Cognitive Behavioral

Therapy for Tinnitus

Bruce Hubbard, Ph.D.
ATA Professional Member since 2014

“I’m trapped! It won’t stop! It’s on 24-7 and I trigger your brain to react
against a possible threat.
can’t think about anything else. I’m desperate This reaction is what scien-
for relief, but convinced relief won’t come. tists call hypervigilance.

My life is ruined. I’m certain that I can never Not surprisingly, your brain
judges tinnitus—a loud,
learn to live with tinnitus!” uncontrollable noise—as a
I am an experienced clinical psychologist who has threat to your wellbeing,
worked with countless patients, including many with and it puts your body on
alert. Tinnitus distress is
severe tinnitus. But the words above are not from one
your brain sounding the
of my patients. They came from my own lips, nine
alarm about a perceived
years ago, when my life was hijacked by tinnitus.
possible danger.
These panicked, pessimistic sentiments reflect a condi-
tion called tinnitus distress—a perfect storm of anger, Of course, many suspected threats turn out to be false
annoyance, anxiety, fear, sadness, and despair, that alarms. In most cases, the brain quickly learns that a
impairs concentration, interferes with sleep, and dis- stimulus is not a threat. It then relaxes hypervigilance
rupts functioning in all areas of life. Even as a behav- and the sensory perception is gradually screened out
ioral health specialist, the relentless whine of tinnitus of awareness through a process called habituation.
had me trapped in a synergy of hurt. Habituation explains why people routinely stop notic-
ing loud, annoying noises after prolonged exposure.
For many years, predating my tinnitus, I have special- A passing train, the roar of a freeway, air traffic, and
ized in a science-based form of mental health treatment the hum of a refrigerator are common examples of
called Cognitive Behavioral Therapy (CBT). CBT noises that eventually succumb to habituation.
is a set of learned skills—healthy habits and per-
spectives—that work together to change a person’s For all its bluster, the sounds of tinnitus are a false
emotional response to stress and trauma. In 2005, alarm—distracting and annoying, yes, but ultimately
at the height of my tinnitus distress, I used CBT to harmless and unimportant. Research shows that the
help successfully manage my own condition. majority of people with tinnitus do habituate and
are no longer bothered by the sounds. Until we can
silence tinnitus for good, ignoring tinnitus sounds
What Causes Tinnitus Distress? through habituation is a highly desirable end.
Thank your brain, for it errs on the side of keeping So, why do some people habituate to tinnitus and
you safe. Your brain is constantly on the alert for others do not? Research indicates that it’s not the
potential danger. Any unexpected sensory stimulus— tinnitus itself, but the person’s emotional response
a movement in your peripheral vision, a sudden noise, to tinnitus that determines the course of habituation.
the feeling of something crawling up your leg—can An emotional response that consists of resisting and
bracing against tinnitus maintains hypervigilance by

With practice and patience, CBT can reinforcing the brain’s perception that tinnitus is an
imminent threat, an “intruder” that must be closely
help the patient habituate to tinnitus monitored. Rather than learning to ignore tinnitus,
the persistently hypervigilant brain is locked into a
and quiet the alarm in the brain. negative pattern that maintains emotional distress
and prevents habituation.

12 Tinnitus Today | Winter 2014

 SCIENCE & RESEARCH
Cognitive Behavioral Therapy can
help break this pattern by changing
how the patient thinks and behaves in
response to tinnitus. With practice and
patience, CBT can help the patient
habituate to tinnitus and quiet the
alarm in the brain.
“The Breathing Space”
Careful Thinking: Getting a Here is a mindfulness exercise to help soften your inner rela-
New Perspective on Tinnitus tionship with tinnitus. The goal is to practice adopting a new
Our internal thoughts (cognitions) can stance toward tinnitus, one that is open and accepting, that
exert a strong influence over our feel- allows tinnitus to exist as a strand in the fabric of your being.
ings and actions. Personal judgments, Think of mindfulness as stepping back from a fire—you may
beliefs, and expectations can either still feel the heat, but are no longer consumed by the flames.
nurture healthy emotions and lifestyle, The exercise takes about three minutes, though this may
or promote suffering, avoidance, and vary as time and emotional stamina permit:
withdrawal. ■ First, observe your experience by gently turning your
In my experience working with tin- attention to sensations, then feelings, then thoughts, each
nitus patients—and even in my own in turn. You may notice the sounds of tinnitus. For these
personal ordeal with tinnitus—I have few minutes, practice allow-
seen how negative thinking reinforces ing these sounds to be pres-
hypervigilance, blocks habituation, ent, as part of your whole
and impedes recovery. Common exam- experience, observing your
ples are “catastrophizing,” where the experience neutrally, in the
patient jumps to the worst case sce- present moment, just letting
nario without considering other, more it unfold as it will.
likely outcomes, and “Mental Filter” ■ Now turn your attention
where the patient picks out a single to your breath, breathing
negative detail and dwells on it exclu- in a slow, relaxed manner.
sively so that their vision of all reality Notice the rhythm of your
becomes darkened. breath, the sensation of air
entering and exiting your
CBT begins with a careful look at the
body, the slight increase
patient’s thoughts to identify cognitive
of tension as you inhale
patterns that fan the flames of tinnitus
and release as you exhale.
distress. The goal is to develop rea-
It is likely your attention
sonable judgments and expectations
will wander—to tinnitus, to
about tinnitus, a new perspective that
thoughts about tinnitus, to
is grounded by facts, to provide reas-
any other concern. Notice
surance and guidance throughout
these lapses as they occur
recovery.
and gently, neutrally return
to your breath.
Acceptance and Mindfulness: ■ Finally, using your breath
Learning to Share Your Space as an “anchor”, return your
with Tinnitus attention to your experience as a whole, gently
allowing tinnitus, any other sensations, thoughts and
The inner world of tinnitus distress is feelings, to occur in the present moment, without
characterized by resisting, fighting, criticism and judgment.
longing with every fiber of your being
for the sounds to stop. Such resistance As you move back into your life, remember to bring this
is understandable—tinnitus is genuine- calm, accepting attitude with you, returning often to your
ly stressful. But the fact remains that breath to soften any distress.
there is no off switch for tinnitus. We
(continued on page 14)

Winter 2014 | Tinnitus Today 13

 Cognitive Behavioral Therapy for Tinnitus
(continued from page 13)

have limited, or in most cases, no direct control over Bruce Hubbard, Ph.D. is a Licensed Psychologist, an
the sounds and sensations. Until we find a cure, Adjunct Assistant Professor at Columbia University
wishing tinnitus will stop only feeds hypervigilance and Director of the Cognitive Health Group in
and starves recovery. You can’t change tinnitus, but New York City. To learn more about Dr. Hubbard’s
you can change your inner relationship with the experience with tinnitus and Cognitive Behavioral
sounds of tinnitus. Research suggests that accep- Therapy, visit www.cbtfortinnitus.com.
tance—willingly sharing your space with tinnitus—
aids in recovery from tinnitus distress.
The benefits of acceptance are clear: You stop
banging your head against the tinnitus wall Looking for a CBT Specialist?
and instead free up energy to go around it. You
relinquish attempts to control tinnitus in exchange for Use ATA’s online Tinnitus Health
the confidence of knowing you can handle it. You Professional Listing to find a
come to find that tinnitus is not the boogey man you provider in your area.
have imagined. It is just a meaningless collection
of auditory signals that have no direct bearing on Get started at www.ATA.org/provider-search
the true value of your life.
Sharing space with an intruder as invasive as tinnitus
is a courageous, noble endeavor. Studies show that
mindfulness can help. Mindfulness is the practice
of taking a more neutral, objective stance toward
tinnitus, to soften your emotional response, making
it easier to take the next step in your recovery.

Exposure: Rejoining Your Life

The most natural response to emotional distress is to
avoid experiences that trigger it. Disruptive in its own
right, tinnitus-induced avoidance can lead to more
serious conditions, like panic disorder, phobia, and
depression. The ultimate goal of CBT for tinnitus
is the return to a healthy lifestyle by resuming
the activities that bring happiness and meaning.
Your Best
Sound
Exposure is the process of gradually reversing avoid-
ance, reintroducing yourself to sound, to silence, and
to the activities you may have formerly believed to
be forever tarnished by tinnitus.
Exposure is a whole brain workout, enlisting each of
your new CBT skills—careful thinking, acceptance,
and mindfulness—to sand the edge off your distress
and make it easier to engage your new soundscape,
Experience
a new, valued life, even with tinnitus.
Now offering the
Recovery from tinnitus distress requires hard work,
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persistence and time. My own experience with
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weight it once carried. Sweet habituation!
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14 Tinnitus Today | Winter 2014