Presentation on theme: "Tinnitus Activities Treatment"— Presentation transcript:
1Tinnitus Activities Treatment Shelley Witt, MA/CCC-AThe University of IowaDepartment of Otolaryngology – Head and Neck Surgery
2Tinnitus Patient #1 Problems with concentration; struggles to read Emotional disturbance;Can no longer make decisions; forgetful; confusedHas a lot of fear-based thinking with regard to what she can physically do because of her tinnitus;Is depressed and battling anxiety;Admits that her tinnitus is keeping her from doing things she has always enjoyed; stays home; tries to complete daily chores but admits that it is difficult; focused on pre-tinnitus lifeBecause of the tinnitus must keep a very strict routine or else her sleeping pattern becomes disrupted and without sleep she cannot functionFamily very disappointed in her (changing roles)
3Purpose of Today’s Talk Introduce you to a counseling approach that is currently being used and has been found to be successful in some patientsNo magic; all clinicians can do this; not all patients need to fly to Iowa CityRecognize that the Iowa Clinic is unique in that we do specialize in Tinnitus and HyperacousisThe Iowa approach may need to be modified for your clinicGet you excited about providing this type of treatment
7SoundCure® Quote“For the tinnitus patient, living with this persistent condition requires changing the way he or she thinks about health care and daily life. Part of the audiologist’s role is to help the patient regain a sense of control and become an active participant in treatment.”
8Tinnitus Activities Treatment A counseling and sound therapy treatmentPicture-basedFocused on individual needsDirected at primary areas affected by tinnitus1) Thoughts and Emotions2) Hearing and Communication3) Sleep4) Concentration
9Tinnitus Activities Treatment Is provided for free on our website
10Activity Therapy PicturesBelow you will find different counseling presentations that relate to the thoughts and emotions, hearing and communication, sleep, and concentration abilities for people experiencing tinnitus. Within each presentation are activities to complete following the counseling. In addition, there is a review for each counseling section that is typically completed at the beginning of the subsequent follow-up appointment. IntroductionThoughts and EmotionsReview of Thoughts and EmotionsHearing and CommunicationReview of Hearing and CommunicationSleepReview of SleepConcentrationReview of ConcentrationSummary
11Tinnitus Activities Treatment The series of picturesProvide orderly fashionNot overlook important conceptsEasy format to understand concepts
12Tinnitus Activities Treatment There is no right or wrong way to use the picturesThere is no specific orderThere are a few main topics but you can pick and choose how you want to use them and in which order you’d like
13Tinnitus Activities Treatment Techniques in one are (sleep) can be used to help in others (thoughts and emotions)The area addressing thoughts and emotions is typically where you will spend the most timenot easy conceptsnot easy for everyone to incorporate into their daily lifecan be the most helpful
14Tinnitus Activities Treatment Providing handouts after each session can be helpfulUsing the handout as a quick review prior to a new session can also be helpfulA tinnitus diary is a great tool to help pts better understand their own thoughts and emotionsHandouts will be provided
15Tinnitus Activities Treatment Introduction (Tinnitus History) Allows the pt to tell their storyAnswers to questions given during this session can influence the direction of counselingMore listening than talkingPts first opportunity to tell the whole story
20How do you think we might be able to help you? Use this slide to help set goals (short and long term)First opportunity to help pt start to make changes in their thinking (SoundCure Quote)
21Clinician Responsibilities ListenBe PatientBe SympatheticBe Encouraging; but not a cheerleaderBe Able to Talk CandidlyHave Confidence in Your Ability to HelpGuideHave the time
22Understand Your Role Help your patient learn how to successfully live with tinnitusnot eliminate the tinnitus, but rather to function in spite of the tinnitusadopt a new identity as a person with tinnitusbecome their own coachfigure out which techniques/tools work best for them
23Make the Experience Collaborative and Verbalize This “I am here to help”“I am here to help you learn how to live with tinnitus”“I cannot take your tinnitus away, but I can show you some tools and techniques that have been successful for other people with tinnitus, which might work for you”“I need you to take an active role in this process and together let’s see if we can make things better”“The process of counseling is for me to help you become your own coach so when you are struggling with tinnitus in your own environment you have some tools and techniques that might help”
24Tell Yourself That It’s Okay If You Don’t Know all the Answers Be honest and supportivePt: “Why does my tinnitus do this?”Clinician: “I don’t have an answer for that.” “There is no predictable pattern for tinnitus.”Don’t put pressure on yourself to have all the answers. Remind patients that tinnitus is different for every individual and that there is much we are still learning about tinnitus.Be an expert in helping, not in having all of the answers.
25Be willing to address additional support Mental health counselor; psychologistThis process of tinnitus counseling can uncover additional areas that might need to be addressedAnxiety, Depression, Marital Problems, Loss of IdentityMake referrals; work in conjunction with other professionals
26Identify the Psychology that was there prior to the tinnitus Have a discussion about pre-vs-post tinnitus dispositionWhat was your sleep like prior to tinnitusDid you ever have depression prior to tinnitusPrior to tinnitus have you ever had an episode of anxietyIn general whatever psychology was there prior to the tinnitus can be magnified post-tinnitusIf you have generalized anxiety disorder, depression this path might be harderIf your marriage was strong if might hit some roadblocks; if your marriage was weak it might fall apart
29Set Goals List goals for using sound therapy Hearing better Notice tinnitus lessList goals for counselingNot hate my tinnitusReturn to a more normal lifeAttend meetingsGo to movies
30Tinnitus Activities Treatment Thoughts and Emotions (many parts) Hearing and hearing lossTinnitusAttention, behavior, and emotionsChanging your reactionsActivities for home
31Tinnitus Activities Treatment Thoughts and Emotions 1) Information about Hearing, Hearing loss and TinnitusProvide knowledge to remove unknowns, misconceptions, fearsuse patient’s own audiogramsection that most audiologists feel comfortable discussing
32How We Hear Sound causes movement of air molecules Air molecules movement causes air pressure in ear canal to increaseAir pressure in ear canal causes eardrum to vibrate3 bones connected to eardrum also vibrateBones connected to inner earInner ear made up of snail shaped cochleaCochlea has hair cells and nerves which react to soundCochlea is filled with fluidVibration of ossicles causes fluid to moveMovement of fluid causes hairs cells to moveHair cells send message to auditory nervesAuditory nerves deliver message to brainBrain interprets message as sound
36Hair Cells Normal Hearing Loss Normal hearing, have all/most of hair cellsHairs stand up straightWith hearing loss, some of HCs are missingOn other hairs cells, hairs no longer stand straight up, look like tornado went throughHearing Loss
38Tinnitus Tinnitus results from damage to the hearing system May be associated with hearing lossTinnitus will not damage your hearingHearing may continue to decrease, but not because of tinnitusSome people have normal hearing with tinnitusHaving tinnitus does not mean you will lose your hearing
45Basic treatment components Introduction Section (validation)Information about hearing, hearing loss and tinnitus (understanding)Individualized topics (hearing, sleep, concentration, thoughts and emotions)10 in 100 (10%) people have tinnitusCurious and Concerned Patients1 in 100 (1%) people are bothered by their tinnitusDistressed Patients
47Therapeutic Challenges Areas that create roadblocks to living successfully with tinnitusNot acknowledging grief regarding having tinnitusGiving up ways of controlling your tinnitusControlling your thoughts and emotions about tinnitus
48Acknowledge griefAsk the pt how they are feeling about having tinnitus and its impact on their lifeCreate an atmosphere where it is okay for the pt to grieveGrief over the loss of silenceGrief over changes in lifestyle (less spontaneous; letting go of hobbies)Verbalize that it is okay to be sad and to cryAcknowledge their emotional upset; help them come to terms with the fact that this has happened and is disrupting their lifeThe introduction is a great time to address this
49Acknowledge grief Grief may surface throughout many sessions In later sessions start re-directing the grief towards a change in thinkingExample: Let’s re-define silence for you; Silence is now relaxing while listening to a sound that mixes well with your tinnitus (sound searching)Help them let go of hobbies that no longer work for them and to discover new hobbies; get them excited about a new chapter in their lifeWarn them that there will be people who have tinnitus who won’t understand their distress (refer back to mechanisms and Hearing/Hearing Loss/Tinnitus pictures); tell then not to feel bad about this (mechanism); share Tyler Alumni response (“not bothered, but if you have a cure I’ll fly there….”
50Acknowledge griefPts must move past the grieving stage and must start taking controlIf a pt is stuck here you can try an expressive writing exercise (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain)Take 10 min and write about your deepest thoughts and feelings regarding your tinnitusWrite for yourself and not as if you are going to share (uncensored)You might tie your thoughts and feelings regarding your tinnitus to other aspects of your lifeWrite continuously; don’t worry about spelling, grammar or repeating yourselfIt’s natural to experience a wide range of emotions, including sadness and anger and it’s okay to express themDo this for 3 consecutive days; at the end of the assignmentKeep the writings for future reference ORMake a ceremony of burning the writings to let go of the emotions and to take with them what they have learned
51Acknowledge grief Review the assignment by asking the pt If they completed itWhat they learnedDid they see any patterns (can help you find a focus for counseling)How they felt over the course of 3 daysWhat did you do in the end with your choice of either keeping the writings for future reference OR to make a ceremony of burning the writings to let go of the emotions and to take with them what they have learned(Discuss case example of pt who turned this into a daily negative exercise; adjust to create a gratitude journal)
52Let go! (physiology) Stop trying to control the tinnitus (it is what it is; tinnitus doesn’t have a heart, soul or mind )Some pts try to physically manipulate their tinnitus to “calm it down”Spend hours trying to make sense of what it is doingGet stuck trying to figure out the direct cause or what they might have done wrong to “bring it on”Continue to search for the one successful treatment to eliminate the tinnitus
53Let go! (physiology) Stop trying to control the tinnitus (it is what it is; tinnitus doesn’t have a heart, soul or mind)Help them understand that tinnitus is the result of an auditory insult (refer back to hearing/hearing loss/tinnitus pictures); no different than being diagnosed with a disease (physiology versus perception)Verbalize that by trying to control or understand the tinnitus that the tinnitus is really controlling them and they are giving tinnitus importance
54Let go! (physiology) Stop trying to control the tinnitus (it is what it is) – homework examples Stop internet searches (force them to keep an internet search diary)Only try various interventions (acupuncture, hypnotherapy, herbalist) for better health and well-being; not for the goal of getting rid of the tinnitusStop mentally taking an inventory of what your tinnitus is doing; what are you learning that’s new about your tinnitus today that you didn’t know yesterday; how does this information help us; write down all the things you know about your tinnitus; read it and then burn it or throw it away (tinnitus diary)Send me an at the end of each day listing 3 things you did that was not tinnitus related (initiating of re-focus therapy)Complete 1 enjoyable activity each day that has nothing to do with tinnitus (initiating reduction of the impact of tinnitus on daily life/increasing pleasant activities)Create a mantra that will help you re-focus (mantra’s are very powerful!; self-talk)
56Tinnitus Activities Treatment Thoughts and Emotions 2. Provide a clear explanation of the role of our conscious versus subconscious with regard to attention (interactive mini-lecture)Types of attentionHow things capture our attentionHow we can direct our attentionWhy some things cannot be ignored
57Two Types of AttentionConscious— selectively attend to and think about information.Subconscious—monitor background information. However, a monitored item may grab your attention at any time and move to conscious attention.Your conscious attention is paying attention to meYour subconscious is monitoring all of the sounds around you and outside this room
66Tinnitus Activities Treatment Thoughts and Emotions Purpose of this mini-lecture help pt understandWe are meant to notice important stimuliWe are meant to ignore unimportant stimuliRight now tinnitus is important and is very noticeableYou do have control over what you are attending topractice adjusting attentionhelp them find some control
67Attention Control Exercises Learn to switch attention from one stimulus (e.g. object, sensation, thought, activity) to another at willAllows you to refocus your attention from your tinnitus onto other stimuli, external or internal
68Tinnitus and Attention If you determine tinnitus is not important,the tinnitus will be easier to habituate toIf you determine tinnitus is important,you will attend to itIf a sound is important to us we will continue to pay attention to it
69Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? (Summary)Change Interpretation of ImportanceUnderstand TinnitusUse self-talk to remind yourself thatTinnitus is likely the result of increased spontaneous nerve activityMany people have tinnitus – you are not aloneTinnitus is not threatening your health or hearingTinnitus and your reaction to tinnitus are two different things (physiology vs perception)
70Change Emotional Reaction Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus?Change Emotional Reaction
71Tinnitus Activities Treatment Thoughts and Emotions Understand the Connection between our Thoughts and our Emotions
75Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Have an open discussion with pt about their own thoughts, beliefs, attitudes and perception about their tinnitus (example = what was your first thought this morning)Show them the link between thoughts and emotionsI hate this noise elicits feelings of frustration, angerThis noise is okay is calmingWhen engaging in negative thoughts, challenge these thoughts; neutralize them or turn them into a positive.Engage in constructive thoughts
76Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears McKenna, L., Baguley, D. & McFerran, D. (2010) Living with tinnitus and hyperacusis. London: Sheldon Press.
77Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsNeed to have a discussion about automatic thoughtsWe all have negative, neutral and positive thoughtsGive examples in your own life (having lunch); discuss thoughts in their own lifeNeutral = I’m going to have lunchPositive = I can’t wait for lunch today they are having my favoriteNegative = Yuck I can’t stand what is being offered for lunch todayNeed to have a discussion about the emotional consequences of our thoughtsNeutral = I’m going to have lunch (no response)Positive = I can’t wait for lunch today they are having my favorite (excitement)Negative = Yuck I can’t stand what is being offered for lunch today (discuss)This is the basis of a CBT A-B-C modelA) the situation/eventB) thoughts/beliefsC) emotional consequence(waiting for a friend)
78Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsABC Modelgo back to pt’s own list and review“Why me?“I’m suffering”“I’m in agony”“I can’t live with this sound”Re-discussion of the emotional consequences of our thoughtsVicious cyclenegative thoughts – negative emotions – greater focus on the tinnitus/allowing the tinnitus importance – further negative thoughts – continued negative emotions…….Go back to pt’s own ABC Model and physically write out the emotions to understand their own vicious cycle“Why me? - helplessness“I’m suffering” – despair/depression“I’m in agony” – annoyance/frustration/tension“I can’t live with this sound” – hopelessness/miserable
79Connection Between Thoughts and Emotions Feedback LoopTinnitusProblemAnnoyedEventInterpretation/ BeliefConsequence
80Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsReview = In order to change your reaction you must become aware of your thoughtsHomework1 week of daily tallies monitoring the amount of negative thoughtsCompleting the ABC model daily (e.g. 3 times/day when doing your tally stop and complete your ABC model)Set aside time at the end of the day and think back over your day and pick 3 events and complete your ABC modelThis type of homework increases your awareness of your thoughtsProvides some control because the pt has an activity to completeSometime I see the number of tallies drop over 1 week simply by doing the activity
81Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsMight be helpful to review the 12 common styles of negative:All or nothing thinkingMind readingJumping to conclusionsEmotional reasoningOvergeneralizationBlamingCatastrophizing/MagnificationMinimizationShould statementsFilteringPersonalizationLabelingGo over the definitions via the book; find and highlight the ones that match the pt’s style of thinking(go over personal example)Go over their own list of negative thoughts with regard to their tinnitus and label them
82Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsFor some pts you need to quickly jump to the next discussion which is changing the negative automatic thoughtsPts need to learn to control the negative thinking (heart of CBT)A-B-C-D-E modelA) the situation/eventB) thoughts/beliefsC) emotional consequenceD) dispute or challenge your original thought THEN replaceE) new emotional consequence(personal example from last night)D – What are the chances the sound was due to a person who wants to harm meThat wasn’t a person it was a small, soft, fuzzy animalIt was just a sound/houses make sounds at night
83Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsGo back to pt’s own ABC Model and physically write out and add the D and EA – situation/event) Having TinnitusB - thought) “Why me?C - emotion) HelplessnessD - dispute/challenge/replace) I have tinnitus because there is damage in my auditory systemE – new emotion) Understanding/Reassurance/Neutral
84Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your EarsGo back to pt’s own ABC Model and physically write out and add the D and EA – situation/event) Having TinnitusB - thought) “I can’t live with this”C - emotion) Helplessness/Hopelessness/MiserableD - dispute/challenge/replace) My tinnitus is a bother, but I can live with it; My tinnitus is only a part of me and I enjoy life; My noise is not pleasant, but I can cope with it; this sound is okayE – new emotion) Reassurance/Neutral/Acceptance/PositiveRe-discussion of the vicious cycle after use of ABCDE modelnegative thoughts – negative emotions – greater focus on the tinnitus/allowing the tinnitus importance – further negative thoughts – continued negative emotions…….
85Change Negative Thoughts I hate this noise!I can’t live the rest of my lifewith this noise in my head!I can’t concentrate with thissound in my head!I know this noise can’t harm me,so I don’t need to be afraid of it;I can learn to ignore it.It’s OK if this noise doesn’t go awaybecause I can learn to put it in thebackground.Try to identify your thoughts, beliefs, attitudes and perception in response to your tinnitus (have a discussion with pt about these)What does/did pt believe the tinnitus was?Did they think the tinnitus was harmful to them?What goes on in their mind when they hear their tinnitus?When engaging in negative thoughts, challenge these thoughts.Engage in constructive thoughts
86Learning to Control Negative Thinking Takes a conscious effort!Visual cues (handouts that can be put in a visible place)Coping cards/Wild cardsThought-stopping TechniquesDistraction MethodsIncreasing Positive Thoughts (case example of catatonic pt – M-Ms)Increasing Pleasant Events (Scheduling them into your routine/showers/drives in the car/)Increasing Pleasant SoundsUse of mantrasAllow the tinnitus to be present; it’s not good or bad, it’s just a soundHelp pt feel a shift in the physical sense when going from negative to neutralUse neutral thoughts as much as possible when thinking or referring to your tinnitus“I can’t do this” – “This is okay, I can do this”“I’m so tired of this sound” – “This sound is okay”Letter to a Tinnitus Sufferer by Stephen M. Nagler, M.D., F.A.C.S.(Nagler SM. Letter to a Tinnitus Sufferer. Tinnitus Talk (Australian Tinnitus Association, NSW) Jun.)
88Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Change Emotional ReactionTakes a conscious effortWhen you can hear your tinnitus and not react with annoyance, etc. brain will learn to ignore itWe all have negative, neutral and positive thoughtsTake all negative thoughts and try to neutralize them, challenge them, replace them with something more constructive
89Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain) Tinnitus is realTinnitus can trigger stressStress can make tinnitus worseManaging stress can reduce tinnitusStress is a three-part reaction to something that people think they cannot cope with:Biological – increased blood pressure, muscle tension, etcEmotional – anxiety, sadness, anger, depressionCognitive – thoughts and images about the event and the self
90How we judge or appraise stress is important to know Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain)How we judge or appraise stress is important to knowThreat – the stress poses a danger that can outweigh your ability to cope; leads to avoidance or anxietyHarm/Loss – the stress has caused damage; leads to helplessness or depressionChallenge – the stress cannot outweigh your ability to cope; leads to determination and perseverance
91Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain) Patient #1:Tinnitus OnsetStressStress-AppraisalBiologicalHeart rate increasedLack of energyDeep breathing; Muscle relaxation; physical exercise; increase pleasant eventsEmotionalfeeling anxious (fear) and depressed (sad/loss)Imagery Training (self-talk); Muscle Relaxation; Deep Breathing; increase pleasant eventsCognitiveI hate my tinnitus! I want my old life backCBT (ABCDE Model); Mindfulness; expressive writing
92Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Focus on other areas of your lifeHelp them let go of hobbies that no longer work for them and to discover new hobbies; get them excited about a new chapter in their lifeFocus on activities for the intrinsic value of the activity and not as a method to reduce or get rid of your tinnitus (massage, acupuncture)
93Activities in Your Life If you are doing less in your life, does this help?If you keep so busy you can’t sit still, does this help?If you are doing this just to escape tinnitus, it is unlikely to helpActivities need some intrinsic value also
94Tinnitus Activities Therapy Thoughts and Emotions How do you change your reaction to tinnitus? Focus on other areas of your lifeStop comparing your “pre-tinnitus” lifestyle to your current lifestyle living with tinnitusRemind yourself that you have had an auditory insult; this is now the new you; no different than if you have been diagnosed with a disease
95Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Reduce the Contrast Between Tinnitus and Background SoundsTalk about ways to introduce low level noise or sounds into their environmentNon-wearableWearable options
110Thoughts and Emotions Two main patterns for greatly bothered tinn pts Rumination is a way of responding to distress that involves repetitively focusing on the symptoms of distress, and on its possible causes and consequences (focusing on the past)Worry is thoughts, images and emotions of a negative nature in which mental attempts are made to avoid anticipated potential threats (focusing on the future)
111Thoughts and Emotions Both patterns (rumination and worry) can create Anxiety/FearDepression/Grief/SadnessPerceived sense of helplessnessAvoidanceWhat sets these pts apart?They are bothered when they don’t hear their tinnitus(case example/fan)(case example/being in the shower)(case example/can’t describe the tinnitus because its not there)
112Rumination/Worry Learn techniques to stay in the moment Rumination keeps you thinking about the pastWorry keeps you wondering about the futureCreate a mantra (very powerful self-coaching tool)A word, sound or statement (“I statement”) that is frequently repeated to aid in concentration(case example of rumination)- guilt regarding cause of tinn/stuck; took a long time to come up with an appropriate mantra (“I am moving forward”)(case example of worry)- fear/stuck/what if the sound gets worse- “It is what it is right now” (Lamaze technique)- fear/stuck/wanting to travel- “I will go on this vacation” “I will be fine if my sleep is disrupted”
113Rumination/Worry Pair the mantra with an object to remember to use it (case example: rock/watch/small plastic piece of paper/sutinnit)
114Mindfulness (Jennifer Gans) Gans, O’Sullivan & Bircheff (2013) Mindfulness means paying attention in a particular way: On purpose, in the present moment, and nonjudgmentally (Kabat-Zinn, 1994)
115Mindfulness http://www. the-guided-meditation-site Most of the time we live our lives on "autopilot". Our minds seem to have a will of their own. Thoughts come and go, and it seems as though we don’t have much say in what thoughts turn up in our head.When we are not mindful of our thoughts, they skip from one unfinished idea to the next, constantly interrupting each other and overlapping in a constant stream of pictures, ideas, memories and desires.Children are free from much of this mental chatter and they are not burdened by the responsibilities of adulthood that we all know so well. To a young child the world is full of newness, fascination and wonderment. In some ways, practicing mindfulness is like reclaiming the pure, simple awareness that you had in your youth.Mindfulness activities will help you to appreciate your life more completely. They'll help you to free your mind and renew the way you experience your life.
116Mindfulness eating http://www. the-guided-meditation-site This mindfulness activity is definitely the tastiest of them all! It involves nothing more than eating a meal. HOWEVER, there are some do’s and don’ts that will turn this into a technique for mindfulness and not just any old meal.No gobbling! Eat slowly and deliberately. Mindful eating means paying full attention to each piece of food you select to eat, how it looks, how it smells, how you cut the food, the muscles you use to raise it to your mouth, the texture and taste of the food as you chew it slowly. Be absorbed by the experience.If possible, avoid engaging in any other activities. Put away the newspaper or book. Turn off the TV or radio, and remain quiet whenever you enjoy your mindful meals!You will be amazed at how much more enjoyable food can be when eaten in this way and how much more fulfilling a meal can be. Eating this way also happens to be very good for your digestion.Remember, the purpose of mindfulness is to bring you into the present moment, and to quiet your mind. The whole point of mindful eating is to dedicate your attention to the experience of eating, leaving no room for mental chatter. This is a meditation on the present moment and the present moment consists of you eating a meal...nothing more. If your mind wanders off, then bring your attention back to the experience of eating. Be with the moment throughout your mindful meal.
117Mindfulness walking http://www. the-guided-meditation-site The same principles apply to mindful walking as they do to mindful eating. In this mindful activity, you simply bring your full attention to the simple act of walking.With this mindfulness technique, you become consciously aware of and absorbed in the movement of your body as you walk.Concentrate on the feel of the ground under your feet, or your breathing as you travel. Just observe everything that you physically experience, staying in the present moment as you do so. If thoughts pop up, just let them go and return your awareness to the walk.
118Mindfulness listening http://www. the-guided-meditation-site When was the last time you REALLY listened to the sounds that are taking place around you? Most of the time you are surrounded by a whole range of environmental noises and most of them barely register in your awareness. Much like the noise inside your mind, external noises often go unnoticed. The noise in your mind and the noises in the world around you both form an invisible backdrop to your entire life. Stop and notice some of the sounds around you right now...the sound of the computer humming away under your desk. The car that passes by in the distance. The sound of the television in the next room. The birds outside. All these sounds present you with an excellent opportunity to experience the serenity that comes from mindful listening. Stop whatever you are doing and just listen. Sounds simple doesn’t it? Well it is simple, but this mindfulness activity does require some concentration or you’ll find your mind wandering off. If you are new to this experience then you may find that it will be more effective if you begin by deciding how long you will spend practicing mindful listening....You might say to yourself, "For the next five minutes, I will practice mindful listening." Now stick with it for that amount of time. Let the sounds you hear be your anchor to the present moment. Don’t judge what you hear or analyse the sounds, just listen, observe and experience them. If you become restless or impatient, notice these feelings and allow them, but do not react to them.
119Mindfulness breathing http://www. the-guided-meditation-site Breathing is absolutely crucial tool to learn to calm yourself down with. I recommend for everyone to do some in-depth research on proper breathing techniques and how to breathe powerfully with your diaphragm. Breathe in strongly and slowly through your nose as you expand your diaphragm. Your stomach should rise up and down, not your chest. Now, blow it out strongly and steadily through your mouth using your diaphragm. Repeat this several times.Sitting comfortably or lying down with eyes closed, let's begin by becoming aware of the breath......Feel the breath as it enters with a cool feeling and then warming as it gently travels down into the lungs.....Fill the lungs with a deep inhale, bringing in energy and vitality.....As you exhale, feel the body releasing toxins, stress and any negativity that has accumulated.....Stay with this breath, focusing on the feeling of deep peace for ten deep inhalations and exhalations....Feel the energy that is in the body....Become aware of the warmth and tingling of every cell.....Feel the energy that is in the extended environment, in every part of nature and in every living thing.....Bring all those energies together and feel them as one.....Visualize all of that energy shining brightly, as the sun.....Bring the shining glow of bright energy over the crown of the head.....Feel it starting to travel down into your body from the top of your head, slowly going down into your face and neck, traveling down into the shoulders, all the way down into the arms, down to the fingers.....Feel the healing energy and light going down into your chest, all the way down to your hips.....Feel it continue traveling down your legs all the way down to your toes.....Your whole body is now filled with divine healing light and energy.....Allow that healing energy to completely fill any physical area that needs healing energy.....Feel it warming, healing and expanding through the area......Allow the healing light to bring peace and healing to any emotional issues or traumas.....Bring your awareness to any intentions or desires that you may have.....Hold the thoughts of those intentions or desires as you allow the healing energy to bring your deepest desires to life and your intentions into reality.....Feel your connection to divine energy and light, and know that all is ONE.Stay with this deep, relaxing, peaceful feeling of bliss.
120“Pop Psychology”Sixteen Strategies for Combating Rumination How altering the inner dialogue enhances creativity and happiness Published on July 14, 2012 by Carrie Barron, M.D. in The Creativity Cure - for some pts this type of internet search is fun - takes the focus away from the tinnitus - can echo what you are saying during CBT
121Basic Relaxation Tools Tinnitus is more manageable when we are relaxed Muscle RelaxationImagery TrainingDeep BreathingMindfulness TrainingApplied relaxation (Gerhard Andersson – Tinnitus Treatment Clinical Protocols)NeurofeedbackWhat can the pt do for better relaxation????
122Depression and Tinnitus Break your routine - Going through the same routine, day after day, can be monotonous and depressing. It often leads to getting caught in a rut. To get out of it you need to temporarily change your routine. Do something you don’t normally have time for or something you’ve never tried.Start a project. For many, this may seem like that last thing they want to do but an enjoyable project can give you something to concentrate on that will bring your thoughts away from depression and give you something to feel proud of when you’re done.
123Tinnitus and the Spouse/Partner/Loved One I invite loved ones to sessions if the patient wants thatI am not a marriage counselor OR a certified family counselor so I make that clear and if problems arise I stop the drama and make referralsI feel it is important for the pt’s support system to also understand the basics of tinnitus and try to appreciate what the pt is going through (especially in the beginning)HOWEVER, I feel it is important that the pt not use their support system as a therapy systemAdvice from a fellow tinn suffer “Stop talking about your suffering with your friends and family members. They love you and want to help, but there is nothing they can do. Keep those discussions with your tinnitus professional.”
124Tinnitus and the Spouse/Partner/Loved One Marriage Help: Coping with a Spouse's IllnessCoping with a Sense of LossThe Impact of Shifting RolesCoping with UncertaintyLetting Go of GuiltUnderstanding the sick partner's emotional reactionsTinnitus Spouse Survival by Terri E. Nagler, R.N.
125Counseling Techniques Stuttering Foundation DVD featuring Dr. David LutermanDavid M. Luterman, Ed.D., CCC-SLP, joins Peter Reitzes and Eric Jackson interview to discuss counseling people who stutter and their families. We ask Dr. Luterman to discuss counseling from both speech therapy and self-help perspectives.Dr. Luterman’s Stuttering Foundation DVD tiled Sharpening Counseling Skills and his book Counseling Persons with Communication Disorders and Their Families.No cheerleadingBest compliment…….when a pt stops treatment and you never hear from them again….you have clearly taught them tools.Tools for Success: A Cognitive Behavior Therapy Taster
127Tinnitus Activities Treatment Hearing and Communication Difficulties Helps pt separate what is a hearing and communication difficulty versus a tinnitus issueFactors that affect hearing and communicationHow tinnitus can affect hearingHow to improve your hearing
1285. Strategies to Improve Hearing and Communication AmplificationReducing background noiseWatching facesUsing ‘repair’ strategiesPositively influencing the communication situation
132Tinnitus Activities Treatment Concentration Another mini-lectureProvides basic informationWhat is concentrationWhy is it importantThings that affect concentrationHow tinnitus affects concentration
133Concentration is Important Necessary to complete many tasksInability to concentrate results in frustration and stressGood concentration will enable you to remember more
1341. Things That Affect Concentration The environmentNoiseDistractionsLightingTemperature
135Tinnitus Activities Treatment Concentration Another mini-lectureProvides an opportunity for pt to think about specific problems they are having with concentrationProvides information on how to improve concentrationAllows pt to take a mental inventory of whether they have tried to make a difference or not
1363. Strategies to Improve Concentration Eliminate distractionsAdjust work habitsStay focusedConsider task difficultyDecrease prominence of tinnitusTake control of your attention
137Effects of Tinnitus on Concentration Observe the effects of tinnitus on your concentration when you are doing simple or complex tasks.Simple tasks (e.g. filing) may not be stimulating enough – tinnitus fills in the gaps.Complex tasks (e.g. learning a new computer program) are more demanding – tinnitus less noticeableEffects can be different for each person
138Tinnitus Activities Treatment Concentration Some tinnitus pt complain of poor memory and inability to concentrateIn the field of cognitive psychology there is a divided attention theory (Kahneman, 1973) that suggest that we have a limited capacity for attentionPerhaps if someone is overfocused on tinnitus there is less attention for other cognitive tasksConcentration can become easier for some individuals as they focus less and less on their tinnitus
140Tinnitus Activities Treatment Sleep Another mini-lectureProvide basic informationNormal sleep patternsThings that affect sleepDaytime activities to facilitate sleepEvening activities to facilitate sleepPreparing for sleepWaking up at nightWaking up in the morning
1411. Normal Sleep Patterns Tinnitus doesn’t usually wake people Normally, the amount of sleep required varies greatly from one individual to another(6 ½ - 9 hours/ night)Normal sleep includes several periods of light sweep or awakeningsOlder adults have more awakeningsTinnitus doesn’t usually wake peopleBut when they wake normally and hear tinnitus, it may create difficulties getting back to sleep
142Normal stages of sleep during one night. Sleep stages cycle from light (stage 1) to deep (stage 4) and the cycle can repeat many times.
143Tinnitus Activities Treatment Sleep Provides an opportunity for pt to think about specific problems they are having with sleepTo think about their sleep hygieneIntroduces the concept of a worry diaryGives you an opportunity to introduceProgressive muscle relaxationImagery training
144Progressive Muscle Relaxation Two stepsDeliberately apply tension to certain muscle groupsStop the tension and focus on how the muscles feel as they relax
145Imagery Training Similar to daydreaming Attention is focused on some type of sensory experienceCreating novel mental imagesRecalling past places and eventsWarm and cozyThe smell of roses
151Advice from a pt who had been in counseling for 1 year (ruminator) Work with a tinnitus professional because they understand what is going on, but be open to working with other professionals as wellStop talking about your suffering with your friends and family members. They love you and want to help, but there is nothing they can do. Keep those discussions with your tinnitus professional.Have faith that things will get better.No matter the characteristics of your tinnitus focus on your thoughts and try to control them, not the tinnitus.