[This is the second book published with the last couple of years that fills the very noticeable dearth of self-help books for applying Cognitive Behavioral Therapy to tinnitus. At approximately $20 (though only $6.99 for the Kindle version) it is significantly cheaper than Cognitive Behavioral Therapy for Tinnitus by Eldre Beukes et al., which I have reviewed elsewhere on this site.]
There is a lot to like about this book and, unfortunately, a lot to dislike as well. It is a methodical presentation of CBT as it applies to tinnitus, offering lively language, colorful examples, and numerous worksheets for independent study. It goes in depth into the practice of CBT to a degree that I have not seen in any previous CBT book. And there is some solid practical wisdom that goes beyond what folks are likely to hear from their audiologist, especially in terms of acceptance and self-compassion. But on the dark side (and there definitely is a dark side) it misstates data, misreads historical sources and outright contradicts itself in places. It recommends—or rather, insists upon—some questionable practices. And most importantly, it encourages practices that could well retraumatize the reader.
At its core, the program consists of a fairly conventional application of Cognitive Behavior Therapy (CBT) to tinnitus. Hence, it is helpful to know a little bit about how CBT works in general. Regardless of what mental health issue it is applied to, the process of CBT is the same. The therapist demonstrates to the client that their distressing emotion (e.g., depression) is caused by their thoughts. The therapist then assists the client in identifying the specific thoughts that are causing these distressing emotions, challenging the rationality and/or usefulness of those thoughts and, finally, replacing the problematic thoughts with healthier ones. The hope is that these healthier thoughts will result in happier, more balanced emotions.
Following this model, the authors begin by offering an overview of CBT (chp. 3). Next, they educate the reader on how to connect her emotional distress about tinnitus to her thoughts about tinnitus, using something they call the “Tinnitus Mood and Thought” worksheet or TMT (chp. 4). From there, the reader is presented with the basic cognitive distortions and how they might apply to tinnitus using a worksheet they dub the Tinnitus Related Thought Distortions or TRTD (chp. 6). Chapter 8 instructs the reader in how to come up with counterstatements to negative tinnitus thoughts. Finally, in Chapter 9 they put this all together with something they call the Know, Keep on, Identify and Substitute (KKIS) worksheet.
As you might be able to figure out by this point, this book has a lot of worksheets, which is one of the first ways it stands out from other books on the subject. In additions to the ones listed above there is: THT (Tinnitus Hot Thought worksheet), TRS (Tinnitus Reaction Source worksheet), RCW (Rule Challenge worksheet), CBW-T (Core Belief worksheet), and several others which I lost track of and really don’t want to go back and look up. Although keeping track of these worksheets can be overwhelming—to say nothing of completing them—overall the proliferation of worksheets is a good thing, since rather than just talking about how CBT works the book provides a lot of ways for you to dig down and see how CBT applies to your tinnitus.
Another unique feature of the work is the varied language and colorful examples used in the writing. With its emphasis on rationality and logical requirements of belief, CBT can have a Mr. Spock-like character to it and thus lends itself naturally enough to dry, analytical prose. The authors counter this tendency by invoking a variety of historical and contemporary to explicate key points. Romeo and Juliet, Beauty and the Beast, the Woody Allen film Hannah and Her Sisters, Dante’s Inferno, Greek stoicism, Aristotle, the Muslim poet Rumi, the great boxer Muhammad Ali and the Buddha all make extended appearances in the work, livening up what could be potentially sleep-inducing discussions.
On a more serious note, the book covers an issue of CBT that I have not seen covered in any other discussion of the topic relating to tinnitus: core beliefs. As the authors point out, in CBT there are three layers of beliefs: automatic thoughts, intermediate beliefs (rules, attitudes, assumptions, and core beliefs). Automatic thoughts are the actual words that go through a person’s mind in a specific situation. If I am dealing with tinnitus, it might be something like “I cannot handle this.” However, these automatic beliefs, which are specific to the situation that is occurring, are often grounded more fundamental beliefs that one holds about oneself and the world such as, for example, “I am incompetent.” These are core beliefs.According to Judith Beck’s classic work, the key to helping patients improve is “direct modification of their core beliefs as soon as possible.”
Yet most books on CBT stick to working with and modifying automatic thoughts. The recently published CBT for Tinnitus does not broach the subject of core beliefs but sticks to working with automatic thoughts while Lawrence McKenna’s excellent Living with Tinnitus and Hyperacusis mentions them only to assert that “a discussion of such deeper beliefs is a huge topic that deserves a book on its own”—and more or less leaves it at that. Now, there is good reason these other works have avoided discussing core beliefs, since working with core beliefs is hard work and and really best left to a trained therapist. But the authors should be commended for at least venturing into this realm in order to provide the reader with ta full picture of the procedure of CBT.
A final strength the I will discuss is the authors willingness to venture outside of the realm of classic CBT to bring in concepts from later theories, specifically endorsing elements of what is often referred to as third-wave CBT such as mindfulness and Acceptance and Commitment Therapy (ACT). Whereas CBT devotes most of its energy changing negative emotions, therapies like as mindfulness and Acceptance and Commitment Therapy (ACT) offer a radically different approach of acceptance—an approach which the authors seem to approve of: “But perhaps we should not rush into rejecting negative emotions out of fear of being able to cope with them.”
Another concept broached by the authors that is not part of traditional CBT is self-compassion. It is not that CBT rejects self-compassion. It is simply not part of the vocabulary of the intervention, which was developed long before the therapeutic work on self-compassion began to be researched. But the authors clearly have this strategy in mind when they assert: “The willingness of be aware of our vulnerabilities and weaknesses without judging them is a key concept and related therapies such as mindfulness and acceptance and commitment therapy” (125). Or again: “If we accept ourselves as who we are even at difficult moments of experiencing tinnitus, we remove barriers for recovery and self-growth so that we actually can get to the place where we need to be as a person” (135). There is a lot of wisdom in this approach which, although owing its origin to Buddhism, has been validated by a good amount of scientific research on mindful self-compassion.
Although the discussion or Acceptance and Commitment Therapy and Mindfulness is one of the high points of the book for me, it does raise problems for the authors. Classic CBT is sometimes referred to as second-wave CBT. It works on problematic thoughts by challenging and ultimately changing the thoughts that cause emotional distress. This is the process CBT uses not only in working with tinnitus but in working with any psychological problem, and this is the approach the authors adopt in dealing with tinnitus thoughts. Mindfulness and ACT, however, offer a profoundly different approach. Rather than try to change/challenge thoughts, the strategy for ACT/mindfulness is simply to become aware of the thoughts. As Jon Kabat Zinn puts it. “If you don’t do anything with them [thoughts], if you don’t touch them, If you don’t get caught in them, they self-liberate naturally.” This approach is sometimes referred to as “third-wave CBT.” In a real sense, these approaches are mutually exclusive. You can’t both challenge and try to change a thought like “I can’t live with tinnitus” and accept it and let it self-liberate in awareness. So which is it? We don’t know because for all their talk about ACT and mindfulness they never mention that these systems take a fundamentally different approach to working with thoughts.
However, one telling, or rather, annoying, aspect of the book, is the ubiquitous use of boxing metaphors to describe the relationship with tinnitus. By my count (well, Kindle’s count actually) there are no less than 19 boxing references in the work to describe the relationship with tinnitus. Here is a typical one: Just as “we should overcome our fear of inevitable pain if we are in a boxing match,” so “annoyance, irritation, sadness and other negative emotions are also part of the match if we want to learn how to beat tinnitus.” This confrontational attitude with tinnitus—which as I said is not an isolated incident but a theme running through the work—is the polar opposite view of the attitude that ACT would have us address an issue with. What this demonstrates is that the authors have not really understood the intervention, which in any case would undermine their basic approach. In short, the authors seem at times to embrace a tactic that goes against the fundamental strategy of the book. In my opinion, this intellectual confusion seriously damages the authors’ credibility. Contradiction may be a poetic strength (“Do I contradict myself,” said Walt Whitman in Leaves of Grass. “Very well then I contradict myself”). But it has to be considered a tremendous deficit in a work attempting to provide instruction in the treatment of a serious condition.
Another intervention which the authors struggle with is positive psychology. The field of positive psychology involves the study of the practices that have been demonstrated to increase happiness. The basic idea is that just as we know what routines and strategies will increase our physical well-being so we have knowledge of the practices guaranteed to increase our mental well-being. For example, multiple studies have demonstrated that the regular expression of gratitude has been demonstrated to increase our overall sense of well-being. The authors presentation of Positive Psychology is essentially the view of Martin Seligman, an approach that focuses on development of virtues. Now although Seligman is rightly credited with establishing the field of positive psychology, the development of virtue is one aspect of positive psychology but is by no means the entirety of the field.For example, Rick Hanson has developed a practice dubbed “Taking in the Good,” which essentially involves focusing on positive experiences throughout the day in order to intensify their beneficial effect. He notes that we have a natural “negativity bias” that makes us be like Velcro for bad experiences and Teflon for good. While this attitude had some evolutionary benefits in keeping us alive, today it can result in excessive worry and anxiety. A regular practice of focusing on positive experiences is intended to increase our overall sense of well-being. His research into this, which was recently published in the Journal of Positive Psychology, does not fit nicely into the category of development of virtue yet is an obvious positive psychology intervention. So unlike their presentation of ACT, which is mired in inconsistency, the presentation of positive psychology is merely incomplete.
In addition, I have serious issues with the authors’ recommendation on sound therapy. In the case of tinnitus, the authors have a blanket prohibition against sound therapy. Instead of using music or background noise to decrease the anxiety associated with tinnitus, the authors recommend simply facing one’s tinnitus without any such support: “exposing ourselves to our feared scenarios can improve our tolerance for tinnitus and for the uncomfortable feelings that it may cause.” By contrast when it comes to using music or sound to reduce the anxiety associated with tinnitus distress, the authors claim that “the use of such techniques can prevent us from learning how to manage tinnitus without being dependent upon them.”
To begin, I do not see the evidence that banishing the use of sound reduces tinnitus distress. There is some evidence that the use of avoidance behavior is linked to more distressing tinnitus (McKenna). But avoidance behavior is generally taken to refer to actual behavior, for example, not going into situations like concerts or restaurants because of one’s tinnitus. It is generally not understood as avoidance if one goes into a situation with some coping strategy or mechanism in place. If you have social anxiety and you still go to a crowded restaurant using breathing techniques or a mantra to calm you down, no therapist is going to say you are engaged in an avoidance behavior. Nor do I know of any study that has demonstrated that people who use sound therapy as a way of coping are in more distress than those who do not (But I am always ready to be enlightened on this point).
A second point is that even if one were better off without using sound--or even if one simply wanted to try to do without the use of sound—it is not clear the authors’ offer the best path to achieve this end. That is, the authors are recommending what is known exposure therapy. This is not what I have a problem with. Exposure therapy is a well-established intervention in dealing with many forms of psychological distress in which one is directly exposed to the event that is causing the distress. However, there are two strategies for exposure therapy: systematic densensitization and flooding. The former is more gradual while the latter consists in jumping right into the most fear-provoking situation. I could try to overcome my fear of dogs by first watching videos about dogs, then maybe going to a park and viewing people walking their dogs on leashes and occasionally asking to pet one. I can then go to a pet store or shelter and view dogs and handle a few more of them and maybe ultimately working my way into walking into a dog park full of unleashed canines. Or I can just cut out all the middle stuff and go right to the dog park. Now the authors have every right to advocate for the extreme view of exposure therapy, just jumping right into your most feared scenario—in this case a world without background sound. But they owe it to their readers to make them aware both of the alternative to the extreme form of exposure therapy they are recommending and of the potential dangers involved in their own strategy. And it is the potential dangers of the extreme version of exposure therapy which leads to the major issue I have with this book.
Consider the possible outcomes of using the extreme form of exposure therapy to get over my fear of dogs. It is possible the strategy catapults me into overcoming this fear. But it is possible as well that instead of winding up cured I end up huddled in a corner shivering and screaming. This might happen if, say, my fear of dogs was the result of a traumatic event like being mauled by dogs. But exposure might cause traumatization even without a conscious memory of an attack, for example, if the attack happened as a very young child and I have suppressed any conscious memory of the event. This is why a therapist using exposure therapy would be extremely sensitive to the possibility of trauma and of the possibility of exposure causing re-traumatization.
But there is no mention of the possibility or retraumitization in using exposure therapy to work with tinnitus, nor any mention of trauma whatsoever. This ignores the already established link between PTSD and trauma (Fagelson). So, for example, if the tinnitus were the result of a combat situation, then exposing someone to the sound of tinnitus could retrigger their PTSD from the combat situation. But it is not only combat vets with tinnitus who may be dealing with traumas. Two studies have found a reduction in tinnitus distress as a result of EMDR, which is primarily a trauma therapy. As the authors of one of these studies has suggested (Moore, 2020), one’s negative belief about the meaning of having tinnitus (e.g., “I’m not in control”) might have a thematic link with a past, potentially unrelated traumatic experience (e.g., being the victim of violence). In brief, the possibility of trauma needs to be considered when offering any strategy on tinnitus. Hence, the need for the tinnitus community to become trauma-informed. And this the authors fail to embody.
Instead, the authors go in the exact opposite direction. In one of the worksheets called the Tinnitus Hot Thought worksheet (THT),they instruct the reader to write down situations they and find particularly triggering and then ask the reader to note: “what images or memories come to mind.” In the example provided, the sound of tinnitus calls to mind a memory of growing up with a depressed mother. This is treated like it is just a normal image for the reader to contemplate and even ignore since “we can’t change the past.” In fact, when an event from the present triggers a painful memory from the past (as is the case in this example) this is the very definition of one of the symptoms of PTSD: intrusive memories. True, we cannot change the past; but we need to process it if we are going to deal with our trauma. And I suggest that in dealing with tinnitus we at least need to be aware of the possibility that we are also dealing with trauma.
So in the end I would recommend this book as informational only and not as to be used as a way to work with one’s tinnitus distress by oneself. It provides an excellent overview of the process of CBT. But CBT I would argue is best carried out working with someone who is trained in the practice. This is what the research demonstrates and my own experience as a therapist reaffirms. It is extremely difficult to talk ourselves out of our own beliefs since we are incredibly attached to them. I am grateful the work includes information on ACT and mindfulness that can open up important avenues for those with tinnitus to explore. But not enough information about these latter two therapies is introduced to allow the reader to meaningfully apply them. Finally, the possibility that the exposure therapy they recommend may retraumatize individuals makes me want to add a warning label to the work. Use at your own risk.
References
Rick Hanson, Shauna Shapiro, Emma Hutton-Thamm, Michael R. Hagerty & Kevin P. Sullivan (2023) Learning to learn from positive experiences, The Journal of Positive Psychology, 18:1, 142-153, DOI: 10.1080/17439760.2021.2006759
McKenna L, Handscomb L, Hoare DJ, Hall DA. A scientific cognitive-behavioral model of tinnitus: novel conceptualizations of tinnitus distress. Front Neurol. 2014 Oct 6;5:196.