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Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists

Henry, James A.1,2; Goodworth, Marie-Christine1,3; Lima, Elizabeth4; Zaugg, Tara1; Thielman, Emily J.1

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doi: 10.1097/AUD.0000000000001150
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Abstract

INTRODUCTION

Tinnitus is experienced by 10 to 15% of adults world-wide (Baguley et al. 2013; Henry et al. 2020). For about 20% of those who experience tinnitus, clinical services are indicated to mitigate its functional and emotional effects (Tunkel et al. 2014).

The American Academy of Otolaryngology-Head & Neck Surgery Foundation (AAO-HNSF) conducted a systematic review of the literature relating to providing clinical care for tinnitus. Based on their review, they published a clinical practice guideline (CPG) for tinnitus management (Tunkel et al. 2014). The CPG noted that tinnitus is usually a permanent condition and that there is no cure to eliminate or even reduce the sensation of tinnitus. Providing clinical care for tinnitus therefore centers around reducing the functional and emotional effects of tinnitus, which broadly include sleep disruption, concentration difficulties, and emotional reactions. The only intervention recommended by the AAO-HNSF was Cognitive Behavioral Therapy (CBT).

In addition to the AAO-HNSF CPG, four separate CPGs on tinnitus were published in Europe; those guidelines, together with the AAO-HNSF guideline, were summarized by Fuller et al. (2017) and by Cima et al. (2019). These summaries concluded that the consensus across the five CPGs was that CBT had the strongest evidence for tinnitus intervention and was the only method recommended for this purpose.

Other systematic reviews support the premise that CBT is an effective and appropriate method of providing clinical care for tinnitus. Based on at least a dozen tinnitus-intervention systematic reviews conducted by the Cochrane Collaboration, the only intervention for tinnitus judged effective was CBT. The most recent Cochrane review (Fuller et al. 2020) included a total of 28 studies published up to November 2019 in its qualitative synthesis. This review also used the newer Cochrane standards for the conduct of intervention reviews (Higgins et al. 2016; Higgins et al. 2013). Fuller et al. concluded, “the conclusions are consistent in that CBT appears to be superior to other control conditions for alleviating the impact of tinnitus on quality of life” (p. 40).

In spite of the consistency of conclusions across guidelines, a recent survey of 625 clinicians and policy-makers from 24 European countries revealed extensive differences in tinnitus clinical care both within and between countries (Cima et al. 2020). This finding is likely representative of how tinnitus services are nonuniform in countries around the world.

Many behavioral health providers (a.k.a. mental health providers, e.g., clinical psychologists, clinical social workers, professional counselors, advanced nurse practitioners, psychiatrists) have expertise in CBT, but very few are trained in applying CBT to tinnitus (Schmidt et al. 2018). One option for filling this gap in availability of CBT for tinnitus is to train non-behavioral health providers in this method. Audiologists are typically the primary point of contact for individuals who seek clinical services for tinnitus. Some have argued that audiologists can provide CBT for tinnitus, while others have argued that CBT is outside of their scope of practice. We will attempt to provide a balanced perspective regarding this controversy. Two of the present authors (J. A. H. and T. Z.) are audiologists who have conducted tinnitus research together for over 20 years, and are co-developers of Progressive Tinnitus Management (PTM). Author T. Z. has collaboratively provided care for tinnitus with research and clinical psychologists in clinical and research settings. Author E. J. T. is a statistician who has worked with authors J. A. H. and T. Z. for 12 years, including on two clinical trials of PTM. Authors M.-C. G. and E. L. are clinical psychologists who have considerable experience performing CBT for tinnitus, both in the clinic and for research.

The delivery of CBT by non-behavioral health providers is not without precedent. Studies of guided internet-based CBT have shown outcomes equivalent to treatment provided by behavioral health providers: (1) for treatment of panic disorder, general practitioners who received specialist training in CBT obtained results comparable to those obtained by psychologists (Shandley et al. 2008); (2) social anxiety disorder was treated as effectively when psychology students provided support versus licensed psychologists (Andersson et al. 2012); and (3) both clinician- and technician-assisted CBT were effective in the treatment of depression (Titov et al. 2010) and generalized anxiety disorder (Robinson et al. 2010). It therefore appears that guided internet-based CBT by non-behavioral health providers has the potential to greatly increase access to CBT by individuals seeking intervention for bothersome tinnitus.

The following sections describe how CBT is used in the management of tinnitus, pros and cons of audiologists administering CBT for tinnitus, internet-based CBT for tinnitus, clinical application of CBT, and recommendations based on the above.

CBT ADAPTED TO TINNITUS MANAGEMENT

The application of CBT for tinnitus was modeled after CBT as utilized for pain, anxiety, depression, and insomnia (Bandura 2004; Henry & Wilson 2001; Martinez-Devesa et al. 2010). The overall objectives of CBT for tinnitus are to (1) promote reconceptualization of the tinnitus problem as one that is manageable and (2) teach and encourage the use of specific coping strategies to establish perceptions of self-efficacy and self-control regarding tinnitus (Schmidt et al. 2017). CBT involves numerous distinct therapeutic components, though there is no consensus as to which components are most efficacious for tinnitus (Cima et al. 2014). Typical CBT-for-tinnitus protocols include applied relaxation, behavioral activation, and cognitive restructuring along with psychoeducation regarding health, sleep hygiene, and the auditory system (Andersson 2002; Cima et al. 2014; McKenna et al. 2020; Schmidt et al. 2018). These components and adhering to the standard CBT structure are shared characteristics of most robust clinical trials (Fuller et al. 2020). Recent adaptations to third-wave CBT components, including cognitive flexibility, acceptance, and values-based care also appear to be beneficial for patients. CBT in general is clinically implemented using a variety of formats: group or individual sessions, different frequencies and length of sessions, and conducting sessions in-person versus delivery via telehealth or internet (Schmidt et al. 2017).

Numerous trials involving the use of CBT for tinnitus have been conducted, all of which involved behavioral health providers delivering the intervention (Cima et al. 2014). The first of these trials was a small randomized controlled trial (RCT) (Scott et al. 1985) that was most likely the first RCT evaluating psychological methods of treatment for tinnitus (Cima et al. 2014). Cima et al. reviewed the CBT trials that had been conducted during the previous three decades and concluded, “Based on the evidence described at present, we suggest that a CBT-based approach, whether in groups or individually, is the most evidence-based choice for effectively relieving tinnitus complaints so far” (p. 38). Aazh et al. (2019) conducted a more recent review of CBT-for-tinnitus trials and concluded, “the meta-analyses and studies reviewed above all indicate that CBT is effective in alleviating the distress caused by tinnitus (p. 997). These conclusions are also consistent with the 2020 Cochrane review referenced above (Fuller et al. 2020).

ARGUMENTS IN SUPPORT OF AUDIOLOGISTS PERFORMING CBT FOR TINNITUS

First Use of CBT for Tinnitus

CBT has been applied to tinnitus since the 1980s (Hallam et al. 1988; Scott et al. 1985). Notably, one of the first people to publish on the use of CBT for tinnitus was audiologist R. Sweetow (Sweetow 1985,1986). He argued that CBT “can be effectively administered by audiologists” (Sweetow 1986) (p. 390). He described the tinnitus program practiced in his clinic that utilized CBT, which was preferentially administered in group settings. His version of CBT was to “identify maladaptive behaviors and thought patterns associated with tinnitus which are subject to modification, and then the systematic, measurable implementation of strategies designed to alter them” (p. 390). While these objectives are consistent with CBT, they would be considered a subset of components that are normally included in a full CBT program offered by a behavioral health provider. Further, his clinic incorporated a multidisciplinary model, which, depending on the patient, included biofeedback, ear-level sound generators (“tinnitus maskers”), and hearing aids. Sweetow reported that, “Of over 100 patients treated with the above program, 78% have reported themselves to be ‘significantly’ improved in their ability to handle their tinnitus (p. 394).

CBT As a Mind-Body Therapy

Some skills that are part of CBT overlap with other fields such as mind-body medicine, which involves practitioners in multiple fields, not limited to behavioral health. In fact, in many studies, examining the application of mind-body practices to medical conditions, CBT is listed as an example of a mind-body therapy (Astin et al. 2003). Therefore, some of the CBT skills in tinnitus management might not require such restrictions and protection of scopes of practice. For example, the argument that teaching relaxation requires understanding the scientific underpinnings of the CBT methodology is not easily supported. However, other skills, such as cognitive restructuring, do require such a level of competence.

Studies of Audiologists Performing CBT

To our knowledge, the only studies that have addressed the question of whether audiologists can perform CBT for tinnitus were conducted in the United Kingdom. This question has been of particular interest in that country as evidenced by the British Tinnitus Association listing audiologist-delivered CBT for tinnitus (and hyperacusis) as being one of the top 10 tinnitus research priorities (Hall et al. 2013).

Aazh and Moore (2018) pointed out numerous practical problems impeding the delivery of mental/behavioral health services to patients with tinnitus. These United Kingdom investigators suggested a potential solution is for these services to be delivered by audiologists. They noted that, although audiologists in the United Kingdom had increasingly been delivering CBT to their patients with tinnitus, no studies had been conducted on audiologist-delivered CBT. The authors had their own clinic where audiologists were conducting CBT for tinnitus, and they reported preliminary data. Each of the audiologists attended a specialized class that taught: (1) audiologic and psychologic assessment of both tinnitus and hyperacusis; (2) client-centered therapy as derived from Rogers (1965); (3) CBT methodology adapted to the treatment of tinnitus and hyperacusis; and (4) motivational interviewing skills. Completing the course involved 30 hours of direct contact, 100 hours of reading recommended materials, and 20 hours of reading relevant materials, participating in an online discussion forum, and “reflective practice.” Following the course, each audiologist received 6 months of supervised observation of CBT delivery to patients. Ancillary training involved continuing education classes and conferences as well as weekly meetings. A retrospective analysis was conducted with 68 consecutive patients in their clinic who received CBT delivered by audiologists. All of their measures showed significant improvements following the intervention, with medium (≥0.50) to large (≥0.80) effect sizes (Cohen 1988). In spite of these positive results, the authors noted that the study was uncontrolled and therefore difficult to assess the extent to which the improvement was due to the CBT versus a placebo effect.

Internet-Based CBT With Support From Audiologists

Another group evaluated the use of 8 weeks of internet-based CBT to provide tinnitus intervention with guidance and support from audiologists (i.e., a self-paced, patient-driven, internet-based CBT protocol with audiologist support) (Beukes et al. 2018). Throughout the study, the audiologists providing the support to the participants were supervised by a clinical psychologist who specialized in interventions for tinnitus. This study was an RCT with a control group that performed weekly monitoring. Results showed significant improvement for the internet-based CBT group with respect to the Tinnitus Functional Index (Meikle et al. 2012) as well as measures of different comorbidities. These effects were sustained for 2 months postintervention. A follow-up study was conducted to investigate the long-term outcomes from this group 12 months following the end of the internet-based CBT, which showed sustained benefits (Beukes et al. 2018).

A book was very recently published that describes guidelines for the clinical implementation of CBT to patients with bothersome tinnitus (Beukes et al. 2021). It is noteworthy that the book is directed to audiologists and not to behavioral health providers. In the book’s foreword it is stated, “Psychologists are the licensed professionals most equipped to provide CBT; unfortunately, though, most psychologists do not routinely see patients specifically requesting tinnitus management, particularly those lacking a concurrent mental health diagnosis. …although audiologists routinely employ tenets of CBT in their rehabilitative endeavors, most would consider formal CBT to be outside an audiologist’s scope of practice. …The question is not ‘Should audiologists perform CBT for their tinnitus patients?’ but rather ‘Can audiologists refer patients, administer, and support patient matriculation through a self-paced ICBT [Internet-delivered CBT] protocol that addresses clinical management of bothersome tinnitus?’ As the authors’ work demonstrates, the answer, thankfully, is ‘yes’” (pp vii-viii). Although the foreword indicates that the authors of this book are not promoting audiologists delivering CBT themselves, but rather supporting patients through an internet-based CBT protocol, the book itself provides a how-to manual of sorts for audiologists to provide CBT for tinnitus, not limited to internet-based CBT.

The book’s authors explained that access to CBT for tinnitus is a major concern around the world (Beukes et al. 2021). They noted that a large epidemiologic study (Bhatt et al. 2016) found that medications, which have the weakest evidence-base for improving quality of life with tinnitus, are the most recommended form of therapy, while CBT, which has the strongest evidence-base, is the least recommended form of therapy (Beukes et al. 2021). This paradox may indeed be due to a shortage of behavioral health professionals who have expertise in both CBT and providing clinical care for tinnitus. This sets the stage for the book’s authors to justify their view that access to CBT for tinnitus could be improved if delivered by audiologists. Audiologists typically receive limited training in tinnitus management during their graduate training, although many audiologists provide structured tinnitus management through the help of manuals to guide their program (Henry et al. 2007a,2007b; Henry et al. 2010a,2010b). The authors further stated that, by delivering CBT, audiologists would increase patients’ access to CBT for tinnitus intervention, and that there was the need for a manual to guide audiologists in providing this service. The authors concluded, “materials presented in this book will help audiologists to facilitate habituation in their tinnitus patients using evidence-based CBT techniques” (p. 24).

Summary: Arguments Supporting Audiologists Performing CBT for Tinnitus

To briefly summarize arguments for audiologists performing CBT for tinnitus management: (1) whereas CBT has the strongest research evidence for tinnitus intervention, very few behavioral health providers are available to provide CBT for tinnitus (Schmidt et al. 2018). Therefore, audiologists could increase access to CBT for tinnitus to people who otherwise would be unable to access it. (2) Clinical audiologists have been reported to conduct CBT with beneficial results (Sweetow 1986; Aazh & Moore 2018). (3) Internet-based CBT for tinnitus supported by audiologists has been shown to be efficacious (Beukes, Allen, et al., 2018). (4) Materials have been developed for audiologists to support internet-based CBT for tinnitus (Beukes et al. 2021).

ARGUMENTS AGAINST AUDIOLOGISTS PERFORMING CBT FOR TINNITUS

As reviewed below, issues that argue against audiologists performing CBT pertain to scope of practice, the patient-provider therapeutic relationship, foundational and functional competencies to perform CBT, and mental health comorbidities.

Scope of Practice for CBT As a Psychotherapy

Certain foundational competencies are considered key to conducting CBT. These competencies apply to all forms of psychotherapy, of which CBT is one form. Competency in conducting CBT requires practitioners who understand the scientific underpinnings of the methodology (Clark et al. 1999). They further stay up-to-date with respect to the CBT literature (Newman 2010). These are providers who are licensed to perform psychotherapy.

Licensing and credentialing requirements for psychotherapists vary by state (in the United States) and by country. Most generally, training to become a psychotherapist requires specific higher education to learn theory and obtain clinical experience. Fully licensed psychotherapists have received thousands of hours of practice and supervised experience. They are also required to complete continuing education to maintain their license. This degree of training and experience would not be attained by audiologists—a point that is underscored by McFerran and Baguley (2009) who stated, “The studies that have been published on the efficacy of CBT in the treatment of tinnitus have been undertaken by psychologists with an international reputation for managing this condition. It seems extremely optimistic to imagine that audiologists with a fraction of a psychologist’s training will be able to achieve comparable results” (p. 100).

Patient-Provider Therapeutic Relationship

One issue of critical importance to CBT is the therapeutic relationship between provider and patient (Gilbert & Leahy 2007). The importance of this relationship has been increasingly recognized for psychotherapy and its role in determining outcomes (Catty et al. 2007). Potentially impacting this relationship is cultural competency, a skill that is increasingly being recognized as critical for administering CBT (Tseng & Streltzer 2004). It is well documented that cultural factors can affect the quality of, and patient satisfaction with, health care, and ultimately impact treatment outcomes (Flores 2000). Cultural competency is meaningfully distinguished from competency in general, and counseling psychologists have advocated for multicultural guidelines since the 1970s (Sue et al. 2009). Cultural competency practices have become widely adopted within the mental health field.

Foundational and Functional Competencies

Attaining and maintaining psychotherapeutic competency, both foundational and functional, is a core value for behavioral health providers (Newman 2010). Foundational competencies for conducting CBT include understanding the foundations of cognitive theory of psychological disorders, being familiar with studies on CBT methods and outcomes, and staying up-to-date concerning new studies and developments on related concepts.

Functional competencies for CBT most broadly have to do with “the ability to structure sessions, teach clients to perform rational reevaluations exercises, conceptualize cases in terms of dysfunctional beliefs and behavioral patterns, and assign and review homework assignments that help clients learn durable self-help skills” (Newman 2010) (pp. 12-13). Core techniques must be practiced and mastered to effectively teach them to their patients. The inexperienced CBT therapist may prioritize achieving short-term benefits by focusing on supporting the client in feeling better, while avoiding the rigorous activities that are required for CBT to attain long-term benefits. In essence, CBT can be “watered down” if the therapist does not have functional competency to teach the more challenging activities of CBT.

Conditions of Patients Requiring Expertise of Behavioral Health Providers

Conditions under which audiologists should not be providing CBT for their patients with tinnitus include: current untreated mental health comorbidities, significant history of mental illness, suicidal ideation or behavior in the last year, active substance abuse, and multiple psycho-social stressors (e.g., lack of social support and/or unstable conflictual relationships, unstable housing or employment, complicated bereavement, etc.). Each of these mental health conditions is clearly beyond the scope of practice for audiologists and requires attention from a behavioral health provider.

Summary: Arguments Against Audiologists Performing CBT for Tinnitus

To summarize arguments against audiologists performing CBT for tinnitus management: (1) Audiologists do not normally receive training to acquire the foundational and functional competencies that are essential to conduct CBT. (2) Only behavioral health providers receive training in methods of psychotherapy and are licensed and credentialed to perform psychotherapy, of which CBT is one form. (3) The patient-provider therapeutic relationship is not cultivated by audiologists to the degree that it is by behavioral health providers. (4) Audiologists are not trained to identify or manage mental health conditions, or problems with sleep that are commonly comorbid with bothersome tinnitus.

DISCUSSION

Considering all methods used for tinnitus intervention, CBT unequivocally has the strongest support in the scientific literature (Fuller et al. 2020; Fuller et al. 2017; Tunkel et al. 2014). Unfortunately, a relative paucity of behavioral health providers are available to serve as practitioners to deliver CBT as an intervention for bothersome tinnitus (Aazh & Moore 2018). This paradoxical situation means the majority of people with bothersome tinnitus do not have access to the most evidence-based form of tinnitus intervention. This gap in clinical care could be overcome if a sufficient number of behavioral health providers skilled in providing CBT for tinnitus were to become available, which is unlikely to occur any time soon. It is therefore imperative to increase access to effective tinnitus intervention.

CBT can be delivered via a number of different modalities. Traditionally, face-to-face counseling is delivered in person on an individualized basis or in groups of patients. Because of the general lack of availability of providers who have expertise in CBT for tinnitus intervention, alternative delivery modalities have been developed and investigated. One modality is the use of CBT self-help manuals, which have been shown to be less effective than in-person CBT (Andersson & Lyttkens 1999; Fuller et al. 2020; Hesser et al. 2011; McKenna et al. 2020). CBT has also been developed as internet-based programs and numerous studies have been conducted with the conclusion that internet-based CBT is equivalent in benefit to in-person CBT (Andersson et al. 2002; Kaldo-Sandstrom et al. 2004; Kaldo et al. 2008).

A reported concern with internet-based CBT is a high attrition rate (Abbott et al. 2009; McKenna et al. 2020). However, other studies have not shown high attrition [e.g., Weise et al. (2016)]. A systematic review and meta-analysis that included nine studies of tinnitus intervention, most with CBT, reported the mean attrition rate across studies of 14% (Beukes et al. 2019). Another systematic review and meta-analysis was conducted to evaluate studies that compared internet-based CBT to face-to-face CBT for a variety of psychiatric and somatic conditions (Carlbring et al. 2018). That study showed an average dropout rate of 15.7%. These average dropout rates of 14 to 16% are actually lower than the average of 17.5% observed from a meta-analysis of studies of in-person psychotherapy for depression (Cooper & Conklin 2015).

Internet-based CBT appears to be a viable option for making effective tinnitus care more accessible. Internet-based CBT for tinnitus can be made available in either an assisted or unassisted format (Beukes et al. 2021). If assisted (or guided), then the online program would also provide access to a clinician, either while completing the program (i.e., synchronously) or separate from the program (asynchronously). Whether synchronous or asynchronous, the clinician can answer questions, clarify instructions, and generally be available to provide support as needed. If unassisted (or unguided), then the online program is completed by an individual without any support from a clinician.

An important question when offering an assisted/guided internet-based CBT-for-tinnitus program is the role of the professional providing the guidance. Clearly, a qualified behavioral health clinician would be required for any comorbid psychological conditions. Diagnosing these conditions would require the services of, specifically, a psychologist. If no comorbid psychological conditions were present, then it can be argued that a well-trained non-behavioral health provider could facilitate the online CBT-for-tinnitus program (Beukes et al. 2021). A non-behavioral health provider would typically be an audiologist, but could include other disciplines. Audiologists are the front-line clinicians who provide tinnitus services, and it would seem logical for them to fill this gap in clinical care.

Recommendations

We have addressed the pros and cons of audiologists performing CBT for tinnitus management. There are different perspectives to this question and making recommendations is not straightforward. Given the different perspectives, we can make recommendations that can be used as a general guideline for determining whether audiologists should perform CBT, and, if so, which parts of CBT they should perform.

Audiologists have minimal, if any, training in behavioral health counseling techniques (Husain et al. 2018), and being qualified as a CBT provider requires these basic counseling skills plus specific CBT skills. Ideally, audiologists would have a path available to become qualified in delivering components of CBT or even full CBT. The path would of course require the development of specialized training in CBT as well as clinical experience supervised by a licensed behavioral health provider (Aazh & Moore 2018). Ideal training would involve a live training event—either webcast or in-person. The training would need to be substantial and attendees would need to pass a comprehensive exam. Supervision following the training could be done on site or provided remotely if attendee clinicians record their interactions with patients and a program exists to have those recordings reviewed by a CBT-for-tinnitus specialist. The specialist would provide feedback to the clinician on consecutive patients until it was deemed that the clinician was fully competent in providing the therapy, at which time the clinician would receive a certificate of competency. Without follow-up and supervision, it is not possible to verify the fidelity of CBT delivery.

CBT supervision performed remotely is not without precedent, as the Department of Veterans Affairs (VA) has conducted a national CBT-for-depression training program, including workshop training followed by weekly consultation with a specialist (https://www.mirecc.va.gov/docs/cbt-d_manual_depression.pdf). The VA’s program has been shown to both improve patient outcomes and significantly enhance therapists’ skills (Karlin et al. 2012). Another program trained therapists remotely to provide CBT for chronic pain (Stewart et al. 2015) and found that broad remote dissemination of CBT for chronic pain was effective and feasible (although 15% of the therapists did not complete all training requirements). It should be noted that the providers in both programs (CBT for depression and CBT for chronic pain) had a mental health background. However, this does not guarantee they had a CBT background and so this model of training could still be viable for audiologists. It should also be noted that such a training program would of course involve significant cost.

Alternatively, it would be more straightforward for audiologists to learn to deliver the behavioral components of CBT, such as relaxation training and distraction techniques, rather than the cognitive components. Learning to teach the behavioral coping skills is far less complex than learning to teach the cognitive components of CBT. The behavioral components would normally include teaching patients deep breathing and imagery techniques (for relaxation), and how to plan and implement activities that are enjoyable and pleasant (for distraction). With abbreviated training on these specific skills, audiologists could at least provide the behavioral components of CBT to their patients. It is important to note that it would not be appropriate for audiologists providing only the behavioral components of CBT to describe the services they provide as being CBT.

Audiologists interested in delivering CBT for tinnitus can become aware of the common therapeutic factors associated with positive outcomes such as empathy, therapeutic relationship quality (i.e., positive regard for the patient), and expectancy (i.e., instilling hope) (Lambert 1992; Lambert et al. 2001). It is possible and desirable for health care providers, other than behavioral health professionals, to attend to the therapeutic relationship as a way of improving clinical outcomes, but they need to be proactive in developing these skills. Combined with safer self-management practices such as relaxation training and pleasant activity scheduling, audiologists can offer a viable pathway for expanding tinnitus management services in populations in which behavioral health providers are not readily available.

In summary, some options for non-behavioral health care providers to support access to CBT-based coping strategies include: (1) All non-behavioral health providers can promote the use of CBT supportive materials (videos, websites, books, internet-based CBT). (2) Non-behavioral health providers could be trained to deliver components of CBT (relaxation training, increasing pleasurable activities, identifying thought patterns, behavioral modification), though in this case they may not describe the care they are providing as CBT for tinnitus. (3) Some non-behavioral health providers can receive extensive training and supervision to become qualified to deliver any aspect of CBT, thereby increasing access to CBT for tinnitus for individuals who currently do not have access.

Clinical Application

Following the recommendations outlined above, it seems evident that audiologists can at least provide certain components of CBT without extensive training. It would seem that audiologist-delivered instruction in relaxation and distraction techniques would be generally helpful for the majority of patients seeking intervention for their bothersome tinnitus. This could be done in conjunction with any formal method of tinnitus intervention. Further, the evidence that is accumulating for guided internet-based CBT for tinnitus offers many opportunities for audiologists to become engaged in performing this service if they have the appropriate training and supervision.

PTM is a multidisciplinary, stepped-care, evidence-based program for management of tinnitus. PTM involves collaboration between audiology and behavioral health and incorporates elements of CBT into a program of coping skills education. PTM and its telehealth version (Tele-PTM) are particularly well suited to enabling audiologists to deliver some of the behavioral components of CBT. Large RCTs have demonstrated the effectiveness of both PTM (N=300) and Tele-PTM (N=205) (Henry et al. 2019; Henry et al. 2017). After receiving an audiologic evaluation, a relatively small portion of PTM patients require tinnitus-specific intervention. If so, then they are advised to move to the next level of PTM, involving coping skills education.

PTM skills education includes two sessions (group or individual) of skills education by an audiologist and three by a behavioral health provider. The audiologist covers how to use sound to manage reactions to tinnitus in situations when tinnitus is bothersome. The behavioral health provider teaches coping skills from CBT, generally focusing on relaxation and distraction techniques, and cognitive restructuring. Learning these coping skills satisfies the needs of most patients who receive these services (Beck et al. 2019; Edmonds et al. 2017; Henry et al. 2017).

Consistent with the lack of availability of CBT for tinnitus in general, a barrier to the implementation of PTM is difficulty securing the services of a behavioral health provider to deliver CBT coping skills (Tuepker et al. 2018; Zaugg et al. 2020). It is therefore of great interest to enable audiologists to deliver the CBT, or portions of CBT, if a behavioral health provider is not available. The recommendations provided here would apply, that is, any audiologist desiring to deliver the CBT portion of PTM would require substantial training and follow-up supervision, which may be provided in-person or remotely. It is conceivable that such a training and supervisory program could be established specifically for PTM. Audiologists with proper additional training can gain competence in incorporating the PTM skills of relaxation training and pleasant activities scheduling.

CONCLUSIONS

We have focused on the potential for audiologists to deliver CBT to their patients who require intervention for bothersome tinnitus. It would not be recommended that audiologists perform CBT without substantial training and follow-up supervision. An abbreviated training program could be created to learn the behavioral components of CBT, that is, relaxation and distraction techniques. Audiologists providing only the behavioral components of CBT would need to take care to not describe the services they are providing as being CBT. Audiologists could learn to deliver the behavioral components, which would require much less training than needed for learning to deliver the cognitive components, that is, cognitive restructuring. It is important that the field of audiology consider moving in this direction in order to provide adequate treatment and relief to patients experiencing bothersome tinnitus. Patient intervention with PTM serves as an example of how audiologists trained in CBT skills can implement portions of CBT for tinnitus into their clinical care.

ACKNOWLEDGMENTS

The views expressed in this manuscript are those of the authors and do not necessarily represent the official policy or position of the Department of Veterans Affairs, or any other U.S. government agency. This work was prepared as part of official duties as U.S. Government employees and, therefore, is defined as U.S. Government work under Title 17 U.S.C.§101. Per Title 17 U.S.C.§105, copyright protection is not available for any work of the U.S. Government.

This work was supported by a U.S. Department of Veterans Affairs (VA) Rehabilitation Research and Development (RR&D) Research Career Scientist Award (1 IK6 RX002990-01). This material is also the result of work supported with resources and the use of facilities at the VA RR&D National Center for Rehabilitative Auditory Research (VA RR&D NCRAR Center Award; C9230C) at the VA Portland Health Care System in Portland, Oregon, as well as salary support at the VA Medical Center, Asheville, North Carolina.

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Keywords:

Audiologists; Behavioral therapy; Cognitive; Counseling; Psychologists; Tinnitus

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