I  have started using the acronym CORE to explain the skills developed in mindfulness.
C=Concentration
O=Observation
R=Relaxation
E=Equanimity
 
Each of these skills, I believe, is transferable to our work with tinnitus.

I.Concentration is a translation of the Pali term “samadhi.” Samadhi has been described as one-pointedness. When you are in formal practice and placing your attention on the breath, this is what you are aiming at developing (to the degree that meditation can be said to aim at anything).

As described by Andrew Olendzki, in samadhi:

“The mind becomes tranquil but alert, with neither too much nor too little energy, and finds an equanimous stance that neither favors nor opposes anything but rather rests with quiet confidence on its object. A growing sense of well-being ensues and slowly matures into a state of profound equanimity. The mind in this state is said to be luminous, malleable, cleansed of its impurities, and thus able to see things clearly. Now the process of developing wisdom can begin.”

This doesn’t happen right away. However, as a result of sustained practice we slowly gain glimpses, and the longer we meditate, the more of this you will experience. But it is not only on the meditation cushion that samadhi happens. Informal practice develops this skill as well. If you mindfully eat a meal, focusing on the taste, smell, and sights of the food, you are developing this capacity. Nor is this state of samdhi unique to meditators. Meditation merely fosters and develops this skill. If you are completely absorbed in an activity, you are probably fostering samadhi. A professional musician playing her instrument is well-versed in samadhi, and would not be a professional without that single-pointed concentration. In my own small way, I notice something of this same state when I am playing my classical guitar.

So what does this have to do with tinnitus? In short, when we concentrate on a single thing (be it our breath, playing a musical instrument, or eating a meal), we are telling our mind that everything else except what we are concentrating on (including our tinnitus) is unimportant. Eventually, the mind will get the message. This ability to put the tinnitus in the background is key to the process of habituation.

II. In meditation (both formal and informal practice) we develop the ability to observe our thoughts without getting overwhelmed by them. This is a multi-layered process. It starts the first time we sit in meditation and notice that our attention has wandered from its focus on the breath. Here, we observe that we are (usually) caught up in thinking. We may even have been lost in the thought for a period of time without being aware of it. In either case, at this point we simply notice that we are thinking and return our attention to the breath. This is the first encounter with thought, a brief observation. But here we learn an important lesson. We may not be able to control our thoughts, but we can control our attention. Specifically, we can turn our attention away from thought and towards present moment experience (in this case, the experience of the breath).So one way of working with a thought is to simply place your attention elsewhere. As with all of mindfulness training, this is not merely something we tell ourselves to do ; it is something we train ourselves to do. And over time, it becomes second nature to turn away from thought and focus our attention on present moment experience.

This is the first stage of training, and is developed by simply noticing our attention has wandered off, and bringing our attention back to the breath. Ultimately, though, we want to acquaint ourselves more intimately with our thoughts. And so at this second stage we observe the thoughts in a little more depth and detail so that we can actually note what sort of thought it is. We engage in the practice of mental noting. We say to ourselves: this is a planning thought, or an anxious thought, or a self-critical thought, or a depressed thought. Importantly, we are not merely objective observers of thought. Instead, we aim to be friendly, compassionate, and curious towards our thoughts. If it is a self-critical thought, for example, we feel compassion for the person who has turned against himself and attempt to understand why this may have happened.

This naming of thoughts is a key step, for there is all the difference in the world between being anxious and noticing you are having an anxious thought. Once you notice you are having an anxious thought, you can create a space between you (the observing self) and the thought and decide what you wish to do with the thought. This is the insight behind the phrase : “mindfulness gives you time. Time gives you choices. Choices, skillfully made, lead to freedom.” We can then decide whether or not it is useful for us to adopt a thought or whether our self-interest is best served by letting it go.

This process has profound implications in working with tinnitus. Since our thoughts about tinnitus are a source of distress, we need to find some way to work with these thoughts to reduce their negative impact. Turn to any book on CBT and tinnitus and you will see a list of tinnitus thoughts and then instructions on how to challenge and replace the thought. It can get quite complicated and exhausting and it is not clear at the end of the day how effective we can be of talking ourselves out of things we already believe. Mindfulness accomplishes the same process of disempowering a negative thought by simply noticing it. 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.”  We discover that we don’t have to be swept away by your feeling. We can respond with wisdom and kindness rather than habit and reactivity.

III.The third core meditation skill is relaxation. Whereas the first two skills—concentration and observation—involve working with the mind, relaxation is primarily about working with the body.  The research on the ability of meditation to bring about relaxation goes back nearly a half-century to Dr. Herbert Benson’s groundbreaking and best-selling book, The Relaxation Response. This book is still in print today and worth picking up. In that book, Benson presented his research that meditation (he didn’t call it that but simply referred to “the relaxation response”) lowered oxygen consumption, heart rate, respiration, and blood lactate and that these results were signs of decreased activity of the sympathetic nervous system. In a practical sense, this training reduced blood pressure and was responsible for getting patients off of medication.

Now as for the relevance to tinnitus, we know that those with tinnitus have increased activation of the sympathetic nervous system, or what is known as fight or flight. Anything that can calm us down is good. The relaxation response calms us down. In his book, Benson described what he saw as four basic elements to meditation. The first was a quiet environment. The second was an object to dwell on. For Benson, this could be a word or a sound repetition. It should be said that Benson did a lot of his initial research with Transcendental Meditation or TM, which utilizes the repetition of a mantra. For traditional practices, the breath provides the focus.  The third element was a passive attitude. For Benson, this meant emptying of all thoughts and distractions from one’s mind. This can be accomplished by noticing when a thought arises and bringing the attention back to the initial object of focus. The fourth element is a comfortable position.

I like to point out that relaxation is not the goal of meditation (technically, there is no goal of meditation). It is like the runner’s high—a reliable companion to a practice that has its own rewards: in the case of running, cardiovascular fitness, in the case of meditation, attentional fitness/awareness. What we are trying to do with meditation is to bring our attention under control, to train it to be in the present  moment. But the inducement of relaxation is a nice side effect, and one that no doubt plays a role in continuing the practice.

Of course, there is a paradox here in that consciously trying to relax is almost guaranteed to backfire. There is nothing more certain to make you tense than trying to relax, just like going out with the conscious intention of having a good time is almost always bound to backfire. We just have to let good times and relaxation happen. But we can set up the conditions for the event to occur. For meditation, this means things like setting up a quite place and regular time to meditate, doing so on a regular basis and just accepting what happens. One device I have taught to folks to jump start the relaxation response is the repetition silently to yourself of the word "peace" on the inhale and "calm" on the exhale.

IV. Equanimity is the fourth of the CORE skills cultivated in the practice of meditation.  Although it is somewhat of an oversimplification, we can say that the first two skills (concentration and observation) work with the mind, while the third (relaxation) deals with the body. Equanimity, to complete the picture, is concerned with the emotions. Now this story is somewhat of a simplification for several reasons, not the least of which is that emotions are not separate from body and mind but are in fact a combination of the body and mind. The anger you feel when someone cuts you off in traffic is a combination of the thought “this guy is disrespecting me” and the activated state of your body (e.g., increase heartbeat and breath rate).

There are two fundamental tasks in working with the thought/emotion complex in tinnitus. On the one hand, we need to limit the impact of negative thoughts, what is referred to as the second arrow of suffering.  The second arrow of suffering involves all the negative thoughts we tell ourselves about some painful experience we are undergoing (including but not limited to tinnitus). The painful experience may be inevitable, but the suffering induced by our negative thoughts is optional, something we inflict upon ourselves. Through practice we learn to observe negative thoughts and simply let them go. I think it is important to add here that we’re not getting rid of thoughts.  As Jon Kabat-Zinn says, the only thing we get from trying to sweep our thoughts away is a headache.  We simply observe the thoughts and then come back to the present experience.

But we need to do more than just damage control, which is how I view the limiting of negative thoughts.  We need to instill positive and constructive thoughts in our consciousness. Fortunately, the area of positive psychology is filled with empirically validated practices (most of which piggy back on traditional practices thousands of years old) that can serve to do precisely this. Activities like the gratitude journal, practicing awe, and taking in the good, and countless other practices, are demonstrated to induce states of mental well-being in the same way the physical exercise produces states of health. An article in the journal Mindfulness found that more dispositional mindfulness, gratitude and self-compassion were associated with lower tinnitus distress and psychological distress. More negative cognitions and fewer positive cognitions about tinnitus were associated with more tinnitus and psychological distress.  And we need to do this not just occasionally  but consistently, methodically, and on a regular basis. Neurons that fire together, wire together. Through practice we can turn the states of well-being produced by these practices into traits of well-being, happiness, and joy. As with negative thoughts, the goal is not to eliminate negative emotions (see the article on negative emotions below), but to increase our capacity to experience these emotions. As Jon Kabat-Zinn puts it , we may not be able to stop the waves (of distressing emotions), but we can learn to surf. This is the practice of equanimity.