Mindfulness-based psychological therapy for tinnitus has, in recent times, been the subject of well-designed clinical research that demonstrated impressive benefits. Dr Liz Marks guides us through this field, and advocates for better access and availability of these techniques.
Mindfulness can significantly benefit people with chronic tinnitus, and a recent systematic review of seven studies found that mindfulness-based therapies led to clinically significant reductions in tinnitus distress across a wide range of patients [1].
The size of these clinical improvements is equivalent to other evidence-based psychological interventions in tinnitus, such as cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT). Clinical guidelines in the UK and Europe now advocate mindfulness-based cognitive therapy (MBCT) as a treatment for people with persistent and distressing tinnitus [2].
Such guidelines are encouraging but clinical services lag behind and recent surveys indicate only 9% of patients in the UK currently receive mindfulness therapies. To address the gap between recommended treatments and current access, we must consider what benefits mindfulness offers to tinnitus patients and how we might improve access to these benefits across the audiology community.
What do mindfulness therapies do?
Mindfulness therapies train one in mindfulness meditation and by “systematically exercising one’s capacity for paying attention, on purpose, in the present moment and non-judgmentally”, one learns to relate to inner experiences more wisely and helpfully [3]. The cultivation of mindfulness enhances health and wellbeing across clinical and non-clinical populations, with associated changes in cognition and emotion, including reduced reactivity, reduced negative thinking, improved cognitive flexibility and enhanced self-compassion [4].
“Psychological models of tinnitus indicate key emotional, cognitive and behavioural factors contribute to distress and intrusiveness”
Applied psychological science and mindfulness for tinnitus
Psychological models of tinnitus indicate key emotional, cognitive and behavioural factors contribute to distress and intrusiveness. How an individual reacts to tinnitus is important and often involves:
- Cognitive reactivity: Negative, catastrophic thoughts and beliefs.
- Behavioural reactivity: Safety-seeking behaviours (avoidance, distraction, escape) from tinnitus and distress, ‘fighting’ tinnitus.
- Attentional change: Narrowing of attention and monitoring of tinnitus.
- A negative view of self and world: Blaming oneself for tinnitus persistence; hopelessness about the future and medical care.
Such reactions to tinnitus are understandable, but unfortunately can lead to long-term counterproductive effects, preventing both habituation and the discovery of alternative, more helpful responses. Mindfulness therapies offer a new approach. In an ideal world there would be a cure that can ‘silence’ tinnitus. Scientists are working hard on this but, as yet, it does not exist. Psychological science comes from a different angle, looking at the intrusiveness and suffering associated with tinnitus and not just the presence of tinnitus. Rather than asking ‘how can we silence tinnitus?’ we ask, ‘If tinnitus cannot be silenced, how can we reduce distress and live well?’. The second question opens up space for creative and flexible thinking about how to live a full and normal life with tinnitus.
How mindfulness is helpful
Mindfulness therapies lead people to a radically different relationship with tinnitus, helping them to stop their exhausting fight with tinnitus and test out new ways of allowing tinnitus into awareness instead [5]. This does not mean resignation or submission; it means experimenting with new ways of approaching tinnitus and then making an informed decision about what responses are most helpful. This can be challenging at first but practising mindful awareness of tinnitus can bring surprising discoveries: tinnitus may not be what you expect when you pay close attention, nor will it overwhelm you completely.
“Repeated practice of allowing tinnitus supports habituation and challenges catastrophic beliefs about tinnitus”
Repeated practice of allowing tinnitus to be present in awareness supports habituation and challenges catastrophic beliefs about tinnitus. People see that their automatic thoughts about tinnitus are merely repeatedly occurring patterns rather than ‘facts’ about the nature of reality and they grow in confidence as they learn to let thoughts come and go without necessarily having to do something about them. People are then less likely to be swept along and preoccupied by well-known patterns of negative thinking, and their distress reduces.
Mindfulness meditation provides greater stability in the face of unpleasant emotions and sensations by teaching people how to remain non-judgemental and present with all experiences, even difficult ones. Mindfulness meditation is a powerful attentional training tool which teaches a critical skill: that of disengaging from experiences like tinnitus which ‘capture’ attention and reorienting onto other foci which can be more neutral or pleasant (such as the breath). It also teaches skills in changing between narrow and broad attentional focus, which is particularly helpful in sound meditation when working with tinnitus. Here, the individual practises attending to specific sounds (e.g. tinnitus, traffic, birdsong) and switching to an open awareness of the entirety of their soundscape. Furthermore, rather than analysing, labelling and thinking about the meaning of the sound, the individual is encouraged to explore the nature of sound itself, its pitch, tone, volume, rhythm etc. Unlike sound therapies which tend to involve partial masking, sound meditation helps people to notice how their experience of tinnitus is affected by how and where they pay attention.
Working skilfully with attention is not about improving strategies for control or distraction, it is about making wise choices about how to relate to experience. Those aspects of experience that are aversive but changeable, can happily be changed. Those aspects which are not changeable invite one to practise acceptance instead. Acceptance is the active recognition that some things, like tinnitus, may not be resolved, followed by the choice to allow this experience to be present in awareness. In this allowing, one can find freedom from the pain that arises when we long for things to be different. This, in turn, can have unexpected effects, as summed up by the famous psychotherapist, Carl Rogers: “The curious paradox is that when I accept myself just as I am, then I can change.” [6].
Mindfulness therapies cultivate beneficial attitudes of kindness, compassion, gentleness, appreciation, friendliness and equanimity [5]. Such attitudes mitigate negative views of the self and world. People offer themselves greater compassion and notice moments in life where tinnitus does not dominate, and joy can flourish. Usually delivered in groups, mindfulness therapies offer the benefits of shared experiences and ideas. As people see how their suffering with tinnitus is part of the suffering shared by all humanity, they feel less alone, and may also recognise how they still have much for which they are grateful. Patients have indicated they value mindfulness delivered by clinicians who have expertise and knowledge of tinnitus as it enhances trust and engagement. As such, a biopsychosocial approach to tinnitus, where mindfulness is integrated into audiology, is important.
What types of mindfulness therapies work for tinnitus?
The strongest evidence base in tinnitus is for MBCT, a structured eight-week course delivered by highly-trained clinicians. Benefits last for at least six months (with recent clinical evaluation suggesting this may sustain for years). Other ways of learning mindfulness, such as through websites, books and apps are as yet unexplored in tinnitus. Robust research testing such approaches is a vital next step.
“Working skilfully with attention is not about improving control or distraction strategies, it is about making wise choices about how to relate to experience”
What can the clinician on the ground, and the person with tinnitus do?
The evidence for the benefits of mindfulness for tinnitus is compelling. Services must now find ways to offer this to patients. Various models exist, including employing clinical psychologists skilled in MBCT within services, training audiologists to deliver MBCT or engaging MBCT teachers to work alongside audiologists. All models require service development, proper resourcing, and a commitment to excellence in tinnitus care.
Until such care is standard, clinicians can still use many ideas from mindfulness, and encourage their patients to find new ways of relating to their tinnitus. The audiology community must appreciate that offering a psychological approach to tinnitus is not second best, and although we currently lack a cure that can ‘silence’ our patients’ tinnitus, we have a wealth of resources that can heal their suffering.
References
1. Rademaker M, Stegeman I, Ho-Kang-You K, et al. The effect of Mindfulness-Based Interventions on Tinnitus Burden. A Systematic Review. Frontiers in neurology 2019;10:1135.
2. NICE guideline NG155. Tinnitus: assessment and management. 2020.
3. Mindful Nation UK. Report by the Mindfulness All-Party Parliamentary Group (MAPPG). 2015. https://mindfulnessinschools.org/
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Last accessed September 2020.
4. Alsubaie M, Abbott R, Dunn, B, et al. Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) in people with physical and/or psychological conditions: a systematic review. Clinical psychology review 2017;55:74‑91.
5. Marks E, Smith P, McKenna L. I Wasn’t at War With the Noise: How Mindfulness Based Cognitive Therapy Changes Patients’ Experiences of Tinnitus. Frontiers in Psychology 2020;11:483.
6. Rogers C. On Becoming a Person: A Therapist’s View of Psychotherapy. Mariner Books; 1995.
Images courtesy of Felix Boot / urbanimage.tv
