Evolving Counselingand Sound Therapies for Tinnitus

By Richard S. Tyler, Ph.D.The University of Iowa

12 FEEDBACK • VOLUME 18, NUMBER 2 • SUMMER 2007

13FEEDBACK • VOLUME 18, NUMBER 2 • SUMMER 2007

Evolving Counseling and Sound Therapies Feature

Sincethe pioneer ingwork in the 1980sof psychologist

Richard Hallam and his TinnitusHabituation Therapy,many counseling andsound therapies have emerged. The 1995Paul Davis book Living with Tinnitus andthe more recent Tinnitus:A self-managementguide for ringing in your ears (2002) by Jane Henry and Peter Wilson, have benefited thousands of tinnitus sufferersworldwide. The approaches range fromintensive psychology-based counselingapproaches (such as Cognitive BehaviorTherapy (Andersson et al, 2005; Caffier etal., 2006)) to approaches that focus prima-rily on providing information (such asTinnitus Retraining Therapy (Bartnik &Skarzynski, 2006).

The University of Iowa Department ofOtolaryngology — Head and NeckSurgery — has a long history of tinnitustreatment and research,encompassing morethan two decades of work in this area.Thedepartment’s treatment protocol, started inthe 1980s, has evolved into TinnitusActivities Treatment.This treatment – whichdepends on an individual’s needs – focuseson four areas: thoughts and emotions,hearing, sleep and concentration.

There are actually many new counselingand sound therapies.Several clinicians favortaking a global perspective,considering thebroader lifestyle of the patient (e.g. Folmeret al., 2006). Mohr and Hedelund (2006),with their Patient-Centered Therapy, nur-ture an acceptance of the tinnitus.Hearingaids can be adjusted to maximize tinnitusrelief (e.g. Searchfield, 2006), and of coursemany patients prefer music to listening tobroadband noise. Some treatments such asthe “Scary Monsters and Waterfalls” byKentish and Croker (2006) specifically focuson children with tinnitus.

The University of Iowa approach startswith an individual assessment to understandwhat the needs are of each patient.As tin-nitus often affects the patient’s emotionalwellbeing,hearing,sleep and concentrationabilities,we worked to develop strategies foreach of these areas.

Sound TherapyVarious treatment strategies use sound to

decrease the loudness or prominence of tin-

nitus. Sound therapies include both wear-able (hearing aid-like devices) and non-wearable devices (such as table-top soundmachines or even a whirring fan). Often,sound is used to completely or partiallycover the tinnitus.Some people refer to thiscovering of sound as masking. Sound therapies should always be combined withcounseling. For those patients who want to mask the sounds, they report that the presence of background noise or music is helpful.

These sounds can:

• Partially mask the tinnitus – The back-ground sound mixes with the tinnitus,butthe patient is still able to hear the tinnitus.

• Totally mask the tinnitus – The back-ground sound completely covers up thetinnitus.

Both of these partially and total maskingapproaches can:

• Reduce the loudness of the tinnitus

• Distract the patient from attending to thetinnitus.

Successful Masking SoundsMasking is generally successful because

the masking sound and the tinnitus soundare vastly different in quality.Tinnitus usu-ally produces a shrill,high-pitched,unpleas-ant tone.In contrast,water,masking soundsand music are typically soothing.

• Most individuals can and usually do“automatically” ignore certain externalsounds.

• These sounds are ignored if they are nottoo loud or harsh and if they are relative-ly constant and monotonous.

Many patients report that it is easier to lis-ten to broadband noise (heard as “sssshhhh”)than it is to listen to their tinnitus.Similarly,soft, light background music (e.g. classicalbaroque or simple piano music) is a greatway to partially mask the tinnitus.Sound produced particularly for relaxationor distraction (e.g., waves lapping againstthe shore, raindrops falling on leaves—sometimes these are combined with lightmusic) is another form of masking.

Masking DevicesSo what types of devices producing these

melodic sounds do patients use? It dependson the patient’s preference. Some patientsprefer wearable devices with earphones orinsert earphones (e.g. portable music play-ers),while other patients favor non-wearabledevices that include radios, compact discplayers or sound generators specifically pro-duced for relaxation or tinnitus.Some of thenon-wearable devices were intended for useat the bedside with timers and can includemany different sound types.

Sound therapy is effective for manypatients. People use sound therapy in dif-ferent ways. For example,some people findthat their tinnitus does not bother themexcept at night.Others require sound ther-apy during the entire day. Sound therapydoes not have to be used all the time.

Some people find that they require masking less as they use it for severalmonths. They use the noise to decrease theprominence of the tinnitus and enable themto move forward and no-longer focus on the tinnitus.

It is possible to obtain a noise generatorand a hearing aid combined in one wear-able device.

Additional Therapies

Hearing Aids Some patients with tinnitus also have a

hearing loss and can benefit from a hearingaid. As tinnitus may be caused by stress,hearing and better communication mayreduce stress and tinnitus at the same time.Hearing aids also amplify background noise,and many tinnitus patients report that theirtinnitus is better when they listen to low levels of background noise (note the soundtherapy above).

Psychological TherapiesCognitive Behavior Modification.

This approach helps you to talk about tinnitus in a reasonable fashion, and to planand carry out trials to change the way youthink about tinnitus and react to it.

Relaxation Therapy. There are manyrelaxation techniques, for example usingrecorded soft music or biofeedback, whichcan help patients relax when they are particularly bothered by their tinnitus.

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Feature Evolving Therapies Feature Retraining Therapy

MedicationsThere are no medications that are wide-

ly accepted (based on replications of con-trolled studies) to cure tinnitus. However,several medications can be helpful inreducing stress and in getting to sleep.Several studies are underway or beingplanned to test new medications, newapplications of existing medications andeven supplements. It is likely somethingwill be found soon, at least to help somesubgroups of tinnitus patients.

In most cases, tinnitus remains the samethroughout the person's life, but in someinstances it can get worse, or even improveover time.

Many studies now underway!Previous published research has focused

on Cognitive Behavioral Therapy, and sev-eral studies have shown significant treat-ment effects. Hearing aids have also beenshown to provide benefit. Worldwide,thereare now currently several other studiesunderway on many of the other counselingand sound therapies. To learn more aboutthe therapies currently underway at TheUniversity of Iowa Department ofOtolaryngology visit www.uihealthcare.com/depts/med/otolaryngology/clinics/tinnitus/index.html.

The Department of Otolaryngology —Head and Neck Surgery and theDepartment of Speech Pathology andAudiology at The University of Iowa will behosting the 15th Annual Conference onManagement of the Tinnitus Patient.Theconference, for patients and professionalstakes place Thursday – Saturday,September20-22, 2007 for patients and professionals.View the most up-to-date program on ourWeb site: uihealthcare.com/depts/med/otolaryngology/conferences/. ■

REFERENCESAndersson,G.,Porsaeus,D.,Wiklundm,M.,

Kaldo, V. & Larsen, H.C. (2005).“Treatment of tinnitus in the elderly: acontrolled trial of cognitive behaviortherapy.” International Journal ofAudiology 44(11): 671-675.

Bartnik, G.M. & Skarzynski, H. (2006).Tinnitus Retraining Therapy. TinnitusTreatment:Clinical Protocols.R.S.Tyler.New York,Thieme: 133-145.

Caffier, P., Haupt, H., Scherer, H. &Mazurek,B.(2006)."Outcomes of Long-Term Outpatient Tinnitus-CopingTherapy: Psychometric Changes andValue of Tinnitus-Control Instruments."Ear and Hearing 27(6): 619-627.

Folmer, R.L., Martin W.H., Shi, Y. &Edlefsen, L.L. (2006). Tinnitus soundtherapies.Tinnitus treatment:clinical pro-tocols. R.S. Tyler. New York, Thieme:176-186.

Henry,J.,Wilson,P.H.& Dragin,S.D.(2002).Tinnitus:A Self-Management Guide forthe Ringing in Your Ears. Boston, MA,Allyn & Bacon.

Kentish, R.C., Crocker, S.R. (2006). ScaryMonsters and Waterfalls: TinnitusNarrative Therapy for Children.TinnitusTreatment:Clinical Protocols.R.S.Tyler.New York,Thieme: 217-229.

Mohr, A., Hedelund, U. (2006). TinnitusPerson-Centered Therapy. TinnitusTreatment:Clinical Protocols.R.S.Tyler.New York,Thieme: 198-216.

Searchfield, G.D. (2006). Hearing Aids andTinnitus. Tinnitus Treatment: ClinicalProtocols.R.S.Tyler.New York,Thieme:161-175.

stood, the unpleasant psychological reac-tions can begin to disappear.

4) Sound enrichment — sound that doesnot completely mask tinnitus because one cannot habituate to a sound they can-not hear

5) Retraining Tactics — retrainingreflexes to tinnitus by exercises that reducethe sound enrichment and evaluating reac-tion to the tinnitus

There are more than 800 professionalsaround the world who have attended train-ing courses on TRT and the success ratereported is nearly 80 percent. PawelJastreboff and Jonathan Hazell have estab-lished the Tinnitus Retraining TherapyAssociation (TRTA).The association helpsmaintain high standards in the proper uti-lization of TRT and provides a list of prac-tioners by state.

When working with patients with tinnitus, it behooves audiology as a profession to continue to expand ourthinking, knowledge, and experience inareas that often have been a mystery for somany years. ■

REFERENCESEmory Center Helps Hyperacusis and

Tinnitus Patients With A UniqueRetraining Therapy, http://whsc.emory.edu/_releases/2003august/hyperacusis.html

Hazell, Jonathon, F.R.C.S. TinnitusRetraining Therapy Implementing theJastreboff Neurophysiological Model.Tinnitus and Hyperacusis Centre,London UK www.tinnitus.org

Hazel, Jonathan F.R.C.S. TinnitusRetraining Therapy from the JastreboffModel. J Director, Tinnitus andHyperacusis Centre, London UK,October 2002

Jastreboff, Pawell Ph.D. and Jastreboff,Margaret Ph.D. “Tinnitus RetrainingTherapy: An Update.” AudiologyOnline, October 2000.

Tinnitus Retraining Therapy by WCBEvidence Based Practice Group. Dr.Craig W. Martin, Senior MedicalAdvisor, January 2004

Several studies are underwayor being planned to test newmedications, new applicationsof existing medications andeven supplements. It is likelysomething will be found soon,at least to help some sub-groups of tinnitus patients.

Richard S.Tyler, Ph.D. is professor specializ-ing in audiology with The University of IowaDepartment of Otolaryngology – Head andNeck Surgery. He has a B.S. in Communi-cation Disorders; a M.Sc in Audiology; and aPh.D. in Psychoacoustics.Tyler’s clinical spe-cialty is Audiology and Tinnitus. For moreinformation visit,www.uihealthcare.com/depts/med/otolaryngology/clinics/tinnitus/index.html.

17FEEDBACK • VOLUME 18, NUMBER 2 • SUMMER 2007