Level 3 Group Education

Chronic tinnitus usually is a permanent condition. In most cases tinnitus cannot be quieted, but 

patients can learn to manage their reactions to it. 

These reactions may need to be managed for a 

lifetime. Clinical intervention with PTM focuses 

on educating patients to become self-sufficient in 

managing their reactions to tinnitus.

This chapter provides a description of PTM 

Level 3 Group Education. Level 3 is the first level 

within the clinical hierarchy of PTM for which 

intervention specific to tinnitus is the primary purpose of patient visits to the clinic. During Level 2, 

the main focus is to evaluate and manage hearing 

problems, with a very brief assessment of tinnitus 

impact. (Fitting hearing aids at Level 2 to assist in 

the management of a hearing problem sometimes 

also results in a reduction in the impact of tinnitus, 

but this is not the primary purpose of fitting hearing aids at Level 2.) Intervention provided specifically for tinnitus during Level 2 is ancillary, such as 

answering questions and providing patients with 

educational materials.

Level 3 Group Education consists of a series 

of patient-education classes that are termed “workshops” because of their emphasis on interaction 

and participation. The standard protocol consists 

of five weekly workshops—two presented by an 

audiologist and three by a psychologist (or other 

qualified mental health provider). With respect to 

ordering the weekly workshops, it is recommended 

that the first and third workshops be those led by 

the audiologist, and the second, fourth, and fifth be 

those led by the psychologist.

The audiologist instructs patients in how sound 

can be used in different ways to manage reactions 

to tinnitus, and directs them through the process of 

developing individualized action plans using the 

Sound Plan Worksheet (Appendix N). The three 

workshops conducted by a psychologist provide 

instruction for patients to learn how to use specific 

coping skills to manage their reactions to tinnitus.

It should be noted that group education is not 

an appropriate venue for some patients, who may 

be unwilling to attend a group session or who may 

just require one-on-one intervention. Furthermore, 

if a patient has a cognitive impairment or other 

medical or mental health condition that would disrupt learning in a group education format, then the 

7
	 58	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

information from the groups can be discussed with 

the patient and his or her significant other on an 

individual basis.

Self-Help Workbook

In Chapters 3 and 5 we described the patient 

self-help workbook How to Manage Your Tinnitus: A 

Step-by-Step Workbook (J. A. Henry et al., 2010a). The 

workbook is fairly comprehensive in that it provides 

a great deal of information to guide patients in 

learning how to self-manage their reactions to tinnitus. We have recommended that patients who 

participate in Level 3 Group Education receive a copy 

of the workbook when they attend their first workshop. In Chapter 5, we described reasons for waiting 

until Level 3 to provide the workbook. In general, it 

will be more effective for patients when used in conjunction with their participation in the workshops.

Collaborative Self-Management

As explained in Chapter 3, when referring to intervention for chronic tinnitus, we do not use the 

word “treatment,” which can imply that a provider 

performs some procedure (or administers a drug) 

that is intended to quiet the tinnitus of a patient 

who passively receives the procedure. We instead 

adhere to the notion that intervention should primarily involve educating the patient about managing reactions to tinnitus. Different strategies often are 

needed to manage reactions to tinnitus that occur 

in different situations. Patients need to learn these 

strategies so they can manage any life experience 

disrupted by the symptom. This learning should 

take place with a compassionate and knowledgeable clinician who provides the education.

The PTM approach to self-management is 

modeled closely after clinical methodologies recently 

developed for chronic pain management (Blyth, 

March, Nicholas, & Cousins, 2005). In the past, 

urgent pain relief depended on treatments such as 

opioid drugs or invasive surgeries. It now is recognized that effective management of chronic pain 

depends much more on patients’ own efforts and 

expectations than on their passively receiving a 

treatment. In essence, biomedical solutions are being 

supplanted by educational approaches that focus 

on supporting long-term rehabilitation.

As patients become more actively involved in 

decisions affecting their clinical care, they naturally 

experience a greater sense of commitment to participate in the management process. This results in 

“a shift of responsibility from the health-care professional to the individual for the day-to-day management of their condition” (S. Newman, Mulligan, 

& Steed, 2001) (p. 1). Accomplishing this “shift of 

responsibility” requires working with patients to 

help them: (a) understand their condition; (b) participate in decisions regarding their management 

plan; (c) develop and follow the plan; and (d) monitor success of their self-management efforts and 

revise the plan as needed. The clinician and patient 

should maintain a therapeutic relationship, with 

contacts occurring either on an “as needed” or periodic basis (i.e., regular follow-ups). This overall 

approach appropriately is termed “collaborative 

self-management.”

Educating Patients to Use

Therapeutic Sound

The use of therapeutic sound for tinnitus management is well supported clinically and by clinical 

research (J. A. Henry et al., 2008c). Evidence for 

sound-based tinnitus management has been reported 

for tinnitus masking (Folmer & Carroll, 2006; Hazell 

et al., 1985; Schleuning et al., 1980; Stephens & 

Corcoran, 1985), tinnitus retraining therapy (Bartnik et al., 2001; Berry et al., 2002; Herraiz et al., 2005; 

Herraiz et al., 2007), and neuromonics tinnitus 

treatment (P. B. Davis et al., 2007). In addition, hearing 

aids are well known to provide benefit for patients 

with tinnitus (Del Bo & Ambrosetti, 2007; Folmer & 

Carroll, 2006; Saltzman & Ersner, 1947; Surr et al., 

1999; Surr et al., 1985; Trotter & Donaldson, 2008).

We completed two prospective clinical trials that involved fitting hearing aids, ear-level 
Level 3 Group Education	 59

noise generators, or combination instruments to 

most of the subjects (see “First Study” and “Third 

Study” in Chapter 2). All cohorts, regardless of the 

specific intervention involved, showed significant 

improvement (to varying degrees). Folmer and 

Carroll (2006) evaluated long-term outcomes in 

OHSU Tinnitus Clinic patients. Three groups of 

50 patients each were evaluated who: (a) used earlevel noise generators; (b) used hearing aids; and 

(c) did not use ear-level devices. Although significant improvement was observed for all patients, 

those who used ear-level devices experienced significantly better outcomes than those who did not 

use devices.

An abundance of studies and clinical techniques support the use of therapeutic sound to 

manage tinnitus. It is important to note, however, 

that no one method has been shown to be superior 

over the others. With PTM, patients are not limited 

to a single method or a particular device. Rather, the 

approach is to provide patients with the knowledge 

and skills to use sound and sound devices in adaptive ways to manage any life situation disrupted by 

tinnitus. This is accomplished by teaching patients 

the different ways that sound can be used to manage reactions to tinnitus, and helping them develop 

and implement custom sound-based management 

plans that address their unique needs.

Workshops Conducted by an

Audiologist

As mentioned above, Level 3 Group Education 

ideally consists of two workshops facilitated by 

an audiologist and three by a mental health provider. A PowerPoint presentation (Managing Your 

Tinnitus: What to Do and How to Do It) is given during each workshop (the two PowerPoint presentations made by audiologists are provided on the CD 

that is included with this handbook). The leader 

makes the presentations, facilitates discussion, and 

addresses any questions or concerns. The focus of 

the two Level 3 classes facilitated by an audiologist 

is to assist patients in learning how to self-manage 

their reactions to tinnitus using therapeutic sound 

in adaptive ways.

First Workshop (With Audiologist)

The goal for session one is for all group participants 

to use the Sound Plan Worksheet (see Appendix N) 

to develop an individualized “sound plan” for 

managing their most bothersome tinnitus situation. It is essential that participants learn how to 

use the worksheet to organize their efforts for using 

therapeutic sound.

The focus of education with PTM is to provide patients with practical, how-to information. 

The group sessions thus are task-oriented so the 

time must be spent teaching the participants what 

to do to manage their reactions to tinnitus. Covering all of the structured material during each session requires up to an hour and a half. Keeping 

these groups on-task can be challenging. There is 

a natural tendency for patients to want to share 

their experiences and thoughts about tinnitus, and 

they have limited opportunity to do that during the 

sessions. Also, any discussion about tinnitus inevitably leads to many questions. For these reasons, 

participants are asked to refrain from asking questions and discussing topics unrelated to the workshop until the end of the session. Discussion and 

questions relevant to the topics being presented are 

encouraged.

Review the Tinnitus and Hearing Survey

Prior to enrollment in group education, each participant should have filled out the Tinnitus and 

Hearing Survey (THS; Appendix D). As described 

in Chapter 5, the THS is designed to assist patients 

and clinicians in understanding how much of a 

patient’s problem is due to tinnitus and how much 

is due to hearing problems. It is critical for participants to have used the THS to determine candidacy for enrollment in Level 3 Group Education. In 

Chapter 5, a list of requirements was provided that 

should be used to ensure that a patient’s participation in Level 3 is appropriate.

If group participants do not bring their completed THS to the session, then they should complete one at the start of the session. The THS is then 

reviewed during the session—the concepts are 

discussed and participants are asked to share their 
	 60	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

responses on the THS. This is done to ensure that 

all participants understand that the purpose of the 

classes is to address tinnitus-specific problems and 

that problems related to hearing are not addressed 

during the workshops.

Sound Plan Worksheet

Use of the Sound Plan Worksheet (see Appendix N) 

facilitates the process of identifying sounds and 

sound-generating devices that are expected to be 

effective in managing specific tinnitus-problem situations. The worksheet is used throughout the first 

session with the objective for each participant to 

develop a “sound plan” that will be used until the 

second session to manage the participant’s “most 

bothersome” tinnitus situation. After participants 

have gained experience and confidence with the 

process and the concepts of developing sound 

plans, then additional bothersome tinnitus situations 

can be addressed and more complicated and sophisticated technology can be incorporated. Participants 

are encouraged to use the worksheet on a regular 

basis to refine and improve their sound plans.

Creating a sound plan to address one problem 

situation involves four small tasks (No. 1 to 4 on the 

Sound Plan Worksheet) that likely can be accomplished successfully by patients: (1) identify a situation when tinnitus is problematic; (2) determine 

which strategy (or strategies) for using sound will 

be implemented in that situation; (3) determine a 

specific sound that will be used with each strategy; 

and (4) determine a specific device for presenting 

each sound. The plan is used for at least one week 

and then evaluated for its effectiveness (No. 5 on 

the worksheet).

Group participants are instructed to identify, 

using the Tinnitus Problem Checklist (see Appendix H), the life situation in which their tinnitus is 

the “most bothersome.” To increase the likelihood 

that the initial sound plan will be implemented 

successfully, they then create a sound plan to manage just that one situation using sounds and sound 

devices that are readily accessible. In this way, participants are empowered in creating a sound plan 

that can be implemented with minimal effort and 

usually at no cost to address their most bothersome 

tinnitus situation.

Three Types of Sound

To complete the Sound Plan Worksheet, participants must learn about the three types of sound 

(soothing, interesting, and background) that can 

be used to manage reactions to tinnitus. The three 

types of sound have been described in detail elsewhere (J. A. Henry et al., 2008c), and are reviewed 

briefly below.

Soothing Sound. Soothing sound is any sound 

that provides an immediate sense of relief from 

stress or tension that is caused by tinnitus. The use 

of soothing sound has its roots in the method of 

tinnitus masking, which originally was described 

by Vernon (1976). The method of tinnitus masking continues to be used, and relies on the use of 

ear-level “maskers” that generate broadband noise 

(Schechter & J. A. Henry, 2002). The use of sound 

with tinnitus masking is intended to provide an 

immediate sense of relief—not to “mask” tinnitus, 

as the name would seem to imply.

Soothing sound for tinnitus management is 

not restricted to the use of ear-level maskers and 

broadband noise. Any sound that produces a sense 

of relief (or that the patient considers soothing) 

can be used as soothing sound. When using soothing sound, it is important that patients focus on 

obtaining a sense of relief from stress and tension 

rather than focusing on how much their tinnitus is 

masked. We therefore decided to abandon use of 

the term “masking” altogether. Whether or not the 

tinnitus is masked is completely irrelevant to the 

use of soothing sound.

Interesting Sound. Interesting sound is used to 

actively divert attention away from the tinnitus. 

The use of interesting sound for tinnitus management has not been a part of any formal method of 

therapy for tinnitus. However, distraction is a concept that is used for pain management, and the use 

of interesting sound follows the basic pain model 

(M. H. Johnson, 2005). In essence, using interesting 

sound to manage reactions to tinnitus is intended 

to shift the patient’s attention away from the tinnitus and onto some other sound. Patients thus 

learn to “actively listen” to sounds that they find 
Level 3 Group Education	 61

interesting or entertaining, which accomplishes the 

distraction objective.

Background Sound. Some patients do not experience a satisfactory sense of relief from sound and 

so may be tempted to abandon its use altogether. It 

is important that patients understand that even if 

sound does not provide immediate relief (or if it is 

not interesting), it still can be very effective in managing reactions to tinnitus by reducing the contrast 

between tinnitus and the acoustic environment, 

thereby making it easier for the brain to let the tinnitus go unnoticed.

The “candle in a dark room” analogy is used 

to demonstrate the concept behind background 

sound (as shown on the video that is provided 

with this handbook). A burning candle in a dark 

room naturally attracts attention because of the 

high contrast between the flame and the dark surroundings. If the room is then lighted, the contrast 

is reduced causing the flame to attract less attention—even though it has not changed. This analogy helps patients to understand the purpose of 

using background sound.

The use of background sound for tinnitus 

management is derived from the method of tinnitus retraining therapy (TRT) (P. J. Jastreboff & 

Hazell, 2004), which started as a clinical technique 

in the late 1980s. The method continues to be used 

and relies on the use of sound to promote “habituation” (decrease in responsiveness) to tinnitus reactions and perception. Patients with more severe 

tinnitus are advised to use ear-level sound generators (or combination instruments). These patients 

are instructed to adjust the level of the broadband 

noise to below the “mixing point,” that is, below 

the level at which their tinnitus sound starts to 

change (J. A. Henry, Trune, et al., 2007a). Many of 

our patients and research participants had difficulty adjusting the sound to the mixing point, and 

often seemed generally confused and sometimes 

anxious about the mixing-point concept. The use 

of background sound is intended to accomplish 

essentially the same purpose as for TRT. However, 

we do not refer to the mixing point, habituation, 

or other terminology that is specific to TRT. In this 

way, patients learn what to do but are not expected 

to adhere to a protocol that can seem complicated 

and daunting to accomplish. Patients certainly are 

encouraged to learn more about the TRT concepts 

if they are interested.

Demonstrating the Three Types of Sound

Specific activities were developed to give group 

participants the opportunity to experience each of 

the three types of sound. Visual scales are provided 

to enhance understanding of the activities (J. A. 

Henry et al., 2008c). The visual scales are demonstrated to participants during the first session so 

that they can appreciate their utility. Participants 

learn that they can use the tools on their own to 

evaluate the effectiveness of different sounds for 

ongoing tinnitus management.

The Relief Scale (Appendix O) was developed 

as a tool for PTM patients to use to (a) learn how 

soothing sound is used to manage reactions to tinnitus, and (b) identify sounds and evaluate their 

ability to induce relief. Patients listen to the demonstration sound and then answer the question, 

“How much relief do I feel?” The six-point response 

scale ranges from “no relief” (no reduction in stress 

or tension caused by tinnitus) to “complete relief” 

(elimination of stress or tension caused by tinnitus). Participants are asked to share their ratings 

with the group.

The Attention Scale (Appendix P) was developed for use during an activity in which patients 

learn how interesting sound can divert attention 

away from tinnitus. The scale is used as a tool to 

help patients identify the kinds of sounds that most 

effectively shift their thoughts away from the tinnitus. Patients are instructed to select any sound 

or sound passage that they would expect to keep 

their attention. After listening to the sound for at 

least one minute, they estimate the percentage of 

attention focused on the “interesting” sound versus the tinnitus. A sound passage is played during 

the workshop to demonstrate interesting sound, 

and participants are asked to share their ratings on 

the Attention Scale with the group.

The notion of reducing auditory contrast 

between tinnitus and sound in the environment 

can be demonstrated to participants using a visual 

analog. Tinnitus in a quiet environment results in 

high contrast. The addition of sound reduces the 
	 62	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

contrast. Patients can hear this effect by first noticing 

how their tinnitus sounds in quiet, and then adding 

sound. The Tinnitus Contrast Activity (Appendix Q) 

serves as a visual analog to facilitate demonstrating 

this effect. Patients use the Tinnitus Contrast Activity while listening to different sounds. Although 

each sound reduces contrast by a different amount, 

patients are taught that any amount of contrast 

reduction can be beneficial—provided the sound is 

experienced at a comfortable level. One or more 

background sounds are demonstrated to the group, 

and participants are asked to relate the concept 

depicted by the analog to the effect that is achieved 

with the sound.

Sound Grid

For each of the three types of sound (soothing, background, interesting), environmental sound, music, 

and speech can be used. This results in nine possible combinations, as shown by the sound grid (Figure 7–1). Environmental sound includes any nature 

sound (sounds of animals, weather, moving water, 

etc.) or synthetic (manmade) sound (e.g., electric 

fans and appliances, broadband masking noise, 

synthesized sounds). Music of all styles can be used, 

including music with and without lyrics. Speech of 

all varieties is appropriate to utilize, including lectures, sermons, talk radio, guided imagery, crowd 

noise, one-on-one conversation, and so forth.

Case Example

A case example demonstrates how patients 

use the Sound Plan Worksheet (please refer to 

Appendix N). Mr. Roberts’ most bothersome 

situation was “being annoyed by his tinnitus 

while working in his quiet office” (No. 1). As a 

general strategy (No. 2), he thought that using 

background sound might in general be helpful. The specific sound he would try would 

be constant fan noise (No. 3) from a small fan 

in his office (No. 4). He tried this plan for one 

week and determined that the plan was “a 

little” helpful (No. 5). He then revised his plan 

by adding soothing sound (No. 2). He liked 

sounds of nature and decided to listen to beach 

sounds (No. 3) using a CD and CD player that 

he already owned (No. 4). After trying a combination of fan noise and sounds of nature for 

one week, he indicated that the plan helped 

him “a lot” (No. 5). Mr. Roberts’ initial sound 

plan demonstrated limited success. Based on 

that experience, he revised his plan and the 

new plan worked well for him. He experienced success using the worksheet to address 

one particular problem situation, and he now 

uses the worksheet as needed to develop plans 

to address other problem situations.

Figure 7–1. Sound grid.This grid shows that there are three types of sound (soothing, background, interesting) that can be used to manage reactions to tinnitus. Each

type of sound can involve the use of environmental sound, music, and/or speech to

manage specific tinnitus-problem situations. A total of nine combinations of sound

are possible as indicated by the nine checkmarks.
Level 3 Group Education	 63

Second Workshop (With Audiologist)

At the end of the first workshop, group participants are asked to return for a follow-up workshop 

two weeks later. Between workshops, their “homework” is to carry out and evaluate the effectiveness of their initial sound plan. Participants should 

bring their worksheet developed at the first session to the second session. They are told that they 

can modify the plan during the second session to 

improve its effectiveness.

The objectives of the second workshop are for 

participants to: (a) share their experiences using 

their initial sound plan; (b) engage in collaborative 

problem solving (to address any problems implementing their sound plans); and (c) improve their 

sound plan or develop a new sound plan. In addition, new information is covered during the second 

workshop, including descriptions of: (a) different 

types of sound-producing devices; (b) ideas for 

using sound to improve sleep; (c) sound-based 

methods of tinnitus management and how they 

relate to the sound grid (see Figure 7–1); and (d) 

lifestyle factors that can affect tinnitus and hearing. Participants should attend both workshops to 

maximize their benefit. Participants who attend 

only the first workshop should receive follow-up 

by telephone.

Workshops Conducted by a

Psychologist

Mental health intervention can be an important 

component of an overall approach to managing tinnitus for all patients. Patients who are bothered by 

tinnitus can, in general, benefit from receiving mental health intervention to alter maladaptive reactions to tinnitus and to aid in coping with tinnitus. 

Mental health intervention is particularly important for patients with tinnitus who also experience 

post-traumatic stress disorder (PTSD), depression, 

anxiety, or other mental health problems.

A major question in the development of CBT 

for Level 3 was the number of sessions that should 

be conducted. Six to ten sessions of CBT are typical 

in many clinical settings. The actual number of CBT 

sessions is flexible, however, and depends on the 

purpose of the therapy. Beck (1995) explained that 

“Most straight-forward patients with depression 

and anxiety disorders are treated for 4 to 14 sessions” (p. 7). One controlled study has shown 

that a condensed version of CBT for tinnitus can be 

conducted in two sessions with no differences in 

disability reduction relative to a group that attended 

11 sessions (Kroner-Herwig, Frenzel, Fritsche, 

Schilkowsky, & Esser, 2003). Consistent with a “progressive” approach to tinnitus management, patients 

should receive less intervention at lower levels and 

more intervention at higher levels. Therefore only 

certain components of CBT are taught at Level 3 so 

as to minimize the number of sessions that patients 

are expected to attend at this level of care.

We determined that three CBT sessions at 

Level 3 would be necessary to cover the most 

important components of CBT (described below). 

Patients then have the option of attending additional sessions if further CBT counseling is needed. 

These additional sessions normally are offered to 

patients following, and depending on the results 

of the Level 4 Interdisciplinary Evaluation. In addition, the Level 3 protocol is flexible such that if multiple participants in the CBT workshops require 

additional intervention, then additional workshops 

can be added—which again is consistent with the 

progressive approach.

Typically, in CBT when basic information about 

the problem is provided, this is called psychoeducation and usually is presented during the first session 

of CBT. The last session of CBT typically includes 

information about preventing the problem from 

recurring or getting worse. For example, when CBT 

is used to treat depression, during the last session 

patients normally are taught how to identify early 

signs of depression relapse (such as overeating) or how 

to prevent depression (such as exercising regularly). 

Psychoeducation and planning for flare-ups and 

exposure to loud noise during PTM is presented in 

the self-help workbook provided to each patient, 

and thus, this information is not repeated during 

the Level 3 CBT workshops with the mental health 

provider. Consequently, more than three sessions 

of CBT would create some redundancies using the 

PTM structure. However, all information (basics 

of CBT, psychoeducation, protecting hearing, and 
	 64	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

flare-up planning) and the CBT skills addressing 

stress reduction, attention diversion, and cognitive 

restructuring are reviewed if the patient progresses 

to Level 5 Individualized Support.

Patient learning in all of the Level 3 workshops is facilitated by use of the PTM self-help 

workbook (J. A. Henry, Zaugg, Myers, & Kendall, 

2010a). Each of the CBT components taught during Level 3 is described in the workbook. After 

each session, patients practice their new skills by 

using worksheets and activities in the workbook. 

These worksheets and activities are intended to 

facilitate learning the new skills and recording 

progress. When patients return for the next workshop, they are asked to report their progress to the 

group. Group education based on CBT, as opposed 

to individual CBT sessions, is efficient and allows 

patients to apply skills to a variety of situations 

and to develop a social network from which to 

draw support.

Changing Thoughts and 

Feelings Worksheet

During the CBT workshops the Changing Thoughts 

and Feelings Worksheet is used, which is modeled 

after and used simultaneously with the Sound 

Plan Worksheet (see Appendix N). The Changing 

Thoughts and Feelings Worksheet helps patients 

track their use of the three coping skills offered 

during the CBT portion of Level 3. The worksheets 

are used throughout the sessions with the objective for participants to develop personalized plans 

for managing their reactions to tinnitus in specific 

problem-situations.

CBT group participants are instructed to 

identify, using the Tinnitus Problem Checklist (see 

Appendix H), the life situation in which their tinnitus is the “most bothersome.” This is the same 

task that is required when they use the Sound Plan 

Worksheet during the workshops conducted by an 

audiologist. It is helpful if patients identify the same 

tinnitus problem on their two different worksheets 

to learn how very different strategies can be used 

to address a single problem situation. The audiologists and mental health providers who teach these 

workshops should point this out and ask participants to focus first on their most bothersome tinnitus problem. In the process, patients learn that 

managing reactions to tinnitus involves using a 

combination of strategies that each are developed 

and refined through trial and error. Learning to 

manage tinnitus is a process that should be conducted systematically—by learning the strategies, 

developing action plans, implementing the plans, 

and revising the plans to improve outcomes.

After the group participants have gained experience and confidence with the process and the use 

of CBT concepts to manage their reactions to tinnitus, they can use any of the skills as “tools” to help 

them cope with their tinnitus. They are encouraged 

to use the Thoughts and Feelings Worksheet on a 

regular basis to refine and improve their use of 

these coping skills.

Essential CBT Components

The Level 3 workshops led by a mental health provider focus on teaching three CBT techniques: stress 

reduction (“relaxation”), attention diversion (“planning pleasant activities”), and cognitive restructuring (“changing thoughts”). During the first CBT 

session, the basic premise that how one thinks and 

acts influences one’s feelings is described. Emphasis is placed on clarifying goals and tracking efforts. 

Later, patients learn techniques to assist them in 

learning ways to modify thoughts and increase or 

decrease behaviors that influence how they feel 

about their tinnitus. Each of these coping skills can 

be helpful to patients who want to learn ways to 

manage their reactions to tinnitus. These skills also 

are applicable to many other chronic conditions 

such as anxiety, depression, and pain.

CBT Session 1

Stress Reduction

Many patients report that their tinnitus is exacerbated by stress. By reducing stress or managing 

reactions to stress, patients are able to reset the 

body’s natural stress arousal system to a more 

relaxed and calm state. Practicing relaxation tech-
Level 3 Group Education	 65

niques can modify one’s response to stress and 

can serve to distract attention from the tinnitus 

to other things. The goal of providing this skill is to 

empower patients with a simple and easy way 

to relax when stressed.

Relaxation techniques taught during the first 

session of Level 3 with the psychologist include 

controlled breathing and imagery. A video demonstration of these techniques (“Deep Breathing” and 

“Imagery”) is included on the DVD that is provided 

with the self-help workbook. The “Deep Breathing” exercise is a controlled breathing exercise that 

helps patients focus on taking slow and rhythmic 

breaths. Controlled breathing encourages attention to the mechanisms of the lungs and sounds of 

breathing, which releases tension and diverts attention from tinnitus. The “Imagery” exercise teaches 

patients to imagine being somewhere calming and 

safe. Imagery is useful as a relaxation technique 

when a pleasant or neutral image is envisioned 

during distress (J. L. Henry & Wilson, 2001). These 

techniques also require practice, thus, patients are 

asked to complete “homework” between sessions.

Instructions for both of these relaxation exercises are specific for patients with tinnitus. For 

example, patients are instructed not to practice 

the relaxation exercises in silence. Patients are 

encouraged to use soothing sound such as calming music during the exercises. Furthermore, since 

many patients with tinnitus also have hearing loss, 

instructions take into account the fact that some 

patients may feel more comfortable not closing 

their eyes during the relaxation exercises. They are 

instructed to focus on an object in the room or on 

the open-captioning of the relaxation demonstrations on the video.

Attention Diversion via Increasing 

Pleasant Activities

There are many ways to divert attention from one 

activity to another. Many patients stop doing the 

things they like to do (pleasant activities) and tend 

to focus on required activities such as work and 

house chores. The goal of providing this coping 

skill is to help patients learn ways to divert attention away from the tinnitus and onto other things 

by increasing pleasant activities in their lives. This 

skill also is taught during the first session of Level 3 

with the mental health provider. The skill typically 

is easy for patients to understand.

Group participants are instructed to examine 

the impact of tinnitus on their activities, particularly on pleasant activities, and to learn ways to 

increase their activities. They are provided a list of 

types of activities (solitary, indoor, social, musical, 

etc.) from which to develop ideas about the types 

of activities they would enjoy. They then are asked 

to add one pleasant activity to their daily routine 

and rate how effective it was in diverting attention 

away from the tinnitus.

Increasing activities helps to distract patients 

from their tinnitus and helps them to gain meaningful experiences that typically result in a greater 

sense of relatedness and connectedness to the 

world. Also, patients may have become isolated 

over the course of learning to cope with their tinnitus. Some patients will need encouragement to 

become social again.

CBT Sessions 2 and 3: Cognitive 

Restructuring

During the second and third CBT workshops, the 

group participants are taught how their thoughts 

and behaviors influence feelings via a step-by-step 

guide for evaluating thoughts, modifying thoughts, 

and developing healthy attitudes. These cognitive 

restructuring activities require two sessions to adequately cover all the material.

CBT Session 2

During the first of the two sessions on cognitive 

restructuring, participants learn about healthy 

attitudes and examining their own thoughts; this 

sometimes is called “mindfulness” training. Mindfulness is a state of being consciously aware of one’s 

own thoughts and behaviors. Some patients tend to 

use faulty logic when thinking about experiences.

During this session, participants learn the 

12 most common types of negative appraisals 

(also called thought errors): (1) overgeneralization, 

(2) all-or-none thinking, (3) filtering or selective 

abstraction, (4) mind-reading, (5) magnification 
	 66	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

or catastrophization, (6) minimization, (7) personalization, (8) jumping to conclusions or arbitrary 

inference, (9) emotional reasoning, (10) “should” 

statements, (11) labeling, and (12) blaming (Beck, 

1995). They are taught to be mindful by systematically examining their thoughts so as to provide 

insight into which of these 12 negative appraisals 

they may be using. They are asked to cite personal 

examples for each of the 12 negative appraisals as 

homework. As they do this exercise, thought patterns or “habits” typically emerge, helping them 

understand their own thought processes.

CBT Session 3

During the second of the two sessions on cognitive 

restructuring, the participants learn to systematically modify or restructure their thoughts so as to 

create different, more desirable emotional reactions. Constructive approaches to stress, such as 

thinking of a stressful event as a challenge rather 

than a threat, are presented. Negative attitudes and 

appraisals of situations often lead to negative emotions, which immediately are applied to individuals’ unique problems and concerns.

During this session, step-by-step instructions 

are provided for changing negative appraisals to 

more constructive, positive appraisals. The group 

works through an example in their workbook of 

using the step-by-step process to address a negative 

thought about an event and come up with alternative, more constructive thoughts. The participants’ 

life situation in which their tinnitus is most bothersome as identified on the Tinnitus Problem Checklist (see Appendix H) is used during this exercise 

to keep the CBT sessions aligned with the sessions 

with the audiologist.

Post-Workshop Follow-Up

Patients who attend the workshops should be 

informed that they will receive a follow-up phone 

call approximately one month after the last workshop. The call is made by the audiologist or the 

mental health provider who conducted the workshops. The purpose of the call is to determine if the 

patient will return for the Level 4 Interdisciplinary Evaluation. During the call, the clinician asks 

about progress implementing the action plans, 

discusses any problems encountered, and answers 

questions. The clinician can use any of the written 

questionnaires that were administered previously 

to assist in determining if a Level 4 appointment is 

warranted.

Conclusion

Any person who has tinnitus can benefit from 

being educated concerning what to do about the 

phantom sound. Many patients are interested only 

in a cure for their tinnitus, and they may not realize 

the importance of learning good management techniques. In general, clinical services for tinnitus are 

provided only to patients who are bothered by their 

tinnitus. The majority of individuals who experience tinnitus are not bothered by the constant 

sound and they mainly need to learn and adhere 

to good practices to avoid situations that can damage their hearing. Those who are bothered by their 

tinnitus need to learn methods to self-manage their 

reactions to tinnitus. With PTM, these methods 

include education about using therapeutic sound 

and effective coping techniques.

The goals of PTM are achieved through the 

process of collaborative self-management. Clinicians 

who provide PTM should consider themselves as a 

source of information and support that empowers 

patients to manage any situation in which tinnitus 

is problematic. As already discussed, collaborative 

self-management is very different from the traditional “treatment” model, which involves patients 

passively undergoing some kind of therapeutic 

procedure(s). The keys to collaborative self-management are the availability of appropriate educational materials and the means to provide the 

education to patients efficiently and effectively. The 

framework of PTM provides for a variety of modalities through which patients can learn the essential 

self-help information. Level 3 Group Education is 

sufficient for most patients who are bothered by 

tinnitus. If further services are required, then the 

patient should be scheduled for a Level 4 Interdisciplinary Evaluation, which is described in the 

next chapter.