The CBT for Tinnitus E-Programme's Journey
How the CBT for Tinnitus E-Programme Evolved
30 years ago
I began my journey in 1993 - I started training as a Hearing Therapist AND started hearing tinnitus just a few months later! All those years ago, I think I might have expected to be feeling somewhat jaded after 30 years in the same field of work. Had you asked me 30 years ago if I thought I’d still be helping people live a normal life with tinnitus rather than struggle with it, I’m sure my answer would have been a definitive “NO WAY!” 30 years is a very long time - well it was to me, 30 years ago!
20 years ago
20 years ago, after 10 years of increasing frustration at the limitations of the training I’d received as a Hearing Therapist and the low-priority status and attitude in general towards tinnitus by ear and hearing related services given the responsibility for tinnitus services in the NHS, I started a PGDip qualifying three years later as a psychotherapist. It was this that TURNED NIGHT IN TO DAY for me, most significantly because of training to use Cognitive Behaviour Therapy. Now it was 2005, by which time I was Head of Hearing Therapy Services at East Lancs NHS Hospital Trust where I was able to transform Hearing Therapy services for patients with hearing loss, tinnitus and balance because of it.
10 years ago
By 2012, 10 years ago, I’d been running the Tinnitus E-Programme as an online intervention for 3 years. In its infancy, the Tinnitus E-Programme was already helping people across the world. It was also in 2012 that I was invited to speak to the researchers at NHBRC (Nottingham Hearing Biomedical Research Centre) about my work including the Tinnitus E-Programme. I still have the presentation I gave to my auspicious research colleagues that day that led to the NHBR Unit as it was then carrying out an Independent Evaluation of the original Tinnitus E-Programme several years later.
From 2009-2018, the Tinnitus E-Programme continued to be a 6 module CBT-based online self-help programme with the aim of helping people to live with tinnitus rather than continuing to struggle living with it every day. In 2017, I improved collection of data including user registration with an email address and a mechanism to identify when content was being accessed. It was this data that demonstrated extremely high attrition when self-directed - much, much higher than I had previously been aware of.
There being no sign of the Independent Evaluation being published any time soon* (it was finally published in 2021 in the American Journal of Audiology), 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 remained low thereafter.
* Unfortunately, there was hold-up after hold-up with the publication of the findings of the Independent Evaluation through no fault of the NHBRC - their frustration was no less than my own. Early findings though were similar to the conclusions I had reached, in that users did find it to be helpful; however, there was enormous difficulty ascertaining a non-biased selection criteria of participants to ask questions, as the only participants for whom we had contact details were those who had registered an email address (this hadn't been mandatory until 2017). The majority who had registered an email address were those who had joined the Tinnitus E-Programme Support Group. This automatically made selection criteria biased. Part two of the evaluation was to create a Tinnitus E-Programme 2.0, evaluate and publish. Part two was due to be completed by 2018, but it was nowhere near completion.
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 personally had serious reservations as to how effective online CBT could be for people with high and very high distress. Could it be effective combining it with far fewer one to one appointments? I did, however, consider it worth trying to do.
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 5 (73-100%). These patients also had anxiety either at moderate or severe levels. From my analysis, I was able to translate the process in to what became the 12 Stage Cognitive Behaviour Therapy for Tinnitus E-Programme with a choice of combining one, two or three 1-1 appointments. There are 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. It was launched in July 2020 and has been running very successfully now for nearly two and a half years at the time of writing (December 2022) - view Outcomes and Feedback/Reviews
Cognitive Behaviour Therapy has continued 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.
One of the main issues that is off-putting for many is the term acceptance itself! It is frequently through misunderstanding what is meant by acceptance that is off-putting. For example, when we think of acceptance as meaning "tolerate", "give in or give up", "put up with", it is no wonder we are put off by ACT!
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).
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 the CBT for Tinnitus E-Programme, 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 included during the initial months of 2023, and a fresh look at "goal setting" (Stage 5) extending it in to "Values Based Action" from ACT.
I found a recent self-help "guide to using cognitive behavioural therapy for tinnitus" publication by an audiologist somewhat disturbing. In the book, 2nd wave CBT is used as though there is only one form of cognitive behaviour therapy for tinnitus which is at best misleading to those seeking help. 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 already 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 newer 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, with more Outcomes due to be published later in 2023. The programme combines 1-1 support by a qualified experienced Psychotherapist as well as Hearing Therapist via 1-1 appointments, email and interactive tools, with a self-help element, but to differentiate it further from other applications claiming to be Cognitive Behaviour Therapy for tinnitus, be they in book or online format, from May 2023 the process used in the programme is defined as a Neuroscience & CBT Protocol.
Page last updated 29 May 2023