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Tinnitus Activities Treatment Shelley Witt, MA/CCC-A The University of Iowa Department of Otolaryngology – Head and Neck Surgery.

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Presentation on theme: "Tinnitus Activities Treatment Shelley Witt, MA/CCC-A The University of Iowa Department of Otolaryngology – Head and Neck Surgery."— Presentation transcript:

1 Tinnitus Activities Treatment Shelley Witt, MA/CCC-A The University of Iowa Department of Otolaryngology – Head and Neck Surgery

2 Tinnitus Patient #1 Problems with concentration; struggles to read Emotional disturbance; Can no longer make decisions; forgetful; confused Has 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 life Because of the tinnitus must keep a very strict routine or else her sleeping pattern becomes disrupted and without sleep she cannot function Family very disappointed in her (changing roles)

3 Purpose of Today’s Talk Introduce you to a counseling approach that is currently being used and has been found to be successful in some patients No magic; all clinicians can do this; not all patients need to fly to Iowa City Recognize that the Iowa Clinic is unique in that we do specialize in Tinnitus and Hyperacousis The Iowa approach may need to be modified for your clinic Get you excited about providing this type of treatment

4 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 4 Tinnitus A sound produced in your ear(s) or head Different sounds heard by different people (e.g. ringing, buzzing, hissing, etc.)

5 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 5 Tinnitus is Common 10 in 100 (10%) people have tinnitus 1 in 100 (1%) people are bothered by their tinnitus

6 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 6 Who Will Come Into Your Office? 1.Curious -What is this sound? 2.Concerned but not bothered -Can this sound hurt me? -Could it get worse? 3.Distressed -Can’t sleep -Can’t concentrate -Feel anxious -Are depressed -Contemplate suicide 10 in 100 (10%) people have tinnitus 1 in 100 (1%) people are bothered by their tinnitus

7 SoundCure ® 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.”

8 Tinnitus Activities Treatment A counseling and sound therapy treatment Picture-based Focused on individual needs Directed at primary areas affected by tinnitus 1) Thoughts and Emotions 2) Hearing and Communication 3) Sleep 4) Concentration

9 Tinnitus Activities Treatment Is provided for free on our website

10 http://www.medicine.uiowa.edu/oto/research/tinnitus/ Activity Therapy Pictures Below 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. Introduction Thoughts and Emotions Review of Thoughts and Emotions Hearing and Communication Review of Hearing and Communication Sleep Review of Sleep Concentration Review of Concentration Summary

11 Tinnitus Activities Treatment The series of pictures –Provide orderly fashion –Not overlook important concepts –Easy format to understand concepts

12 Tinnitus Activities Treatment There is no right or wrong way to use the pictures There is no specific order There are a few main topics but you can pick and choose how you want to use them and in which order you’d like

13 Tinnitus 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 time –not easy concepts –not easy for everyone to incorporate into their daily life –can be the most helpful

14 Tinnitus Activities Treatment Providing handouts after each session can be helpful Using the handout as a quick review prior to a new session can also be helpful A tinnitus diary is a great tool to help pts better understand their own thoughts and emotions Handouts will be provided

15 Tinnitus Activities Treatment Introduction (Tinnitus History) Allows the pt to tell their story Answers to questions given during this session can influence the direction of counseling More listening than talking Pts first opportunity to tell the whole story

16 Where do you want to start?

17 What do you think caused your tinnitus? Unknown? Noise Head Injury Age Medications Disease

18 When your tinnitus began, what was your life like (home, work, etc)?

19 How has tinnitus influenced your life?

20 How 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)

21 Clinician Responsibilities Listen Be Patient Be Sympathetic Be Encouraging; but not a cheerleader Be Able to Talk Candidly Have Confidence in Your Ability to Help Guide Have the time

22 Understand Your Role Help your patient –learn how to successfully live with tinnitus –not eliminate the tinnitus, but rather to function in spite of the tinnitus –adopt a new identity as a person with tinnitus –become their own coach –figure out which techniques/tools work best for them

23 Make 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”

24 Tell Yourself That It’s Okay If You Don’t Know all the Answers Be honest and supportive –Pt: “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.

25 Be willing to address additional support Mental health counselor; psychologist This process of tinnitus counseling can uncover additional areas that might need to be addressed –Anxiety, Depression, Marital Problems, Loss of Identity Make referrals; work in conjunction with other professionals

26 Identify the Psychology that was there prior to the tinnitus Have a discussion about pre-vs-post tinnitus disposition –What was your sleep like prior to tinnitus –Did you ever have depression prior to tinnitus –Prior to tinnitus have you ever had an episode of anxiety In general whatever psychology was there prior to the tinnitus can be magnified post-tinnitus -If you have generalized anxiety disorder, depression this path might be harder -If your marriage was strong if might hit some roadblocks; if your marriage was weak it might fall apart

27 © Copyright: R.S. Tyler 2006, The University of Iowa Intro 27 Your Outlook on Life Are you depressed? NoYes No Are you anxious?

28 © Copyright: R.S. Tyler 2006, The University of Iowa Intro 28 How would you describe yourself? –e.g. curious, concerned, distressed, sad… What are some things you are doing to help with your tinnitus?

29 Set Goals List goals for using sound therapy –Hearing better –Notice tinnitus less List goals for counseling –Not hate my tinnitus –Return to a more normal life –Attend meetings –Go to movies

30 Tinnitus Activities Treatment Thoughts and Emotions (many parts) 1.Hearing and hearing loss 2.Tinnitus 3.Attention, behavior, and emotions 4.Changing your reactions 5.Activities for home

31 Tinnitus Activities Treatment Thoughts and Emotions 1) Information about Hearing, Hearing loss and Tinnitus Provide knowledge to remove unknowns, misconceptions, fears use patient’s own audiogram section that most audiologists feel comfortable discussing

32 How We Hear

33 Hair Cells in Cochlea

34 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 34 Nerve activity carries information to the brain Inner Hair Cell Nerve Activity Nerve Fiber To Brain

35 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 35 Causes of Hearing Loss Unknown? Noise Head Injury Age Medications Disease

36 Normal Hearing Loss Hair Cells

37 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 37 Protecting Your Hearing Avoid exposure to very LOUD sounds whenever possible If noise is unavoidable, wear ear protection to prevent damage to your ears Exposure to everyday loud sounds is okay

38 Tinnitus Tinnitus results from damage to the hearing system –May be associated with hearing loss Tinnitus will not damage your hearing Hearing may continue to decrease, but not because of tinnitus

39 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 39 There are many different causes of tinnitus Unknown? Noise Head Injury Age Medications Disease

40 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 40 Auditory System Tinnitus, whatever the cause, must be represented in the brain in the auditory area. It is represented there like any other sound. It can be measured.

41 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 41 Tinnitus is likely the result of an increase in spontaneous nerve activity Hearing Loss (No Tinnitus) Normal Hearing Tinnitus Hear Silence Hear Silence Hear Sound

42 Robert Sweetow model Carol Bauer animal research

43 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 43 What does your tinnitus sound like? Whistle Cricket Your tinnitus?

44 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 44 Currently no drug, surgery or other treatments can reliably eliminate the source of tinnitus However, you can change your reaction to tinnitus and how it affects you

45 Basic 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 tinnitus Curious and Concerned Patients 1 in 100 (1%) people are bothered by their tinnitus Distressed Patients

46

47 Therapeutic Challenges Areas that create roadblocks to living successfully with tinnitus Not acknowledging grief regarding having tinnitus Giving up ways of controlling your tinnitus Controlling your thoughts and emotions about tinnitus

48 Acknowledge grief Ask the pt how they are feeling about having tinnitus and its impact on their life Create an atmosphere where it is okay for the pt to grieve –Grief over the loss of silence –Grief over changes in lifestyle (less spontaneous; letting go of hobbies) Verbalize that it is okay to be sad and to cry Acknowledge their emotional upset; help them come to terms with the fact that this has happened and is disrupting their life The introduction is a great time to address this

49 Acknowledge grief Grief may surface throughout many sessions In later sessions start re-directing the grief towards a change in thinking Example: 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 life Warn 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….”

50 Acknowledge grief Pts must move past the grieving stage and must start taking control If 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 tinnitus –Write 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 life –Write continuously; don’t worry about spelling, grammar or repeating yourself –It’s natural to experience a wide range of emotions, including sadness and anger and it’s okay to express them –Do this for 3 consecutive days; at the end of the assignment 1.Keep the writings for future reference OR 2.Make a ceremony of burning the writings to let go of the emotions and to take with them what they have learned

51 Acknowledge grief Review the assignment by asking the pt –If they completed it –What they learned –Did they see any patterns (can help you find a focus for counseling) –How they felt over the course of 3 days –What 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)

52 Let 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 doing Get 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

53 Let 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

54 Let 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 tinnitus Stop 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 email 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)

55 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 55 Thoughts and Emotions (Goals) 1. Change Interpretation of Importance 2. Change Emotional Reaction 3. Refocus on Other Activities 4. Reduce Contrast Between Background Sound and Tinnitus

56 Tinnitus 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 attention How things capture our attention How we can direct our attention Why some things cannot be ignored

57 Two Types of Attention Conscious— 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.

58 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 58 We are not even aware that our subconscious monitoring goes on all the time Did I hear my name? Blah, blah, blah, Fred, blah, blah

59 Normally, we focus our attention on one stimulus at a time Subconscious Conscious

60 Many stimuli compete for our attention Smell Vision Touch Sound Taste

61 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 61 Several things can influence our attention Unknown? Emotional state Important event Novelty

62 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 62 We can direct our conscious attention to different smells, sounds or things we feel Subconscious Conscious

63 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 63 An important sound can ‘grab’ our attention Subconscious Conscious

64 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 64 Some stimuli cannot be ignored

65 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 65 Things that capture our attention Unusual Scary Unexpected Important

66 Tinnitus Activities Treatment Thoughts and Emotions Purpose of this mini-lecture help pt understand We are meant to notice important stimuli We are meant to ignore unimportant stimuli Right now tinnitus is important and is very noticeable You do have control over what you are attending to –practice adjusting attention –help them find some control

67 Attention Control Exercises Learn to switch attention from one stimulus (e.g. object, sensation, thought, activity) to another at will Allows you to refocus your attention from your tinnitus onto other stimuli, external or internal

68 Tinnitus and Attention If you determine tinnitus is not important, the tinnitus will be easier to habituate to If you determine tinnitus is important, you will attend to it

69 Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? (Summary) Change Interpretation of Importance –Understand Tinnitus –Use self-talk to remind yourself that 1.Tinnitus is likely the result of increased spontaneous nerve activity 2.Many people have tinnitus – you are not alone 3.Tinnitus is not threatening your health or hearing 4.Tinnitus and your reaction to tinnitus are two different things (physiology vs perception)

70 Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Change Emotional Reaction

71 Tinnitus Activities Treatment Thoughts and Emotions Understand the Connection between our Thoughts and our Emotions

72 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 72 Our Thoughts and Emotions Doorbell Neutral Anxiety Happiness Fire Injury Angry neighbor Flowers Friend Prize

73 Tinnitus Activities Treatment Thoughts and Emotions Identify Unhealthy (negative) Thoughts

74 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 74 Change Negative Thoughts What kind of thoughts have you had about your tinnitus? –Situations where tinnitus is bothersome –Thoughts and beliefs about tinnitus –Feelings about tinnitus

75 Tinnitus 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 emotions –I hate this noise elicits feelings of frustration, anger –This noise is okay is calming When engaging in negative thoughts, challenge these thoughts; neutralize them or turn them into a positive. Engage in constructive thoughts

76 Cognitive 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.

77 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears Need to have a discussion about automatic thoughts –We all have negative, neutral and positive thoughts –Give examples in your own life (having lunch); discuss thoughts in their own life Neutral = I’m going to have lunch Positive = I can’t wait for lunch today they are having my favorite Negative = Yuck I can’t stand what is being offered for lunch today Need to have a discussion about the emotional consequences of our thoughts Neutral = 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 model –A) the situation/event –B) thoughts/beliefs –C) emotional consequence (waiting for a friend)

78 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears ABC Model –go 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 thoughts Vicious cycle –negative 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

79 ProblemTinnitus ConsequenceInterpretation/ Belief Annoyed Event Feedback Loop Connection Between Thoughts and Emotions

80 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears Review = In order to change your reaction you must become aware of your thoughts Homework –1 week of daily tallies monitoring the amount of negative thoughts –Completing 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 model This type of homework increases your awareness of your thoughts Provides some control because the pt has an activity to complete Sometime I see the number of tallies drop over 1 week simply by doing the activity

81 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears Might be helpful to review the 12 common styles of negative: All or nothing thinking Mind reading Jumping to conclusions Emotional reasoning Overgeneralization Blaming Catastrophizing/Magnification Minimization Should statements Filtering Personalization Labeling Go 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

82 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears For some pts you need to quickly jump to the next discussion which is changing the negative automatic thoughts Pts need to learn to control the negative thinking (heart of CBT) A-B-C-D-E model –A) the situation/event –B) thoughts/beliefs –C) emotional consequence –D) dispute or challenge your original thought THEN replace –E) new emotional consequence (personal example from last night) D – What are the chances the sound was due to a person who wants to harm me That wasn’t a person it was a small, soft, fuzzy animal It was just a sound/houses make sounds at night

83 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears Go back to pt’s own ABC Model and physically write out and add the D and E A – situation/event) Having Tinnitus B - thought) “Why me? C - emotion) Helplessness D - dispute/challenge/replace) I have tinnitus because there is damage in my auditory system E – new emotion) Understanding/Reassurance/Neutral

84 Cognitive Behavioral Approach (CBT) Henry and Wilson (2002) A Self-Management Guide For The Ringing In Your Ears Go back to pt’s own ABC Model and physically write out and add the D and E A – situation/event) Having Tinnitus B - thought) “I can’t live with this” C - emotion) Helplessness/Hopelessness/Miserable D - 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 okay E – new emotion) Reassurance/Neutral/Acceptance/Positive Re-discussion of the vicious cycle after use of ABCDE model –negative thoughts – negative emotions – greater focus on the tinnitus/allowing the tinnitus importance – further negative thoughts – continued negative emotions…….

85 Change Negative Thoughts I hate this noise! I can’t live the rest of my life with this noise in my head! I can’t concentrate with this sound 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 away because I can learn to put it in the background.

86 Learning to Control Negative Thinking Takes a conscious effort! –Visual cues (handouts that can be put in a visible place) –Coping cards/Wild cards –Thought-stopping Techniques –Distraction Methods –Increasing Positive Thoughts (case example of catatonic pt – M-Ms) –Increasing Pleasant Events (Scheduling them into your routine/showers/drives in the car/) –Increasing Pleasant Sounds –Use of mantras –Allow the tinnitus to be present; it’s not good or bad, it’s just a sound –Help pt feel a shift in the physical sense when going from negative to neutral –Use 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). 2008 Jun.)

87 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 87 You can change your emotional reactions Tinnitus Negative Thoughts Constructive thoughts Tinnitus not as prominent Negative Reaction Anxiety, Irritation Less Irritation No Reaction

88 Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Change Emotional Reaction –Takes a conscious effort –When you can hear your tinnitus and not react with annoyance, etc. brain will learn to ignore it –We all have negative, neutral and positive thoughts –Take all negative thoughts and try to neutralize them, challenge them, replace them with something more constructive

89 Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain) Tinnitus is real Tinnitus can trigger stress Stress can make tinnitus worse Managing stress can reduce tinnitus Stress is a three-part reaction to something that people think they cannot cope with: –Biological – increased blood pressure, muscle tension, etc –Emotional – anxiety, sadness, anger, depression –Cognitive – thoughts and images about the event and the self

90 Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain) How we judge or appraise stress is important to know –Threat – the stress poses a danger that can outweigh your ability to cope; leads to avoidance or anxiety –Harm/Loss – the stress has caused damage; leads to helplessness or depression –Challenge – the stress cannot outweigh your ability to cope; leads to determination and perseverance

91 Stress – Appraisal Connection (taken from Beverly Thorn; Cognitive Therapy for Chronic Pain) Tinnitus OnsetStressStress-Appraisal Biological 1)Heart rate increased 2)Lack of energy Deep breathing; Muscle relaxation; physical exercise; increase pleasant events Emotionalfeeling anxious (fear) and depressed (sad/loss) Imagery Training (self-talk); Muscle Relaxation; Deep Breathing; increase pleasant events CognitiveI hate my tinnitus! I want my old life backCBT (ABCDE Model); Mindfulness; expressive writing Patient #1:

92 Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Focus on other areas of your life –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 life –Focus on activities for the intrinsic value of the activity and not as a method to reduce or get rid of your tinnitus (massage, acupuncture)

93 Activities 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 help –Activities need some intrinsic value also

94 Tinnitus Activities Therapy Thoughts and Emotions How do you change your reaction to tinnitus? Focus on other areas of your life –Stop comparing your “pre-tinnitus” lifestyle to your current lifestyle living with tinnitus –Remind 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

95 Tinnitus Activities Treatment Thoughts and Emotions How do you change your reaction to tinnitus? Reduce the Contrast Between Tinnitus and Background Sounds –Talk about ways to introduce low level noise or sounds into their environment –Non-wearable –Wearable options

96 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 96 Tinnitus Low Level Noise Tinnitus in Low Level Noise Low level noise makes tinnitus more difficult to detect

97 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 97 Ways to Add Low Level Background Sound Use sound in the environment

98 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 98 Do any sounds make your tinnitus less noticeable?

99 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 99 Activities for Home

100 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 100 Activities 1.Identify activities you would enjoy 2.Try different low-level sounds in the background

101 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 101 Activities 3. Complete the Tinnitus Diary –Modify your lifestyle to engage in activities where tinnitus is less noticeable/bothersome –Use low-level background sound to make tinnitus less prominent

102 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 102 Tinnitus Diary Write down your thoughts and worries about tinnitus 1.____My tinnitus will ….________ 2.____________________________ Check to see if these thoughts match what actually happens 1.____________________________ 2.____________________________ List the alternative ways of thinking about tinnitus that you find helpful e.g. I have tinnitus, but it is really a small part of my life. 1.____________________________ 2.____________________________ We will discuss your thoughts next visit.

103 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 103 Tinnitus Diary List things that reduce your tinnitus 1.________________ 2.________________ 3.________________ 4.________________ 5.________________ 6.________________ 7.________________ List things that worsen your tinnitus 1.________________ 2.________________ 3.________________ 4.________________ 5.________________ 6.________________ 7.________________

104 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 104 Tinnitus Diary List sounds you enjoy 1.________________ 2.________________ 3.________________ 4.________________ 5.________________ 6.________________ 7.________________ List activities you enjoy 1.________________ 2.________________ 3.________________ 4.________________ 5.________________ 6.________________ 7.________________

105 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 105 Tinnitus Diary List alternative activities to engage in when you find tinnitus bothersome 1.________________ 2.________________ 3.________________ 4.________________ 5.________________ 6.________________ 7.________________

106 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 106 Tinnitus Diary For a two week time period, keep a list of new activities you engage in each day and the effect your activities have on your tinnitus. List any low level background sound you used & its effect on your tinnitus

107 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 107 Tinnitus Diary Week 1 Make changes in your daily life so you are doing more activities where your tinnitus is better and fewer activities where your tinnitus is worse. List the new activities and how your tinnitus was affected. Activity: Day 1____________________ ____________________________ Day 2____________________ ____________________________ Day 3____________________ ____________________________ Day 4____________________ ____________________________ Day 5____________________ ____________________________ Day 6____________________ ____________________________ Day 7____________________ _____________________________ Effect on Tinnitus: Day 1____________________ ____________________________ Day 2____________________ ____________________________ Day 3____________________ ____________________________ Day 4____________________ ____________________________ Day 5____________________ ____________________________ Day 6____________________ ____________________________ Day 7____________________ _____________________________

108 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 108 Tinnitus Diary Week 2 Activity: Day 1____________________ ____________________________ Day 2____________________ ____________________________ Day 3____________________ ____________________________ Day 4____________________ ____________________________ Day 5____________________ ____________________________ Day 6____________________ ____________________________ Day 7____________________ _____________________________ Effect on Tinnitus: Day 1____________________ ____________________________ Day 2____________________ ____________________________ Day 3____________________ ____________________________ Day 4____________________ ____________________________ Day 5____________________ ____________________________ Day 6____________________ ____________________________ Day 7____________________ _____________________________

109 © Copyright: R.S. Tyler 2006, The University of Iowa Thoughts & Emotions 109 Tinnitus Diary After two weeks, stop keeping this diary. The goal of this diary is to help you make changes in your daily life so you are doing more activities where your tinnitus is better and fewer activities where your tinnitus is worse. The diary will also help you find alternative activities you may engage in to take your mind off your tinnitus.

110 Thoughts 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)

111 Thoughts and Emotions Both patterns (rumination and worry) can create –Anxiety/Fear –Depression/Grief/Sadness –Perceived sense of helplessness –Avoidance What 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)

112 Rumination/Worry Learn techniques to stay in the moment –Rumination keeps you thinking about the past –Worry keeps you wondering about the future Create 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”

113 Rumination/Worry Pair the mantra with an object to remember to use it (case example: rock/watch/small plastic piece of paper/sutinnit)

114 Mindfulness (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)

115 Mindfulness http://www.the-guided-meditation-site.com/mindfulness-activities.html 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.

116 Mindfulness eating http://www.the-guided-meditation-site.com/mindfulness-activities.html 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.

117 Mindfulness walking http://www.the-guided-meditation-site.com/mindfulness-activities.html 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.

118 Mindfulness listening http://www.the-guided-meditation-site.com/mindfulness-activities.html 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.

119 Mindfulness breathing http://www.the-guided-meditation-site.com/mindfulness-activities.html 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

121 Basic Relaxation Tools Tinnitus is more manageable when we are relaxed Muscle Relaxation Imagery Training Deep Breathing Mindfulness Training Applied relaxation (Gerhard Andersson – Tinnitus Treatment Clinical Protocols) Neurofeedback What can the pt do for better relaxation????

122 Depression 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.

123 Tinnitus and the Spouse/Partner/Loved One I invite loved ones to sessions if the patient wants that I 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 referrals I 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 system Advice 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.”

124 Tinnitus and the Spouse/Partner/Loved One Marriage Help: Coping with a Spouse's Illness http://www.articlesbase.com/marriage-articles/marriage-help-coping-with-a-spouses-illness-826450.html –Coping with a Sense of Loss –The Impact of Shifting Roles –Coping with Uncertainty –Letting Go of Guilt –Understanding the sick partner's emotional reactions Tinnitus Spouse Survival by Terri E. Nagler, R.N.

125 Counseling Techniques Stuttering Foundation DVD featuring Dr. David Luterman David 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 cheerleading Best 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

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127 Tinnitus Activities Treatment Hearing and Communication Difficulties Helps pt separate what is a hearing and communication difficulty versus a tinnitus issue –Factors that affect hearing and communication –How tinnitus can affect hearing –How to improve your hearing

128 5. Strategies to Improve Hearing and Communication 1.Amplification 2.Reducing background noise 3.Watching faces 4.Using ‘repair’ strategies 5.Positively influencing the communication situation

129 © Copyright: R.S. Tyler 2006, The University of Iowa Hearing 129 Communication Styles Assertive –Interacts appropriately, guides communication partner –Takes responsibility for communication difficulties Passive –Withdraws from conversations/avoids social situations –Bluffing/nodding/pretending to understand Aggressive –Dominates conversation –Bad attitude, hostile/belligerent, unwilling to take responsibility for communication difficulties

130 © Copyright: R.S. Tyler 2006, The University of Iowa Hearing 130 Communication Repairs and Style What communication style do you believe best describes you? What repair strategies would you be most comfortable using?

131 © Copyright: R.S. Tyler 2006, The University of Iowa Hearing 131 Communication Style Take charge of hearing loss by using an effective communication style Guide your communication partner Inform communication partners that you have a hearing loss

132 Tinnitus Activities Treatment Concentration Another mini-lecture Provides basic information –What is concentration –Why is it important –Things that affect concentration –How tinnitus affects concentration

133 Concentration is Important Necessary to complete many tasks Inability to concentrate results in frustration and stress Good concentration will enable you to remember more

134 1. Things That Affect Concentration The environment –Noise –Distractions –Lighting –Temperature

135 Tinnitus Activities Treatment Concentration Another mini-lecture Provides an opportunity for pt to think about specific problems they are having with concentration Provides information on how to improve concentration Allows pt to take a mental inventory of whether they have tried to make a difference or not

136 3. Strategies to Improve Concentration A.Eliminate distractions B.Adjust work habits C.Stay focused D.Consider task difficulty E.Decrease prominence of tinnitus F.Take control of your attention

137 Effects 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 noticeable Effects can be different for each person

138 Tinnitus Activities Treatment Concentration Some tinnitus pt complain of poor memory and inability to concentrate –In the field of cognitive psychology there is a divided attention theory (Kahneman, 1973) that suggest that we have a limited capacity for attention –Perhaps if someone is overfocused on tinnitus there is less attention for other cognitive tasks –Concentration can become easier for some individuals as they focus less and less on their tinnitus

139 © Copyright: R.S. Tyler 2006, The University of Iowa Concentration 139 B. Adjust Work Habits Work in shorter time spans Set a realistic pace Take breaks as needed Reward yourself when task is complete

140 Tinnitus Activities Treatment Sleep Another mini-lecture Provide basic information –Normal sleep patterns –Things that affect sleep –Daytime activities to facilitate sleep –Evening activities to facilitate sleep –Preparing for sleep –Waking up at night –Waking up in the morning

141 1. Normal Sleep Patterns 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 awakenings –Older adults have more awakenings Tinnitus doesn’t usually wake people –But when they wake normally and hear tinnitus, it may create difficulties getting back to sleep

142 Normal stages of sleep during one night. Sleep stages cycle from light (stage 1) to deep (stage 4) and the cycle can repeat many times.

143 Tinnitus Activities Treatment Sleep Provides an opportunity for pt to think about specific problems they are having with sleep To think about their sleep hygiene Introduces the concept of a worry diary Gives you an opportunity to introduce –Progressive muscle relaxation –Imagery training

144 Progressive Muscle Relaxation Two steps 1.Deliberately apply tension to certain muscle groups 2.Stop the tension and focus on how the muscles feel as they relax

145 Imagery Training Similar to daydreaming Attention is focused on some type of sensory experience –Creating novel mental images –Recalling past places and events Warm and cozy The smell of roses

146 © Copyright: R.S. Tyler 2006, The University of Iowa Sleep 146 3. Daytime Activities to Facilitate Sleep Avoid napping –Don’t modify behavior after a poor night of sleep Get regular exercise –3 to 4 hours prior to sleep Lead life as normally as possible, even if tired

147 © Copyright: R.S. Tyler 2006, The University of Iowa Sleep 147 4. Evening Activities to Facilitate Sleep Create a curfew separating day and night (at least 1½ hours before bedtime) –for example, 8:00 pm After that time –Avoid stress, exercise, eating, alcohol, caffeine

148 © Copyright: R.S. Tyler 2006, The University of Iowa Sleep 148 Evening Activities to Facilitate Sleep Exercise during the ‘day’ period Go to bed only when tired enough to sleep Sleep is best when you make the least effort

149 © Copyright: R.S. Tyler 2006, The University of Iowa Sleep 149 Ways to Reduce Worrying at Bedtime 1.Set aside time before curfew to write down your worries—deal with them in the morning 2.If you think of additional concerns when in bed, write them down and go back to sleep 3.Do this approximately 1 hour before bedtime, so that the mind is not still buzzing from this.

150 © Copyright: R.S. Tyler 2006, The University of Iowa Sleep 150 Sound and Your Spouse Play sound 24 hours/day that you both agree is pleasant Use a pillow loudspeaker that only you will hear You go to sleep first listening to sound that turns off with a timer

151 Advice from a pt who had been in counseling for 1 year (ruminator) 1.Work with a tinnitus professional because they understand what is going on, but be open to working with other professionals as well 2.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. 3.Have faith that things will get better. 4.No matter the characteristics of your tinnitus focus on your thoughts and try to control them, not the tinnitus.


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