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Techniques of Cognitive
CBT is focused on managing hyperacusis/tinnitus-related distress and patients
with symptoms of co-morbid psychological disorders should be referred to mental
health professionals for assessment and appropriate management of their
psychological symptoms. These should be identified at the assessment stage
prior to initiating the treatment. Patients should undergo
psychiatric/psychological assessment/treatment at the same time or prior to
their tinnitus and hyperacusis rehabilitation, when needed.
The audiologist-delivered CBT for tinnitus
and/or hyperacusis involved individual face-to-face sessions, each lasting
about one hour. Table below shows a summary of the typical techniques used in
each session. For details see Dr. Aazh’s paper on audiologist-delivered CBT
for tinnitus and/or hyperacusis published in International Journal of
Summary of the
interventions provided in each audiologist-delivered cognitive behavioral
therapy (CBT) session for management of tinnitus and/or hyperacusis.
of tinnitus/hyperacusis-related distress using in-depth interview
of the patient’s cognitive, behavioral and emotional reactions to
tinnitus/sound and the impact these have on their life.
of a cognitive behavioral formulation for tinnitus/hyperacusis distress
of the patient’s motivation for the therapy
of full CBT or discharge
of a behavioral experiment (BE) to target and challenge troublesome thoughts
to complete the BE as a between-session assignment
and reflecting on the outcomes of the BE
of counter-statements to negative thoughts
the diary of thoughts and feelings (DTF) to be filled in as a between-session
of the DTF and giving help to the patient to appraise and modify the thoughts
responsible for producing tinnitus/hyperacusis-related distress
another DTF to be filled in as a between-session assignment
of the DTF
“acceptance” of tinnitus/hyperacusis
education about CBT
and reflecting on progress
In-depth interview are used in order to explore
the impact of tinnitus and/or hyperacusis on the patient’s life (Green &
Thorogood 2009). If the tinnitus and/or
hyperacusis does adversely affect the patient’s activities or mood then Socratic
questioning should be used in order to help the patient to explore their
thoughts, emotional reactions, physical sensations, and safety-seeking
behaviors (SSBs). The information gathered here will be used for formulation of
the processes and stages involved in producing their tinnitus and/or
hyperacusis-related distress (Muran 1991). The formulation will be shared with patients and the principles of
CBT will be discussed. Examples of formulation for tinnitus and
hyperacusis are shown in Figures 1 and 2.
The case formulations for tinnitus and hyperacusis which are proposed here
begin with the initial emotional response and physical sensations related to
the experience of tinnitus or hyperacusis. These initial symptoms are then
followed by the individuals’ negative thoughts leading to further negative
emotions, physical sensations, and evaluative thoughts which feed back into the
patient’s initial reaction leading to exacerbation of their symptoms, a vicious
Behavioral experiment (Bennett-Levy
et al. 2004) should be used in order to
help the patient to explore their negative predictions about what might happen
to them when exposed to sounds that they found unpleasant (in the case of
hyperacusis) or when they become aware of their tinnitus, and the precautions
that they typically take to prevent these from happening (Bennett-Levy
et al. 2004; McManus et al. 2012). The behavioral experiment provides an opportunity for the patient to
drop these precautions or safety seeking behaviors (SSBs) so that they could
face their fear, which is intended to help them to find out whether their
negative predictions and fear are justified. Most patients state that at least
some of their predictions do not come true.
For example a 6 years old girl with
hyperacusis found the classroom environment difficult due to noise levels and
at times had to cover her ears. This created unnecessary stress which hampered
her progress in school and impacted her self-confidence. Her mum reported that
when they went to a theme park she covered her ears for almost the whole time.
During the therapy she learned how to explore her thoughts and modify them.
After a behavioural experiment she wrote the text below which showed her progress
in resolving her intolerance to sound.
Then patients are encouraged to create
counter-statements for their negative thoughts based on the evidence they
gathered during the experiment (Henry &
Wilson 1995). Patients are encouraged
to use these counterstatements in real-life scenarios as soon as the
troublesome tinnitus and/or sound-related thoughts goes through their mind.
Diary of Thoughts and
DTF is used to provide a
structured method for the patient to take notes about their tinnitus and/or
sound-related problems, and their associated thoughts and emotions (Bennett-Levy 2003; McManus et al. 2012). DTF is completed by patients between sessions. During
the session, audiologist use Socratic questioning style (Braun et al. 2015) to encourage the patient to think of the
advantages and disadvantages of the thoughts that they recorded in the DTF, and
to replace them by counter-statements if the patient decide that their thoughts
were unrealistic or unhelpful. The overall approach is collaborative with a
strong emphasis on the clinician and patient exploring the problem together.
Throughout, the principle of guided discovery (Todd & Freshwater 1999) should be employed, in that the patient makes
discoveries with the help of careful questioning from the audiologist rather
than the audiologist giving information and advice.
(2003). Mechanisms of change in cognitive therapy: the case of automatic thought
records and behavioural experiments Behavioural
and Cognitive Psychotherapy, 31,
Bennett-Levy, J., Butler, G., Fennell, M., et al. (2004). Oxford guide to behavioural experiments in
cognitive therapy. Oxford University Press.
Braun, J. D., Strunk, D. R., Sasso, K. E., et al. (2015). Therapist
use of Socratic questioning predicts session-to-session symptom change in
cognitive therapy for depression. Behav
Res Ther, 70, 32-7.
Green, J., & Thorogood, N. (2009). In-depth Interviews. In Qualitative Methods for Health Research (pp.
93-122). London: Sage.
Henry, J., & Wilson, P. (1995). The psychological management of
tinnitus: comparison of a combined cognitive educational program, education
alone and a waiting-list control. The
international tinnitus journal, 2,
McManus, F., Van Doorn, K., & Viend, J. (2012). Examining the
effects of thought records and behavioural experiments in instigating belief
change. Journal of Behaviour Therapy and
Experimental Psychiatry, 43,
Muran, J. C. (1991). A reformulation of the ABC model in cognitive
psychotherapies: implications for assessment and treatment. Clin Psychol Rev, 11, 399-418.
Todd, G., & Freshwater, D. (1999). Reflective practice and
guided discovery: clinical supervision. Br
J Nurs, 8, 1383-9.