The CBT4T Evolution

How CBT4T Evolved

Author & CBT4T Founder Debbie Featherstone

CBT4T 2025

The latest evolution is CBT4T 2025 made available from December 2024. It includes framing the process in to four Elements:

Element 1: Preparation - Stages 1-3 (3 modules)
Element 2: Moving forward - Stages 4-6 (5 modules)
Element 3: Meaning & Beliefs - Stage 7 (4 modules)
Element 4: Consolidation & Completion - Stage 8 (2 modules)

The Original Online Tinnitus E-Programme began in 2009

2009-2018

The Tinnitus E-Programme was provided online, free of charge as a 6 module CBT-based self-help programme with the aim of helping people to live with tinnitus rather than continuing to struggle living with it every day. It was run informally, openly accessible to anyone. In its infancy, the Tinnitus E-Programme was already helping people across the world, but being self-directed - just as with other free self-directed health-related help - attrition was very high indeed. In 2012 I was invited to speak to the researchers at NHBRC (Nottingham Hearing Biomedical Research Centre) about my work in tinnitus - including the Tinnitus E-Programme. This led to the NHBR Unit as it was then, to carry out an Independent Evaluation of the original Tinnitus E-Programme later (2015-2018).

2018-2020

The Independent Evaluation was finally published in 2021 in the American Journal of Audiology. However, following a trial 6 month period that included therapist-support in 2018, I took the decision to make the Tinnitus E-Programme therapist-supported. The impact was immediately noticeable. Attrition was zero during the 6 month trial period, and has remained low thereafter.

2020-2025

The 6 module Tinnitus E-Programme was only ever intended for people with up to moderate/low-end severe tinnitus distress. The higher the level of distress, the less suitable such a short programme was, and the alternative of individual CBT for Tinnitus with me involving 12-15 one-to-one appointments was prohibitive because of cost for the vast majority of people needing this level of support.

I spent around six months analysing my process and data from work I had carried out with patients individually over many years, all of whom had started out with either a Tinnitus Functional Index (TFI) category 4 (54-72%) or category 5 (73-100%). These patients also had anxiety and/or stress either at moderate or severe levels (GAD-7, PSS, ASQ). From my analysis, I was able to translate the process in to what became the first online CBT for Tinnitus E-Programme (12 Stage Cognitive Behaviour Therapy for Tinnitus E-Programme) with a choice of combining one, two or three 1-1 appointments. In those early days, there were numerous interactive logs, progress checks, and bespoke ACT & CBT tools built in to the process, combined with the all-important 1-1 appointments and email support. This advanced therapist-supported programme was launched in July 2020, and proven very successful - see Feedback & Reviews. Each year since 2020, the course is reviewed, updated and improved. In October 2025, the 6th edition for 2026 was launched.

Cognitive Behaviour Therapy itself continues to evolve beyond the traditionally understood framework commonly referred to as 1st and 2nd wave CBT. Third wave CBT practices, in particular ACT (Acceptance & Commitment Therapy), has built a substantial evidence base since it was first developed by Steven Hayes way back in 1982. The premise for ACT is: "ACT and CBT are similar in that they can help clients break through difficult thoughts and feelings. However, both approach this goal differently: In CBT, you learn to reframe any harmful thought patterns. In ACT, you would learn to accept your situations and negative feelings as a typical part of life." (Psych Central, 2022). Technically, ACT is a behavioural therapy, whereas traditional 2nd wave CBT is a cognitive therapy.

In ACT, "Acceptance means opening up and making room for unwanted private experiences: thoughts, feelings, emotions, memories, urges, images, impulses, and sensations"; Commitment relates to committed action: "Committed action means taking effective action, guided by our values. This includes both physical action (what we do with our physical body) and psychological action (what we do in our inner world). It’s all well and good to know our values, but it’s only through putting them into action that life becomes rich, full, and meaningful." (Ref: Harris, Russ. ACT Made Simple (The New Harbinger Made Simple Series) (p. 7). New Harbinger Publications. Kindle Edition).

Neuroscience: Adaptive vs Maladaptive brain plasticity / CBT and ACT

The more information that emerges from the field of neuroscience, the greater our understanding of why BOTH Cognitive Behaviour Therapy (CBT) and Acceptance & Commitment Therapy (ACT) have the profound impact that they do. Relevant neuroscience has been included in the CBT for Tinnitus E-Programme since 2018, and due to ever more understanding over subsequent years, this too has been incorporated in to the programme's process. It is neuroscience that has the explanation for the triggering reaction that hearing tinnitus has for so many - indeed for EVERYONE coming to CBT4T, as well as the thousands of patients I've worked with in the past 30 years. There has therefore been more relevant neuroscience-related sections added to CBT4T year on year.

Who provides "CBT"?

My view is that where any clinician wishes to provide CBT or any other type of psychotherapy for patients, in whatever format they provide that psychotherapy, they should undertake the necessary additional formal psychotherapy education and training to a minimum of post-graduate level. Surprisingly, this is not imposed on clinicians in the UK, although there are concerns being expressed more widely than in the UK, for example: Henry, J. et al, (2022) Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists, Ear & Hearing 43(2):283-289

The process used in the in-depth CBT for Tinnitus E-Programme from July 2020 developed specifically for those with severe and very severe tinnitus distress has gone on to produce consistent Outcomes over time. The programme combines 1-1 support by a qualified experienced Psychotherapist-Hearing Therapist (Debbie Featherstone) via 1-1 appointments, email, logs, bespoke interactive cognition tools, and weekly SITREP - more about this

Note: From May 2023, the process used in CBT4T is defined as a Neuroscience-informed CBT Process in an attempt to differentiate the bespoke CBT4T programme - evidence-based over at least five years since 2020 - from other courses and applications claiming to be Cognitive Behaviour Therapy for tinnitus.