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Is CBT for Tinnitus Overemphasized?

Tyler, Richard S. PhD; Mohr, Anne-Mette MA

doi: 10.1097/01.HJ.0000513099.64592.f5
Journal Club

Dr. Tyler, left, is a professor of Otolaryngology–Head and Neck Surgery and of Communication Sciences and Disorders at the University of Iowa. Ms. Mohr is a clinical psychologist based in Copenhagen, Denmark. She has been working with tinnitus patients since 1992, and specializes in existential psychotherapy.

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Cognitive Behavior Therapy (CBT) was introduced by Aaron Beck, MD, in the 1960s based on the notion that dysfunctional thinking plays a major role in people's problems (Beck. Guilford Press, 2011). CBT challenges negative thoughts through a structured process. It has been promoted for tinnitus for several years and adapted into current counseling programs, such as Tinnitus Activities Treatment (Sweetow. In: Tyler, ed. Singular Publishing, 2000; J Clin Psychol. 2004;60[2]:171 http://bit.ly/2ivODOk; Henry & Wilson. Allyn & Bacon, 2001; Prog Brain Res. 2007;166:425 http://bit.ly/2ivJw0D).

However, a recent article on CBT for depression concluded that the effectiveness of CBT had declined steadily since its introduction (Psychol Bull. 2015;141[4]:747 http://bit.ly/2ivR7w5). The authors said that “modern CBT clinical trials seemingly provided less relief from depressive symptoms as compared with the seminal trials.” They cited recent studies demonstrating that CBT is not superior to other techniques, and discussed online information available to those suffering from depression. The authors also suggested that the “ostensibly simple” objective of CBT—to change maladaptive cognitions—might have erroneously implied that CBT is easy for clinicians to learn, which, they argued, is not the case.

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LIMITATIONS OF CBT

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Beck recommended that clinicians should not deviate from the CBT manual. Proper training, practice, and competent supervision are critical to the clinician's ability to properly administer CBT. Alas, the patient must fit into the manual. However, not everyone can fit into the same schema; patients are different, often with complex situations. As a result, many clinicians have realized that CBT could not meet everybody's needs, and extended CBT to include additional protocols such as mindfulness, and acceptance and commitment therapy (ACT), which both evolved from CBT. These protocols basically train the patient to be in the present and accept what is there (tinnitus), instead of fighting it or fearing a future with tinnitus. Whatever the method, Johnsen and Friborg argued that there is a danger in addressing the symptom in isolation with the aim of curing the patient's suffering from it (Psychol Bull. 2015 http://bit.ly/2ivR7w5).

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SHIFTS IN PERSPECTIVE

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Another way of working with tinnitus is to view it as a symptom that does not stand alone but is connected with other parts of the patient's life (Mohr. In: Tyler, ed. Auricle Ink, 2016; Mohr & Hedelund. In: Tyler, ed. Thieme, 2006). Seen from this perspective, the aim of treatment will not be to change the person's emotional reactions to or thoughts about tinnitus like in CBT; rather, the goal is to explore tinnitus in terms of how the patient lives his or her life. Clinicians may ask these questions: What if tinnitus is pointing to something much bigger in the patients’ lives? What if tinnitus is the voice of something more complex? Are we letting our patients down if we only focus on curing the symptom and avoid exploring what is perhaps being expressed through the symptom?

Having worked with tinnitus patients for more than 22 years, it is our experience that when it comes to suffering, tinnitus often provides an entrance into a world where patients find themselves trapped by existential issues (e.g., trauma, grief, stress) due to limitations of what they can expect to get from life, choice, or death. When clinicians and patients explore ways to better navigate these issues and limitations instead of feeling trapped, the patient will begin to understand that there is more to tinnitus: It is not just an annoying sound, but something that points to issues that need to be understood and addressed in a different way. This process leads to change, even though this change was not the initial focus for treatment, but rather, exploration and understanding. The patient will begin to relate to tinnitus in a different way. Tinnitus will be increasingly perceived as a familiar sound instead of a sound connected to fear or anxiety, thus helping the patient stay on track of his or her new fruitful insights. As a result, many of our patients will say: “Even though I would never have wanted to suffer from tinnitus, I would otherwise not have had this experience. My understanding of myself, my life, and others has increased due to tinnitus, making my life a better place to be.” In the long run, the impact of tinnitus will be reduced and perceived only in stressful situations.

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ROLE OF THE THERAPIST

Rather than focusing on a special therapeutic method, what is important when working with tinnitus patients is the willingness of therapists to really listen to and understand patients, the way they hear and perceive themselves. This is done by asking questions that lead to a deeper understanding of why tinnitus is accompanied by so much suffering. Consequently, patients will feel that their therapists have a genuine interest in their situation. This enables the development of a trustworthy relationship between therapist and patient—a relationship that allows for exploration, not only of tinnitus, but also of other related and important issues in life. We find that focusing on a special therapeutic method—be it CBT or a strict tinnitus rehabilitation program—may pose the risk of moving the therapist away from forming this constructive relationship with the patient, and may even prevent the therapist from providing valuable insights. According to Scott D. Miller, PhD, founder of the International Center for Clinical Excellence, the therapist is nine to 10 times more important to the outcome of therapy than the method of choice (Psychotherapy [Chic]. 2013;50[1]:88 http://bit.ly/2iw5uAH).

Although CBT offers useful concepts, Johnsen and Friborg emphasized the critical importance of therapists in treating tinnitus patients. While providing a comprehensive tinnitus treatment program is important, clinicians also need to understand the importance of creating a safe and therapeutic relationship through which tinnitus can be explored as a symptom that is significantly connected with difficult issues in the patient's life.

Journal Club Highlight

The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Johnsen TJ & Friborg O. Psychol Bull. 2015;141(4):747.

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