Dr. Hashir Aazh(Tinnitus and Hyperacusis Team-lead at the Royal Surrey County Hospital)
Professor Brian C.J. Moore(Department of Psychology, University of Cambridge)
Dr Fiona Seaman-Thornton(Clinical Psychologist at the Royal Surrey County Hospital)
This is the audio recording of Dr Hashir Aazh reading out loud the text of this module and offering some further explanations. You may listen to this audio recording before, during, or after completing this model. This is a supplementary feature that is aimed to improving your learning experience.
A behavioural experiment helps to test the validity of your negative predictions/thoughts about your tinnitus and the helpfulness of your responses to these thoughts. This module provides an opportunity to explore and challenge tinnitus-related negative thoughts by testing out different behaviours, influencing any corresponding anxiety and negative emotions that you might be experiencing.
Once you have identified helpful ways to respond to tinnitus and your thoughts and beliefs about it, with the help of iCBT, any anxiety and negative emotions caused by tinnitus may start to subside, which is likely to also reduce the perception of tinnitus.
At this stage, it would be counterproductive to aim for reducing tinnitus perception, as this cannot be enforced directly and it is more likely for it to be achieved by changing your emotional response to tinnitus via modifying your tinnitus-related thoughts and behaviours.
Your focus should only be on learning the CBT techniques and modifying your thoughts and behaviours in response to tinnitus. Once you achieve this, the rest will be an automatic process which our brain does for all types of stimuli that are not emotionally significant (e.g., often background noises get filtered out so we can concentrate on more important matters). The behavioural experiment is one step in developing CBT skills.
By the end of this session, you will be able to:
Ask yourself "What is an experiment?"
If you were going to explain to a 9 year old child what an experiment is, how you would phrase it?
Think for a minute and type your answer below and click next.
Experiments in general are planned activities that aim to answer questions and test hypotheses.
The experiments in this module are intended to help you to test some of your beliefs and responses to your tinnitus.
To take some simple examples, you may tell yourself that because of my tinnitus “I cannot enjoy reading a book or newspaper,” or “I cannot sleep,” or “I cannot concentrate on any tasks”. The thought of not being able to enjoy reading a book may make you feel frustrated. The thought that you won’t be able to fall asleep may make you feel afraid of going to bed at your usual time.
In the next page, we will discuss the impact of these thoughts on your behaviour.
To avoid your negative predictions about sleep difficulties from happening, you may change your behaviours. For example, you may go to bed very late or resort to drinking or sleeping pills.
The thought of not being able to enjoy reading a book may make you feel so frustrated that you may decide not to try doing it.
To avoid your negative prediction about concentration difficulties from happening, you may use background sounds or music in order to distract yourself from tinnitus while trying to work.
Although some of these strategies may feel like they help us to reduce the impact of tinnitus in the short-term, we know that they typically do not work to manage tinnitus in the long-term.
In fact, we know that if we always repeat these patterns of behaviour, this can make tinnitus a more important stimulus and encourage your brain to focus on it even more.
The purpose of the behavioural experiment is to test the validity of such thoughts and help you to modify them.
Of course our thoughts are based on our past experiences and have some logic in them. However, our thoughts are not always necessarily true.
When we are distressed it is likely that our thoughts have more errors of judgment compared to the times when we are not feeling distressed. In the other words, if you are anxious or depressed due to your tinnitus, it is more likely that your thoughts may become erroneous.
Often, we can develop what we call ‘safety behaviours’ – things that we believe that we always have to do in order to reduce the impact of tinnitus on our lives. For example, we might believe “I cannot enjoy the cinema because my tinnitus will be too distracting”. So we decide to stop going to the cinema and never go again. Our brains make the connection that the cinema will always be not enjoyable because of tinnitus. We might even feel some relief about our decision to stop going and feel a short-term reduction in stress and anxiety.
However, this thought may not be true. We may be able to still enjoy the cinema just as much as anything else, even if tinnitus is there. We may be over-estimating the likelihood that we will not enjoy ourselves because of tinnitus if we go the cinema. But, if we never go back to the cinema again, our brain will never learn that we the opposite might be true. Instead, our brain thinks that we are only managing our tinnitus because we have this safety behaviour.
The difficulty with safety behaviours is that they can lead us to make a lot of restrictions about how we live our lives, they can take a lot of time and effort to maintain, and ultimately, they keep us from learning that the beliefs that we have might not actually be true.
It can be anxiety-provoking to test out whether or not some of our behaviours are actually helpful, and work towards letting go of these safety behaviours. For some of us, stress and anxiety by themselves can make tinnitus seem worse, which may lead us to go back to our safety behaviours when we try something new. However, we know that over time, if we experience the same event repeatedly without negative consequences (a process we call exposure), we will feel less stress and anxiety and our brains will start to get used to these events or may stop noticing them almost entirely (a process called habituation).
So, it can be helpful to know how to test our thoughts and behaviours and consider whether these thoughts are actually true, and whether these behaviours are actually helpful.
It is helpful to notice that our emotions can also affect our thoughts. All of us have experienced the effect of our emotions on our thoughts some time during our lives. For example, when you are angry or depressed, your thought processes are different in comparison with the times when you are feeling calm and content. That’s why they say “don’t make important decisions when you are angry”. This also is the case when you experience some positive emotions. For example, you might not think as sensibly when you are very excited or perhaps you may not think at all when you are in love!
You may find it helpful to consider – am I thinking this way because I am feeling nervous/angry/excited? Would I think about this the same way if I felt differently?
Let’s go back to the thoughts about tinnitus. Although these thoughts might have materialised in the past, this doesn’t guarantee that they will happen in the future.
But the thoughts themselves can create negative emotions (e.g., anxiety, depression, sadness, anger, etc.). And these emotions can affect our behaviours (e.g. anxiety, anger and other negative emotions are known to affect our sleep, concentration and enjoyment of life.)
Therefore, our negative thoughts, emotions and behaviours may lead to our negative thoughts actually becoming true. It is then that you may take such events as proof of the validity of your negative thoughts about tinnitus, a self-fulfilling prophecy. During CBT, the aim is to help you to break this vicious cycle of negative thoughts, negative emotions, unhelpful behaviours, and negative events.
How would you feel if you could get rid of the negative impact of tinnitus despite hearing it?
To test the validity of your thoughts and behaviours, you can ask yourself:
"Is it really true that I won’t enjoy reading my book?"
"Is it really true that I cannot enjoy the cinema?"
"Is it really true that I will stay awake for hours before falling asleep?"
"Is it really true that it will be impossible to concentrate due to tinnitus?"
Add any other thoughts about tinnitus that you may have. Use the space below to type your questions (if you have any).
In the next page, more information is given about how to do a behavioural experiment for tinnitus.
In order to carry out a behavioural experiment for tinnitus, you may find it helpful to use an experimental worksheet.
An example of the experimental worksheet is given here.
(Record the before each activity)
(Record the after each activity)
For each activity, there is one worksheet to complete. There are 5 activities, so 5 worksheets in total. You need to complete the first 3 columns for each worksheet and submit them to your own email address. The next step is to carry out the experimental activities as planned. Once all are done, then refer back to your emails and complete the 4th column for each worksheet.
There are 3 suggested activities that you can use for this experiment. However, at least 5 activities are required to pass this module. You can either use the three default activities and add 2 of yours or ignore my 3 activities and add 5 brand new activities of your own.
The 3 default activities for the experiment are aimed at testing certain negative thoughts that people often experience due to tinnitus. These are given in the next page.
Based on my years of clinical experience and research, many of my patients at least experienced some of these negative thoughts about their tinnitus.
The following steps should be taken for this behavioural experiment. There are 8 steps in total. Step 1 is to write down in the first column the negative thoughts that you would like to test. For the first 3 worksheets, this is already done by default. But you need to do this for the final 2 worksheets.
Step 2 is to write about the method of your experiment in the 2nd column of the worksheet. You need to give details of the activity that you have chosen in order to test the target negative thought. For instance, you could write "I will work on my project from 9 am to 1 pm on Monday 12th January. This will involve reading and writing as well as creative thinking. At 1 pm, I will review how many mistakes I have made due to tinnitus or assess whether the work progressed enough."
Step 3 is to use the 3rd column in order to rate the extent to which you anticipate tinnitus affecting your activity on a scale from 0 to 100%. Try to think of the worst scenario that you can imagine happening when you rate on the scale from 0 to 100%. For instance, ask yourself: “in the worst scenario that I can imagine happening, how much concentration will I lose due my tinnitus when I am working on my project from 9 am to 1 pm on Monday 12th January? How much of the work will I be able to do? Some examples are given in the next page.
For example, you could write: “I will lose 90% of my concentration” “I will make 10 errors”, “The work will take twice as much time to be completed”, “I will get 0% enjoyment from working on the project”, “The negative impact of tinnitus on my task will be 100%”. Please note that these are just some examples. You need to write down your own predictions as to how tinnitus might affect this activity in the worst scenario that you can imagine.
Step 4 is to submit the form and move on to the next activity.
Steps 5 and 6 are described here.
Step 5: Once you have submitted all 5 activities, the first part of this module is complete. Please check your email and follow the instructions provided on how to complete the experiment worksheet.
Step 6: Carry out the activities as planned. For example, work on your project from 9 am to 1 pm on Monday 12th January for the experiment on the effect of tinnitus on your project at work. Do not use any avoidance techniques on that day. For example, if you usually distract yourself from your tinnitus by listening to music, don’t do that during the experiment. We want to see what happens if you don’t use any avoidance behaviour.
Step 7: Refer to your email and complete the last column for each activity. You need to be open minded and objective when reflecting on the outcome of the experiment. Ask yourself if the impact of the tinnitus was as bad as you anticipated? If not, type what actually did happen. What is your judgement?
For example, you could write: “I lost 50% of my concentration not 90%”, “I made no errors, despite anticipating 10 errors”, “The work took twice as much time to be completed”, “I got 80% enjoyment from working on the project despite anticipating 0% enjoyment ”, “The negative impact of tinnitus on my task was 10%”. Please note that these are just some examples and you need to write down the learning outcome based on your observations during the experiment. Maybe the effect of tinnitus on the task was worse than anticipated. So these really should be based on your observations.
Step 8: After doing step 7 for all 5 activities then continue to Part II of Behavioural Experiments module by clicking on the link which is emailed to you.
Please use this experimental worksheet for testing thoughts about usual activities that do not pose any risk of harm to you or others. This module is not to be used for testing thoughts about the impact of tinnitus on driving, piloting, shooting, working with explosives, surgical operations, working with heavy machinery or any other types of machines and operations that can cause physical harm to you or to people around you. If your key negative thoughts about tinnitus are related to such activities, then you should see a tinnitus specialist/therapist who can offer comprehensive therapy.
Tick here to confirm that you agree with the above statement.
This experimental worksheet is intended to help you test a common thought about tinnitus:
"I will not be able to concentrate on my work."
Please follow the steps listed below:
This example is not relevant to my experience of tinnitus. Therefore, I will add a more relevant event/activity instead when I reach to the final experiment worksheet on page 33.
For the last 2 experiments you need to follow the steps listed below:
Thank you for completing the steps 1-5. Step 6 is to carry out the experiments. An email will be sent to you with the experiment worksheet once you click on "Complete Part 1" button below. Please carry out the experiment and complete your experiment worksheet which is sent to you via email. Once all are done then click on the link in your email in order to continue the remaining parts of this module.
Good luck experimenting!
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