Basic Mechanics of CBT for Tinnitus
Published by Debbie Featherstone in Discovering Series · 27 August 2019
It seems to me there is quite a lot of ambiguity out there about the difference between having tinnitus and being distressed by it, even though the difference has been clear for many years now in the research carried out in terms of prevalence of tinnitus.
There is a high prevalence of tinnitus (around 1 in 10 of the population); however, 85% of those 1 in 10 habituate (get used to) and as a consequence, are not greatly distressed by having tinnitus. There are relatively simple indicators - the validated tinnitus distress questionnaires such as the Tinnitus Functional Index, the Tinnitus Handicap Inventory along with several others - that can be used to identify levels of tinnitus distress, so there are clear mechanisms to identify tinnitus distress and the lack of distress.
Taking myself as an example here, I have had tinnitus since 1993 and I most definitely include myself in the 85%. I am not distressed by it, lucky for me I never was; in my opinion, it's because I knew what it was when it began. It's true I would sooner not have it! But it is equally true that I’m not distressed by it. The key in my own case is “I knew what it was”.
"I knew what it was" - five little words with so much power, they made the difference to me between being distressed about it or not. Having “it” held no implications for me, and for that, I am eternally grateful!
What ever happens to us in life, what ever situation, what ever circumstance, has “implied meaning” to us. That implied meaning originates from what we believe we know and our understanding of it, including when that understanding is unknowingly faulty, skewed, learned from others, from what we read about or are told by others.
It’s the “implied meaning” and subsequent imaginings that cause us to react to any given circumstance.
Let's take an everyday example of what I mean by "implied meaning":
You are expecting a call from a friend to make arrangements to meet up. But she doesn't call. You wait a few days, a week, and still there is no call. What do you do? Forget about it? Highly unlikely! What might go through your mind (ruminating/implied meaning)?
- I wonder what's happened?
- Is she ill? Has something happened to her?
- She must be ill.... or..
- What if I've done something to upset her?
- I'm sure I haven't... but why hasn't she called?
- She obviously doesn't want to meet up - I wish she'd just say so
- I'm not going to call her - I remember she made a point of saying SHE would call ME
- I bet that's because she didn't want to hear from me
- Well, she should have just said so - I don't care!
There could be a thousand and one thoughts (implied meanings) to have had! One leading to another.... imaginings with meanings, most - if not all - with no truth in them. They are ruminations, imaginings, but the emotions we experience as we are having them are very real indeed. From minor upset to anger and bitterness.
Wouldn't it have been easier to have picked up the phone and just called her? Chances are, she'd answer and apologise profusely because she forgot to call!
These implied meanings come about through using COGNITIVE DISTORTIONS (distorted thinking/understanding). They ALWAYS make us feel "bad" in some way through triggering emotions that make us feel uncomfortable and unhappy.
Earlier, I explained that I am one of the 85% of people who have tinnitus. It doesn't cause me "distress", I only hear it when my attention goes to it and when I hear it, I will usually notice whether it's loud or maybe not so loud. But it has little to no meaning to me - I "know" it's there and I also "know" there's no pill that will take it away - no matter how much I may WISH there was.... although my thoughts/ruminations don't go down the route of "wishing" because I KNOW there isn't! I have been lucky enough never to have formed a HABIT of thinking negatively about tinnitus. Because I never formed the HABIT, there was no HABIT to grow in to a COMPULSION (stronger than a habit)
This is not the case for the 15% who remain non-habituated! They - for whatever reason - never did "get used to having tinnitus" or to "tinnitus being there".
Provided all pathologies have been ruled out (done through a medic - usually ENT), where tinnitus distress is present, it is ruminations (implied meanings) that are responsible for "distress" (emotional reaction). The Tinnitus Cognitions Questionnaire can help you identify some of yours, and here are just 4 of the (hundreds if not thousands) implied meanings people have that become habitual - if not compelling:
- I can't get away from this awful noise
- I hate it because it's ruined my life
- No one understands how bad it is
- I will always feel like this
Each one of them have Cognitive Distortions behind them. For example:
"I can't get away from this awful noise"
Cognitive distortions: Magnifying the negative, Minimising the positive, Catastrophising
Rationally, it could be replaced by "I keep thinking about the noise and reacting to it - there are times, albeit only short periods, when I think about other things"
"I hate it because it's ruined my life"
Cognitive distortions: All or nothing thinking, Emotional reasoning
Rationally, it could be replaced by "I do other things - I have family/friends. Experiencing tinnitus has spoiled my enjoyment of some activities, but I do still have a life and people who are important to me"
"No one understands how bad it is"
Cognitive distortions: Jumping to conclusions, Mindreading, Labelling, Other-blaming
Rationally, it could be replaced by "No one else can hear my tinnitus so they aren't going to know what it sounds like to me. There are times when it seems worse than others"
"I will always feel like this"
Cognitive distortions: Predicting the future, Magnification of the negative, Catastrophising
Rationally, it could be replaced by "I am assuming I will always feel the same as I do at my worst and I am at my worst at the moment. I don't know how I will feel in the future because no one can predict the future - including me! Because there are times that feel worse, that is a good indicator that there MUST be times when I am not feeling as bad"
It is by identifying and then challenging the habitual ruminations (implied meanings) that enables us to change how we feel, therefore bringing about a change in how we behave - we grow better, more rational HABITS of thinking.
CBT for Tinnitus Distress
My work is with people struggling with tinnitus distress. More than 50% of those I work with have severe or very severe tinnitus distress, and very often anxiety and/or depression too. NONE OF THEM ONLY HAVE TINNITUS. None of them are like I was back in 1993 or since, although they do get there. They DO reach that "place" in their minds where tinnitus is there when they give their attention to it; but because they don't care about it - because they no longer live with the "implied meanings" they used to have, there is little in the way of tinnitus distress any more. Some examples are on other websites here and here, with some typical Outcomes here.
This is precisely what CBT (Cognitive Behavioural Therapy) for Tinnitus is for: To develop understanding of Implied Meaning and the Cognitive Distortion mechanism in order to achieve the breaking of old patterns of behaviour (habits) and as a result, eliminate distress.
Please note: The website www.tinnitusmanagement.com is currently being updated