If you are reading this blogpost, chances are you are familiar with Cognitive Behavioral Therapy (CBT) and its uses in treating tinnitus distress. Professional opinions about its effectiveness are in agreement: CBT should be a part of one’s tinnitus management strategy. According to the American Tinnitus Association website, “CBT has been shown to significantly help many patients with tinnitus.” A 2019 comprehensive review of the research concurs that “there is strong evidence supporting the effectiveness of CBT in alleviating the distress caused by tinnitus.” Completing this consensus, a recent therapeutic manual on the topic declared CBT “the most clinically evaluated therapy and the most effective in alleviating emotional distress in relation to health problems like tinnitus” (1).
There is a danger, however, in this admittedly accurate verdict; for in my experience as a mental health professional I have found CBT functions best as one part of a much larger and more encompassing mental health strategy for treating tinnitus distress. This view coincides with one interpretation of tinnitus distress according to which cognition is seen as playing a role but not necessarily a central one in tinnitus distress (2). As I see it, mental health strategies for tinnitus are like a five-course meal at a fine French restaurant. Using only CBT is like eating just one of the five courses—not even the main one (in my opinion, that title would go to mindfulness). There are numerous mental health interventions that should be a part of one’s tinnitus toolkit, each contributing something different. The sum total of these interventions can be a powerful ally in your tinnitus journey.
In the next couple of blogposts I will be introducing you to other therapeutic interventions that you might want to consider as part of your tinnitus management. I will start with the one other intervention that has a substantial body of research in back of it in relation to tinnitus. This is mindfulness.
Mindfulness can trace its most recent incarnation to Jon Kabat-Zinn, who in the late 1970s began working with patients from the pain clinic at the University of Massachusetts Hospital. Specifically, he worked with patients who had undergone all of the services the pain clinic had to offer but were still reporting high levels of pain. Using a millennial old mental training practice, Jon Kabat-Zinn put them through a program designed not to reduce their pain but to change their attitude towards the pain. And it worked. At the end of the program patients reported being significantly less distressed by their pain. Jon Kabat-Zinn ultimately developed an 8-week program, which he called Mindfulness Based Stress Reduction (MBSR)—a program that would become the basis for much of the research into the benefits of mindfulness. From this humble beginning, the modern mindfulness movement was born. Since that time the program has been the source of hundreds of studies over more than four decade linking mindfulness training to increased heart health, reduced cell aging, increased immune system response, decreased depression and anxiety and a variety of other physical and psychological conditions (3).
But what is mindfulness? And how can it help with tinnitus? Mindfulness can be defined as nonjudgmental awareness of the present moment. As a stress reduction tool, mindfulness works by training the body not to react to external stressors in our normal, automatic pilot-type manner. A car cuts us off, a computer malfunctions, an appliance brakes down, the stock market takes a dip, or an encounter does not go as planned and the body’s ancient threat defense mechanism—fight or flight—kicks in, increasing heart rate and blood glucose levels, dilating coronary arteries, pupils, and bronchial tubes, increasing oxygen flow to the lungs and shutting down nonessential systems like digestion. From an evolutionary perspective, such a response was essential for survival, helping us to flee or fight the advancing mastodon. But this response was invariably followed by long periods where the body’s “rest and digest” mechanism—the parasympathetic nervous system—was allowed to kick in and restore the body to balance.
Unfortunately, in our modern times balance is elusive and instead we jump from one fight or flight incident to the next, never really relaxing or calming down. Often, we exacerbate the situation by using destructive coping mechanisms such as binge-watching Netflix, losing ourselves in social media, or escaping into substance use. The result of such toxic stress and destructive coping mechanisms is a variety of physical and psychological ills: insomnia, hypertension, coronary heart disease, reduced immune system functioning, ulcers, migraines, depression and anxiety, to state a few of the greatest hits of prolonged stress.
Mindfulness training combats this modern phenomenon in a couple of different ways. First through meditation practice mindfulness allows us to bring the body’s parasympathetic system on line on a regular basis, lowering the body’s stress level. More importantly, mindfulness training develops the capacity of nonjudgmental awareness. This allows us to see that the car and the computer, the rude waitress and the dismissive coworkers are not threats in any meaningful sense of the term. Bringing that realization into the present moment we allow the body to calm down, or never go into fight or flight in the first place.
Although the physical and psychological benefits of mindfulness training have been known and studied for more than four decades, it is not until relatively recently that its effectiveness has been demonstrated with tinnitus. A 2019 systematic review found that a decrease of tinnitus distress scores occurred directly post therapy in seven moderate-to-high quality studies, with six of the seven studies showing a "statistically significant decrease in tinnitus distress scores directly after mindfulness training"(4). Although the exact mechanism of how mindfulness works on tinnitus is a matter of some dispute, mindfulness most likely is effective with tinnitus for the same reason it is effective in general—by inhibiting our tendency to go into fight or flight. In the case of tinnitus, it is not some external stimuli like obnoxious driver or the malfunctioning computer that catapults us into fight-or-flight but the sound of our tinnitus. Unsurprisingly, research has shown that those with bothersome tinnitus have higher levels of the stress hormone cortisol in their system (5). As mindfulness trains us to watch our thoughts and experience with nonjudgmental experience, it opens up a space in us to ultimately view our tinnitus in the same nonjudgmental fashion—neither being overwhelmed by it nor attempting to push it away but simply accepting it as part of the present moment. This nonjudgmental awareness is the key to habituation.
I want to emphasize that this is easier said than done and that reaching this state takes time and effort. Mindfulness is not something we tell ourselves to do; instead, it is something we train ourselves to do, just as we train to run marathons. The basic 8-week mindfulness course—which can be said to be the start of training—involves 45 minutes of daily practice in addition to other related practices. Nevertheless, mindfulness training will provide you to tools to deal not only with tinnitus but with your life. Forty years of research demonstrate the benefits of this training are well with the effort.
MINDFULNESS RESOURCES:
A lot of places will claim to provide mindfulness training. It is important to realize that all of the studies demonstrating that mindfulness training decreases tinnitus distress were done with some version of the Mindfulness Based Stress Reduction class. You should work with someone trained in either Mindfulness Based Stress Reduction (MBSR) or Mindfulness Based Cognitive Therapy (MBCT). The most inexpensive way to achieve mindfulness training is the free mindfulness course offered at www.palousemindfulness.com This is a do-it-yourself version of the famous 8-week mindfulness class. It is completely legit, with videos, resources, and readings. The only caveat I would add is that in my experience it is extremely difficult to teach oneself mindfulness, which is why there are trained teachers on this topic. Jennifer Gans has a mindfulness for tinnitus class you can likewise do by yourself. It has the virtue over the previous class of being designed for tinnitus. At last check it cost $225. The link is here: https://mindfultinnitusrelief.com/ Closing this section out, I teach a live, online version of the 8-week MBSR class designed just for tinnitus. The website is www.onlinetinnitusclass.com . The current cost is $295. Generally, I start a new class every month. Last, you can always take a live or online MBSR class. If you cannot find one in your area, look to the website for University of California at San Diego Center for Mindfulness. The class runs about $600. https://cih.ucsd.edu/mindfulness/schedules-registration#mbsr It should be noted that Dr. Gans’ course and my own are specifically focused on tinnitus, while the free class or the MBSR class you can take in person or online are general in nature.
Notes
1.https://www.ata.org/managing-your-tinnitus/treatment-options/behavioral-therapies; Aazh, Hashir, Michael Landgrebe, Ali A Danesh, and Brian CJ Moore. "Cognitive Behavioral Therapy For Alleviating The Distress Caused By Tinnitus, Hyperacusis And Misophonia: Current Perspectives." Psychology Research and Behavior Management 12 (2019): 991-1002. Web.; Beukes, E, et al. (2021). Cognitive Behavior Therapy for Tinnitus. Plural Publishing. Importantly it needs to be added that all the reviews also concur that CBT does not reduce the loudness of tinnitus. As the National Center for Rehabilitative Auditory Research declared,“There currently is no therapy that can safely and consistently reduce the loudness of tinnitus.”
2. McKenna, Laurence, Lucy Handscomb, Derek J Hoare, and Deborah A Hall. "A Scientific Cognitive-behavioral Model of Tinnitus: Novel Conceptualizations of Tinnitus Distress." Frontiers in Neurology 5 (2014): 196. Web.
3.https://greatergood.berkeley.edu/article/item/five_ways_mindfulness_meditation_is_good_for_your_health
4. Rademaker, M. M., Stegeman, I., Ho-Kang-You, K. E., Stokroos, R. J., & Smit, A. L. (2019). The Effect of Mindfulness-Based Interventions on Tinnitus Distress. A Systematic Review. Frontiers in neurology, 10, 1135. https://doi.org/10.3389/fneur.2019.01135
5. Mckenna et al.
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