Tinnitus Coaching Final...Tinnitus “Coaching”: Managing severe tinnitus and sound sensitivity...

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Tinnitus “Coaching”: Managing severe tinnitus and sound sensitivity

disorders

Lisa G. Fox-Thomas, Ph.D., CCC-A

AP Associate Professor, Audiology

The University of North Carolina at Greensboro

Disclosures

• The presenter has no relevant financial and

nonfinancial disclosures.

• The content presented is for informational purposes

and is not intended to support one management

approach above all others.

• The clinical experiences of the presenter inform and

guide her audiological practice, which is in a constant

state of evolution.

Learning Objectives

1) Identify management approaches for tinnitus and

sound sensitivity disorders

2) Discuss barriers for managing severe tinnitus and

sound sensitivity disorders

3) Describe how tinnitus “coaching” compares to

traditional management strategies

Prevalence of Tinnitus

• Transient Tinnitus

• Chronic Tinnitus

▫ “People with tinnitus”

• Severe Tinnitus

▫ “Tinnitus patients”

People with

Tinnitus (50 M)

Bothered by

Tinnitus (16 M)

Debilitating

Tinnitus

(2 M)

Severity of Tinnitus

• Disturbance is not directly

related with tinnitus

loudness, pitch, or other

attribute.

• Rather, the importance

assigned to the tinnitus,

and its negative associations,

determines its severity.

People with

Tinnitus (50 M)

Bothered by

Tinnitus (16 M)

Debilitating

Tinnitus

(2 M)

2 – 20 dB SL

2 – 20 dB SL2 – 20 dB SL

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Neurophysiological Model(Jastreboff, 1990)

The body’s stress reaction (“fight, flight or freeze” response)

is triggered automatically.

Sympathetic Dominance

http://faculty.pasadena.edu/dkwon/PNS%20and%20propioception/peripheral%20nervous%20system%20and%20propio

ception_files/textmostly/slide2.html

Sound Sensitivity Disorders

Hyperacusis Phonophobia

Misophonia

Sound Sensitivity Disorders

• Hyperacusis – hypersensitivity to the physical

properties of sound regardless of source or situation

(LDLs < 70-90 dB HL)

• Phonophobia – fear of sound and/or what it represents

(e.g., sounds that hurt; sounds that may damage

hearing or make tinnitus worse)

• Misophonia – strong dislike of sound and/or what it

represents (e.g., selective sound sensitivity syndrome

or 4S)


Hyperacusis Phonophobia

& Misophonia

Overamplification of external sounds within the CANS.Strong negative emotions associated with external sounds.

Comorbidity

• 40% of patients with tinnitus

also have hyperacusis.

• 2/3 of patients with

hyperacusis also have tinnitus.

• Can work on both disorders

at the same time.

• May need to address sound

sensitivity first.

Tinnitus

Hyperacusis

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Management of Tinnitus

• To date, there is no medical “cure” or treatment for

tinnitus.

• The goal is to habituate the

conditioned emotional

responses and stress reaction

to the perception of an internal

stimulus (tinnitus).

• Tinnitus patient � Person with tinnitus

People with

Tinnitus (50 M)

Bothered by

Tinnitus (16 M)

Debilitating

Tinnitus

(2 M)

Treatment of Sound Sensitivity

Disorders

• Sound sensitivity disorders can be treated effectively using

a combination of counseling and daily sound therapy.

• Desensitization occurs gradually over time.

• LDLs are shifted upward as sound tolerance improves

(hyperacusis and phonophobia).

• Triggers are gradually reduced and/or the responses to

triggers become more manageable over time

(misophonia).

Traditional Approaches to

Intervention

Directive Counseling/Patient

Education

Sound Therapy

General Wellness

Recommendations

Referrals


Sound

Therapy

Directive

Counseling

Referral for Ancillary Services

General

Wellness Rx


Education• Demystification and neutralization of tinnitus and sound

sensitivity

• Role of limbic system and autonomic nervous system in

creating vicious cycle of disturbance

• Principles of selective attention

and habituation

• Use of sound therapy for short-term

relief and control

Vicious

Cycle


Intervention


Education

Sound Therapy

General Wellness

Recommendations

Referrals

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Tinnitus Retraining Therapy (TRT)

(Broadband noise)

SoundCure

(S-tones)

WZT

(Fractal tones)

PTM

(Broadband

noise)

CHATT

(Broadband

noise)

TAT

(Whatever

works)

Neuromonics

(Music)

Tinnitus Masking

(Broadband noise) Tinnitus Masking

• Jack Vernon (1970s) & Jonathen Hazell (1980s)

• Sound therapy approach:

▫ Broadband sound (e.g., white noise) that is steady state

and nature-like

▫ Masks/covers the tinnitus providing

immediate relief

• Residual inhibition – temporary suppression

of tinnitus after masking sound is

removed

Tinnitus Retraining Therapy (TRT)

• Pawel and Margaret Jastreboff (1990s)


▫ Partial masking approach using broadband noise at “mixing

point”

▫ Keeps sound level below level of annoyance

and/or LDL

▫ Avoid silence (”more is better”)

• Provides short-term relief and promotes

long-term habituation.

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11 010 0001 100

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10 10 0000 TINNITUS

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00101 01010 01 11

1000101010101010000111111111110100101111111111100010101010101000000

0000000000000101000101010100010101010101010111110101010000010

001010001010000111101011101001010001000101010100001010101010001

010100010001011110101010101001010001000001010101001010101001001

000101010100101010000001110101TINNITUS0000111111100101010101010

010101010001000010100101010100001000100001001111111100101010100

1001010100100010100100111111101011101010101010101000101000100101

0001010010101000000111101001010010101010001010111110101010101010

1000101010100100101010011110011101011010101010010101010100101000

101010010101010001010100010101001001010010101001000101011100101

010101001010001111101010101010101001001010100010101001010010010

0111111010101100010100101001010100101111101011111010110TINNITUS101

010001000001010100101010101010010000101010101010001011111010101

0101010100101000011111101010100101010100101010100101001010100010

1110010101010100100010101001011111101010010100100100001010100100

00000000001010100101111110001111101011111010000000011111101010111

001010001000001100010100010011110000010000010100100010100100

1000101010010TINNITUS010101001010101001010000001111111101010101

01010101010101000101000101010101010100000101000000101010100100

10100101010010010011111000100100101001011111110001111111101111111100

00011101010000011110100010101010TINNITUS10000011111100101010101

0100010101010101010101011010101000010101010101010101010100001111

10000010101010111010101010101010101010101010100001111010101001011

Progressive Tinnitus Management

• Developed for the VA by Jim Henry and colleagues (2008)

• Sound therapy approach: “Personal sound plan” using

(1) Environmental sound

(2) Music

(3) Speech

• Self-help workbook also covers relaxation exercises, behavior modification, and attitudes toward tinnitus

Soothing

Sound

Background

Sound

Interesting

Sound

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Progressive Tinnitus Management

http://www.ncrar.research.va.gov/education/documents/tinnitusdocuments/index.asp

Progressively

more severe

problems caused

by tinnitus

Cognitive Habituation Tinnitus

Treatment (CHaTT)

• Natan Bauman, founder of TPA

• Sound therapy approach: partial masking with broadband noise

• Combines principles of TRT and Cognitive Behavioral Therapy (CBT) to change attitudes toward tinnitus.

� All or Nothing: “My life with tinnitus is totally ruined.”

� Tunnel Vision: “If I could only find the cause of my tinnitus, I could make it go away.”

• Also incorporates relaxation strategies (de-stress) and distraction techniques.

Neuromonics®

• Paul Davis (1998)


▫ Acoustically modified music at the

resting heart rate

▫ Frequency response up to 12.5 kHz

▫ Can use at a lower volume

▫ Dosed approach (2 – 4 hours per day)

during most disturbing times

• Promotes systematic desensitization over time.

Widex Zen Therapy (WZT)

• Francis Kuk (2008) and Robert Sweetow (2010, 2012)


▫ Adjustable fractal tones and broadband noise with or without amplification

▫ Frequency response is limited by hearing aid

▫ Advocates passive listening at a soft, but audible level (all day if needed)

• WZT counseling incorporates principles of CBT and relaxation

http://www.widex.com/en/products/thewidexsound/zen/

SoundCure® Serenade

• Reavis and colleagues (2010)

• Sound therapy approach: S-tones matched to the pitch

tinnitus

▫ Frequency response up to 12

kHz

▫ Slow- and Fast-modulation

(tracks 1 and 2)

▫ Narrow- and Broadband noise

(tracks 3 and 4)

Tinnitus Activities Treatment (TAT)

• Rich Tyler and audiologists at University of Iowa (2006)

• Sound therapy approach: Whatever works

• Counseling sessions available online:

▫ Thoughts & Emotions

▫ Hearing & Communication

http://www.medicine.uiowa.edu/oto/research/tinnitus/

� Sleep

� Concentration

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Sound Therapy Devices Hearing Aids

• Compensate for auditory deprivation by feeding sound to the brain.

• Amplify low-level environmental sounds to provide natural masking.

• Decrease “central gain” boost caused by straining to hear.

• Reduce load of listening and fatigue.

• Help to separate the disturbance caused by hearing loss from tinnitus disturbance (tinnitus as “scapegoat”).

• ReSound Tinnitus Solution –adjustable, modulated noise

• Widex Zen – adjustable noise; fractal

tones

• Siemens micon – adjustable noise

• Phonak Quest – adjustable noise

• Starkey Xino – adjustable noise

• Oticon Tinnitus Support – adjustable,

modulated noise and preset ocean-like sounds

Combination Hearing Instruments

• No “one size fits all” management approach

• Selection depends on the following:

▫ Symptoms - hearing loss, tinnitus severity,

sound sensitivity

▫ Life variables – lifestyle; time of day

disturbed

▫ Personal preferences – interaction and

relief provided by sound stimulus;

goals and expectations

Selection Considerations


Intervention


Education

Sound Therapy

General Wellness

Recommendations

Referrals

General Wellness Recommendations

• Diet

• Exercise

• Alcohol/drug use

• Sleep hygiene

• Stress reduction

(good and bad stress)

• Pleasurable activities

(hobbies)

• Carving out “me” time

vs. treatment timeWork

Family

Home

HobbiesMe Spiritual

Health

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Mindfulness-based Tinnitus Stress

Reduction

http://mindfultinnitusrelief.com/

Mindfulness-based Tinnitus Stress

Reduction• Jennifer Gans (2012)

• 8 week online course using mindfulness training for tinnitus

• “Mindfulness is paying special attention

▫ on purpose

▫ in the present

▫ without (clinging to) judgments

to the unfolding experience, moment by moment.”

~Jon Kabat-Zinn

Full Catastrophe Living

Sympathetic Sympathetic Sympathetic Sympathetic

Nervous SystemNervous SystemNervous SystemNervous SystemFight or FlightFight or FlightFight or FlightFight or Flight

ParasympatheticParasympatheticParasympatheticParasympathetic

Nervous SystemNervous SystemNervous SystemNervous SystemRest and DigestRest and DigestRest and DigestRest and Digest

HeartHeartHeartHeartIncreased/Decreased Increased/Decreased Increased/Decreased Increased/Decreased

RateRateRateRate

LungsLungsLungsLungsInflation/ConstrictionInflation/ConstrictionInflation/ConstrictionInflation/Constriction

DiaphragmDiaphragmDiaphragmDiaphragmMuscle Muscle Muscle Muscle

Contraction/FlexionContraction/FlexionContraction/FlexionContraction/Flexion

Somatic N

ervous System

Somatic N

ervous System

Somatic N

ervous System

Somatic N

ervous System

Quick and Dirty Pathway to Amygdala




Afferent Pathways > Efferent Pathways




The Ins and Outs of Breathing

• Slow, even breathing

• Equal count of 4-5 on

inhale and exhale (6

breaths per minute)

• Expand the diaphragm

and breathe deeply into

the belly

Autonomic Nervous SystemTraditional Approaches to

Intervention


Education

Sound Therapy

General Wellness

Recommendations

Referrals

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Referrals for Ancillary Services

• Otolaryngologist

• Neurologist

• Vascular specialist

• Dentist

• Sleep specialist

• Physical therapist

• Mental health professional

The Vulnerable Tinnitus Patient

• Patients who lack resilience, or the ability to “bounce back” in the face of adversity.

• Some patients may even report suicidal ideationbecause of their tinnitus.

• It is important to have a safety plan that provides patients with resources (e.g., suicide prevention lifeline: 1-800-273-TALK)

http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf

The Severe Tinnitus Patient

• Something extra is needed for patients who are:

▫ “Difficult”

▫ “Complex”

▫ “Complicated”

▫ “Challenging”

▫ “Needy”

▫ “Noncompliant”

The Severe Tinnitus Patient

• Complex tinnitus cases: I’ve tried it all,

Now what? (March 2014)

• The “non-compliant” patient may be

unable to comply for reasons known or

unknown to them.

• “Challenging” patients often have

challenges that serve as barriers to

intervention.

Barriers to Intervention

• Cognitive Distortions

• Emotional Disturbance

• Health Problems

• Work/Family Stress

• Financial/Legal Problems

• Trauma

• Lack of Support

• Social Stigma

• Denial

• Untreated Hearing Loss

• Unrealistic Expectations (e.g., Search for the “cure”)

Now What?

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Person-Centered Tinnitus Therapy

• Anne-Mette Mohr (2006)

• For some patients, there is a “connection between the suffering from tinnitus and the way the person with tinnitus approaches life.”

• “The objectives of therapy will be to support the client to understand, learn from, and integrate tinnitus into his or her life. The person owns the tinnitus instead of being owned (victimized) by it.”

• The clinician serves to be with the client in addition to being for the client.

Health Coaching

• Coach serves as the patient’s ally or guide

• Helps patient establish his/her own personal goals and

identify barriers to success

• Coach is different than a counselor in that the focus is

not on solving past problems, but on changing future

behaviors.

• Patient is in charge of his/her own plan of care.

(http://hhs.uncg.edu/wordpress/health-coaching/)

“Tinnitus Coaching”

• A novel approach to working with tinnitus patients

that applies principles of health coaching.

• The purpose is to provide guidance and

encouragement for patients who need extra

support.

• Helps patient recognize barriers to intervention.

• Can be added to existing management approaches.

Tinnitus Coaching Approach to

Intervention


Education

Sound Therapy

General Wellness

Recommendations

Referrals

Coaching

Mindset Shift

Approach Diagnostician Educator Coach/Ally

Assumption Treat what is wrong Knowledge = Change Client is capable

Style Do as I say Let me tell you I am your advocate

Outcome Low adherence Information overload Self-efficacy

Application Tinnitus Evaluation Tinnitus Consultation Tinnitus Coaching

• Patient is more than a set of ears and disturbance

(typically) is about more than just tinnitus.

• Patient should take an active role in devoloping his/her

own treatment plan.

▫ He knows himself better than anyone else.

▫ He should set own personal goals.

▫ He can identify barriers to his own success.

▫ He is accountable for adhering to plan.

▫ He ultimately gets all the credit for success/failure of plan.

Tenants of Tinnitus Coaching

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Motivational Interviewing

• Open-ended questions allow for free response.

▫ “Tell me what you hope to accomplish.”

▫ “How much support do you think you need moving forward?”

• Set aside the “why?” to avoid placing blame on the patient.

▫ “ “Why aren’t you using your sound therapy every day?”

versus

▫ “I wonder when you can incorporate sound therapy into your daily life?”


• Reflections repeat and/or summarize what the patient

has said.

▫ “What I heard you say was…”

▫ “You are not sure if you are ready for hearing aids.”

▫ “Your tinnitus negatively impacts your quality of life.”

(amplified reflection + pause)

▫ “You know you have hearing loss, but you are not ready to

get hearing aids.”

(two part reflection)


• Affirmations acknowledge the patient’s effort,

accomplishments, and emotions.

▫ “You have tried lots of different ways of coping with your

tinnitus.”

▫ “You really care how about what your children think about

your tinnitus.”

▫ “You are ready to do something about your tinnitus.”


• Challenge the patients to come up with own solutions.

For example:

• “What would you like to start working on first?“

• “You have said that your tinnitus is worse when you are

stressed. What could you do to reduce your stress?”

• “What would it take for you to wear your hearing devices

more consistently?”

• Patients are more likely to following through with their

own ideas.

“I” versus “You” Statements

• Avoid “I” statements to shift responsibility of treatment outcome to the patient:

▫ “I am happy for you!”

▫ “I am proud of you.”

▫ “I want you to do X for me.”

▫ “I think you should do X by next visit.”

• Use “you” statements to recognize patient’s accomplishments and autonomy:

▫ “You did it!”

▫ “Good for you!”

▫ “You have worked hard.”

▫ “What do you think youwill do?”

▫ “How do you feel about that?”

Value Judgments

• Avoid assigning judgments on behaviors, experiences, and/or outcomes.

▫ “That is discouraging”

▫ “You must feel terrible.”

▫ “You did a good job.”

• Your interpretations may be based on your own values and experiences (e.g., smoking is not good for your health), which can create barriers between you and the patient.

• Allow the patient to consider his/her own value judgments (e.g., “What do you think about that?”)

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Helpful tool: The Wheel of Life

http://www.timstringer.com/wp-content/uploads/2010/10/Wheel-of-Life.png

Helpful tool: The ruler

• On a scale of 1 – 10, how important is it for you to….

• On a scale of 1 – 10, how confident are you that you can…”

• On a scale of 1 – 10, how ready are you to make this

change?

What would it take for you to go from a # to #?

Ditching the “All or None”

Mentality

• Patients often make a black and white

judgment regarding intervention as

either a “success” or “failure”.

• Often they don’t recognize the gradual

improvements and/or forget where they

started.

• Patients may forget to reward

themselves along the way.

The “Treatment” Journey

• Coaching helps patients celebrate

small successes along their treatment

journey.

• As a result, patients are reminded of

their destination and can better

appreciate how far they have come.

• Ultimately, this results in better

adherence to the intervention.

Regaining Control

• “When tinnitus is the filter by which you live your life

and it prevents you from doing the things that you

enjoy, tinnitus becomes very powerful and important.

Thus, the goal of intervention is to reclaim your life

from tinnitus.”

• Tinnitus coaching helps patient regain control.

▫ Patient controls tinnitus disturbance

▫ Patient controls plan of care

▫ Patient controls end destination / goals

▫ Patient gains confidence (I did it myself!)

Relinquishing Control

• Patient also learns to re-conceptualize his life with tinnitus and/or sound sensitivity.

• The fight against tinnitus (and sound sensitivity) can be the primary source of disturbance.

• Acceptance of tinnitus cannot be imposed upon the patient (e.g., “You must learn to live with it”).

• Rather, learning to integrate tinnitus requires the patient to accept it on his own terms (“I can live with tinnitus…it is part of me”).

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Take-home Message

• There is no “one size fits all” management approach.

• The best approach for an individual patient is the one

that she chooses as being the most likely to help her

achieve her own treatment goals.

• The role of the clinician is to guide and encourage the

patient as she travels down the path she as chosen.

• Tinnitus coaching supports the patient during her

journey and helps her to reach her destination.

Tinnitus Coaching Final...Tinnitus “Coaching”: Managing severe tinnitus and sound sensitivity...

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