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.

And it seems I am not the only one with this insight. There is growing recognition of a condition called “Chronic Illness Induced PTSD.” More technically, this is known as the “Enduring Somatic Threat” model of PTSD. The idea is that having a chronic illness can bring on the same symptoms as PTSD. As an article in SELF magazine put it:

Chronic illness is an under-recognized and misunderstood source of trauma. “Oftentimes in our society and our culture, we think about trauma as something that’s associated with combat or a very violent, terrifying event,” says  Dr. Ashwini Nadkarni, a Harvard Medical School instructor and psychiatrist at Brigham and Women’s Hospital who specializes in working with people living with a chronic illness “What’s not well understood is that the burden of having a chronic medical condition very much meets those criteria for a trauma experience.”

This becomes especially clear when we examine the classic symptoms of PTSD in relation to tinnitus.

Intrusion symptoms, which include re-experiencing the traumatic event. Those of us with tinnitus re-experience the trauma on a daily/hourly basis. It is there when we wake up in the morning and, at least for me, especially when I go to bed at night.

Hyperarousal symptoms for chronically ill people often manifest as an intense awareness of bodily sensations. Research demonstrates those with tinnitus are in a state of sympathetic activation. Difficulty sleeping and irritability are also hallmarks of PTSD hyperarousal and common in tinnitus.

Avoidance occurs as a way of managing the intense anxiety that accompanies re-experiencing and hyperarousal. In the case of tinnitus, we go out of our way so as not to experience situations that might cause our  tinnitus to spike, to the degree that many of us avoid much of life.

Negative alterations in mood. These include negative beliefs about oneself, distorted cognitions about the cause of the event, persistent negative emotional states, diminished interest or participation in activities, inability to experience positive emotions–all of which sounds like an inventory check list of an new tinnitus client.

Now, importantly, if tinnitus can cause PTSD, this does not mean everyone with tinnitus will develop PTSD. Generally speaking, about 10% of those who experience a trauma develop PTSD, which is about the same percentage of those with tinnitus who report being distressed by it. This might be a coincidence. But then again, it might not be.

The upshot is: If tinnitus is trauma, this might explain why, for those in whom it develops into PTSD, a few sessions of CBT might not be sufficient to deal with it. Fortunately, the therapy filed has come a long way in treating trauma in the past couple of decades, and there are numerous innovative therapies that can be useful in working with trauma.

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.

The first chapter is devoted to each of the authors detailing how he began his meditative practice.

Chapter two is entitled “Drop It,” and introduces a technique for getting out of our worrying minds. The practice is quite simple: while standing, you raise your arms and let them drop onto your thighs. You exhale a loud, big breath and you drop your awareness from thinking mind into what your body feels. Do this, says Rinpoche, for about five minutes. Goleman’s scientific addendum here is to describe this technique as working on the amygdala, the smoke detector of the brain, which is constantly scanning our environment for threats. A technique like “dropping it” can be quite effective, he notes, in suspending the anxiety-producing exercise of the amygdala by placing our attention not on the future but on the present moment.

Belly-breathing, the third chapter, describes this simple yet effective technique (as well as a few others) in terms unique to the Tibetan yogic physiology, like nadi (channels)and bindu (essences). Goleman uses his part of the chapter to outline the stress response and the distinction between the sympathetic and parasympathetic nervous system. As he points out “studies looking at the impacts of slow breathing on our brain, mind, and body find a strong shift to the parasympathetic mode.” In other words, slow breathing like the belly breath calms the body.

Chapter four discusses a phenomenon with the rather disturbing name “Beautiful Monsters.” BMs (no, not that bm) can best be understood as things like self-criticism and negative self-talk.  Rinpoche defines them as “patterns of reaction that are slightly or greatly distorted.” He introduces what he calls the handshake method, which involves befriending these negative parts of our personality. Goleman connects this technique to aspects of Western psychology, specifically detailing how the latest version of Cognitive Behavior Therapy endorses mindfully accepting self-critical or negative thoughts—in essence, befriending them—as opposed to classic CBT approach of challenging thoughts.

Chapter five talks about something Rinpoche dubs “essence love.” He contrasts essence love with expression love. Expression love is directed outwardly: parental love, friendship, romantic love. Essence love is where expression love is born. Essence love is essentially self-love. Goleman connects this concept to the recent research on mindful self-compassion, demonstrating how this capacity is linked with well-being.

Chapter six follows this concept by focusing on compassion for others. The classic Buddhist practice on this is well-known to many, the loving-kindness meditation.  Rinpoche reiterates the Dalai Lama’s claim that the way to ensure happiness for yourself is to work for the happiness of others. As Goleman points out, there is now research verifying this claim. The loving-kindness meditation itself has been studied and shown to increase well-being. In addition, an oft-cited experiment verified this concept. Participants in the study were provided a certain sum of money, with one group being commanded to spend it on themselves and another group to spend it on others. Those who spent money on others reported being happier.

Chapter seven, Calm and Clear, presents a discourse on the meditative state of shamata, or calm abiding, and reviews meditative practices that bring about this state. Here Rinpoche presents a lovely image, discussing how the mind begins as a waterfall but with meditation we transform it first to a rushing stream then to a meandering river and final to a placid lake. One of the most helpful pieces of advice I found in the book comes in this chapter, where he encourages meditators to embrace the concept of “short experiences, many times.” They can do this by breaking longer meditation sessions, where we often become distracted and fatigued, into short 3-5 minute sessions with a minute break, allowing us to bring more awareness and freshness into the session. I have been integrating this into my own practice lately with great success and satisfaction. Goleman points to the research, started by Dr. Herbert Benson in the 1970s with his best seller The Relaxation Response, about the stress-reducing benefits of meditation—research that has since been verified by numerous studies.

Chapter eight, A Deeper Look Within, focuses on one of the least commented upon aspects of the practice of meditation, at least in Western discussions of the topic. According to the Buddhist tradition, one of the aims of meditation is to demonstrate the lack of a permanent self—one of the three marks of existence (the other two being suffering and impermanence). As we meditate, we realize we are not our thoughts, which just come and go as we watch them and are always in flux anyway. If we cannot be identified with our mental content, what about identifying ourselves with our body? This is changing even more than our mental nature. But if we are neither our physical or mental selves, what is left. Nothing, actually; or at least nothing substantial.

Goleman connects this rather esoteric sounding view to research demonstrating that in the brains of depressed people during rumination a part known as the default mode network is lit up. By contrast, when we are involved in an activity (and no so focused on ourselves) this part of the brain is relatively quiet. This part of the brain also quiets during meditation (and with psychadelics, but that is another story).  Meditation then seems to facilitate a healthier concept of the self, one where we can take ourselves less seriously and live with a little more lightness.

The benefits of meditation for working with tinnitus should be obvious by what has already been written here. The calmness and stress reduction that meditation fosters are invaluable to those of us with tinnitus. Nothing ramps up our tinnitus like stress. And one of the best stress reducing tools is a meditation practice. But it is not enough to have learned to meditate at one time. You need an active practice in order to reap the benefits of meditation. And I think this book can be an aid for someone starting out to develop a practice by explaining the benefits of it in Western scientific terms and by providing some instruction on how to maintain and enrich a practice.

Overall, the book is more geared towards beginning meditators or those just getting their feet wet in the practice. The techniques and terminology discussed will be familiar to long time practitioners. But even I learned a thing or two. Indeed, the practice of “short experiences, many times” has transformed my practice. And while I personally would have preferred a deeper dive into the scientific research–and was hoping for one after hearing an interview with the authors–enough is presented to provide the beginning meditator with the assurance that they are following a path with a good amount of scientific evidence backing it up. And it provides me with a handy reference shall I want to review the more salient studies. Overall, I can recommend this book. I believe meditators at any stage would benefit from it.

Two possible explanations have proposed for the connection between tinnitus and trauma (Moore et al, 2020). First, it is possible that the tinnitus originated in a traumatic experience, for example, if the tinnitus were the result of a life-threatening event like a loud explosion. In my experience, this is a rare situation outside of military and first responders. The other possibility is that the tinnitus retriggers an early trauma. For example, “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).”

Both of these situations, however, focus on what we might call traditional trauma. Traditional trauma involves “exposure to actual or threatened death, serious injury, or sexual violence.” Traditional traumas are usually (though not always) one-time events. Anyone involved in some way in 9/11—from victims to first responders—experienced a traditional trauma. PTSD, for example, can only be diagnosed in relation to traditional trauma. And in fact there has been research demonstrating a link between PTSD and tinnitus (Fagelson, 2007).

Traditional trauma, however, does not exhaust the scope of trauma. In addition, there is what is referred to as complex or developmental trauma. Although perhaps not as dramatic as traditional trauma, complex trauma is much more widespread and, unfortunately, equally impactful. As opposed to traditional trauma, which usually involves a single event, complex trauma involves multiple events over time, for example, a child’s repeated exposure to abuse or neglect.  Research has demonstrated the long-lasting and destructive impact of complex trauma on adult life. The related condition is known as C-PTSD (Complex Post Traumatic Stress Disorder). Anyone interested in this topic should pick up the best-selling book The Body Keeps the Score by Bessel van der Kolk.

Complex trauma opens up another possible pathway between tinnitus and trauma–one similar to that proposed for the connection between tinnitus and traditional trauma. Let’s say, for example, that my parents belittled me constantly and that as a result I never felt myself competent in handling challenges. Instead, I was made to feel powerless in the face of adverse circumstances and carried this insecurity into my adult life. Hence, when I am faced with the challenge of responding to tinnitus, my sense of helplessness as a child reemerges and blocks my ability to adequately deal with it. As the authors of the EMDR studies propose, this would mean that to treat the tinnitus we would need to treat the trauma.

The implication of trauma in tinnitus distress is a possible explanation for why many people with tinnitus are not helped by traditional cognitive therapy. Certainly, the few studies done on this topic in no way demonstrate such a connection. But the fact that many with tinnitus are not helped by CBT should cause us to look for other explanations outlets and the corresponding therapeutic interventions they would entail.

References

Phillips JS, Erskine S, Moore T, Nunney I, Wright C. Eye movement desensitization and reprocessing as a treatment for tinnitus. Laryngoscope. 2019 Oct;129(10):2384-2390. doi: 10.1002/lary.27841. Epub 2019 Jan 28. PMID: 30693546.

Rikkert M, van Rood Y, de Roos C, Ratter J, van den Hout M. A trauma-focused approach for patients with tinnitus: the effectiveness of eye movement desensitization and reprocessing – a multicentre pilot trial. Eur J Psychotraumatol. 2018 Sep 11;9(1):1512248

Moore, Tal & Phillips, John & Erskine, Sally & Nunney, Ian. (2020). What Has EMDR Taught Us About the Psychological Characteristics of Tinnitus Patients?. Journal of EMDR Practice and Research. 14. 229-240. 10.1891/EMDR-D-19-00055.

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.

This is not so clear. Generally, if the insomnia is the result of another condition, say a medical condition like an overactive thyroid, or a psychological condition like anxiety, the recommendation is to treat the primary condition first. Since tinnitus-related insomnia is the result of tinnitus, it would seem to imply we should treat the tinnitus before attempting to utilize CBT-i? Besides the fact that this distinction between primary and secondary insomnia is itself controversial, it is not clear exactly what a treatment for tinnitus would look like. As the National Center for Rehabilitative Auditory Research reminds us: “Many people with bothersome tinnitus spend a lot of time and energy searching for a way to quiet or eliminate the tinnitus. Unfortunately, there currently is no therapy that can safely and consistently reduce the loudness of tinnitus.”

Logic, then, would dictate we’ve nothing to lose by applying CBT-i to tinnitus-related insomnia, since there is not agree upon treatment for the primary condition.  Yet surprisingly no study testing the effectiveness of this treatment on tinnitus related insomnia had been carried out until just a few years ago. Marks et al (2019) provided twenty-four tinnitus patients with six sessions of CBTi, supplementing it with some tinnitus-related elements such as a nighttime sound machine. The intervention achieved improvement across a range of well-established sleep outcomes, with 66.7% reporting reliable improvement on the ISI (insomnia severity index) post-treatment, sustained by 54.2% at follow-up. Patients in this evaluation also reported significantly lower tinnitus-related and psychological distress following treatment. This is pretty impressive.

I want to talk here in more detail about what exactly CBT-I since the Tinnitus Today articles did not describe the protocol in any detail. CBT-i is a qualitatively different intervention than CBT for tinnitus, as different, really, as physical therapy is from acupuncture, although that admittedly is not the best analogy. It is more accurate to say that CBT-I adds several processes that are not present in basic CBT. Indeed, the key component of CBT-i (the sleep diary) is not present at all in CBT for tinnitus. More importantly, CBT-i is an intervention that even more than CBT should be undertaken under the guidance of a therapist (and in consultation with one’s physician). With those caveats, I want to outline the intervention, explain some key concepts and provide some resources.

CBT-i is centered around the sleep diary.  In the sleep diary, you record such information as when you go to bed, when you try to get to sleep, how often you wake up and how long it takes you to get back to sleep. The sleep diary will be used to set your sleep schedule for the course of treatment and will be used to adjust that schedule as well. You will keep a sleep diary for the entirety of your therapy.

Basically, you start off limiting your time in bed each night to the amount of time that you are actually sleeping according to your first week’s sleep diary. Hence this aspect of CBT-i is called, quite fittingly, SLEEP RESTRICTION. So, for example, if you determine that although you are in bed for eight hours between time spent trying to fall asleep and getting back to sleep you are only sleeping for six hours out of the eight, you would limit yourself to six hours of sleep for the first week. You are also expected to wake up at the same time every day of the week (including weekends) for the entirety of your therapy. Hence, if your baseline is six hours of sleep a night, and you regularly get up at six, you would not go to bed until midnight. One caveat here is that the minimum time in bed is five hours.

With your sleep and wake time determined, you would continue to keep your sleep diary to determine your sleep schedule, adjusting it slightly up or down depending on how you are responding using a formula we don’t need to go into here. SLEEP RESTRICTION lays the groundwork for the second component of CBT-i: STIMULUS CONTROL. Here, think Pavlov’s dog. Remember how Pavlov ultimately conditioned his dogs to salivate at the sound of a bell?  Pavlov presented the stimulus of a bell each time he gave the dogs meat. Ultimately the dogs salivated at the very sound of the bell. This was the creation of a conditioned response. Essentially you are trying to do the same thing with your bed, only connecting your bed with sleep instead of a bell with salivation. Consider this. If Pavlov had rung a bell, blown a whistle, hummed a tune and tapped danced (I hear he was quite the hoofer) before giving the dog the meat, ringing the bell would not have elicited salivation. He had to specifically pair one stimulus with one response.  Just so, if you read, watch TV, do work reports, worry, and engage in social media while in bed, sleep will not be the conditioned response when you go to bed. In short, you want your bed associated with one and only one (well, actually two, but this is a family friendly newsletter).

There are five components of stimulus control, which are all designed to strengthen the association between bed and sleep. They are: (1) The bed is to be used only for sleep and sex, (2) you are to unwind for one hour before bed, (3) no bed until sleepy, (4) avoid naps, and (5) If you cannot sleep after 15 minutes, get out of the bed and do something relaxing until you feel tire.

The final and most crucial part of CBT-I is the COGNITIVE THERAPY. Cognitive therapy is premised on the claim that is not a situation that causes our emotional reaction but our thoughts about the situation. Hence when it comes to insomnia, the assumption is that you are not worried, stressed and anxious because you can’t get to sleep. You are worried stressed and anxious because of your thoughts about not getting sleep, and most of these are unbalanced and extreme.  In cognitive therapy as applied to insomnia, we examine the specific beliefs the person has about insomnia. We next look at how accurate or helpful a specific belief is. Finally, we attempt to come up with an alternate belief that can be more accurate/less harmful.

Someone who believes that their insomnia will destroy their health is asked to examine whether this assumption is in fact accurate or useful. The evidence certainly does not demonstrate a health link between periodic insomnia and negative health outcomes, while the belief is one that obviously not helpful. Someone who believes they cannot exercise if they did not sleep for eight hours likewise questioned about the validity of that claim. Is it that they cannot exercise, or that it is difficult to exercise? Have they ever had difficulty exercising when they had a good night’s sleep? Perhaps the bad night’s sleep is not the reason for difficulty exercising. And so on:

Some potentially unhelpful thoughts involve

• Unrealistic expectations about sleep
• Catastrophizing about the impact of a poor night’s sleep
• Erroneously blaming insomnia for all daytime problems
• Misattributions about causes of/control over insomnia
• Placing too much importance of sleep and intolerance for sleep loss

CBT-i is the most effective nonpharmacological treatment for chronic insomnia is cognitive-behavioral therapy for insomnia, producing  results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment. (Rossman). If this is something you might consider, you should find a therapist who is familiar not just with CBT but with this specific intervention.

References

Gu H, Kong W, Yin H, Zheng Y. Prevalence of sleep impairment in patients with tinnitus: a systematic review and single-arm meta-analysis. Eur Arch Otorhinolaryngol. 2022 May;279(5):2211-2221.

Marks E, McKenna L, Vogt F. Cognitive behavioural therapy for tinnitus-related insomnia: evaluating a new treatment approach. Int J Audiol. 2019 May;58(5):311-316

OKAJIMA, Isa, Yoko KOMADA, and Yuichi INOUE. “A Meta-analysis on the Treatment Effectiveness of Cognitive Behavioral Therapy for Primary Insomnia.” Sleep and Biological Rhythms 9.1 (2011): 24-34. Web.

Rossman J. Cognitive-Behavioral Therapy for Insomnia: An Effective and Underutilized Treatment for Insomnia. Am J Lifestyle Med. 2019 Aug 12;13(6):544-547.

The similarities between tinnitus and pain have long been noticed. Both are subjective sensations that may turn chronic, they are often accompanied by hypersensitivity in their respective sensory system, and overlapping brain changes have been observed. This neurobiological connection has been the basis of recent research.

In a 2015 article, Rauschecker et al proposed that tinnitus, or ringing in the ears, and chronic pain are the result of similar changes in two regions of the brain. These regions — the nucleus accumbens and the ventromedial prefrontal cortex — are both in the front of the brain, and may act as “gatekeepers” for sensory stimuli such as noise and pain, the researchers said. But in people with tinnitus or chronic pain, there’s something wrong with this “gatekeeping” system. That means that instead of your brain ignoring the signals, that information is able to get through. “If you step back, you can see the similarity” between the two conditions, Rauschecker said. In both tinnitus and chronic pain, the body sends signals to the brain that really don’t mean anything, he said. But these signals are not filtered out, as they normally would be.

Although at this point we are not able to engage the filtering mechanism for either condition, we do know that there is significant research demonstrating the ability of mindfulness to improve the quality of life of those living with chronic pain. In light of the neurobiological connection between the two phenomena, I believe many of these strategies can be applied to working with tinnitus. I have been delving into this issue recently and in October I will be taking a class through the University of Massachusetts Medical Center on Chronic Pain and Mindfulness. In the meantime, I have been reading You Are Not Your Pain: Using Mindfulness to Relieve Pain, Reduce Stress and Restore Well-Being by Vidyamala Burch. The book outlines how mindfulness can be used to work with chronic pain. I believe a lot of the advice can be applied as well to tinnitus distress. Three examples are below

Primary vs. Secondary Suffering

When it comes to chronic pain, Burch distinguishes between primary suffering and secondary suffering. The actual unpleasant sensations felt in the body is known as primary suffering. This is the raw data that is sent to the brain. By contrast, secondary suffering is made up of all the thought, feelings, emotions and memories associated with the pain. This might include anxiety, stress, worry, depression and feelings of hopelessness and exhaustion. The pain and distress you actually feel is a fusion of primary and secondary suffering. When it comes to tinnitus, the actual unpleasant sounds we hear constitute our primary suffering. Secondary suffering are all the thoughts and emotions we layer on top of this. Burch’s point is that primary suffering is inevitable. Whether it is chronic pain or tinnitus or heartbreak or cancer or the death of a loved one or a thousand different slings and arrows of life, pain in life (primary suffering) is inevitable. No one here gets out alive. Secondary suffering—the anxiety, stress, and worry we add to these events—is entirely optional. We endure secondary suffering by choice.

“If you have chronic health condition or suffer from stress, you cannot stop the triggering of unpleasant sensations,” states Burch. “But you can stop what happens next. You can stop the spiral of negative thoughts, feelings and emotions that drive the pain. It is possible to relate differently to your suffering. When you do so, you will find suffering (at least secondary suffering) evaporates.” This is the work of mindfulness and the same scenario can be applied to our tinnitus.

Doing vs. Being

In the book, Burch distinguishes between what she calls the “Doing” mode and the “Being” mode. The Doing mode is always trying to fix things, to solve problems. And in many things, this Doing mode is essential. As she writes, “It’s a fantastically powerful process that helps you solve countless different types of problems, from navigating across a city to arranging a hectic work schedule. In a more refined form, it’s how engineers design even more fuel-efficient cars and how doctors treat disease.” So when it comes to pain, the Doing mode tries to find a way for the pain to stop, which works fine except when it doesn’t, specifically when you are dealing with chronic pain. When it comes to chronic pain, the doing mode highlights the gap between where you are an where you want to be. And if where you want to be is pain free, then the doing mode is stumped. She writes: “You become fixated on the gap and are unable to escape, trapped like a rabbit in a car’s headlights. You end up torturing yourself with questions like : why does it hurst so much? What started it this time? Is it getting even worse? What have I done? Such open-ended questions increase anxiety, stress and depression…You end up thinking, It’ll get worse…I don’t know wat’s going on…Nobody knows what’s going on… my life will be ruined, maybe I’ll never get better.

If this doesn’t sound like a description of tinnitus, I don’t know what does. Thankfully, there is an alternative path, one which promises a much different outcome: the Being mode:

“The Being mode allows you to step back from your pain and suffering. It helps you break free of the tendency to overthink about your pain and suffering. It stops your thoughts from acting as a filter or a distorting lens and breaks the cycle that leads to anxiety, stress, depression—and ultimately more pain. It helps you to realize at the deepest of levels that you are not your pain.”

This is what Jon Kabat-Zinn describes as non-striving. It is an attitude that mindfulness inculcates in us and one that promises a different pathway to work with our tinnitus than struggling and fighting against it.

Blocking vs. Drowning

Burch distinguishes between two unpleasant states those in chronic pain find themselves in: Blocking and Drowning. The titles pretty much sum up the states. In blocking, one is devoting an enormous amount of energy to fighting the pain, while drowning consists of the sense of being overwhelmed by pain. These two states, which have obvious parallels with tinnitus, call for two different strategies.

In either situation, “the first thing to do is to notice what’s happening. Bring mindfulness, awareness to your experience and notice it.”

If you notice that you are blocking the pain (or tinnitus) “soften your breath. . . because if one is blocking one is generally contracting around the breath in some way. So soften the breath and turn towards your experience with this softer more kindly attitude. Say hello to the thing it is you’re running away from.”

If you notice you are drowning, “the practice is to broaden your perspective. So the image I use is like a lens on a camera. If you’re drowning it’s a bit like you zoomed on a close up lens. So you need to pull back to more of a wide angle lens on your experience, and maybe actively look in the moment for what’s pleasant. There’s always something pleasant. I’ve not yet found a single person who couldn’t find at least something, you know, one tiny thing that’s pleasant.”

She goes on to describe how when she was in the hospital after an operation that resulted in a serious infection, she tried practicing this: “I thought, ‘What’s pleasant in my experience right now?’ I noticed the crisp sheets that I was lying on, and I thought, ‘Well that’s pleasant! You know, I’ve got nice clean sheets on my bed.’ After that my experience changed.”

I would urge everyone with tinnitus to undertake a regular breath work practice. To begin, breathing practices can be useful in calming the body in a spike, when what is needed is to extricate the body from the pitched state of fight/flight the spike has thrown one into.  But his is not just about using a breathing technique when your tinnitus spikes. This is about an ongoing practice that will allow you to breathe slower, longer, and deeper on a regular basis and hence assist you in gaining control over your nervous system. The benefits and the mechanics of developing a regular breathwork practice are detailed in James Nestor’s best-selling book Breath: The New Science of a Lost Art, which I highly recommend to everyone. See also Anders Olsson’s website www.consciousbreathing.com (Olsson is featured in Nestor’s book).

Here are some practices you might find useful.

Paced breathing: Research (see Nestor’s book) suggests an ideal breath rate is about 5.5 breaths per minute, much slower than our normal breath. There are a variety of apps and YouTube videos that can guide you in breathing at this pace. This practice can be used as your daily meditation practice or as a stand along practice. A good basic app to start with is Breathe2Relax, which has a breath timer you can set to any rate. You can look up 5.5 breaths per minute” on Youtube and find numerous videos. Here is one of my favorites

The 4-7-8 technique: Andrew Weil’s Breathing: The Master Key to Self-Healing is a CD loaded with practices. One of his most popular practices is the 4-7-8 breathing technique, which is designed to induce calm in stressful situations. It involves breathing in for four, hold for seven and breathing out for eight. Here is a YouTube link to him demonstrating this technique

Box breathing:  Another popular practice is known as box breathing, where you breathe in for a count of four, hold your breath for four, exhale for four and then hold your breath again for a count of four. Again, doing a google search will yield a ton of information on this tactic.

Breathwalking: This is something I picked up from Andrew Weil’s newsletter. Breathwalking basically has you breathe in and out in a paced manner while walking.

Doral vagal breathing: Finally, while most breathing techniques are designed to extricate us from fight/flight Peter Levine has developed an exercise specifically designed to work with the shutdown/dorsal vagal state: https://www.nicabm.com/reducing-overwhelming-feelings-of-despair-with-peter-levine/

Put simply (and you probably need it put simply after that last paragraph) our nervous system is in one of three states: a sympathetic state of fight/flight, a dorsal shut down state, or a ventral state of connection. You can probably go through your day and identify examples of each. You sit and have breakfast with your wife before going off to work, savoring the quiet of the morning, the aroma of the coffee, and the shared intimacies of the conversation—a ventral vagal moment. On the road, the stress mounts as you find yourself stuck in a traffic jam and cut off by crazy drivers, causing your hands to clench the wheel and your heart rate to increase, a sure sign of fight or flight. At work, a backlog of tasks along with a notification of even more demands on your time push you precipitously close to a dorsal shut down state.

Actually, we enter different states of our nervous system not just a few times but probably hundreds of times a day. It is the psychological equivalent of touching your face in that most of the time we are unaware of the changes, which may be slight and subtle or deep and noticeable.  Importantly, the point is not to remain in the connected state of ventral vagal as much as possible and avoid the other two. This would not only be impossible but unadvisable, since there are times we require the sympathetic energy in order to rouse ourselves and times when the suppressing nature of the dorsal can be of use. Rather, the goal is to develop an elasticity, an ability to move between the states. This requires first that we identify where in our nervous system we currently are, which is why mindfulness is a useful adjunct to polyvagal work. Once we are able to recognize the state of our nervous system, we want to develop strategies to extricate ourselves from the sympathetic or dorsal states as well to increase our ability to linger in the ventral state.

There are some general strategies that can be recommended to anyone as a way to the goal of what we might call polyvagal flexibility. To take just one example: breathing exercises are a time-tested way to help extricate us from a sympathetic fight or flight state. By exhaling for longer than we inhale, we activate the parasympathetic nervous system, which can control and calm us when we are in a state of fight or flight. However, most of the ways we manipulate our nervous system will be specific to the individual. What works for me might not work for you, and what works for me in one situation might not work in another.  I might get out of a dorsal state by going to the gym, or meeting up with a friend, or taking a walk in nature; I might be able to remove myself from sympathetic by recalling a favorite passage from a spiritual work, diverting myself with a hobby, or when all else fails, counting to ten, while just stroking my wife’s skin or petting my dog’s hair may bring me to a ventral state. In fact, there exists a good deal of research on practices that enhance our ability to enter and remain in the state of ventral vagal. Many of these are dealt with in the area of positive psychology that we have already discussed.

By developing more and more strategies to extricate ourselves from sympathetic and dorsal and to remain in ventral, over time we begin to reshape our nervous system, spending less time in the states that often undermine our well-being (destructive sympathetic and dorsal) and more time in the state (ventral) that supports it. This is especially important for those with tinnitus because, as Polyvagal theorists remind us, story follows state. That is, the state that our nervous system determines the story we are telling ourselves: both about our lives in general and about our tinnitus in particular. Our tinnitus looks and feels very different to us when we are feel connected with others than it does when we are under the stress of fight and flight or in dorsal collapse.

Resources

Deb Dana is responsible for bringing the polyvagal theory into the therapy world. Although she has published several books intended for therapists, she recently released book aimed at teaching the principles of polyvagal theory to the general public. That book is called Anchored: How to Befriend Your Nervous System Using Polyvagal Theory.  You may also enjoy the book Breath: The New Science of a Lost Art by James Nestor.