The Treatment of Tinnitus Using Cognitive Behavioral Therapy (CBT)

Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present in the environment. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus? There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

What are the components of the CBT treatment for tinnitus?

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Listening Effectively to Strong Emotions

Listening effectively is hard. Especially when the other person has strong negative emotions. We usually and intuitively do the wrong things.

Let me give you a quick test.

Which of the following is a better response?

Speaker: I’m so depressed about being passed over for a promotion at work. I’m worried that I’m going to be fired, or just that I’ll never get another promotion.

Listener:

  1. Cheer up, it’s not that bad. You still have a job and I’m sure eventually you’ll get promoted.
  2. Wow, that sounds really upsetting. It makes sense that you’re feeling down. Being passed over is a huge disappointment. And it also sounds like you’re worried about the future and your job. Tell me more.

Which do you think is a better response? If you picked a) then you are in good company. Most people think that that’s a better response. It’s a response that attempts to change the person’s emotion to a positive one. What’s wrong with this?

What’s wrong with it is that it is based on what I call the switch-on-the-forehead model of human emotion. In this model, we imagine that there’s a switch panel on our forehead that controls all of our negative emotions. If you feel depressed,  just reach up and flip the depressed switch to the off position. If you feel anxious, do the same with the anxiety switch. I’ve written quite a bit about depression and anxiety in previous posts, and this model of negative emotion doesn’t really work. 

Emotional Toggle Switches

Too bad we don’t have one of these on our forehead! Instead, we need to listen effectively to strong emotions.

Unfortunately, human beings don’t actually have an emotional switch panel. In reality, we are really bad at changing our feelings quickly. When someone we are talking to implies we should be able to switch off our negative emotion we end up feeling the original painful negative emotion as well as an additional layer of shame that we can’t control.

We say things like “I feel so weak that I can’t overcome my depression.” “I’m such a loser to get so anxious about a job interview.” “I should not get so angry.” Notice that all of these statements are trying to negate a strong emotion and shame comes with failing to do so.

It gets worse. There’s actually quite a bit of research on thought suppression and what this research has found is what I call the pink elephant effect. The more you try not to think or feel something the stronger those thoughts and feelings become. Try not to think of a pink elephant and if you try hard enough that will be all you can think about. This is also true of anxiety, anger, sadness, and virtually all negative emotions. Thus when we try to “cheer up” someone who is upset, it usually backfires.

Why do people use invalidating listening responses instead of listening effectively? It’s not out of malevolence. We all want to help. But these attempts to “cheer up” people are usually doomed to failure. People typically push back against the “cheer up” message. If you tell a depressed person to look at the positives in their life, they will push back and tell you about all the negatives, or they will negate the positives. Tell an anxious person that their fears are overblown and they will tell you why their fears are realistic. As they push back, they feel more depressed and more anxious.

What Not to Do When Listening to Emotions

What are the most common “try not to think of the pink elephant” invalidating listening responses?  Why are they unhelpful?

1. Simple negation statements: “Don’t feel sad, don’t feel anxious, don’t feel angry.” These are statements that simply instruct the person to stop feeling the negative emotion. Another version of a negation statement is “cheer up”, “don’t worry”, or “chill out.” Or perhaps the worst of all, “Get over it!”

These are unhelpful because we don’t have that switch panel on her forehead that allows us to simply turn off negative emotions. In fact, because throughout human history negative emotions had more survival value than positive emotions, the brain overweighs negative emotions. On the ancient savanna, fear of being eaten by a lion when you hear rustling in the brush is a survival mechanism. Dismissing this fear could lead to disaster.

2. Problem-solving suggestions: “Maybe you should look for a different job.” “Have you considered ending your marriage or relationship?”

The problem with these kinds of suggestions is that they implicitly dismiss the person’s right to have negative emotions. They suggest a simple solution that will remove the negative emotions. But they are disrespectful because most people have already thought through all of these simple solutions and either they’re not simple, or they’re not solutions that they are willing to take.

Sometimes problem-solving is reasonable, but is best done after lengthy supportive listening. And usually, it’s best to avoid problem-solving and advice-giving entirely. 

3. Look-on-the-bright-side statements: “It’s not that bad, at least you have your health (money, relationship, kids, etc.)” or my favorite one, “At least it’s not cancer.”

These kinds of statements are not helpful because typically they are experienced as dismissive of our right to have these negative feelings. And we often push back and point out that there is no bright side, which can end up in a struggle between ourselves and the listener. This struggle is frustrating for both.

4. Changing the topic entirely: “Let’s not talk about your depression, what are you doing the rest of the week?”

Again, this is usually experienced as dismissive and unsupportive. It’s like saying to the person, “Shut up and stop talking about your suffering.”

5. Get therapy or go on medication suggestions. This is when your friend or family member suggests you may need therapy or medication to deal with your negative emotions. Again, this comes from a helpful place but is often experienced as dismissive. It’s like saying, “I can’t deal with your negative vibe, so please talk to somebody else.”

There are certainly times when it’s appropriate to recommend therapy, but this is best done after using positive listening approaches. Doing it at the front end is another way of invalidating the person’s feelings.

How to Listen Effectively to Strong Emotions

If these are all examples of what not to do, what should we do when someone expresses strong emotions to us?  How should we respond? What skills can we use to listen effectively? 

1. The first step is to listen empathically. What that means is to reflect back to the person what you hear them saying particularly the emotion. This skill is called a reflection of feelings. You basically just paraphrase their emotions, making an effort to be accurate as to the intensity. If someone says I am massively depressed, you don’t reflect back “You’re feeling a little bit down.” Instead, you reflect, “You’re really feeling overwhelmingly down.”

If you accurately reflect feelings,  then the person will elaborate on what they are feeling and you reflect again. Or you ask open-ended questions like, “How did that make you feel?” or “What did you feel then?” This will also expand the responses to their emotions.

Another good option is to reflect back the emotion and then ask the person to tell you more. “Sounds like you’re really mad at your wife about her spending. Tell me more.”

Of course, basic listening guidelines apply. Make good eye contact, use head nodding and nonverbal encouragers like “mmmm”, and “go on.” And of course, turn off your phone or mute it so you can listen fully.

2. Try to avoid the temptation to problem-solve or give advice. Especially try to avoid what I call the narcissistic shift. The narcissistic shift is when you shift to your own experience instead of staying with the other person’s experience. Many people mistakenly believe that these kinds of shifts are actually empathic but they are not. Here’s an example of the narcissistic shift:

Speaker: “Ever since I went off my antidepressants I’m feeling very depressed.”

Listener: “Yes, that happened to me a few years ago. I ended up having to go back on them. That’s probably what you should do.”

Even though it may be true that the listener had a similar experience it is invalidating because typically the exact experience was quite different. Also, the message becomes, “Let’s  not talk about you, let’s talk about me.”

It is like my favorite narcissist joke. The narcissist says, “Let’s not talk about me, let’s talk about you. What do you think of me?”

3. Normalize the speaker’s emotions. Statements like, “Of course you are feeling overwhelmed, so much has been going on lately.” Or, “Of course you are feeling depressed, you lost a job you loved. It makes perfect sense.”

The benefit of normalizing emotions is that it takes away the shame. Just try not to do the narcissistic shift as part of this. Avoid saying, “when I lost my job I got depressed also.” Just remember good listening is not about you, it’s about the other person.

4. Ask questions. Open-ended questions or encouragement to talk more are the best. Examples of open-ended questions are: “What are you feeling?” “How did that affect you?” Try to avoid asking why questions as they often come across as attacking. Example: “Why are you so sad?”

John Gottman, the well-known marriage therapist, suggests some of these questions:

  • Tell me what happened.
  • Tell me everything that’s bothering/worrying you.
  • Tell me all of your concerns.
  • Tell me everything that’s led up to this.
  • Help me understand more about what you’re feeling.
  • What set off these feelings?
  • What’s the thing that’s worrying you the most?
  • What’s the worst that could happen?

Notice that all of these encourage the person to feel safe venting and talking about their most painful emotions.

Some final thoughts on Listening Effectively  

Listening effectively is simple but very hard. Most of us will have a strong temptation to do all of the wrong things when confronted with strong emotion in another person. Fundamentally, we are all uncomfortable with strong negative emotions both in ourselves and in other people. It is a hard practice to learn to accept and tolerate negative emotions in others and in ourselves.

Now you’re probably thinking about a friend or family member who tends to ruminate about things and wondering if this approach would actually be counterproductive with them. I tend to think that much rumination is actually an interpersonal phenomenon that is based on unsupportive listening. A good analogy, although somewhat gross, is training an abscess or boil. When it’s fully drained, a painful process, healing begins. If you just put a Band-Aid over it, it only worsens. Unsupportive listening forces the speaker into pushing back by staying stuck with their emotions rather than fully expressing them.

If you really believe that someone you care about is stuck in rumination, then do an experiment. Listen effectively and fully for an hour. Let them cry, scream, quiver, whatever they need. In most cases, they will feel better and be less stuck in rumination. And you will have given them an amazing gift of love and kindness. Try it sometime, you will be amazed at the results.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Your Smartphone Is Making You and Your Teenager Dumb and Depressed!

smartphone making you dumber

Your smartphone. Smartphones are very cool devices. You can text, Snapchat, or email from anywhere. You can find your way through traffic using Google Maps or Waze. Find a good restaurant with Tripadvisor or Yelp. Take pictures and send them to all of your friends and family instantly. Nothing but upside right?

Wrong! Multiple research studies show that our smartphones are actually making us dumber, and maybe more depressed as well. Let’s look at some interesting facts. I’ve written previously about smartphone use and happiness but wanted to revisit the subject with more data.

Fact One: The average smartphone user looks at their phone 80 times a day, according to Apple.

Other reports suggest that people look at their phone 130 times a day. That means 30,000 to 47,000 times a year! Each of those glances distracts you from your current circumstances, and if you are trying to do something complex, or learn something, you are getting dumber 30,000 to 47,000 times a year! That’s a lot of time to lose. And since studies show it takes 25 minutes and 15 seconds to recover from distraction, that means you are losing 526 days a year, which is more than a year, which means that you are basically distracted and dumber all the time.

Fact Two: The closer your phone is to you, the dumber you get.

The University of California, San Diego conducted a study of 520 undergraduate students. The students took two tests of intellectual functioning.  The main variable in the study was where student put their phones. Some students put the phones in front of them on the desk, others put the phone in their pockets or purses, and others left their phones in an adjoining room.

The results: the closer the phone was, the dumber the person based on the test results. Phone in front of you, bad, phone in your pocket or purse, a little better, and phone in the next room, best results. And remember, this was with participants never checking their phones!

Fact Three: We don’t realize how much our phones impair our performance.

All of the participants in the UC study later said their phone was not a distraction, and that they never thought about their phones during the experiment. This shows we don’t even recognize the damage our phones are doing to our minds.

Fact Four: Smartphones bring down college grades by one whole letter grade when brought to class!

Researchers at the University of Arkansas found that those students who left their phones at home scored a full grade higher on material presented in the classroom than those who had their phones in class. It did not matter whether the students used their phones or not. In another study from the U.K. found that when schools ban smartphones, test scores go up a lot, with the worst students benefiting the most.

Fact Five: Your smartphone makes you worse at relationships as well.

Another study from the U.K. had 142 people divided into pairs and asked to talk in private. Half had a phone in the room, while the other half had no phone. The pairs then rated each other for affinity, trust, and empathy. “The mere presence of mobile phones,” the researchers reported in 2013 in the Journal of Social and Personal Relationships, “inhibited the development of interpersonal closeness and trust” and diminished “the extent to which individuals felt empathy and understanding from their partners.”

Fact Six: It Is Worse For Teenagers

According to Neilson, teenagers send and receive 3,339  texts per month, which is about 7 texts per hour, or one text every 8.5 minutes. Actually, it is worse. Let’s assume that most teens don’t text during classes. That means outside of class, they are texting about 12 times an hour, or once every 6 minutes.

iphone woman

This can’t be good for learning or memory.  Imagine you are trying to learn something hard, and every 6 minutes someone asks you a question and you have to respond. How’s your performance? And since we know that distraction lasts 25 minutes, that basically means that all teenagers are distracted every minute that they are awake and not in class.

What’s even worse is that smartphone usage also affects happiness. The Monitoring The Future Survey, which is funded by the National Institute on Drug Abuse, has collected data on 10th graders and 12th graders for decades. They asked teens how happy they are and how much time they spend on various activities including non-screen activities like socializing and exercise, and screen activities such as social media, browsing the web, or texting.

The results? All screen activities are linked to less happiness, and all non-screen activities are linked to more happiness! Eighth graders who spent 10 or more hours a week on social media were 56% more likely to say they’re unhappy. Even those who spent six hours a week on social media were still 47% more likely to say that they were unhappy. And even more ominously, the more time that teenagers spent looking at screens the more likely they were to report symptoms of depression. Teens who spent three hours a day or more on electronic devices were 35% more likely to have at least one risk factor for suicide.

Here are a few somewhat radical suggestions:

  1. This one teenagers will really hate. What if parents took away smartphones from their kids, and gave them flip phones, for phone calls only? Turned off texting on the phone. I suspect the average teenager’s grades would go up a grade. Not to mention better learning and memory. Flip phones would allow teenagers to call their parents for a ride, thus having much of the convenience factor without any of the negative smartphone factors.
  2. If this is not practical then I would recommend that parents take smartphones from their children when they arrive home from school, put them in a locked drawer, and only give them back the next morning. Certainly, there should be no access to smartphones while studying or doing homework. When children have finished their homework and are in relaxation mode, they can have limited access to their smartphone, but only until a reasonable hour because the use of smartphones before bedtime is very disruptive to sleep.
  3. For adults, leave your phone in your car trunk when having dinner out. You’ll connect with your dinner partner much better.
  4. For families, all smartphones, tablets, laptop computers go away before every family meal. Unless you are a physician on call, nothing is so important that you can’t put away your smartphone and have a nice family dinner.
  5. Finally, consider a digital device Sabbath. Orthodox Jews do not use any digital devices during Sabbath, which starts Friday night and ends Saturday night. All of us should emulate this, and pick a day on the weekend which is a digital-free day.

I am reminded of the first time I met my friend Fred Luskin, a psychologist who studies stress and forgiveness. I was attending a workshop he led. At the beginning, he asked everyone to take out their smartphones and turn them off. Not “turn off the ringer” or “set to vibrate” but actually power down the phones. Participants were shocked and resistant. It took a few minutes for him to get people to actually turn off their phones. At the time I wondered about this, but now I can see that it makes a big difference. When your phone is powered down, you are not anticipating anything from it, so that little bit of attention that is always focused on the phone is freed up for other purposes.

Now I’m going to turn off my computer and my phone, go outside, and take a walk…

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.