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)
Full Name(This is only needed if you would like to be issued a certificate after completing this module. If you do not need a certificate of completion then leave this blank)
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.
The Diary of Thoughts and Feelings (DTF) provides a structured method for you to record your tinnitus-related problems, and their associated thoughts and emotions. This can be a helpful tool to draw together the different techniques that we have learned to identify and challenge negative automatic thoughts, and counter them with counter-statements.
The knowledge that you have gathered from studying the previous modules can assist you in challenging your thoughts in the DTF tasks. For example, you could look for any errors of judgment in the thoughts identified in your diary. The current module offers an opportunity to put into practice the principles of CBT in managing tinnitus-related distress.
By the end of this module, you should be able to:
What is tinnitus?
Tinnitus is the perception of sound without any external acoustic sound source. Tinnitus can be perceived in one ear, both ears, centre of the head, or back of the head. Some people perceive tinnitus as an outside sound. It is not uncommon that people look for an external sound source at home or in a workplace when they initially start noticing tinnitus. Most people who experience tinnitus also have some degree of hearing loss, but not all people with hearing loss have tinnitus.
The mechanisms leading to tinnitus perception are not fully understood and there is no known “cure” available. In the majority of people, tinnitus is not related to any known disease. In some, tinnitus may be related to disorders of the auditory system. For more medical information please refer to the assessment report that has been emailed to you after completing the assessment and 4C module.
Tinnitus is not a life-threatening condition. However, in some people it can lead to severe distress, sleep deprivation and damage to their general quality of life. In the absence of a “cure” for tinnitus, people often benefit from various forms of therapy that help them to learn alternative ways of reacting to tinnitus which will modify the emotional responses caused by the tinnitus. This makes it possible for the tinnitus percept to lose its significance and fade away into the background instead of being in the centre of attention. CBT can help you to explore and modify your negative thoughts and beliefs that produce tinnitus-related annoyance and consequently enhance its perception.
The philosophical underpinnings of CBT can be traced back thousands of years to the time of the Greek Stoics, who believed that destructive emotions result from errors in judgment. Anyone will experience thoughts that they believe are true but in fact are distorted and unrealistic. Aristotle is quoted as saying “the arousing of prejudice, pity, anger, and similar emotions has nothing to do with the essential facts, but is merely a personal appeal to the man who is judging the case.” So, our emotional reactions to life events are not literal facts but a reflection of the interpretation of those events.
How can my thoughts affect my tinnitus?
According to the CBT model of Albert Ellis and Aaron Beck, tinnitus-related distress might be initiated in the following way. You could have an irrational rule of life, for example that “I must control everything at all times”. However, since tinnitus is not controllable, you become anxious. Recall the examples given about the A-B-C model in the module Introduction to CBT for Tinnitus.
Here is a reminder: “A” (the Activating event) is hearing tinnitus. “B” is the Belief or negative automatic thoughts regarding the tinnitus (e.g., “I can’t sleep because of my tinnitus. I will be tired in the next day and unable to function properly. My colleagues will notice and I may lose my job if this happens often.”), and “C” (the Consequence) is the emotional reaction (e.g., anxiety, sadness). As a result, you become anxious and this prevents you from sleeping, which reinforces your belief that “I can’t sleep because of my tinnitus”, a self-fulfilling prophecy.
For more information on levels of cognition (i.e., automatic thoughts, rules of life, and core beliefs) see the module on Challenging Negative Thoughts.
Why should I change my thoughts if they are literal facts?
You may believe that your thoughts about tinnitus are true and changing them is beyond your control. Of course there is some truth in your thoughts about tinnitus. However, errors of judgment (or thought distortions) are common in all human beings. So your thoughts about tinnitus may have some misunderstandings or over-generalisation and other types of errors of judgment.
Tinnitus elicits negative thoughts which can consequently lead to negative emotions. When tinnitus produces negative emotions, it is less likely for your brain to be able to push it into the background. It is an evolutionary feature within us that any kind of stimuli that is emotionally significant should be consistently monitored. CBT can help you to break this vicious cycle. According to the CBT principles, you can control your tinnitus-related thoughts and change them. But this is a skill that needs learning and practice.
In the next few pages, we will talk about the CBT skills that help with tinnitus management.
There are 3 skills that you need to learn:
In the next few pages a more detailed explanation of these skills is offered.
Although you may hear your tinnitus all the time, it may not cause distress or interrupt your activities at all times. You only need to use CBT skills when tinnitus is bothering you (i.e., interrupting your activities or affecting your mood), or when you notice yourself changing your behaviours (what you are doing) to avoid activities where you think that tinnitus will bother you.
Examples of tinnitus bothering you are as follows:
For the examples in the previous page, CBT skills can be used. As a general rule, CBT skills for tinnitus can be applied whenever tinnitus is the cause of the interruptions in your activities or tinnitus makes you feel anxious, depressed or worried. If you hear tinnitus but it doesn’t affect you, you may not need to use any of these skills, or you might notice what skills you are already using at these times. In the next page, some examples of such events are given.
Examples of tinnitus not bothering you are as follows:
Of course it would much better if you didn’t have tinnitus in all of the above examples. However, CBT cannot help you with that. CBT can help you to minimise the effect of tinnitus on you. In the examples on page 14, use of CBT is not needed, as tinnitus is not significantly affecting your emotions or behaviours.
In fact, hearing tinnitus in such situations sends a message to your brain that “look! I can do such and such even though I am hearing tinnitus.” Therefore, tinnitus loses its significance which in turn makes it possible for it to fade away into the background.
The key factor that shows you that it is the right time to use CBT skills for tinnitus management is if tinnitus is causing some problems (e.g., affecting what you are doing or how you feel).
However, there may also be times when the direction of causation is reversed (when how you feel and what you do affects your tinnitus).
Some examples are as follows:
These situations may not need you to use any CBT skills for tinnitus if they do not affect how you feel or what you do.
In the scenarios of the previous page tinnitus is not causing any problem, so CBT for tinnitus doesn’t apply. In the other words, CBT is not designed to stop changes in tinnitus which could have been due to loud noises, life stress, etc. Once tinnitus is changed for any reason, it either affects you or not. If it affects you then CBT can minimise this. So the key point is the impact of tinnitus on you.
Choose the scenarios when you need to use CBT for tinnitus management.
To sum up, the first CBT skill is to know when to use CBT. CBT for tinnitus only applies if tinnitus is interrupting your activities or affecting your mood. Later on in this module you will be introduced to how to enhance your skill in realising when to use CBT for tinnitus.
The second skill is to identify your thoughts about tinnitus. In the next few pages you will learn about what to do once you recognise that it is the right time to use CBT.
The second skill for CBT is to identify what is your negative thought about tinnitus at the moment that it is bothering you.
When tinnitus bothers you, think of this stop sign. Then ask yourself "what is going through my mind about my tinnitus right now?" For example you could be thinking that "I cannot enjoy reading my book with this noise screaming in my ears".
It is important to develop the skill of being able to realise what goes through your mind at the time. What is the negative thought about tinnitus?
In the next page some examples of tinnitus-related negative thoughts are given.
Often I tell my patients that negative automatic thoughts are like dark clouds. Here are some examples of tinnitus-related negative thoughts:
More examples of tinnitus-related negative thoughts are given in the next page.
Tinnitus affects my sleep Often I tell my patients that negative automatic thoughts are like dark clouds. Here are some examples of tinnitus-related negative thoughts:
and concentration. Hence it reduces my efficiency. I can no longer be in control at my work place.
We usually do not consciously recognise our negative automatic thoughts. We tend to link various events to our emotional reactions but the thoughts leading to those emotions are not normally recognised. For example, we link being told off by our boss with feeling upset. But what is the thought that makes us upset? With respect to tinnitus, we link hearing tinnitus with feeling anxious. But what is the thought that makes us anxious?
In order to apply different CBT skills, you need to develop the skill of recognising what goes through your mind at the times when you are bothered by your tinnitus.
Once you have identified your thought, then what? See the next page for the answer.
Often I tell my patients that negative thoughts are like dark clouds and you need to blow them away. One day a patient of mine who was a 12 year old girl said: I like to push away the dark cloud and let the sun shine with my positive thoughts. So “Let the Sun Shine” is consistent with the next CBT skill, which is to substitute the negative thought with a corresponding counter-statement.
Prior to making a counter-statement you need to appraise your negative thoughts. Ask yourself:
If you decide that the negative thought that goes through your mind is unhelpful or has some distortions or errors, then you need to ask yourself: Do I like to keep thinking this way or I would prefer to modify this thought? If the decision is to change then you need to develop counter-statements that are alternatives to the negative thoughts.
More information on counter-statements is given on the next page.
In CBT for tinnitus, counter-statements are used to neutralise negative tinnitus-related thoughts. Unlike the common perception, CBT is not about positive thinking. It is more about realistic and rational thinking. In other words, the counter-statements should be related to the negative thoughts without having the same errors of judgment (or thought distortions).
Please note that it is not expected for anyone to be completely rational or in control of their thoughts and feelings all of the time. In fact, the important features that make us human are our shortcomings. If we were completely rational all of the time, then we wouldn’t have experienced a lot of human emotions such as love, sadness, excitement, carefreeness, vulnerability, bravery, selflessness, etc. There are lots of human desires that may not be rational but are part of us. In my view, it would counter-productive and rather impossible to be rational at all times.
The use of CBT skills does not imply that you have to be completely rational at all times, nor is that possible in my view. The version of CBT that is taught in this iCBT programme is about being able to break the vicious cycle of tinnitus distress by noticing and modifying some of your key troublesome thoughts. This can help you to minimise the distress caused by tinnitus. Once this happens, tinnitus loses its significance and it is more likely for it to fade away into the background.
To sum up, counter-statements should be related to negative thoughts without having the same errors of judgment.
Counter-statements should meet the criteria listed below:
On the next page some examples of negative thoughts and corresponding counter-statements are given.
Have a go and develop counter-statements for these negative thoughts.
In the next page, the counter-statements that I could think of are presented. Please note that these are just some examples. In CBT, you need to develop the skill to create counter-statements in your own words, statements that are believable to you, statements that are reflections of reality based on the reality checks you have done in the module for the Behavioural Experiment.
These are just examples and may not be believable or even true in your particular case. However, I thought having some examples could be helpful in step by step learning.
The Diary of Thoughts and Feelings (DTF) provides an opportunity to practice the three CBT skills that we talked about throughout this module:
In the next few pages, the DTF and instructions to complete it will be introduced. It is very important that you undertake this practical component of iCBT.
If you were going to learn playing the piano, you would need to practice. So, to learn CBT, you need to practice too!
In the next page some information about the importance of adhering to the practical components of iCBT is given.
Some people choose not to do the CBT assignments (e.g., the diaries, experiments). This is very understandable, as they may feel overwhelmed by their tinnitus, lack of sleep and perhaps the distress it causes. They may feel hopeless and not convinced that carrying out the assignments can make any difference. Of course, there are many people who choose to complete the CBT assignments and feel that these are crucial to the success of therapy.
We can use the skill of a behavioural experiment here to notice what our predictions might be about doing assignments and test this belief by trying out doing the assignment, and noticing whether or not these predictions were true!
For example, we might think “what’s the point, it won’t make any difference” (i.e. it will help me 0%). We might then be willing to try it out anyway and plan a date and time that we will do this. We can then look back after and write down what we noticed – such as “It didn’t take the tinnitus away, but I feel like I understand CBT better now and could use it in the future”. We might then rate it as helping 50% - which would be very different to what we predicted!
Research shows that people who do the CBT assignments improve far more than those who do not.
Would you like to improve the management of your tinnitus and enjoy your life fully despite hearing tinnitus? If your answer is yes, then I need you to complete the CBT assignments given to you in this module. Practice makes perfect!
Next is the DTF and the instructions for you to use as your assignment.
The DTF helps you to practice your CBT skills. This is your homework!
The first column “Event” helps you to practice the skill of identifying when to use CBT. Whenever your tinnitus is bothering you, it is considered as an event. Although you may hear your tinnitus all the time, it may not cause distress or interrupt your activities at all times. You only need to use CBT skills when tinnitus is bothering you (i.e., interrupting your activities or affecting your mood).
The second column “Thoughts” helps you to practice identifying what goes through your mind, the second CBT skill.
The fifth column “Counter-statements” helps you to practice creating counter-statements, the 3rd CBT skill.
Further instructions on how to use the DTF are given in the next few pages.
You need to make entries into this diary on a daily basis for 5 days. Usually 5 events per day is enough. For the “Event” column, as soon as tinnitus bothers you, make a note of when it was (time, date), what you were doing, how loud the tinnitus was on a scale from 0 to 10, what happened, and with whom you were involved. You need to make this entry right away at the time of the event or as soon as possible afterwards.
An example is given here.
For the “Thought” column, you need to pause for a moment and ask yourself “What is it that I am thinking about my tinnitus right now?” For each event, you need to identify a thought and record it here right away at the time of the event or as soon as possible afterwards. It is hard to remember what exactly went through your mind if you don’t do it at the time.
For the “Emotion” column, you need to pause for a moment and ask yourself “What am I feeling that is connected to me thinking this way?” You need to make this entry right away at the time of the event or as soon as possible afterwards.
For the “Distortions” column, you need to write down what distortion or error of judgment you can identify in your thought. This does not need to be done right away at the time of the event. You can do this later on or at the end of the day.
For the “Counter-statement” column, you need to write down a counter-statement for your negative thought. Each negative thought should have a corresponding counter-statement. This does not need to be done right away at the time of the event. You can do this later on or at the end of the day.
To sum up, you need to complete 5 diaries (DTF), one diary per day for 5 days. Each diary should have 5 events, 5 thoughts, 5 emotions, corresponding distortions, and 5 counter-statements.
At the end of this module we will email you the DTF worksheet that you can use.
In the next few pages more information is given about how to use CBT skills in management of tinnitus.
When you complete your assignment (i.e., DTF for 5 days), then it is very likely that will acquire the skills needed to use CBT for tinnitus management. If you are not confident enough, then please read the previous modules to enhance your understanding.
In the next page we will talk about how to actually use the CBT skills on day to day basis.
The steps that you need to take are as follows:
How do I know what counter-statement to use?
How will I be able to think of counter-statements quickly enough when I am in the heat of the moment hearing tinnitus?
Over time I will notice that the same negative thoughts tend to repeat themselves very often. It may be helpful to make a list of my common negative thoughts and come up with a corresponding list of counter-statements to neutralise them.
Then I need to memorize that list...
...so the positive thought will come to me quickly when I need it.
If this is a new negative thought and you haven’t got a counter-statement for it, then you need to create a new counter-statement right away. Of course it takes practice to be able to do this.
Don’t forget to identify the negative thought first and then think of a corresponding counter-statement. It is common that people start thinking of some random counter-statements whenever they are bothered by their tinnitus. This is like shooting in the dark and is less effective. The point is to neutralise the negative thought with a corresponding counter-statement. If you don’t know what the negative thought is then it is a defeated game from the start.
Press submit to have a copy of the diary sent to your mailbox. You may use this diary for your homework.
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