists follow-up 0.35]
Quality of life
−0.82 [−1.36,
−0.27]
Hesser et al. 1. ICBT (n = 32) Shorter version of Medium effect: d = Medium effect:
(2012) 2. ACT (n = 32) the CBT manual 0.70 [0.20, 1.20], Anxiety
Sweden in THI compared d = 0.56 [0.07, 1.06]
3. Online discussion 8 modules guided
with the online
forum (n = 32) by clinical Small effect:
discussion
psychologists Depression
Measured: Pre, d = 0.36 [−0.13,
post, 10 weeks 0.85]
post, & 1-year
Insomnia
follow-up
d = 0.18 [−0.30,
0.67]
Quality of life
d = 0.17 [−0.32,
0.65]

continues

21
TABLE 2–3. continued

Study and Intervention Tinnitus

Country Groups Description Outcomes Other Outcomes

Nyenhuis, 1. ICBT (n = 79) Intervention Medium effect: Small effect:

Zastrutzki, 2. GCBT (n = 71) based on 67-page d = 0.63 [0.31 to Depression
Weise, Jäger, manual from 0.95] for ICBT d = 0.13 [−0.18,
& Kröner- 3. Bibliotherapy CBT-oriented compared with
(n = 77) 0.44]
Herwig, Tinnitus Coping information only
(2013) 4. Information only Training
Germany (n = 77) Group sessions
guided by 3
psychologists
No guidance
for the other
interventions
(only self-help)
Jasper et al. 1. ICBT (n = 41) 10 weeks German Medium effect: d = Medium effect:
(2014) 2. GCBT (n = 43) self-help CBT 0.54 [0.11, 0.98] Anxiety
Germany manual (Kaldo Measured: Pre, d = 0.56 [0.12,
3. Online discussion and Andersson,
forum (n = 44) post, & 6-year 0.98]
2004) guided follow-up
by clinical Small effect:
psychologists Depression
d = 0.36 [−0.07,
0.78]
Insomnia
d = 0.33 [−0.09,
0.76]
Weise, 1. ICBT (n = 62) 10 weeks German Large effect: Medium effect:
Kleinstauber, 2. Online discussion self-help CBT d = 0.83 [0.46 to Insomnia
& Andersson forum (n = 62) manual (Kaldo 1.21] in THI d = 0.66 [0.29,
(2016) and Andersson, 1.03]
2004) guided Measured: Pre,
Germany post, & 1-year Small effect:
by clinical
psychologists follow-up Depression
d = 0.36 [0.00,
0.72]
Anxiety
d = 0.35 [10.01,
0.71]
Beukes, 1. ICBT (n = 73) Adapted English Medium effect: Large effect:
Baguley, 2. Weekly-check in (n self-help CBT d = 0.69 [0.35, Insomnia
Allen, = 73) manual (Kaldo 1.02] in TFI d = 0.88 [0.51, 1.26]
Manchaiah, and Andersson,
& Andersson 2004) guided Measured: Pre, Small effect:
(2018) by a clinical post, 2-months, & Depression
audiologist 1-year follow-up d = 0.28 [0.04,
UK
0.61]
Anxiety
d = 0.29 [−0.03,
0.62]

22
TABLE 2–3. continued

Study and Intervention Tinnitus

Country Groups Description Outcomes Other Outcomes

Beukes, 1. ICBT (n = 46) Adapted English Small effect: Medium effect:

Andersson, 2. Individualized F2F self-help CBT d = 0.45 [−0.001, Insomnia
Allen, (n = 46) manual (Kaldo 0.91] in TFI d = 0.74 [0.26,
Manchaiah, and Andersson, Measured: Pre, 1.20]
& Baguley 2004) guided post, & 2-months Depression
(2018) by a clinical post follow-up d = 0.57 [0.01,
UK audiologist
1.03]
Small effect:
Anxiety
d = 0.45 [−0.001,
0.91]
Note. ACT = Acceptance Commitment Therapy; CBT = Cognitive Behavioral Therapy; ICBT = Internet-based Cognitive
Behavioral Therapy; GCBT = Group Cognitive Behavioral Therapy; F2F = Face-to-face; TFI = Tinnitus Functional Index;
THI = Tinnitus Handicap Inventory; TRQ = Tinnitus Reaction Questionnaire

TABLE 2–4. Summary of Trials Investigating the Effects of CBT for Patients Attending a Regular Clinic
in Sweden

Within Group
Intervention Tinnitus
Study Setting Description Outcomes Other Outcomes
Lindberg, Patients attending CBT for tinnitus Small effect: Significant for
Scott, Melin, a regular clinical (n = 75) d = 0.32 general mood,
& Lyttkens setting in Sweden insomnia,
(1988) headaches, dizziness,
and muscle tension
Kaldo- Patients attending Internet-based Medium effect: Significant pre–post
Sandström, a regular clinical CBT for 6–10 d = 0.66 results for anxiety,
Larsen, & setting in Sweden weeks (n = 77) depression, and
Andersson insomnia
(2004)
Kaldo et al. Patients attending Provided either Medium effect: For the full ICBT
(2013) a regular clinical Internet-based d = 0.58 group — Medium
setting in Sweden CBT (n = 293) effect:
or low-intensity Small effect for
the low-intensity Insomnia
Internet-based
CBT (n = 81) group: d = 0.63
d = 0.32 Depression
d = 0.53
Anxiety
d = 0.53
Small effect:
Hyperacusis d = 0.26

23
24 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Otolaryngologists focus their efforts on the medical
management, whereas audiologists provide sound
therapy and informational counseling (Henry &
Manning, 2019; Henry, Piskosz, Norena, & Fournier,
2019). Although there is limited training offered to
audiologists about tinnitus management during
their training program, many audiologists provide
structured programs such as TRT or PTM with the
help of clinical manuals. These manuals include
the PTM Clinical Handbook for Audiologists (Henry,
Zaugg, Myers, & Kendall, 2010a), PTM Counseling
Guide (Henry, Zaugg, Myers, & Kendall, 2010b), TRT
Clinical Guidelines (Henry, Trune, Robb, & Jastreboff,
2007a), and TRT Patient Counseling Guide (Henry,
Trune, Robb, & Jastreboff, 2007b). A psychologi-
cally informed, audiologist-delivered, manualized
intervention is also being investigated in the United
Kingdom (Thompson, Taylor, et al., 2018).
Although there are these and other tinnitus self-
help books for professional training (e.g., Habets,
1995; Henry & Wilson, 2001; Hogan, 1998; Vernon
& Sanders, 2001), no English published standard-
ized CBT guide exists. Using a range of professionals
to deliver CBT-based interventions, such as audiolo-
gists, can increase access to CBT interventions for
those with tinnitus. There is a need for a standard-
ized CBT program in English that audiological pro-
fessionals can use. Hence, the aim of this book is
to present the CBT materials that are specifically
developed for the tinnitus-affected population. The
authors believe that materials presented in this
book will help audiologists to facilitate habituation
in their tinnitus patients using evidence-based CBT
techniques.
Selecting an Appropriate Program
According to Dr. James Henry at the National Cen-
ter for Rehabilitative Auditory Research (NCRAR),
the main goals of tinnitus management are reduc-
ing the (a) emotional reactions, (b) associated stress,
(c) attention given to tinnitus, (d) effect on other
life activities, and (e) idea that further help is not
needed or warranted. Psychological interventions
such as CBT are best suited to achieve these goals
(Thompson, Hall, Walker, & Hoare, 2017).
Various CBT programs for tinnitus have been
used, as CBT for tinnitus does not represent only one
form of treatment. Professionals differ in the com-
ponents they prefer. The choice should be based on
a program that (a) has a strong theoretical base,
(b) leads to behavioral change, (c) has been empiri-
cally tested in randomized controlled trials (RCTs),
and (d) indicates improvements in the long term.
The program selected for this book fulfills these cri-
teria; the Tackling Tinnitus CBT intervention has
been specifically developed for the tinnitus-affected
population. More information about this program
is presented next.
Development of the Tackling
Tinnitus CBT Program
The CBT program presented in this book has been
evolving over nearly 35 years and has been used
by thousands of tinnitus sufferers across the globe.
This program has a strong theoretical base and is
founded on a cognitive rationale (Henry & Wilson,
2001) and a learning theory approach (Hallam et
al., 1984). Following an initial face-to-face version
(Scott, Lindberg, Lyttkens, & Melin, 1985), the pro-
gram was developed for a Swedish population (Kaldo
& Andersson, 2004), and the first RCT trial using the
materials in an online intervention was published
by the same group (Andersson, Strömgren, Ström,
& Lyttkens, 2002). The materials were frequently
updated by Andersson and Kaldo-Sandström (2003)
and Kaldo et al. (2007). The program was then
translated to English (Abbott et al., 2009) and
German (Jasper et al., 2014) and underwent fur-
ther updating and cultural adaptations, although
the main components have remained the same
(e.g., Beukes, Vlaescu, Manchaiah, Baguley, Allen,
et al., 2016; Beukes, Andersson, Allen, Manchaiah,
& Baguley, 2018; Beukes, Baguley, Allen, Man-
chaiah, & Andersson, 2018; Beukes, Manchaiah,
Allen, Baguley, & Andersson, 2019; Beukes, Man-
chaiah, Fagelson, et al., 2020; Weise, Kleinstauber,
& Andersson, 2016).
The CBT program presented in this book includes
the following principles:
n Evidence-based content: The intervention
materials were developed by input from
psychologists, audiologists, and tinnitus
sufferers across the globe. The content
promotes habituation to tinnitus and
identifies and targets factors that slow down
habituation. It incorporates both audiological
 CHAPTER 2 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
and psychological principles, combining
expertise from both disciplines. This provides
individuals with different perspectives on
managing their tinnitus. The program has
continually evolved by incorporating appro-
priate elements. For instance, a new module
on “mindfulness meditation” was added due
to the growing evidence-base supporting this
approach as an effective method of treating
tinnitus (McKenna, Marks, & Vogt, 2018).
n Comprehensiveness and materials
tailored to suit individual needs: Various
multidisciplinary team members have gone
through the intervention materials, modified
the content for comprehensiveness, and
identified instances in which tailoring was
required. Both recommended and optional
chapters are included. The final program
consists of 22 chapters of which five are
optional. It is important that the intervention
is time restricted. An 8-week period provides
adequate time for participants to explore
the broad range of topics. The chapters have
been carefully organized in a logical order
that starts with an overview, followed by
simple and important concepts, subsequently
introducing strategies the participants could
work through.
n Encouraging behavioral and cognitive
changes: To aid habituation to tinnitus,
it is important to ensure that intervention
leads to behavioral and cognitive changes
(i.e., thought processes). For these changes
to take place, there must be an opportunity
to address them, and the individual must
be provided the tools to make these changes
and be motivated to implement the tools.
Michie, van Stralen, and West (2011) devised
a behavioral change model to help ensure
that an intervention provides all these aspects
(i.e., the Capability, Opportunity, and Motiva-
tion Model of Behavior [COM-B model]; also
see Thompson, Diaz-Artiga, Weinstein, &
Handley, 2018). This specific CBT interven-
tion provides all these aspects. Both physical
and psychological capability opportunities
are provided through content that addresses
relaxation and pattern analysis. Motivation
25
is encouraged through goal setting, moni-
toring, problem-solving, and the provision
of worksheets. The tool ensures that the
homework is practical and can be used
during everyday life. The relaxation tech-
niques can, for instance, be applied during
stressful events or while being among a
number of people.
n User-centric approach: To ensure the
content is accessible it needs to be free of
jargon and complicated language use. The
current intervention materials were rewritten
so that they are below the recommended
sixth-grade reading level to ensure compre-
hension by a majority of people (Beukes et
al., 2020). Moreover, to accommodate audi-
tory and visual learners, video explanations
are available on YouTube to accommodate
the written text.
Components of Tackling Tinnitus CBT Program
This program includes a range of components to
aid behavioral and cognitive changes (i.e., thought
processes) to help habituate to tinnitus (Beukes,
Vlaescu, Manchaiah, Baguley, Allen, et al. 2016).
Relaxation techniques reduce the effects of tension
and stress, cognitive restructuring addresses unhelp-
ful thinking patterns, and exposure to tinnitus, all to
aids habituation. To emphasize the theoretical base,
individual chapters are organized into a clear struc-
ture, including an overview of the content, expla-
nations of the techniques, a clear and rationale.
Step-by-step instructions and a further help section
cover possible difficulties that may be experienced.
Table 2–5 provides details of the Tackling Tin-
nitus CBT Program that was specifically developed
for individuals with troublesome tinnitus. The chap-
ters are grouped into five subsections, which include
(a) an overview, Chapters 4 and 5; (b) relaxation
guide, Chapters 6 to 11; (c) CBT techniques, Chap-
ters 12 to 18; (d) dealing with the effects of tinnitus,
Chapters 19 to 23; and (e) maintaining the results,
Chapters 24 and 25.
Empirical Evidence for the
Tackling Tinnitus Program
This particular intervention has also been exten-
sively evaluated in clinical trials in Australia, Ger-
TABLE 2–5. Components of Tackling Tinnitus CBT Program

Intervention Load
Section Video Short
B Content (see Expla­ Work­ Reading Daily
Chapter Module Chapters 4–25) nations sheets Time Practicing
Part 1: Overview
4 Introduction to Explanation and 1 4 15 min Setting goals
Tackling Tinnitus introduction to the
program content
5 Tinnitus Explanations to 1 1 15 min Reading the
overview aid understanding module
tinnitus
Part 2: Progressive relaxation guide
6 Deep relaxation The rationale for 2 3 15 min Twice a day
using relaxation for 10–15 min
and the difference
between tense and
relaxed muscles
7 Deep breathing Using 1 5 10 min Twice a day
diagrammatic for 10 min
breathing
8 Entire body Relaxing the 1 3 10 min Twice a day
relaxation entire body at for 10 min
once instead of
individual muscle
groups
9 Frequent Incorporating 1 3 10 min 5–10 times a
relaxation sorter relaxation day for 1–2
frequently during minutes
daily activities
10 Quick relaxation Using relaxation 1 3 10 min 7–15 times a
following stressful day for up to
events 1 minute
11 Relaxation A routine to 0 2 10 min Deep
routine incorporate relaxation
deep and quick twice a week
relaxation every
Frequent
week
relation 8
times a day
Rapid
relaxation
during,
before. or
after difficult
situations

26
TABLE 2–5. continued

Intervention Load
Section Video Short
B Content (see Expla­ Work­ Reading Daily
Chapter Module Chapters 4–25) nations sheets Time Practicing

Part 3: CBT techniques

12 Positive imagery The use of positive 1 5 10 min Twice a day
metal images to for 5 min
aid relaxation and
reduce stress
13 Changing views Reinterpreting the 1 7 10 min Once a day
of tinnitus tinnitus to associate for 5 min
it with a different,
more neutral or
positive sound
14 Shifting focus Ways of moving 1 3 10 min 4 times a day
focus from the for 2 min
tinnitus to other
tactile, auditory, or
visual stimuli
15 Thought patterns Understanding 1 4 15 min 3 times a
the influence week for 10
of thoughts on min
emotions and
behaviors
16 Challenging Addressing 2 3 15 min 4 times a
thoughts negative thought week for 5
patterns min
17 Being mindful Focusing on the 1 2 10 min 2–5 times a
present moment day during
normal
activities
18 Listening to Graded exposure 1 3 10 min Once a day
tinnitus to reduce the
avoidance of and
fear associated
with tinnitus
Part 4: Dealing with the effects of tinnitus
19 Sound Using background 1 2 10 min As required
enrichment* sounds to distract
from tinnitus
20 Sleep guidelines* Strategies to 1 7 15 min Implement
improve sleep daily
21 Improving focus* Tips to improve 1 2 10 min As required
concentration and
task management
continues

27
28 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

TABLE 2–5. continued

Intervention Load
Section Video Short
B Content (see Expla­ Work­ Reading Daily
Chapter Module Chapters 4–25) nations sheets Time Practicing

22 Increasing sound Strategies to 1 4 15 min As required,

tolerance* improve sound 1–2 minutes
tolerance and
difficulties increasing
23 Listening tips* Communication 1 2 15 min As required
tactics to aid
listening difficulties
Part 5: Maintaining the results
24 Summary Key messages for 0 0 15 min Reading the
each chapter module
25 Future planning Maintenance and 0 4 15 min Future plan
relapse prevention
planning
Note. * = optional modules

many, Sweden, the United Kingdom, and the United
States in more than 2,000 individuals with tinni-
tus — all indicating that the intervention has the
potential to reduce tinnitus distress (e.g., Abbott
et al., 2009; Andersson & Kaldo-Sandström, 2003;
Andersson, Strömgren, et al., 2002; Beukes, Anders-
son et al., 2018; Beukes, Baguley et al., 2018, Jasper
et al., 2014; Kaldo et al., 2007; Weise et al. 2016). The
content of this CBT intervention was thus selected to
be the most appropriate and evidence-based content
available. Table 2–3 indicates some of the RCTs that
have used the Tackling Tinnitus program and their
outcomes. The program has the potential to reduce
both tinnitus distress and some of the associated
comorbidities. Tracking Tinnitus is the CBT for tin-
nitus program that has been the most widely used
in research studies. It has also been provided face-
to-face and in self-help forms (see systematic reviews
and meta-analysis, e.g., Beukes et al., 2019; Nyen-
huis et al. 2013). Results have furthermore been
maintained for up to 1 year post-intervention (e.g.,
Andersson, Strömgren, et al., 2002; Beukes, Allen,
Baguley, Manchaiah, & Andersson, 2018; Hesser
et al., 2012; Jasper et al., 2014; Weise et al., 2016).
Further studies are planned to continue evaluating
and improving this intervention.
Key Messages
n There are two main approaches to managing
tinnitus: approaches that target the tinnitus
percept, and approaches focusing on
emotional reactions to tinnitus.
n CBT for tinnitus is an effective and compre-
hensive approach that can be tailored for the
individual with tinnitus. It focuses on cogni-
tive strategies and behavioral modifications
with an emphasis on long-term maintenance
of the results.
n CBT delivery using different formats does
not deter from the positive results obtained.
A CBT approach to tinnitus has the strongest
research evidence-base compared to other
management approaches.
n The Tackling Tinnitus CBT program was
specifically developed for a tinnitus popula-
tion by a multidisciplinary team including
 CHAPTER 2 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
psychologists, audiologists, and tinnitus
patients and has been tested in many clinical
trials across the globe.
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 Chapter
HOW TO DELIVER COGNITIVE
BEHAVIORAL THERAPY
FOR TINNITUS
What This Chapter Covers
n Pre-intervention assessment and monitoring
of outcomes
n Models to deliver CBT for tinnitus
n User engagement and monitoring progress
during intervention delivery
Introduction
Considering the distress often associated with tin-
nitus, treatment focused on reducing the negative
effects should be readily available. Unfortunately,
in many cases, access to effective tinnitus care is
limited or unavailable. This is of great concern
because the number of people with persistent tin-
nitus is continually on the rise and is set to increase
by more than 500,000 over the next decade (Mar-
tinez, Wallenhorst, McFerran, & Hall, 2015). Fur-
thermore, there simply are not enough health care
professionals available to treat all these people, and
this situation is unlikely to improve. In the United
States, there are between two and seven audiologists
per 100,000 people, and 57% of U.S. counties have
no audiologist at all (Planey, 2019). Countries with
lower household incomes and older populations
are at a disadvantage based on numerous levels of
inequality. The World Health Organization (WHO)
reported one audiologist per 20,000 people in high-
income economies and one audiologist per 500,000
to 6,250,000 in low-income economies (Goulios &
Patuzzi, 2008).
3
Reasons for this poor ratio include shortage of
resources, lack of trained professionals, poor infra-
structure, and a focus on basic health care. Moreover,
many of these audiologists are not specialized to
provide tinnitus care, and few are trained to provide
Cognitive Behavioral Therapy (CBT), which has been
shown to be a highly effective treatment for coping
with tinnitus. Although some psychologists provide
CBT for tinnitus, those personnel are limited. Hence,
despite the positive outcomes of CBT to reduce tin-
nitus distress, it is rarely offered in clinical practice.
A study in the United States by Bhatt, Lin, and Bhat-
tacharyya (2016) reported that the most commonly
discussed option for tinnitus by primary care phy-
sicians was prescribed drugs in 45% of instances,
whereas CBT was discussed in only 0.2% of instances.
A further barrier to treatment is the cost involved.
The most recent evaluation of the cost of tinnitus
service to date was in the United Kingdom (U.K.)
where health care is largely provided by public
funds. The annual cost of tinnitus interventions in
the U.K. was calculated to be £750 ($960) million in
total, and the annual societal cost relating to tinni-
tus was calculated at £2.7 ($3.5) billion (Stockdale
et al., 2017). This cost would be higher in countries
dominated by private care, as equipment would not
be subsidized.
Rapidly increasing demand for services further
constrains their delivery. This delay in accessing care
has been associated with poorer outcomes. Working
around these barriers is important so that those with
tinnitus can access the help they need. Clearly, care-
givers must develop alternative methods of deliv-
ering tinnitus interventions that improve access to
35
36 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
care. This chapter discusses options for service deliv-
ery models that can be used in the provision of CBT
for tinnitus and outlines the entire process, including
the required assessments and intervention structure.
Pre-Intervention Assessment and
Monitoring Intervention Outcomes
Assessing Tinnitus and Its Consequences
Before focusing on any intervention, assessing the
impact and severity of tinnitus is important. This
helps tailor the intervention to individual needs. It
also ensures that the effects of the intervention can
be measured. This aspect is essential to ensure that
the program has the desired effect. Evaluating tin-
nitus is, however, exceptionally difficult. Experienc-
ing tinnitus involves both the percept of the sound
and the impact on daily functioning such as trouble
sleeping or concentrating. It is difficult to quantify
the severity of the impact of tinnitus and how change
is effected through intervention. Although various
approaches exist, rating scales and questionnaires
are commonly used in both the management of
tinnitus patients and in tinnitus research, as they
can generally be completed independently in a short
time.
The assessment measures selected must be
appropriate for their purpose (Hall, 2018) and well-
designed. It is wise to select those that have been
validated through research. For instance, diagnos-
tic measures should help provide precise clinical
diagnosis and comprehensive understanding of the
condition and its severity, along with its wider con-
sequences such as the related comorbidities of sleep-
ing problems, high anxiety, depression, and others
difficulties. A comprehensive assessment will help
the health care professional to fully understand the
problem and to decide on the necessity of a referral
to any other specialist. On the other hand, to mea-
sure therapeutic benefits (i.e., intervention effects),
the assessment needs to measure change over time
as opposed to merely being used as a diagnostic
tool. Hence, the outcome measures should be sensi-
tive to change and help clinicians understand the
type and degree of benefit to patients. One way to
ensure the appropriateness of specific assessment
tools is by examining the psychometric proper-
ties of the instrument. The psychometric properties
refer to the validity, reliability, and responsiveness of
the questionnaire instruments. For instance, when
performing the same measure in succession, the
results should be stable. Hence, the questionnaire
instrument should have good test–retest reliability.
Detailed discussion about psychometric properties
is outside the scope of this chapter; however, read-
ers are encouraged to refer to appropriate sources
for further information (e.g., Coster, 2013; Jerosch-
Herold, 2005).
Considering that tinnitus affects individuals across
many dimensions, a test battery approach is recom-
mended; this approach uses different questionnaires
focusing on different domains. Where this is not pos-
sible, then at a minimum, a demographic or case
history questionnaire may be used together with a
validated questionnaire measuring tinnitus severity.
Where possible, further questionnaires should be
administered to monitor the additional effects of tin-
nitus. These may be individualized to the patient’s
unique difficulties. Measuring the coexistence and
severity of associated comorbidities is critical (e.g.,
insomnia, anxiety, depression), although other
aspects such as hearing difficulty and quality of life
also can be measured. An international project, the
Core Outcome Measures in Tinnitus (COMiT) ini-
tiative, which is based on consensus recommenda-
tions for core outcome domains, sets different types
of intervention for chronic tinnitus in adults (Hall
et al., 2018); these are presented in Table 3–1. It is
noteworthy that these recommendations are made
for research purposes (i.e., clinical trials), although
the authors believe that they are also relevant to
clinical practice. For a CBT intervention in the “psy-
chological intervention” category, the important
outcome domains include tinnitus intrusiveness,
tinnitus acceptance, mood, negative thoughts and
beliefs, and sense of control. These domains can be
measured using standardized outcome measures
touching on one or more of the outcome domains.
Purpose of Tinnitus Assessments
The tinnitus assessment may serve different pur-
poses depending on individual circumstances. These
include:
n Understanding problems that the individual
is experiencing;
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS 37

TABLE 3–1. Recommendations for Core Outcome cal guidelines in place to establish when this is the
Domains Sets for Different Types of Intervention case. Clinicians may recommend referrals to ear,
for Chronic Tinnitus in Adults nose, and throat (ENT) specialists or psychologists,
for example, wherein those professionals have an
Intervention Outcome Domains to interest in and clear understanding of tinnitus.
Type Be Measured Assessments can be completed using various elec-
Sound therapy • Tinnitus intrusiveness tronic formats or paper versions. The specific ques-
tionnaires selected depend on the circumstances.
• Ability to ignore
This book provides an overview of a few question-
• Concentration
naires, but is not intended to represent all the avail-
• Quality of sleep able questionnaires. The specific questionnaires
• Sense of control selected can be decided upon for the individual
Psychological • Tinnitus intrusiveness situation. Due to copyright restrictions, copies of all
therapy these questionnaires have not been included in this
• Tinnitus acceptance
book. However, some pre-assessment measures and
• Mood weekly measures are provided in Section C.
• Negative thoughts and
beliefs Pre-intervention Screening
• Sense of control Together with standardized questionnaires, case his-
tory questions should also be asked. A standard case
Drug therapy • Tinnitus intrusiveness
history format can be used and adapted. A detailed
• Tinnitus loudness
pre-intervention screening questionnaire is pre-
Source: Adapted from “The COMiT’ID study: Developing sented in Section C. However, not all the elements or
core outcome domains sets for clinical trials of sound-, questions may be relevant to every practice. Hence,
psychology-, and pharmacology-based interventions for it is essential to choose the appropriate question-
chronic subjective tinnitus in adults,” D. A. Hall, H. Smith,
naires for the target patient population.
A. Hibbert, V. Colley, H. F. Haider, A., Horobin, . . . K.
Fackrell, 2018, Trends in Hearing, 22, 2331216518814384. The pre-intervention assessment should primar-
https://doi.org/10.1177/2331216518814384 ily focus on three elements. First, it is necessary to
understand the possible causes of tinnitus. This is
essential to make appropriate treatment plans.
n Identifying whether further interventions or
Moreover, people are often unable to engage in an
referrals to other professionals are required; intervention if they do not understand why they
n Identifying whether “now” is an appro- have tinnitus. Hence, understanding the possible
priate time to start an intervention for the cause is essential. Second, it is important to exam-
individual; ine whether the individual with tinnitus may have
n Monitoring progress while undertaking the any serious auditory pathologies (e.g., acoustic neu-
intervention; roma) or psychological problems (e.g., self-harm or
suicidal thoughts) that require further investigation.
n Establishing improvements following under-
Specific kinds of questions will determine whether
taking the intervention;
any further referral to other professionals is required.
n Post-intervention, identifying whether further Prior to starting an intervention, a thorough medical
interventions or referrals to other profes- investigation is thus recommended where this has
sionals are required; and not been previously performed. This investigation is
n Ensuring that the intervention effects are especially warranted if any indication arises of med-
maintained long-term. ical problems or serious auditory pathologies that
would require a referral to an ENT specialist. Also, a
As tinnitus encompasses so many different detailed assessment by a clinical psychologist may
aspects, professionals from other areas of expertise be necessary if an individual is experiencing high
are often required. It is important to have clear clini- levels of depression and/or thoughts of self-harm
38 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
(i.e., passive or active suicidal thoughts). Third, a
detailed understanding of the consequences, life
effects, and coping behaviors are necessary to tailor
the intervention to meet individual needs.
Evaluating Tinnitus Severity
Numerous self-reported questionnaires to quantify
tinnitus severity have been developed (Frackell &
Hoare, 2014), outlined in Table 3–2. Haider, Fack-
rell, Kennedy, and Hall (2016) provided a detailed
list of tinnitus specific questionnaires. However, in
recent years, the Tinnitus Handicap Inventory (THI;
Newman, Jacobson, & Spitzer, 1996) and the Tinni-
tus Functional Index (TFI; Meikle et al., 2012) have
become the most used tinnitus severity measures.
Both tools can be used to diagnose the severity of
tinnitus and to measure outcomes to evaluate thera-
peutic benefits. Both tools also have good psycho-
metric properties.
The THI is a 25-item questionnaire that measures
the impact of tinnitus on everyday function (New-
man et al., 1996). It uses a 3-point response scale
(i.e., yes [score of 4]; sometimes [score of 2]; no [score
of 0]). The total scores range from 0–100, with higher
scores indicating higher tinnitus severity. In terms of
clinical use, a grading system has been developed
in which THI scores define five categories of tinni-
tus severity (i.e., slight, mild, moderate, severe, and
catastrophic) providing usable clinical categories. For
example, based on the score, does a patient shift from
TABLE 3–2. Primary Questionnaires to Evaluate Tinnitus Severity
Questionnaire
Tinnitus Functional Index (TFI; Meikle et al., 2012)
Tinnitus Handicap Inventory (THI; Newman,
Jacobson, & Spitzer, 1996)
Tinnitus Questionnaire (TQ; Hallam, Jakes, &
Hinchcliffe, 1988)
Tinnitus Handicap Questionnaire (THQ; Kuk, Tyler,
Russell, & Jordan, 1990)
Tinnitus Reaction Questionnaire (TRQ; Wilson,
Henry, Bowen, & Haralambous, 1991)
one category of severity to another after an interven-
tion? A minimal clinically important change score of
seven points has been determined to indicate treat-
ment-related changes (Zeman et al., 2011).
The TFI is a 25-item questionnaire that cov-
ers eight aspects of tinnitus severity (Meikle et al.,
2012). TFI helps discriminate between levels of tin-
nitus distress and provides a responsive measure
of treatment-related change. For each question,
patients respond on a scale of 0 to 10, allowing for
the detection of small changes over time. The scaled
global score ranges from 0 to 100, with higher scores
denoting higher levels of severity. The authors of the
questionnaire provide both a grading system and
a minimal clinically important change score. TFI
scores can be used to classify tinnitus patients in
two ways. For evaluating tinnitus impact at intake,
TFI mean scores can be stratified into five levels: not
a problem (mean = 14; range of 0–17); small prob-
lem (mean = 21; range of 18–31); moderate problem
(mean = 42; range of 32–53); big problem (mean =
65; range of 54–72); and very big problem (mean =
78; range of 73–100). As another way to interpret
TFI scores, preliminary data support the following:
relatively mild tinnitus (scores below 25) requires lit-
tle or no need for intervention; significant problem
with tinnitus (scores from 25 to 50) indicates possi-
ble need for intervention; and severe tinnitus (scores
over 50) means that tinnitus is severe enough to
qualify for more aggressive intervention. A 13-point
No. of Response Scale,
Items Scores Range
25 10-point, 0–100
25 3-point, 0–100
52 3-point, 0–82
27 100-point, 0–100
26 5-point, 0–104
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
change in TFI is considered to be clinically meaning-
ful change by the original authors (Meikle et al.,
2012), although studies in the U.K. have suggested
that a 22-point change should be considered clini-
cally meaningful change (Fackrell, Hall, Barry, &
Hoare, 2016).
Although the severity score indicates the level
of need for tinnitus treatment, many people have
undertaken self-help treatments and received bene-
fit regardless of their severity scores. Those with both
low, middle, and high scores have improved. Thus,
this score should not be used as the only indicator
regarding provision of tinnitus therapy. Individuals
with lower scores may still derive benefit but may
not need to complete the entire program. Informa-
tional counseling, which includes some principles
outlined in the first few chapters of section B, may
be sufficient. Those with higher scores may bene-
fit more from professional health assistance while
undertaking the self-help treatment.
Evaluating the Comorbidities
Associated With Tinnitus
Caregivers must determine whether tinnitus is af-
fecting aspects of an individual’s daily life, includ-
ing sleep, mood, and concentration. Where possible,
a comprehensive assessment is recommended. It
may include assessments for insomnia (e.g., the
Insomnia Severity Index [ISI]; Bastien, Vallières, &
Morin, 2001); anxiety (e.g., the Generalized Anxi-
ety Disorder [GAD–7]; Spitzer, Kroenke, Williams,
& Löwe, 2006); and depression (e.g., the Patient
Health Questionnaire (PHQ–9; Kroenke & Spitzer,
2002). Additional questionnaires to assess sound
sensitivity, hearing disability, cognitive functions,
and quality of life may be added, as shown in Table
3–3.
As tinnitus sufferers are at real risk of severe
depression or even suicidal thoughts or inclinations,
these aspects should be carefully monitored. If the
depression questionnaire score is significant and no
psychological input has been provided, it may be
required first before considering a tinnitus interven-
tion. Living with depression can make it difficult to
engage in other activities and may make it hard to
commit to the intervention. A referral to a psycholo-
gist with tinnitus expertise would, in such cases, be
advisable.
39
Some questionnaires ask about self-harm (or sui-
cide). The PHQ–9, for instance, asks whether there
are “Thoughts that you would be better off dead or
of hurting yourself in some way.” If this response is
affirmed, appropriate urgent care is required. Pro-
cesses and protocols should be in place outlining
who to contact — in this case, a psychologist with
expertise in this area who can assess risk and begin
a stabilization plan if required.
Assessment of Hearing Problems
Hearing loss is commonly comorbid with tinnitus.
At least two thirds of those with some degree of hear-
ing loss also have tinnitus, and there is a higher
probability (odds ratio of 2:1) of developing tinnitus
when there is an associated hearing loss (e.g., Gopi-
nath, McMahon, Karpa, & Mitchell, 2010; Manche,
Madhavi, Meganadh, & Jyothy, 2016). A detailed
hearing evaluation should be undertaken to deter-
mine whether the individual with tinnitus has hear-
ing loss. This is especially necessary for those who
have self-reported hearing problems and for those
that have been exposed to loud noise recreationally,
occupationally, or during military service. Moreover,
it is important to appropriately address hearing loss.
A hearing device, such as hearing aids, may help
tinnitus if the individual has both hearing loss and
tinnitus. Ambient noises can render the sound of
the tinnitus less noticeable and intrusive. Moreover,
many individuals with tinnitus who have hearing
loss attribute their hearing problems to tinnitus by
explaining that it makes hearing conversations dif-
ficult. Communication problems due to hearing loss
may contribute to their tinnitus distress. The Tin-
nitus and Hearing Survey (THS; Henry et al., 2015)
can be used to assess whether intervention for tin-
nitus is appropriate in these cases.
Monitoring Outcomes of CBT Intervention
Pre–Post Evaluation
To determine whether the intervention has had a
positive effect, the initial standardized assessments
should be repeated. This pre–post comparison can
indicate whether further help is required. Table 3–4
provides an example of the change in outcomes
after completing an online CBT intervention for
one individual. Several standardized measures
40 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

TABLE 3–3. Examples of Secondary Questionnaires to Evaluate General Health and

Comorbidities Associated With Tinnitus

No. of Response Scale,

Questionnaire Items Scores Range
Hospital Anxiety and Depression Scale (HADS; 14 4-point, 0–42
Zigmond & Snaith, 1983)
Generalized Anxiety Disorder (GAD–7; Spitzer, 7 4-point, 0–21
Kroenke, Williams, & Löwe, 2006)
Patient Health Questionnaire (PHQ–9; Kroenke & 9 4-point, 0–27
Spitzer, 2002)
Insomnia Severity Index (ISI; Bastien, Vallières, & 7 5-point, 0–26
Morin, 2001)
Hearing Handicap Inventory for the Elderly– 10 3-point, 0–40
Screening Version (HHIE–S; Lichtenstein, Bess, &
Logan, 1988)
Cognitive Failures Questionnaire (CFQ; Broadbent 25 5-point, 0–100
et al., 1982)
Satisfaction with Life Scales (SLS; Diener, Emmons, 5 7-point, 5–35
Larsen, & Griffin, 1985)
Hyperacusis Questionnaire (HQ; Khalfa et al., 2002) 14 4-point, 0–42
Tinnitus Cognition Questionnaire (TCQ; Wilson & 26 5-point, 0–104
Henry, 1998)
EuroQol EQ-5D-3L (EuroQol Group, 1990) 5 5-points on five
dimensions to
define 3,125
health states
Visual analogue
scale score: 0–100

are included to illustrate improvements in several
dimensions, including numerous outcome mea-
sures, may not be feasible in a clinical scenario,
although including more than one outcome mea-
sure would be ideal.
One way of quickly evaluating whether the CBT
intervention has had a positive effect is to check
whether the severity of tinnitus is reduced (e.g.,
changed from severe to mild). Moreover, if the
standardized questionnaires provide a minimal
clinically important change score, that data can
be used to interpret the intervention outcome (e.g.,
a 7-point change in THI or 13-point change in
TFI). Nevertheless, the final scores should be com-
pared to those suggested to ensure minimal impact
of the tinnitus. Scores below 25 (ideally lower) for
the TFI and THI may suggest that no further inter-
vention is required. Likewise, it is important to
look at the scores for all the other questionnaires
to ensure that they fall below the level of sig-
nificant difficulty. It may be that the tinnitus has
improved sufficiently, but there are still other dif-
ficulties that may remain, such as hyperacusis and
sleep problems. These areas can then be addressed.
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS 41

TABLE 3–4. An Example of the use of Outcome Measures to monitor progress after completing an Online
CBT Intervention

Pre- Post- 1-Year

Outcome intervention intervention Follow-Up
Domain Measures Range of Scores Score Score Score
Tinnitus Tinnitus Functional 0–100, >25 = 72 9 2
Index (TFI) significant tinnitus

Hearing Hearing Handicap 0–40, >10 = 50% 14 6 6

disability inventory for probability of mild–
Elderly–Screening moderate hearing
(HHIE–S) impairment

Anxiety Generalized 0–21, >5 mild = 13 5 5

Anxiety Disorder anxiety
questionnaire
(GAD–7)

Depression Patient Health 0–28, >5 mild = 8 1 0

Questionnaire depression
(PHQ–9)

Insomnia Insomnia Severity 0–28, >8 = sub- 18 0 0

Index (ISI) threshold insomnia

Sound Hyperacusis 0–42, >28 = strong 28 14 11

sensitivity Questionnaire (HQ) hypersensitivity

If scores have not improved, the reasons for this
should be explored. It may be that the individual
has not actually implemented the suggested tech-
niques. There may be other issues that have pre-
vented progress.
Weekly Monitoring
Monitoring tinnitus severity during the course of an
intervention is important. If the intervention is being
followed appropriately and is helping, these scores
should start deceasing around halfway through the
program. Monitoring whether this is the case is use-
ful as a safety precaution. However, selecting an
appropriate questionnaire for weekly monitoring is
difficult. Using the same questionnaire as that used
at baseline would become too familiar and affect
posttreatment results. Furthermore, a questionnaire
that is too long would become tedious to complete.
A shorter but reliable questionnaire is preferable, as
not to be too taxing to complete weekly.
One option is the Tinnitus Handicap Inventory–
Screening version (THI–S; Newman, Sandridge, &
Bolek, 2008), as this consists of 10 questions with
three response options each (i.e., yes, sometimes,
no). The scores can range from 0 to 40, with higher
scores indicating more tinnitus distress. Figure 3–1
provides an example of a weekly monitoring of tin-
nitus distress using the THI–S. A further option is
the Tinnitus Qualities Questionnaire (TQQ) that was
recently developed to monitor tinnitus weekly dur-
ing the course of an intervention. It was designed
to identify the effects of an intervention on tinnitus
qualities such as pitch and loudness as opposed to
the functional aspects. This questionnaire also con-
sists of 10 questions with a 10-point rating scale and
score range from 0 to 100. A copy of the TQQ can be
found in Section C.
It may be necessary to have weekly monitoring
on other dimensions if the individual has associated
comorbidities of serious concern. This again applies
42 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Problems caused by tinnitus

40

32

30

24
Tinnitus severity

20
16 16 16

10
10
8

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7

FIGURE 3–1. Example of a weekly monitoring of tinnitus distress using the Tinnitus
Handicap Inventory–Screening (THI–S).

to people with tinnitus who may suffer severe
depression and/or self-harm thoughts. In such cases,
it would be appropriate to use a questionnaire such
as the PHQ–9 to monitor their mental condition dur-
ing the course of the intervention.
Models to Deliver CBT for Tinnitus
Much evidence indicates that CBT is effective in
addressing negative reactions caused by tinnitus.
The effects have been similar regardless of format.
CBT for tinnitus was initially provided in the 1980s
as individualized therapy (Scott, Lindberg, Lyttkens,
& Melin, 1985). In the 1990s, there was an increased
use of CBT due to its positive results, and group-
based CBT was initiated (Kröner-Herwig et al., 1995).
Due to increased demand and cost of CBT, Inter-
net-based treatments were developed around 2000
(Andersson, 2002; Andersson, Strömgren, Ström,
& Lyttkens, 2002). Studies followed indicating that
CBT for tinnitus produced in self-help scenarios also
had beneficial effects (Kaldo & Andersson, 2004;
Kaldo, Cars, Rahnert, Larsen, & Andersson, 2007).
Combining the results of various studies in a sys-
tematic review and meta-analysis, Nyenhuis, Golm,
and Kröner-Herwig (2013) found that CBT self-
help interventions were an effective treatment for
tinnitus distress. CBT in any form is helpful and,
where available alternatives exist, they should be
accessed. The purpose of this book is to increase
access to tinnitus treatment. This section provides
practical suggestions in aid of delivering interven-
tions to achieve optimal outcomes. The delivery of
this program can be adapted to be used in various
contexts, including:
n Face-to-face (Individual);
n Face-to-face (Group);
n Internet-based self-help;
n Guided Internet-based self-help;
n Self-help guides (bibliotherapy); and
n Combined approach (e.g., face-to-face and
Internet-based, face-to-face and self-help).
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Professional Support
Self-help treatments can be undertaken indepen-
dent of professional support (i.e., unassisted or
unguided) or with professional support (i.e., guided).
The benefit of professional support is that the care-
giver can give feedback about progress, make sug-
gestions for adjustment, and answer questions that
come up. Guidance promotes collaboration between
the health care professional and the individual
with tinnitus. Guidance does not have to be face-
to-face; it can also be offered remotely. Providing
guidance during self-help Internet interventions has
been highly rated by those receiving it (e.g., Beukes,
Baguley, Allen, Manchaiah, & Andersson, 2018;
Beukes, Manchaiah, Allen, Baguley, & Andersson,
2019). Guidance can be synchronous (e.g., real-time
chats on the telephone or video conferencing) or
asynchronous (e.g., e-mailing). A blended approach
can also be effective. As better outcomes have been
reported for guided interventions (e.g., a systematic
review by Baumeister, Reichler, Munzinger, & Lin,
2014), they are recommended where possible. This
book can, however, be used in either form, with or
without assistance.
Guidance during CBT therapy was originally
provided by psychologists due to the nature of the
intervention. As outlined in Chapter 1, formulation-
driven CBT for specific psychological difficulties or
conditions should always be provided by a CBT-
licensed psychologist. The initial assessment is cru-
cial prior to embarking on an intervention. However,
where self-help interventions are indicated, individ-
uals may be assisted by other professionals. Where
assessed, outcomes in these instances have been
comparable. Outcomes have, for instance, been
comparable using a psychologist versus a technical
assistant for Internet-based interventions for depres-
sion, social phobia, and anxiety (e.g., Titov et al.,
2010). Moreover, when providing CBT online, favor-
able outcomes were obtained using an audiologist
instead of a psychologist (Beukes, Baguley, et al.,
2018; Beukes, Manchaiah, et al., 2019). This find-
ing extends the reach of CBT self-help substantially.
A possible way to assist those with tinnitus is to see
them face-to-face for an initial audiological and/or
medical consultation. In this way, any audiological,
psychological, or medical concerns can be addressed
and an appropriate treatment plan agreed upon.
43
This consultation may include the fitting of hearing
aids where hearing loss exists. If a CBT program is
recommended, the health care professional can offer
a clear explanation of the intervention. During the
initial visit, treatment goals can also be identified
(see the next section). This initial contact can help
motivate the individual to commit to the program.
If the individual is not seen face-to-face, a telephone
consultation also works. The flowchart provided in
Figure 3–2 can be helpful as a step-by-step guide
when planning a CBT intervention for individuals
with tinnitus.
Tinnitus intervention can then be provided in the
order of the chapters or according to the outline in
Table 3–5. Ideally, progress should be monitored at
regular periods. This may be weekly, although this
frequency may not always be possible. The contact
may be by e-mail or a phone call.
Time Span
An important aspect of CBT is that it is time limited.
A set period of time, preferably 8 to 10 weeks, should
be set aside to do the program. Table 3–5 suggests a
framework for the delivery of CBT intervention for
individuals with chronic tinnitus.
Goal Setting
Goal setting is helpful prior to starting an interven-
tion. A goal states the desired result a person plans
to achieve by undertaking the intervention. Writ-
ing down goals is powerful as it helps an individual
know what to concentrate on, and motivate them
to commit to doing the program daily. Goals can
also be reviewed on a regular basis as a measure of
progress.
To formulate goals, it is best to have some smaller,
clearly defined, achievable goals. Before defining
goals, the five main difficulties with tinnitus should
be identified. A goal can then be formulated for
each problem area. A useful way of defining each
goal is using the SMART mnemonic (i.e., make the
goals specific, measurable, attainable, relevant, and
time-based). Chapter 4 provides further details about
SMART goals. In addition, there is a section to record
goals in the individual chapters of section B. This
can be completed with individuals, or they can do it
in their own time.
 Individuals with tinnitus distress seeking help

Perform a comprehensive clinical assessment. Include a hearing assessment,

screening questionnaires, and self-reported outcome measures to include
assessments of tinnitus severity. Assess readiness, expectations, and motivation.
Assessment

Yes Further investigations required? No

Refer to other
professionals Is a tinnitus
where indicated intervention required?
(e.g., for depression Appropriate as well?
or hearing loss).
Yes

No
Identify / discuss
Arrange a follow-up
appropriate management
appointment after other
options depending on
Decision-making

investigations are
tinnitus severity, motivation,
complete or discharge as
expectations.
appropriate.

Refer for other tinnitus Motivated and

management (e.g., No suitable for
group sessions). self-help CBT?

Commence guided CBT Yes

Professional:
• Provide the specified chapters for self-study for the week.
Intervention

• Provide a general weekly overview of the chapters.

• Monitor engagement/ compliance. Weekly Initial interview to
• Provide weekly feedback. motivate / prepare /
explain the intervention.
Individuals with tinnitus:
• Read materials and practice suggested techniques.
• Complete the weekly monitoring questionnaire.
• Submit the week’s diary/ worksheets.

End of Post-intervention
Poor engagement
treatment. assessment
End of treatment

Arrange a consultation or
phone call to identify barriers Discharge or determine whether
and how to overcome them. further help is required.

FIGURE 3–2. A flowchart with a step-by-step guide when planning a CBT intervention for individuals
with tinnitus.

44
TABLE 3–5. Suggested Structure for Tinnitus Intervention if working on differnt aspects simultaneously

Possible Health
Week Assessment Chapter Content Professional Input
Before Full baseline Carefully check the assessment
starting assessment, to results. Explain how the
determine tinnitus treatment works. Encourage
severity and commitment to do the
comorbidities (e.g., treatment.
insomnia, anxiety,
and depression)
Week 1 4 Program rationale Set treatment goals together or
and outline review the goals set.
5 Tinnitus overview
6 Deep relaxation
Monitoring: THI–S & TQQ At the end of the week, review
End of (PHQ–9 for high work, compliance, and benefits.
week 1 depression) Keep monitoring the weekly
questionnaire results.
Week 2 12 Positive imagery
7 Deep breathing
Monitoring: THI–S & TQQ At the end of the week, review
End of (PHQ–9 for high work, compliance, and benefits.
week 2 depression) Keep monitoring the weekly
questionnaire results.
Week 3 13 Changing views
8 Entire body
relaxation
19 Sound enrichment*
Monitoring: THI–S & TQQ At the end of the week, review
End of (PHQ–9 for high work, compliance, and benefits.
week 3 depression) Keep monitoring the weekly
questionnaire results.
Week 4 14 Shifting focus
9 Frequent relaxation
20 Sleep guidelines*
Monitoring: THI–S & TQQ At the end of the week, review
End of (PHQ–9 for high work, compliance, and benefits.
week 4 depression) Keep monitoring the weekly
questionnaire results.
Week 5 15 Thinking patterns
10 Quick relaxation
21 Improving focus*
continues

45
46 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

TABLE 3–5. continued

Possible Health
Week Assessment Chapter Content Professional Input

Monitoring: THI–S & TQQ At the end of the week, review

End of (PHQ–9 for high work, compliance, and benefits.
week 5 depression) Keep monitoring the weekly
questionnaire results.
Week 6 16 Challenging
thoughts
11 Relaxation routine
22 Sound tolerance*
Monitoring: THI–S & TQQ At the end of the week, review
End of (PHQ–9 for high work, compliance, and benefits.
week 6 depression) Keep monitoring the weekly
questionnaire results.
Week 7 17 Being mindful
23 Listening tips
Monitoring: THI–S & TQQ At the end of the week, review
End of week (PHQ–9 for high work, compliance, and benefits.
7 depression) Keep monitoring the weekly
questionnaire results.
Week 8 18 Listening to
tinnitus
24 Key point summary
25 Future planning
After Repeat the Send out end of treatment
finishing the outcome measures questionnaires and revise
intervention done at baseline results. This may be done face-
to-face or via telephone.
Also, check treatment goal
attainment.
Long-term Repeat outcome Send out end of treatment
follow-up measures where questionnaires and revise
assessments possible after 3, 6, results. This may be done face-
12, & 24 months to-face or via telephone.
to ensure sustained
improvement
Note. THI–S = Tinnitus Handicap Inventory–Screening; TQQ = Tinnitus Qualities Questionnaire; PHQ–9 = Patient Health
Questionnaire–9; * = optional modules
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
User Engagement
The intervention described here is intended to help
individuals be more actively involved in their own
health care. This requires both activation and
engagement. Activation refers to an individual’s
knowledge, skills, ability, and willingness to man-
age his or her own health. Engagement involves
completing the activities suggested in the program,
such as reading or doing exercises. When individu-
als are activated and engaged, health outcomes are
improved; this in turn lowers overall health care costs
and the need for later interventions (James, 2013).
Encouraging engagement is thus very important
and this program does so by using materials that:
n Use a range of formats. The CBT chapters
include text, images, suggested videos, and
exercises to ensure an interactive intervention
is offered. These interactive elements can
encourage user engagement.
n Are written in an understandable way.
Ensuring the materials are accessible in terms
of their linguistic difficulty was addressed
earlier. Readability is the ease with which a
person understands written materials. Guide-
lines from U.S. Health and Human Services
and the American Medical Association
recommend that health materials be written
in plain language at or below the sixth-grade
reading level, interpreted as the number of
years of U.S. education required to under-
stand what is written (Doak, Doak, & Root,
1996; Weiss, 2003; Weiss & Coyne, 1997). To
ensure the materials are more accessible, they
are all written below the sixth-grade reading
level to promote ease of engagement.
n Provide a clear rationale. Clear explana-
tions and ample information are provided
regarding the reasons for suggesting the
techniques.
n Offer support and encouragment. Where
possible, individuals should be encouraged
periodically. Examples of such messages are
provided in Section C.
n Ensure that the intervention is relevant
and up-to-date. The intervention has been
revised periodically to ensure that informa-
47
tion and trends are current and that the
presentation and style remain pleasing.
When facilitating this self-help program, the fol-
lowing suggestions can be implemented to ensure
that users stay engaged:
n Set intervention goals and regularly monitor
them.
n Encourage setting aside a time and place to
work on the chapters every day.
n Suggest that individuals tell family members,
friends, and colleagues about the interven-
tion. These people can offer support by
providing time and opportunity to go through
the materials.
n Provide some form of weekly professional
contact. This may be to check in by phone or
e-mail to discuss progress.
n Include a few group sessions where feasible.
n Provide key information and overviews prior
to starting new chapters. Section C provides
examples.
n Encourage individuals to use all the materials
provided, such as the supplementary videos,
and to read the materials carefully to under-
stand the rationale for each technique.
n Encourage completion of the exercises sug-
gested and monitoring of their own progress.
Monitoring Engagement and Adherence
Most of the chapters in Section B include exercises
and practice worksheets that can be completed. It is
important to encourage individuals to record their
practice. This serves two purposes. The first is that
individuals may look back and see their progress
which may encourage them. It is often difficult to
realize that progress is being made without looking
back at where one started initially. Secondly, record-
ing progress helps the health professional monitor
the individual’s progress and engagement with the
intervention. It also helps to guide expectations.
Tinnitus may initially become louder due to sud-
den increased focus and attention on it. This should
improve, however, after a few weeks of intervention.
Including weekly monitoring using a short question-
narie to assess progress is also helpful. Within 4 to
48 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
6 weeks of working with the program, the weekly
scores should be systematically decreasing. Where
this is not the case, further input may be required.
Dealing With Challenging Clients
A range of individuals may want to undertake this
program. Some may be very positive and compli-
ant and have excellent outcomes. There may be
others that are negative, disengaged, and show no
improvement. It is important to preempt such pos-
sible problems. Some suggested strategies follow.
Professionals can ensure that they have the
needed support by taking the following actions:
n Arrange for clinical supervision. Clinicians
should ensure that they have regular clinical
supervision in place with a mentor so that
they can discuss and address difficulties they
are facing.
n Be involved in professional networks.
Many associations provide networking events,
professional focus group discussions, and
regional conferences. This contact with other
professionals provides the opportunity to
discuss difficult situations and obtain new
perspectives.
n Ensure that there is a clear pathway.
Prior to any engagement with patients, it is
important to have a clear pathway. If there
is hearing loss present, it should be addressed
prior to starting another intervention. Where
there may be a medical reason for the
tinnitus, this diagnosis should be sought, as
alternative interventions may then be more
appropriate.
n Ensure that a program is the most appro-
priate intervention. There are different
ways to manage tinnitus. Those with mild
problems may not require an in-depth inter-
vention. A one-off counseling session may be
sufficient for them. Some people may do well
once hearing loss is addressed and not require
further help. The choice of intervention needs
to be tailored for each individual.
Before starting an intervention, professionals
should address the following topics with individ-
uals suffering from tinnitus:
n Hopes of a cure Many individuals believe
such an intervention will cure tinnitus. It is
important to stress that this is not the case.
This program is not going to cure tinnitus;
the tinnitus will remain. The program aims to
help individuals manage the tinnitus better
through improved reactions and behaviors.
n Expectation management Many people are
keen on improvements but do not want to put
in any effort. For tinnitus to be improved, it
is going to require time, dedication, and hard
work.
n Dealing with preconceived ideas Many
individuals may have tried other tinnitus
interventions that were unsuccessful. It is
important to explore with them why certain
types of interventions may not have worked
and to encourage them to fully engage with
this intervention due to its evidence-based
support.
When progress has been slow, professionals
should:
n Monitor individuals Monitor individuals
during the course of the program to identify
problems as they develop instead of waiting
until the end of the intervention.
n Determine why progress may be slow. This
may be due to poor engagement or following
advice from other programs that is interfering
with the results.
n Consider alternative approaches. It may
be that this individual is not suited for a
self-help intervention and requires more
face-to-face sessions.
n Consider alternative referrals. It may be
that problems such as anxiety or depression
are preventing active engagement in the
intervention. Referral to a wider sphere of
professionals may be indicated.
Introduction to the Self-Help Materials
Section B, the next section of this book, is written
for the individual with tinnitus so that it can be pre-
sented as a self-help intervention. Section C outlines
 CHAPTER 3 HOW TO DELIVER COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
what each week involves so that you can provide
introductions to individuals you guide through the
process. You may choose not to use this as a self-help
option, but instead to use the materials to guide
counseling sessions by reading through the materi-
als yourself. This may be useful where an individual
simply needs some guidance and does not require
more intensive treatment. The materials can thus be
adapted and tailored for individual needs.
Key Messages
n A thorough assessment is recommended prior
to providing any intervention. This will help
with understanding the effects of the tinnitus,
whether additional referrals are required,
and what the most appropriate intervention
option may be.
n The program described in this book is
evidence-based and has been empirically
tested. It provides the opportunity to change
reactions, thoughts, and behaviors associated
with hearing tinnitus.
n Goal setting before starting is important. A
time-limited period should be set to complete
goal setting. This includes focusing on
different tactics each week.
n Some guidance is recommended to support
individuals while they undertake the
intervention. This involves monitoring
engagement and progress. This can be done
by administering weekly questionnaires and
reviewing completed worksheets.
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Section B
COGNITIVE BEHAVIORAL
THERAPY INTERVENTION
(SELF-HELP) MATERIALS
FOR TINNITUS
Part I
OVERVIEW
 Chapter 4
TACKLING TINNITUS
PROGRAM OUTLINE

You aren’t going to find anybody that’s going to be
successful without making a sacrifice and without
perseverance.
— Lou Holtz
What This Chapter Covers
n Helping you plan how to get the most from
this program
n An overview of the content of this program
n Setting goals that you want to achieve
Introduction
The first question people experiencing tinnitus often
ask is, “How can I stop hearing tinnitus?” As tin-
nitus is such a complex symptom, researchers are
still working toward stopping the tinnitus sound.
Presently there is no magic pill, herb supplement,
oil, or treatment that has been proven to cure tinni-
tus. When seeking advice for your tinnitus, you may
have been told there is nothing that can be done
to help. You just live with the tinnitus. This is not
helpful and not true. Although there is often no
cure, there are things to do that can help. The first
step if you have tinnitus is always to have a medi-
cal examination. This may identify the reasons for
the tinnitus, and there may be some interventions
that can help you. The most common approaches to
managing tinnitus are shown in Table 4–1. Of these
approaches, those that focus on reducing the annoy-
ance induced by tinnitus, without trying to change
the tinnitus itself, have been shown to have the best
outcomes.
Psychological approaches have been shown to be
generally effective, and of these, Cognitive Behav-
ioral Therapy (CBT) has the most evidence for help-
ing to reduce the effects of tinnitus.

TABLE 4–1. Commonly Used Approaches for Tinnitus Management

Approach What It Involves

Medical For a few medical conditions, medication or surgery may be an option.
Sound-based • Hearing aids can be helpful when there is hearing loss and tinnitus.
• Different types of therapies using background sound can be used.
Psychological • Cognitive behavioral therapy
• Relaxation
• Mindfulness
• Acceptance and commitment therapy
Self-help and The individual actively learns to control his or her tinnitus by learning
self-efficacy new tools and ways of thinking.

57
58 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Tinnitus interventions can be provided by a pro-
fessional or can be offered as self-help. This program
can be used either way but is largely designed to be
used as a self-help intervention together with pro-
fessional support. A health care professional can
explain the exercises, tailor the training, answer
questions, and monitor progress. It is important
that you start this program only after you have
been medically assessed for tinnitus. This chapter
provides an overview of how the Tackling Tinnitus
program may help you and how you may get the
most from the program.
Problems Caused by Tinnitus
A good starting point for working on solutions is
identifying exactly what the problem is. Having
tinnitus can be very bothersome and can interfere
with many aspects of your daily life. Most people
without tinnitus cannot understand why those who
suffer with it say it is ruining their lives. You yourself
may have been one of those people; and now that
you are dealing with tinnitus, you understand. It is
not merely the tinnitus that is bothersome, but the
effects of it. Tinnitus can make almost every aspect
of life difficult. Tinnitus research studies have found
the following to be some of the most frequent prob-
lems reported by individuals with tinnitus:
n “Tinnitus really affects my sleep. It is hard
going back to sleep after waking up during
the night.”
n “The tinnitus stops me from hearing what is
being said. It affects my ability to communi-
cate with others.”
n “I can’t go out anywhere anymore. Being in
a noisy place with a band playing makes my
tinnitus worse for days afterward.”
n “I miss it being quiet. Tinnitus is always
there. My tinnitus is worse when I am in a
quiet room after being at work all day. I can
no longer sit and read.”
n “My tinnitus often gets so loud. When I am
stressed, it is much worse.”
n “I just can’t focus on my work. My tinnitus is
so annoying.”
n “I am no longer able to relax. I feel angry
and annoyed all the time. I have no control
over the tinnitus.”
These difficulties can affect not only you, but also
those close you — your friends and family. Work,
hobbies, and your social life may also be impacted
negatively. Tinnitus impacts each individual differ-
ently, and that is where this program comes in. It is
designed to address your specific, unique problems
with tinnitus.
The first step in this program is to identify your
top five problems with tinnitus. Rank them in order
of importance, with number one being most impor-
tant and number five being least important. We will
review these problems later in this chapter.
My most important problems due to
tinnitus are:
1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________
5. _________________________________________
Tinnitus sufferers often are overwhelmed by prob-
lems like the ones you listed here. They are frustrated
that there is no cure or treatment to take away tin-
nitus. A helpful exercise for this frustration is to try
to separate tinnitus as a “sound” and the effects of
tinnitus as the “problems” associated with it. These
are two separate things. We cannot take away the
sound, but we can lessen the annoyance and prob-
lems with tinnitus. You can choose between living
the rest of your life frustrated and annoyed by tin-
nitus or by addressing these problems. This program
is designed to address these problems. Although the
tinnitus may not go away, you can reduce its effects
by working through this program.
 CHAPTER 4 TACKLING TINNITUS PROGRAM OUTLINE 59

How This Program Helps

Having tinnitus does not need to affect your daily Hear

life. Different strategies have proven successful in tinnitus
lessening the effects of tinnitus, and this program is
based on those evidence-based strategies and tools.
Although there are many proposed treatments for
Neutral Neutral
tinnitus, this book includes only those that research
emotions thoughts
has shown to be effective. Specifically, this program
The aim of
is based on CBT principles. CBT has been shown to CBT
be effective for many different conditions, such as
depression, anxiety, and eating disorders. CBT can
also be helpful for medical conditions that are sig-
nificantly affected by psychological and behavioral
factors — for example, chronic pain, cardiovascu- Relaxed Calm
behaviors reactions
lar problems, sleeping disorders, and headaches.
These types of problems are normally referred to as
somatic, and tinnitus falls into this category. Tinni-
tus research studies have demonstrated that CBT for
tinnitus annoyance is probably the most effective FIGURE 4–1. The influence of tinnitus on thoughts
intervention (treatment) and has the greatest scien- and feelings.
tific support in both the medical and psychological
disciplines, especially where the long-term effects
are considered.
The basic idea of CBT is that what we do and of tinnitus. In summary, this program is based on the
think affects how we feel. Thoughts and feelings can following tools to lessen the effects of your tinnitus:
in turn be influenced by working on them and try-
n CBT principles: The use of CBT helps you to
ing new ways to react and behave. CBT for tinnitus
(a) change unhelpful behaviors and reactions
is based on the principle that it is not the tinnitus
to tinnitus, and (b) change the meaning
per se that causes problems, but how we interpret
you give to your tinnitus. This will result in
and think about the tinnitus. It focuses on the pres-
reduced distress associated with tinnitus.
ent time by looking for ways to change the mean-
ing you give to your tinnitus. By changing your n Practical tips: Tinnitus can interfere with
thoughts about the tinnitus, you can improve the many aspects of life. This program will give
way you behave and react when hearing the tin- you a range of strategies to address these
nitus, as shown in Figure 4–1. The program is also problems. You can use the tips to deal with
designed to provide many practical tips to help with things you may find difficult in your daily
things that you may find difficult in your daily life, life, such as sleeping or focusing.
such as sleeping or focusing. These tips are discussed n Empowerment: The aim of these tools is to
in the next chapters. Each chapter aims to lessen the help you know how to control your tinnitus.
impact of your tinnitus in a different way. It does this This empowers you to lessen the effects of
by changing unhelpful behaviors and reactions to your tinnitus by yourself, without needing to
tinnitus and changing the meaning given to tinnitus, rely on professionals for help. Once you have
as shown in Figure 4–1. Each chapter has been care- learned about strategies that work for you, you
fully selected to provide new knowledge, skills, and can use them in different situations. They will
habits to lessen problems caused by your tinnitus. provide a tool kit for you to use when your
Although everyone’s tinnitus is different, the tools tinnitus bothers you. You can also apply them
shared have been shown to work for different types to other problems that you are facing.
60 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
The Goals of the Program
This program is designed to give you information
and ideas to help you better manage your tinnitus.
It consists of various chapters. Each chapter has
reading material to increase your knowledge and to
introduce new strategies. Each chapter also provides
suggestions to try after you have read the content
and understand the suggestions. Ideally, you will
spend a week at a time practicing 2 to 3 strategies.
The strategies aim to help you to:
n Increase your knowledge. Learn more
about tinnitus and its effects.
n Improve your ability to relax in different
situations. Lower tension and stress.
n Improve your emotional well-being and
how you deal with problems. Reduce
negative emotions associated with hearing
tinnitus. This will include reflecting on the
impact of your thoughts and how to lessen
their effect.
n Improve daily functioning. Work on prob-
lems with sleep, focusing, and listening. This
program will help you form new habits and
routines to help you do the things you want
to do despite having tinnitus.
n Better manage your tinnitus. There are
strategies to help you cope when tinnitus is
annoying, so that you feel in control over
your tinnitus and how you respond to it.
Applying these strategies will help you be
more accepting of the tinnitus and reduce
your annoyance with tinnitus.
What Do You Want to Achieve?
It is important to work out what you want to accom-
plish. By setting goals, your aims will become clearer.
This process will help you know why it is worth mak-
ing the effort. Your goals need to be realistic and
concrete. Some examples follow, but you can select
your own as well. There is a lot of power in writ-
ing your goals and checking in with them regularly.
Hang them up somewhere where you can look at
them often to remind yourself why you are putting
in so much effort.
Goal Setting
We all have choices in life. What you choose depends
on what you want to achieve and where your pri-
orities lie. If your goal is to run a marathon, you
may commit to putting in the time to train instead
of sleeping late. You may choose to eat a healthy
meal instead of one that may not sustain you. These
changes are not going to be easy, but if it is impor-
tant to you, you will keep focusing on your end
goal. In the same way, it is important to make these
conscious choices to work at improving your ability
to cope with tinnitus. You have taken the first step
by choosing to do this program. To help you keep
your commitment to the program, it will help for
you to formulate some goals. Looking back at the
main problems you have with your tinnitus, think
of goals to overcome these problems. For example,
if your main problem is that tinnitus makes it dif-
ficult for you to read in a quiet room, the goal may
be “to be able to read a book in a quiet room again.”
Once you have an idea of your goal, it is helpful
to bring more structure to the goal. Using Specific,
Measurable, Achievable, Realistic, and Timely
(SMART) goals can help you, and these are shown
in Table 4–2.
Select a goal to address each of the five problems
you wrote down earlier. The goal should be specific
to the problem. Use the guide to form SMART goals
as in Table 4–2. You can view the following goals to
give you some ideas. These ideas are broad category
goals. You can make these specific to you. You can
also make up your own goals.
n Reduce annoyance of tinnitus;
n Notice the tinnitus sound less;
n Be able to relax more easily;
n Be able to spend time in quiet places without
my tinnitus bothering me;
n Feel less tension and stress due to having
tinnitus;
n Have a better control of my tinnitus;
n Have an improved quality of life;
n Be less sensitive to certain sounds;
n Focus on a task better without the tinnitus
bothering me;
 CHAPTER 4 TACKLING TINNITUS PROGRAM OUTLINE 61

n Don’t worry about the tinnitus as I presently
do;
n Fall asleep faster and not wake up as often.
Set goals for this program using Table 4–3.
Getting the Most From This Program
CBT for tinnitus annoyance demands that you take
time, make a commitment, and have a will-ingness
to try out new and unfamiliar things. The effort to
change can be exhausting at first, and the aware-

TABLE 4–2. Examples of Setting Specific, Measurable, Achievable, Realistic, and Timely
(SMART) Goals

Is My Goal
SMART? Description Example
Specific What exactly do I want to I want to read a book in the lounge without
achieve? my tinnitus bothering me.
Measurable How will I know I have I will be able to read for an hour without
reached my goal? being bothered.
Attainable Can I accomplish this goal? An hour is about three times what I can
Is it realistic? do now but is only about one third of what
I could do before my tinnitus.
Relevant Does this make sense for Yes, reading used to be one of my main sources
my life? of pleasure and is one of the things I am most
angry about losing because of tinnitus.
Time-based What is the time frame for I want to reach my goal by the end of the
this goal? intervention (8 weeks).
End goal By the end of the intervention, in 2 months’ time, I want to be able to read a
book in the lounge for an hour without the tinnitus bothering me.

TABLE 4–3. My Goals

Problems caused by tinnitus, in order Specific goal for each of these needs
of importance or problems
62 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

ness of tinntus may temporarily increase. The treat- There are key tools recommended for everyone
ment is an intensive trial period of new habits and and optional tools that can be selected if you think
new ways of thinking. CBT can be thought of as an they will be useful. Optional tools are presented in
experiment: You get to try methods, or “tools,” as Part IV. The program is structured as follows.
we like to call them, that have helped many other
people with tinnitus. There is no guarantee that a Part I introduces the program and provides an
certain tool will help everyone, though. By following overview of these topics:
the instructions properly, you can examine each tool n Tackling Tinnitus program outline
and then evaluate whether the method was benefi-
n Tinnitus overview
cial for you. If there is no positive effect with a cer-
tain tool, you move on to other tools. If the tool was
Part II is a progressive relaxation guide with
useful, however, outline a plan on how to keep using
these topics:
it. The main point is not to give up too soon and
to apply long-term thinking. Many of the tools have n Deep relaxation
a long-term effect and may require weeks of hard n Deep breathing
work before results start to show. Fortunately, after
n Entire body relaxation
the intense period of treatment, it is rarely necessary
to continue to devote the same amount of time and n Frequent relaxation
energy, because the different methods have, to a large n Quick relaxation
extent, been learned. In other words, the tools can n Relaxation routine
become a part of your daily life and become new rou-
tines that will help you better cope with your tinnitus. Part III covers a range of CBT techniques, includ-
Many people with tinnitus have done this pro- ing these topics:
gram and have gained much from doing it. They
n Positive imagery
have found it has not only helped with the tinnitus,
but also other aspects of their lives. Make sure you n Views of tinnitus
understand what to do and why you are using each n Shifting focus
technique. Sometimes it takes a while to learn a new n Thought patterns
skill; what is important is not giving up too soon.
n Challenging thoughts
Commit fully by giving this program your best.
Work hard at the suggestions for 8 weeks. You can do n Being mindful
it, and it can help you — just remember that as with n Listening to tinnitus
most things in life, the more you give, the more you
will get. There are no quick fixes; consistent work Part IV deals with the effects of tinnitus with
will help the changes last. Plan carefully and get these optional topics:
support from those around you. Here are some fur-
n Sound enrichment
ther tips for getting the most from the program:
n Sleep guidelines
n Talk to the important people in your life
n Improving focus
about this program and what you are
learning and inform them of your progress. n Increasing sound tolerance

n Be open to new ideas and try them for long n Listening tips
enough to see whether they are useful.
Part V addresses maintaining the results with
n Commit fully to the program by dedicating these topics:
some time to do it each day.
n Summary
The Different Tools n Future planning
Each chapter covers a different tool used to man-
age problems causes by tinnitus. Each tool should You can either do the program by doing in in the
be tested carefully to see whether it is useful or not. Chapter order, first focusing on relaxation, then CBT
 CHAPTER 4 TACKLING TINNITUS PROGRAM OUTLINE
and then practical aspects or you can work simul-
taneously on each aspect. Table 4–4 provides a sug-
gested structure to follow when working together on
different aspects. Always focus on only a few tools
at a time. There is quite a bit of reading, because
it is important for you to understand the rationale
for the tools and how to use each one. At the end
of each chapter are further help sections that you
can refer to if you are having any difficulties. Spend
more time on the tools that are most useful to you.
Some ideas may work better for you than others. You
will find that some chapters have more reading to
do while others focus on things you need to practice.
You will also find some question and comment sec-
tions you can fill in on the pages themselves. Com-
pleting these sections will help you to understand
what you have read about. It will also give you a
place to jot down ideas you may have.
Monitoring Your Progress
While you do this program, there will be highs and
lows. Initially, as you focus more purposefully on
your tinnitus, it may become temporarily louder.
The more you think about tinnitus, the more you
notice it. This is not unusual. Don’t let this discour-
age you. After about 4 to 5 weeks, your tinnitus
will become less noticeable. Many have found that
the program helps for months after finishing it. So
make every effort to work through the whole book.
At times it may feel as though progress is slow, so
we suggest the following ways to track your prog-
ress. First, make notes of your daily practice in the
worksheet provided at the end of each chapter. You
can then look back at your notes as time goes on.
Looking at where you originally started will remind
you how much progress you have made. Second,
complete the monitoring questionnaires in Section C
once a week. This will help you monitor your prog-
ress and help guide you through the program. Keep
the materials with you all the time so that you can
review what you have read and write down your
progress wherever you are. Having the instructions
close by will also help you to refer to them if you
have some free time.
Making Time for the Program
To reduce your tinnitus distress, you will have to
work actively and consistently with the tools in
63
the program. This program is designed to focus on
improving your tinnitus for an intensive and dedi-
cated period of time. Try to spend some time each
day on the program by practicing the suggested
techniques. Although this requires dedication, it will
be well worth the effort. If you have a lot of spare
time, this should not be a problem. However, if you
have lots of commitments, it will be a challenge for
you to make time for this program. The amount of
time spent on each chapter may vary widely.
Each chapter provides strategies that will take time
to master, but the time spent practicing them can be
very beneficial. To maximize results, schedule some
time each day into your calendar to work on the pro-
gram and commit to it. A key element is in planning;
set aside periods for just the program and nothing
else. What works best for you? You may prefer to
practice after meals or first thing in the morning.
You may choose different times on different days,
depending on your schedule. Tell people your plan
so that they understand when and why you need
to be excused for a few minutes. Do not reduce or
stop activities that are good for you, such as exercis-
ing and socializing. However, consider other adjust-
ments you can make to prioritize this treatment,
such as spending less time watching television.
Making a Time Commitment
n Why are you going to make time and
commit to the program?

n When will you work on the program
each day?

Key Messages
n This treatment is based on techniques that
research has shown to be most successful at
lowering the distress linked to your tinnitus.
n It is aimed at helping you change unhelpful
behaviors and reactions to tinnitus.
64 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

TABLE 4–4. Suggested Tackling Tinnitus Program Structure to Follow if Working on

Different Aspects Simultaneously

Reading
Week Chapter Content Time Practice Time
Week 1 4 Program outline 15 min Goal setting
5 Tinnitus overview 15 min Reading
6 Deep relaxation 15 min Twice a day for 10–15 min
Week 2 12 Positive imagery 10 Twice a day for 5 min
7 Deep breathing 10 min Twice a day for 10–15 min
Week 3 13 Changing views 10 min Once a day for 5 min
8 Entire body relaxation 15 min Twice a day for 10–15 min
19 Sound enrichment* 10 min As required
Week 4 14 Shifting focus 10 min 4 times a day for 2 min
9 Frequent relaxation 10 min Twice a day for 5 min
20 Sleep guidelines* 15 min Implement daily
Week 5 15 Thought patterns 15 min 3 times a week for 10 min
10 Quick relaxation 10 min 7–15 times a day for up to
1 min
21 Improving focus* 10 min 4 times a day for 2 min
Week 6 16 Challenging thoughts 15 min 4 times a week for 5 min
11 Relaxation routine 10 min Deep relaxation twice a
week
Frequent relation 8 times
a day
Rapid relaxation during,
before, or after difficult
situations
22 Sound tolerance* 15 min As required, 1–2 min and
increasing
Week 7 17 Being mindful 10 min 2–5 times a day during
normal activities
23 Listening tips 15 min As required
Week 8 18 Listening to tinnitus 10 min Once a day
24 Key point summary 15 min Reading the module
25 Future planning 15 min Future plan
Note. *Optional modules. Supplementary videos for each chapter are available as outlined in Chapter
26.
 CHAPTER 4 TACKLING TINNITUS PROGRAM OUTLINE 65

n The program is going to help to change the

meaning you give to your tinnitus. Reflection Activity
n By fully committing to going through each
n What is the most important thing you have
chapter and trying the suggestions, you will
get the best results. learned from this chapter?

n Take time to ensure you stay focused on


your goals, and plan to make time for this
program every day. n What tips are you going to apply?
n It is going to take time and effort to deal
with problems that have affected you for a 
long time.
 Chapter
Understanding is the first step to acceptance, and only
with acceptance can there be recovery.
— J. K. Rowling
What This Chapter Covers
n Learning more about tinnitus
n Understanding why tinnitus becomes
bothersome
n Discussing how to habituate to tinnitus
Introduction
Research has found that learning more about your
tinnitus helps you to cope better with it. The more
you know, the better chance you have to lessen the
effects of your tinnitus. Thus, this Chapter helps you
learn more about tinnitus.
Interesting Tinnitus Facts
Tinnitus is the perception of sound that is not gener-
ated by a sound source in the environment around
you. You might think of tinnitus as something that
has only been experienced recently due to the noise
in our modern-day world. Surprisingly, this is not
the case. There are mentions of tinnitus symptoms
in ancient Egyptian texts from as early as 668 BCE,
before a time when loud sounds were common.
Although tinnitus has been around for a long time,
it is only in recent years that we have understood
more about it. There are, however, still many unan-
swered questions regarding tinnitus.
Tinnitus is the awareness of sounds that are not
linked to a sound in the setting. Many aspects of tin-
nitus are complex. One is the way in which tinnitus
5
TINNITUS OVERVIEW
is heard. This differs among people. Some hear it in
one ear, others in both ears or in their head. Some-
times tinnitus may seem to be coming from some-
where else, perhaps outside the body. Many people
hear tinnitus occasionally, some hear it only when
it is quiet, and others notice it all the time.
The word tinnitus comes from the Latin word tin-
nire, which is a verb meaning “to ring.” A ringing
sound is just one of the endless forms of tinnitus.
Some people hear high-pitched sounds and others
low-pitched sounds. At times the sound is like a hiss-
ing or buzzing. Nearly half of those with tinnitus
hear more than one sound. The sound may be dif-
ferent in each ear or be a combination of sounds.
Examples of what tinnitus sounds like include ring-
ing, buzzing, hissing, whistling, humming, whining,
chirping, roaring, clanging, droning, engine noise,
grinding, clicking, and crackling. It is always best to
see a health care professional if you have tinnitus.
This is particularly advised if the tinnitus is in one
ear only, if it beats or pulsates in sync with your heart
beat, if others can hear your tinnitus, or if move-
ments change your tinnitus. It is also important to see
someone if there is a sudden change in your tinnitus.
If your tinnitus sounds like parts of simple songs or
clear voices, it is best to let your doctor know.
Research that has measured tinnitus volume has
found that it is actually very quiet. It is often per-
ceived as a very loud sound. This is due to it being an
internal noise that does not behave the same as an
external noise does. This makes comparing tinnitus
to other sounds difficult.
A Common Symptom
Studies have sought to estimate how many people
have tinnitus and found that having tinnitus is very
common. For about 13% of people, tinnitus is always
heard. That is about one in every eight people. Studies
67
68 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

by various groups have reported that tinnitus is com-
mon all over the world. These studies have shown
that at least 10% of adults have tinnitus. Rates may
be higher in older adults and slightly lower in chil-
dren. This means that more than 700 million peo-
ple are bothered by tinnitus. That’s a lot of people!
Many famous people have (or had) tinnitus. These
include composers, rock stars, artists, actors, and
even politicians. Ludwig van Beethoven, Charles
Darwin, Vincent van Gogh, Martin Luther King, Jr.,
Liza Minnelli, Eric Clapton, Barbara Streisand, Phil
Collins, Whoopi Goldberg, Bob Dylan, Halle Berry,
and Ronald Reagan are just a few examples.
Tinnitus Triggers
It is important to know that your tinnitus is a symp-
tom; it is not a disease or an illness. There are many
factors that may put someone at an increased risk
of acquiring tinnitus. These factors may not cause
tinnitus directly but can act as a trigger. The big-
gest risk factor for tinnitus is hearing loss. This may
even include a slight hearing loss that is not always
detected on traditional hearing tests. However, not
everyone with hearing loss develops tinnitus.
Factors other than hearing loss can cause tinnitus.
Some of these risk factors include exposure to noise
for long periods at harmful levels; the natural aging
process; muscle tension; blood circulation problems;
side effects from medication, head trauma, or whip-
lash; jaw problems; ear wax; genetic factors; ear
infections; or certain illnesses. It is wise to let your
doctor know if you believe your tinnitus is linked to
events such as these. Sometimes, no cause for hav-
ing tinnitus can be found.
Why Is Tinnitus Heard?
Who gets tinnitus and who doesn’t has always puz-
zled medical communities. Several researchers have
addressed this question in experiments where they
placed adults in a soundproof booth for 5 minutes.
What do you think these adults reported? About
60% of them report hearing sounds, such as hiss-
ing, ringing, or buzzing. They heard tinnitus in the
sound booth even though they were not aware of
tinnitus at the outset of the study. Why is this?
There are many sounds within your body, like your
heartbeat and other random bodily noises that are
always there. Often, background noise makes it dif-
ficult to hear these sounds. Your hearing nerves are
always actively sending nerve signals to the brain.
It is a basic role of the hearing system, even when
you are not actively listening. Normally, people do
not notice these nerve signals. This is because your
hearing system can learn to respond to or ignore
certain sounds.
You, thus, normally notice when your name is
being called, yet you may not notice sounds like
the buzzing of a fridge or your breathing. Let’s use
the example of people who live next to a noisy rail-
way line. At first, they may be bothered by the loud
trains passing. After some time, they do not even
notice the trains passing. This shows that people
can habituate to sounds. Neutral sounds that you
hear often, you mostly ignore, even if they are loud.
When heard, such sounds are filtered, or given low
importance. People habituate to them, as they lack
meaning or importance to them. Thus, although
these sounds are present and exist, you don’t notice
them, as shown in Figure 5–1.

Filtering
Random system Signals not
activity in regards the noticed or
your hearing signals as heard
nerve unimportant

FIGURE 5–1. How our brains filter sounds. Source: Adapted from Living with
tinnitus and hyperacusis, L. McKenna, D. Baguley, & D. McFerran, 2010, Lon-
don, UK: Sheldon Press.
 CHAPTER 5 TINNITUS OVERVIEW 69

We now know what ongoing random nerve signals
are present just below the level of awareness. Some-
times people start noticing them , and this is known
as tinnitus. The triggers, such as stress or change in
environment, are different among people. A slight
change in your hearing can trigger tinnitus — even
hearing loss that is imperceptible to you. Some wax
blocking your ear could, for instance, change the
way you hear, and as a result, you notice tinnitus.
When you are unable to hear as well, you hear fewer
sounds around you. Your hearing system may try to
make up for the damage by sending more signals.
This leads to a greater awareness of these random
noises in your body. Instead of these sounds being
filtered, you are now aware of them. This leads to
constant tinnitus, as shown in Figure 5–2.
Who Is Bothered by Tinnitus?
What is interesting is that when tinnitus is heard,
not everyone reacts the same way to it. Most people
are annoyed when the tinnitus first starts, but the
level of this annoyance decreases rapidly. So some
people have tinnitus, but it does not bother them.
Tinnitus really bothers other people. Research has
shown that most people with tinnitus are not both-
ered by it, and a much smaller percentage (10%–
20%) are severely affected by having tinnitus. This
means that only 1% to 3% of the entire population
is severely affected by tinnitus. You may think those
with very loud tinnitus are bothered more by their
tinnitus. This is not the case. Research has shown
that tinnitus loudness and tinnitus annoyance are
not always linked. In fact, people who realize that
tinnitus does not have to interfere with their daily
life tend to start noticing the tinnitus less, and the
annoyance linked to the tinnitus starts to decrease.
When tinnitus is seen as a problem, however, this
draws more attention to it.
Let’s explore this. Hearing sounds can lead to feel-
ing certain emotions. Hearing a song or music you
really enjoy can cause happy emotions, as shown
in Figure 5–3.
Some sounds alert us to danger. Emotions such as
fear are triggered. This happens when you hear a
sound you did not expect in your house late at night.
This may be the sound of a creaking floorboard. Your
hearing system thinks the sound is important and
alerts you to the sound. Hearing such sounds may
lead to a sudden response such as fear or the sense

Filtering
Random Awareness of
system
activity in these signals,
regards the
your hearing perceived as
signals as
nerve sounds
important

FIGURE 5–2. Becoming aware of tinnitus.

Positive
Hearing your Pleasure and
emotional
favorite music enjoyment
response

FIGURE 5–3. How our brain responds to pleasant sounds.

70 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
of threat. Sounds can thus trigger strong emotions.
When you become aware of the nerves firing in your
hearing system, you may respond with fear or con-
cern. This response leads to these random sounds
taking on meaning. When emotions of worry or fear
become linked, it can lead you to become even more
aware of the random sounds in your hearing system.
This is shown in Figure 5–4. Once the brain sees tin-
nitus as a problem, it doesn’t just ignore it. Instead,
it focuses more on your tinnitus. This happens even
if you don’t want it to. When you hear tinnitus, these
emotions may be triggered. This makes the tinnitus
more bothersome. Your brain learns to link hear-
ing tinnitus with negative emotions and thoughts
about the tinnitus. This draws more attention to the
tinnitus and makes it seems even stronger. If, for
instance, a person has been bothered by tinnitus in
situations such as when sleeping or reading, that
person’s attention will automatically and involun-
tarily be directed to the tinnitus when they return
to the same situation. The situation then becomes
Random
activity in
your hearing
nerve
Reactions
such as
getting upset,
irritated, &
frustrated
Emotional
brain
activated
FIGURE 5–4. Emotional responses that can be activated when hear-
ing tinnitus.
even harder to deal with, and the negative emotions
associated with tinnitus are reinforced. This leads
to a negative cycle, where the tinnitus remains or
becomes more annoying and causes distress.
The Negative Cycle of Tinnitus
Certain factors may contribute to tinnitus becoming
a continual problem.
Whether your tinnitus has just started or is con-
tinuing, you may be in one these situations:
n Your tinnitus began after a serious illness, an
accident, a lot of stress, or a loud noise.
n You did not receive helpful information when
your tinnitus started, so it kept you from
dealing well with it initially.
n You have no understanding about why you
have tinnitus or why it started.
n You are constantly looking for a solution to
take away the tinnitus.
Filtering
system
regards the
signals as
important
Conscious
awareness
of these
signals

You might be having some of these thoughts about
your tinnitus:
n You think that hearing tinnitus means
something is terribly wrong with you.
n You think that tinnitus will cause you to lose
your hearing.
n You fear that your tinnitus will become worse.
n You think that you will not be able to cope
with tinnitus.
You may be experiencing some of these problems
associated with tinnitus:
n Your tinnitus creates problems with sleep,
concentration, headaches, and so forth.
n You avoid doing things you enjoy due to
tinnitus, such as reading or going out, or
tinnitus restricts your life in some other way.
Although changing the character of tinnitus is not
always possible, all of these factors can be addressed.
This means that the negative cycle of tinnitus can be
stopped, even if you have had tinnitus for a long time.
Habituating to Tinnitus
To lessen the distress of tinnitus, some people might
start to change the way they behave in order to
address noise sensitivity and hearing impairment.
They might partially or entirely avoid things they
used to do, because these feel too distressing. For
example, some people try to avoid quiet settings or
places with loud noises. Some may try to avoid all
forms of stress or mentally demanding activities,
while others keep constantly busy to distract them-
selves from tinnitus. Some may even try to avoid
places where people tend to speak at the same time,
because they know they will have difficulties hear-
Filtering
system
Hearing
regards
tinnitus
sounds as
unimportant
FIGURE 5–5. Habituating to tinnitus.
CHAPTER 5 TINNITUS OVERVIEW 71
ing. The different ways people try to adjust to their
tinnitus to alleviate the annoyance associated with
it can sometimes make their tinnitus worse in the
long run, as different ways to handle the annoyance
can have varying amounts of success.
How can the distress of tinnitus be lessened? When
you are bothered by tinnitus, your hearing system
is paying attention to your tinnitus. Your hearing
system then attaches importance to the sound. This
link between your hearing system and the impor-
tance of the sound needs to change. Breaking the
meaning attributed to tinnitus will help that nega-
tive emotions are not as stongly associated when
hearing tinnitus. This explains why the loudness of
the tinnitus has been found to be irrelevant to how
bothersome it is. Its annoyance depends on how
people feel about their tinnitus and then behave.
Thus, by changing how you think about your tin-
nitus, you can lessen the importance you give to it.
This will then reverse unhelpful behaviors associated
with tinnitus, it can become less problematic, such
as becoming tense or irritated. By changing the way
you view your tinnitus, your reactions and behaviors
will improve when hearing the sound, and it will no
longer be as annoying. This will help you habituate
to hearing tinnitus, as shown in Figure 5–5.
Let’s recap the concept of habituation. If some-
thing is new, you notice it and pay attention to it.
Over time, if it does not change, you get use to it and
do not notice it as much. It no longer has the same
effect on you. For example, you may have a new pair
of shoes or a new picture on your wall. At first it con-
tinually catches your attention. As you become used
to it, you pay less attention to it. It has less of an effect
on your attention. When your response to something
decreases, you habituate. This is not an instant pro-
cess, and you will need time to change the mean-
ing given to your tinnitus. This program is going to
Neutral
response
leading to lower
awareness of
the tinnitus
72 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
help change the meaning of your tinnitus and your
reaction when hearing it. Just as your hearing sys-
tem gets accustomed to random neutral sounds, it
can also grow accustomed to your tinnitus.
Common Myths About Tinnitus
There is a lot said about tinnitus that is not always
accurate or true. If you have beliefs about your tin-
nitus that are not correct, it is going to slow down
the progress you can make. It is important to ensure
that myths are debunked. Table 5–1 presents some
common myths about tinnitus and provides actual
facts that prove them wrong.
Key Messages
n Everyone’s tinnitus is different, but you are
not alone. There are maothers who are also
struggling to deal with having tinnitus.
n When tinnitus is heard and perceived as a
threat, it may lead to negative emotions.
These emotions become linked to the tinnitus.
This link often becomes a vicious cycle, lead-
ing to constant awareness of your tinnitus.
n You can learn to habituate to your tinnitus.
This program provides the tools you need to
do this.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

 CHAPTER 5 TINNITUS OVERVIEW 73

TABLE 5–1. Common Myths and Facts About Tinnitus

Myth Fact
Tinnitus always causes Only about 10 to 20% of those with tinnitus, which is 1 to
severe distress. 3% of general population, are very distressed by tinnitus.
Most people are initially bothered, but after a few months
their annoyance lessens.
Tinnitus is loud and Tinnitus loudness and annoyance are not always linked.
very bothersome. When tinnitus is really loud, it sometimes make tinnitus
more bothersome. There are also factors that affect how
bothersome it is. These include what you are doing or your
focus at the time. Some people with loud tinnitus are less
annoyed than others with a quiet level of tinnitus. Overall,
the loudness of the tinnitus is not as important as how
people feel about their tinnitus.
The only way to reduce Although this is no quick cure for tinnitus, many people
the distress caused by have habituated to the tinnitus and report noticing it
tinnitus is by stopping much less frequently. More importantly, many people with
the tinnitus. severe tinnitus have learned to cope with it. They are not
as bothered by tinnitus, despite the tinnitus sound not
changing in any way.
Tinnitus disturbs sleep Tinnitus may indirectly affect your sleep, as it can increase
and causes tiredness stress and anxiety caused by not being able to sleep.
during the day. Tinnitus may also be indirectly linked to fatigue, because
tinnitus forces you to concentrate harder and makes you
more irritable and stressed. Reducing tension and anxiety
often help overcome sleeping and fatigue problems.
Tinnitus may lead to Thinking about suicide is no more common among those
suicide. with tinnitus than it is among those without tinnitus.
Having depression can increase the risk of suicide. When
depression is treated, it will lower the risk of suicide. If you
have depression, see your doctor, Primary Care Physician
(PCP), or General Practitioner (GP). If you have thoughts
about suicide, these should be discussed with your doctor. It
is noteworthy that a recent study found that veterans with
tinnitus were less likely to commit suicide than veterans
without tinnitus.
Tinnitus can cause Although tinnitus makes it harder to focus on things, it
hearing loss, sound doesn’t cause hearing loss. Being dizzy or having a hearing
sensitivity, or dizziness. loss are due to damage in the hearing system. These
changes are common in tinnitus. They may thus occur at
the same time, but tinnitus is not the cause.
 Part II
RELAXATION GUIDE
 Chapter
The time to relax is when you don’t have time for it.
— Jim Goodwin
What This Chapter Covers
n Why relaxation is important
n Helping to increase awareness of tension
n Feeling the contrast between tension and
relaxation
Introduction
Hearing tinnitus can lead to tension, stress, and irri-
tation. This tension may happen without you even
knowing. It can increase your heart rate and the
speed at which you breathe without your realizing.
Such feelings of tension can make your tinnitus even
more bothersome. Lessening the associated tension
and stress is important. This will help reduce your
annoyance with the tinnitus as well. When you are
less tense, the way your body works also improves.
Reducing tension can slow down your breathing
and heart rate. When you are less tense, stress and
annoyance with the tinnitus will also decrease.
Being able to relax is a good way to support and
control the body’s reaction to tinnitus and stress,
although the purpose is not to lessen the tinnitus.
The relaxation will reduce the stress, anxiety, and
irritability, which lessen the tinnitus distress. Lower-
ing tension often makes the tinnitus less annoying.
The thought that lessening muscle tension can affect
tinnitus may be a new idea to you. This part covers a
relaxation program that can really help you.
6
DEEP RELAXATION
How Relaxation Helps
Learning how to relax has been very beneficial for
many people bothered by tinnitus. Being able to
relax can help everyone, not only those with tin-
nitus. When you relax, your tinnitus often seems
less annoying and easier to handle. There are many
other physical benefits such as lowering tension,
relaxing your muscles, slowing down your heart
rate, controlling your breathing, and improving the
blood flow to the brain. Relaxation also helps you
to concentrate, focus, be able to deal with problems,
and lower levels of stress. It can also improve your
well-being, boost your energy, and improve your
mood. So there are many benefits, helping you
unwind and recover from stress. Learning to relax
takes time but is not difficult. It is just a skill requir-
ing practice.
Types of Relaxation
Sometimes you realize that you need to relax, but
don’t know how. You may zone out in front of the
TV at the end of a stressful day. Although this can
have a relaxing effect, it does not start the body’s
natural relaxation response. Your body will learn
to relax with practice. All the steps you need are
explained here. The steps aim to help you to relax
as part of everyday life. This relaxation plan is a
progressive program. It will help you be able to do
deep and rapid relaxation. The plan is divided into
five steps and ends with a relaxation routine. This
is an applied relaxation program, so it can be used
in your daily life in many different situations. You
will first learn more about deep relaxation and then
how to relax faster and to relax in many different
77
78 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
situations. This program will allow you to relax
when you are uptight or stressed. The relaxation
steps start slowly but, by the end, you will be able to
relax within seconds. By the last step you will also
be able to relax even if you are in a busy place. The
skill of being able to relax in a short time will come
in handy during daily life.
What Deep Relaxation Involves
The first step in applied relaxation is deep relax-
ation. This involves tensing and relaxing one
muscle group at a time. This step is effective as it
helps you be more aware of tension. It also helps
you to control your muscles. First you tense them,
then you relax them. Controlling your muscles is
easier if you tense them first, instead of making
them relax right away. This process teaches you the
difference between tension and relaxation. Relax-
ing a tense muscle also needs less effort, because
the tension tires the muscle and it then rests. The
increased awareness of your body’s state of tension
and relaxation will help with the next relaxation
steps in subsequent chapters. Deep relaxation forms
the basis for the other relaxation steps. It takes the
most time; the other steps are faster. Although it
may seem like hard work, keep going. The result
will make the effort you put in, worthwhile. To be
able to relax is a skill you can learn. It is not hard; it
just takes time and practice. The main aim of this
current relaxation step is not to achieve relaxation,
but to strengthen the awareness of your body and
develop control of your muscles. The next relaxation
steps will build on this awareness.
Where and When to Practice
Deep Relaxation
For this relaxation step, you need to think about
where and when you can practice. Select somewhere
peaceful where you will not be disturbed. Places
may include:
n A park or garden;
n A library or study;
n A quiet room in your house or where you
live; or
n A quiet spot near or at your work or place of
study.
Do deep relaxation for around 10 to 15 minutes,
twice a day. This allows time to get into a peace-
ful state of mind before starting and to stay relaxed
when ending. Choose a time when your telephone
does not need to be on. Also, select a time when
nobody is around to disturb you. Some ideas are:
n After meals;
n Before going to bed;
n When waking up;
n During your lunch break;
n After work;
n After exercise; or
n After watching television.
To help you remember to do relaxation, add the
times you will relax to your calendar or another
reminder system, such as an alarm on your smart
phone, so that you do it each day. Make doing relax-
ation as important as eating or brushing your teeth.
Set aside some time to relax when you are not busy
with other things. Doing relaxation at the same
time or place each day will help you get into a rou-
tine. By planning times to practice, you are going to
have a greater chance of doing relaxation each day.
In Which Position to Relax
At first, you are going to learn this relaxation tech-
nique while sitting in a chair. Although it is easier
doing relaxation lying down, this is not always pos-
sible. Learning to sit and relax is going to prepare
you to be able to relax in many different places. If
possible, choose a chair in which you cannot slip
down. Chairs with a long straight back and no arm-
rests work best. Alternatively, you can use a stool,
which you can place against a wall. Your head
should not tip back too much. Make sure that there
is not much distance between the back of your head
and the chair. Your feet should be flat on the ground,
knees at right angles. Use a footrest if needed. Make
sure your arms are alongside your body and your
hands are in your lap.
 CHAPTER 6 DEEP RELAXATION 79

Table 6–1. It is most important to focus on the mus-

n When are you going to do relaxation cle groups from your shoulders upward. If you find
this week? it hard, leave out the lower muscle groups. You can
change the sequence to suit yourself. First, it may be
 easier starting with your hands, as these are easy mus-
cles to control. You may choose to do the sequence
n How will you remember to do relaxation? from the head down or feet up, as well. Focus on the
upper body muscle (shoulders upward) if you don’t
 have time to focus on all the muscles. You can repeat
the sequence if you still feel tense. If certain muscle
groups are more tense, you can repeat by focusing on
these muscles until they feel less tense. You can keep
How to Do Deep Relaxation?
your eyes closed if this helps you to relax and focus on
A suggested sequence regarding which group of your muscles. The goal is to feel completely relaxed.
muscles to tense and in which order is shown in Once you feel relaxed, you can stop. There should be

TABLE 6–1. One Possible Order of Muscle Groups to Tense and Relax

Wider Group Muscle Group Tense for 5 Seconds, Relax for 10 Seconds
Hands and forearms Clench your fists.
Upper arms Press your elbows against the side of your body
while resting your hands in your lap.
Shoulders Lift your shoulders up, letting your arms rest in
Arms, shoulders,
your lap.
neck
Neck Pull your chin and head backward without
tipping your head.
Back of your neck Press the back of your neck against the back of
the chair or wall.
Jaws Clench, but not too tightly.
Lips Press together.
Tongue Press against the roof of your mouth.
Face
Eyes Close your eyes tightly.
Eyebrows Frown.
Forehead Raise your eyebrows as much as possible.

Chest and stomach Chest Tighten by taking a deep breath.

(optional) Belly Pull your belly in.
Legs Tighten your calf muscles, upper leg muscles,
Lower limbs and buttocks.
(optional)
Feet Curl your toes downward.
80 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

no pain or discomfort. If this happens, change the
suggested sequence by tensing in a different way or
leaving out that muscle group. Try to spend some time
each day doing the relaxation. In time, your body will
be able to relax within a few seconds. A summary of
this relaxation step is provided in Figure 6–1.
Remember the following guidelines:
n Switch off your phone and close the door.
n Choose a time when people may not be
around to disturb you.
n Remove objects such as your glasses or items
from your pockets.
n Remove your shoes.
n Set a timer for 10 to 15 minutes to avoid
watching the clock. Later you can stop once
you feel relaxed. Feeling relaxed is the main
goal, not how long you do it for.
n Sit in a straight chair, arms alongside your
body, hands in your lap.
n Remind yourself of the sequence before
starting.
n Try to do the relaxation without looking at
the sequence. It will soon become easy to
remember.
n Close your eyes and relax for a short while
before starting.
n Tense each muscle group for 5 seconds,
release the tension for 10 seconds.
n Count to 5 while tensing and carry on
counting from 6 to 15 when relaxing. Once
you get into a rhythm, you can stop
counting.
n Close your eyes and relax for a short while when
finishing.
n Do this twice a day for 10 to 15 minutes.

Go to an undisturbed peaceful setting.

Sit in an upright chair.

Tense each of your muscles for 5 seconds,

release for 10 seconds.

Start with your hands and move to your

arms, neck, and facial muscles.

Do this for 10 minutes twice a day.

10 min 10 min
FIGURE 6–1. Summary of the steps in deep relaxation.

Return to these instructions several times and
make sure that you are following them correctly.
That way you will soon learn the exercises. It is
most important to focus on the upper body, and
that will save time. If you find it hard to relax in
quiet, you may use soothing background music for
a few minutes before starting. Using relaxing scents
such as lavender may also help. As you become bet-
ter at relaxing, you will no longer need this extra
help.
Addressing Common Difficulties
As learning to relax is a new skill, you may have
difficulty in the beginning. Here follows some prob-
lems you may experience and suggestions to address
these difficulties.
My tinnitus disturbs me, or it feels more
annoying during relaxation.
Your tinnitus can sometimes feel more intense dur-
ing relaxation. Relaxation will not make your tinni-
tus more bothersome. The tinnitus may seem worse
because you are alone and may notice your tinni-
tus more clearly. When you practice relaxation, you
may become tense at first, as it is something new to
learn. This may affect your tinnitus. If you keep on
with the relaxation, the feeling will go away in time.
Try to keep focusing on your muscles and on the
exercise. If you struggle, put some relaxing music
on in the background. Try to slowly stop using the
music, as you will not be able to have music on in
all the next relaxation steps.
I do not feel more relaxed after doing this exercise.
You have just started learning to relax. It may take
a few weeks before you feel the effects. The aim of
deep relaxation is to learn the difference between
tension and relaxation. The next step is a much
easier relaxation method. It does not involve tens-
ing the muscles first. Once you are able to relax your
muscles you can move onto the next step, which will
help you feel more relaxed than this first step.
I find it hard relaxing certain muscle groups.
Some people find it difficult to relax certain muscle
groups, for example, the neck or shoulders. It may
help to massage, stretch, or tense these areas before
you start the relaxation exercise. If you have exist-
CHAPTER 6 DEEP RELAXATION 81
ing problems, consult your doctor for exercise sug-
gestions. Once you have finished the sequence, focus
on the muscles with the most tension.
The exercise takes too little or too much time.
It is natural for people to rush through the sequence
of muscle groups. Not doing anything during the
10 seconds of relaxation can feel very long. Do not
be tempted to move on to the next muscle group
too quickly. You need this time to help your muscles
relax. If you are going too fast, silently count to five
during the tension step and from six to 15 during
the relaxation step. Once you start getting the tim-
ing right, stop counting. Try to avoid focusing on the
time, as it diverts your focus away from the muscles
and relaxation.
Before tensing the first muscle group, it is impor-
tant to relax the entire body for a short while. You
should also relax for 3 to 5 minutes after finishing
the relaxation sequence. Maybe you would find it
useful to set a timer for 10 to 15 minutes. If the timer
makes you feel stressed, try it three times anyway,
and see whether you can get used to it.
I forget to practice.
There is a lot you can do to remind yourself to relax.
Here are some ideas. Put it on your calendar or set
an alarm on your smart phone. Place notes where
you are likely to see the reminder. This may be on
the door, the fridge, or the bathroom mirror. Have
someone remind you or set an alarm. Instead of put-
ting up reminder notes, you can change your nor-
mal routines. By something being different, it will
grab your focus and act as a reminder. For example,
turn your shoes upside down, move your toothbrush,
or put the remote control somewhere strange. Make
sure you get this reminder when you have planned
to relax. A good way to remember to relax is to do it
at the same time and place each day. This will help
you get into a routine and habit.
I am not at ease when relaxing.
Some people find relaxing hard — even people with-
out tinnitus. Relaxation may be difficult because
you become more aware of things you normally do
not notice. For example, you may notice your heart-
beat, muscle soreness or your breathing. Closing
your eyes for a long period can make you feel dizzy
or strange. These feelings may let you think there is
something wrong, but this is normal when you are
82 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
learning a new skill. As you get better at relaxation,
these feelings will lessen.
I lose track of what I am doing, get disturbed,
or my mind starts wandering.
Don’t worry if you forget a couple of muscle groups
or if you change the sequence. Try not to look at the
instruction paper during the exercise. Rather, do it
when you finish to see what you have missed. In
time, doing the sequence will become more natural.
If your mind starts to wander during the exercise,
don’t give up. Just direct your focus to your mus-
cles again. It is normal to have trouble relaxing at
first, because you are not used to it. If an annoying
thought pops up, tell yourself, “I can get back to that
later. Right now, I am relaxing.” You can also imag-
ine a box or a bag where you can put the thought
so that it will not disturb you. Put it in and close the
lid or close the bag. You can also make a note of the
thoughts that come into your mind. Then continue
with the exercise. Once you have finished, you can
then address the things you put aside or wrote down.
I get disturbed.
If others disturb you, try to go to a private spot. Tell
them why you need to practice without being dis-
turbed. For example, tell people that you “will be
busy until . . .”, or set a timer marking when you will
be finished. Try to select a time when people are less
likely to bother you.
Your phone may also be very distracting. Smart-
phones may send you constant notifications of
e-mails and messages. Try to select a time you do
not need to be checking your phone and put it aside.
You can set an alarm on your phone for the length
of time you want to practice.
I do not have enough time.
Many people find it hard to make time to relax. It
may seem like a lot of time. It won’t always take
as long. Being able to relax will help your tinnitus
have less of an effect on your life overall. You will be
less disturbed by your tinnitus when you are trying
to concentrate in the future. Putting time aside for
yourself is also important. Try to focus on the help
this will bring in the long run. Think about ways you
can build relaxation into your daily life. This may
be at times you need some down time and when you
are not busy with other things. Focusing on relaxing
will help motivate you to do it every day.
I feel restless or stressed.
Stress and restlessness make relaxation hard. Try to
keep setting time aside to do relaxation. Your tin-
nitus will become less bothersome if you do. Keep
doing relaxation. This will help you become less
restless and stressed. Review your list of goals to help
motivate you.
I fall asleep doing relaxation.
Although sleeping feels good and relaxation can
help you fall asleep at night, you will not learn the
skill of being able to relax if you fall asleep often.
As we progress you will use the relaxation skills in
different situations, so it is important that you learn
how to do them. Initially, do not lie down when you
are relaxing. It may help to set an alarm for 10 to 15
minutes and then stop once the alarm goes off. Try
to practice at times when you are not tired so that
you can master the skill of relaxation.
I find it hard to relax sitting up straight.
It is often easier to relax lying down. The main aim
of relaxation is not to make it as easy as possible
for you to relax. The aim is to be able to relax any-
where. This will be hard to achieve if you can only
relax when lying down. In your daily life, there are
few chances to lie down for a couple of minutes.
Sitting is something you do a lot. This means that
relaxing while sitting up straight prepares you for
future relaxation steps.
Relaxation does not lessen my tinnitus.
The purpose of the relaxation is not to lessen your
tinnitus, although there are many positive effects.
Relaxation can help you become less annoyed and
frustrated with your tinnitus. As you get better at
relaxing, you will notice all the ways it helps you.
The skill of relaxing will take time to learn and to
master.
I don’t feel tense. Should I still
practice relaxation?
Yes. There are still times your body will get tense.
Relaxation will help with unconscious tension you
may not be aware of. Many people who are clearly

not stressed or tense can still have problems unwind-
ing below a certain level. It is very important to
give your body a chance to recover. Over time, even
being in a normal state can be tiring on both the
mind and the body.
Can I listen to music while relaxing?
Music can calm you. It may be a good idea to listen
to some soothing music for a few minutes before
starting to relax. As you become better at relaxing,
you will start using relaxation in more places. This
program is going to help you learn to quickly relax
in situations where you are not alone. You will thus
not always be able to switch on music. Although it
may help when you start, try not to use music all the
time. As you become better at relaxing, you will find
it easier to relax without the help of music.
What is the connection between stress,
tension, and focus on your tinnitus?
When you face problems, you may become tense.
This leads to feeling anxious, afraid, or stressed,
which can lead to a negative cycle where your dis-
tress just keeps growing. This increased tension can
often make you focus more on the problem. If you
can solve the problem easily, it is best to try to do
that straightaway. If there is no easy answer, reduc-
ing tension will help. This will lower your levels of
stress and help you find an answer to the problem.
It would be good if you could just ignore your
tinnitus and focus on something else. This is hard,
though. Your brain tends to focus on problems and
things that are important. Once tinnitus becomes
a problem, your brain is drawn to it more easily.
The more negative emotions you have about your
tinnitus, the more important it gets. This makes it
harder to ignore. Your tinnitus may thus stop you
from doing what you want to do, which increases
the stress, tension, and your body’s arousal even fur-
ther. This extra tension may lead to you becoming
more negative towards the tinnitus, which leads to
the tinnitus becoming more important. This vicious
negative cycle increases the focus on your tinnitus,
which raises tension and levels of stress.
CHAPTER 6 DEEP RELAXATION 83
Why does tinnitus affect the way
I deal with a problem?
Having tinnitus can make it harder to solve prob-
lems and carry on with daily life. The tension in
your body due to your reactions toward tinnitus
makes it more difficult to deal with problems. It also
makes it harder to work, read, sleep, listen, make
decisions, remember things, or stay focused for long
periods of time.
Key Messages
n Spending time each day relaxing can help
you in many ways.
n This relaxation step focuses on learning to
feel the difference between tense and relaxed
muscles.
n By first tensing your muscles, it is easier to
relax them.
n It is important to relax for 10 to 15 minutes
twice a day this week.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

Worksheet
To keep track of when you practice, use the work-
sheet shown in Table 6–2. This will help you see your
progress. It is good to have something to remind you
of how much you have accomplished. The first few
rows provide some examples.
TABLE 6–2. Deep Relaxation Worksheet

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 1 I did relaxation early this morning in the study. I 2
forgot the sequence but did feel more relaxed for a
short time. I need to read the sequence again. 11 min
1/1/20: pm 2 Before going to bed I did relaxation in the garden. 3
I remembered more of the sequence. It went too fast
though. I need to be more peaceful before, during,
and after tensing and relaxing. I want to try a
different setting tomorrow. 12 min

84
 Chapter
Success is the sum of small efforts, repeated day in and
day out.
— Robert Collier
What This Chapter Covers
n Using deep breathing to help you relax
n Using a trigger word associated with relaxation
n Relaxing your muscles without first tensing
them
Introduction
How many breaths do you think you take a day? It
is around 25,000 breaths to give oxygen to the cells
in your body to help them work well. Not all breaths
are equally effective though. It has been found that
most people breathe at only 10 to 20% efficiency.
Paying attention to your breathing can help your
body run properly. This helps your blood flow, diges-
tion, and emotional state. Breathing well can also
improve your body’s response to stress, anger, and
fear. Ensuring that you are doing deep breathing is
important and the focus of this chapter. During this
relaxation step you will also learn to relax without
tensing. Although deep relaxation is very effective,
it takes more time to tense the muscles first. Once
you know the difference between tense and relaxed
muscles, you can learn to relax without first tensing
your muscles. This chapter focuses on three skills: (a)
deep breathing, (b) using a relaxation word, and (c)
relaxing your muscles without first tensing them.
Types of Breathing
There are two types of breathing patterns, shallow
and deep breathing.
Shallow breathing uses your chest for breathing and
is linked with fast and shallow breaths. Shallow
7
DEEP BREATHING
breathing takes in only a small amount of air, which
is not enough to supply all the cells in your body. This
type of breathing leads to an imbalance in the levels
of oxygen and carbon dioxide in your body. Restricted
breathing can thus result in lower energy levels and
make it hard for the body to get rid of toxins. Poor
breathing may even lead to health problems such
as high blood pressure and sleep problems. Shallow
breaths are linked to fast breathing and the fight-
or-flight response. Shallow breaths can lead to more
stress and can trigger panic attacks in some people.
Deep or belly breathing uses the muscles below your
lungs. Deep breathing from the belly is helpful for
everyone and a good skill to have. Deeper breaths
calm the body and mind and provide an excellent
way to unwind. This type of breathing slows down
the activity in your body, for example, lowering your
heart rate. Controlling your breathing increases the
control over your body’s responses to your tinnitus
and other problems. Breathing in and out through
your nose aids deep breathing because the lungs get
more oxygen than when breathing through your
mouth. Your belly should rise and fall with each
breath instead of your chest. This movement kneads
the belly and removes toxins from your body.
Deep Breathing
Deep breathing is a useful “shortcut” to helping you
relax. As you tense, your breathing rate increases.
When you do short, fast breaths, you breathe
through your chest rather than your belly. Your
blood then, does not get enough air. This make your
body even tenser. Thus, belly breathing can improve
how you react to stress, anger, and fear. When you
are able to relax, you can respond better to tinnitus
and other problems. Belly breathing is slow and
stops you from breathing too fast. Fast breathing
85
86 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
can cause dizziness, a light head, or a feeling of not
getting enough air. Try to find the rhythm of your
own breaths then pause for a few seconds between
breathing in and out. A common mistake is to tense
the entire body while breathing in. Try to use only
the muscles in your belly. Belly breathing may seem
hard at first. After doing it for a few weeks it will
become easier.
How to Do Deep Breathing
Lie on your back on a flat surface (or in bed) with
your knees bent. You can use pillows under your
head and your knees for support if that is more com-
fortable. Place one hand on your belly and one on
your upper chest. Look at which rises and falls more.
If it’s your chest, focus on breathing from your belly.
Once you feel the difference, try belly breathing for
a few minutes. The hand on your chest should stay
still, while the one on your belly should rise. Tighten
your belly muscles and let them fall inward as you
breathe out. The hand on your belly should move
down to where you started. You can also put an
object on your belly. Watch it rise as you breathe
in and fall as you breathe out. Breathe in slowly
through your nose, letting the air in deeply, toward
your lower belly.
You can also do this sitting in a chair. Try to relax
your shoulders, head, and neck. Feel the change in
breathing by breathing from your chest and then
from your belly. Once you can do it lying down, try
doing deep breathing when sitting.
n How have you been breathing?
 n In a park
n How can you remind yourself to use belly
breathing?

Relaxation Triggers
It helps to have triggers that can help you to relax.
By thinking about a certain word every time you
exhale, you create an association between the
word and being in a relaxed state. Thinking about
the same word every time you breathe out can
help you relax. By using the same word, you can
link this word with being relaxed. In time, this word
will “signal” your body to relax. Think of a word
that is relaxing to you. Thinking or saying that
word or phrase while breathing out can help you
feel more relaxed.
You can use any word, such as serene, out, exhale,
breathe, relax, calm, peace, rest, quiet, or go away
stress. You can also use a three syllable word that is
more in time with your breathing. This could even
be a made up nonsense word. What is important is
to choose a word and use the same word every time.
Your body will later start to relax by just hearing this
word. During your relaxation, focus on this word
when you breath out and use it consistently.
What relaxation word have you chosen?

Where and When to Practice
Deep Breathing
Select a place where you will be alone and will not
be disturbed. You can keep using the places you used
last week if these worked well for you. As you get
better at relaxing, you will learn to relax in differ-
ent places. Relax for 10 minutes twice a day. Ideas
of places to practice are:
n At work when alone
n In a garden or
n In a library
Suggested times to relax include:
n After parking the car
n Before starting the car
n Before going to work
n After meals or
n After brushing your teeth
 CHAPTER 7 DEEP BREATHING 87

n After trimming bushes TABLE 7–1. Relaxation Sequence for Deep Breathing
n After washing the car
Muscle Group to Relax
By planning times to practice, you are going to Wider Group for 10 Seconds
have a greater chance of doing relaxation each day.
Forehead
A good way to remember to relax is to always do it
at the same time and place. This routine will remind Eyebrows
you. Commit to two times each day this week. Make
Eyes
a note of them here to remind yourself. Face
Lips

When and where will you try to practice relax- Tongue

ation this week? Jaws
Neck

Neck, arms, Shoulders
shoulders Upper arms
How to Do Deep Breathing Hands and forearms
Your body now knows the difference between tense Chest
and relaxed muscles. Next you are going to learn to Chest and stomach
relax your body without first tensing your muscles. Stomach
You can start with working from the top of your Upper legs
body downward. If you find this hard, follow the
sequence that worked for you during deep relax- Calf muscles
Lower limbs
ation. Think of relaxing each muscle group in turn Feet
for 10 seconds. It may help to create a picture in
your mind of your muscles relaxing. See them relax- Toes
ing and feel the calming effect. Table 7–1 provides a
possible sequence.
Tips for deep breathing are given in Figure 7–1. n Focus on a word that helps you relax every
Aim to do deep breathing twice a day for 10 minutes time you breathe out.
each time, using these tips: n Then relax each group of muscles in turn
without first tensing them. You can use the
n Find a cozy place to sit.
suggested sequence provided in the steps in
n Breathe in through your nose and let your Table 7–1.
belly expand. Hold for 5 counts.
n End by focusing on your breathing again.
n Breathe out slowly through your mouth,
n Repeat until you feel relaxed.
letting your belly get smaller again for 10
counts. n Once you learn about using positive imagery
as suggested in Chapter 12 you can use
n Use your hands to feel your belly move
positive imagery before, after, or while doing
initially. Make sure it is your belly and not
this relaxation sequence.
your chest that is moving. Then relax your
hands by your side or in your lap.
n Feel your body getting heavier and more Addressing Common Difficulties
relaxed with each breath.
n Repeat this for a few minutes until you feel Like when learning deep relaxation, deep breathing
relaxed. is a new skill, and you may have difficulty in the
88 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Go to an undisturbed peaceful setting.
Breathe from your belly, through your nose.
Say your relaxation word as you breathe out.
Focus on relaxing each group of muscles
for 10 seconds without first tensing them.
Do this for 10 minutes twice per day.
10 min 10 min
FIGURE 7–1. Steps in deep breathing.
beginning. Here follows some problems you
may experience and suggestions to address these
problems.
Being relaxed is not helping me.
It may take a couple of weeks before you get the
hang of relaxing. The positive effects of relaxation
will start to show, so don’t give up. By focusing on
this twice a day, you will notice the effects quicker.
What you should expect is to be able to relax your
tense muscles. If you are hoping for your tinnitus to
lessen, reread the section on the aim of relaxation
at the start of Chapter 6.
I find it hard to relax certain or all muscles.
Sometimes it can be hard to relax without tens-
ing your muscles first. You can try to first tense the
muscles and then later try just to relax them. Find-
ing it hard to relax some of your muscles does not af-
fect relaxation as a whole. Try to picture the muscle
relaxing in your mind. Feel the muscles going numb,
warm, and heavy or start to “tingle.” Another tip is
to massage, stretch, or tense the area before relaxing.
I find belly breathing hard.
Taking full breaths from your belly can be hard, as
people often breathe “higher up” through the chest.
Now you have to focus on taking breaths through
your belly. In time, it will feel easier. It can be useful
to try this:
n Lie on your back. It is easier to control your
breathing this way. In time, move toward
sitting until you can do it sitting in a chair.
Keep breathing through your belly.
n Place one hand on your upper chest and one
on your belly. Feel the difference between
“low” and “high” breathing.
 CHAPTER 7 DEEP BREATHING 89

n After breathing out, hold this for a second n To help you relax, see a picture in your mind
before breathing in. of being relaxed. Try to feel your muscles
n In time, it will be easier. become heavier.

I find it hard to use a word to help me relax.

Try another word, something short and simple. It Reflection Activity
doesn’t have to involve relaxing or breathing as
long as you keep using the same word. Instead of n What is the most important thing you have
using a word, you can also use a positive image or learned from this chapter?
a small movement of your body when you breathe
out. Examples of these types of body movements are
wiggling a finger or a toe or slightly pressing two 
fingers against each other.
n What tips are you going to apply?

Key Messages

n Deep breathing from your belly and through
your nose helps the cells in your body get
enough air. This type of breathing can help
your health in many ways.
Worksheet
n Focus on the same word every time you
breathe out. This will help you to link feeling Complete the worksheet shown in Table 7–2. This
relaxed with this word. will help you see your progress. It is good to have
n To speed up the relaxation process, focus on something to remind you of how much you have
relaxing each group of muscles without first accomplished. The first few rows provide some
tensing them. examples.
TABLE 7–2. Deep Breathing Worksheet

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 1 I am most stressed before work, so I decided to 4
relax once I arrived at work. I was still tense,
so I repeated the sequence. It was harder not
tensing my muscles first. I am still struggling with
abdominal breathing. I used the word peace. 12 min
1/1/20: pm 2 As I struggle to sleep, I did relaxation before 5
going to bed sitting on the chair in my room.
The relaxation word does help. Although time-
consuming, I can really feel the benefit. 15 min

90
 Chapter
ENTIRE BODY RELAXATION
Everything you do can be done better from a place of
relaxation.
— Stephen C. Paul
What This Chapter Covers
n How to relax your entire body all at once
n Focusing on relaxing muscles that seem
most tense
n Relaxing when you are not alone
Introduction
During relaxation using deep breathing, you learned
the importance of using a relaxation word. You also
learned about deep (or belly) breathing and relax-
ing your muscles without first tensing them. There
are, however, times that you can’t spend 10 minutes
doing deep relaxation although you feel tense. There
may also be times you get tense when it is hard to
get away or be alone. For these times you need to
learn to do faster relaxation in public spaces. This
is the aim of this relaxation step: to help you feel
relaxed in a shorter amount of time. This chapter
discusses more about entire body relaxation.
Entire Body Relaxation
What Entire Body Relaxation Involves
You will be doing everything you have learned about
in deep breathing. You will continue to use your
8
relaxation word and deep breathing. The difference
is that instead of relaxing each muscle group one
at a time, you will relax your entire body at once.
The focus is on feeling your entire body get heavier
and more relaxed with each breath. You may find
that some parts are still tense. You can then focus on
relaxing just these parts.
Where and When to Practice
Entire Body Relaxation
This week try to do relaxation in different places. Try
to do it when others may be nearby. Think about
where and when you may try it. This may include:
n Being a passenger in a car
n During a coffee break
n After doing gardening or trimming bushes
n When having a meal out
n While watching a movie
n Waiting before an appointment
n In a public park
n Watching a television series or
n As a break from using social media
n After washing the car
A good way to remember to relax is to always
do it at the same time and place. This routine will
remind you. Commit to two times each day this
week. You may practice spontaneously in certain
other situations as well.
91
92 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

aim for shorter periods as you improve. Here is a

n When and where are you going to do entire
body relaxation this week?

n How are you going to remind yourself to
practice?

How to Do Entire Body Relaxation
Figure 8–1 provides the main steps in the entire body
relaxation. Aim to practice twice a day for 5 minutes
each time. At first it may take longer to relax but
guide to help you:
n Breathe in through your nose and let your
belly expand. Hold for 5 counts.
n Breathe out slowly through your mouth,
letting your belly get smaller again for
10 counts
n Repeat this for a few minutes until you feel
relaxed.
n Think of your relaxation word (chosen from
Chapter 7 e.g. “calm”) each time you breathe
out.
n As you breathe out, relax all your muscles at
the same time.
n Scan your body for tense muscles and relax
these areas.

Alone and in settings where other people

may be around.

Breathe from your belly, through your nose.

Say your relaxation word as you breathe out.

Feel your entire body getting heavier and

more relaxed with each breath and scan
your body for tense muscles.

Do this for 5 minutes twice per day.

5 min 5 min
FIGURE 8–1. Entire body relaxation.

n Feel your body getting heavier and more
relaxed with each breath.
n Enjoy the calmness coming over you.
n Once you learn about using positive imagery,
as suggested in Chapter 12, you can use
positive imagery before, after or while doing
this relaxation sequence.
Addressing Common Difficulties
As learning to relax all your muscles at once is a
new skill, you may have difficulty in the beginning.
Here follows some problems you may experience
and suggestions to address these problems.
I still haven’t managed to relax.
Go through the other relaxation chapters again.
Also, go through all the possible problems that may
occur and think about how you can resolve them. If
you do not manage to relax as much as you want
to, this is okay. The amount of time needed to learn
relaxation varies, and your skills will improve if you
keep practicing. If your results are better now than
at the start, you are already on the right track.
It is harder to relax the entire body at once in a
short time.
You may find it hard when you are not relaxing
each muscle group in turn. If so, spend 5 minutes
doing deep relaxation and then faster relaxation.
Also, remember to do belly breathing. It makes it
easier to relax the entire body at once. When doing
deep relaxation, move through the muscle groups
faster and faster. Slowly try to decrease the time it
takes. Still move through the muscle sequence but
CHAPTER 8 ENTIRE BODY RELAXATION 93
speed up this process. Give extra focus to the mus-
cles that are most tense.
Key Messages
n Due to the value of relaxation, it is important
to learn to relax in a shorter space of time.
n First relax your entire body at once. Then
scan your body and focus on the muscles that
are most tense.
n Try to increase the number of places in which
you relax. Also, relax when you are not alone.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

Worksheet
Complete the worksheet shown in Table 8–1. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide some
examples.
TABLE 8–1. Entire Body Relaxation Worksheet

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 2 Did during my coffee break. I found it hard 4
relaxing all my muscles at once, will keep trying
though. 9 min
1/1/20: pm 3 Did after watching TV. I found it slightly easier by 5
really focusing on my breathing. 8 min

94
 Chapter
FREQUENT RELAXATION
We are what we repeatedly do. Excellence, then, is not
an act, but a habit.
— Aristotle
What This Chapter Covers
n Being able to relax as part of your daily
routine
n Relaxing with your eyes open and in any
position
n Making a habit of relaxing often during
the day
Introduction
Well done! You are now more than halfway through
the relaxation training. During entire body relax-
ation, you learned to relax when you are not alone.
You have also practiced to relax all your muscles at
once instead of one at a time. You learned to focus
on the muscles that were most tense. This chap-
ter focuses on relaxing frequently during the day
instead of two longer relaxation sessions. Relaxing
often during the day for short periods of time can
help you stay calm. This will improve your focus
and ability to solve problems. Frequent relaxation
throughout the day can reduce stress and irritation
that builds up during the day. By practicing often
throughout the day, relaxation becomes a habit that
you can do without having to think about it. It will
also help your tinnitus to remain in the background.
Frequent Relaxation
You may feel the need to relax while you are with
other people. It is handy being able to relax without
9
drawing attention to yourself or closing your eyes. It
is thus useful to learn to relax with your eyes open.
To do this, keep your eyes open but fix them on
one spot. Then try to blur your vision to lessen how
much of the visual image you see.
To make relaxation more useful, you need to start
using it in different positions. Instead of only relax-
ing while sitting, also do it when you are standing
up or lying down.
Where and When to Practice
Frequent Relaxation
Frequent relaxation works best by building it into
your routine. This may be every time after you wash
your hands or after you have a drink or check your
smart phone. Select a few places and relax every
time you find yourself there. Choose places that
don’t make you feel too stressed or tense. Although
you may be among people, select places where you
will not be disturbed, and you can focus on relaxing
for 1 to 2 minutes. You can pick some places you are
alone and try adding some places where you are not
alone as well.
Here are some ideas for situations (both alone
and between other people) to practice frequent
relaxation. Aim for 4 to 8 situations:
n Every time after you check your phone for a
message
n After you read a social media post
n Before starting the car
n After brushing your teeth
n While waiting for the microwave
n After sending a message or email
n While waiting at traffic lights
n When stuck in traffic
95
96 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

n While waiting for coffee to brew
n On the hour
n Having breaks during gardening on trimming
the hedges
n While shutting down or starting your
computer or before going on the internet
n Before opening the fridge
n Before getting out of your car
n After washing your hands
n After taking off your coat or cardigan
n When you are walking
n During a conversation
n When you have pushed the elevator button
Practice Reminders
you will not get into a routine. Try to make a real
effort this week to practice in the places you have
selected. Set some reminders to help you. Here are
some tips:
n Schedule it in your calendar or diary
n Set alarms for certain times of the day
n Put up reminder notes at the places in which
you want to do relaxation
n Set reminder messages on your smart phone
or computer
How to Do Frequent Relaxation
Aim to do frequent relaxation at least 5 to 10 times
a day for 1 to 2 minutes each time (Figure 9–1). Here
are some tips:

You may forget to practice at first. If you relax each n Relax wherever you are. This may be
time you are in a given place, it will soon become a standing, lying down, or sitting. You may be
habit. If you relax only now and then in each place, alone or between other people.

A setting where other people may be around.

Choose places you will always relax at (e.g.,

after brushing teeth and post reminders).

Use belly breathing, your relaxation word and

entire muscle relaxation.

Do this for 1 to 2 minutes, 5 to 10

times per day.

5–10 times
per day

1-2 min
FIGURE 9–1. Frequent relaxation.

n Keep your eyes open but fix them on one
spot. Then try to blur your vision to lessen
how much of the visual image you see.
n Start by focusing on belly breathing.
n Let the air flow out by itself; you should not
be pushing each breath.
n Next think of your relaxation word each time
you breathe out.
n Feel your body get heavier and more relaxed
with each breath.
n Relax your body from the head down.
Although this relaxation step is harder than the
other steps, keep trying. It is not as helpful as deep
relaxation, but being able to relax in a shorter time
is a good skill to have.
Together with frequent relaxation, keep doing at
least one deep relaxation practice a day. It is impor-
tant to carry on with longer deep relaxation as this
will help you achieve a deeper state of relaxation.
n When and where are you going to do
frequent relaxation this week?
 try the following:
n When and where are you going to do deep
relaxation this week?
 become light-headed.
n How are you going to remind yourself to
practice?

Addressing Common Difficulties
As learning to relax frequently is a new skill, you
may have difficulty in the beginning. Here follows
CHAPTER 9 FREQUENT RELAXATION 97
some problems you may experience and suggestions
to address these problems.
I forget to practice.
Before you get into a routine, you may forget to do
relaxation. Set reminders on your phone or make
notes. You can put a note next to the coffee maker
and your toothbrush, for instance. By doing relax-
ation in these places every time, it will soon become
a good habit.
I find it hard to relax in the new places.
It may be that the places you have selected have
too many distractions. Make sure there are not too
many people around you. Do not try to do it when
you do not have enough time or are stressed. Go
back to the places you used last week for now. Slowly
add one or two new places where doing relaxation
is not hard. As you become better at relaxing, you
will find it easier to do in new places.
I am not as relaxed as before.
Do not compare this step of relaxation to the ear-
lier relaxation steps. Shorter relaxation is very dif-
ferent from deep relaxation. You will not reach the
same feeling of deep relaxation. The advantage of
frequent relaxation is that you can use it often and
when you really need to. To become more relaxed,
n Add one or two deep breaths through your
belly. Then continue with belly breathing.
You should avoid taking too many deep
breaths in a row. This can cause you to
n Close your eyes if it helps. Later progress by
trying to keep your eyes open.
n Make an extra effort to become aware of the
tensions in your body.
n Scan your muscles. Focus on the tense areas
and try to relax them. If this doesn’t help, try
tensing the area first for a couple of seconds.
I do not have time for the relaxation.
Doing this relaxation step should take only 1 to
2 minutes at a time. There should thus be many
chances to practice it during the day. If your days
are so full that you cannot take short breaks, this is
a problem in itself. You will need to think of creating
98 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

more time for yourself. When you make time to look n Try to do it during your daily routine such as
after yourself, your tinnitus tends to be less bother- after brushing your teeth.
some. It also helps you manage stress better which n Put up some reminders. In time, relaxing will
indirectly also makes the tinnitus less noticeable. become a habit.
There are also many health benefits associated
with relaxation, so making time for relaxation can
improve many aspects of your well-being.
Reflection Activity

My tinnitus and thoughts bother me.

n What is the most important thing you have
There are many factors that can make relaxation
learned from this chapter?
hard. These include noises around you, your tinni-
tus, and having too many people around. Keeping
your eyes open and feeling stressed can also make it
hard. These factors can also make it tough to focus, 
may increase tension, and make relaxation less use-
ful. Try to find more peaceful places to do relax- n What tips are you going to apply?
ation. Keep focusing on your relaxation word, your
breathing, and relaxing your muscles. If you lose
focus, don’t worry, just go back to trying. You just

started practicing frequent relaxation. It is always
hard at the start.

Key Messages Worksheet

n Try to increase the number of times you do Complete the worksheet shown in Table 9–1. This will
relaxation during the day. help you see your progress. It is good to have some-
n Relax for a minute or two, 5 to 10 times thing to remind you of how much you have accom-
every day. plished. The first few rows provide some examples.
TABLE 9–1. Frequent Body Relaxation Worksheet

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 3 I tried this every time I went to the water fountain. 5
I blurred my eyes and focused on relaxing my body.
This worked well despite people passing around me.
1/1/20: pm 4 Trying to do every time I dry my hands under the 6
hand dryer. This helps me remember. The frequent
relaxation is helping me feel less stressed during
the day.

99
 Chapter
Sometimes the most important thing in a whole day is
the rest we take between two deep breaths.
— Etty Hillesum
What This Chapter Covers
n Relaxing within a few seconds
n Relaxing when you are feeling stressed or
upset
n Relaxing often throughout every day
Introduction
This program so far has helped you to start using
relaxation more often during the day. Hopefully
practicing relaxation is becoming more natural
and a good habit. Up to now you have used relax-
ation when you are calm. The times you may need
relaxation most are when you are upset or stressed.
During these times, your body becomes more tense
without your realizing it. These are also the times
your tinnitus may bother you most. If you are able
to relax right away, this tension will not build up. It
will also help you handle the problem before it gets
worse. Relaxing on the spot while you are upset or
stressed can calm you down and also help your tin-
nitus to improve. You are now going to learn to use
relaxation during these times as well.
10
RELAXING WHEN
STRESSED OR UPSET
Relaxing When Stressed or Upset
This relaxation step focuses on doing quick relax-
ation at times when you are feeling stressed or upset.
This will involve:
n Relaxing before, during, or after a stressful
event.
n Relaxing more often during the day.
n Relaxing in less than a minute.
The focus of this relaxation step is practicing
quick relaxation when you are stressed or upset. It
is also intended to increase the number of times you
relax so that it becomes a routine.
Where and When to Do Quick Relaxation
Keep doing frequent relaxation in the places where
you used it before. Also, do it when you are tense or
upset. It will always be easier to do where there is
not a lot going on around you. As you become better
at relaxation, you will be able to do it when there is
more going on around you. Here are some ideas for
when you can try quick relaxation:
n When you have a headache;
n When you can’t focus;
n When you are getting irritated;
n When you can’t hear what others say;
n When tinnitus annoys you;
101
102 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n When tinnitus is louder than usual;
n When you are feeling tense;
n In a meeting;
n When feeling stressed;
n When noises bother you; or
n Before or after something that worries you.
Together with relaxing when you are upset or stress-
ed also do deep relaxation at least twice a week
and frequent relaxation regularly every day (in the
places you selected in Chapter 9, e.g., after hand
washing).
n When and where are you going to do deep
relaxation this week?
 you breathe out.
n When and where are you going to do
frequent relaxation practice?
 and then carry on with the activity you were
n In which situation may you do quick
relaxation e.g. when feeling stressed while
working or when getting annoyed or
irritated

n How are you going to remind yourself to
practice?
 ple around. Relaxing during these times will not feel
How to Do Relaxation When
Stressed or Upset
Figure 10–1 provides quick relaxation steps to apply
when stressed or upset. The aim is to relax for a short
period of time, for up to 1 minute each time you are
upset or stressed. Try to remember to always do this
quick relaxation before, during, or after any stress-
ful event. It may not be easy to relax quickly at first,
but in time you will find it easier. Getting rid of a
bit of tension before it builds up is better than not
relaxing at all.
Here are some tips:
n When you get stressed or upset, relax
wherever you are. This may be standing,
lying down, or sitting. You may be alone or
between other people.
n Keep your eyes open but fix them on one
spot. Then try to blur your vision to lessen
how much of the visual image you see.
n Start by focusing on belly breathing.
n Let the air flow out by itself; you should not
be pushing each breath.
n Next think of your relaxation word each time
n Feel your body get heavier and more relaxed
with each breath.
n Relax your body from the head down.
n Aim to do this entire process under 1 minute
about to do or that you were doing.
Addressing Common Difficulties
As learning quick relaxation when stressed or upset
is a new skill, you may have difficulty in the begin-
ning. Here follows some problems you may experi-
ence and suggestions to address these problems.
I find it hard to relax when I am upset or stressed.
It is much harder to relax when you are feeling
stressed. It is also harder when there are many peo-
as calming as when you do deep relaxation. Taking
a short break will lower your level of tension. Keep
practicing. Try to relax before, during, or after the
event. In time, it will become easier.
Key Messages
n The aim of this relaxation step is to stop
tension from building up.
 CHAPTER 10 RELAXING WHEN STRESSED OR UPSET 103

Do quick relaxation anytime you are

stressed, irritated or annoyed.

Stay where you are and relax for 1 minute.

Focus on deep breathing, your calming

word, and relaxing your muscles.

Do this when stressed and also 10 other

times during the day.

10 times
per day

1 min
FIGURE 10–1. Quick relaxation steps to apply when tense or stressed and frequently throughout the day.

n Instead of waiting to be alone to do relax- Worksheet

ation, do it wherever you are.
n When you feel upset or worked up, try to
relax for a few seconds. This may be before,
during, or after the event.
Reflection Activity
Complete the worksheet shown in Table 10–1. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide some
examples.

n What is the most important thing you have

learned from this chapter?

n What tips are you going to apply?


TABLE 10–1. Quick Relaxation Worksheet to use When Upset or Stressed

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 0 I tried to focus on relaxing when I was getting 3
worked up during a meeting. It probably helped me
not get more wound up.
1/1/20: pm 1 I had an argument with my partner and was very 4
annoyed. I tried to do the relaxation during and
after this time. It is hard not to just focus on being
angry, but I know in the long run it will be helpful.

104
 Chapter
RELAXATION ROUTINE
I believe that if you truly understand the importance of
relaxation, you will make time for it in your schedule.
— Gudjon Bergmann
What This Chapter Covers
n Planning a relaxation routine
n Relaxing during stressful events and when
you are calm
n Planning activities you enjoy
Introduction
It has been a steep learning curve, but all your efforts
have brought you to the end of this relaxation pro-
gram. Well done! You have learned how to do deep,
frequent, and quick relaxation. Hopefully, you are
learning that relaxing regularly lowers your body’s
tension before it builds up. Also, relaxing during
stressful events helps keep you calm. You can relax
in different positions — standing, sitting, and lying
down — with your eyes open and closed. You have
many relaxation skills now; the important thing is
to keep up these new habits. This chapter is going to
help you establish a relaxation routine.
Why Plan a Relaxation Routine?
This relaxation step is about putting all the earlier
relaxation steps together. You have learned new
relaxation skills that can help you manage your
tinnitus and other stressful events. The best way to
remind yourself to do relaxation is by making it part
of your daily routine. A planned, scheduled relax-
ation time will help relaxation become a habit.
11
Planning Enjoyable Activities
People often get caught up in things they must do.
However, making time to do things you enjoy, but do
not have to do, can also help you relax. These activi-
ties can ease your reaction to tinnitus by helping
you overcome irritations and frustrations and thus
help you manage your tinnitus and other stressful
events better. Having more positive feelings can help
distract you from your tinnitus and help you feel
better overall. Together with planning relaxation
activities, it is important to plan enjoyable activi-
ties. Here are some ideas:
n Doing something creative such as woodwork,
drawing or painting.
n Enjoying nature by going for a walk in a
beautiful area or rowing on a river.
n Taking yoga, Pilates, or stretching classes or
doing online videos.
n Doing something active like dancing, swim-
ming, playing a sport like golf.
n Gardening.
n Cooking or baking.
n Meeting friends and doing an activity with
them.
n Reading or writing.
n Listening to music you enjoy.
n Playing games with your family.
n Doing relaxation activities together with your
partner.
Taking Care of Yourself
Often, as people are so busy doing all the urgent
things, they forget to take care of themselves. The
105
106 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
value of healthy eating and exercise cannot be
overlooked. By following a healthy lifestyle, your
well-being can be improved both mentally and
physically. This can also help you notice your tin-
nitus less. Even small changes, such as introducing
more fruits and vegetables into your diet and getting
a small amount of exercise such as walking, can
make a massive difference.
How to Plan a Relaxation Routine
Here are a few tips for planning a relaxation routine:
n Choose two times a week when you will spend
10 minutes doing a longer relaxation routine,
incorporating deep breathing and muscle
relaxation. This could be every Sunday and
Thursday before going to bed.
n Choose situations or times during your day
during which you will do frequent relaxation
for 1 to 2 minutes. This may be after lunch,
when sitting down at your desk, or after
sending a message on your phone.
n Think through events you find stressful or
upsetting. These may include a difficult
conversation, before meetings or when you
have a deadline. Commit to relaxing before,
during or after such events for 1 minute.
n Make relaxation a habit when you are
unwinding or resting.
n It is helpful to keep noting when you do
relaxation. Once it becomes a habit, you
won’t need to keep writing down what you
have done.
n Add specific times into your routine to do
things you enjoy. These might include 10
minutes each day to read and an hour a week
to go for a walk.
n Plan to do something relaxing with your
partner, a family member, or a friend.
n Plan a healthy meal at least once a day to
ensure that you get all the nutrients you need
to help you cope better with daily problems.
n Plan a weekly exercise routine to ensure you
make time for exercise.
Well done! You have now finished the relaxation
program.
Key Messages
n You need to plan when to do relaxation. By
doing relaxation often, it will become a habit.
n Aim to do both deep and frequent relaxation
every week.
n Remember to do quick relaxation when
feeling stressed or upset.
n Ensure that you plan some enjoyable activi-
ties each week and set times to exercise. This
routine will create healthy habits.
Reflection Activity
Complete Table 11–1 to consider your relax-
ation routine.
Worksheet
Complete the worksheet shown in Table 11–2. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide some
examples.
 CHAPTER 11 RELAXATION ROUTINE 107

TABLE 11–1. Relaxation Routine Planner

Weekly Planner When To Do Where To Do

Deep relaxation (10–15 minutes
twice a week)

Frequent relaxation (8 different

situations throughout the day)

Possible stressful or upsetting

situations to do quick relaxation

Exercise

Enjoyable activities

Healthy meals
TABLE 11–2. Applying My Relaxation Routine Worksheet

Estimated How Well

Level of This Went
Relaxation Comments Rate from 1 to 10
Rate from 1 to These may include when, where, and for how long with 10 being very
10 with 10 being something was done. You can also note what you can successful as you
Date very relaxed. do differently or change next time. feel very relaxed.
1/1/20: am 3 I woke up and did deep relaxation with belly 8
breathing and my relaxation word followed by
positive imagery for 10 minutes. It helped set me
up for the day.
1/1/20: pm 4 I focused on remembering to do frequency 7
relaxation today after washing my hands, brushing
teeth, having coffee and after climbing the stairs.
This will hopefully become a habit soon.

108
 Part III
COGNITIVE BEHAVIORAL
THERAPY TECHNIQUES
 Chapter
Visualization is daydreaming with a purpose.
— Bo Bennett
What This Chapter Covers
n Advice on using and exploring mental
pictures
n Using a mental picture to distract you from
your tinnitus
n Using this image to help you unwind and
lower your stress
Introduction
Sometimes your tinnitus may be really annoying,
and you wish there was an “off” button. Other times
you may be in a stressful place that you want to get
away from, but you can’t leave. This may be a noisy
family gathering or a meeting at work. When tin-
nitus leads to an unpleasant and negative feeling, it
can increase your stress level. Instead of not know-
ing what to do when your tinnitus is bothersome,
you can use some tools described in this chapter.
These will help you to be more in control of the tin-
nitus. This chapter is going to show you how to shift
your mind onto something else by learning to focus
on a picture you imagine. A positive image is an
image of a scene, event, or place you recall in your
mind — somewhere you were relaxed, peaceful, and
happy. A good image is one that brings up feelings
of well-being, such as your favorite vacation spot.
This chapter is going to show you how to use posi-
tive mental pictures.
12
POSITIVE IMAGERY
The Purpose of Positive Imagery
Positive imagery can work as a well-needed “mini-
vacation” from a stressful day or troublesome
thoughts. The purpose is to enhance your ability to
focus as well as to make you feel more peaceful and
relaxed. It works by directing your attention away
from something unpleasant. This can help you to
relax and cope with something you find difficult.
A positive mental picture works well at distracting
you from your tinnitus. It is a powerful method to
use when you can’t focus or sleep, as it can quickly
calm your body and relax your mind. Positive imag-
ery is easy to learn and may be done almost any-
where. It can recharge you so that you can cope
better when things are tough. In the long run, your
training to focus on and explore a mental image,
despite distractions from tinnitus and other things,
can increase your ability to keep your focus also in
other situations when you are distracted.
What Images to Use
The aim is to select one or two images that will be
effective for you. It is good to think of places you
know well. Choose images that have a calming
effect, without too much activity. There needs to be
enough detail to actively explore the image. The
image should not remind you of problems, stress,
work, or your tinnitus. Put yourself in the picture.
Don’t choose an image involving too many others.
Your images may include a beautiful waterfall, gar-
den, or sparkling lake. They can include a forest,
the seaside, or a town you really like. Figure 12–1
provides an example of a positive image.
111
112 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

FIGURE 12–1. Example of a positive image (sunset).

anything moving?” “What are the colors?” “How

What positive images come to mind? much light is there?” “What does the air feel like?”
Change your focus to different places within the
scene by looking down and up, to the left and right,
 far away and nearby. Figures 12–2 and 12–3 are two
examples you can use to practice exploring images.
Later, you will actively explore the images you have
selected in this same way.
Exploring Images

When using this positive imagery technique, try to Which images can you think of that you can
explore the mental scene actively by moving your use all your senses to explore the image?
attention between different parts of the image.
Explore the details instead of trying to take in the
entire scene. Use all your senses when you are cre- 
ating your mental scene. Ask questions such as “Is

FIGURE 12–2. Image of a beach.
Looking at Figure 12–2, ask yourself questions:
n What do you see? Blue skies, sunset, white
clouds, dancing sunlight, white sand, rocks,
sea gulls, or palm trees.
n What do you hear? The waves rolling, the
wind whistling, or birds singing. You may
hear the water splashing, children laughing,
flags flapping, or insects buzzing.
n What do you smell? Seaweed, sun lotion, or
flowers.
n What do you taste? It may be a picnic sand-
wich, a cold drink, or ice cream.
n What do you feel? The sun against your skin
or sand between your toes. Think of the
CHAPTER 12 POSITIVE IMAGERY 113
roughness of the rocks, wind blowing, and
feeling peaceful and relaxed.
Looking at Figure 12–3, ask yourself questions:
n What do you see? The sky, clouds, or rooftops.
You may see the people and cars moving far
below. Perhaps the balcony, the shapes of
buildings, birds, and airplanes. You may see
windows, details of buildings nearby, street-
lights, or flowers on the balcony.
n What do you hear? Distant traffic, building
work, murmuring voices, or the singing of the
wind. Perhaps you hear music from a nearby
window, airplanes, birds, or a fan.
114 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
FIGURE 12–3. Image of a view from a balcony.
n What do you taste? Fresh air, a refreshing
drink or enjoyable snack.
n What do you smell? The warm concrete,
flowers, fresh coffee, perfume, or aftershave.
n What do you feel? The wind against your body
or the thrill of being high above everything
else. You may feel the chair in which you are
sitting, your clothes and shoes against your
skin. You could feel the texture of what you
are eating or your fingers touching something.
How to Explore a Positive Image
Start practicing imagining your own image for
5 minutes twice a day. It is ideal to use a positive
image while doing your relaxation practicing. At
first try to think of your positive image while you are
somewhere you will not be disturbed.
n Close your eyes.
n Start by relaxing and taking a few deep
breaths.
n Then think of a scene, place, or event. This
place should be safe, peaceful, restful, beau-
tiful, and happy.
n When thinking of your positive image, try to
actively explore the details of the scene.
n Focus on the different parts of the image.
Don’t try to take in the entire scene at
once.
n Ask yourself questions and find the answers
by exploring the image.
n Explore the image using all your senses.
What does it smell, taste, sound, look, and
feel like?
n Try to keep your mind focused on the image.
If you find your thoughts drifting, redirect

them to the positive image. This will gradu-
ally help you to focus.
n After you’ve explored the image, take a few
moments to enjoy relaxing before carrying on
with your daily routine.
Addressing Common Difficulties
As learning to use positive imagery is a new skill,
you may have difficulty in the beginning. Here fol-
lows some problems you may experience and sug-
gestions to address them.
I am not able to visualize an image.
There may be several reasons for this. Because this
exercise is new for you, you will probably find it diffi-
cult at first. After a few days of practice, it should get
easier. Try thinking of a place that you know well.
Also make sure the image is peaceful, and you are
somewhere you won’t be disturbed. Some people find
it hard to think of positive images, even after practic-
ing for some time. If you are one of these people, try
thinking of a more active event. For example, when
you are doing something you like, perhaps baking or
sailing. Actively thinking of a busy image, though,
may stimulate you rather than have a calming
effect. You can also just think of something positive
and relaxing instead of an image such as the joy
your garden, pet, or grandchildren bring to you.
I lose my concentration because of my tinnitus,
disturbing thoughts, or something else.
Things going on around you can easily distract you.
Focusing can also be hard when you start thinking
about recent events or things you need to do. Your
tinnitus can also distract you. This is natural; one’s
mind often wanders. When you get distracted, you
need to remember one of the purposes of this exer-
cise: to train your ability to refocus on the task you
want to do, despite distractions. So, an important
part of the exercise is that you actually get distracted
and then learn how to focus on the image again.
Also try to relax before starting to think of your
positive image. To keep your mind busy, it is impor-
tant to engage all your senses. Explore the look,
smell, taste, and sounds within the image. Have
CHAPTER 12 POSITIVE IMAGERY 115
someone else ask you questions about the image if
this is easier. If disturbing thoughts pop up during
the exercise, try the following. Picture a container,
drawer, hole, or bag within your image. Imagine
putting away your disturbing thoughts in the item
you chose. After the exercise, you can take them out
again if you still want to.
I feel stressed, uncomfortable, or
unable to relax.
If the positive image does not relax you, think about
whether you have selected a useful, positive, and
relaxing image. If the image is causing a stress-
ful reaction, select another. For example, a sunny
beach may remind you that you can’t afford to go
on a vacation this year. If so, try another image that
might work better.
To increase your focus on the positive image, relax
before starting the exercise. You can also try using a
picture of a place that looks lovely, where you have
not been before. Focus mainly on the details in the
image. This allows thoughts to pass through your
mind without paying much attention to them.
My tinnitus doesn’t go away when I am
visualizing the positive image.
Your positive image is not an on/off switch for your
tinnitus. If it was, nobody would get annoyed by tin-
nitus anymore. How well the image takes your mind
away from tinnitus varies. The aim of the exercise is
not to ignore your tinnitus completely. It is supposed
to help you unwind and focus on something peace-
ful and positive. If you are hoping for your tinnitus
to disappear, the positive image will be less effective.
Key Messages
n Seeing a picture in your mind of a scene,
place, or setting can help distract you from
your tinnitus.
n Daydreaming by focusing on this image can
help you to relax.
n Actively exploring the image with all your
senses and refocusing on it when you get
distracted by tinnitus or something else will
train your ability to concentrate also in other
situations.
116 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Worksheet
Reflection Activity
Complete the worksheet shown in Table 12–1. This
n What is the most important thing you have will help you see your progress. It is good to have
learned from this chapter? something to remind you of how much you have
achieved. The first few rows provide some examples.

n What tips are you going to apply?


TABLE 12–1. Worksheet to Make Notes When You Practice Positive Imagery

Comments
Estimated Which image did you use? How did you actively explore How Well This
Level of the image? Which senses did you include? Could you Went
Relaxation keep your focus on the image? How long did you do Rate from 1 to 10
Rate from 1 to this for? Did you combine it with other relaxation with 10 being very
10 with 10 being techniques? Where did you do it? Would you change successful as you
Date very relaxed. anything? feel very relaxed.
1/1/20: am 2 I started with deep breathing, then focused on my 7
mountain image. I stood at the top of a ski slope
looking down at the snow on the branches of the
trees. I placed myself in the image, listening to the
sound of the skis gliding on the snow, feeling the
warmth of the layers of clothes, absorbing all the
positive feelings I have when surrounded by nature
in this way. Went well. Probably 5 min
1/1/20: pm 2 Again started by focusing on deep breathing for a 8
few minutes. Tried a different scene, running next
to a long stretch of beach early in the morning.
Seeing the waves, soft sand, and experiencing
the peace of having a long stretch of beach all to
myself. Really worked well for me. Around 7 min

117
 Chapter
Incredible change happens in your life when you decide
to take control of what you do have power over.
— Steve Maraboli
What This Chapter Covers
n How to weaken the link between hearing your
tinnitus and negative feelings
n How to view tinnitus as a more neutral sound
n How to have better control over your tinnitus
by experiencing it as a sound separate from
you
Introduction
Different sounds can cause diverse reactions. Think
about various sounds such as the sound of the wind
rustling through leaves, sirens rushing past you, and
the fridge buzzing. Which are pleasant, neutral, or
unpleasant sounds to you? Now, how about your
tinnitus. Is this a pleasant, neutral, or unpleasant
sound to you?
You have probably selected different reactions
for these contrasting sounds. For most people, some
sounds bring happy feelings. These may be the
sounds of children playing or of calming music.
Other sounds, like your breathing or the fridge buzz-
ing, do not trigger strong feelings. This is because
the fridge buzz is just another sound in your mind.
There may be sounds like a scream or a bang that
cause a strong reaction. These feelings help people
react quickly and make a fast decision when they
need to. People will, for example, cross the road
faster if they hear a car coming closer very quickly.
If you hear some birds chirping, you may stop. You
may try to find them and enjoy the sounds. For some
13
VIEWS OF TINNITUS
people, hearing tinnitus brings feelings of irritation
or anger. This chapter will focus on changing the
way you view your tinnitus.
The Purpose of Changing
Your View of Tinnitus
The purpose of this chapter is to help you to react
to tinnitus the same way you do to a neutral sound.
It also aims to help you to view your tinnitus as
something separate from you. If you can picture
your tinnitus as something neutral, manageable, or
positive, it will be easier to adjust to. The key concept
behind this strategy is to weaken the connection
between tinnitus and negative emotions. Focusing
on tinnitus when you are relaxing and imagining
something comforting, such as a positive image, will
in time make tinnitus feel less bothersome and more
controllable. If you can picture tinnitus as some-
thing neutral, manageable, or even positive, it will
be easier to adjust to living with it. The fact that you
are voluntarily focusing on tinnitus instead of trying
to avoid it can reduce problems caused by tinnitus
in the long run.
Positive Experiences Related to Tinnitus
Can anyone have a positive outlook despite having
tinnitus? Research has shown that the answer is yes.
Personal growth and gratitude are possible despite
having tinnitus. Some have used their tinnitus in
a positive way. They have perhaps used it to help
those they know that have tinnitus. Here are some
examples of positive reactions to tinnitus:
n “I am proud of myself as I have learned how
to manage my tinnitus.”
119
120 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

n “I have become more aware of what causes

changes to my stress levels and how to deal
with stress.”
n “Having tinnitus has helped me appreciate a
more active lifestyle.”
n “I am more motivated to do something with
my life.”
n “I realize a lot of others have tinnitus, and I
want to help them.”
n “I now know how people with tinnitus feel.
I got a lot of help from a tinnitus support
group.”
n “I am thankful that my tinnitus is not due to
a serious health problem.”
As you progress, keep trying to see whether you
also can find some positive aspects of tinnitus. Keep
in mind that your life consists of so much more than
having tinnitus. Don’t forget the positive things in
your life that you are thankful for. Find ways you
can enjoy aspects of your life despite having tinni-
tus. Being positive will help you to face other prob-
lems and hardships.
Has tinnitus resulted in any positive outlook
on life, such as making you more grateful or
learning new skills?
 another sound, instead of a sound that you don’t
Neutralizing Tinnitus by Describing It
Tinnitus can be very hard to describe to people who
don’t have it. It can even be difficult to describe to
yourself, aside from labelling it emotionally as being
“terrible” or “painful.” To help, you can compare
your tinnitus to real objects. The composer Bedřich
Smetana described his tinnitus as sounding like a
huge waterfall in one ear. The tinnitus in the other
ear sounded like a musical cord from music he had
written. Michelangelo described his tinnitus as crick-
ets singing in one ear and a spider’s web in the other.
Think about how you can describe your tinnitus to
liken it to a real object. This will be helpful for the
exercises to come.
How would you describe your tinnitus, by lik-
ening it to a real object, to someone who does
not have tinnitus?

How to Change Your View of Tinnitus
The way you view your tinnitus is the same as
the way you view most things. It depends on your
thoughts and the context. You are going to work at
changing the negative emotions linked with your
tinnitus to a more neutral view of tinnitus. This will
make your tinnitus affect you less negatively and
become a more neutral sound in the background.
Instead of hearing the tinnitus and thinking “Oh
no, it’s so loud I can’t think,” you will aim to change
this thinking by linking tinnitus to another sound
that you view as neutral or positive. For example,
the refrigerator turning off can catch you by sur-
prise. You may not have been aware that the refrig-
erator was humming, because the sound from the
refrigerator is not linked to any strong emotions
and thus is something you quickly ignore. If you
can equate your tinnitus to an unimportant back-
ground sound, your attention to it will change over
time. Now, imagine you viewed your tinnitus as just
like. By viewing your tinnitus more neutrally, it can
become a less unpleasant sound. By placing the
tinnitus sound in a more neutral or even positive
context, it will be easier accepting its presence and
will make your tinnitus easier to adjust to. This will
increase your sense of control over your tinnitus and
let you feel less bothered by it.
Steps to Follow
There are three steps to follow to change your views
on tinnitus.
Step 1: Find another sound.
n Listen carefully to your tinnitus.
n If you hear more than one sound, select the
most pleasant one.
 A

B
FIGURE 13–1. Examples of reinterpreting tinnitus as something more pleasant: tinnitus as cicadas (A) or a
waterfall (B).

121
122 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Try to think of something else that reminds
you of that sound so you can link it to your
tinnitus. This may be the sound of cicadas or
a waterfall as shown in Figure 13-1.
If this doesn’t work, try to imagine your tinnitus as
just another sound in the house, external to you.
Here are some ideas:
It is not tinnitus I am hearing. I am hearing . . .
n Leaves rustling in a breeze;
n A train;
n A rippling brook;
n A fire crackling;
n Ocean waves;
n Wind chimes;
n A cat purring;
n A car engine;
n Birds chirping;
n The drone from an airplane while it takes you
to an exciting destination;
n Putting your ear to a sea shell;
n A clock ticking;
n The mechanical hum from a kitchen appliance;
n The washing machine spinning;
n Rain pattering on the window pane;
n Crickets; or
n Bells ringing.
What alternative sound or metaphor are you
going to use to interpret your tinnitus?
 n A crackling fire nearby diminishing the sound
Step 2: Give this sound a positive context.
The next step is to imagine the surroundings this
sound would normally be in. It might be fishing
next to a lake or being at the ocean. If the sound you
choose is waves, picture being on the beach. Hear
the waves, feel the sand, smell the air, see the waves
breaking. If the sound you choose is that of drag-
onflies, see them flying over a river shining in the
sunlight. The alternative sound you imagine that
tinnitus represents may not be positive, but rather
more neutral or even slightly annoying, such as a
car engine. Even so, you can imagine the sound in
a positive context, for example sitting in a cozy café
while there is a car outside in the street.
What contexts can you use?


Step 3: Lower the volume of the alternative sound (the
object that you have now linked with tinnitus).
Now reduce the volume of the alternative sound
(e.g., birdsong, rainfall). You can do this by think-
ing about moving away from the sound or muffling
the sound by closing a door or window. You can
also imagine other sounds masking it. You can for
instance, focus on a different sound in your image
such a dogs or children playing. Alternatively, try
to imagine that your tinnitus sound is coming from
somewhere else, away from you. The sound is then
coming from a distance and not from your ear. It
is not your tinnitus; it is an external sound. Think
of when tinnitus initially started; perhaps you may
have searched the environment to find out where
the sound was coming from. Another variation is
to imagine your tinnitus sound playing on a music
player or somewhere external from you, so the
sound is coming from a distance.
Examples may be:
of the crickets;
n Increasing the speed of a fan to dull the
sound of a clock ticking;
n A waterfall or fountain overpowering the
sound of a birdsong;
n Murmurs from people speaking that are
muffled by the rain; or
n Hearing the seaside and then going for a dive
under the water to lessen the sound of the
waves.
 CHAPTER 13 VIEWS OF TINNITUS 123

Listening to my tinnitus is bothersome.

In what ways can you control the volume or If you often try to avoid hearing your tinnitus, this
mask the sound? strategy can help. At first you will probably find it
very tiring, but if you keep going it will become eas-
ier. Relax more often, as this will also help.


Key Messages

n You can change your view of tinnitus. One
way to do so is by linking it to another posi-
Where and How to Practice tive or pleasant sound.
n Viewing your tinnitus as a neutral sound can
Initially practice in peace and quiet; later you may
help you have more control over the way
be able to practice in different settings.
tinnitus affects you.
n Spend a few minutes relaxing before starting. n It can help make you become less distracted
by tinnitus and get distance from it.
n Focus on the sound you chose to link to tinnitus.
n Next, lower the volume of the sound by
moving away from the sound or muffling it. Reflection Activity
n See the sound in its natural contex.
n Focus on the positive parts of the environ- n What is the most important thing you have
ment, and let the tinnitus sound slip away learned from this chapter?
between the other sounds.
n Try to link your tinnitus to another sound for

around 5 minutes at least once a day.
n What tips are you going to apply?
At first it is difficult to do. Keep trying because it
can help. It may take some time but will become
easier and can be a hugely effective strategy. This 
technique also helps you to focus on your tinnitus
instead of trying to avoid it, this itself reduces the
problems with tinnitus in the long run.
Worksheet
Addressing Common Difficulties Complete the worksheet shown in Table 13–1. This
will help you see your progress. It is good to have
As learning positive imagery is a new skill, you may something to remind you of how much you have
have difficulty in the beginning. Here follows some accomplished. The first few rows provide some
problems you may experience and suggestions to examples.
address them.

The exercise is too difficult.

When you focus on your tinnitus, you can lessen
how unpleasant it seems. Try to relax for a longer
time before starting. Otherwise, try another sound.
TABLE 13–1. Worksheet to Make Notes When You Practice Trying to Change Your Views of Tinnitus

How neutral
or positive
are your How Well
emotions This Went
associated Step 1: Step 2: Step 3: Comment and
with hearing Which In which How did you rate from 1 to
tinnitus? alternative context did lower the 10 with 10 being
Rate from 1 to sound did you place the volume of the very successful
10 with 10 being you use? Did sound? Did alternative as you feel
very neutral this work? this work sound? Was the tinnitus is
and tinnitus not well? this possible? causing less
causing irritation Any other annoyance or
Date or annoyance. suggestions? irritation.
1/1/20: am 1 A sewing My mom is We run outside It went
machine sitting making to play, and surprisingly
me clothes and now the sewing well, not what
letting my sister machine is I expected.
and I play with quieter. We just
5
the scraps of hear it from the
material. window, but
we run further
away.
1/1/20: pm 2 The drone of an I am sitting I put on my This also
airplane in the plane headset and worked.
knowing I can look at a Will keep
just relax and movie, which experimenting.
get excited I never get time
6
about my for, so I really
vacation. focus on it.

124
 Chapter
Focus 90% of your time on solutions and only 10% of
your time on problems.
— Anthony J. D’Angelo
What This Chapter Covers
n How to improve control of where you direct
your focus
n Helping you divert your focus away from
your tinnitus
n Shifting attention to something on which you
want to focus
Introduction
It is difficult to really focus on more than one thing
at once. Sometimes tinnitus can take over and make
it hard to focus on something else such as a task or
your work. You just want to stop hearing the tinnitus
and focus on what you are doing. It is hard to try
to ignore something by simply trying not to think
about it. Let’s try a classic example. Try not to think
of a cat. Didn’t you think of a cat right away? In the
same way, just telling yourself “don’t listen to my
tinnitus” can make you focus on it more. It is very
difficult to ignore something by simply trying not
to think about it. The best way to divert your atten-
tion from the tinnitus is by focusing on something
else. This chapter is going to help you do this. It is a
technique that you can apply in almost any place.
The Purpose of Shifting Focus
The purpose of shifting focus is to increase your
control of where you direct your attention. Being
14
SHIFTING FOCUS
able to shift your focus will also help you focus
away from your tinnitus. Focus exercises will not
help you ignore tinnitus at all times, but rather will
teach you how to shift your focus between differ-
ent stimuli. That way it will be easier to focus on
work, background sounds, positive images, and
things in your environment instead of tinnitus. You
will never gain full control of where you direct your
attention, but you can improve your ability to con-
trol it. You will learn to change focus consciously,
although you may still lose your concentration
occasionally.
More About Focusing
It is hard to focus on two different tasks at the
same time. Even when you are doing a few tasks
at the same time, your focus is always moving. The
more often you have to change focus, the more
frustrated you will be. Some things draw you more
easily than others. It is easier to focus on things
that keep changing than on things that do not. For
example, compare watching television with focus-
ing on a static object. Also, when you are involved
in something, you need to focus more than when
you are just watching. For instance, you may be
involved in sports, gardening, or games. Things
that are important to you, or in which you have
an active interest, often stay in the foreground.
This also applies to your tinnitus. Your focus may
often be on your tinnitus, especially if negative
emotions are linked to it. Most of the time you may
be unaware of focusing on anything. Your focus
on tinnitus may just happen without you think-
ing about it. By practicing often, you can learn
where to focus and learn to focus away from your
tinnitus.
125
126 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Why Shifting Focus Is Helpful

Being able to shift your focus away from your tin-

nitus can greatly lessen how much you notice it.
By improving control of where you focus, you can
decide to shift your focus. You can shift your focus
away from your tinnitus onto something else. Shift-
ing focus is an important skill to practice as it can
also help at other times. It can help you focus on
things you really need to focus on. Learning to fully
focus on something else and not your tinnitus is
hard. It is a skill that takes time to learn.
A

How to Shift Your Focus

To focus less on your tinnitus, you first need to be able

to shift your focus. You will practice this by moving
your focus between two different things. They can be
things you feel, see, or hear. Figure 14–1 shows some
examples of a something you hear (like music) and
something you see (like a flower). It is helpful to work
out what is easiest for you to shift your focus onto.
You can focus on any two things, such as:

n Something you see: an interesting picture, a

photograph, a flower, the view.
n Something you feel: squeezing your hands
together, wriggling your toes, rubbing your
hands together.
n Something you hear: a clock ticking, your
foot tapping, music, birds chirping, raindrops,
noise from a distance.
n Both objects selected should be present while
practicing.

Here are some examples of two things you may

choose:
n Squeezing your hand and looking at a
photograph;
n A picture in a book and your fingers tapping;
n A clock ticking and rubbing your hands
together;
n The view and the sound of birds chirping; or B
n Your foot tapping and the texture of your hair.
FIGURE 14–1. Shifting focus between an auditory
n Feeling beach pebbles and looking at the sky (listening to music) (A) and a visual (looking at a
or a picture, as shown in Figure 14–2. flower) (B) stimulus.
 CHAPTER 14 SHIFTING FOCUS 127

B
FIGURE 14–2. Shifting focus between a tactile (stones against your feet) (A) and a visual
(picture of planes or looking at the sky) (B) stimulus.
128 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
At first it will be hard to focus. With practice, you
will be able to refocus. It is helpful to use things you
really like focusing on, such as your favorite music
or picture.
What two things are you going to choose to
focus on?
 tening to the tinnitus, shift your focus away to some-
You can use the following three steps to learn to shift
your focus. Start with Step 1 and progress to Steps
2 and 3.
Step 1
n Choose two things; they can be something
you see, feel, or hear.
n Focus on one thing for 15 to 30 seconds, then
the other for 15 to 30 seconds, and then back
and forth to each four times for around 2 to
3 minutes.
n Actively focus fully on each thing you have
selected.
n If you lose focus, go back to the object you
focused on last and try again.
n Make sure both things are present while you
practice. If one thing is music, keep it on
while focusing on something else like
a picture.
n Do this step for 3 to 4 days until you feel you
can easily shift your focus.
Step 2
After you can shift your focus between two objects,
shift your focus between your tinnitus and one other
thing. This can be something you can feel, hear, or
see. This practice will help you to apply this tech-
nique on days when you are struggling with the tin-
nitus. The idea is to be able to switch your focus
away from the tinnitus onto something else. Here
are some examples:
n Rain on the windowpane and your tinnitus;
n A pretty view and your tinnitus;
n A pen tapping against your hand and your
tinnitus; or
n Feeling a fabric and your tinnitus.
Practice this step for 3 to 4 days until you feel you
are able to do it.
Step 3
Once you are better at shifting your focus, try it
when your tinnitus is bothering you. Instead of lis-
thing else that you see, feel, or hear. Focus fully on
something else. In time this will help the tinnitus
move to the background and not be as bothersome.
Once you have mastered the technique, you will be
able to use it more often. It will be handy to shift the
focus away from your tinnitus onto something else.
Choose something to focus on to shift your atten-
tion away from your tinnitus. Try to use something
around you that you can easily focus on.
What kinds of stimuli capture your attention
best (things you see, hear or feel) and which
will you focus on, to shift attention away from
your tinnitus?

When to Shift Your Focus
Practicing often helps you to improve and makes the
process easier. Try to practice shifting your focus four
times a day for 2 minutes at a time using this guide:
n At first, try to practice someplace where you
will not be disturbed.
n Start by trying to relax before practicing.
n You can also practice at other times, such as
when struggling to sleep or relax.
n When your tinnitus is bothersome, shift your
focus from your tinnitus onto something else.
Keep your focus there until your tinnitus goes
into the background.
n Actively focus on and analyze all aspects of
the other stimulus.

Addressing Common Difficulties
As learning to shift your focus is a new skill, you
may have difficulty in the beginning. Here follows
some problems you may experience and suggestions
to address them.
My tinnitus attracts my attention.
Tinnitus is often more bothersome than other
sounds because you are in the habit of focusing on
your tinnitus. This makes it hard for you to shift
your focus from your tinnitus to something else. To
break this habit, you will need time and practice. It
will get easier.
Start by choosing things that don’t include your
tinnitus. This may be focusing first on tensing your
muscles and then listening to music. Find things
that are easy to focus on. Also choose things to focus
on that you enjoy.
My thoughts or things going on around me
disturb me.
It is easy to start focusing on things going on around
you. You may lose yourself in thoughts and think
of things you have to do. This is normal. This tech-
nique will help you refocus when you find your
thoughts wandering. In time you will get better at
focusing fully.
My ability to concentrate or to ignore
my tinnitus has not improved.
The aim is not to learn how to ignore your tinni-
tus, but to lessen how much you focus on it. If you
haven’t been practicing for very long, it is normal
to feel that you are not making progress. Working
on your focusing skills and making a habit of shift-
ing routinely on other things rather than on your
CHAPTER 14 SHIFTING FOCUS 129
tinnitus takes time. Learning to shift your focus is
only one of many tools that can help you have more
control over your tinnitus.
Key Messages
n Being able to control where you focus can
help keep tinnitus in the background.
n Learning to shift your focus between things
you see, hear, or feel is a great skill to have.
n When you can control where you focus,
you will start to focus on things around you
instead of on the tinnitus.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

Worksheet
Complete the worksheet shown in Table 14–1. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide some
examples.
TABLE 14–1. Worksheet to Make Notes When You Practice Shifting Your Focus

How well can What two things are

you shift your you going to shift
focus? your focus between? Comments How Well
Rate from 1 to These may include How long were you able This Went
10 with 10 being something you see, hear, to do this for? What was Rate from 1 to 10
very well. or feel. They may also effective? If you were with 10 being very
be your tinnitus and distracted, what would you successful shifting
Date something else. do differently next time? of your focus.
1/1/20: am 1 The feeling of rubbing It was hard to keep my 2
my hands together focus on each thing.
Listening to music Maybe I will try this after
relaxation.
1/1/20: pm 2 Running my hands I tried this after 3
through my hair relaxation and managed
A picture my grandson about 3 minutes. I need
painted more practice, but can
see this may work.

130
 Chapter
It isn’t the events themselves that disturb people, but
only their judgments about them.
— Epictetus
What This Chapter Covers
n Learning more about different thinking
patterns
n Realizing how thoughts influence your
emotions
n Detecting your thoughts on tinnitus and how
they affect you
Introduction
Many thoughts constantly pass through our minds,
often in the form of a chat we are having with our-
selves. Thoughts depend on many factors, includ-
ing our present mood. Many of our thoughts are
almost instinctive. These thoughts can be useful, as
they provide a quick overview — for example, “It is
cold, I need a coat.” Many situations are so habitual
that we don’t pay attention to what we are doing or
thinking. Other thoughts are more analytic, such as
when we think through a plan. Thoughts can also
be negative, neutral, or positive. An example of a
negative thought may be, “It is cloudy, I feel sad
when the sun is not shining.”
There are many times when you may have nega-
tive thoughts. Negative thoughts can lower your
mood and make it hard to enjoy things. Negative
thoughts can make things worse, as they make it
harder to improve your mood. Many things in life
are negative or sad. You need to be able to interpret
and respond properly to thoughts and events even
when they are challenging or negative. Sometimes
15
THOUGHT PATTERNS
negative thoughts slip into your mind and can be
hard to switch off. Many people have problems
when negative ways of thinking become a habit.
These thoughts may keep us from doing what we
want to do. Having a balance between different
types of thoughts is important. This chapter is going
to explore thinking patterns.
The Purpose of Identifying
Thinking Patterns
The purpose of this tool is to become more aware of
your thoughts and how they affect you. It is also to
identify what thoughts you have about tinnitus and
to learn how to express your thoughts in writing.
If it turns out that your thoughts are often nega-
tive, the next chapter on challenging thoughts will
provide strategies to deal with these thoughts and
reduce their negative influence. You will be trying
to prevent habitual and automatic thoughts from
affecting your life in a negative way.
What Affects Thoughts
Two people facing the same event can react in a dif-
ferent manner. This depends on a range of factors
such as:
n What they are doing;
n What they know;
n Their mood before and during the event;
n Events from the past;
n How they feel about themselves, others, and
the world; and
n How they felt before the event arose.
131
132 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Thoughts also have a strong influence over emo-
tions. We do not always pay attention to what we
are doing or thinking. For example, we may go
through our morning routine instinctively. Other
events influence our mood as shown in Figure 15–1,
such as burning the toast and getting annoyed by
this or receiving an unexpected complement.
In any given situation, we often tend to notice
only the situation and the emotion. We consider the
situation to be the origin of the emotion. Most situa-
tions, may, however, give rise to a variety of thoughts
and those, in turn, will make us feel a certain way.
However, although the situation can influence our
emotions directly to some extent, our thoughts about
the situation usually influence our mood much
more. Interestingly, the same situation can have
different effects on our emotions. So, any given situ-
ation may lead to any number of different thoughts
and emotions. Under the exact same circumstances,
we may react in a completely different way than we
did at another time. Different people may have vari-
ous reactions, and these may change from day to
day. There is, therefore, a connection between your
thoughts and emotions, regardless of the situation
you find yourself in. It is not only the situation that
influences your mood, but your thoughts about the
situation that affect your emotions.
In summary, the way you think affects how you
feel, as shown in Figure 15–2. The way you feel also
affects how you think. Most thoughts just pop up
and, regardless of whether the thoughts are correct
or true, they influence actions and emotions. When
Burn the toast
Receive a
compliment
FIGURE 15–1. Emotions associated with different situations.
negative thoughts dominate, these thoughts can
change your mood for the worse.
There may be certain situations that trigger nega-
tive thoughts, such as when you are trying to sleep,
alone, in a quiet place, talking to others, hearing
loud noises, reading, resting or relaxing, talking to
other people about your tinnitus, stress or irritation,
or working on something that demands concentra-
tion. Hence, being aware of when these thoughts
may occur is a good starting point.
Consider an example. If someone does not reply to
a message you send, you can interpret it in several ways.
You may think the person is upset with you, which
leads you to feel depressed. You may think the per-
son is unreliable, which leads you to feel annoyed.
You may think something bad has happened to the
person, hence the person is unable to respond; this
may lead to a lot of anxiety. Thoughts bout the same
situation thus lead to different emotional responses.
Our
The way Affects
behaviors
we think and
emotions
FIGURE 15–2. The association between the way we
think and the way we feel.
Feel frustrated
Feel good
 CHAPTER 15 THOUGHT PATTERNS 133

Identifying Thoughts, Understanding the Link Between

Feelings, and Behaviors
Think of an example of something that happened
in the past week that upset you.
n What was the situation? What happened,
why did it happen, what else was going on,
and is it a common situation?
n What thoughts went through your mind?
n What distressing emotions did you feel?
n What did you notice in your body? Was it
anxiety, anger, your heart racing, rapid
shallow breathing, light-headedness, dizzi-
ness, an unset stomach, difficulty focusing,
exhaustion, or tiredness?
n What did you do? Became angry, stay at
home, or avoid people?
Thoughts, Feelings, and Behaviors
Imagine something has happened that has led to
you to feeling depressed. As a result, you may not
want to leave the house, and you may want to just
stay in bed all day. If an event causes anxiety, there
will be a different response. You may feel an adren-
aline rush, your heart racing, and your breathing
getting faster. Your muscles may tense, and you
may become more alert. If a situation makes you
angry, the result will be a different set of behaviors,
thoughts, and physical sensations. You may start
shouting, become aggressive, and argue. We need
to try to break these cycles. Starting to identify them
is the first step. Table 15–1 provides an example of a
thought, possible emotions, and possible behaviors
in a situation.

Practice noticing these thoughts, feelings, and

behaviors. The more you practice, the more you will Thoughts About Your Tinnitus
become aware of them. The more you notice them,
the more you will be able to make helpful and effec- When you hear your tinnitus, it can bring on nega-
tive changes. tive thoughts and emotions. These feelings lead to

TABLE 15–1. Thoughts, Emotions, and Behavior Patterns for a Situation

Situation Thoughts Emotions Body Reactions Behaviors

You drop your People are so Happy, relieved Calm Smile, thank the
bag of shopping friendly. helper.
and someone
comes to help you I am so clumsy. Depressed, Slowed down, Withdraw as fast
collect your items. I can’t even carry hopeless, negative lethargic, sagging as possible.
a bag. self-view shoulders
I think there must Anxious Adrenaline Walk away fast to
be something response, heart get to go phone
wrong with racing, faster the doctor to make
me. This is not breathing, tense an appointment.
normal. Maybe muscles
I have a serious
illness.
The floor is so Angry, feelings of Tension, fired Argue with the
slippery. Why unfairness up, energized, shop owners,
didn’t they put in faster breathing, shout at the
different flooring increased heart person helping,
here to prevent rate, difficulty snap at people
trips? concentrating around you.
134 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

changes in your stress levels, mood, and actions.
Having tinnitus may thus set off a vicious cycle
and cause much worry. You need to actively work
at reversing this cycle and its effects. One way to do
this is to check your thought patterns. When you
have tinnitus, you may always be thinking about
your tinnitus. Thoughts about your tinnitus make
you focus on the tinnitus and can add to the dis-
tress related to the tinnitus. It is important to notice
these thoughts and where and when they are likely
to occur.
Let’s think about your thoughts regarding hav-
ing tinnitus. Health care workers often hear stories
about the effect tinnitus has on people’s lives. What
is noteworthy is that everyone’s reaction to tinni-
tus differs; different people have different thoughts
about their tinnitus. Some thoughts, such as “l will
never be able to cope if the tinnitus doesn’t go
away,” lead to feelings of despair. Other thoughts
may be “I will never be able to do the things I used to
enjoy.” These thoughts can lead to feelings of anger
toward having tinnitus. Thoughts such as “Tinni-
tus is a sign that something is wrong” are worrying
thoughts. There are also thoughts of longing again
for silence. This leads to being annoyed at always
hearing tinnitus. Further examples of thinking pat-
terns are shown in Table 15–2.
It is useful knowing about when these thoughts
arise to see whether there is a pattern. Thoughts
about your tinnitus may arise when you are:

TABLE 15–2. Examples of Thinking Patterns and Mindsets About Tinnitus

Thinking Pattern Description Example

All or nothing thinking When things are seen as either black
or white, with no grey area
Catastrophizing Thinking of the worst case scenario
Discounting the positive Discounting any positive experiences
and continuing to focus only on the
negatives
Labeling Limiting yourself through your own
criteria
Jumping to conclusions Making up your mind without
having all the facts
Overgeneralizing Seeing a single event as something
that will never end
Personalizing Blaming yourself for events not
going well
Should and must Living by rules that limit you
Misfortune telling Predicting only the worst scenario
Mind reading Jumping to conclusions before
having all the facts
Mental filter Paying attention to a small
negative detail as if it takes on great
importance
The tinnitus will ruin my life.
If I don’t sleep, I will fail my exam
tomorrow.
Anyone would have managed to do
that easy task.
I can’t socialize anymore.
Tinnitus means I have a serious
disorder.
I can never get it right.
It is all my fault that I have tinnitus.
I should never go to a noisy place
due to my tinnitus.
I will never change my depressed
mood.
My friends won’t understand my
difficulties with tinnitus.
The tinnitus sounded slightly
higher today. That means there is
something wrong with my health.

n Going to bed;
n In a quiet place;
n Talking to others;
n Reading;
n Resting or relaxing;
n Talking to other people about tinnitus;
n Stressed or irritated; or
n Working on something that demands a lot
of focus.
These unhelpful thoughts lead to certain feelings
and actions. You may be feeling hopeless. This feel-
ing may lead you to avoiding certain things, includ-
ing withdrawing from social events that you enjoyed
in the past. In turn, avoidance will make you miss
out on things you enjoy, and this will negatively
influence your mood and outlook.
Being aware of the thoughts you have about
tinnitus can be helpful.
What thoughts do you have about tinnitus, and
do they fit into one of the thinking patterns?

Helping to Change Thoughts
Sometimes we get into a rut during which certain
thoughts keep popping up by themselves. These
thoughts can cause us to jump to conclusions,
assume the worst, or doubt ourselves.
Changing the way you think about things is dif-
ficult, but helpful. One effective technique that can
help is the cognitive or thinking aspect of Cogni-
tive Behavioral Therapy, often called CBT. CBT deals
with how what we think about an event decides how
we feel about it. Further, how we feel about the event
affects how we behave. CBT aims to help you under-
stand your thought patterns about certain events.
It shows how your thoughts influence how you see
each event. CBT reminds us that how we interpret
an event is not the only way to see things. Different
reporters may describe a news story in a different
manner. In the same way, each of us will have our
CHAPTER 15 THOUGHT PATTERNS 135
own version of what happened due to our own set
of beliefs and values. These beliefs shape how we see
an event and how we are likely to respond.
Consider an example. Imagine you are being
served at a shop by someone who seems very
unfriendly. You may initially think “how rude”
and want to make a complaint. You may treat that
person in the same way the person is treating you.
Imagine that the person has just received some sad
news and is really struggling to process it. If you
were aware of that, you would then react very dif-
ferently and maybe show friendliness and empathy
despite the person seeming unfriendly. The key is to
recognize that it is not the event itself that decides
how you feel and behave. Rather, it is what you
think about the event at that moment.
Very often we don’t notice our thoughts; they just
pop up. Thus, we often assume our emotions are
due solely to the event itself. We don’t notice how
our thoughts shape our version of an event. CBT
is about teaching us to step back from, and notice,
our thoughts. Thoughts are our ideas, beliefs, words,
or images that come into our minds. Our response
emerges from different thoughts or beliefs, leading
to different feelings (happy, sad, angry), physical
reactions (sweaty, racing heart), and actions. Our
response emerges from different thoughts or beliefs
that lead to different feelings, physical reactions,
and actions. The links among these elements are
complex. CBT tell us that all four parts interact. Our
thoughts are often influenced by our feelings at that
time. We are more likely to think in a negative way
if we are already stressed or tired. At the same time,
how we behave can affect how we think and feel. For
example, getting angry and throwing something
may make us even angrier. This can make it harder
to calm down. A change in one element is likely to
affect the other elements. Where CBT in useful is in
finding when our thoughts may be leading us down
unhelpful paths. It’s almost like wearing sunglasses
that tint our perception of the world, filtering what
we see. When you are really anxious, you may be
focusing on possible threats and danger. When you
are feeling down, you are more likely to see things
through dull lenses.
By becoming aware of unhelpful thought pat-
terns, you can watch out for their influence. You can
allow yourself to consider and accept other views.
Once you fully grasp this idea, it can be extremely
136 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

helpful. It is helpful to recognize that our thoughts and
our thinking can change over time. These changes
influence how we interpret events. Facts do not
change. What we think about the facts and how
they affect us do change. You may dislike a certain
song until you hear it while having fun with a friend.
How you interpret the song changes without any
change to the song itself. Figure 15–3 provides an
example of how thoughts about tinnitus, can influ-
ence emotions, behaviors, and physical reactions.
How to Associate Thoughts and Emotions
If you recognize thoughts not as facts, but as how
you interpret the world, you realize you have choices.
This can allow you to consider ways of thinking that
may be more helpful. You can then change your
actions in the direction of your goals and values.
Challenging the negative predictions and assump-
tions of these instinctive thoughts may provide very
helpful perspectives. Challenging your thoughts
and assumptions is going to take time. A way to
start is by writing them down until you can detect
patterns more easily. Make a note of what hap-
pened. Then try to recognize the associated feelings
and thoughts. Although it may not be easy, try to
detect the links between your thoughts, emotions,
physical reactions, and actions. Over time, and with
practice, this will become easier. By seeing which
thoughts affect you, you can learn to challenge
these thought patterns.
Capturing Thoughts and Emotions
Some people find it easy to increase their awareness
of negative thoughts, while others have a harder
time. Expressing what you are thinking in writing
really helps you detect different types of thoughts.
Your thoughts may be hard to put into words, but it

Thoughts

“This will
never stop.”

Physical Emotions
reactions
Sad,
Tired hopeless

Behaviors

Withdraw,
stay home

FIGURE 15–3. How our thoughts about tinnitus can influence our
emotions, behaviors, and physical reactions.

is worth trying. Write roughly what you were think-
ing and the event you were in. Try to separate your
thoughts and emotions.
A rule is that many words are used to describe
thoughts. One word is used to describe emotions. Try
to capture the thought itself and not to write your
thoughts as questions.
How to Capture Thoughts and
the Resulting Emotions
At least three times this week for 10 minutes, write
down negative experiences and thoughts when
you feel depressed or worried, or when tinnitus both-
ers you. Follow these suggestions:
n Try to make a note as soon as possible.
n Write all the thoughts you have about tinnitus
(many words) or other negative thoughts.
n Then write how you feel (one word).
n To help, think about when and where your
tinnitus often bothers you.
n What are your thoughts about tinnitus at
these times?
n Be aware of your thoughts at times when
your tinnitus is loud and more bothersome.
n What does this sensation of increased tinnitus
lead to?
n Try to see the link between your feelings and
your thoughts about tinnitus.
n You can also write other thoughts that make
you worry or think negatively.
n Write what is going through your head.
n Complete the worksheet provided at the end
of the chapter every time you detect a nega-
tive thought so that you can link it to your
emotions.
n In the next section are some examples that
may help you.
Examples of How Your Thoughts
Can Affect Your Feelings
You have learned that it is not the situation, but your
thoughts, that influence your mood. Therefore, your
CHAPTER 15 THOUGHT PATTERNS 137
thoughts about tinnitus will influence your resulting
emotions, as illustrated in Table 15–3.
Addressing Common Difficulties
As learning to identify thoughts and the resulting
emotions is a new skill, you may have difficulty
in the beginning. Here follows some problems you
may experience and suggestions to address these
problems.
I have very few or no negative thoughts
about my tinnitus.
This is a good thing. You should not spend more time
working with negative thoughts than you need to.
Do you have negative thoughts about other things,
perhaps? Thoughts are so typical that we rarely
notice them, but they still affect our emotions. All
people have negative thoughts to varying degrees.
Try to be aware of what kinds of thoughts you have.
If you do identify unhelpful or negative thoughts
you can make a note of these, even if they are not
related to your tinnitus.
I don’t find my thoughts on tinnitus
very negative.
This is also good. The important thing is to deter-
mine whether your thoughts affect your mood in
a negative way. Even true thoughts can lower your
mood levels. Write down all the other negative
thoughts you have.
I find it difficult to express my thoughts in writing.
Thoughts don’t always come to us as complete sen-
tences. The important thing is that what you write
is in close agreement with what you are thinking.
You don’t have to be convinced about the thoughts
you are writing. If you wish, you could rephrase
a thought at a later stage. Make the distinction
between your thoughts and emotions. A thought is
a statement to which you react with an emotion.
I don’t think there is a way to deal with
negative thoughts, even if I do manage
to identify them.
You will learn more on how to handle negative
thoughts in the next chapter. Before giving up, you
TABLE 15–3. Thought Patterns

Situation Possible Thoughts Resulting Emotions

“My tinnitus will get worse in the future.”
“My tinnitus will not return to its normal level.” Anxious, sad
Noticing your
“If my tinnitus was always this loud, I couldn’t stand it.”
tinnitus has
suddenly “This is only temporary. If I do something else, it will
increased or Calm, in control
return to normal.”
changed
“It’s strange that it keeps changing.” Neutral, curious, a
“I wonder why it changed?” little anxious

Thinking about “I’ll go crazy, get depressed, stressed out, burn out, or
what your have a nervous breakdown.”
Anxious, sad,
tinnitus might “My tinnitus will always bother me.” hopeless
lead to in the
“Having tinnitus will make me go deaf.”
future
“I have a brain tumor.”
Thinking about “Having tinnitus is a sign that something within my body Afraid, anxious
what caused your is wrong.”
tinnitus
“Maybe something can be done.” Hopeful, happy
“I can’t cope with this.”
Out of control,
“My tinnitus drives me crazy.”
helpless, panicky
“I need a tranquilizer to cope with this.”
Feeling more “If I were stronger, I could cope with this.” Guilty, negative
annoyed by your “Why can’t I just ignore my tinnitus?” self-esteem
tinnitus than
usual “The sound really bothers me right now, but I have coped
with this before and will do so again.”
Confident, in control,
“Nothing will get better if I keep thinking about how hopeful
annoying my tinnitus is. I will find something else to do
instead.”
Hearing of or “Finally a possibility that I might get rid of this noise!”
reading about Happy, hopeful
“Maybe it can help me in some way.”
a new tinnitus
treatment “Nothing will work. It’s not worth trying.” Hopeless
“My tinnitus will keep me awake.”
Trying to fall “If I don’t fall asleep soon, I won’t make it through
Irritated, anxious
asleep tomorrow.”
“If I don’t get enough sleep, I will feel even worse.”
“This day is off to a bad start.”
“My tinnitus keeps waking me up.”
Noticing your “My tinnitus is the reason I don’t sleep soundly; that’s Irritated, hopeless
tinnitus is why I’m constantly tired.”
particularly loud
“It just keeps getting worse.”
when you wake
up “If I just get going, the sound will return to normal.”
Calm, decided, in
“This is how it is every morning, probably because control
everything is so quiet around me.”

138
TABLE 15–3. continued

Situation Possible Thoughts Resulting Emotions

“If I don’t get some rest now, I won’t make it through the
Noticing your rest of the day.” Stressed, anxious,
tinnitus bothers “Because of my tinnitus, I will never be able to get a good irritated, hopeless
you when you try night’s sleep, and I will be constantly tired.”
to get some rest “If I wait for a while and think about something else, my
Calm, in control
tinnitus will soon feel less annoying.”

Thinking about “Things were much better then. What is my life worth today?”
the times before “If my tinnitus doesn’t go away, my life will never again Sad, pessimistic,
your tinnitus be as good as it used to be.” hopeless
started “Why did it have to be me?”
Noticing your “I’ll never be able to do this if my tinnitus is this loud.”
tinnitus bothers “I never used to have problems with this kind of activity.”
you when you Irritated, sad, out of
“Because of having tinnitus, I will have to give up control
do things that
working/studying/doing this.”
demand your
full attention, “I find it harder to focus due to having tinnitus.”
such as working, “I can lessen this distraction. I am going to put on some
studying, background sounds.”
reading, or some In control
“When I relax, that often helps. Let me try it.”
hobby
“My tinnitus will get worse, so I won’t do it.”
“It won’t be as much fun as before my tinnitus started.”
Trying to decide “Maybe I’ll make whatever problem is causing my
whether or not tinnitus worse.” Sad, angry,
you should do “I won’t be able to cope because of my tinnitus.” pessimistic, anxious
something, such
as listening to “Having tinnitus makes it impossible for me to enjoy
music, going things I used to like.”
somewhere nice “Having tinnitus always gets worse afterward; it is no use.”
but loud, working “My tinnitus may get worse, but it is worth a try.”
out, meeting
people, having “Even if my tinnitus gets worse, it is better than not doing
Determined, in
special foods, or it at all.”
control
doing something “I will not let my tinnitus decide what I should or should
fun not do.”
“Good! That way I can forget about my tinnitus for a
Dedicated, happy
while, or at least it won’t bother me as much.”
“I’m sure that is how it will be for me as well.”
“Having tinnitus is really terrible.” Afraid, anxious,
“Why isn’t there more help available for those who suffer angry, in despair
Talking to or
from tinnitus?”
reading about
someone with “I wonder why they suffer much more than I do?” Curious, thoughtful
severe tinnitus
“I’m so lucky I’m not that bothered.”
“It is good to know that I’m coping rather well with my Relieved, in control
tinnitus after all.”
continues

139
140 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

TABLE 15–3. continued

Situation Possible Thoughts Resulting Emotions

“The only way to solve my problems is if my tinnitus

disappears, which I know it won’t.”
Hopeless
“If I haven’t found a way to cope with my tinnitus by
now, I never will.”
Thinking about
your problems “The problems come and go; it is difficult, but
and how to solve manageable.”
them Harmonious, hopeful,
“If I make sure my life is good in other ways, my distress
a little anxious, in
won’t be so bad.”
control
“I’m unlucky to have tinnitus, but on the other hand, I’ve
been lucky in other aspects of my life.”
“Having tinnitus makes it impossible for me to hear what
other people say.” Angry, irritated
Finding it hard to
hear what other “Having tinnitus blocks out other sounds.”
people say
“I know tinnitus is not the cause of my hearing loss. I am
Proactive
going to use some good listening tactics I learned.”
“Having tinnitus is the reason why I can’t stand loud
sounds anymore.” Afraid, anxious,
Finding loud “What if my tinnitus gets worse or if the sound is harmful irritated
noises in your to me in some other way?”
surroundings
bothersome “Although these sounds are loud to me, they are not
bothering anyone else around me. I know they are thus Accepting
not damaging my hearing.”

should at least read the next chapter. Because these
thoughts can be an example of negative thinking,
they may lead to your not trying new tools that
may help.
How do we process thoughts?
“Cognitive” means something that concerns our
thoughts or the brain’s processing of information.
For example, a “cognition” can be a thought, a
memory, or a mental image. We often do not know
the difference between thoughts and emotions. In
our everyday language, though, this distinction
is rarely made. For example, we might say, “I feel
like he doesn’t like me”. There are both thoughts
and emotions in this statement. The thought may
be, “He doesn’t like me,” and the emotion could
be sadness.
What do we mean by “identifying” a thought?
It may seem strange to try to detect thoughts that
are always present. In this case it means becom-
ing aware of them and expressing them in writing.
Thoughts rarely come to us as complete sentences.
They may be a constant flow of words, images, and
memories. Often it is hard to write exactly what
is going through your mind. The point is to make
yourself aware of your thoughts and how they affect
your mood.
Can positive thoughts constitute a problem?
Positive thoughts will often raise your mood as they
go through your mind. This makes them less of a
problem than negative thoughts unless they are
very unlikely. Many people keep hoping that their
tinnitus will go away. The drawback is that such
 CHAPTER 15 THOUGHT PATTERNS 141

thoughts have the potential of becoming upsetting,

because tinnitus rarely disappears. If you think the Reflection Activity
only solution is getting the tinnitus to stop, you will
miss finding other ways of feeling better. You could, n What is the most important thing you have
unfortunately, learn to become passive while wait- learned from this chapter?
ing for your tinnitus to go away. You should always 
be aware of how your thoughts, positive or negative,
affect your actions and your mood. n What tips are you going to apply?


Key Messages

n It is not the event, but your thoughts that

influence your mood.
n Thus, your thoughts on tinnitus, and not the
tinnitus itself, will influence your resulting
emotions.
n It is important to notice these thoughts and
the effect they have on your feelings.
Worksheet
Complete the worksheet shown in Table 15–4. This
will help you to identify the connection between your
thoughts, emotions, body sensations, and behaviors.
The first few rows provide some examples.
TABLE 15–4. Worksheet to Make Notes to Identify the Connection Between Your Thoughts, Emotions,
Body Sensations, and Behaviors

Situation Thoughts Emotions Body Behaviors

When, where, What went What did you Reactions What did
what through your feel and how What did you you do or
mind? intense were notice in your avoid? What
the feelings? body and was your What
where did you automatic have you
Date feel it? response? learned?
1/1/20: I was trying I wish this Angry Tense, I stormed Instead of
am to write a sound would wound up away from focusing on
report and just stop. my desk. the tinnitus,
couldn’t I should
because the try to see
tinnitus was whether
so loud. I can
improve my
focus despite
tinnitus.
1/1/20: I was trying I can’t do Sad Low energy I disengaged I need to
pm to read a anything and excused find ways
book to my I enjoy myself. of doing the
children. anymore. things I want
to despite the
tinnitus.

142
 Chapter
CHALLENGING THOUGHTS
What we see depends mainly on what we look for.
— John Lubbock
What This Chapter Covers
n Looking more closely at your thoughts
n How to lessen the effects that negative
thoughts have on your life
n Helping you challenge your thoughts
Introduction
Take a few minutes to focus on the effects of tinnitus.
Researchers have looked at the effects that tinnitus
may have on people’s lives. They found that peo-
ple with tinnitus often limit themselves from doing
certain things. This happens when they stop doing
things they like or stop going to certain places. For
example, those with tinnitus were found to go to
fewer social events due to fear of their tinnitus get-
ting worse. Stopping doing the things you enjoy can
lower your quality of life. What is really important
is being able to keep doing the things you want to
do, despite having tinnitus. You may worry that you
need to stop doing certain things due to having tin-
nitus. Often the events are not themselves a prob-
lem, however, worrying thoughts makes dealing
with them harder. Your thoughts about such events
may be a problem. Remember you learned that it is
not only the event itself that causes your emotions,
but also your thoughts about the event, which have
a strong influence. Make sure that you are not stop-
ping doing things you enjoy. It is important to chal-
lenge thoughts that restrict you. You should not just
accept them. This chapter discusses what challeng-
ing thoughts involves. It provides ideas to help you
16
to think in a different way about worrying thoughts.
There are many new ideas in this chapter. Take your
time going through it. You may choose to read a bit
every day this week instead of reading it all at once.
The Purpose of Challenging Thoughts
The purpose of challenging thoughts is to help you
deal with your thoughts and reduce their negative
effect on your mood and your everyday life. The aim
is not to have “positive” or “correct” thoughts at all
times, but rather to make your negative thoughts
more sound and balanced as well as to learn to
ignore them at times and instead focus on doing
what you want to do.
Why Challenging Thoughts Is Important
Thinking is something we do, just as we breathe,
eat, walk, or sleep. Our ways of thinking are often
habitual and follow a certain pattern. If you can put
your thoughts into perspective and find new ways of
relating to them, it is possible to make a change. This
chapter is going to help you learn how to deal with
unhelpful thoughts. You don’t need to just accept
thoughts. You can question them and view them in
a different way. For example, suppose your tinnitus
changes. Alternatively, you may think: “My tinnitus
is suddenly worse. There must be something serious
wrong with my health.” You can think about this
and conclude, “My tinnitus sounds often change; it
has not meant a serious health issue in the past.”
Taking some time to question your thoughts helps
you get some distance from them so you can explore
a different view about them. Being able to challenge
your thoughts is important. If your brain is always
focusing on the problem, it lessens the chance of
143
144 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
solving it. You also miss the chance of getting a dif-
ferent viewpoint, which may be more correct.
We can easily get ourselves into a vicious cycle of
negative thinking, feelings, and behaviors. When
you see the parts of the vicious cycle clearly, you
can change them and thereby alter the way you
feel. It is also useful to look at the way our thoughts
and feelings affect us emotionally and physically.
This chapter is aimed at helping you reach a point
where you can work out how to tackle problems
by yourself.
How to Explore Thoughts
The following steps can be used to logically and sys-
tematically explore your thoughts.
1. First, discover the type of thought.
2. Then ask yourself questions about the
thought. This will help you view the
thought from different angles.
3. Challenge the thought.
Step 1: Detect the type of thought or mindset.
n At first it will be hard, but try to take a step
back from your thoughts.
n Make a note of thoughts or mindsets that are
unhelpful.
n Try to determine in which mindset your
thought falls.
The previous chapter indicated that people become
trapped in thought patterns without being aware
of the thoughts themselves. Sometimes you may be
aware only of the effect, such as avoidance or stress.
Other times, you may become trapped in a pattern
of thinking without being aware of its effects. An
unhelpful mindset is when your thinking is too basic
or inflated. The majority of our thoughts are not
very clear or tangible. Words, emotions, and images
intertwine, making it hard to tell what a thought is
really about and what it means.
To help you to deal with a negative thought, it
is important that you try putting it into words as
clearly as possible. Sometimes you may have to
change the thought a little and move away from
what was going through your mind. If you realize
that a thought is vague, rephrase it to make it more
concrete. Sometimes, doing this is in itself a pow-
erful way to disarm negative thoughts — by forcing
fuzzy, but strongly emotional thoughts into some-
thing more concrete and specific. Doing this makes
you realize that your thoughts may be simplified,
exaggerated, or not so realistic or threatening as
they first felt. Also, write down how accurate you
find a thought when you look at it from a distance,
instead of experiencing the effects without question.
Here are some steps to help.
Is the thought a mindset?
n Focusing on the negatives: Not thinking of
the positives by focusing only on how bad
something is. You then do not notice whether
there is anything good about it.
n Assuming the worst: When you believe that
something is far worse than it really is.
n All or nothing thinking: When you see
things in only two categories such as black or
white. You may think that everything has to
be perfect, otherwise it is no good at all — for
example, “I will never be able to do things
I enjoy again due to tinnitus.”
n Jumping to conclusions: Being very
convinced that something will turn out badly.
Before trying, you decide that there is nothing
that can change the outcome.
n Blaming: Blaming someone or something
for what goes wrong or for making you feel or
act a certain way. It is easy to blame all your
problems on one thing, such as your tinnitus.
For example, some patients with hearing loss
and tinnitus blame their tinnitus for problems
hearing. By doing so, they might not take
charge of their hearing problems. At the same
time, they may make their tinnitus problem
bigger than it is by placing all the blame
on tinnitus.
Is the thought unhelpful?
Sometimes it is not a mindset but a negative, worry-
ing, or unhelpful thought that causes stress. In these
cases, try to identify the type of thought according to
the following list. Keep in mind that it is not always
easy to do and is going to take time.

n Clear or vague;
n Correct or incorrect;
n Realistic or inflated;
n Truthful or false;
n Helpful or unhelpful; or
n Engaging or restrictive.
Step 2: Ask questions.
When you notice an unhelpful thought, explore it.
n Ask yourself questions about the thought.
n Try to determine whether there is another
way to view it.
n This can help challenge, explore, and
distance yourself from negative thoughts.
Doing so will lessen their effect.
There are different types of questions you may ask.
Ask questions to clarify the thought.
n Is there any truth behind the thought? Is it
fact or opinion?
n How accurate is the evidence this thought is
based on?
n Is it fact-based or something you feel?
n Are these feelings based on what is really
happening?
n What are the claims for and against the
thought?
n Is there any proof to support the thought?
Ask helpful questions.
n If someone close to you shared that thought,
what would you say to that person?
n What would someone who cares about you
say to you if you shared the thought with that
person?
n What does continuing to think these worrying
thoughts lead to?
Use self-belief and positive self-talk.
n Reassure yourself that you can get through
this. You have done it before.
n This situation will also pass. It is only
temporary.
CHAPTER 16 CHALLENGING THOUGHTS 145
n Think of times you have managed before and
know that you can again.
Step 3: Challenge the thought.
By working at dealing with negative thoughts, you
may find that some thoughts go away and bother
you less. You are trying to get distance between you
and the negative thinking to get a new viewpoint.
Writing down the thought may help. Table 16–1 pro-
vides some examples of how to challenge thoughts.
After observing a thought, the first step is always
to tell yourself to just stop for a moment, take some
deep breaths, and focus on a safe positive image.
Breathe mindfully and focus on the sensation of the
belly breathing calming you down. You may choose
to first focus your attention on a different activity,
listen to some relaxation music, or do some physi-
cal exercise. This will help you to then address the
problems you are facing.
How to Overcome Negative Thoughts
and Unhelpful Mindsets
Table 16–2 gives ideas on challenging thoughts
using the same examples found in the previous
chapter. You will find tips on how to explore and
deal with each thought. These thoughts may be dif-
ferent from the ones that you have. They try to show
how you can manage thoughts that are not helpful
and negative. This is hard, but worth working at, as
explained by this quote:
Those who don’t have power over the story that
controls their lives truly are powerless. Think new
thoughts to retell it, joke about it, and change it.
— Salman Rushdie
When to Challenge Thoughts
Challenge your thoughts for 5 to 20 minutes at least
four times this week. Do this as often as possible
when a negative thought pops into your head. Prac-
tice when your thoughts bother you or have a nega-
tive effect on you.
Summary of How to Challenge Thoughts
n List your negative thoughts, mindsets, or the
tinnitus myths you have noticed. on Table 16-3.
146 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

n You can use thoughts you wrote down in
the previous chapter about identifying your
thought patterns.
n Write how much you really believe this
thought, for example, “I believe it 100% or
50%.”
n Note the type of thought or mindset, and how
concrete the thought is.
n Then reword any thoughts that you are
unable to clearly explain to another person.
n Take the thought and ask questions about it.
The questions should clarify, challenge, and
help you think about the thought.
n Now, again, rate how much you believe this
thought. Is it a lower percentage, such as
20%?

TABLE 16–1. Examples of How to Challenge Thoughts

How to Challenge a
Thought Explanation
Get more proof or Explore the claims based on accurate research. Don’t rely only on the
information. thought, all media, and unreliable Internet sources.

Discuss with someone Talk to someone who is supportive and a good sounding board.

Stop the thought. Stop thoughts that are unhelpful and stay in your head. Imagine you can
press the stop button as you do when you are listening to music. Press the
button and say, “Stop, I am not going to carry on with this thought.”

Get the views of others. Think of views for and against the thought.

Oppose the thought. Do the opposite of what the thought suggests. In this way your thoughts do
not control your life. An example may be going for a run although you at
that moment think you would rather rest.

Think of other When you have negative thoughts, think of other views of the situation. You
possibilities. may be worried about possible harm to someone who is late getting home.
Write down other views. It could be that the person’s phone battery is dead so
he or she cannot contact you. The person could be in an important meeting
that cannot be interrupted, or the traffic could be bad.
Change your focus. This is a good time to relax and focus on a positive image or do mindfulness.

Do a detailed 5-minute Spend 5 minutes carefully analyzing the thought by writing it down. Write
analysis. down how realistic, concrete, and helpful the thought is. If you find it
difficult, stop when the 5 minutes are up, but keep the paper and return to it
later for another 5-minute session.

Make vague thoughts Vague thoughts cannot be controlled, can create anxiety, and are harder to
more clear. deal with. See whether they can be rephrased.

Evaluate the thought Behavioral experiments focus on first doing something about a problem,
in practice (behavioral then evaluating the results and the consequences. Start by writing down the
experiment). evaluation of the thought. For instance, the thought may be, “I can’t go out
because my tinnitus will get worse.” Next, write down what will happen if
you acted on this thought (for example, I didn’t go and regretted it). Then
write down the opposite of the thought (for example, I went and had fun. My
tinnitus was louder, but only for a few hours). Evaluate the results and decide
if you are going to act according to the thought or not.
TABLE 16–2. Examples of How to Challenge Thoughts

Possible
Event Thoughts Challenge the Thought
Noticing your “My tinnitus will Challenge: These statements are concrete, but not always correct.
tinnitus has get worse in the It is very hard to predict how your tinnitus might change and how
suddenly future.” you would cope. Your tinnitus often changes for a short period
increased or without getting worse. The thoughts are not helpful and do not
“My tinnitus will
changed help you resolve the problem.
not return to its
normal level.” Other options: “It is common and normal for my tinnitus to
change. It should go back to normal soon. I am going to do
“If my tinnitus something else to take my focus away from my tinnitus.”
was always this
Mindsets/Myths: These statements are jumping to conclusions or
loud, I couldn’t
assuming the worst.
stand it.”
Idea: Try thought stopping. Develop other thoughts, such as
focusing in a mindful way or on sights and sounds around you.
Do not let your thoughts about tinnitus decide your emotions and
actions.
Thinking “My tinnitus will Challenge: The thought is vague. In what way will your tinnitus
about how always bother bother you? Does “always” mean 24 hours a day? How troublesome
tinnitus will me.” do you think it will be? Will you be slightly bothered once a day
affect you in or will you be totally unable to work? The thought is too vague to
the future assess, and it is not helpful because it can make you feel down.
“My tinnitus Challenge: The statement is specific, but clearly untrue. Tinnitus
will make me go does not cause deafness. There may be various reasons for
deaf.” tinnitus, as well as for the hearing loss. For many people, tinnitus
gets better over time even though hearing gets worse.
Myth: “Tinnitus can cause hearing loss.”
Idea: Try to get more advice from your doctor or someone (such
as ATA.org) that will provide accurate facts.
“I’ll get depressed, Challenge: This is a vague thought because it is not clear
stressed out, what is meant by “crazy,” “stressed,” and so on. How will your
burned out, tinnitus cause these effects? It is hard to answer because there
have a nervous are a number of other factors affecting your well-being. You are
breakdown, or go also trying to predict the future. This program has been very
crazy because my helpful for others. In addition, even people who don’t receive any
tinnitus is always treatment feel that their distress gets less over time. The thought is
there.” not helpful because it makes you feel more stressed and depressed.
Although it can help you to deal with the problem, using more
exact thoughts can make it easier.
Other options: “Anyone can feel down or sad, whether or not the
person has tinnitus. I will focus on feeling good in other aspects of
my life. In that way I can keep the annoyance of tinnitus under
control. This program will help me cope with my distress.”
Mindsets/Myths: This statement is jumping to conclusions.
Idea: Explore the thought for 5 minutes or practice thought
stopping. Also make sure you make vague thoughts more
concrete. Find and correct thoughts that convey misplaced blame
and negative predictions, such as “tinnitus causes severe distress”
and “the only way to stop the distress is if my tinnitus stops.”

continues

147
TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Contemplat- “A brain tumor Challenge: This statement is concrete, but very unlikely if you
ing what caused my have already had a medical check and nothing was picked up
caused your tinnitus.” then.
tinnitus Mindset: This statement is assuming the worst and jumping to
conclusions.
Idea: Try to get more advice from your doctor and trust the advice
given.
“Tinnitus is Challenge: Thoughts such as “Tinnitus is a sign that something
a sign that is wrong” are very general. Although there are many potential
something is causes, in many people no specific cause for the tinnitus can be
seriously wrong.” found. In most cases, having tinnitus does not mean there is a
major health problem. The thought does not have details, which
makes it hard to challenge and assess. Overall this type of thought
is not helpful.
Other options: “There is often no reason for getting tinnitus,
and sometime is is due to a slight change in hearing. It does not
always indicate that there are other things wrong with me.”
Mindset/Myths: This state is assuming the worst and jumping to
conclusions.
Idea: Challenge the thought or do thought stopping. Also, make
sure you make vague thoughts more concrete.
“Maybe Challenge: The thought is vague because it is not clear what
something can be could be done. The thought can be helpful if it provides comfort
done.” or hope. It can also add to your distress if you think that stopping
the tinnitus is the only solution. This can stop you from dealing
with your tinnitus because you are hoping that it will go away.
Other options: “I have to accept the fact that my tinnitus will not
go away. I am thus going to focus on coping better with it.”
Mindset/Myth: This is all or nothing thinking as the thought
indicates that the only way to address tinnitus is if it stops.
Idea: Try exploring the thought for 5 minutes. Make vague
thoughts more specific and challenge the thought.
Feeling more “I can’t cope with Challenge: Both thoughts are vague. What do “can’t cope with”
annoyed by this.” and “crazy” mean? These thoughts need to be reworded in a more
your tinnitus specific manner. They can make you feel sad because you have a
“Having tinnitus
than usual constant threat hanging over your head.
drives me crazy.”
Other options: “Tinnitus really bothers me right now. I have
coped with this before and will do so again.”
Mindset: These statements draw negative attention and make
negative predictions. For example, “having tinnitus causes severe
distress.”
Idea: Try exploring the thought for 5 minutes. Make vague
thoughts more specific. Use thought stopping. Don’t let your
thoughts decide what you should do.

148
TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Feeling more “I need a pill or Challenge: Although it is not very clear what “cope with” means,
annoyed by medicine to cope this thought is more concrete than the earlier ones. It is possible
your tinnitus with this.” to assess this thought. Research shows that using pills a lot can
than usual lead to your relying on them. You may need help to break your
continued reliance on them. The thought is not helping you find other ways
of coping.
Other options: “This is very hard, but if I can cope without using
pills now, it will be easier next time. I can use the skills I learned
during the course to cope with this. The distress is tiresome but
does not cause any harm.”
Mindset: This is all or nothing thinking.
Idea: Try making the vagueness of “cope with” more concrete. Do
not let the thought decide what you should do, or do the opposite
of what the thought suggests. Also discuss the thought with
someone else, or jot down other thoughts.
“If I was stronger, Challenge: You will feel weak if you think you can’t cope with the
I could cope with event. Then you will think you can’t cope with the event due to
this.” feeling weak. Thinking you can just shake off the problems that
you have had for a long time is not realistic. You have to practice
“Why can’t
coping with your problems in smaller steps. These thoughts are
I just ignore my
not helpful. You are not weak; you just need more tools to help
tinnitus?”
you with the tinnitus.
Other options: Other statements include, “Nothing will get better
if I keep thinking about how annoying my tinnitus is or how weak
I am. I will find something else to do instead. It is normal that
I feel this way in the beginning. It takes time to learn how to cope
with having tinnitus.”
Idea: Challenge the thought and try thought stopping. Also make
sure you make vague thoughts more concrete.
Hearing of “Finally a Challenge: It is not realistic to hope for a treatment that could
or reading possibility that remove your tinnitus at present. Research is still working on
about a new I might get rid of this, but no cure has been found. Claims to “help you” in some
tinnitus this noise!” vague way are very common. The media often inflates the effect
treatment of different treatments in order to make them appear better than
“If I can’t make
they really are. Because there are different types of tinnitus,
the tinnitus go
certain things will work better for some people than for others
away completely,
with tinnitus. You should question things that claim to cure
then there is no
tinnitus.
point in trying a
treatment.” Myths on tinnitus: “The only way to stop the distress is if my
tinnitus goes away.”
Mindset/Myths: This is all or nothing thinking.
Idea: Try to get more advice from a doctor on treatment options.
Discuss the thought with someone else or explore the thought for
5 minutes.

continues

149
TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Trying to fall “Having tinnitus Challenge: All three thoughts are quite vague. It is not clear
asleep will keep me how long your tinnitus will keep you awake. What does “won’t
awake.” make it” or “feel even worse” mean? Having tinnitus together
with these anxious thoughts will probably make it harder for you
“If I don’t fall
to fall asleep and might interrupt your sleep. Look at the “Sleep
asleep soon,
Guidelines” chapter. That can help you. The negative effects of
I won’t make
not having enough sleep are not always as serious as you might
it through
think. The thoughts are not helpful as they make it even harder to
tomorrow.”
fall asleep.
“If I don’t get Other options: “My body will get as much sleep as it needs;
enough sleep, feeling tired is not harmful. If my sleeping problems carry on,
I will feel even I can use the advice from the chapter on sleep. I have had
worse.” problems sleeping before and these got better.”
Mindset/Myths: These statements are finding things to blame,
assuming the worst, or all or nothing thinking, for example, “My
tinnitus disturbs my sleep and makes me tired during the day.”
Idea: Write down what you think will happen. How correct are
these thoughts? Have a look at the sleep chapter.
Noticing your “This day is off to Challenge: The first and last thoughts are very general. The other
tinnitus is a bad start.” two are more concrete, but not very realistic. The way they are
particularly worded makes it hard for you to know whether they are true or
“Having tinnitus
loud when not. These thoughts are not helpful because they all focus on your
keeps waking me
you wake up distress and on your tinnitus.
up.”
Other options: “I can’t know for sure whether it is tinnitus that
“Having tinnitus wakes me up. If I just get started on things, the sound will return
is the reason to normal. This is how it is every morning, probably because
why I do not it is so quiet at that time. Instead of thinking about it, I will do
sleep soundly. something else that will cheer my mood.”
That is why I’m
Mindset/Myths: These statements are finding things to blame,
constantly tired.”
for example, “My tinnitus disturbs my sleep and makes me tired
“It just keeps during the day.”
getting worse.” Idea: Get more advice on improving your sleep. Use thought
stopping. Make general thoughts more concrete. Follow the advice
in the sleep management chapter carefully.
Noticing “If I don’t get Challenge: The first thought is more vague and harder to assess
your tinnitus some rest now, than the second one. What does “won’t make it” mean? Both
bothers you I won’t make it thoughts also try to predict the future, which makes them harder
when you try through the rest to challenge. The thoughts are also not realistic. Thus, both
to get some of the day.” statements are not helpful.
rest Other options: “If I wait for a while and think about something
“Because of my
tinnitus, I will else, I won’t notice my tinnitus as much. I need to do something
never be able active or exercise to help.”
to get good rest Mindset/Myths: These statements are finding things to blame
and I will be or negative predictions, for example, “Having tinnitus always
constantly tired.” disturbs my sleep and makes me tired during the day.”
Idea: Make general thoughts more concrete. Make sure you do
regular exercise and relax often.

150
TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Thinking “Things were Challenge: These thoughts are very general and partly formed
about the much better then. as questions. If you make them more concrete, you will probably
times before What is my life spot things that have become worse as well as things that haven’t
your tinnitus worth today?” changed. It is very hard to decide how realistic these thoughts are.
started Other options: Other options could include, “Although I can’t
“If my tinnitus
doesn’t go away, change the past, things can be different in the future. My quality
my life will never of life depends on many other factors, not only on having tinnitus.”
again be as good Mindset/Myths: These statements are all or nothing thinking
as it used to be.” and finding things to blame, for example, “The only way to stop
the distress is if my tinnitus goes away. Having tinnitus causes all
“Why did it have
my problems.”
to happen to
me?” Idea: Challenge the thought, use thought stopping, or do
mindfulness.
Noticing “I’ll never be able Challenge: The thoughts are concrete because they are clearly
your tinnitus to do this when about your ability to focus. Although having tinnitus can have a
bothers you my tinnitus is negative effect on your ability to focus, the thoughts may not be
when you do this loud.” true. Other factors also affect your focus. These types of thoughts
things that often only add to the problem, as they demand your attention
“I never used to
demand your and contribute to your feeling distracted. It makes it hard to
have problems
full attention, concentrate when your mind is on something else.
with this kind of
such as Other options: “Maybe I won’t be able to do it as quickly as
activity.”
working, I used to, but I will manage. I will focus more on things I’m good
studying, “Due to my at. I will get better with practice.”
reading, or tinnitus, I will
Mindsets/Myths: These statements are assuming the worst,
some other have to give
finding things to blame, or all or nothing thinking.
hobby. up working/
studying/doing Idea: Use thought stopping. Follow the advice on focusing. Don’t
this.” let your thoughts decide what you should do. Do the opposite of
what your thoughts suggest, for example, try carrying out the task
“Tinnitus makes on a small scale.
it hard to focus
on anything.”
Trying “It won’t be as Challenge: These thoughts need specifics that make them more
to decide enjoyable as the concrete. Though it is probably realistic to think that your tinnitus
whether times before my may get louder for a little while, this thought is not very helpful.
or not you tinnitus started.” Most of the time these types of thoughts make you avoid things
should do you might have enjoyed. This makes you feel even more alone.
“Maybe I’ll make
something, The thought about your hearing getting worse is only true if you
the hearing loss,
such as listen to really loud noises without using hearing protection.
which is causing
listening to Other options: “Good, that way I can forget about my tinnitus
my tinnitus,
music, going for a while. At least it won’t bother me as much. My tinnitus may
worse.”
out, meeting get worse for a little while, but I know that ahead of time and can
people, deal with it.”
having
certain foods,
or doing
something
fun
continues

151
TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Trying “I won’t be able Mindsets/Myths: These statements are negative predictions or

to decide to cope due to all or nothing thinking, for example, “My tinnitus will get worse
whether having tinnitus.” if I go.”
or not you Idea: Do not let your thoughts decide what you should do, or do
“Having tinnitus
should do the opposite. Discuss the thought with someone else or think of
makes it hard
something, other thoughts.
for me to enjoy
such as
things that I used
listening to
to like.”
music, going
out, meeting “My tinnitus
people, always gets worse
having going out. It’s no
certain foods, use.”
or doing
something
fun continued
Talking to “I’m sure that is Challenge: The last two thoughts are very general. The first one
or reading how it will be for may also be too general. Comparing yourself to someone else is
about me as well.” not helpful because everyone is different, even others who have
someone who the same condition. The thoughts are not helpful and will only
“My tinnitus is
is annoyed make you worry and focus on the negative.
really terrible.”
by severe Other options: “I wonder why he or she suffers much more
tinnitus “Why is there than I do? I am lucky I am not as distressed about my tinnitus.
not more help It is good to know I am coping rather well with my tinnitus. It
available for is interesting that the annoyance of tinnitus can vary greatly
those that suffer between people.”
from tinnitus?”
Mindsets: This is all or nothing thinking, for example, “Having
tinnitus causes all my problems.”
Idea: Try thought stopping. Explore the thought for 5 minutes.
Make general thoughts more concrete and get more facts.
Thinking “The only way Challenge: These thoughts are quite clear and concrete but
about your to solve my refer to all tinnitus problems as exactly the same. This is not
problems and problems is if very realistic because the distress can get less while your tinnitus
how to solve my tinnitus remains the same. You can also learn many different ways to cope
them disappears, with your tinnitus. The first thought leads to feeling hopeless.
which I know The second may cause you to not to want to solve the problem.
won’t happen.” Neither are helpful.
“If I haven’t Other options: “The problems come and go. It takes a lot of effort
found a way to on my part, but it is possible to manage. If I work on improving
cope with my other aspects of my life, the distress caused by my tinnitus won’t
tinnitus by now, be so bad. If I try several different ways of coping with tinnitus, it
I never will.” will get better. I will find something that works.”
Mindsets/Myths: This is all or nothing thinking and negative
attention, for example, “The only way to stop the distress is if my
tinnitus goes away.”
Idea: Try thought stopping, discuss the thought with someone
else, and make notes with questions and think of other options.

152
 CHAPTER 16 CHALLENGING THOUGHTS 153

TABLE 16–2. continued

Possible
Event Thoughts Challenge the Thought

Finding loud “Having tinnitus Challenge: These are quite concrete thoughts. The first thought
noises in your is the reason shows this concept is not grasped. Refer to the section on common
surroundings why I can’t stand myths at the end of Chapter 5 in the tinnitus overview chapter.
bothersome loud sounds The second thought is inflated. It can be helpful to anyone when
anymore.” there are harmful levels of loud sounds. Being sensitive to sound
often makes harmless sounds feel harmful. It is important to
“What if my
learn more about how to assess sounds and whether they are
tinnitus gets
really a risk.
worse or if the
sound is harmful Other options: “Although a sound feels harmful, it may not cause
to me in some any harm. Tinnitus may not be the cause of feeling this way.”
way.” Mindsets/Myths: This is finding things to blame and negative
predictions, for example, “Having tinnitus can cause hearing loss.”
Idea: Try to find more facts; read the chapter discussing being
sensitive to sound. Use thought stopping. Don’t let your thoughts
decide what you should do, or do the opposite.

Addressing Common Difficulties
As learning to challenge your thoughts is a new skill,
you may have difficulty in the beginning. Here fol-
lows some problems you may experience and sug-
gestions to address these problems.
It is hard to explore my thoughts.
You don’t have to explore all negative thoughts
carefully. Select those affecting you the most. If you
believe there is only one way to view things, you will
not find new ways of thinking. Because you may
have been thinking a certain way for some time,
it may take a long time to change this. It is not
realistic to think that you should be able to explore
thoughts perfectly after reading about it once. You
may need to read the content of this chapter more
than once. Go through the suggestions given to help
you. Use the examples of common thoughts shown
in Table 16–2 if you need help. Also remember that
sometimes you do not need to explore all thoughts.
You may choose to just stop the thought.
I find it hard to challenge thoughts.
You may try to deal with a negative thought, but
also feel silly doing this. You may forget how to, or
not get the results you want on the first try. Because
this way of thinking may be an old habit, it will
take time and hard work to challenge old patterns
of thinking. At first it may be hard, but will soon
become more natural. After a while, other ways of
thinking will develop and begin to feel more natu-
ral. If you find it hard to reword vague thoughts,
try to do the opposite of the thought. After a couple
of times, the negative thoughts will have less of an
impact on you. You will feel more at ease with the
different tools.
Start by selecting a small number of ideas. Even
if the tips you selected are not the ones that are best
suited for you, you will still benefit from them. After
carefully trying a couple of things, move on to some
of the others.
How do we process thoughts?
Finding new perspectives on negative thoughts and
viewing them “from a distance” is often very helpful.
It can help you to move on and gain some clarity.
When you are analyzing a thought, you are making
it clear to yourself that you are considering what is
really just a thought. Just because it feels true doesn’t
necessarily mean that your interpretation is correct.
It shouldn’t automatically be accepted as a fact or
154 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

allowed to control your actions. By analyzing your n Challenge these thoughts by exploring them
thoughts, you demonstrate to yourself that they can and thinking how to deal with them. This
be questioned and viewed in a different way. This is may include talking with someone else or
a better starting point than just accepting them. See stopping the thought.
the analysis of your thoughts as a first step to cop-
ing with negative thoughts more successfully as they
come up. However, be aware that it may not always Reflection Activity
be enough to simply analyze a thought. Sometimes
you need to do something active to deal with it. n What is the most important thing you have
learned from this chapter?
Can I get rid of unwanted thoughts and emotions?
Regardless of whether or not you have tinnitus, life
is full of negative events. It is important to remem-

ber that negative thoughts are a part of our lives.
You can work at ensuring these have less of an effect
n What tips are you going to apply?
on you. Being able to think about the way your
thoughts affect emotions and actions gives you the
chance to adapt to different events. When thoughts
are having a negative effect on you, it is important 
to try to change them and focus less on them. If you
are finding it hard, take a break and switch your
focus to something else.
Worksheet
Key Messages
Complete the worksheet shown in Table 16–3.
n There may be thoughts that are stopping you This will help you see your progress. It is good to
from doing things you want to do. have something to remind you of how much you
n Ask questions to help you clarify and chal- have accomplished. The first row provides some
lenge these thoughts. This can help you view examples.
the thought from a different angle.
TABLE 16–3. Worksheet to Make a Note of Your Challenging Thoughts and the Strategy You Use to
Overcome Them

Strategy How
and much
How replacement do you
much What thought, believe
do you mindset such as the
believe or type of rewording thought
the thought the thought now,
thought, is going to explain e.g., not
What e.g., through to others, very
was the partially your challenge much
Date Situation thought? (50%) mind? the thought (30%)? Result
1/1/20 I couldn’t Tinnitus 50% Assuming Oppose the 30% This is
hear my is going to the worst thought. I difficult,
students. cause me recently got but I can
to lose my a promotion. see the
job. My boss is value.
pleased with
my standard
of work.

155
 Chapter
The present moment is filled with joy and happiness.
If you are attentive, you will see it.
— Thich Hanh
What This Chapter Covers
n Learning to focus on the “now”
n Focusing on the present moment
n Noticing the good things around you
Introduction
Often, we are very focused on things that we still
need to do during the day. Other times we keep
thinking about the future. We also often think about
the past and how things could be different. It can be
very hard to clear your mind. Thoughts keep com-
ing, and it can be difficult to switch them off. When
life is hard, thoughts about these problems stay in
our minds. This can be very tiring and make it hard
to focus on the present moment. Other times we are
in autopilot mode. For example, sometimes you
may be busy with something but not notice you are
doing it. You may have gobbled down your food in a
rush without having even tasted or enjoyed it. So we
spend a lot of time inside our heads, thinking about
what happened, what we have to do, or worrying.
This chapter is going to help you focus attention on
the present moment. This is called being mindful. It
helps you for that moment not to worry about the
future or dwell on the past.
17
BEING MINDFUL
The Purpose of Being Mindful
Being mindful aids directing your focus to what you
are doing instead of being on autopilot. It helps you
engage in and enjoy the present moment. Kabat-
Zinn, 2015, defined being mindful as, “On purpose,
in the present moment, and without judging.” Being
mindful has many benefits. It calms down your
mind. It also helps you to notice the world around
you. It is like stopping to smell the roses. It lets
you see things that you might overlook during the
bustle of a busy day. It sharpens your memory and
improves your focus. Research has shown that being
mindful can help lessen the effects of tinnitus. It can
also lower stress and other negative emotions. It has
also been found to improve overall well-being and
sleep.
It even helps people cope with pain, high blood
pressure, and healing. Learning to be more mindful
can help with tinnitus and has many other benefits.
What Being Mindful Involves
Being mindful helps the focus to be on the present
moment — for instance, how your body feels right
now. It provides a period of time when the focus is
not on your daily worries or concerns. Being mind-
ful will take practice. You may, for instance, not be
aware of certain sounds. If you stop to listen, though,
you may notice the sound of a car passing by or the
sound of the wind outside. Mindfulness helps you
to learn to focus more on these sounds. It does not
157
158 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
need to take any extra time away from daily activi-
ties. It may be focusing on one thing, such as your
breathing or on what is going on around you at any
moment. This involves noticing things you see, feel,
hear, and taste.
The acronym NOW can help.
n Notice, right now, your focus of attention.
n Observe, and say to yourself (and notice)
whatever you are doing, for example,
“I am breathing sitting, listening, walking.”
Describe rather than judge.
n Where should I focus my attention now?
When to Be Mindful
You can be mindful at any point during the day. You
can do it as part of your daily routine. This may be
when brushing your teeth or folding the laundry.
Following are some examples.
When washing your hands:
n Feel the softness of the soap against your skin.
n Enjoy the smell of the soap.
n Notice the shape of the soap you are holding.
n Hear the sound of the water against your
skin.
n Feel the texture of the towel when drying
your hands.
When eating:
n Take something small to eat, such as a
grape or raisin. Instead of finishing it as
fast as you can, take a moment to feel the
texture.
n Smell it and look at its shape and color.
n Involve all five of your senses and ask your-
self, “What does it look like, feel like, sound
like, taste like, and smell like?”
n Look at the grape or raisin as if you are
tasting one for the first time.
n Let other thoughts pass and try not to focus
on them. Focus only on the grape and enjoy
eating it.
When walking:
n You may be walking in town. Notice the color
of the shops and the shapes of their windows.
Look at the contents of their displays.
n You may be in nature walking the dog. Listen
to your footsteps, the rustling leaves, and the
birds singing. Look at the color of the sky and
the shape of the clouds.
n You may be walking to your car. Notice the
shape of the curb, the air on your face, the
sound of distant traffic.
n Take a moment to look at things around you
and take time to gently shift your focus onto
your breathing while you look around.
n Observe the colors of the leaves and the
scent in the air. Hear the sound of your feet
walking and feel the breeze on your cheek.
n If worrying thoughts creep in, try to focus
back on what is happening around you.
When stuck in traffic:
n It can be frustrating being stuck in traffic.
Instead of getting upset by it, try to focus on
things you normally wouldn’t.
n This may be the pattern the clouds are
making in the sky. It could be the music
on the radio or the color of the cars around
you.
n Focus on the moment by taking a few deep
breaths, relaxing, and letting go of some
tension.
How to Start Being More Mindful
n Set time aside every day to be mindful. This
does not need to be for a long time. It can be
for only a few moments.
n Choose 3 to 5 times or places during the day
when you will be mindful.
n Try to get completely absorbed in what is
going on around you for a few minutes at
a time.
n It is easiest to do while you are doing the
normal things you do every day, such as

having a cup of coffee, putting cream on your
hands, or watering the plants.
n When your mind wanders, just bring it back
to focus on the sights and sounds around you.
n Don’t worry about thoughts that go through
your mind or about how well you’re doing.
Try not to fight thoughts. Just gently refocus
on what you are doing.
n If you find sitting still difficult, focus on doing
something rhythmic. This may be dancing
around the room, going for a walk, swim-
ming, or riding your bike.
n If you are finding these suggestions are
difficult initially, you can start by being
FIGURE 17–1. Practicing mindfulness by coloring in the picture.
CHAPTER 17 BEING MINDFUL 159
mindful while doing something creative
such as drawing. Take a blank piece of
paper and just draw whatever comes to
mind, it may be patterns or an object. If this
does not work, you can color in a picture.
One is provided in Figure 17-1 for you
to try.
Addressing Common Difficulties
As learning mindfulness is a new skill, you may
have difficulty in the beginning. Here follows some
problems you may experience and suggestions to
address them.
160 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

I find it hard to focus on the present moment.

Start by relaxing, and then focus on your positive Reflection Activity
image. This will help you relax and become less tense.
It may then be easier to notice things around you. n What is the most important thing you have
learned from this chapter?
I don’t have time to be mindful.
As a start, try to do it while doing something else you

have to do. This could be brushing your teeth. Focus
fully on feeling the grip of the toothbrush, tasting
n What tips are you going to apply?
the toothpaste, smelling the mint, and seeing the
pattern of the bubbles forming. Just do this every
time you brush your teeth. It will become easier and 
a good habit. You can then add being mindful to
your daily routines.

Key Messages
n Select 3 to 5 times during your daily routine
to focus on the present moment.
n Think about what you see, feel, taste, and
smell.
n Try to focus fully for at least 2 minutes.
n Put worrying thoughts aside until you have
finished.
Worksheet
Complete the worksheet shown in Table 17–1. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide some
examples.
Reference
Kabat-Zinn, J. (2015). Mindfulness. Mindfulness, 6(6), 1481–
1483.
TABLE 17–1. Worksheet to Make a Note of Practicing Being Mindful

How successful When Comments How well this went?

am I at being were you These may include when, Rate from 1 to 10 with
mindful? mindful? where, and for how long 10 being very successful.
Rate from 1 to something was done. You can Then comment about it.
10 with 10 being also note what you can do
Date very successful. differently or change next time.
1/1/20 1 Looking at I was opening the blind 5
the sunrise and, instead of rushing off It was amazing how
to make breakfast, I took a much this helped me to
moment just to absorb the get through the morning
beauty of the sunrise. routine much more calmly.
It took no extra time, so it
did not make me late.

161
 Chapter
LISTENING TO TINNITUS
To escape fear, you have to go through it, not around.
— Richie Norton
What This Chapter Covers
n Reducing the need to distract yourself from
your tinnitus
n Helping you to accept your tinnitus
n Increasing your sense of control over your
tinnitus
Introduction
Consider the concept of habituation. When you
habituate, you learn to tune out sounds that are not
important or are neutral. When we hear sounds that
are not important to us, we often do not pay atten-
tion to them; we notice them only when we decide
to tune into them. The sound could be the fan whir-
ring or the traffic in the distance. One of your goals
should be to get used to the sound of tinnitus. If you
grasp that tinnitus is a sound with no meaning, you
then can learn to tune it out. This is similar to the
way you tune out the sound of your breathing. The
goal is for you to respond in a neutral manner when
you do hear your tinnitus. Remember that tinnitus
is a natural by-product of changes in your hearing
system. The aim of this chapter is to help you pro-
cess and think about tinnitus as you think about
neutral sounds. These do not cause strong emotions.
Your tinnitus does not need to lead to anxious emo-
tions. Always hearing your fridge buzz helps you to
get used to this sound. When your tinnitus is seen as
a neutral and not a negative sound, you can adapt
18
more easily to it. Reacting to the sound of tinnitus as
neutral lessens the distress and fear related to hear-
ing tinnitus. In this chapter you will be working at
lessening the fear and other emotions that you have
when hearing tinnitus.
The Purpose of Actively
Listening to Your Tinnitus
The purpose of actively listening to tinnitus is to
stop trying to avoid it, because doing so may lower
your quality of life. Knowing that you can listen to
your tinnitus for periods of time also increases your
sense of control over and tolerance for tinnitus. It
helps to realize you don’t need to avoid your tinni-
tus all the time by distracting yourself, and this will
lessen the distress linked to hearing tinnitus.
Tinnitus Habituation
Think about how you tend to manage your tinnitus.
Do you perhaps keep busy or play other sounds
to distract you from your tinnitus? Although this
does work, it will not help you to manage your tinni-
tus. For example, you may find it difficult to manage
your tinnitus when you are in a quiet place. How-
ever, by always needing to distract yourself, it will
make it harder to be in a quiet room. You may also
find it challenging to have a peaceful time when
you are not doing things. Or, do you try to avoid
your tinnitus? It is hard to get used to a sound that
you avoid or that concerns you. Always avoiding
tinnitus is not a good plan. Trying to escape some-
thing distressing often maintains the distress or adds
to it. This then lowers your quality of life.
163
164 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

When you listen only to your tinnitus, you can
get used to it. Being able to listen to your tinnitus
will help you to view it as a neutral sound that is
unimportant.
Consider an example. Imagine that someone
is very scared of being in the dark. To overcome
this fear, a person has to accept being in the dark.
This may start by being in a room with the lamp
on the brightest setting for a few seconds. The next
day it may be for slightly longer. Over time, you
can dim the light and increase the time in the dark.
By dimming the lights slowly, the fear of darkness
will become less. Later, a different room at different
times of the day can be tried. This gradual, graded
contact with something feared can help overcome
the fear. Intently listening to tinnitus is based on
a technique used in Cognitive Behavioral Therapy
(CBT) for many years; it’s called the “exposure tech-
nique.” This technique has been shown to change
the way your brain responds to tinnitus. It has also
been shown to help in adapting to something that
causes distress, such as tinnitus.
Benefits of Listening to Your Tinnitus
Although listening to your tinnitus may seem like
something you certainly don’t want to do, there are
many benefits, as illustrated in Figure 18–1. These
include:
n Lowering the need to avoid or distract your-
self from tinnitus;
n Increasing your sense of control over your
tinnitus;
n Helping you be less annoyed by your tinnitus;
n Promoting adaptation to the tinnitus;
n Weakening the link between your tinnitus
and feeling anxious;

Listening to
tinnitus

Feeling in Neutral
control thoughts
Actively
exploring
tinnitus

Relaxed Calm
behaviors reactions

FIGURE 18–1. The benefits of actively listening to your tinnitus.


n Helping you accept your tinnitus; and
n Improving your thoughts about tinnitus.
Often people that actively listen to their tinnitus find
they have more control over the tinnitus and can
thus make it less noticeable.
How to Listen to Your Tinnitus
Because you always hear your tinnitus, you may
think there is no need for this technique. Listening
to the tinnitus is different from just being aware
of it. Listening means hearing someone talking,
paying attention, and listening carefully to what
is being said. When you listen intently to your tin-
nitus, you focus on your tinnitus without trying to
avoiding it. Although this may seem scary at first, it
will increase your acceptance of your tinnitus. The
purpose is not to focus on your tinnitus all the time ​
— only for certain periods that you choose. Listen-
ing to tinnitus on purpose may not be pleasant, but
remember that tinnitus is harmless. Your goal is to
change the effect tinnitus has on you. This will hap-
pen when you view tinnitus as a neutral sound. This
tool involves slowly facing tinnitus in a controlled
and gradual way. It is a process that supports lower-
ing the fear and stress linked to hearing tinnitus. It
may be a challenge at first because you may have
tried to structure your life around not hearing your
tinnitus. Although it seems strange, listening to tin-
nitus can increase your sense of control over tinni-
tus. It can also help you accept your tinnitus. By
exposing yourself to something that is not pleasant,
but harmless, the distress can get weaker with time.
Where and When to Practice This Technique
Begin in a place where you feel relaxed. Select some-
where that allows you to focus on your tinnitus. As
you progress, you can try other places, such as a dif-
ferent quiet room. Select somewhere you feel peace-
ful. Select a time when you feel relaxed and calm
and nothing is rushing you.
How to Actively Listen to Your Tinnitus
Try to ask yourself questions about your tinnitus.
The following questions can help:
CHAPTER 18 LISTENING TO TINNITUS 165
n What does it sound like?
n How loud is it?
n What is the pitch?
n Does it remind you of anything?
n Where do you hear the sound coming from?
n Does it move around?
n Is it one sound or many?
n Does it change somehow when you listen to it?
Managing Your Thoughts
n When focusing on your tinnitus, negative
thoughts may arise.
n Remember not to focus on these, but instead
to listen to your tinnitus.
n Write down any negative thoughts or
emotions that occur.
n If you have negative thoughts, use the
techniques you have learned in Chapters 15
and 16. This may be saying “stop” to these
thoughts or pretend yes, or pretend you rub
them out (either) rubbing them out on a
whiteboard so that they are no longer there
and then focus on your tinnitus again.
Steps to Take When Actively
Listening to Tinnitus
Try to do these steps once a day this week. Once you
have positive results, you can lessen this frequency.
Step 1: Start by relaxing and viewing your positive
mental image.
Step 2: To explore your tinnitus, think about what it
sounds like for the time period set aside.
n It is normal for the tinnitus to seem louder
when you focus on it. This effect of focusing
on your tinnitus may make the tinnitus
seem louder for a short period. This is not
uncommon. Do not let this put you off.
n Remember to try to keep listening until the
distress lessens before stopping.
n Write down any negative thoughts and try to
address them when you finish. Look back at
Chapters 15 and 16 on challenging thoughts
if you need help.
166 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Start by listening to your tinnitus for 1 minute
and gradually increasing the time period you
feel comfortable doing this for.
Step 3: End by again relaxing and viewing your
positive mental image.
n If it was very hard, try to find what was
unpleasant and try to change that aspect the
next time you practice.
Step 4: When you are finished, reward yourself.
n Reward yourself for getting through this
exercise.
n Select something that will take your mind off
the tinnitus.
n This may be listening to your favorite music,
meeting a friend, watching something you
enjoy, or having something you like to eat.
Gradually Increasing the Listening Time
n Do this exercise at least once a day initially.
n Start by trying to listen to the tinnitus for
1 minute.
n Slowly increase the time each day until you
can reach at least 10 minutes.
n Try to keep to the time you have decided
on and keep listening even if your tinnitus
bothers you.
Once you are able to listen to tinnitus without it
causing distress you can do it less frequently. Start
using it daily. After a few weeks you can use it twice
a week and after this at least once a month.
Addressing Common Difficulties
As learning to listen to tinnitus is a new skill, you
may have difficulty in the beginning. Here follows
some problems you may experience and suggestions
to address them.
The volume of my tinnitus increases.
It is normal for tinnitus to seem louder or change in
some way when you focus on it. This effect will not
last long. Exposing yourself to tinnitus will not make
the medical damage that caused your tinnitus worse.
The extra focus on your tinnitus sound also will not
continue for a long time. This advice will not help
if you stop listening when your tinnitus gets louder.
The discomfort does not disappear.
The reason may have to do with the way you think
about your tinnitus. You may think, for example,
“My tinnitus will get louder.” These kinds of thoughts
increase your fears and make you anxious. In turn,
your thoughts and emotions may prevent you from
getting used to your tinnitus. Take a break to write
about your thoughts. Then return to the exercise
and try to focus more on what your tinnitus sounds
like and less on your thoughts. Explore your tinnitus
actively or link your tinnitus to a different neutral
image. After the exercise, challenge your thoughts
using the techniques provided. Listening to tinni-
tus may be very hard if you choose somewhere to
do it where you do not feel at ease. Try somewhere
you feel more relaxed next time. You can also try to
relax or think of your positive image to help calm
you down.
Key Messages
n To help you accept having tinnitus, you need
to realize that you are able to listen to it.
n This will help you control the effect your
tinnitus has. You will realize that you do not
need to distract yourself from the tinnitus.
n Intently listening and exploring what it
sounds like for a gradually increasing time
period will help you to accept the tinnitus.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

 CHAPTER 18 LISTENING TO TINNITUS 167

Worksheet have something to remind you of how much you

have accomplished. The first row provide some
Complete the worksheet shown in Table 18–1. examples.
This will help you see your progress. It is good to
TABLE 18–1. Worksheet to Make a Note of Practicing Listening to Your Tinnitus

Benefit from
actively
Length listening to
of time your tinnitus
spent (on a scale
listening How did of 1–10, with
Where were to Comments on how you reward 10 being very
Date you? tinnitus it went yourself? beneficial)
1/1/21 I sat in my room, 10 min I found it very I listened to my 2 for actually
which was quiet difficult initially until favorite piece of doing it
so that I could I remembered to try music.
focus on my positive imaging at the
tinnitus. same time. This helped.
Also tried to relax when
I began to feel tense,
and that also helped.
I can see that I will
benefit from this, but it
will take time.

168
 Part IV
DEALING WITH THE
EFFECTS OF TINNITUS
 Chapter
SOUND ENRICHMENT
All things are difficult before they become easy.
— Saadi
What This Chapter Covers
n Using other sounds to make you less aware
of your tinnitus
n Helping your ears tolerate sounds that
annoy you
n Exploring ideas about how to use sound
enrichment
Introduction
People often say their tinnitus seems extra loud when
they are in a quiet setting. When you are in a quiet
place, there is a bigger contrast between hearing your
tinnitus and hearing no sound. It is natural then to
focus more on your tinnitus. When there are other
sounds around you, this contrast is less. Your tinnitus
may blend in more with the other sounds. When your
tinnitus seems very loud, you often just want to switch
it “off.” Something easy to do is to use other sounds
to take your focus off the tinnitus. This is known as
sound enrichment, a strategy people with tinnitus have
been using for hundreds, if not thousands of years. It
helps you have some control over your tinnitus. This
chapter discusses how to use sound enrichment.
The Purpose of Sound Enrichment
The purpose of sound enrichment is to help the tin-
nitus signal get less attention within your hearing
system and become less noticeable. It does not mask
tinnitus entirely or stop you from hearing tinnitus.
19
Instead, external sounds are allowed to compete
with tinnitus. It helps your ears’ ability to tolerate
sounds within your body as well as sounds originat-
ing from an outside source. This helps you habituate
to tinnitus.
When to Use Sound Enrichment
Sound enrichment is useful for three main situations:
when needing to focus, when tinnitus is annoying,
and when the level of sound in the environment
varies a lot. Sound enrichment is not something
to be used all the time because you don’t want to
have to rely on always needing sound to cope with
your tinnitus.
Using Sound Enrichment to Help You Focus
Using meaningless background sounds can help
when you need to focus on something else. Exam-
ples may be:
n When you need to concentrate;
n When being creative;
n When you are struggling to relax;
n When doing something that you find hard
to do;
n When you are in a quiet place or in places
with few natural sounds;
n When going to sleep or resting;
n When reading;
n While busy with daily tasks around the house;
n When struggling to do relaxation; and
n When doing something that is physically
demanding.
171
172 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Using Sound Enrichment When
Your Tinnitus Is Annoying
When your tinnitus disturbs, bothers, or annoys
you, and you want complete distraction from it, you
may then select other sounds that grab your atten-
tion and shift your attention away from the tinnitus.
Using Sound Enrichment to Adapt
to Changes in Sound Levels
When you go from a quieter place into a noisier
environment where the level of sound you hear
varies a lot, your ears can find it difficult to adjust.
It is advisable to use sound enrichment to help
your ears cope with the change from quiet to loud.
Similarly, when leaving a noisy environment, it is
also advisable to listen to enriching sounds to avoid
the sudden contrast from loud sound to no sound.
When other sounds around you vary a lot in vol-
ume, using another steady sound source will lessen
these contrasts. Enriching sounds soothe the con-
trast between a quiet place and a sudden noise.
Examples of when you might use sound enrichment
may be:
n When there are sudden noises, for example, a
pot falling onto the kitchen floor;
n When other sounds around you vary a lot in
volume; and
n Before or after going somewhere that is noisy.
Sounds That Can Be Used
You could use any sound that distracts you from your
tinnitus. Some sounds are better than others to use.
The sounds selected can vary in terms of how much
of your attention or interest they grab. For example,
a meaningless background sound is good when you
are trying to focus on other things. This will ensure
that you do not fully focus on these sounds. A sound
source making a constant and more or less neutral
sound is ideal. When your tinnitus is very annoy-
ing, an interesting sound may be preferred. This will
help redirect your focus.
Examples of Background Sounds
Some people find it best focusing on other sounds
that are already in the environment (a more natural
sound). This may be the sound of a fireplace or run-
ning water as shown in Figure 19–1. Other people
find they need to introduce a new sound and focus
on that. Here are some examples of background
sounds you can try:
n Sound entering from an open window;
n A water sound (e.g., running water);
n A fan or ventilator;
n White noise (e.g., a radio tuned off station);
n Nature sounds (e.g., a recording of ocean waves);
n Chimes;
n A clock ticking;
n A bedside sound device. This is a system that
you can buy. You can select different sounds
from it, such as noise, ocean waves rain
falling.
n Any of a range of smartphone apps that
provide sound; and
n Gentle instrumental music.
You can also use pillow speakers if you want to
listen to sound during the night. In this way, you will
not disturb others.
You may want to start by selecting one sound
and getting used to it. The idea is to carry on with
your daily tasks and just have the sounds in the
background.
Examples of Attention-Grabbing Sounds
n A podcast;
n An audiobook;
n Music with lyrics;
n Any music you enjoy; and
n Any pleasant sounds.
Selecting the Volume of the
Sound You are Using to Distract
You From the Tinnitus
Regardless of the type of sound you are selecting, the
most important thing is to ensure that the volume
is not too loud. If it is a background sound, set the
volume so that you can just notice it. You should
not be focusing fully on the sound, and it should not
 A

B
FIGURE 19–1. Examples of sound enrichment: A. water sound; B. fire crackling.

173
174 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
cover your tinnitus fully. The aim is not to drown
your tinnitus with sound. It is to have enough sound
to “take the edge off” of your tinnitus. Allow sounds
to blend in with the tinnitus. This will help you to
notice the tinnitus less, but you should still be able
to hear the tinnitus. You may still be aware of your
tinnitus but at a low level so that the tinnitus is not
as intrusive. This is important because your brain
may search for the tinnitus if it cannot hear it. To
locate the tinnitus, it may subconsciously become
louder. You then need to turn up the volume, and
this can turn into a vicious cycle.
When you are listening to attention grabbing
sounds, the sounds need to be loud enough so that
you can hear the music, lyrics or words. It is impor-
tant that the volume is not so loud that it drowns out
the tinnitus. The music should divert your attention
but the tinnitus should still be audible.
To adjust to having tinnitus, you need to hear it.
You cannot adapt to something you never hear. If
you can’t hear your tinnitus, it may be extra loud
when the sound stops. It is better to use a softer
sound that distracts you from your tinnitus instead
of blocking out your tinnitus. The sound should,
thus, be at a calming volume. Even though you
do not notice the sound, it will make you focus less
on your tinnitus. It is useful being able to control
the volume of the enriching sound. This may be
either by using a volume control or by moving closer
or further away. Research has shown that listen-
ing to other sound is useful, but should not be the
only tool you rely on. You need other ways of cop-
ing when you can’t listen to another sound. Try not
to rely only on using sound enrichment. Use other
tools as well.
Addressing Common Difficulties
Here follows some problems you may experience
when using sound enrichment and suggestions to
address them.
The background sounds disturb me.
If you are used to silence, the new sound may an-
noy you. Many people with tinnitus are sensitive
to sound. Try to select a different sound that has
less of an effect. Try to use soft nature sounds. You
can also turn down the volume. Over time, you can
turn up the volume slowly to blend in with your
tinnitus.
My tinnitus gets louder when I am using or
have been using background sounds.
Sounds can sometimes seem to make your tinnitus
worse. They may make you feel tenser. This tension,
in turn, will affect your tinnitus. Your hearing sys-
tem can also become more active or tired when lis-
tening to these sounds. This can again affect your
tinnitus. Going from a noisy place to a quiet one can
also affect your tinnitus. Your tinnitus can go from
your not noticing it to seeming very loud. Although
annoying, this change should not last long. Using
sound enrichment in these instances can be help-
ful as it lessens how your tinnitus responds to these
sounds.
Try to relax or use one of your positive images to
help you. You can start having the volume on very
low and slowly increase it. Also try using other types
of sounds.
I can hear my tinnitus even though I am using
sound enrichment.
The purpose of using sound is not to cover your tinni-
tus. Doing this can let the tinnitus come back louder
when you switch off the sound. For most people, it is
more helpful to keep hearing the tinnitus. You can
only adjust to having to tinnitus if you can hear it.
Key Messages
n Using enriching sounds can help you notice
the tinnitus less.
n It is a good tool to give you some control over
the tinnitus when your tinnitus is very loud.
n The tinnitus should still be heard, and it
should blend in with the other sounds. Do not
let these sounds cover up the tinnitus.
Reflection Activity
n What is the most important thing you have
learned from this chapter?

n What tips are you going to apply?

 CHAPTER 19 SOUND ENRICHMENT 175

Worksheet enrichment and whether it is helpful. It will also

help you find out which types of sounds work
Complete the worksheet shown in Table 19–1. This best for you. The first few rows provide some
will help you monitor how much you use sound examples.
TABLE 19–1. Worksheet for Making a Note of When You Use Sound Enrichment

How well this went

Comments about the type of sound Rate from 1 to 10 with
When and where and level of sound used 10 being very successful
did you use sound These may include what sound you used, at making your tinnitus
Date enrichment? how long for and at what volume. less noticeable.
1/1/21 While working at home I put on some gentle nature sounds in 8
the background for most of the day.
1/1/21 When my tinnitus was I put on my favorite music at a 8
really annoying comfortable level and this moved my
focus away from the tinnitus

176
 Chapter
It’s not what we do once in a while that shapes our
lives. It’s what we do consistently.
— Anthony Robbins
What This Chapter Covers
n An outline of the sleep process
n Finding things that may affect your sleep
n Improving your sleep routine and your sleep
quality
Introduction
Sleep is a very important process and is needed
to function well during the daytime. Sleep helps
restore your body. It is needed to give your body
and brain a chance to rest. Sleep is important for
memory, learning, and helping you focus. Sleep
problems are common, with about 10% of adults
having persistent problems. Sleep problems occur
in those with and without tinnitus. Seventy-five
percent of people report that their sleep problems
started during a stressful period in their lives. This
is due to the body and brain actively trying to deal
with these problems. Long-term sleep problems are
often due to unhealthy sleep habits, and those often
require quite an effort to change. Lack of sleep adds
to other concerns you may have, thus creating an
even bigger problem. It is important to know more
about sleep before addressing your sleep problems.
The Purpose of Sleep Management
The aim of these guidelines is to improve your sleep
quality, your alertness, and your performance dur-
ing your time awake. They are intended to help
20
SLEEP GUIDELINES
you worry less about your sleep. They help you set
new sleeping routines that work together with, not
against, the biologically rooted rhythm of sleep. By
reducing your sleep problems, you may also lessen
other problems that are made worse by your lack of
sleep. Similarly, reducing your sleep problems can
be helpful in making tinnitus less bothersome. This
chapter is intended for people who have problems
falling asleep, wake up frequently during the night,
or have a poor quality of sleep.
The Sleep/Wake Cycle
Our bodies work on a sleep/wake cycle. This is like
a 24-hour inner-body clock that controls when we
feel sleepy or awake. It is our sleep rhythm. We have
different levels of alertness at different times of the
day, as shown in Figure 20-1. Your sleep rhythm
can change, and many factors can affect it. These
include the light, darkness, day of the week, and
night-time habits. There are several stages in a
night’s sleep, which are discussed next.
Sleep Phases
Sleep is complex, involving light and deep sleep,
dreaming, thinking, waking, and periods of being
still. Our sleep during the night is split up into four
stages as follows:
Stage 1: The period between sleep and wakefulness
Stage 2: When we sleep lightly
Stages 3 and 4: When you are in deep sleep
Stage 1 is the lightest sleep, and Stage 4 is the deep-
est sleep. In healthy sleep patterns, each sleep cycle,
177
178 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

12:00
9:00 pm Midnight
Melatonin
secretion starts 2:00 am
Deepest sleep

7:00 pm
Highest body
temperature 4:30 am
Lowest body
temperature
6:30 pm
Highest blood
pressure

Circadian
6:00 pm rhythms in 6:00 am
humans

5:00 pm
Greatest 6:45 am
cardiovascular Sharpest blood
efficiency and pressure rise
muscle strength
7:30 am
Melatonin
3:30 pm
secretion stops
Fastest reaction time

2:30 pm 10:00 am
Best coordination Highest alertness
12:00
Noon

FIGURE 20–1. Sleep/wake cycle.

which includes these 4 stages, lasts around 90 min-
utes, as shown in Figure 20–2. As part of this pattern,
everyone routinely has periods of lighter sleep dur-
ing the night, although you may not remember this
happening. Each sleep cycle (going between stages
1 to 4 of sleep) includes periods known as rapid eye
movement sleep (REM) and non-REM sleep. REM
sleep is deeper and is generally the period during
which you dream.
The Effects of Disrupted Sleep and
Why and When We Fall Asleep
People with sleep problems often report being drowsy,
having a lower mood, finding it hard to be creative,
and struggling to focus during the day. However, if
we get a minimum of 5 or 5.5 hours of sleep a night,
the problems seem to remain relatively minor. The
human body is very good at recovering lost sleep
and efficiently using the time we sleep. If a person
who usually sleeps 7 hours a night stays awake for
two nights in a row, 14 extra hours of sleep are not
needed to repay the sleep debt. About 5 hours on top
of the usual 7 is sufficient. When we have to catch
up on our sleep, deep sleep is lengthened. This gives
better quality of sleep. So, when needed, the body
will sleep more and more efficiently.
We can’t force ourselves to fall asleep when we
want to. There are two main things that decide
when we fall asleep, our personal sleep/wake cycle
and sleep debt. We will discuss both of these.
 CHAPTER 20 SLEEP GUIDELINES 179

Sleep phases

Relaxed 1st cycle 2nd cycle 3rd cycle 4th cycle

waking state

Stage 1:
Falling asleep, dreaming, REM REM REM REM
and waking phase

Stage 2:
Light sleep

Stage 3:
Mid-deep sleep

Stage 4:
Deep sleep

1 2 3 4 5 6 7
Time (hours)

FIGURE 20–2. Sleep phases.

Our personal sleep/wake cycle is the times we
have programmed our bodies to fall asleep and
wake up. At the time we usually fall asleep, the body
is “programmed” to more easily fall asleep than if
we try to go to bed 2 hours earlier. If we set the alarm
for the same time every morning, our “biological
clock” will soon adjust to this and actually be more
prepared to wake up at that time, making it easier
for us to get up. Having a stable personal sleep/wake
cycle is the basis for having good sleep, because it
helps us to both fall asleep and to feel less sleepy
when waking up.
The second thing that decides when we fall asleep
is sleep debt, or the amount of sleep we’ve been miss-
ing. This is affected by both how long you have been
awake and whether you have slept less than usual
during the previous nights. If your sleep debt is
really high, you might be able to fall asleep before
you usually do. A disrupted sleep/wake cycle, how-
ever, will have a negative impact on your sleep, both
regarding quality and length.
Factors Affecting Sleep
A lack of sleep may affect how well you do things
during the day. Identifying what may be affecting
your sleep is important to getting a good night’s
sleep. There are many factors that may play a role.
These may be reasons unrelated to your tinnitus.
The Difference Between Feeling
Sleepy and Feeling Tired
It is important to remind yourself that there is a dif-
ference between feeling tired and sleep problems.
180 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Feeling sleepy is due to a lack of sleep. Feeling tired
and fatigued can be linked with many factors. These
include:
n Weather and temperature variations;
n Illness;
n A lot of stress;
n Lack of water;
n Poor diet;
n Side effect of some medicines; and
n Too much/too little exercise.
Thinking that feeling tired is the same as a lack
of sleep can make you worry more about sleep. You
may sometimes make minor problems into big ones.
This may make things worse by giving you more
things to address. It is useful to find things that
may be making you feel tired. You can then work
on these first.
Sleep allows the body to rest. If you are unable to
sleep, there are many ways of resting when you feel
tired, such as using relaxation techniques suggested
in this program. To let the body rest, active relax-
ation can sometimes be more efficient than sleep-
ing. Inactivity, such as watching TV or just lazing
around does not allow the body to recuperate as well
unless you actively relax at the same time.
Factors Linked to Sleep Problems
Quality of sleep depends on a range of factors. Your
sleep rhythm works best when you have regular
sleep habits — that is, a stable sleep/wake cycle.
Going to bed at around the same time and waking
up at around the same time is important. For some
people, daytime napping can lead to poor sleep dur-
ing the night. Sleep can be affected by many factors.
These include:
n Your sleep habits. What time you go to bed,
fall asleep, wake up, and get out of bed in
the morning are important. Another factor
is what you do when you cannot fall asleep.
As mentioned, going to bed and waking up
at different times each day often affects your
sleep negatively.
n Your thoughts and ideas about sleep. These
can lead to stress and worry, which in turn
can lead to sleep problems. This is due to
the brain responding to these worries. Your
mind becomes aroused, which makes sleep
less likely. This also happens when you feel
excited, stressed, or worried about other
things. Everything that activates the brain
makes sleep more difficult.
n Daytime and lifestyle factors. These may
include lack of exercise, too many high
demands, some medicines, pain, and your
diet or eating habits.
n Your sleep space. Factors such as how light,
dark, noisy, hot, or cold the room is can affect
your sleep.
n Your health. Sometimes your health, such
as thyroid problems, can affect sleep. If the
cause of your sleep problems is not known, it
is best to go and see a doctor.
What factors do you think may contribute to
your sleep problems?

How Tinnitus Affects Your Sleep
The fact that most people with tinnitus don’t have
problems sleeping shows that it is possible to sleep in
spite of tinnitus. Tinnitus doesn’t necessarily lead to
poor sleep nor has it been proved that certain types
of tinnitus would disturb sleep more than others.
Tinnitus can, of course, affect our sleep, but so can
many other factors that may change independently
of tinnitus. The tinnitus sound in itself has a minor
effect on our sleep, but our emotional reactions to
tinnitus can be more of a problem. Our sleep can
be disturbed indirectly if we worry about tinnitus.
Tinnitus can also indirectly impair our sleep by
increasing our daytime stress level — stress that may
not wear off before bedtime. Everyone awakens for
brief periods during the night, although we may

not remember doing so in the morning. So, waking
up occasionally is normal, but tinnitus can wake
you up more often and make it harder to go back
to sleep. Long periods of increased stress levels can
trigger persistent sleep problems, whether or not tin-
nitus has caused the stress. So even if tinnitus hasn’t
disturbed our sleep at first, it can in time create sleep
problems indirectly through the stress that it triggers.
Regardless of why we have sleep problems, they can
often be reduced by the guidelines suggested.
Improving Sleep Quality
Four sleep guidelines have been selected for you.
Sleep restriction and stimulus control have been
shown to help many people with sleep problems,
but others can also be helpful in some cases. Improv-
ing your sleep will most likely make your tinnitus
less bothersome. Following the sleep guidelines is
not always easy. The most efficient guidelines are
the most difficult to follow, but the overall outcome
will be worth the effort. It takes time to change your
sleep patterns. It may take 3 to 6 weeks before you
see an effect. Keep doing the same things over and
over. In time, they will help. It may just take lon-
ger than you hoped for. It does take a lot of effort
to improve your sleep. What is really important is
being consistent. For sleep to improve, you need to
do the same thing each day.
For motivation, think through the negative effect
of your sleep. Keep in mind that the positive effect
can bring change. Start with a small number of
things you are going to focus on. Once you manage
them, start adding more. It is very important that
you do not stick to only the most easily implemented
guidelines, such as sleep hygiene and relaxation.
If you do, you will not get the effect you want. You
need to also add sleep restriction and stimulus con-
trol. Remember that the guidelines that are harder
to do produce better results. The guidelines focus on
your sleep habits, which includes everything con-
cerning sleep, wakefulness, and rest. Good sleep
habits tell the body when its time to sleep and is in
sync with your sleep rhythm and sleep pattern.
Read through all the tips and decide which you
want to use at first. You can then try the others as
well. The four guidelines that will be covered are:
CHAPTER 20 SLEEP GUIDELINES 181
(1) sleep hygiene; (2) relaxation; (3) stimulus con-
trol; and (4) sleep restriction.
Guideline 1: Sleep Hygiene
Sleep hygiene consists of habits and the practical
things you can do to improve your sleep.
Sleep hygiene involves both things to do and
things to avoid. The steps are easy to follow and can
have a positive effect, especially if you avoid certain
things. Select methods that are new to you — ones
you haven’t tried before or are not already following.
You can’t expect any method to work right away.
And remember, if the sleep hygiene advice does
not have a clear effect, be sure to move on to other
guidelines because those are often more effective.
Your sleeping space
n Have a good bed where you can stretch out
fully.
n Have a bedroom that is not too cold or too
hot.
n Darken your bedroom for sleeping or use an
eye mask or blackout blinds.
n You should have a quiet sleeping space or a
constant and neutral sound environment. For
individuals with tinnitus, using some kind of
background noise, as described in Chapter 19,
can be helpful.
n Use a reliable alarm clock to lessen the worry
about not waking up on time.
n Have a night light to avoid having to turn
on the full light during the night. Use just
enough light to make sure you are safe if you
need to get up in the dark. In the morning,
on the other hand, try to get as much light as
possible when you are ready to wake up.
n Put your smartphone somewhere where it will
not distract you while you’re sleeping.
Your level of physical activity
n Engage in exercise during the day. Research
has shown that the higher levels of exercise
help tinnitus to be less obvious. Exercise can
also improve your mood and quality of life.
182 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Try to do exercises that increase your heart rate
earlier in the day and not too late at night.
n Stretching types of exercises, such as yoga
stretches, are calming and can be effective at
night-time.
n Surround yourself with light during the day,
especially in the morning, to help your sleep/
wake cycle stabilize.
n If you do get up during the night, try not to
be too active. This makes it harder to get back
to sleep.
Your diet
n Be mindful of your diet. Some foods are more
difficult to digest and may affect your sleep.
n Consider completely leaving out caffeine and
foods that you find difficult to digest from
your diet. If some foods cause digestive pain,
avoid these because pain may keep you awake.
n Make sure that you have eaten something
within 3 hours before bedtime. This helps you
not be hungry when going to bed.
n Try not to drink too much so that you won’t
need to get up often to go to the bathroom
during the night.
n Only drink water, not any other drinks,
during the night if you get thirsty.
n If waking up during the night, most people
do not need to eat or drink. For some people,
if being hungry is the reason for waking,
eating may help.
Your evening routine
Have an evening ritual to prepare your body for
sleep. Ideally, do relaxing activities for the period
before going to bed. You may have a relaxing bath,
a good conversation, read a relaxing book, listen
to relaxing music, or do some gentle stretches. Cer-
tainly, avoid any screen activities close to bedtime.
There are some things to avoid before going to bed.
These are described next.
At least 5 hours before bedtime
n Avoid caffeinated drinks, any stimulants,
alcohol, cola drinks, and sugary drinks.
At least 3 hours before bedtime
n Avoid large meals.
n Avoid lots of cardiovascular exercise. However,
doing exercise is better than doing none, and
this may be the only time possible to fit it in.
n Avoid smoking.
2 hours before bedtime
n Avoid mentally engaging things.
n Try to avoid your computer, phone, and
screen activities.
Which sleep hygiene guidelines are you going
to implement?

Guideline 2: Relaxation
Sleep is disturbed by muscle tension, stress, and
thoughts that pop up in your mind. Relaxing helps
lessen body tensions. You should not try to force
yourself to go to sleep. Instead, try relaxing to help
your body recover. Being passive, such as watching
TV or just sitting still, does not allow the body to
recover as well. Relaxation will only help you fall
asleep if you fully focus on it. Use the following
guidelines for 2 weeks. Try to use them together with
the stimulus control and restricting sleep guidelines,
discussed later in this chapter.
Some tips:
n Refer to the chapters about relaxing.
n Relax at frequent periods during the day to
lessen your stress levels and to help you to
unwind at night.
n Practice the relaxation guidelines before
going to sleep and when trying to fall asleep.
n Do relaxation when you wake up during the
night to help you fall asleep again.
n Use an image of something neutral and posi-
tive. Refer to the positive imagery chapter.

n Keep your mind off problems or things that
you need to do.
n Concentrate on something else, such as
counting backward by 3’s or repeating mean-
ingless words (e.g., ada, ada).
n Exercise during the day because this will help
to lessen stress.
Which of these relaxation strategies are you
going to implement?
 TV, with your bed.
Guideline 3: Stimulus Control
When you have problems sleeping, your bed,
bedroom, and bedtime often become linked with
increased thoughts and tension. This includes toss-
ing and turning, perhaps trying to force yourself to
sleep, worrying about sleeping and your tinnitus,
and worrying about how to get through tomorrow.
Other times of the day, such as after work or after
lunchtime when you may take a nap may become
linked with sleep. Other places, such as the sofa
or an armchair, may become linked to sleep. This
may create irregular sleep patterns and disturb your
sleep/wake cycle. You need to create a stronger link
between your bed and sleep. This involves weaken-
ing the link between your bed and other activities,
worrying, or just lying awake. Also, the link between
sleeping in other places aside from the bed and
sleeping at other times of the day aside from bed-
time needs to be undone.
Stimulus control helps you improve links between
sleep, your bed, and bedroom. A stimulus is a place
or time that is linked with certain actions, thoughts,
and emotions — for example, linking your bed (the
stimulus) with sleep (the action). Your mind needs
to link your bed and bedtime with sleep, and not
with wakefulness or other actions. Stimulus control
does this in a very straightforward way, by changing
what you do in bed as well as actually getting out
of bed if you cannot sleep. For stimulus control to
help, you need to follow these tips every day. It will
be worth the effort. Seeing results might take weeks,
CHAPTER 20 SLEEP GUIDELINES 183
because it is difficult to break habits and change
your current undesirable links. Stimulus control
tips, together with sleep restricting tips, are the best
methods for improving your sleep. You can work
toward using them all at the same time. Following
are tips to help link your bed with sleeping instead
of lying awake in bed.
Avoid linking daytime activities to being
in bed.
n Avoid linking daytime actions, looking at
messages on your cell phone, and watching
n If you have difficulty sleeping, try reading
before bed, but try read in a different place
n In time, your brain will associate your bed
with only sleep.
Avoid lying in bed awake.
n If you haven’t fallen asleep within 20 minutes,
get out of bed.
n Keep it dark and quiet for at least 5 minutes
before going back to bed. This time should
preferably be longer to help you become
sleepier before you return to bed. You may
not be sleepy enough after only 5 minutes.
In this case, extend the time until you do feel
sleepy.
n Don’t look at your clock when you wake up
during the night.
n Avoid watching or checking the clock
throughout the night.
Avoid worrying in bed.
n Don’t bring your worries to bed. Instead, get
up and write down these thoughts in another
room.
n Once your thoughts have slowed down, your
stress has lowered, and you have been awake
for at least 5 minutes, you can go back to
bed.
n Writing down your worrying thoughts
might make it easier to let them go so you
can sleep.
184 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Avoid daytime napping.
n Limit daytime napping and resting. Instead,
use relaxation during the day when feeling
tired or sleepy.
n Only go to bed when sleepy.
What parts of stimulus control do you plan to
try?
 lems, the average is usually somewhere between 4.5
 time you spent in bed each night during the week.
Guideline 4: Sleep Restriction
Sleep restriction, in many aspects, works in the same
way as stimulus control. But sleep restriction focuses
more on stabilizing your sleep/wake cycle by keep-
ing more regular bedtimes and often spending less
time in bed. By following this advice, your sleep
habit will adjust itself, and you will start sleeping
better. Sleep restriction tips teach you to sleep well
and link your bed with sleep instead of being awake.
You should not spend very much additional time in
bed other than the time you are actually sleeping.
This is the restricting part. You restrict the time you
could spend in bed each night. Following this advice
may mean less sleep at the start, but that is part of
the plan, and soon it will help you to sleep better.
Sleep restriction also gives you more time out of
bed that can be used for better things than trying
to, but failing, to fall asleep. Once your sleep “effi-
ciency” (discussed next) reaches a certain level, you
can increase the allowed time in bed a bit, which
means you can sleep longer. However, make sure
that in doing so, your sleep efficiency does not go
below 80%. It is often very helpful to use the stimu-
lus control and sleep restriction guidelines together.
Week 1: Work out your sleep efficiency.
Every morning, write down the estimated hours you
actually slept and how many hours you spent in
bed during the night. Estimate the total time you
were awake during the night if you woke up one
or more times before morning. Napping during the
day doesn’t count as sleep time, but write it down
anyway. It can be hard to know exactly how long
you slept, but make a rough estimate. It is better
to underestimate than overestimate the number
of hours. For each night, you should estimate how
many hours you spent in bed, regardless of whether
you slept or not, and how many hours you actually
slept. It is important not to be clock watching.
When you have done this for a week, calculate
your average sleep time by dividing your total sleep
time for the week by 7. For a person with sleep prob-
and 7 hours. Then, do the same calculation for the
It is important to really try to find out both the time
spent in bed and the time spent sleeping; that is why
you should write it down each morning.
Now, you can calculate your average sleep effi-
ciency for the week. This is calculated as the hours
you actually slept divided by the hours you spent in bed
times 100. Of course, you could also calculate the
sleep efficiency for only one night, but it is usually
more informative to measure it over a week or at
least 4 to 5 nights. The goal is to achieve at least
80% sleep efficiency.
The following weeks: Start the sleep restriction.
During the weeks that follow, you are only allowed
to be in bed between certain fixed hours, and you
are not allowed to sleep at any other time of the
day. To decide your fixed bedtime and waking time,
start by deciding when you want to wake up in the
morning. To be efficient, this should be the same
time for both weekdays and weekends, because this
stabilizes your sleep/wake cycle. Then, look at the
average sleep time you previously estimated (prob-
ably between 4.5 and 7 hours). Set your fixed bed-
time that many hours before the wake-up time you
selected. Write down these fixed hours on the work-
sheet in Table 20–1 at the end of this chapter.
Every night, you must only try to sleep between
these hours. You can go to bed later but avoid sleep-
ing earlier. You must always get out of bed at your
fixed waking time. Avoid sleeping or spending any
time in your bed outside of these hours. No napping
is allowed. You could also use the stimulus control
guidelines. It is important not to allow too much
time in bed when you are not asleep. Sleep restric-
tion will very often result in an initial lack of sleep.

This is, of course, not what you want in the long
run. However, when the purpose is to increase your
sleep efficiency and stabilize your sleep/wake cycle,
this lack of sleep is actually helpful. It will increase
the sleep pressure the next night and make it easier
to fall asleep soon after you go to bed. It will also
make your sleep deeper and more efficient. Being
stubborn in sticking to the rules of sleep restriction
will make your sleep less fragmented and more effi-
cient, and thus of higher quality. It will also stabilize
your sleep/wake cycle, which will in the long run
make it easier for you to fall asleep and wake up at
the times you have chosen.
As in the first week, always note the time you went
to bed, got out of bed, and your actual sleep time.
Make separate notes if you napped, even though
you should not nap. Write down your sleep effi-
ciency every morning. For example, if your allowed
time in bed is 6 hours and you slept for 4 hours, your
sleep efficiency is 67% (4/6 = 0.67 = ×100).
When your average sleep efficiency exceeds
85% for 4 to 5 days in a row, increase the time you
are allowed to be in bed by 15 minutes. You should
do this by going to bed 15 minutes earlier, because
the wake up time is the most important “anchor”
in the sleep/wake cycle; but chose what is most con-
venient for you. Importantly, if your sleep efficiency
becomes lower than an average of 80% during a
week, decrease the time you are allowed to stay in
bed by 15 minutes.
In summary:
n Calculate how much time you actually sleep.
n Set a fixed hour for going to bed and a fixed
hour to wake up, where the period between
them should equal the hours you actually
sleep.
n Stick strictly to those fixed hours. The key is
to be consistent even if you worry that you
are getting too little sleep. Remember that an
increased sleep pressure will help you.
n Avoid napping during the day.
n Keep working out your average sleep efficiency
for 1 week, or at least 4 or 5 days, and record
it on the worksheet provided at the end of this
chapter.
CHAPTER 20 SLEEP GUIDELINES 185
n If it exceeds 85%, increase your allowed time
in bed by 15 minutes.
n If it is lower than 80%, decrease your allowed
time in bed by 15 minutes.
n By being consistent, your sleep habits and
sleep/wake cycle will adjust, and your sleep
will become less fragmented and of better
quality. You will start to sleep better.
n New habits are hard to form and take time.
Be honest with yourself. Even if you do things
you know you shouldn’t do, still record these
on the worksheet. This will help you find out
what you need to work on.
What fixed time are you going to wake up, and
what is your earliest allowed bedtime?

Addressing Common Difficulties
Addressing sleep difficulties is difficult in the begin-
ning. Here follows some problems you may experi-
ence and suggestions to address them.
I don’t want to sleep less.
The two sleep guidelines that are most effective will
often make you sleep less at first. Keep the following
in mind:
n The temporary lack of sleep will help you
to have better sleep habits in the long run.
These guidelines will improve your quality of
life and how you cope with your tinnitus.
n Lack of sleep is tough, but it is not harmful
if you are still getting some sleep. Give your
body the chance to sleep for at least 4.5 hours
each night.
n Be consistent in the use of the tips. If you give
up within a week, it will be too early to see
whether they have had a positive effect.
Sometimes it is easier to use the advice at a time
when losing sleep does not matter as much. This
186 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
may mean starting over a weekend. Staying active
will also help you.
My tinnitus gets worse when I am tired.
The increase in your tinnitus will only be short-lived.
You don’t need to worry about it. You know it is just
the short-term effect of lack of sleep. Stay active and
use the deep relaxation and other strategies in this
program to lessen your tinnitus distress. Although
it is hard, try to keep working at your sleep even if
your tinnitus gets worse at the start. In time, both
should improve.
My sleep is not getting better.
You need to use the tips for at least a week. Some-
times it may take 3 to 4 weeks before seeing an effect.
It is impossible to determine how well a technique
works after a couple of days. During the first few
days you may only have had more distress due to a
change in sleep habits. Thus it is important to fol-
low the stimulus control and sleep restriction guide-
lines carefully. It is easy to fall back into old sleeping
patterns. This will prolong the period of transition
between your old and your new sleep habits.
I don’t have the energy to work at changing
my sleep.
It is difficult to believe that these tips can help
before trying them. The tips on sleep hygiene are
easy but rarely have a major effect. The techniques
in this program for deep relaxation can be very
useful. Stimulus control and sleep restriction can
be hard, but, again, they are the most effective. If
you hang in there for a while, they can be very help-
ful. Short-term urges may block progress toward
your goal of improving your sleep for the long-
term. For example, you may want to stay in bed
because it is easier than getting up on time. Only
you can decide whether it is worth the effort. Unless
you try, you will never know whether the technique
could have been helpful. Hoping your sleep prob-
lems will solve themselves can keep you from deal-
ing with the problem and trying something new.
You may think some easy trick such as taking sleep-
ing pills will change things. Although this may
be useful for the short-term, it is not a long-term
solution.
I have a hard time staying awake or I feel
drowsy during the day.
Remember, feeling tired and feeling sleepy are two
different things. Check other factors that can make
you feel tired, such as food and water intake. Look at
the chapter that discuss different thinking patterns.
What are your thoughts on being tired and on sleep?
Stay active during the day. If you find it hard, it
may help to plan events for yourself. For example,
do some exercise such as taking a walk. Do this
instead of doing passive things like watching TV or
reading a book.
Participating in social events is helpful. Exer-
cise will increase your energy and make you more
relaxed and wanting to socialize. Allowing your-
self to think “I can’t do this, I am too sleepy” and
not trying can make things worse. You can also do
relaxation because it can lessen stress and help you
to feel less tired.
I don’t know what to do when I get out of bed
during the night.
Instead of just waiting for the moment you are
allowed to get back to bed, keep yourself busy. Do
simple, soothing, and practical things such as read-
ing. Avoid mentally engaging things that may have
an arousing effect. Try to switch off your smart-
phone. Also avoid doing puzzles, computer games,
or work. Instead, look out the window, relax, or use a
positive image. Also be careful that you don’t allow
yourself to fall asleep somewhere other than in
your bed. Prepare various things to do before you
go to bed. When you are up, keep it as dark as
possible.
I can’t get out of bed after lying awake thinking
or worrying.
Getting out of bed is tough, because you know you
will not be able to fall asleep anytime soon. Often,
the thought “If I stay in bed, I will at least have a
fair chance at falling asleep” arises. The reason to
get up is to make your mind link the bed with falling
asleep quickly. Your mind should not link your bed
with worrying or tossing and turning. You may have
tried many different ways of falling asleep faster and
sleeping for longer periods. Getting out of bed after
15 to 20 minutes may seem drastic, but it is the only

way to break the link between your bed and being
awake.
I only stay up for a few minutes before I go
back to bed.
The purpose of getting out of bed when you are
unable to sleep is to learn to fall asleep faster. If you
only wait a couple of minutes before you go back
to bed, it will not have made a big difference. You
will not be more tired than you were when you got
up, and you will still spend most of your time lying
awake during the night.
It is important to strengthen the link: your bed
means sleeping; staying up means being awake.
You should at least stay up for the same length of
time you lay awake in bed. It is best for you to be
really sleepy, yawning, or with heavy eyelids when
you go back to bed.
I am too tired to get up at my fixed waking time.
Weekends are often used to catch up on our sleep.
Sometimes, we may even sleep in on a weekday.
Doing so when you are using sleep restriction or
stimulus control can lessen the positive effect. For
now, you may need to pass up catching up on sleep
in order to meet your goal of improving your sleep
habits.
I fall asleep in other places other than my bed
or can’t stop myself from napping.
Keep yourself more active during the day so you do
not fall asleep. Avoid places where you know you
are running the risk of falling asleep. If you are
reading, watching TV, resting, or relaxing, set an
alarm clock. You can also hold something in your
hand, such as a bunch of keys. If you should fall
asleep, the keys will fall to the floor and wake you
up. Ask others to help you stay awake.
How much sleep do we need?
It is very common to hear that we need to sleep
8 hours a night. Two thirds of adults sleep be-
tween 7 and 8.5 hours a night and are content
with that amount. Some need only 4 to 5 hours
of sleep, while others may still feel sleepy after 9
hours. The amount of sleep a person needs decreases
with age. Infants sleep for 18 hours, and 10-year-
olds for 9 to 11 hours. Teenagers need 8 hours of
CHAPTER 20 SLEEP GUIDELINES 187
sleep on average. Middle-aged people need 7 hours,
and by the age of 70, we only need 6.5 hours of sleep.
Do I need to follow the sleep guidelines to
sleep well?
Many people go against sleep advice and still sleep
well without having any sleep problems. How well
we fall asleep varies greatly. Try not to compare
yourself to people who don’t have sleep problems.
This can make your own problems seem bigger than
they really are. If you are having problems sleeping,
following this advice can help improve the quality
of your sleep and life in general.
How good are these sleep guidelines?
The tips on sleep hygiene mainly help keep sleep
processes from being disturbed. If you have a lot of
stress and worries, your sleep can be disrupted. You
may need to work on these things first.
Are there other factors that can affect sleep?
There could be other reasons for your sleep prob-
lems. These include pain, muscle spasms, breathing
problems, or asthma. Allergies, bronchitis, digestive
problems, and headaches may all affect our sleep.
Certain conditions are directly linked to sleep as well.
An example may be when brief pauses in breathing
lead to too little oxygen in the blood. Limb move-
ment disorders also cause problems, for example,
twitching in the arms and legs lasting a couple of
minutes to several hours. Frequent nightmares or
night terrors, grinding your teeth during the night,
or sleepwalking can all affect sleep. Stress, depres-
sion, or a sad event can all affect sleep.
Should I use sleeping pills?
Sleeping pills can help severe sleep problems. They
are handy for times such as a crisis or following jet
lag. They should not be used long-term unless pre-
scribed and monitored by your doctor. Long-term
sleeping pills that have not been prescribed for you
may do more harm than good.
Although pills can let you fall asleep faster and
longer, they may have a negative effect on sleep
quality. There is less deep sleep and less REM sleep
when taking tablets. It is best to let your doctor guide
you when taking sleep medication to ensure you are
taking the best medication for your circumstances.
188 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Key Messages
Reflection Activity
n Stick to a sleep schedule. Keep your bedtime
and wake time the same every day including n What is the most important thing you have
the weekends. Follow the advice of stimulus learned from this chapter?
control and sleep restriction.
n Avoid or limit naps. Naps can make it
harder to fall asleep at night. If you can’t 
get by without one, try to limit a nap to only
15 minutes. n What tips are you going to apply?

n Have the right sleep space. This may include

a dark room that is not too hot or too noisy.

n Stay active. Regular exercise helps promote
a good night’s sleep. Schedule exercise at
least a few hours before bedtime. Try to avoid
mentally engaging before bedtime.
Worksheet
n Avoid or limit coffee, tea, caffeine, alcohol,
and smoking. Complete the worksheet shown in Table 20-1. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first few rows provide a example.
TABLE 20–1. Worksheet for Making a Note of When You Practice

Comments Log your sleep

What sleep These may include when, where, and for how long efficiency.
strategy have something was done. You can also note what you How long were you in
Date you applied? can do differently or change next time. bed and sleeping?
1/1/21 Looking at my I didn’t realize so many factors can play a Went to bed: 11 pm
sleep environment role. I need to try to do a few things. I am Woke up: 5 am
and night-time going to look at getting blackout blinds, as
Estimated hours
routine my room gets light very early in the morning.
asleep: 4 hours
I am going to stop screen activities when in
bed. I am also going to try to have lighter Estimated time in bed:
meals in the evening and focus on healthier 6 hours
eating and doing some daily exercise. A lot to Daytime napping:
work on! 0 hours
(Make a note of your
estimated hours asleep
for 7 days. Add the
total and divide by 7)

189
 Chapter
Many of life’s failures are people who did not realize
how close they were to success when they gave up.
— Thomas A. Edison
What This Chapter Covers
n Looking at what affects being able to focus
n Strategies for focusing on things other than
tinnitus
n Improving your focus when working
Introduction
To complete many tasks, you need to be able to
focus. Being able to focus helps you to recall what
you read or heard. Focusing helps you direct your
thinking in the direction you want. Focusing is a skill
you can learn but takes practice. What does it mean
to focus? Focusing is paying attention to certain
things while ignoring others. This is more complex
than you would think. You can pay attention con-
sciously when something grabs your attention and
you focus your mind on it. You may also pay atten-
tion without choosing to. It may be when there is
something loud or new that grabs your attention.
This can be very distracting. There are times when it
may be easy to focus and others when it is hard. You
may have noticed that it is much harder to focus
on work when you have tinnitus. Other factors can
also affect your ability to focus. These include worry-
ing thoughts, difficult tasks, distractions, tiredness,
hunger, and illness. Emotions like fear, excitement,
or boredom can make focusing difficult. Focusing
is a skill and something you can get better at. This
chapter is intended for people who struggle to focus
21
IMPROVING FOCUS
and would like some tips on planning, remember-
ing, and being able to do complex tasks.
The Purpose of Improving Focus
The purpose of this chapter is to enhance your ability
to focus by trying new ways of managing demand-
ing tasks and creating better conditions for success.
The goal is not to be able to stay focused at all times,
which is unrealistic, but to gradually improve your
ability to focus and persevere. This will free more
time for things you would like to do.
How Tinnitus Affects Your Focus
Up to 70% of those with tinnitus say it is hard to
focus. However, other factors can also contribute.
Focusing on tinnitus does make it hard to focus on
other things. This is because focusing on more than
one thing at once is difficult. This may especially be
the case if you are distressed by tinnitus. You will
then be less able to pay attention to everything else.
Your tinnitus may have different effects, depending
on the kind of task. If you are doing something fairly
easy, the task may not grab your full attention, and
your tinnitus may thus be more noticeable. When
you are doing something more complex or demand-
ing, your tinnitus can be less noticeable. The effect
tinnitus has may be different for each person.
Improving Your Ability to Focus
Many things can help improve how well you focus.
You may need to use the tips for a few weeks before
noticing a difference. Different tips will work in
191
192 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
different places. This chapter looks at useful tips
in detail.
Improving Your Work Setting
Your work setting can make you more focused and
productive. It is important to declutter this space. This
may refer to the place you do administrative tasks,
read, something creative or practice a new skill.
Here are some tips to help you lessen distractions:
n Remove anything that may take away your
focus.
n Sort out your work space as much as possible.
n Make sure you have a comfortable place to
work in.
n Use good lighting.
n Where possible, make sure it is not too hot or
too cold.
n Try to lessen unwanted sounds.
n Ensure that you get enough fresh air where
possible.
n If possible, put away your phone and turn off
e-mail pop-ups. Only check these during breaks.
n Lessen hunger by eating healthy filling foods.
n Sleep enough to lessen tiredness.
n If your tinnitus bothers you, divert your
attention by using some background sounds.
These can be any soft, pleasant sounds.
n Nature sounds or soothing music can work well.
n If other thoughts bother you, write them
down briefly. Set aside a time when you can
go back and address them.
Planning
Good planning can help you to focus better, cut
down on stress, help you avoid taking on too much,
allow you to work on more than one thing at once,
and manage tasks that are hard. This may be for
household tasks, or activities you want to fit in dur-
ing a day.
Making a Structured Plan
n Think of everything you need to do.
n Divide the work into small steps.
n Breaking up work into smaller chunks can
help keep you focused.
n Finishing smaller tasks propels you to keep
going.
n Clearly define your goals.
n Use recall aids by writing everything down or
using a calendar.
n Write a to-do list and check off everything
that has been done.
Working With Your Natural Rhythm
n Most people are better able to concentrate
during the morning.
n During the afternoon, people are more easily
distracted.
n Focus on the things that need to be done first.
n You may also start with things that need
more focus.
n When you are tired at the end of the day, do
things that do not take much focus.
Looking After Yourself
n Your brain needs oxygen to work well.
n Focus on doing deep breathing while working.
n Make sure you drink enough water.
n Do some exercise during your day. This
can include walking, yoga, or stretching.
Research has shown that people who engage
in moderate physical exercise before doing a
task are better at focusing. Regular exercise
helps your brain to ignore distractions.
Taking Breaks
Often when we have a lot to do, we keep working
nonstop. We think we will get more done if we don’t
stop. Most people can focus for only 30 to 60 min-
utes at a time. This time is even less when you are
stressed or distracted. Tinnitus can also affect how
long you can focus on your work.
Long stretches of work cause you to lose focus.
Working for shorter stretches at a time and taking
more regular breaks can help you regain focus.

Adjusting the way you work can lessen tiredness and
help you be more effective. Frequent short breaks
enable reflection. Breaks also help you get new
ideas. They can help you find new ways of solving
problems and can help improve you work. These
suggestions do not only apply to paid work, but also
tasks you may be doing at home such as adminis-
trative or household tasks. You can apply them to
anything that requires you to focus.
How to Take Breaks
There are different ways of taking breaks. Here are
some suggestions:
Short and longer breaks:
n If possible take a few short breaks, depending
on your type of work. The break may be only
for a minute to get some water and then
carry on with your work again.
n If possible, try to take a longer break if you
are working for a long stretch.
Planned breaks and work-adjusted breaks:
n Depending on the type of work, break up
your work into sections. After each section,
take a break.
n Alternatively, take a break after a certain time,
depending on the type of work you are doing
or work set up you have. You can set a timer
so that you can really focus during this time
What to Do During Your Breaks
By planning some things to enjoy during your
breaks, you can be more focused while you are work-
ing. Think about what you may do. Here are some
suggestions:
For short breaks
n Practice doing relaxation.
n Do some stretches and deep breathing.
n Go get a drink of water.
n Walk to the other end of the room and back
again.
For longer breaks
n Go outside for a short while.
n Chat with a friend or take a break with
someone else.
CHAPTER 21 IMPROVING FOCUS 193
n Do something physical such as climbing
stairs.
n Dog some yoga or stretches.
n Do something like gardening or cooking if
you are at home.
When you finish a task, do remember to reward
yourself for completing it, despite the challenges
you had.
Making Decisions
There are times when tasks make you feel stressed
or when you are unable to see a way forward. There
are other times when you struggle to make a deci-
sion. You may need to be creative but can’t come up
with an idea. During these times, take some time out
and do something else to get some distance from the
problem. Doing physical exercise often helps clear
your mind. Being in nature relieves stress and can
improve your mood.
Get a new point of view by asking for help or dis-
cussing the problem with someone. Reflect on what
will happen if you do not finish or make a decision.
This may help motivate you. Think of all the pos-
sible solutions. Take time to think of the pros and
cons of each.
Remembering
Some people with tinnitus say that they forget things
more easily. You need to be able to stay focused to
recall facts. There are three stages to remembering:
(a) learning, (b) processing, and (c) retrieval. These
are explored next.
Learning: This is the process by which we take in
facts. This may be something you read or hear. You
need to be able to focus to take in all the details. You
may forget new facts if you were not able to focus
on what you read or heard. Reducing factors that
make it hard to focus, such as tiredness or distrac-
tions, can help.
Processing: This phase involves sorting what
you have read or heard. Processing is easier if there
are past events to link the new data to. If there are
no past events to which the new learning can relate,
it is harder to process. Things that are new to you
take more time and energy to understand.
194 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Sometimes past knowledge can be in conflict with

the new learning. It will then also take longer to pro- 5 3 7
cess it. You need time to reflect on new learning to be
able to process it fully. You may forget more easily 6 1 9 5
if what you have learned is not processed properly.
Following are some things that can help: 9 8 6
n Actively take part; 8 6 3
n Take notes;
4 8 3 1
n Ask questions;
n Explain what you have heard to someone else; 7 2 6
n Summarize important points for yourself.
6 2 8
Retrieval: It is often during the retrieval phase
that we find it hard recalling what we heard or read. 4 1 9 5
Often retrieval problems relate to problems during
the learning and processing phases. These phases 8 7 9
need to be in place for good retrieval. Retrieval can
be done in many ways. The hardest way to recall FIGURE 21–1. An example of a challenging activity,
something is by retrieving it without cues. Focusing doing a Sudoku.
on specific things can help. Answering the ques-
tion “What was the meeting about?” is harder than
“What was Julie’s opinion?” Retrieval is helped by
making notes. The easiest way to recall facts is to link looking at your phone or thinking about
them with other related words, items, or thoughts. It what you still need to do.
is always a good idea to make notes. n Challenge yourself by learning a new skill.

Challenging Yourself How to Challenge Yourself

Doing things that challenge you can improve your
focus. Here are some suggestions:
n Do puzzles (e.g., Sudoku, as in Figure 21-1) or
crosswords.
n Set aside a few minutes to focus on the task
and then take a break.
n Increase the time you focus on the task each
day.
n Then start making the task harder.

n Read books or read something factual.
n Try reading a topic that is less known to you.
n Research has shown that people tend to
scroll through words. We don’t always focus
intently on the content of what we read. Take
time to really study the content of a book,
article, or newspaper in more depth.
n Also challenge yourself to really listen to
others. Listen fully when they speak and try
to understand their viewpoint. Listen without
n Make sure you select something that interests
you.
n It is easier for tinnitus to intrude when the
task is boring.
n Review the chapter on shifting focus. The tips
there can also help you to focus better.
n Practice focusing by shifting your attention
between two things.
n This may be focusing on something visual
and then on something you hear.
 CHAPTER 21 IMPROVING FOCUS 195

n Switching back and forth between the two Key Messages

will help you pay attention.
n It will also help you to ignore other things n Although many things can make it hard
around you such as your tinnitus. to focus, including your tinnitus, there are
things that can help.

Addressing Common Difficulties n Look for ways to improve your work setting
by lessening distractions.
Here follows some problems you may experience when n Work with your natural rhythm and plan
trying to focus and suggestions to address them. tasks you need to do.
I do not have time to take breaks. n Adjust your work habits to include regular
If your schedule is so busy that you do not have time breaks. This will help you focus better when
to take breaks, you need to make a change. Some- you are working.
times having so much to do leads to burnout. A few n Challenge yourself to get better at focusing by
short breaks to refresh your mind and help you to learning new skills.
be more productive overall. Studies have found that
people who take breaks work better than those who
don’t. Also, those that have a day off each week, Reflection Activity
work better than those working 7 days a week.
n What is the most important thing you have
How can I improve my focus if my tinnitus learned from this chapter?
is loud?
Being able to focus can be harder when you have
tinnitus. Even when tinnitus is very loud, it is pos-

sible to manage tasks that need you to focus. You
have overcome troubles in the past. Although tin-
n What tips are you going to apply?
nitus is a setback, there is no reason you should not
be able to focus again. Aim for a solution instead of
focusing on the setbacks. Work at improving your
focus, despite hearing tinnitus. Give yourself enough 
time to learn new skills.

I find it hard to focus when feeling stressed.

It is harder to focus when feeling stressed and tense. Worksheet
If you are too calm and relaxed, it will also be hard
to focus. When you are too relaxed, you do things Complete the worksheet shown in Table 21–1. This
slower and are less focused. Likewise, too much stress will help you see your progress. The first row pro-
tires you and makes it hard to focus on a task. You vides an example.
need to be fully alert to focus and be able to respond
to stressful events.
TABLE 21–1. Worksheet for Making a Note of When You Work at Improving Your Ability to Focus

Comments
These may include when, where, and for
How have you worked how long something was done. You can How well this went
at improving your also note what you can do differently or Rate from 1 to 10 with 10
Date ability to focus? change next time. being very successful.
1/1/21 I am going to take I set an alarm for every 20 minutes. 8
regular breaks when I am going to climb the stairs, have This systematic approach
working at my desk. a chat, get a drink, and do some worked well, and
stretches during my breaks. I focused much better.

196
 Chapter
Great things are not done by impulse, but by a series of
small things brought together.
—Vincent van Gogh
What This Chapter Covers
n Increasing your tolerance of sounds that
distress you
n Helping lower the worry and fear certain
sounds cause
n Lessening the need to avoid sounds because
of their effect on daily life
Introduction
Just as being too hot or cold can cause you to feel
discomfort, some sounds can cause discomfort. This
happens when sounds are louder than a certain
level. The discomfort helps warn us about sounds
that can be harmful. This warning helps us protect
our ears and avoid harmful noises. Sound tolerance
varies greatly among people and may include find-
ing certain sounds annoying, painful, or frighten-
ing. Some people can’t tolerate certain sounds, while
most people don’t have this reaction to the same
sounds. If you are more sensitive to sounds that do
not bother others, it is a form of lower sound toler-
ance or collapsed sound tolerance. A lower or col-
lapsed sound tolerance makes some people more
aware of certain sounds. To people with lower toler-
ance for sounds, even neutral sounds, such as the
sound of cutting or buzzing, may seem too much.
Sometime feelings of pain and stress become linked
with these sounds. For those with a low sound toler-
22
INCREASING
SOUND TOLERANCE
ance, sounds that are not harmful can then seem too
loud. Even without pain, some people find it hard
to listen to day-to-day sounds that most people find
quiet or barely notice. For those who are sensitive to
sound, the world, thus, seems too loud. Being sensi-
tive to sound does not mean sounds are more harm-
ful to you. It means that you can’t always rely on
your hearing system’s assessment of when sounds
are harmful or not. This chapter gives you insights
into sound sensitivity and what can be done, and is
intended for people who are particularly sensitive to
sound and who also react negatively to sounds that
are extremely loud and not really harmful.
The Purpose of Increasing Sensitivity
This chapter aims to give you more information
about loud noises and to teach you to assess whether
a certain sound is harmful or not. The key princi-
ple is to gradually increase your exposure to back-
ground sounds and sounds you find distressing. The
purpose is to give you a higher “discomfort thresh-
old,” meaning the threshold above which sounds
are perceived as uncomfortable or painful. The aim
is to make your sensitivity to sound interfere less
with your daily life and to reduce the irritability and
fear of sound you may experience. Training your
ears, using a reasonable sound level, will in time
help increase you tolerate sounds that are presently
uncomfortable.
The Effects of Sound Sensitivity
Being sensitive to sound can cause a lot of distress
and affect many aspects of daily living. Because
197
198 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
your level of sound discomfort may be greater
than it is for most people, your ears may hurt or
feel strange. This can be the case even if you have
not listened to very loud noises in the past. This
sensitivity to sound may lead to a negative chain
of events (Figure 22–1). If that happens, you may
then avoid some sounds even though they are
not really harmful. You may become more easily
tense, stressed, and bothered by certain sounds. You
may have problems focusing and tire more easily.
Because of a lower sound tolerance, some people
restrict many aspects of their lives. They avoid cer-
tain places and events.
Causes of Sound Sensitivity
Sometimes a normal reaction to sound can change.
This may occur when the emotive part of the brain
reacts too much to sound or when the hearing sys-
tem uses too much energy to send the sound mes-
sage to the brain. It is not always clear why people
have a lower sound tolerance. It may be due to:
n Tinnitus (40% of those with tinnitus have
sound sensitivity);
n Hearing loss;
n Head injury;
n Ear infections;
n Sound avoidance;
n Muscle tension;
n Stress and fears;
n Depression or post-traumatic stress disorder;
Anxiety
Withdrawal
FIGURE 22–1. The effects of sound sensitivity.
n Migraines;
n Using earplugs too often;
n Side effects of taking certain pills; or
n Other disorders such as Williams syndrome.
Sounds That May Cause Distress
If a sound frightened you at some time, you may
now have a fear of that sound. The sound could
have been neighbors shouting, loud music, or a
sound at work that shocked you. Because the sound
can trigger a reaction of stress and fear, you try to
avoid it. This avoidance can turn into a major prob-
lem because it may interfere with your daily life. It
is common for people who are sensitive to sound
to worry that certain sounds may cause a hearing
impairment. They also worry that their tinnitus may
worsen. These thoughts may lead to worrying and
depression and affect you even when you are in a
quiet place. Different people have diverse reactions
to sounds. Here are some examples of sounds that
may cause annoyance:
n Sound of a bus or car engine;
n Walking on leaves;
n Turning pages of the newspaper;
n The phone ringing;
n High-heeled shoes;
n An alarm clock;
n Sounds from the kitchen; and
n Pots hitting a surface.
Hearing an annoying sound
Irritability Tension Heightened Fear and
awareness worry
 CHAPTER 22 INCREASING SOUND TOLERANCE 199

is limited. Quieter sounds below 80 dB are rarely

Which sounds do you find distressing, irritat- harmful, even if we listen to them for several hours
ing, or have a fear of and try to avoid? a day. If the sound is very loud, such as 120 dB, lis-
tening to it for a short time may be harmful. Bass

sounds are often less harmful than treble sounds.
 Both can damage your hearing if they are very loud.
There are many factors that determine whether a
sound will be harmful. This includes the duration
of the sound and how loud it is. Some people’s hear-
Sounds That Are Harmful ing is more easily harmed. This may happen when
their hearing is already damaged. Sounds you may
Sometimes people with sound sensitivity worry find loud are not harmful unless they stay loud for
about some sounds being harmfully loud. Whether long enough.
those sounds are really harmful depends on many
factors. Consider how sound works. Sounds travel
through the air as waves of air pressure. We measure Protecting Your Ears
these waves in decibels (dB). You can hardly notice a
sound that is 0 dB. A sound that is 120 dB is a very It is important to be careful with your hearing. Gen-
loud sound. Table 22–1 gives you an idea of different erally, your ears can protect you from loud sounds.
decibel levels. Bass notes sound lower in pitch than There are small muscles that contract and lessen
treble notes. Your threshold of hearing is the softest the damage from a loud sound. However, when the
sound you can hear. You will also have a threshold sound is sudden, the ear muscles cannot always
of discomfort and pain for loud sounds. Between react fast enough. In this case, the ears are more
these ranges you can hear and process many dif- prone to damage.
ferent loudness levels. For some people, their loud-
ness discomfort level to sounds is at a very low level. In places where you may damage your hearing, these
Thus, the range of sounds that they can listen to tips can help:
n Spend time listening to medium loud sounds
every day. These are around 50 to 80 dB.
TABLE 22–1. Examples of Different Decibel Levels This helps your ears to cope better with loud
sounds.
Loudness as n Spend time in places with normal sound
Measured in levels. Do this before and after going to places
Decibels Example where you know that very loud sounds will be
140 Loud sounds that cause pain present. This transition will help your ears to
adjust.
135 Gunshot
n Protect your ears from harmful loud sounds.
120 Jet engine You may, for example, cover your ears or turn
away when sirens pass.
100 Lawnmower
n Use hearing protection such as earplugs when
80 Shouting listening to loud sounds for longer periods.
60 Talking at a normal level For example, do this when going to a loud
concert.
40 Whispering
n You should not use earplugs routinely for
20 Leaves rustling sounds that are not very loud. Earplugs
should be used only in places where most
0 Hearing a pin drop
people would use them.
200 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
What Happens When You Avoid Sound?
The natural response to discomfort caused by sound
is to withdraw from sound, but that can make things
worse. When in a quiet place for a long period, the
brain gets used to the lower level of sound. The lower
the sound level, the lower the threshold will be for
sounds that seem too loud. This may happen when
earplugs are worn too often. Hearing protection
increases your sensitivity to sound when you are not
wearing earplugs. Try not to overuse earplugs. If you
use them too often, your ears are “resting” too much
and not listening to sounds enough. The tiny hair
cells in the ear act a bit like muscles. If you use them
often, the risk of damage is lower; but if they are
often at rest, the risk increases. Someone who has a
lower tolerance to everyday sounds may focus more
on sounds and what those sounds feel like in the ear.
Certain noises and places can make you feel tense.
This can briefly lower your discomfort tolerance and
make your ear hurt or feel strange, although the
sounds are not harmful. It is always a good idea to
observe how others react to the sound. If others do
not seem bothered, then the sound is often not one
that you need to be worried about.
Improving Sound Sensitivity
Many of the techniques that help tinnitus also help
for lower sound tolerance. Many of the techniques
applied in the other chapters are useful for a lower
sound tolerance.
This chapter focuses on four approaches that are
often used to help:
1. Relaxing every day
2. Avoiding silence
3. Preparing your ears for sounds
4. Listening to sounds
Technique 1: Using Daily Relaxation
Learning to relax can be very effective for helping
those with low sound tolerance. Try to build in time
to practice relaxing into your daily routine. Also,
relax before and after facing sounds that you find
disturbing. This helps you cope better with them.
Refer to the chapters that teach you relaxation
techniques.
Consider an example.
Suppose that you are sensitive to the sound of the
car’s tires when driving. You may plan around this
with these tips:
n Relax for 10 minutes before driving and after
stopping.
n Plan to allow extra time for relaxing before
and after the trip.
n Think of ways to relax before, during, and
after the trip.
n If you are not the driver, you may think of a
pleasant positive image.
n Put on some very relaxing music in the car.
n Reward yourself for making the trip. Do
something you enjoy such as spending
5 minutes reading your book before leaving
and when arriving at your destination.
Technique 2: Avoiding Silence
When you avoid sounds, it makes it harder for your
ears to cope with sounds when you do hear them.
Instead of avoiding all sound, it is better to listen to
quiet sound. One suggestion is to listen to pleasant
sounds in the background during the day and night.
Sounds like the rain or the ocean, some quiet music,
or even white noise may help. When your ears listen
to sounds, it increases how tolerant you become of
them. Consider your skin, for example. Your skin
is able to tolerate more sun if you are often in the
sun. In the same way, your ears can tolerate more
sound when you start listening to more sounds. In
this way, you reset your hearing system. You can use
the principles of sound enrichment to help make
you less sensitive to sound.
Which Sounds You Can Use
You need to select sounds that are constant and for
which you can control the volume. Start by using
sounds that you enjoy or neutral sounds that you
can ignore after a period of listening to them.
Background sounds are ideal. The sound enrich-
ment chapter discusses this technique, and here is a
reminder of some sounds that can be used:

n Sound entering from an open window;
n A water sound (e.g., running water);
n A fan or ventilator;
n White noise (e.g., a radio tuned off station);
n Nature sounds (e.g., a recording of ocean
waves);
n Chimes;
n A clock ticking;
n Any of a range of smartphone apps that
provide sound;
n Gentle instrumental music; and
n A bedside sound device. This is a system that
you can buy. You can select different sounds
from it such as white noise, ocean waves, and
rain falling.
Features of the Background Sound
Select sounds that are continuous. Make sure that
you can control the volume of the sound. This may
be either at the source using the volume control or
by moving closer or farther away from the sound.
Setting the Level
The sound does not need to be very loud. It can be
very quiet. Just having some sound in the back-
ground is important.
When to Listen to Background Sounds
The sound can be used as background during the
day and night. During the night, you could use nat-
ural sound, such as that from having the window
open, the air conditioner or a fan on. If you want to
listen to other sounds (from an app, music player,
or bedside tinnitus sound generator) these can be
played through a pillow speaker if they disturb oth-
ers. At first try to listen to the background sounds for
1 to 2 hours twice a day. Slowly increase the listen-
ing time.
Technique 3: Preparing
Your Ears for Sounds
After hearing a loud sound, you may want to get
away from it. You may try to find a really quiet
spot where you can’t hear anything, but this is not
always the best approach. It is very hard for your
CHAPTER 22 INCREASING SOUND TOLERANCE 201
ears to cope with sudden changes in sound levels, so
it is helpful to prepare your ears for sounds. This will
help your ears cope better with the sound. Use sound
enrichment before and after listening or when you
know unpleasant sounds will be present. You can
liken this to going to run in a race. You will not just
start to run at full speed. Instead you will prepare
your muscles to avoid injury. You will warm them up
before the race and cool them down after the race.
The same principle applies to your ears for sounds
that you find loud or hard to tolerate. For example,
suppose you are going to an event where you know
the sound levels will be loud. Instead of avoiding
all sounds, try to listen to some low-level sounds.
You can do this before going somewhere where the
sounds may be unpleasant. After a while, turn up
the volume. This will “warm up” your ears. When
going home again, listen to sounds at a low vol-
ume. You can slowly lower this volume as you “cool
down” your ears.
Technique 4: Listening to Sounds
This technique focuses on the sounds you find dif-
ficult to listen to. Avoiding these sounds will not help
you to overcome fear and annoyance toward these
sounds. Instead you will listen to them in a gradu-
ally increasing and controlled manner. Listening to
sounds that you find difficult at a lower volume may
help raise your tolerance for those sounds. Listen to
these sounds when you have control over them. This
makes you less afraid of hearing them. It is impor-
tant not to overdo it. Listen for only a short time.
Set a time period and try to keep listening during
this time. If you withdraw before the discomfort is
less, you may strengthen the link between the feared
sound and discomfort. The key is to slowly increase
the time you listen to sounds that distress you, but
are not harmful, using a stepped approach. You do
not start by listening to loud sounds. It is about a
gradual approach. You will do short bursts of listen-
ing to these sounds to build up your tolerance for
them. It is important to make your ears less sensi-
tive to them. Very slowly increase the time you listen
to the sounds, using a stepped approach. You need
to feel in control of the sound. One aim is to give
you a higher discomfort threshold. This increases
the level at which sounds seem loud or painful.
Another aim is to raise your tolerance for every-
202 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
day sounds. This will help sounds interfere less
with your daily life. Your annoyance may lessen
because you are training your ears to cope better with
these sounds.
Which Sounds to Address First
If there are many sounds you are sensitive to, start
with the one that causes the least distress. You can
slowly approach more challenging sounds once
your tolerance has increased. Practice in places
you normally avoid or find annoying. Start at the
sound level where you can just manage. You can
record the sound and listen to it in this way at first.
Listen to it and gradually turn up the volume of the
sound until you are able to tolerate it at the level it
is usually set at. You can also move closer and closer
to the sound.
Being in Control
It is very important that you feel in control at all
times. You should be able to regulate the sound. This
may be by:
n Changing the volume;
n Varying your distance from the sound;
n Listening to recordings first and slowly
increas-
ing the volume as you play them back; or
n Covering the sound source and slowly uncov-
ering it.
TABLE 22–2. Examples of a Stepped Approach to Increasing Sound Tolerance
Listening to Music From My
Radio/Phone/Television
1. Switch it on at the lowest volume and go
to the other end of the room.
2. Move closer to the phone.
3. Increase the volume by 3 notches.
4. Let someone else increase the volume.
5. Have it on the middle volume playing
while I do housework.
In time, let someone else increase the volume slowly
while you listen.
A Stepped Approach
Listening to sounds that you have a low tolerance
for in a stepped manner is the key. Before starting,
it is important to decide how to increase the level in
small steps. You need control over these steps. You
may choose to increase the volume slowly. You can
also move closer slowly over time. Plan for 3 to 5
steps as shown in Table 22–2. The last step is some-
thing that you wish you could do in your everyday
life but find hard at the start.
Summary of the Tips Provided
n Try to start daily with 1 to 2 minutes of sound
enrichment (see Chapter 19) and build up to
longer periods. This may just be listening to
sound coming through an open window, the
air conditioning or a fan. It can be a gentle
background sound that you can tolerate.
n The difference in volume will be smaller if
you use sound enrichment before, during,
and after listening to sounds that cause you
distress instead of listening to the sound after
it being completely quiet.
n Practice relaxing before and after listening.
Listening to My Phone Ringing
1. Listen to all the ringtones at the lowest
volume on my phone.
2. Increase the volume by two notches at a
time and listen to all the ringtones.
3. Have someone play all the ringtones
from their phone and slowly increase the
volume.
4. Sit in the corner of a room and play all
the ringtones from my phone.
5. Sit in a room without becoming distressed
by mobile phones ringing and people
talking on their phones.

n Reward yourself each time after listening.
n Plan a larger reward for once you reach the
last step.
n When you reach the last step, select another
sound that you find difficult and repeat the
process.
Addressing Common Difficulties
Here follows some problems you may experience
when working at improving sound tolerance and
suggestions to address these problems.
My tinnitus gets louder when I practice
with sounds.
Many people report an increase in their tinnitus
when they try to listen more often to louder sounds.
At first, the hearing system may react in a way that
leads to both louder tinnitus and being overly sen-
sitive to sound. The two conditions can affect each
other. Increasing the sound level briefly can affect
the hearing system and alter your tinnitus for a
short while.
Many factors could make your tinnitus seem
louder after listening to loud noises:
n When going from a noisy place to a quiet
place, there will be a contrast in the sounds
heard. At first, your tinnitus is one of many
sounds or may even be masked by other
sounds. When these sounds are lower, your
tinnitus will seem much louder. The ear
becomes used to a certain sound level. If the
volume of all sounds except one is lowered,
this one sound will seem louder.
n The ear gets used to a noisy place by lowering
the level of sound it sends to the inner ear.
A reflex kicks in, making it harder for the
hearing bones to let the sound wave pass into
the inner ear. The sound’s volume is thus
dampened. Although the result is a brief hear-
ing loss, the aim is to protect your ears. The
temporary hearing loss will make sounds less
intense. This adds further to the varied effect.
n A brief increase in your tinnitus caused by loud
sounds can cause you to worry. Your worry
may cause you to focus more on the tinnitus
CHAPTER 22 INCREASING SOUND TOLERANCE 203
and this can make the tinnitus seem louder.
This effect may stay for a few hours. For some
people, tinnitus gets louder due to stress.
Worrying about whether you are going to
find sounds painful may make things seem
worse than they are.
The higher volume can cause distress but will not
stay. Keep using the other tools you have learned to
help with your tinnitus, even if your tinnitus seems
louder. Don’t give up too soon. You will never, as
you won’t, then know whether the advice could
have helped.
I worry that I may get a hearing loss.
Hearing damage can occur for many reasons, such
as listening to loud noises, illness, or a head injury.
The damage depends on many factors, such as the
nature of the sound and how long the sound was
present. When you have a lower tolerance for sound,
the signals of pain and discomfort are not always
warning signals for hearing loss. Protect your ears
when you know sounds are going to be loud. Try
not to use hearing protection for sounds that are not
harmful. Letting your ears listen to low-level sounds
before and after hearing a loud sound is helpful in
reducing the effects of this noise.
I am still sensitive to sounds although I have
tried the advice given.
Sometimes the positive effects of the sound train-
ing can take longer than several weeks to notice.
If you have been sensitive to sound for a long time
and have avoided certain sounds, increasing your
tolerance can take time. Be honest when you assess
whether you are listening to the sound enough. If
you are sensitive to sound due to a physical injury,
these techniques may not work as well. The impor-
tant thing is to make sure that low sound tolerance
does not prevent you from doing things that you
like. You should protect your hearing when sounds
are very loud. Try not to avoid sound completely.
Make sure you keep listening to background sounds.
Practice relaxing; sounds around you will be less
bothersome when you relax.
Why do sounds hurt my ears?
When you hear sounds that may be distressing,
the hearing system sends out signals of pain. This
204 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

does not mean the sound is harmful. Many people

Key Messages
also have feelings of pain long after such a sound
has stopped. The reason why is not always known. n A low tolerance to everyday sounds can cause
It is likely that the jaw and two ear muscles play a lot of distress. There are things you can do
a large part. They tense up when hearing a loud that can help increase your tolerance levels to
sound. They can stay tense even after the sound has these sounds.
stopped. This tension may become linked with cer- n Regular deep relaxing can help you to cope
tain places. The different muscles, such as your jaw, with distressing sounds.
could tense too often, as during periods of stress. At
n Avoiding total silence is helpful.
the same time, you may increase the focus on your
ears and how they feel. When the tiny ear muscles n Listen to background sounds at a low level
are tense or cramping, it can cause pain or discom- before and after listening to loud sounds or
fort. It can also cause sound to seem distorted or sounds that cause distress.
cause strange feelings in your ears. n Use a stepped approach to improve your
tolerance for sounds you find difficult to
Why do I worry and become tired when I listen tolerate.
to sounds?
Many people feel that they cannot “handle” hear-
ing a lot of sound. People who are sound sensitive Reflection Activity
tend to tense up when the sound level is high. This
may also happen when they have trouble hear- n What is the most important thing you have
ing or have loud tinnitus. Being stressed or finding learned from this chapter?
it hard to focus can also cause these effects. The
tenser you are, the more tired you become. This

shortens the period over which you are able to tol-
erate sound. Muscle tension can make you more
n What tips are you going to apply?
sensitive to sound. It can also make your tinnitus
seem worse. If so, techniques to help you relax can
be very helpful. Try to do them when you are in a

loud place.

What can I do to lower the distress, worry,

and pain?
Try to relax often. This will help you to be able to
tolerate these sounds better. Also prepare your ears
before, during, and after listening to loud sounds.
This can help ease your worries about sounds and
lessen the pain in your ears.
Worksheet
Complete the worksheet shown in Table 22–3. This
will help you see your progress. It is good to have
something to remind you of how much you have
accomplished. The first row provide an example.
TABLE 22–3. Worksheet for Making a Note of How You Address Sound Tolerance Problems

What is
your sound
sensitivity
like? Comments How
Rate from These may well this
1 to 10 with include when, went
1 meaning where, and Rate
very difficult for how long from 1 to
to tolerate something 10 with
sounds and was done. You higher
10 meaning can also note scores
having almost How are you going what you can indicating
no problems What sound are to grade your do differently that you
tolerating you going to exposure to this or change next had more
Date sounds. target? sound? time. tolerance.
1/1/21 1 The sound of paper I will record the I was less 4
being crumpled sound of paper being distressed than
crumpled. I listened to I expected to be
it at the lowest volume listening to the
for 5 seconds and sound because
gradually increased I felt I had
the time. Once I can control.
listen to it for longer,
I will increase the level.

205
 Chapter
Choose to be proactive, assertive, and self-defining.
— Bryant McGill
What This Chapter Covers
n Looking at what affects your listening skills
n Helping improve the way you listen
n Tips to hear better in tricky places
Introduction
Having a hearing loss, even a mild loss, can make
hearing difficult. Hearing loss is one of the biggest
risk factors for having tinnitus. There are many
people with both tinnitus and a hearing loss. When
tinnitus is loud, it can be distracting. This can also
make it hard to listen because the tinnitus is com-
peting with other sounds. Your tinnitus can also
cause irritation and negative thoughts. These emo-
tions can make it harder to focus on what others are
saying. There are times when it is hard to under-
stand what others are saying, even for people with
normal hearing. In a noisy place, most people find
it is hard to hear. Struggling to hear can increase
levels of stress and your annoyance with your tin-
nitus. Your stress can lead you to focus more on your
tinnitus, making it even harder to hear. This chapter
covers some listening tactics to help cope with hear-
ing difficulties. It is intended for those struggling
to hear.
The Purpose of Using Listening Tactics
The purpose of these tips is to identify factors that
can make it hard to hear and how these can be
23
LISTENING TIPS
addressed or improved. The tips will not change
your actual hearing levels but applying them will
lessen the problems associated with finding it hard
to hear.
Factors That Influence Listening
Listening is influenced by your hearing levels and
your behavior when listening. Listening depends on:
n The setting (i.e., visibility of the speaker,
competing sounds);
n Your position in relation to the speaker;
n The way others speak;
n Your listening skills; and
n Your level of hearing loss.
When you are struggling to hear, the first step is
to find out why. Which of these factors make it dif-
ficult? When you know why you are struggling to
hear, you can focus on improving that aspect. The
tips in this chapter help you look at each of these
factors.
The Setting
There are many settings where it is harder to hear.
For instance, hearing may be more difficult in cer-
tain rooms in your house. When you are out, you
may find certain places harder to hear in. How well
you hear in a setting is influenced by the sources of
noise and how reflective the surfaces are. Sources of
noise may be noise from other rooms nearby. Appli-
ances, ventilation, or pipes may make noise. Reflec-
tive surfaces are high ceilings and hard surfaces that
let sound bounce around the room. Sounds that are
207
208 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
lower in pitch tend to seem very loud in such set-
tings. Hard surfaces cause an echo, making sounds
get tangled in with other sounds. Large rooms with
high ceilings and many hard surfaces make hear-
ing much harder. These reflective surfaces cause an
echo, and sounds reflected off of them sound low and
hollow. Sound clarity also gets lost in bigger spaces.
Improving the Setting
Absorb the sound.
Adding anything to the setting that absorbs sound
instead of reflecting it can help. This includes car-
pets, curtains, rugs, tablecloths, and other fabrics.
Spaces with carpets, cushions, and curtains make
hearing much easier. These objects absorb sound
and lessen echoes.
Lower the background noise.
If you find it difficult to hear, see whether you are
able to turn off any sources of noise. In the kitchen,
there may be a dishwasher running or the radio
playing. Other sound can come from the oven
fan and washing machine. When trying to listen,
switching off some of these sounds will help.
Your Position
Where you place yourself can affect how well you
hear. Being able to see who is speaking is helpful,
provided you have good sight. Everyone uses body
language clues and a degree of lip reading when lis-
tening. These visual clues help decide exactly what
is being said. These extra clues really boost under-
standing. These clues are helpful when you cannot
quite hear. Here are some tips for positioning your-
self to make hearing easier.
At home
n Reposition the furniture so that you can face
people you speak to.
n Have good lighting to help you to lip-read
and notice someone’s body language. You use
these skills, although you may not be aware
of doing so.
n Sit away from any sources of noise that can
make hearing someone speak more difficult.
When going out
n Carefully select where you go.
n When possible, choose settings with less
reflective surfaces. Select places that use
tablecloths, curtains, carpets, cushions,
and soft fabrics.
n Going out for a meal in a smaller setting will
make listening easier.
n Choose places that do not play loud music.
n Sit where the sounds from the kitchen or
coffee machines are not close to the tables.
n Position yourself away from ambient noise,
with as little sound as possible behind you. In
this position, you will pick up less noise than
when you are sitting among lots of people in
other parts of the room. If you sit in the middle
of the room, you will hear sounds from all
around you. This will make it harder to hear.
Tips for People You Speak To
At times it may be difficult to follow what is said.
You may find yourself nodding to everything some-
one says without hearing much. Although this is
common, it does not help involve you in the conver-
sation. Here are some tips to give others.
n Tell them that you find it difficult to hear.
This may help them pay more attention to
how they speak.
n Tell others that it helps seeing their faces.
When they cover their mouth with their
hands, it is harder.
n Let them know that clear slow speech is
helpful and shouting can make listening
harder since it distorts sounds.
n Ask people not to speak to you from a
different room.
n Ask people to get your attention first before
speaking to you. This is always helpful when
you are focusing on something else.
n Ask people to let you know when they change
the topic they are talking about. This will
help prepare you.
 CHAPTER 23 LISTENING TIPS 209

Tips for Speaking With People n Certain words may be harder to hear. You
Using Face Coverings or Masks can ask the speaker to rephrase the sentence
instead of repeating it.
There are situations where people may wear masks
n If you are struggling, you may get tense, and
or face coverings. This makes lipreading impossible
this will make listening harder. Take a few
and following the conversation becomes very hard.
moments to do quick relaxation. This will
Try to prepare for situations where you know you
help you to relax and problem-solve instead
may have difficulty to minimize the frustrations
of building tension.
that may result. Here are some tips that can help:
n Always try to find out what topic people are
n Where it is possible, request that clear or talking about. Even if you hear only parts of
transparent masks be used. You could ask what is said, it will help to know the topic.
your dentist or doctor if this is possible when
you book an appointment.
Effects of Hearing Loss
n If it is not possible to remove face coverings
or when masks are not transparent, there are
Recent research has shown that untreated hear-
apps that can type out what is said so that
ing loss can affect you in various ways, such as the
you can read what other people say. This can
following.
aid communication and reduce frustrations.
There are also amplification apps, but these
n Nine key risk factors have been found
generally require headphones. You can search
to increase the risk of getting dementia.
for transcription, amplifier, or flashcard apps
Untreated hearing loss is the most significant
on your tablet or smartphone.
risk factors for developing dementia.
n Alternatively, take a paper and pen and ask
n Untreated hearing loss can also lead to
people to write down parts of the conversa-
withdrawing from social events. This with-
tion you find hard to follow.
drawal can result in becoming more isolated.
n Prepare well before going someplace where Reducing social isolation is important as
people wear masks in order to know exactly it has been shown to be related to tinnitus
where to go and what to do so that there is being more bothersome.
less need to ask for help or directions from
n Untreated hearing loss can cause problems
people likely to be wearing masks.
talking to friends or those close to you. You
might not always hear what someone has
said.
Listening Tips You Can Apply
n A hearing loss can lower your quality of life
and well-being. Hearing loss can also be
Following are some listening tips you can apply.
linked to depression.
n Be actively involved when conversing by n Untreated hearing loss can also affect your
asking questions and taking turns speaking. health and lead to headaches, muscle
Nod your head and use facial gestures so that tension, increased stress, and raised blood
people know you are following what they are pressure levels.
saying. You may rephrase what you heard n Often people with untreated hearing loss tire
someone say to make sure you heard correctly. easily, due to the effort it takes to listen. This
n If you have not heard the full sentence, let fatigue can make focusing on other things
the speaker know which part you heard. harder.
Then the speaker can just repeat the part n There are also emotional effects. These include
you did not hear. sadness, embarrassment, guilt, and anger.
210 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Due to these effects, people who can benefit
from hearing aids should use them.
Hearing Devices
If you have a hearing loss, hearing devices such as
hearing aids can be very helpful. If you have both
hearing loss and tinnitus, the general approach is
to first treat the hearing loss. Hearing aids may be
very helpful to distract you from tinnitus. When you
can hear better, it is also easier to focus on ways to
deal with the tinnitus. Hearing aids have improved
a lot over the years. They can be finely adjusted for
your specific hearing loss. Hearing aids will reduce
listening effort. Hearing aid technology is constantly
improving to improve hearing in a noisy place.
A further benefit is that they can reduce the impact
of your tinnitus. By picking up more sounds than
you hear without them, your hearing aids distract
your brain from the tinnitus. Hearing aids can be
adjusted in different ways that help to make the tin-
nitus less obvious. If you have hearing aids that are
not reducing the impact of your tinnitus, they may
require adjustments. Do see your audiologist for fur-
ther adjustments. If you go to settings were masks or
face coverings are warn, ask your audiologist to add
a “mask” program. This changes the hearing aid
settings to help you hear better in these situations.
Getting Used to a Hearing Device
Getting used to wearing hearing aids takes time.
Don’t give up even if it’s hard at first.
Try to use your hearing aids in quiet places initially.
Gradually build up your usage so that you get accus-
tomed to listening to all kinds of sounds. Later, proceed
to wear your hearing aids in noisier places. Aim to use
your hearing aids all the time. Consistently having
the same level of sound helps your brain adjust to
various sounds. It is harder for your brain when things
are sometimes quiet and sometimes loud. Wearing
the hearing aids only when going out will make it
harder for your brain to cope with all the sound.
Using hearing aids consistently is important. If your
hearing aids are not helping or you have problems,
go see your audiologist. Your audiologist can make
adjustments to your hearing aids.
Additional Listening Devices
There are many devices that can help you hear bet-
ter in places where it is tricky to hear, such as in
a large room, when there is background noise, or
where you are not in a good position to hear the
speaker. For the phone, there may be an amplifier
or smartphone app to help. In public places such
as theatres, there may be loop systems or special
smartphone apps to help. Loop systems lessen the
distance between you and the speaker and can be
very useful. There are also other listening devices to
help in meetings or in places where there is a lot of
noise. There are also devices that help you link your
hearing aids with the television so that you can have
the television at a level that helps you and your fam-
ily can set it at a suitable level for them.
Addressing Common Difficulties
Following is additional help if you are having any
problems.
I still struggle to hear.
How well you hear depends on many different things.
Try to find out what is making it harder to hear. See
which of the tips you can apply.
People around me don’t consider my
hearing problems.
It is important to try to tell others what they can
do to help you. Remember, everyone needs time to
change a habit. They may need to be reminded. Over
time, they will start applying the tips you have shared.
I find it difficult to make adjustments.
Adjusting your behavior in a new place can be hard.
Start by trying just one change. Select a place that is
hard to listen in and select one tip to apply. As you
gain confidence, you can try more tips.
Key Messages
n Factors such as the setting, your position, and
your listening skills can make listening easier
or harder.
n The first step is to find out why you are strug-
gling to hear.
n Try to reduce sources of noise by adding more
absorbent surfaces to rooms where it is hard
to hear or by choosing places to go that have
absorbent surfaces.
 CHAPTER 23 LISTENING TIPS 211

n You can also sometimes position yourself Worksheet

away from noise and facing the speaker.
n Good listening is a skill that can be improved.
Reflection Activity
Complete the worksheet shown in Table 23–1 to make
a note of things you are trying to improve your abil-
ity to hear. The first row provides an example.

n What is the most important thing you have

learned from this chapter?

n What tips are you going to apply?


TABLE 23–1. Worksheet for Making a Note of Things You are Trying to Improve your Ability to Hear

Comments How well

What listening tips are you
Date going to try?
1/1/21 I am going to reposition the furniture
at home to be able to sit opposite
my partner and to have him in view
when watching television. I am also
going to add cushions to absorb
more sound.
These may include when, where, and this went
for how long something was done. Rate from 1 to
You can also note what you can do 10 with 10 being
differently or change next time. very successful.
It has really helped sitting opposite 7
my partner at mealtimes. I think
the soft furnishings have reduced
the reverberation.

212
 Part V
MAINTAINING THE RESULTS
 Chapter
Success is not a destination, it’s a journey.
— Zig Ziglar
What This Chapter Covers
n An overview of the content in each chapter
n Taking time to reflect on the content
n Thinking about what techniques you want to
continue using
Introduction
Well done getting through most of the chapters!
You have had the chance to try different Cognitive
Behavioral Therapy (CBT) techniques. Looking back
at the content of the chapters to remind you what
they covered is useful to help you identify what you
found the most helpful. This chapter recaps the
content of the chapters. As you read the summa-
ries, think about which you want to keep using and
which you may no longer need.
The Purpose of This Summary
Because you have gone through a lot of tools, it is
useful to review them. This will help you identify
which were the most useful and important for you
to better cope with your tinnitus.
Tinnitus Overview
n Having a better grasp of what tinnitus is
helps to lessen the problems it causes.
n Tinnitus may start after some hearing
damage or after hearing lots of loud noise.
24
SUMMARY
For some, tinnitus may start despite normal
hearing or a mild hearing loss.
n When any sounds annoy you, they can
cause you to notice them more; tinnitus is no
exception.
n By changing the meaning you have given to
your tinnitus, you can lessen your annoyance
with tinnitus. This will change how you react
when you hear the tinnitus.
n It is not always the tinnitus that causes the
annoyance but how it is interpreted and what
you do when hearing it.
n Habituation is the process of getting used to a
repeated stimulus. Because you can get used
to other sounds, habituating to tinnitus is
possible. There are things you can do to help
move tinnitus to the background.
Relaxation Techniques
n Hearing tinnitus can lead to annoyance. This
in turn causes tension and stress to build
up in your body. Releasing this tension is
important.
n Relaxing can help you limit the effects of
these responses and the related feelings of
tension.
n Relaxing using slow deep belly breathing and
repeating a calming word while breathing
can work very well.
n Thinking of a positive picture in your mind
while relaxing is very helpful.
n Relaxing as part of your daily routine can
help you to deal with your tinnitus.
n Do deep relaxation at least once a week. Do
quick relaxation often during the day. Doing
215
216 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
these often helps you learn the skill of being
able to relax.
n During a stressful situation, take a few
moments to do deep breathing on the spot
and release the tension before it builds up
too much. Table 24–1 provides a summary of
different relaxation steps to follow.
CBT Techniques
This section provides a summary of key points
related to CBT techniques, and Table 24–2 provides
Shifting Focus
a summary on how to practice them.
Using Positive Imagery
n Thinking of a peaceful setting in your
mind can help distract you from your
tinnitus.
n Select a picture that has a calming effect on
you and brings peaceful thoughts.
n When you notice your tinnitus, focus on this
picture. Think what it means to you and the
memories it triggers instead of focusing on
your tinnitus.
n Explore the picture by looking at all the
Challenging Your Thoughts
different parts as you imagine them. Use all
your senses to explore the scene.
n Incorporate positive imagery while doing
deep relaxation to enhance your
relaxation.
Changing Views of Tinnitus
n When you view your tinnitus as something
negative, it draws more attention to the
tinnitus.
n Viewing tinnitus as just another sound,
instead of a noise you dislike, helps you focus
less on the tinnitus.
n Think of something that sounds like your
Being Mindful
tinnitus such as bells chiming, ocean waves
hitting the shore, insects buzzing, or a train
passing by.
n Imagine this sound in the place it is normally
found such as waves at a beach.
n Try to control the level of the tinnitus by
letting the other sounds in the picture become
louder. For instance, focus on the sounds of
children and dogs playing on the beach. This
will help you focus less on the sounds of the
waves.
n Spend time exploring all the other parts of
the picture. In this way, you will focus less on
the tinnitus.
n When your tinnitus annoys you, it is helpful
to be able to shift your attention away
from it.
n To increase your ability to shift your focus,
start by shifting your focus between 2 things,
not including your tinnitus. This may be to
something else you see, feel, or hear.
n Once you have learned this skill, you can shift
your attention away from tinnitus as well.
n Learning this skill will also help you focus on
other tasks you need to do.
n Some thoughts are not helpful and can affect
your mood.
n It is important to be aware of thoughts and
the effect they can have on you.
n It is useful to stop some of these unhelpful
thoughts to lessen their negative effect.
n Challenge them by asking questions to
determine how true they are.
n Try to restructure your thoughts to stop nega-
tive thoughts before they have too much of a
negative effect on you.
n People often tend to get absorbed in every-
thing that needs doing or focusing on past
events.
 CHAPTER 24 SUMMARY 217

TABLE 24–1. Relaxation Guide

Step Type Where When How

1 Deep A peaceful Twice a day for • Tense and then relax each muscle
relaxation place where 10 to 15 minutes group in turn.
you can be Sitting in an • Start with your hands (or use a
alone upright chair different sequence).
Phone turned • Tense your muscles for 5 seconds, then
off; door closed release the tension for 10 seconds.
• Do each muscle group separately.
2 Deep A peaceful Twice a day for • Use deep breathing, a relaxation word
breathing place where 10 minutes and progressive muscle relaxation.
you can be Sitting or lying • Breathe in from your belly through
alone down your nose for 5 counts.
• Breath out through your mouth for 10
counts.
• Think of your relaxation word as you
breathe out.
• Focus on relaxing each group of
muscles without first tensing them.
3 Entire Sometimes Twice a day for • Use deep breathing, a relaxation word
body alone, 5 minutes and relax all your muscles at once.
relaxation sometimes Sitting • Breathe in from your belly through
where others your nose for 5 counts.
are near (e.g.
as a passenger, • Breath out through your mouth for 10
watching TV, counts. Think of your relaxation word
before an as you breathe out.
appointment) • Relax all your muscles at once. Feel
your entire body getting heavier and
more relaxed with each breath.
• Scan your body for tense muscles and
relax these areas.
4 Frequent Relaxing 5 to 10 times a Relax frequently throughout the day for
relaxation where you are day for 1 to 2 short periods of time.
comfortable minutes Select 4 to 8 places or times you will
Alone or Sitting, standing, always relax in (e.g., after brushing your
among people lying down, or teeth, on the hour, after having a drink.
waiting • Relax while keeping your eyes open
by doing deep breathing, using your
relaxation word on the exhale, and
relaxing all your muscles at once.
• Remind yourself though notes or
putting it in your calendar.
continues
TABLE 24–1. continued

Step Type Where When How

5 Relaxing Relaxation 7 to 15 times a • Relax before, during or after

when you when stressed day for up to something that is stressful or when
are upset 1 minute feeling annoyed, upset or irritated.
of stressed Any time you feel • Staying where you are, relax while
tense or upset keeping your eyes open by doing deep
breathing, using your relaxation word
on the exhale, and relaxing all your
muscles at once.
6 Relaxation Writing a Deep relaxation • Relax before or after anything stressful.
routine relaxation twice a week • Plan time to do deep relaxation.
plan Frequent • Select times or places to do frequent
Planning some relaxation relaxation.
time to do both 8 times a day
deep and quick Quick relaxation
relaxation before, during, or
after something
stressful

TABLE 24–2. A Summary of CBT Techniques

Principle How
Positive Imagery
Create a picture • Start by first relaxing.
in your mind of a • Imagine a scene, place, or event that is beautiful and happy.
pleasant scene to help • Explore the scene in detail by moving between the different parts of the image.
distract you from your
tinnitus. • Use all your senses, imagining the smells, sounds, and so forth.
• Finish by relaxing again.
Changing Views of Tinnitus
Reinterpret your • First spend time relaxing.
tinnitus to a more • Focus on a positive scene by imagining what it looks like (e.g., a deserted beach).
pleasant or neutral • Link your tinnitus to an alternative sound within this setting (e.g., associate
sound. tinnitus with the sound of the waves on the shoreline).
• Reduce the volume of the scene by moving farther away from it (e.g., by
walking away from the shoreline and higher up the beach).
Focus on the positive parts of the image (e.g., seeing the birds in the sky, the
fishermen, the sun sparkling on the water).
Shifting Focus
Shift your attention • First select two real stimuli and shift your focus between them.
away from your • Focus on each for about 15 to 30 seconds.
tinnitus.
• Select something you see, hear, or feel.
• After a few days, move your attention between tinnitus and something you
see, hear, or feel.
• Later, move your attention away from your tinnitus onto something else.

218
TABLE 24–2. continued

Principle How

Thought Patterns
Be aware of your • Write all the thoughts you have about tinnitus (many words) or other
thoughts and negative thoughts.
emotions and how • Then write how you feel (one word).
they influence you.
• To help, think about when and where your tinnitus often bothers you.
• What are your thoughts about tinnitus at these times?
• Be aware of your thoughts at times when your tinnitus is loud and more
bothersome.
• What does this sensation of increased tinnitus lead to?
• Try to see the link between your feelings and your thoughts about tinnitus.
• You can also write other thoughts that make you worry or are negative.
• Write what is going through your head.
Challenging Thoughts
Addressing unhelpful • List your negative thoughts, mindsets, or tinnitus myths you have noticed.
thoughts so that they • Jot down how much you really believe this thought (e.g., I believe the
have less of an impact thought 100% or 50%).
on you.
• Spot the type of thought or mindset.
• Then reword any thoughts that you could not easily and clearly explain to
another person.
• Take the thought and ask questions about it. The questions should clarify,
challenge, and help you think about the thought.
• Now, again rate how much you believe the thought.
Being Mindful
Notice the present • Try to get completely absorbed in what is going on around you for a few
moment. minutes at a time.
• When your mind wanders, just bring it back to focus on the sights and
sounds around you.
• It is easiest to do while you are doing the normal things you do every
day (e.g., having a cup of coffee, putting cream on your hands, watering
the plants).
• Don’t worry about thoughts that go through your mind or about how well
you’re doing. Try not to fight thoughts. Just gently refocus on what you were
doing.
• If you find sitting still difficult, focus on doing something active but focus
fully on the activity (e.g., dancing around the room, going for a walk,
swimming, riding your bike).
Listening to Tinnitus
Reduce the effect • Start by relaxing and viewing your positive mental image.
tinnitus has on you • To explore your tinnitus, think about what it sounds like for the period you
and your response set aside.
when you hear it.
• End by again relaxing and viewing your positive mental image.
• When you are finished, reward yourself.

219
220 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
n Often, people don’t stop to enjoy the present
moment.
n Being mindful is a way of directing your focus
to notice what you are doing.
n Try to include this in your daily routine,
such as when brushing your teeth, eating, or
walking.
n Try to get completely absorbed in what is
going on around you for a few minutes at
a time.
Listening to Your Tinnitus
n If you always try to avoid hearing your
tinnitus, it may stop you from doing things
you really want to do.
n Being able to hear your tinnitus and not get
annoyed can help lessen the negative effects
it has.
n Having times when you just listen to the
tinnitus can help you accept the tinnitus. It
can also help lessen the stress tinnitus causes.
n Do not be afraid to listen to your tinnitus.
Although it is hard to do, it can have many
benefits.
n Reward yourself for trying it.
Dealing With Effects of Tinnitus
Sound Enrichment
n Sound enrichment helps you notice your
tinnitus less by using other sounds to distract
you from it.
n You may find it most useful when it is quiet.
n The sound should be a pleasant or neutral
sound that does not draw your attention too
much.
n The sound should be able to help you control
the way the tinnitus affects you.
n Sound enrichment can be used in any place
you find your tinnitus is bothersome.
n The sound should be on at a low level. It
should compete with your tinnitus, but never
cover it up completely.
n You can use natural background sounds, such
as leaving the window open; background
sounds such as the sound of ocean waves
or water from a smart phone app or music
player or sounds that grab your attention
such as an audiobook.
Sleep Guidelines
n Relaxing and using good sleep habits can
improve your sleep.
n Incorporate a relaxing evening routine and
do some or your relaxation exercises before
going to bed.
n Ensure you do exercise during the day and
avoid a heavy meal and caffeine shortly
before going to bed.
n You should view your bed as somewhere you
sleep. To help, don’t use your bed for things
you do when awake, such as working on your
computer.
n Adjust your sleep patterns and natural body
rhythms by going to be and waking up at the
same time each day.
Improving Focus
n Being able to focus is a skill, which can
improve with practice.
n Taking frequent breaks helps you to focus.
n Planning tasks and working in a structured
way can help lower stress levels.
n When there is less to distract you, your ability
to focus can also improve.
Increasing Sound Tolerance
n Being sensitive to sound occurs when normal
everyday sounds seem too loud, although
they do not bother others.
n The best way to overcome this is to slowly
start listening to sounds you find distressing.
Make sure you have control over the volume
of the sound.
n Increase your sound tolerance by avoiding
quiet places. Put on some low-level sound,
such as music or nature sounds.
 CHAPTER 24 SUMMARY 221

Listening Tips Key Messages

n Having tinnitus can make it hard to focus on
n Refer back to the chapters that helped you
what others say.
the most.
n Find out why you are struggling to hear. You
n Keep doing the techniques you found the
might have hearing loss. If you do, managing
most helpful.
the hearing loss can be helpful not just for
listening, but also for tinnitus relief. n Over time, these will become good habits.

n Start with one tactic that may help. This

may be changing where you sit so you can Worksheet
see others speaking more easily. It could be
moving away from someone noisy. Complete the worksheet shown in Table 24–3. This
n You may want to add soft cushions in a room will help you to evaluate which tools worked best for
that has many reflective surfaces that cause you and which you want to continue to use. The first
an echo. few rows provide some examples.
n You also may ask others to get your attention
before speaking. Make sure that you can see
the person who is talking to you.
TABLE 24–3. Worksheet for Evaluating Which Tools Worked Best for You

How well How important

it worked it is to keep
Rate from 1 using this tool
to 10 with 10 Rate from 1 to 10
Comments being worked with 10 being most
Date Tool or Strategy What effect did using the tool have? best. important.
1/1/21 Changing my view I don’t think of my tinnitus as 10 10
of tinnitus annoying anymore.
1/1/21 Deep relaxation It calms me down. 10 10
sessions
1/1/21 Frequent quick I am able to deal with my tinnitus 8 10
relaxation and problems more easily.
1/1/21 Positive imagery It improves my ability to focus 7 9
after using it.

222
 Chapter
Doing things in the present that you can see shapes the
future that you are yet to see.
— Idowu Koyenikan
What This Chapter Covers
n Looking at your goal attainment
n Planning which tools you want to keep using
n Reparing for possible setbacks
Introduction
Everyone has set goals for themselves but later real-
ized that they may have lost sight of them. This
chapter intends to make sure that tinnitus will not
affect your life as much as it did in the past. The
important part now is to maintain the results you
have achieved. You have formed new habits that
ensure that the tinnitus have less impact on you.
This chapter helps you plan how to maintain these
good effects.
The Purpose of Planning for the Future
The aim of this chapter is to ensure that you main-
tain your results. It will help you plan which tools to
use and what to do when you have a setback.
Your Goals
When you started the program, you wrote down
some personal goals. Refer back to Table 4-3 and add
these goals to Table 25–1. Then evaluate whether
you have reached your goals.
If you have not reached your goals, consider why
this might be. If you have achieved your goals, the
next step is planning for the future so that you stay
25
FUTURE PLANNING
in control of your tinnitus. If you keep doing the
things that have been most helpful, old habits will
not return.
Making the Good Effects Last
Some tools you may want to use daily and others
only now and then. Keep focusing on doing the
things you found most helpful. Later in this chapter,
you will write your plan and refer to it often. This
will help you keep your tinnitus under control.
How can you remind yourself to keep working
on the techniques and not slip back into old
habits? Select the strategies you will use:
n Incorporating the techniques into my
daily routines; o
n Telling people around me about my goals; o
n Discussing my progress with someone
once a week; o and
n Evaluating my tinnitus distress on a
weekly basis. o
Write down other ways you may think of:

Setbacks
Although things are going well now, you may have
setbacks later on. It is a good idea to try to foresee
223
TABLE 25–1. Look Back at Your Goal-Setting Worksheet. Which Goals Did You Reach?

Degree of Change Since Final Result Due to This

Starting the Program Program
My tinnitus is I am annoyed by my tinnitus
• Worse • A lot of the time
• The same • Half of the time
Original Goals • Slightly better • Occasionally
Transfer these from Table 4-3. • Much better • Hardly ever

224

what problems may arise and to plan ways of deal-
ing with them. If you do face problems later, you will
be prepared. You can look back at your plan and
feel confident that you can overcome them. This will
help you not slide back into old habits and unhelp-
ful thought patterns. Make your plan about YOU,
thinking of the things that worked best for YOU.
Using Table 25–2, prepare for problems or set-
backs that may occur. When they do, you will have
a plan in place, and you will not be pulled back into
old habits and unhelpful thought patterns.
Your Plan for the Future
In the previous chapter, you evaluated the tech-
niques and how useful they were for you. Use your
completed Table 24–3 as a guide to work out which
techniques you want to keep using. Some tools you
may want to use daily, and others only now and
TABLE 25–2. Preparing for Dealing With Any Future Setbacks
Possible Problem/Setback Coping Strategy
CHAPTER 25 FUTURE PLANNING 225
then. Keep focusing on doing the things that you
found most helpful. Write your plan and refer to it
often. This will help you keep your tinnitus under
control.
Using Table 25–3 record which techniques you
want to keep using and how you are going to ensure
that you keep practicing them.
Key Messages
n Congratulations on completing the program!
n Use the next section to monitor how much
you are improving.
n You also need to celebrate your success by
rewarding yourself to something you enjoy.
n When you find things are not going as well as
you hoped, look back at the plans you made
in this chapter.
TABLE 25–3. Planning Activities for the Future

Techniques I Want to Keep Using How and When I Am Going to Use Them

226
 Section C
SUPPLEMENTARY MATERIALS
FOR MONITORING
AND ENGAGEMENT
 Chapter
ADDITIONAL RESOURCES
What This Section Covers
n Description of videos to supplement the
content
n Ideas of other social supports for tinnitus
n Examples of other tinnitus resources such as
apps and other books
Introduction
Often it is not just one thing that helps you man-
age your tinnitus, but a combination of different
things. One may be exploring hearing devices if
you have a hearing loss, There are also other tin-
nitus programs, many are free or inexpensive that
can be considered. If a program is very expensive
or claims to fully cure tinnitus, you should ensure
it is based on research evidence before paying a
lot of money. You should also consider what kind
of program suits you best. Everyone has a dif-
ferent learning style. Some people find it easier
to learn from visual information and others from
auditory information. Information presented in dif-
ferent formats helps to reinforce the content. This
chapter provides ideas of additional resources that
can help you with your tinnitus and that comple-
ment this program.
The Purpose of the Additional
Resources Provided
This chapter is intended to list a few additional
resources you can access to help you with your Knowing exactly what information is most appro-
tinnitus. priate for an individual with tinnitus is difficult.
26
Supplementary Videos
There are explanation and demonstration videos
available that supplement the written materials
in this book. Table 26–1 provides a list of the
videos provided in this book.
Tinnitus Associations and Support Groups
Associations for tinnitus patients are very good at
directing those with tinnitus to accurate information
and available help in the area. Examples are the
American Tinnitus Association in the United States
and the British Tinnitus Association in the United
Kingdom. These organizations generally have a list
of the available local support groups for tinnitus.
Joining these groups and hearing others’ experi-
ences regarding tinnitus can be of great value. The
groups often have special speakers or events. Get-
ting in touch with tinnitus associations or support
groups is highly recommended. If there is no tin-
nitus support group in your area, you could also
find out about starting one. There are also some
online support groups that you can join, if you can’t
attending the group meetings. Moreover, the asso-
ciations’ websites and monthly newsletters offer a
good summary of up-to-date research evidence as
well as useful tools for tinnitus management.
Further Reading
229
TABLE 26–1. A Summary of the Supplementary Videos Available in This Book
Chapter
4. Tinnitus Program Outline
5. Tinnitus Overview
6. Deep Relaxation
7. Deep Breathing
8. Entire Body Relaxation
9. Frequent Relaxation
10. Quick Relaxation
12. Positive Imagery
13. Views of Tinnitus
14. Shifting Focus
15. Thought Patterns
16. Challenging Thoughts
17. Being Mindful
18. Listening to Tinnitus
19. Sound Enrichment
20. Sleep Guidelines
21. Improving Focus
22. Increasing sound
tolerance
23. Listening tips
230
Video Content Speaker
1. Overview: Introducing the program Beth Parks Aronson,
Psychologist
2. An overview of tinnitus Marc Fagelson, Audiologist
3. Demonstration of deep relaxation Matthew East, Learning
Technologist
4. Deep relaxation: Outlining the Beth Parks Aronson,
importance of relaxation Psychologist
5. Demonstration of deep breathing Matthew East, Learning
Technologist
6. Demonstration of relaxing all Matthew East, Learning
muscle groups (entire body) at once Technologist
7. Demonstration of relaxing Matthew East, Learning
frequently during the day Technologist
8. Demonstration of relaxing during Matthew East, Learning
stressful situations (quick relaxation) Technologist
9. Explanation of how positive imagery Beth Parks Aronson,
works and can be used Psychologist
10. Explanation of the purpose of Eldré Beukes, Audiologist
changing your view of tinnitus
together with some examples
(reinterpretation of tinnitus)
11. A demonstration of shifting focus Eldré Beukes, Audiologist
12. Explanations regarding how to shift Marc Fagelson, Audiologist
focus
13. A outline of different thought Eldré Beukes, Audiologist
patterns
14. An explanation of how to challenge Beth Parks Aronson,
unhelpful thoughts Psychologist
15. A discussion around the benefits of Beth Parks Aronson,
mindfulness Psychologist
16. What actively listening to tinnitus Eldré Beukes, Audiologist
entails and how it is helpful
17. Ways of using sound enrichment Marc Fagelson, Audiologist
18. Tips on improving sleep Eldré Beukes, Audiologist
19. Tips on improving your ability to Beth Parks Aronson,
focus Psychologist
20. An outline to address sound Marc Fagelson, Audiologist
tolerance
21. Hearing tactics Eldré Beukes, Audiologist

There is plenty of information about tinnitus man-
agement available on the Internet. This information
is variable in its content and claims. Depending on
where the information is gathered, users can get a
sense that nothing works for tinnitus (i.e., no treat-
ment) or, on the contrary, that everything works
for tinnitus (e.g., various alternative therapies or
instruments). However, it is important to look for
evidence-based management options. Often some
treatments found on the Internet do not provide
clear research evidence. Therefore, it is important
for those with tinnitus to rely on reputable sources
(e.g., professional bodies, government, patient orga-
nization websites) in which the information is vetted
and updated on a timely basis.
There are numerous tinnitus books available.
Again, selecting reputable books written by experts
in the field is important. Here are some examples:
Henry, J. A., Zaugg, T. L., Myers, P. J., & Kendall, C. J.
(2010). How to manage your tinnitus: A step-by-step
workbook. San Diego, CA: Plural Publishing.
McKenna, L., Baguley, D. M., & McFerran, D. (2010).
Living with tinnitus and hyperacusis. London, UK:
Sheldon Press.
Smartphone Apps
There are numerous smartphone apps that can help
you manage your tinnitus or improve your overall
CHAPTER 26 ADDITIONAL RESOURCES 231
well-being. Note that there is limited research evi-
dence on the efficacy of these apps, although anec-
dotal notes from tinnitus sufferers suggest potential
benefits to some users. Following are examples of
the types of available apps.
n Apps for monitoring how much exercises
you are doing;
n Apps for tracking your diet or sleep pattern;
n Apps that provide sound enrichment;
n Relaxation or yoga apps; and
n Mindfulness and Cognitive Behavioral
Therapy (CBT) apps.
Key Messages
n Ensure that you use reputable sources when
finding out more about tinnitus. Look for
resources that are written by tinnitus experts
or tinnitus associations.
n Reinforcing written information with visual
and auditory material such as videos can
help aid learning.
n Social support for tinnitus can be very
beneficial, such as tinnitus support
groups.
 Chapter
PRE-INTERVENTION
SCREENING QUESTIONNAIRE
What This Chapter Covers
n A list of reference questions that can be used
to collect the case history
n Possible responses that can be viewed as red
flags that need further consideration
n Case history presentations that may indicate
the need for referral to other medical specialists
Introduction
Before starting any intervention, it is very impor-
tant to do a thorough assessment. Chapter 3 lists
important aspects that can be assessed. The purpose
of this chapter is to provide example questions for
the initial tinnitus assessment. These questions can
be used while collecting the case history to aid in
assessing the tinnitus patient holistically.
Pre-Intervention Screening Questionnaire
Table 27–1 provides a suggested list of questions with
three main aims:
27
n To identify the possible causes of tinnitus;
n To identify any auditory or psychological
problems that are raised as red-flag concerns
that may need further referral (questions
marked with an *); and
n To understand the consequences of having
tinnitus.
Only the initial questions are provided. Where
questions are answered positively, further follow-
up questions can be asked to get more information.
Part 2 of Table 27–1 provides a summary of red flags
and possible referrals required.
Key Messages
A list of possible case history questions to include in
a tinnitus assessment is provided. These should be
supplemented with additional assessments and self-
reported outcome measures that can be used during
a tinnitus assessment.
233
TABLE 27–1. Example Questions to Ask During an Initial Tinnitus Assessment

Part 1: Demographic Questions

Questions
Why have you come today?
General contact details
What is your age?
Do you work? If so, what do you do?
What activities are you involved in during a typical week? Do you, for instance, attend meetings,
participate in clubs, or go out a lot.
Further standard background follow-up questions, depending on the individual’s lifestyle

Part 2: Tinnitus-Related Questions

Possible Red Flags Indicating the Need for Further

Questions
When did you start noticing
your tinnitus, or how long
have you had tinnitus?
Who have you consulted
about your tinnitus?
What investigations have
been done due to your
having tinnitus?
Has a professional given
you a diagnosis or reason
for your tinnitus? What
reason was given?
What do you think led to
you having tinnitus?
*Where do you notice your
tinnitus?
*Can anyone else hear your
tinnitus?
*Is your tinnitus in
time with your pulse or
heartbeat?
*Can you change the
tinnitus by moving your
jaw or making another
movement?
Referral or Investigation
Tinnitus of a short duration (i.e., less than 3 months) may not be of a
chronic nature. Some more invasive treatments should not be offered.
However, some form of CBT may still be helpful to ensure that unhelpful
reactions and behaviors are not adopted that can prevent habituation.
If no medical professional has been seen, assess whether this is needed.
Are any further investigations indicated?
The reason for the tinnitus may inform the intervention selected.
Further care may be indicated if the reason is a head injury or traumatic
event, for example. Understanding the reasons for the individual’s
tinnitus is often important before beginning tinnitus treatment.
Unilateral tinnitus that has not previously been assessed may need
further investigation.
Objective tinnitus that has not previously been assessed may need
further investigation.
Pulsating tinnitus that has not previously been assessed may need
further investigation.
Somatic tinnitus that has not previously been assessed may need further
investigation.

234
TABLE 27–1. continued

Additional Questions
Describe what your tinnitus sounds like.
Are you receiving any treatment for tinnitus at present?
Have you received treatment for tinnitus in the past?
What help have you tried for your tinnitus?
What improves your tinnitus?
What makes your tinnitus worse?
Are you taking any supplements for your tinnitus? If so, what effect do they have?
Have you made any lifestyle changes due to having tinnitus?

Part 3: Auditory-Related Questions

Possible Considerations or Red Flags Identifying the

Questions Need for Referral
How hard do you find it to Red flags are when hearing loss is sudden, asymmetric, recently changed
hear? significantly, or has not been tested or investigated previously.
Do you have a hearing If unknown, performing audiometric testing is indicated.
loss?
Do you use any hearing Are such devices indicated?
devices such as hearing
aids?
Do the hearing aids help Are adjustments required?
reduce your tinnitus in any
way?
Do you experience any If so, referral for further investigation may be indicated.
dizziness or balance
problems?
Do you get pain in your If the pain is severe, sudden, and not resolving, this may need further
ears or ear infections? investigation.
Do you think you are more Ensure that the intervention selected addresses hyperacusis as well.
sensitive to some sounds
that other people do not
find loud? If so, which
sounds?

continues

235
TABLE 27–1. continued

Part 4: Health-Related Questions

Possible Red Flags Indicating the Need for Further

Questions Referral or Investigation
*Do you have any health Ensure that medical concerns are being addressed. Assess whether the
concerns or serious medical burden of an intervention is appropriate at this time.
conditions?
*Do you have any Assess whether these conditions are effectively being managed or further
psychological conditions, help is needed.
including anxiety and
depression?
Are you on any Is a review of medications indicated?
medication? If so what
kind?
What effects do these If worsening, a medical review may be indicated.
medications have on your
tinnitus?

Part 5: Questions About the Consequences of Tinnitus

Questions
What do you find hard due to having tinnitus?
What effect has tinnitus had on your life?
Do you work less because of your tinnitus?
Has the tinnitus experience made you less effective at doing your work or daily tasks?
What is your sleep quality like? Is this affected by the tinnitus?
What is your ability to concentrate like and is it affected by having tinnitus?
Does having tinnitus impact your ability to work?
Does having tinnitus affect your relationships?
Does having tinnitus affect your social life?
Are there any things you avoid doing due to having tinnitus?
*Further referral may be needed.

236
 Chapter
WEEKLY MONITORING
What This Chapter Covers
n A weekly monitoring questionnaire
n How to score the questionnaire
n Monitoring changes in scores
Introduction
Monitoring tinnitus severity during the course of
an intervention is important. This helps to identify
any problems as soon as they arise. Assessments
can be completed independently or during clinical
consultations.
If the intervention is being followed appropriately
and is helping, these scores should start decreasing
about halfway through the program. It would be too
much of a burden to expect individuals to complete
many lengthy assessment measures weekly. They
will be more likely to complete a short assessment
measure. This chapter discusses how progress can
be monitored using a short questionnaire designed
for this purpose. Alternative questionnaires such as
the Tinnitus Handicap Inventory–Screening version
(THI–S; see Chapter 3) could also be used.
Purpose of This Chapter
The aim of this chapter is to provide a short monitor-
ing questionnaire, The Tinnitus Qualities Question-
naire (TQQ), that can be used for purposes of weekly
monitoring when providing a tinnitus intervention.
28
The Tinnitus Qualities
Questionnaire (TQQ)
The TQQ was recently developed to monitor tinnitus
weekly during the course of an intervention. It was
developed to identify the effects of an intervention
on tinnitus qualities such as pitch and loudness as
opposed to the functional aspects such as difficul-
ties sleeping or concentrating. It was specifically
designed to monitor tinnitus during an interven-
tion and thus only has 10 questions. This question-
naire consists of 10 questions with a 10-point rating
scale and a possible score range from 0 to 100. The
questionnaire is provided in Table 28–1. Note that
this questionnaire is not yet validated psychometri-
cally, although it is being used in the authors’ recent
clinical trials. The authors believe that the scale pro-
vides some useful information that is not captured
in other tinnitus questionnaires.
Monitoring the Frequency
of Tinnitus Awareness
Table 28–2 indicates how the frequency of tinni-
tus awareness is changing during the course of the
intervention.
Add the weekly scores to Table 28–3. Lower scores
indicated fewer problems. These scores should
decrease over time.
237
TABLE 28–1. The Tinnitus Qualities Questionnaire (TQQ)

Instructions: Please respond to the following questions. Select only one of the numbers from 0 to 10
for each question. Select a lower score (0–3) when an aspect has not been a problem. Select a higher
number (7–10) when an aspect has been a big problem. If it is only a moderate problem, select a
middle number (4–6).

Select one number for each question.

Domain
Measured Question 0 1 2 3 4 5 6 7 8 9 10
Loudness 1. How loud has your 0= 1 2 3 4 5 6 7 8 9 10 = Very
tinnitus been? Hardly loud
noticeable
Pitch 2. How annoyed are 0 = Not at 1 2 3 4 5 6 7 8 9 10 = Very
you with the pitch all annoyed
(or tone) of your
tinnitus?
Complexity 3. How many different 0= 1 2 3 4 5 6 7 8 9 10 = More
types of sound do A single sounds
you hear? sound than I
can count
(10+)
Frequency 4. How often are 0 = Rarely 1 2 3 4 5 6 7 8 9 10 =
you aware of your aware Always
tinnitus? aware
Coexisting 5. How easily have you 0 = Very 1 2 3 4 5 6 7 8 9 10 =
lived with having easily Really
tinnitus? struggling
Distractibility 6. How much do you 0= 1 2 3 4 5 6 7 8 9 10 =
notice your tinnitus Hardly Notice it
when you are busy noticeable a lot
doing other things?
Maskability 7. How much do you 0= 1 2 3 4 5 6 7 8 9 10 =
notice your tinnitus Hardly Notice it
when there are other notice it a lot
sounds around you?
Mood 8. How much does your 0 = Not at 1 2 3 4 5 6 7 8 9 10 = Very
mood affect your all much
tinnitus?
Loud sounds 9. How has hearing 0 = Not at 1 2 3 4 5 6 7 8 9 10 = Very
loud noise affected all much
your tinnitus?
Sensitivity 10. How sensitive are 0 = Not at 1 2 3 4 5 6 7 8 9 10 = Very
you to sounds you all sensitive
hear around you?

How to score?
Add all the scores for questions 1 through 10. Add the weekly score to Table 28–3. Lower scores indicate
fewer problems. These scores should decrease over time.

238
 CHAPTER 28 WEEKLY MONITORING 239

TABLE 28–2. Frequency of Tinnitus Awareness Questionnaire

Please rate how aware you are of your tinnitus. Select only one of the numbers between 0 and 4 for
each question. Select lower scores (0–2) when you are not very aware of your tinnitus. Select higher
numbers (3–4) when you are frequently aware of your tinnitus.

0= 1= 2= 3= 4=
Never Seldom Sometimes Often Always
Aware Aware Aware Aware Aware
1. In the morning
2. In the afternoon
3. In the evening
4. During the night

How to score?
Add all the scores for questions 1 through 4. Add the weekly score to Table 28–3. Lower scores indicate
fewer problems. These scores should decrease over time.

TABLE 28–3. Total Weekly Scores

Add your weekly scores to this table to monitor your progress. These scores should be decreasing over time.

Date Date Date Date Date Date Date Date Date

Scores
Overall effects
(Table 28–1)
Frequency of
awareness
(Table 28–2)
Total score

Monitoring Changes in Scores decided upon, depending on how the program is

When individuals are undertaking an intervention,
it is important to monitor them not only before and
after the intervention, but also during the inter-
vention to ensure they are progressing. Chapter 29
discusses how this program can be combined with
professional guidance. As part of the guidance, the
weekly scores can be checked and discussed. If they
are not decreasing, reasons for this should be dis-
cussed and suggestions can be provided. How fre-
quently the questionnaire is completed should be
structured, but completing the questionnaire weekly
is suggested.
Key Messages
Monitoring participants during the course of an
intervention is important to assess progress. The
Tinnitus Qualities Questionnaire is one question-
naire that can be used to monitor participants on
a weekly basis.
 Chapter 29
PROVIDING GUIDANCE

What This Chapter Covers Messages Related to Specific Questions

n Introduction to providing guidance to Table 29–3 provides messages related to specific

patients during the intervention questions individuals with tinnitus may have.
n An outline of weekly guidance messages to
provide during the intervention
Encouraging Messages for
n Examples of positive feedback messages to
provide during the intervention
General Feedback

When individuals do not seem to be practicing the

techniques, it is important to keep encouraging
Introduction
them. It would be best to see them for an appoint-
ment or to contact them by phone. This may not
When providing this program as a self-help program
always be possible, though. Table 29–4 provides
combined with some professional guidance, prog-
some general messages.
ress can be monitored on a regular basis. Reviewing
progress every week is ideal. This review can involve
finding out what individuals have read and prac-
ticed, and how well they have done with the sug-
Positive Feedback
gested techniques. The worksheets at the end of each
Providing positive feedback can encourage and
chapter are very useful for monitoring progress. This
motivate individuals. Try to provide encouraging
chapter provides examples of messages that could
and positive messages whenever an individual has
be adapted and used for feedback.
been trying hard. Some examples of positive feed-
back messages are provided in Table 29–5.
Messages About the
Intervention Materials
Key Messages
It is a good idea to introduce participants to parts of
Providing guidance during the course of interven-
the program every week. Table 29–1 provides some
tion is important to ensure optimal outcomes. The
suggested messages. It also provides some broad
example messages provided in this chapter can be
feedback that can be given for each week.
tailored and used to communicate with tinnitus suf-
fers undertaking the course of intervention.
Messages About Specific
Intervention Materials

Table 29–2 provides messages directed at specific

aspects of the techniques covered.

241
TABLE 29–1. Introducing Weekly Chapters and General Weekly Feedback Suggestions

Week Message
Week 1 chapters: Title: Welcome!
4. Tackling Tinnitus Dear Mr./Ms. XX,
Program Outline
Welcome to the Tackling Tinnitus program. We hope that you will find it
5. Tinnitus Overview
helpful. I want to introduce you to the content of first three chapters, namely:
6. Deep Relaxation (1) the Tackling Tinnitus Program Outline; (2) information about tinnitus; and
(3) the start of a relaxation practice.
The chapters are brief and easy to read. Make sure you understand what is
expected of you. Use the rest of the week to try to do the techniques suggested
every day. This may be, for example, spending some time daily doing the
deep relaxation suggested.
I want to encourage you to make a note on the worksheet provided at the
end of each chapter to record how the practicing is going. This doesn’t need
to be every day or to take long, but will be useful to look back on and see the
progress you have made.
What is very important is to spend enough time working out what you
want to achieve by doing this program. There is a section in Chapter 4 titled
“Setting Your Goals” that focuses on this. We want to help you achieve these
goals, and identifying your goals is the first step.
Best wishes,
Therapist Name
Week 1 feedback Topic: Excellent start!

Dear Mr./Ms. XX,

It is great to see that you are so enthusiastic and committed. You have set
very worthy goals. To remind yourself of them, do put them somewhere you
can see them every day. This will help you keep practicing on days when you
are not as motivated. I am glad to see that you have a better understanding
of tinnitus. I am impressed by your dedication doing the relaxation practice
daily and glad to see that you are finding it easier to do.
I hope you are enjoying the start of the program.
Best wishes,
Therapist Name
Week 2 chapters: Title: Introducing week 2’s chapters
7. Deep Breathing Dear Mr./Ms. XX,
12. Positive Imagery Well done on getting through the first few chapters. The next relaxation
19. Sound chapter can be very effective. It is generally easier to do because you focus on
Enrichment relaxing the muscles and not tensing them as well. It also teaches you about
deep breathing, which has so many benefits.
The next suggested chapter helps you to select a mental image. Although this
concept may seem strange at first, visualization has been found to be a very
useful technique in helping people to relax and cope better with everyday
difficulties and tinnitus.
The final chapter shows how you can use sound to distract you from your
tinnitus, to soothe you, to help you focus, and to reduce large sound contrasts.

242
TABLE 29–1. continued

Week Message
continued I hope you will find week 2 of the program helpful.
Best wishes,
Therapist Name
Week 2 feedback Topic: Well done!

Dear Mr./Ms. XX,

I am impressed by your efforts with both the relaxation and use of positive
imagery. You have selected a great positive image! I am pleaed to see that you
have. Hopefully, these new tools will just get easier and more natural to use
over time.
Keep up the good work!
Best wishes,
Therapist Name
Week 3 chapters: Title: Introducing week 3’s chapters
8. Entire Body Dear Mr./Ms. XX,
Relaxation
I hope week 3 of the program will be beneficial for you. This is an exciting
13. Views of Tinnitus
week with some really useful chapters. During relaxation, you will progress
20. Sleep Guidelines even further to relax your body all at once. This will speed up the relaxation
process, which can really help when life is busy.
The next chapter focuses on changing your perceptions about tinnitus. It
helps you view your tinnitus as just another sound instead of “that irritating
sound.” This technique can be very effective in making tinnitus less of a
problem. It takes time to get this right, but keep trying because the results will
be worth the effort.
If you have sleep problems, go through the chapter providing sleep guidelines.
The key here is to start by selecting a few of the suggestions and trying them
consistently. Once you manage them, add a few of the other suggested
techniques over time. Improving your sleep is hard work but can help you
function better during the day.
Have a good week.
Best wishes,
Therapist Name
Week 3 feedback Topic: Well done!
Dear Mr./Ms. XX,
You are making fantastic progress. Evaluate how you feel each relaxation
practice session is going and modify it for the next time. Hopefully, each
practice will become more effective. Keep up the excellent efforts! Well done
identifying sleep hygiene tips that you are going to implement. Changing
your perception of tinnitus will take time, but keep at it. Try different examples.
Best wishes
Therapist Name

continues

243
TABLE 29–1. continued

Week Message

Week 4 chapters: Title: Introducing week 4’s chapters

9. Frequent Dear Mr./Ms. XX,
Relaxation
This week’s relaxation chapter is intended to help you to relax more
14. Shifting Focus frequently throughout the day. There is also a chapter on shifting your focus.
21. Improving Focus This takes time to grasp, but can help you to move your focus away from the
tinnitus to something else when your tinnitus is particularly bothersome.
Tinnitus can also make it difficult to concentrate and focus. The “Improving
Focus” chapter is intended to help you improve your planning and task
management.
I hope this week goes very well.
Best wishes,
Therapist Name
Week 4 feedback Topic: Fantastic progress!

Dear Mr./Ms. XX,

Good work! Well done trying these different techniques and suggestions.
Hopefully, you are starting to notice a positive effect. Keep trying to
incorporate the tools whenever your tinnitus is particularly bothersome.
Best wishes,
Therapist Name
Week 5 chapters: Title: Introducing week 5’s chapters
15. Thought Patterns Dear Mr./Ms. XX,
10. Relaxation in This week is the last step of the relaxation techniques you have been learning.
stressful situations
It introduces quick relaxation to use when you are stressed, irritated or upset.
22. Increasing Sound In parallel do keep doing deep relaxation regularly as this has many benefits.
Tolerance
Our thoughts are very powerful, but we don’t always realize the influence they
have on us. This week focuses on becoming more aware of your thought patterns.
If you have sound tolerance difficulties, you can review this optional chapter.
If you are very sensitive to sounds that other people are not bothered by, then
this chapter will be very helpful. Tackling sound tolerance issues can take
time, but hopefully the techniques will provide useful guidance.
I hope you have a good week.
Best wishes,
Therapist Name
Week 5 feedback Topic: Brilliant work!
Dear Mr./Ms. XX,
Good work so far! Well done making excellent progress on the relaxation.
Make sure you keep doing the relaxation as much as possible. Good work also
on identifying your thought patterns. In time, this will get easier. In the next
chapters, you will explore how to address unhelpful thoughts.
Best wishes,
Therapist Name

244
TABLE 29–1. continued

Week Message

Week 6 chapters: Title: Introducing week 6’s chapters

11. Relaxation Dear Mr./Ms. XX,
Routine
Huge congratulations on getting this far! Last week you identified your
16. Challenging
thoughts. This week you are going to focus on addressing thoughts that are
Thoughts
not helpful. Changing thinking patterns can help change the way you view
23. Listening Tips many problems in life.
Because relaxation is so beneficial, it would be great to try to incorporate it
into your routine on a long-term basis. Spend some time this week planning
how to fit it in and see whether it works for you.
I hope making relaxation part of everyday life with have many positive
effects.
Tinnitus can sometimes interfere with your ability to listen. The optional
chapter on this topic provides some listening tips to help in these situations.
Nearing the end of the program now!
Best wishes,
Therapist Name
Week 6 feedback Topic: Good job!
Dear Mr./Ms. XX,
You have planned an excellent relaxation routine. In time, relaxing will
become a healthy habit to practice. Keep working on challenging unhelpful
thoughts whenever you notice them. This will help you address problems that
crop up day-to-day.
Best wishes,
Therapist Name
Week 7 chapters: Title: Introducing week 7’s chapters
17. Being Mindful Dear Mr./Ms. XX,
18. Listening to
This week you will explore two new techniques that do take some time
Tinnitus
getting your head around at first. Give it a try. These tools can be very
beneficial for you.
The first technique is for being more mindful. Mindfulness has been shown to
help with many conditions, including tinnitus. The second is intended to help
you quit unhelpful behaviors associated with trying to avoid tinnitus. This is
one of the most challenging chapters, so take it in small steps. The results will
be well worth the efforts made!
This is the last week of sharing tools to use. Next week will summarize what
you have learned. So enjoy the last chapters!
Best wishes,
Therapist Name

continues

245
TABLE 29–1. continued

Week Message

Week 7 feedback Topic: Fantastic work!

Dear Mr./Ms. XX,

Listening to tinnitus is very challenging, so well done giving it a try.
Remember to reward yourself each time try it. Mindfulness is so helpful in
many aspects of life. Keep practicing it, because there are many benefits of
being more mindful.
Best wishes,
Therapist Name
Week 8 chapters: Title: Congratulations!
24. Summary Dear Mr./Ms. XX,
25. Future Planning Well done on reaching the last week of the program! This week is time to
reflect on what worked for you and how you can ensure that you keep using
helpful techniques.
It will also help you plan for possible setbacks in the future.
Congratulations on completing the program! I will be asking you to complete
a questionnaire to assess your progress. I will discuss your progress with you
following this.
Best wishes,
Therapist Name

246
TABLE 29–2. Messages Related to Specific Aspects of Different Strategies

Struggling with relaxation

The relaxation will hopefully become more natural and easier to do as you practice and your body gets
used to the experience of relaxing. In the beginning, to help you relax, you can use a scented candle or
some relaxing music. Make sure no one will disturb you and start by focusing on your breathing. Also
try to use your relaxing word on the outbreath. Starting by picturing your positive mental image may
be helpful at getting you relaxed.
Deep breathing
The deep breathing can be really effective. It takes practice to ensure that you are breathing from your
belly and not your chest, but it’s so much more effective if you do.
Frequent relaxation
You have a great plan. Hopefully, you will remember to do the relaxation during these situations. Put
up reminder notes or set alarms until you get into a routine.
Shifting focus
Shifting your focus can be difficult. Here are some ideas to try. Try to move your focus to something
tactile, for example, clasping your hands or rubbing your hands together. If that doesn’t work, try
something visual instead. Tactile and visual stimuli are sometimes easier to shift your focus to than
things you listen to. Initially start just by practicing to move your attention back and forth.
Shifting focus is easiest when your tinnitus is really noticeable. At this stage consciously decide to
shift your focus on something else. When this is successful, keep your focus away from the tinnitus.
Changing views of tinnitus (reinterpretation)
Some people think of their tinnitus as a very annoying sound. Changing your thought patterns
really helps to change these perceptions, although it is a tricky technique. If you think of hearing the
refrigerator buzz, normally you just think, “that’s the fridge.” There is no negative emotion linked
to the sound. That is what we aim for with your tinnitus: when you hear it, not getting annoyed or
irritated but just viewing it as another sound. Associating tinnitus with a pleasant sound therefore helps.
It helps to change the association with tinnitus as something negative to one where tinnitus is
viewed as a neutral sound. It is best to think of a similar sound, one that matches your tinnitus sound
and is something pleasant in your view. So, when tinnitus is heard, it is associated with something
pleasant such as buzzing insects while enjoying nature, the sound of crickets, or the wind rustling
through leaves. It is just finding the right association that sounds close enough to the tinnitus and yet
brings you a smile instead of irritation. You can try experimenting with different sounds: maybe a wind
chimes, a fire crackling or the sound of a sea shell held to your ear.
The idea is to pretend that you are listening to insects buzzing along a riverbank. You may be sitting
on the side, watching dragonflies playing above the water. This brings pleasant memories and makes
you smile instead of hearing tinnitus and thinking, “there’s that awful sound again.” The aim is, when
you hear tinnitus, to think about the riverside scene, focus on the sounds there, and think of how the
wind comes up and you don’t hear the buzzing as well. This will take your mind off your real tinnitus
and also, in time, help you to view tinnitus in a more pleasant light.
When you hear your tinnitus, instead of thinking, “oh no, there’s that annoying sound again,”
fool yourself by saying, for example, “how lovely being able to hear the sound of the wind.” If that
association gets strong enough, you will start experiencing the benefit.
Thought patterns
Some thoughts are true, such as tinnitus is there all day. Yes, it is, but I don’t need to let it interfere with
my day or get me down. Perhaps I had tinnitus all day yesterday and was still able to have a great day.
I went out with friends. So, I am not going to let the tinnitus get me down today because I am planning
on having a good day.

continues

247
TABLE 29–2. continued

Cognitive restructuring
Consider one negative thought and see which of the techniques can help. Is there evidence for the
thought? Is it concrete? Is it helpful? So, ask yourself these questions and then reach a conclusion. If the
thought is not true, dismiss that thought and say “stop” when it again happens.

Some examples:
Thought: I have to speak at a meeting tomorrow, and with my tinnitus buzzing, I might not be able to
concentrate. You can ask, what is the evidence?
When I spoke at the last meeting, it went well despite hearing my tinnitus, and the meeting had a
good outcome. Evidence: I am able to perform well despite the tinnitus, and it does not affect my ability
to concentrate. So, there is no evidence for this thought. I am going to stop it and focus on getting
ready for the meeting. I will stop this thought every time it comes up.
Cognitive restructuring is difficult, but hopefully, with practice it will start making more sense.
Essentially, you are going to be faced with some “thought” that is going to make you angry. Sometimes
there is good reason to be angry or upset. These emotions should not necessarily be suppressed. At
times, these thoughts and emotions are unhelpful. So, yes, having tinnitus is upsetting and this is
valid, but always dwelling on it is not going to help you move on. Sometimes it is worth trying to do
the cognitive restructuring.
Thought: I have tinnitus, which is unpleasant. I am, however, working hard and have learned to
manage it better. When it upsets me, I am going to try to do some positive imagery or relaxation and
focus on that instead of getting upset.
Listening to tinnitus
The exposure technique is scary initially, but useful to take away the fear of tinnitus. The aim is to
teach you that it is okay to hear it now because you are working to reduce the effects it has.
When exercises are too difficult
You have given [name of strategy] a good try. It is difficult. Give it a break for a few weeks. Sometimes
coming back to it after a break helps. Move onto trying the next technique for the moment.
Sound enrichment
Sound enrichment can be beneficial at times. These times include when your tinnitus is really
bothering you. Sound enrichment is one way of calming it down and helping you to focus on
something else. Often you try to concentrate in a quiet setting, and because it is quiet, your tinnitus
is more noticeable. So, select some sound for the background. You could use some soothing nature
sounds, if these work for you, or try something similar. Keep the sounds in the background. You can
download an app with nature sounds if you wish or listen on YouTube. Depending on the time of day,
you may like waves, a gentle brook, and similar sounds.
Try setting the volume at a quiet level so that you still hear your tinnitus and are not distracted by
the background sound. Try to keep this background sound on for at least an hour. See whether this
improves your concentration and helps you to focus less on your tinnitus.
There are so many forms of background sounds to use. If your tinnitus bothers you at bedtime, try
having some low level background sound in the room. This could be sound coming through an open
window, the sound of a fan or air conditioning. The options of sound are endless: apps, YouTube,
bedside sound generators. Let us know if you need any advice on finding something that works for you.
If the sound of water helps as a background noise, you can listen to a recording of the sound of
water running. Alternatively, use an app that simulates water. There are many online.
When your tinnitus is really bothersome you can use a sound that may grab your attention, such a
listening to music or an audiobook.

248
TABLE 29–2. continued

Sound sensitivity
Although being sensitive to sound and tinnitus are different symptoms, many of the same techniques
can improve both conditions. Addressing sensitivity to sound takes time and there is not a quick
solution, but there are things that can help. These techniques take time to be mastered.
If you feel you can do more, we can work out how to grade exposure to unpredictable noises in a
controlled and manageable way. Work on one bothersome sound at a time and just listen to it initially
without the unpredictable factors. Happy to guide you through this process at any stage.
If the sound of tires on the road bothers you, try the following. You can apply the same principles for
other situations.

n Plan your journey. If you need to leave at 10:00, do 10 minutes of relaxation beforehand. While
doing this, try visualizing yourself in the car feeling relaxed, enjoying the time to be on your own,
enjoying the change of scenery, feeling peaceful and in no way agitated.
n Plan some relaxing music that you really enjoy for the drive. If you are with children, choose
soundtracks of the songs they like without words.
n Plan a reward for making the drive, such as stopping for coffee before or after the trip.
n During the drive, ensure you are doing deep breathing to help you relax.
n If agitated at the end of the journey, repeat the relaxation again.

To deal with other situations that are noisy:

n Try building up the sound. So, don’t go from a quiet room into a noisy place. It’s better if your ears
can acclimate to sound.
n Have some gentle background sound on, even if it is just nature sounds. Then try to increase the
volume a bit. This “warms up” your ears so you can then go into the noisier environment.
n Try to use the quick relaxation technique as much as you can, even just doing a few deep breaths
is helpful.
n After being in a noisy place, again taper down the sound. Don’t go directly from noisy to quiet.
n Reward yourself for making the transition.

Try shorter exposure. For instance, listen to a bothersome sound for 10 minutes and gradually lengthen
the time, using the preceding principles.
For poor sound tolerance, relaxation and avoiding absolute silence is key.
Sleep guidelines
It is difficult when sleep is impaired, because it affects so many other aspects of your life. There is
a connection between sleep and tinnitus and life. So, a good night’s sleep is important. Hopefully,
experimenting with some of the suggestions will help. Read through the chapter on sleep guidelines
and apply some of the techniques you feel may be useful. Focus on one or two tips at a time. Being able
to wind down at night will also help with your sleep. Ensure you have a relaxing screen free routine.
Although sleep is not where you want it to be yet, don’t lose hope. Changing these physical processes
takes time. For the odd very bad nights, remember that everyone has those (even people without
tinnitus); so try to tell yourself that it is okay, and you will just catch up on sleep another night.
Completing worksheets
Sometimes it is just reassuring to see your progress. You can realize that after only a few days since you
were struggling initially, you are actually improving. The more you record your progress, the easier it
is going to be to identify what works best for you. I can also provide feedback when you record your
practice. So try to complete the worksheets occasionally.

249
TABLE 29–3. Examples of Messages Related to Specific Questions

The influence of sharp, sudden, or unpredictable sounds

Unpredictable sounds can be difficult and may affect your tinnitus negatively. This is partly due to the
stress experienced when hearing the sound. So, when the sound is heard, you may react with shock
and panic. This sets your body into high alert, causing your body to physically tense up and bringing
on emotional stress. Although this is all very natural, it causes a strong response. What is needed is
to change this association between the sound heard and your physical and emotional reaction. This
is difficult, but possible. All the techniques we are covering, such as relaxation and positive imagery,
will help. Once these are mastered and used correctly, they can really make a difference. If a sound is
suddenly heard, instead of going into a panic, use a relaxation technique with positive imagery. This
can help avoid your becoming physically stressed and emotionally upset and prevent your tinnitus
from contributing to the stress.
The association between emotions and tinnitus
Tinnitus is so complex; often when you are doing something you enjoy, such as gardening, it is less
noticeable. This is because tinnitus is very much affected by your emotional state.
If the tinnitus stops getting the emotional attention it has received in the past, it tends to go and
hide away in a corner and stop being so prominent.
Experiencing a tinnitus spike
An increase in tinnitus can increase your worry, which in turn increases your tinnitus. This cycle leads
to tension in your body, which causes more irritation with the tinnitus. It is important to try to stop
this negative cycle. Without a reduction in the negative emotions, it is going to be hard to see an
improvement.
So first try to lower the emotional response. That is easier said than done. But try to stop any fears
or negative thoughts. The chapter on thought patterns may help. Relaxation can also really help.
You may need some extra help relaxing, though. Possibly try using something extra, such as scented
candles or relaxing music to create a more relaxed atmosphere.

Try the other techniques:

n Use positive imagery.
n Practice the focus exercises, focusing on other things and shifting your focus away from the
tinnitus.
n Use any of the other techniques that have helped so far.

Try not to give up. Keeping going because some of the techniques that have a positive effect for you
can really help. Hopefully, this is just a bad period that will soon pass, especially if you can have a
calm reaction to it.
The effect of noise on tinnitus
Thank you for your message regarding the effect of noise on your tinnitus. Generally, after noise, the
perception of tinnitus is loud. This is partly due to hearing something very loud and then the world
suddenly going very quiet. This big contrast makes the tinnitus more noticeable. If you go from any
sound to no sound, tinnitus is generally more noticeable, and more so when this contrast is large. As
you notice the tinnitus getting louder, it draws more attention to it; that makes it hard not to keep
focusing on it, so the louder tinnitus lingers.
If you find this happens, try to distract yourself. Put on some sound in the background, do an
engaging activity, try focusing on something else, and try not to get worried about it.
It’s all very normal, but not pleasant. So, try things to help reduce the effects.

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TABLE 29–3. continued

Tinnitus and stress-related messages

There is a definite link between tinnitus getting worse, being tired, and feeling stressed. Tinnitus is
sometimes a warning sign to slow down, which is a good thing in many ways. So, where possible, try to
slow down and rest more during these times.
Having less stress really does reduce tinnitus problems. It’s hard to get away from stress all the time,
though. So, ensuring that you have some strategies to reduce the effects of stress is important. Physical
exercise really helps with this. A lot of the program is related to reducing stress because of the effect
it has on tinnitus. So, even using positive images to take you back to this calm time may help. The
relaxation will help reduce stress and tension that you are often not even aware of.
It is typical for tinnitus to get worse when you are upset. That’s why so many of the techniques try
to reduce your reaction to getting stressed and upset. Using relaxation or positive imagery calms you
down and makes the tinnitus go into the background again.
Situations that negatively affect the tinnitus
Advice for car trips:
1. Plan the trip. You want it to be as pleasant as possible.
n How long is it going to be?
n What is going to help?
n Choose music you like to listen to in the car. Just listening at a comfortable level can take your
mind off the road noise.
n Try anything else that may make it better, such as listening to audiobooks and bringing along a
few snacks.
2. Plan a reward for getting through the trip, such as reading a few pages or stopping for tea or coffee.
3. Once you are ready to leave, spend 10 minutes doing relaxation and positive imagery to calm
yourself before heading out.
4. It may be worth using sound enrichment, such as the sound of the sea, before and after the trip as
well. This will help transition from quiet to car noise, and back to quiet again.
5. Do a few practice trips to somewhere you enjoy driving to see whether you can change the negative
association with car noise to a positive one.
6. Think of this situation again as you try various techniques over the coming weeks. They may help
as well.
7. Ensure that the car is as comfortable as possible. Is there anything you can do to help with this?
Tinnitus and connections with pain
I am sorry to learn about your troubles with pain, but at least this experience has given you more
insight into your tinnitus. There are so many parallels between tinnitus and pain, and they react in a
very similar manner. So, yes, things you have learned from the pain treatment are certainly applicable.
Although the techniques are different and there are a few theoretical differences, the consistency of
applying them is important. So, hopefully, you will have as much success with your tinnitus as you
have had with improving your pain.
Tinnitus and flights
If prebooking, trying to sit in front of the wings where it is less noisy. Try to ensure that you swallow
and yawn as needed to equalize the pressure in your ears. If your ears tend to block up, taking a
nasal decongestant before the flight helps. Listen to the entertainment system, because this takes your
attention away from the tinnitus. Remember that stress may increase the tinnitus, so try to avoid it
where possible. Flying is always stressful, but leave enough time, try to be calm, and take things along
that you enjoy — anything to make it a pleasant and less stressful experience. Try to build in some
things you enjoy as rewards to get you through the experience.

251
 TABLE 29–4. Examples of Encouraging General Feedback Messages

Encouraging someone to do more

I wondered how you are getting along with the program. Is there any support you need
to start the chapters? I recommend trying the next modules, xx, this focuses on xxx.
Habituating to tinnitus
Habituating to tinnitus can be difficult, especially when you just try to ignore the
tinnitus. It is, however, possible to get used to it. Therefore, we have a range of techniques
to try. Because everyone’s experience of tinnitus is different, we have found that some
techniques work better for some people, and other techniques may be better for others.
I really hope that by focusing on giving each technique a good attempt, you will find
some that can assist you.
Not progressing or struggling
I have been so impressed by your continued dedication. It appears as though you are
really still finding certain aspects of your tinnitus problematic. Let’s schedule a telephone
call to discuss what you are finding helpful and what you are struggling with. We can
then work on a plan together to help you with the aspects you find difficult.

TABLE 29–5. Examples of General Positive Feedback

What fantastic commitment you are showing. Well done for making time to try these
techniques and for evaluating their effectiveness for you and adjusting them accordingly.
All your hard work has contributed to tinnitus being less noticeable already. Keep up the
excellent work!
Well done on getting through the first few chapters.
I am really impressed by your dedication to making an effort with these techniques.
It sounds like you are getting along really well with [name of technique].
Excellent progress! Well done!
Good work trying everything out. What a great positive attitude!
Looks like [name of technique] has a good effect overall.
Excellent work on [name of technique]. Well done!
Looks like you have a lot of things in place to aid [name of problem].
Again, congratulations on keeping up the [name of technique] despite it being difficult.
It is great that you have made so much progress overall!
I am really pleased that this is getting easier for you and that there are clear benefits.
Well done persevering.
Excellent work applying these techniques. Keep practicing them and they will hopefully
become easier and more effective. Well done!
You have some really good ideas. Well done at giving all the techniques a good try!
Good job getting through all the chapters!
I am excited to see your quick progress. You have gone from finding the tinnitus really
unpleasant to not even noticing it! All your hard work is definitely paying off.
You have such a great positive attitude!

252
 INDEX

Note: Page numbers in bold reference non-text materials.

A B
Acceptance and commitment therapy (ACT), 4, 15, 23, Behavioral psychology/therapy, 3–4, 8
57 Behaviorism, 4
Amplification, 14, 17 Behaviors
amplification apps, 209 avoidance behaviors, 4, 7, 13–16, 15, 17, 27, 71, 119,
phone amplifier, 210 123, 133, 135, 142, 144, 151, 163–165, 197–198,
Anxiety, vii, ix, 4, 6, 9, 12, 16, 17, 18, 36, 43, 48, 59, 73, 199, 200–201, 203–204, 220
77, 132–133, 146, 198 behavioral activation, 4–5, 16
assessing, 36, 39, 40, 45, 236 behavior analysis, 3, 5, 7, 92, 133, 133, 136, 142
generalized anxiety, 6, 39 behavior change/ modification, ix, 4–5, 16, 24–25, 27,
outcome measure, 40–41 48, 59, 63, 71
Assess behavioral experiment, 9, 146
assess problems, vii, 5, 7, 17, 36–37, 39, 40, 44, 49, 51, COM-B model, 25
60, 233, 234–236 positive/ productive behaviors, vii, 4
assessment measures, 36, 38, 39, 40–41, 47. See also rehearsing behaviors, 7, 9
questionnaires Breathing
audiological assessment, ix, 17, 18, 39, 43 deep breathing, 26, 45, 62, 64, 79, 85-91, 97, 103, 106,
format, 37 114, 145, 158, 192–193, 216, 217
postintervention assessment, 8, 44–46 breathing patterns, 85
preintervention assessment, 8, 36–37, 43, 44–45, 49,
51, 234
purpose of, 36,
C
therapy effects, 6 Challenging thoughts. See thoughts.
tinnitus and its consequences, 36, 38 Cognitive behavioral therapy (CBT)
Attention CBT for tinnitus, 14–29, 17
improving, 125, 191 components, 6, 7, 16
paying attention, 125, 131–132, 134, 139, 165, 191, delivery, 6–9, 18, 42
208 description, vii–ix, 3–9, 11, 36
paying attention to tinnitus, 14, 15, 24, 47, 69, 70, 71, evidence for, 17–18, 19–23, 57, 59
129, 148–149, 152, 171, 191, 216 history, 4, 15
shifting attention/ focus, 14, 16, 27, 45, 62, 64, 111, internet based cognitive therapy (ICBT), viii, 7, 18,
112, 120, 125–126, 127, 128, 145, 172, 174, 192, 21–23, 42–43,
194–195, 216, 218, 230 model, 5, 9, 15
Audiologist, vii–viii, ix, 8, 18, 22–23, 24, 29, 35, 43, 210 principles, 3, 5–6, 15–16,
Auditory scope, 4, 6
information, 235 theoretical basis, 24
pathologies, 37 Cognitive restructuring 7, 16, 17, 25
sensations, 11, 13 Concentrating
stimuli, 27 concentration problems, 12, 17, 36, 39, 71, 73, 115,
system, 11–12 129, 133, 151, 236, 237

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254 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS

Concentrating (continued) Hearing aid/s or devices, 13, 14, 39, 43, 57, 229
improving concentration, 27, 77, 82, 115, 171 Hearing tactics, 17, 207–211
Counseling vii–viii, ix, 3, 13–14, 16, 20, 24, 48–49 Homework, 6, 9, 16, 25
Hyperacusis. See sound sensitivity

D
I
Depression, vii, ix, 4, 6, 8–9, 12, 18, 36–37, 39
assessing, 39–40, 45, 236 Imagery
outcome measurements, 40–41 positive imagery 16, 27, 45, 62, 64, 111–116, 216, 218,
230
Infections
E ear infections, 68, 198, 235
Ear, 12, 67, 69 Insomnia. See also sleep
ear infections, 67, 198 assessing, 12, 36, 39, 45
ear wax, 67, 77 outcomes measure, 40–41
protection, 197, 199, 203
Earplugs, 198–200 L
Emotional distress, 3–5, 7, 9, 17
Engagement, 35, 47 Learning
encouraging engagement, 47, 229–231 preference, 25, 229
monitoring engagement, 44, 47–49 Listening
Ear Nose and Throat (ENT), 37 listening tips, 207–211, 221
Expectations, 8, 44, 47–48 listening to tinnitus, 27, 46, 62, 64, 163–166

M
F
Medication, 3, 18, 57, 68, 187
Focus. See Attention
Mindfulness-based stress reduction (MBSR), 4, 15, 18
Future planning, 28, 46, 64, 223, 225
Mindfulness, 27, 46, 57, 62, 64, 231, 145, 146–147,
157–160, 216, 219, 220, 230
G Mindset, 134, 144–146, 146–153
Misophonia, 12
Goal
Monitoring
setting, 5–6, 24, 26, 43, 45, 47, 60–61, 61, 223, 224
progress, 25, 35–39, 49, 63
Guidance, 8, 43, 49, 241
weekly monitoring, 41, 42, 44–46, 47, 237
example messages, 242–252
weekly monitoring questionnaire, 237, 238–239
Motivation, 16, 25, 44, 181
H
Habit N
changing habits, 16, 59–60, 62, 81, 129, 131, 160, 210, Nonauditory systems, 14
223, 225
Habituation 7, 14–16, 17, 24–25, 68, 71–72, 73, 163,
171, 215 O
Health Otolaryngologists, 18, 24
risk factors related to tinnitus, 11, 68, 70 Outcome measures. See questionnaires
Health care, vii–viii, 35, 47,
Health professional, 8, 18, 35–36, 43, 58, 67
Hearing
P
assessing, 39, 40–41, 44, 48, 68, 235 Pathology, 12, 14
hearing difficulties/ loss, 14, 17, 39 Professional support. See guidance
hearing loss, 14, 17, 39, 66, 68, 69, 71, 73, 144, 147, Progressive Tinnitus (Audiological) Management
198, 203, 207–210, 215, 221, 229 (PTM/PATM), 13, 24
hearing protection, 197 Psychologists, vii–ix, 18, 19–22, 24, 28–29, 35, 37, 43,
 INDEX 255

Q cycle, 177, 178, 180

guidelines, 177–189, 220
Questionnaires habits, 177, 181, 185–187, 220–221
demographic questionnaire, 233–236 hygiene, 181–182, 186–187
Cognitive Failures Questionnaire, 40 medication, 187
EuroQol EQ-5D-3L, 40 napping, 180, 184–185, 187–188
Generalized Anxiety Disorder Questionnaire (GAD-7), problems, 17, 180
39, 40, 41 restriction, 181, 184–186
Hearing Handicap Inventory, 40 space, 180–181, 188
Hospital Anxiety and Depression Scale (HADS), 40 stimulus control, 181, 183–184
Hyperacusis Questionnaire, 40 Sound
Insomnia Severity Index, 39, 40 attention grabbing, 172, 174, 220
Patient Health Questionnaire (PHQ-9), 39, 40 harmful, 68, 197–201, 203–204
Satisfaction with life scales, 40 generator, 13–14, 201
Tinnitus Cognitions questionnaire, 40 masking, 13–14, 122
Tinnitus Hearing Screener, 53 sound enrichment, 14, 16, 17, 27, 45, 62, 64, 171–174,
Tinnitus Handicap Inventory (THS), 44–46 200–202, 220, 231
Tinnitus Qualities Questionnaire (TQQ), 44–46, sound therapy, 13–14, 24, 37
238–239 use of background sounds, 27, 57, 139, 171–172, 174,
176, 181, 192, 197, 200–204, 208, 220
Sound tolerance. See Sound sensitivity
R
Sound sensitivity, 12, 40, 172, 197–204
Referrals, 17, 36–37, 39, 48–49, 233, 234, assessment of, 23, 40–41, 235
Reflection, 16, 193, 195, Stress, 16, 24–25, 60, 69–70, 73, 77–78, 82–83, 85, 95, 98,
Reflection activities, 65, 72, 83, 89, 93, 98, 103, 106, 101–103, 120, 215
116, 123, 129, 141, 154, 160, 166, 174, 188, 204, 211
Reinterpretation of tinnitus. See Tinnitus.
Relapse
T
relapse prevention, 16, 17, 28 Tackling Tinnitus Program
Relaxation components, 25, 26–28
applied relaxation, 17, 77–78 development, 24–25,
deep breathing, 26, 45, 62, 64, 79, 85-89, 97, 103, 106, evidence for, 24–26, 28
114, 145, 158, 192–193, 216, 217 overview, 26–28, 57–65
deep relaxation, 26, 45, 62, 64, 77-83, 217 readability, 47
entire body relaxation, 26, 45, 62, 64, 91–93, 217 time span, 43, 47–48
frequent relaxation, 26, 45, 62, 64, 95–100, 217–218 theoretical base, 24–25
guide, 7, 16, 17, 25,26, 45–46, 57, 64, 62, 75–105, 215 Team
217–218, 230 multidisciplinary, 25, 28
habit 95–98, 105–106 Tension, 4, 25, 60, 68, 73, 77–78, 80–83, 97–98, 101–102,
relaxation for sleep, 182–183, 220 105, 133, 158, 174, 182–183, 198, 204, 209,
relaxation for sound tolerance, 200–201 215–216, 217
relaxation when stressed, 26, 45, 101–103 Thoughts
routine, 26, 46, 62, 64, 105–107 awareness of, 131–133, 135–137, 140–141, 144–145,
Resources 216, 217
additional resources, 229, 231 challenging thoughts, 143, 146–153
videos, 230 thought analysis, 148–152
thought patterns, 3–4, 27, 62, 64, 131– 141, 144, 146,
153, 219, 225
S Tinnitus
Self-help, ix, 7–8, 28, 39, 42–43, 47–49, 57, 58 acceptance, 36, 37, 165
Setbacks, 223, 225, 195 assessment, 36, 38–39, 47
Sleep awareness, 61, 62, 68–70, 69, 78, 165, 171, 174, 238–239
bedtime, 182–185, 188 bothersome, vii, 58, 71, 73, 81, 82, 98, 119, 128–129, 209
256 COGNITIVE BEHAVIORAL THERAPY FOR TINNITUS
Tinnitus (continued)
description, 4, 67, 120
in control of, 60, 111, 164, 223
incidence/ prevalence, 11, 35
intrusiveness, 6, 14, 37
location, 11–12, 67
management, 13–14, 17, 24, 57
mechanisms, 11–12
myths, 72, 73, 149
objective tinnitus, 12, 235
outcome measures, 38–39, 38, 41, 44–46, 238–239
percept, 12–14, 15, 28, 36
reinterpretation, 119-123, 218, 230
reactions to tinnitus, 13–15, 28, 59, 63, 119, 180
tinnitus research, 19–23
tinnitus views, 119-123, 230
unimportant background sound, 120, 128-129, 215
Tinnitus Retraining Therapy, 13, 14, 18, 24
Therapy
CBT. See cognitive behavioral therapy
drug therapy, 37
psychological therapy, 37, 57
sound therapy, 13, 14, 24, 37, 57
Treatments. See therapy
V
Visualizing. See imagery
W
Worksheets, 9, 25, 26–28, 44, 47, 49, 63, 83, 84, 89, 90,
93, 94, 98, 99, 103, 104, 106, 107, 116, 117, 123,
124, 129, 130, 137, 141, 142, 154, 155, 160, 161,
167, 168, 175, 176, 184–185, 188, 189, 195, 196,
204, 205, 211, 212, 221, 222, 224