Online Tech Topic | October 2020 Hearing Review

Update, June 2021: This program is no longer free of charge. Please see https://icbt4tinnitus.com for details.

By Hashir Aazh

ICBT for Tinnitus (internet-based cognitive behavioral therapy) is designed for those who experience bothersome tinnitus and wish to learn how to manage the distress caused by their tinnitus using the techniques of CBT. This program of iCBT for tinnitus has been authored by Dr Hashir Aazh (audiologist, specialist in tinnitus rehabilitation at the Royal Surrey County Hospital) in collaboration with Dr Brian CJ Moore (emeritus professor of auditory perception in the University of Cambridge, Department of Psychology) and Dr Fiona Seaman-Thornton (clinical psychologist at the Royal Surrey County Hospital). 

Audiologists may choose to use this as a complementary intervention to their services for tinnitus patients or perhaps offer it to patients as a stand-alone treatment approach if no other intervention is needed. This program is as the result of collaborative work between audiologists, hearing scientists, and clinical psychologists and comprises seven free online modules as described below:  

Module 1: Assessment and 4C 

After completing the assessment module a report will be developed automatically and will be sent to the user’s email address. The report will include recommendations for further medical evaluations and/or psychological support (if indicated). In addition to routine questions about tinnitus and medical and mental health, this module includes a unique method of therapeutic assessment in which it sets out the direction for the therapy, building on the progress the individual has already made in coping with their tinnitus and identifying room for improvements.

Module 2: Introduction to CBT for Tinnitus 

In this module patients learn about CBT and its relevance to tinnitus distress. They will be able to create a CBT model explaining their own experience of tinnitus distress, which can guide them in finding the way forward in tinnitus management.      

Module 3: Behavioral Experiment for Tinnitus

A behavioral experiment helps to test the validity of their negative predictions/thoughts about tinnitus and the helpfulness of their responses to these thoughts. This module provides an opportunity to explore and challenge tinnitus-related negative thoughts by testing out different behaviors, influencing any corresponding anxiety and negative emotions that they might be experiencing.

Module 4: Challenge Your Negative Thoughts

In this module the patient learns about the mechanism by which tinnitus perception can lead to distress based on the levels of cognitions (ie, automatic thoughts, rules of life, and core beliefs). They will learn about common forms of cognitive distortions and develop the skills to identify errors of judgment in their own tinnitus-related perceptions. 

Module 5: Diary of Thoughts and Feelings (DTF)

This module provides a structured method to record tinnitus-related problems, and their associated thoughts and emotions. This can be a helpful tool to draw together the different techniques that they have learned to identify and challenge negative automatic thoughts and counter them with counter-statements.

Module 6: Positive Psychology in Tinnitus Management

The aim of this module is to help the patient to develop acceptance toward the experience of tinnitus. It may be hard to accept tinnitus, as there is nothing nice about it. The idea of this module is to use the power of positive psychology in generating optimism, which is important for improving mental health.

Module 7: Final Assessment and 4C 

The final assessment module helps to: (1) Establish the progress the patient has made in tinnitus management, (2) Enhance their confidence and motivation in using CBT skills for tinnitus management, and, (3) Evaluate the usefulness of iCBT for your local patient population.     

Key Advantages of This iCBT for Tinnitus Program 

CBT Fine-tuned for Tinnitus Distress 

One advantage of this program is that the CBT methods introduced here are fine-tuned in order to address issues which are specific to tinnitus distress and not to general anxiety or mood disorders. The assessment module automatically guides the patient in the direction of mental health services if they present with symptoms of anxiety and/or depression. This specialized method of CBT has shown to be very acceptable and effective from patients’ perspectives when received in face-to-face clinics from trained audiologists as reported in a trilogy of original articles published in the International Journal of Audiology and the American Journal of Audiology.1-3 Reflecting on real clinical scenarios of delivering CBT for tinnitus management in audiology clinics and research findings, Dr Aazh and his team developed this iCBT self-help program. 

Introducing New Concepts in Tinnitus Management in Addition to the CBT Methods 

In addition to the application of specialized methods of CBT for tinnitus, this iCBT program benefits from implementing a unique method of therapeutic assessment building on the progress the individual has already made in coping with their tinnitus. This method has been designed based on the principles of motivational psychotherapy, psycholinguistics, and behavioral change theories.5,6 This method is entitled 4C as it explores 4 aspects of your confidence in managing tinnitus. Unlike other commonly used tinnitus questionnaires, the 4C explore how confident the person is in managing their tinnitus as opposed to simply checking which aspects of their life are affected by tinnitus. The 4C sets out to evaluate and simultaneously enhance their confidence in managing tinnitus by encouraging them to think about various aspects of tinnitus management. 

Another new concept used here is the application of positive psychology methods in tinnitus management. Positive psychology in this context helps the patient to remind themselves of their strengths and what they are doing well instead of focusing more on negative experiences, discounting positive experiences, and overgeneralizing negative thoughts in relation to self, others, and the future.4 The aim of positive psychology is to try to find a more realistic, balanced perspective. Research studies have shown that realistic optimism is one of the qualities that makes people resilient. Resilience is a critical factor that can help the individual in developing acceptance towards tinnitus.   

Conclusions

This iCBT for tinnitus is a free therapeutic tool which audiologists may choose to use as a complementary intervention to their services or to offer it to patients as a standalone treatment approach. The modules comprise: (1) Assessment and 4C, (2) Introduction to CBT for tinnitus, (3) Behavioral Experiment for Tinnitus, (4) Challenge Your Negative Thoughts, (5) Diary of Thoughts and Feelings, (6) Positive psychology in Tinnitus Management, and (7) Final Assessment and 4C.  

Often patients may be reluctant to enroll in a general CBT program, believing that their problems are related to the auditory system rather than being psychological in nature. 

Unlike general CBT programs, the methods introduced here are fine-tuned in order to address the issues which are specific to tinnitus distress. Therefore tinnitus patients find this approach very acceptable and relevant to their experience of tinnitus. 

In addition to the application of specialized methods of CBT for tinnitus, this iCBT program benefits from implementing new concepts in tinnitus management comprising: 4C assessment method and positive psychology for tinnitus management.   

Free iCBT for tinnitus is accessible via: www.icbt4tinnitus.com.

Over the last 15 years, Dr Hashir Aazh has developed and managed several NHS tinnitus and hyperacusis services in London and Surrey. He has written over 30 scientific papers in the field of audiology and, in 2009, he was awarded the Jos Millar Shield Award from the British Society of Audiology (BSA). Hashir is an affiliate assistant professor in the Department of Communication Sciences and Disorders at Florida Atlantic University and is the course director for the tinnitus and hyperacusis therapy master classes at Guildford, UK; Zurich, Switzerland; Amsterdam, Netherlands; and Copenhagen, Denmark. Additionally, he is the research and development lead in the audiology department of Royal Surrey County Hospital; his current studies focus on tinnitus, hyperacusis, and misophonia. He recently organized a specialist training course for audiologists, otolaryngologists, psychiatrists, and psychologists in Melbourne, Australia on tinnitus and hyperacusis rehabilitation. Hashir is an Associate Editor for the International Journal of Audiology, Guest Editor of Noise & Health, and reviewer for The Laryngoscope, Psychosomatics, The BMJ, and The New England Journal of Medicine. 

Correspondence can be addressed to: Dr Hashir Aazh BSc, MSc, PhD; Hashir Clinic for Tinnitus, Hyperacusis and Misophonia, 1 Farnham Road, Guildford, Surrey, GU2 4RG, UK; Telephone: (+44)1483 362622; Email: [email protected].

References 

  1. Aazh H, Bryant C, Moore BCJ. Patients’ perspectives about the acceptability and effectiveness of audiologist-delivered cognitive behavioral therapy for tinnitus and/or hyperacusis rehabilitation. American Journal of Audiology. 2019;28(4):973-985.
  2. Aazh H, Moore BCJ. Effectiveness of audiologist-delivered cognitive behavioral therapy for tinnitus and hyperacusis rehabilitation: Outcomes for patients treated in routine practice  American Journal of Audiology. 2018;27(4):547-558.
  3. Aazh H, Moore BCJ. Proportion and characteristics of patients who were offered, enrolled in and completed audiologist-delivered cognitive behavioural therapy for tinnitus and hyperacusis rehabilitation in a specialist UK clinic. International Journal of Audiology. 2018;57(6):415-425
  4. Duckworth AL, Steen TA, Seligman MEP. Positive psychology in clinical practice. Annu Rev Clin Psychol. 2005;1:629-651.
  5. Michie S, Van Stralen MM, West R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(42).
  6. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527-537.