by Eldre Beukes, Gerhard Andersson, Vanaya Manchaiah, Viktor Kaldo. Plural Publishing, 2021.

The COVID vaccine may or may not cause tinnitus, but the disease itself offers an interesting point of comparison. In the case of COVID, we have an effective intervention which, for reasons we don’t need to go into here, a large number of potential beneficiaries are able but unwilling to access. By contrast, with tinnitus, we have an effective intervention that a large number of potential beneficiaries want to receive but, for reasons I will go into, are unable to.

That treatment, as most readers of this review will have guessed, is CBT, which can be defined as a type of psychotherapeutic treatment that helps people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior and emotions (1).  Not without reason CBT has been dubbed the “gold standard” in psychotherapy. More than 2,000 studies have demonstrated the efficacy of CBT for psychiatric disorders, psychological problems and medical problems with a psychiatric component (2). When it comes to tinnitus the results have been equally impressive. As the authors of Cognitive Behavioral Therapy for Tinnitus state, “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-based for tinnitus.” Summing up the evidence, the authors assert: “CBT has the most favorable results of all tinnitus treatments.” [16] And, in the best possible world, this should be the end of the story: the effective treatment would be promptly dispensed to those who would benefit. But, as with COVID, there are complications to this storybook ending.

The problem, as the authors point out, is that “there is a shortage of trained tinnitus specialist who can provide CBT for tinnitus.” [18] This puts the problem mildly. Not only, due to COVID, is there a general shortage of therapists. Finding a therapist experienced in providing CBT for tinnitus adds an additional, almost insuperable, level of difficulty—like throwing a quadruple axel on top of an already complicated skating routine.  Importantly, it is not that there are limited therapists knowledgeable and trained in CBT. Pick the first ten therapists on the Psychology Today list of therapists and look under the category of Treatment Approach. Under “types of therapy” nine (if not ten) of the ten will list CBT as a treatment modality they use. We all learn CBT. But without an understanding of the specifics of tinnitus, the CBT therapist working with a tinnitus client is like a pianist with a knowledge of music theory trying to give guitar lessons. This gap—between knowing CBT and knowing CBT for tinnitus—is borne out by my own research survey, which found that only about one-third of those who visited a therapist were helped by the experience.

As a result, the tinnitus world has needed to explore “alternative formats” for delivering CBT. Small groups, internet-based CBT and bibliotherapy (reading books) have all been used to deliver CBT for tinnitus. Although the authors report these alternative means of delivering CBT “can produce favorable results” [18], the most recent review of the research I have come across states “While guided self-administered forms of CBT had larger effect sizes on tinnitus, only face-to-face CBT was shown to make statistically significant improvements” (3).  The conclusion that CBT needs to be delivered by a trained professional in order to be effective jibes with my experience as a therapist. CBT requires a client abandon long and deeply held patterns of thinking--and most of us need to be dragged away from these kicking and screaming (metaphorically speaking, of course). Another alternative the authors explore is for hearing care professionals to deliver the therapy. I’m not sure how audiologists would feel about therapists starting to give ear exams after a brief course on the topic, but if you want to know what most therapists think of the former idea, ask your audiologist about the latter.

But until the therapy world wakes up to tinnitus, these are the options that are offered to those of us with tinnitus seeking relief through CBT. The program offered in this book is a welcome addition to the available options. Specifically, the program offered by this book provides an 8-week course in CBT that can be used on a self-help manual or with professional guidance, although authors report better outcomes have been reported with a guided approach (43).The authors present a detailed four-part program:  Relaxation Techniques such as breathing and mediation, Cognitive Therapy Techniques, including cognitive distortions, thought challenging, and mindfulness; a grab bag section that covers sound therapy and sleep guidelines; and a summary section on maintaining the results. The parts can be covered sequentially or can be mixed and matched. There is a companion website with helpful video tutorials.

The only place where the authors miss the mark is the section on mindfulness, where they offer a four-page chapter on this fascinating and complex topic that is as misleading as it is brief. According to the authors, mindfulness “helps you engage and enjoy the present moment” (157).  But mindfulness is not primarily about engaging in the present as opposed to past and future; rather, the goal of mindfulness training is to get us to focus on our experience rather than our thoughts. Mindfulness offers an alternative way of dealing with our thoughts about tinnitus than CBT—not by challenging them but by simply noticing on the assumption that if we do not react to them will cease to trouble us. This assumption has been validated through the research done on Mindfulness Based Cognitive Therapy (4). By the same token mindfulness is not about enjoying the present moment but accepting it whether pleasant or unpleasant and not pushing it away nor wishing it to be other than it is. Such acceptance of the present without judgment is key to the process of habituation.

Beyond this misstep, the book provides the best foundation out there for the majority of those with tinnitus to engage with CBT and would serve as an excellent manualized intervention by CBT used by all therapists working with tinnitus clients. Manualized interventions have the virtue of providing uniform treatment. In a manualized treatment, a very strict regimen is offered, detailed instructions and exercises are provided, and a specific, usually short, timeline is offered. Such treatments are particularly useful with difficult to treat difficult issues, assuring a standardized care that can then be used as the basis for research.  For example, Cognitive Processing Therapy (CPT) is a 12-week intervention for PTSD that has been demonstrated to be very successful in treating this difficult issue. More recently Complicated Grief Therapy (CGT) offers a 16-week therapy for that condition and has been found to be almost twice as effective as standard grief therapy.

It is clear to me that the answer to the paucity of therapist who can treat tinnitus is to come up with a manualized treatment, train therapists in that treatment and, finally, provide certification so that clients can be assured that the therapist is expert in that treatment. This seems stunningly obvious to me and I am not a genius, so I am sure others must realize this is the path that needs to be followed. With the publication of this work, the most difficult part of this trifecta is in place. I am hopeful that those smarter than me can figure how we can put into place the remaining two components.