Overview of PTM

In this chapter, we provide an overview of progressive tinnitus management (PTM). We start by 

describing basic principles that undergird the PTM 

protocol. We then provide summaries of each of the 

different levels of PTM, followed by case studies 

that exemplify the individualized nature of providing hierarchical services with PTM.

Basic Premises for PTM

Manage Reactions to Tinnitus

Chronic tinnitus (as distinct from somatosounds) 

reflects malfunction somewhere within the auditory system. The phantom perception of sound is 

a symptom of the malfunction. Normally, the malfunction cannot be corrected and intervention cannot permanently reduce the loudness/intensity of 

the symptom. Considering that reducing the loudness of tinnitus normally is not an option, the next 

best thing is to help patients live more comfortably 

with their tinnitus. The focus of PTM is to teach 

patients how to manage their reactions to tinnitus, 

which can make a meaningful difference in quality 

of life.

What do we mean by “manage reactions” to 

tinnitus? Note that we avoid the word “treatment,” 

which might be interpreted by patients to mean 

that a circumscribed course of treatment will permanently quiet or eliminate their tinnitus. Such an 

outcome typically is what patients want, and they 

often are not interested in receiving clinical services 

if those services will not cure their tinnitus. Patients 

need to be informed that although tinnitus cannot 

be cured they can learn to manage their reactions to 

it, thereby improving their quality of life.

Any reference to “managing tinnitus” really 

means “managing reactions to tinnitus.” “Managing 

tinnitus” might be misinterpreted to mean “managing the sound of tinnitus” or “doing something 

to make the tinnitus quieter.” Because we cannot 

change tinnitus itself, tinnitus management should 

be interpreted to mean making lifestyle adjustments 

to reduce any reactions to tinnitus. “Reactions” 

pertains to any negative effects of tinnitus on quality of life, such as sleep disturbance, concentration 

difficulties, or any negative emotions that are associated with tinnitus.

3
22	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

By learning to self-manage their reactions to 

tinnitus, patients are empowered by gaining the 

ability to know how to address any situation in 

which their tinnitus is bothersome or intrusive. 

Patients need varying levels of support and guidance from providers before becoming self-sufficient 

in this process. Thus, there is a level of participation required of patients—they are expected to be 

engaged in the “collaborative self-management” 

process (J. A. Henry, Zaugg, Myers, Kendall, et al., 

2009) until they are able to independently manage 

their reactions to tinnitus (see Chapter 7).

Intervention with PTM specifically involves 

activities designed to reduce reactions to tinnitus 

(no attempt is made to alter the tinnitus sound). 

In addition, patients with tinnitus are taught basic 

concepts of hearing conservation. Learning these 

concepts is universally important and is particularly necessary for anyone who experiences tinnitus to minimize the potential for exacerbation of 

the tinnitus symptom.

Clinical Services Should Be Progressive

As mentioned in Chapter 1, epidemiologic studies reveal that chronic tinnitus is experienced by 

about 10 to 15% of all adults (H. J. Hoffman & Reed, 

2004). However, the condition is “clinically significant” for only about 20% of those who experience 

tinnitus (A. Davis & Refaie, 2000; P. J. Jastreboff & 

Hazell, 1998).

Tinnitus that is “clinically significant” indicates that the tinnitus causes functional impairment 

to such a degree that clinical intervention is warranted. Although difficult to define, some criterion 

level of functional impairment would categorize an 

individual as requiring clinical intervention. Determining this criterion level must be based on the 

person’s perception of the need for intervention. 

As a general guide, tinnitus is likely to be clinically 

significant if the person agrees with each of the following statements:

n The tinnitus disrupts at least one 

important life activity.

n The degree of disruption is “more than 

trivial.”

n The disruption causes a noticeable 

reduction in quality of life.

n The benefit from intervention would 

outweigh the cost and effort (i.e., “the 

effort would be worth it”).

The “tinnitus pyramid” (Figure 3–1) depicts 

how individuals who experience tinnitus are distributed with respect to how the tinnitus impacts 

their lives (Dobie, 2004b). The pyramid shows that 

the majority of these people either are not bothered 

by it or they require only some basic education. 

Approaching the top of the pyramid are people who 

have progressively more severe problems caused 

by tinnitus. The top contains the relatively few 

patients who are “debilitated” by their tinnitus.

Most patients do not require extensive (or expensive) clinical intervention to learn how to manage 

their reactions to tinnitus. We therefore developed a 

hierarchical approach to efficiently provide clinical 

services to patients having diverse levels of need. 

Figure 3–2 shows the five levels of PTM, which are 

described in detail as the primary focus of this book.

The observation that the majority of individuals who experience tinnitus do not require intervention has been supported by numerous subjectrecruitment efforts for controlled studies conducted 

at the Portland VA Medical Center (under the auspices of the National Center for Rehabilitative Auditory 

Research, NCRAR) to evaluate methods of tinnitus 

intervention (see Chapter 2). For each study, we are 

contacted by large numbers of individuals who are 

interested in participating. However, just experiencing tinnitus is not justification for receiving therapy 

that is designed to address reactions to tinnitus. As 

explained in Chapter 2, we had to develop screening 

methodology to determine if a person requires intervention. Furthermore, individuals who do require intervention have different levels of need, ranging from brief 

counseling to individualized, ongoing therapy—

thus the rationale for progressive clinical services.

The overall goal of the hierarchical approach 

used with PTM is to minimize the impact of tinnitus on patients’ lives as efficiently as possible. 

The model is designed to be maximally efficient to 

have the least impact on clinical resources, while 

still addressing the needs of all patients who complain of tinnitus.
23

Nonbothersome tinnitus

(~80% of all those who

experience tinnitus)

Bothersome tinnitus -

seek clinical intervention

(~20% of all those who

experience tinnitus)

Population of 

adults who 

experience

chronic

tinnitus

(10–15% of

all adults)

Debilitating tinnitus

Figure 3–1. The Tinnitus Pyramid (Dobie, 2004b). The concept depicted here is

that the pyramid contains the entire population of people who experience chronic

tinnitus.The majority of these people (in the lower part of the pyramid) are not particularly bothered by their tinnitus. Many of these people only want assurance that

their tinnitus does not reflect some serious medical condition (those in the middle

of the pyramid). Relatively few have tinnitus that requires some degree of clinical

intervention (toward the top of the pyramid).A very small fraction has “debilitating”

tinnitus (in the top of the pyramid).

Nonbothersome tinnitus

Bothersome tinnitus

Individualized Support

Interdisciplinary Evaluation

Group Education

Audiologic Evaluation

Triage

5

4

3

2

1

Progressively

more severe

problems caused

by tinnitus

Figure 3–2.  Five levels of progressive tinnitus management (PTM) superimposed

on theTinnitus Pyramid (see Figure 3–1).Each higher level reflects a greater intensity

of clinical services, and patients progress only to the level needed.
24	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Use an Interdisciplinary Approach

The initial evaluation for a patient who complains 

of tinnitus usually can be conducted by an audiologist and in many cases the audiology assessment (with the possibility of fitting hearing aids) is 

the only service needed. However, many patients 

require referral for additional evaluations, and 

some patients require tinnitus-specific intervention. Because of the multiple dimensions of problematic tinnitus, clinical services are optimized by 

using an interdisciplinary approach.

Clinical evaluations help determine the range 

and types of services needed to manage the full 

scope of medical, rehabilitation, and psychosocial 

aspects of tinnitus. Members of the tinnitus management team administer a variety of assessment 

instruments and then, for difficult cases, meet as a 

group to integrate results into a plan of care tailored 

to the individual needs of the patient. The scope of 

care depends on the severity of perceived tinnitus 

and medical and psychological issues. Intervention 

for tinnitus typically requires audiology and mental health services but may involve medical and 

prosthetic services.

Audiologist

Audiologists are essential for providing clinical services for tinnitus (J. A. Henry, Zaugg, et al., 2005a). 

Although audiologists can independently perform 

all aspects of clinical services for many patients, it 

is vital that they refer patients to other health care 

professionals as the presenting symptoms warrant. 

Audiologists must be aware of certain tinnitusspecific symptoms that indicate the need for medical evaluation services. Audiologists also must be 

aware of symptoms consistent with medical and 

psychological conditions. Optimally, audiologists 

who provide tinnitus services should work with an 

interdisciplinary tinnitus team.

Physician Ear Specialist

Ideally, every patient complaining of tinnitus would 

receive a complete head and neck examination from 

an otolaryngologist, otologist, or neuro-otologist who 

is knowledgeable about the multiple causes and presentations of tinnitus. However, this is not practical 

or realistic in many cases. Guidelines are provided 

in Chapters 4, 5, and 8 for determining when a medical evaluation is necessary. For example, pulsatile 

tinnitus often has an identifiable site, for which there 

are many potential causes. All patients who present 

with pulsatile tinnitus should receive a medical 

evaluation—primarily to rule out pathology (e.g., 

glomus tumor) that requires medical intervention.

Mental Health Professional

Some patients with tinnitus present with behaviors that indicate the need for an evaluation by a 

psychiatrist, psychologist, or other licensed mental 

health professional. Most mental/emotional disorders are not so obvious and require special evaluations to establish their existence and significance. 

A relatively high proportion of patients concerned 

about tinnitus suffer from depression and/or anxiety (Dobie, 2003; Halford & Anderson, 1991; Kirsch, 

Blanchard, & Parnes, 1989). Patients suspected of 

having these problems should be referred for evaluation by a mental health professional. Patients 

also should be referred immediately to a mental 

health professional if they report suicidal or violent 

thoughts, or if they report bizarre symptoms such 

as “hearing voices.”

Tinnitus can be associated with post-traumatic 

stress disorder (PTSD). PTSD is a constellation of 

mental, emotional, and physical symptoms that can 

follow the experience of a traumatic event. Although 

commonly associated with military veterans, PTSD 

affects all strata of the population and all manner 

of psychological trauma. Untreated PTSD can 

impede rehabilitation efforts, including the clinical 

management of tinnitus. Failure to properly refer 

patients for possible PTSD, depression, and/or 

chronic anxiety reduces the likelihood of achieving 

the desired outcomes from tinnitus intervention.

Sleep disturbance is the nonauditory problem 

most frequently reported by patients with tinnitus 

(Erlandsson, 2000; Jakes, Hallam, Chambers, & Hinchcliffe, 1985; Meikle & Walsh, 1984; Tyler & Baker, 

1983). Patients who report sleep problems also tend 

to have the most severe tinnitus. Sleep problems 
Overview of PTM	 25

may be mitigated by teaching sleep-management 

techniques that are included in both the psychologic and audiologic portions of the PTM counseling (and in the PTM self-help workbook). If these 

efforts are not successful, then the patient may need 

referral to a sleep disorders specialist, physician, or 

mental health professional.

Prosthetics

Some aspects of PTM incorporate instruments 

including hearing aids, ear-level noise generators 

(“maskers”) and combination instruments (combined hearing aid and masker), as well as wearable and tabletop devices that are used for sound 

therapy purposes. Involvement of prosthetics and 

sensory aids staff (at VA, military, and some other 

hospitals and clinics) ensures that appropriate technology will be available to patients with tinnitus.

Start with Audiologic Assessment

Patients complaining of tinnitus need an audiologic 

assessment for two basic reasons. First, they must 

be evaluated to determine if referral to a physician 

is warranted. Second, tinnitus usually is associated with some degree of hearing loss (Axelsson & 

Ringdahl, 1989; A. Davis & Refaie, 2000; J. L. Henry 

& P. H. Wilson, 2001; Vernon, 1998). Our research 

has revealed that the great majority of patients 

who complain of tinnitus also complain of hearing problems (J. A. Henry, Loovis, et al., 2007). An 

audiologic examination should be the clinical starting point for all patients who complain of tinnitus, 

unless urgent medical services are required.

In addition to the audiology testing, a brief 

assessment should be performed to determine 

if intervention specific to tinnitus is warranted. 

Patients with tinnitus commonly (and erroneously) 

attribute hearing problems to tinnitus (Coles, 1995; 

Dobie, 2004b; Zaugg et al., 2002). It therefore is critical to determine how much of the patient’s complaint is due to a hearing problem and how much is 

due specifically to the tinnitus. PTM utilizes a brief 

questionnaire (Tinnitus and Hearing Survey—see 

Chapter 5) to help make this determination.

Focus on Patient Education as Intervention

Clinical intervention with PTM relies on a structured program of patient education. The education 

consists primarily of teaching patients how to use 

sound and coping techniques to manage their reactions to tinnitus. More specifically, patients learn 

how to develop and implement individualized plans 

for using therapeutic sound and apply principles of 

cognitive-behavioral therapy (CBT) to manage their 

tinnitus. Success in achieving these goals depends 

largely upon patients acquiring confidence in applying the self-management strategies. Breaking the 

process of learning how to manage tinnitus into 

small achievable tasks helps to ensure that patients 

experience initial success. This approach is in accordance with the self-efficacy theory (Bandura, 1977). 

Research has demonstrated that self-efficacy is a good 

predictor of motivation and behavior. In general, 

the experience of success increases self-efficacy 

while experiencing failure reduces self-efficacy.

Unique aspects of intervention with PTM 

include: (a) its emphasis on collaborative management by patient and clinician, leading to selfmanagement by the patient; (b) development and 

use of sound-based therapy that is customized to 

address patients’ individual needs; (c) application 

of evidence-based principles of patient education 

and health literacy; (d) use of multiple modalities to 

provide education within different levels of PTM; 

and (e) inclusion of essential components of CBT 

to teach coping skills (J. A. Henry, Zaugg, Myers, 

Kendall, et al., 2009).

PTM education is provided to patients at 

Levels 2, 3, and 5, but in a different format at each of 

these levels. Going from lower to higher levels the 

education becomes increasingly more personalized. 

At Level 2, patients can receive the self-management 

workbook (although it is recommended to give the 

workbook to patients at the start of Level 3 intervention). The workbook contains step-by-step instructions for patients to learn the self-management 

techniques on their own. All patients with tinnitusspecific problems are advised to participate in the 

workshops that comprise Level 3 Group Education. At Level 5, the education is provided in a oneon-one format.
26	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

The Audiologist’s Role as Patient Educator

Patient education is the most important aspect of 

providing intervention with PTM. Thus, one of the 

audiologist’s primary roles in this program is that 

of patient educator. Training received by audiologists generally does not include theories and concepts of patient education for achieving changes in 

behavior. We previously have published a description of the principles of education used with PTM 

(J. A. Henry, Zaugg, Myers, Kendall, et al., 2009). 

The information in that article can help audiologists 

better understand their role as patient educator 

and maximize their effectiveness in implementing 

the educational components of PTM.

Address the Problem of Low 

Health Literacy

Nearly one third of English-speaking adults in the 

United States have low health literacy (Gazmararian et al., 1999; Nielsen-Bohlman, Panzer, & Kindig, 2004; Williams et al., 1995). Those with low 

health literacy have an incomplete understanding of their health problems, and are more likely 

to report poor health, have more hospitalizations 

and higher health care costs, as well as suffer worse 

health outcomes overall (Baker, Parker, Williams, 

Clark, & Nurss, 1997; Howard, Gazmararian, & 

Parker, 2005; Weiss, Hart, McGee, & D’Estelle, 1992; 

Weiss & Palmer, 2004). Tinnitus disproportionately 

affects the populations most likely to have low 

health literacy: older adults and low-income individuals (S. C. Brown, 1990; Doak, Doak, & Root, 

1996; Heller, 2003; H. J. Hoffman & Reed, 2004; 

Sindhusake, Mitchell, et al., 2003).

Even literate persons may have difficulty 

understanding health information, so training clinicians to communicate in ways that reach low-literate 

patients is good for all patients (Mayeaux et al., 

1996). There is general consensus among health literacy and communication experts that the seven 

strategies we have described previously (J. A. 

Henry, Zaugg, Myers, Kendall, et al., 2009) can help 

improve provider-patient communication (Doak et 

al., 1996; Williams, Davis, Parker, & Weiss, 2002). 

These strategies are incorporated into the PTM 

educational and counseling materials and should 

be adopted during all interactions with patients.

Refer Patients Appropriately

Because tinnitus can be a multidimensional problem, 

a team approach is the ideal. The team approach, 

however, currently is seen in very few clinics. 

Therefore, it is vitally important that patients are 

referred as appropriate to other health care professionals. Ideally, PTM services will be a joint effort 

between audiology and psychology, with inclusion 

of otolaryngology, psychiatry, and other disciplines 

as needed. Mental health professionals who receive 

tinnitus referrals should have expertise in providing psychological interventions for patients with 

chronic health conditions and at least be familiar 

with the nature of tinnitus within the context of 

comorbid psychological problems.

Five Levels of PTM

Synopsis

The PTM Flowchart (Appendix A) shows the five 

hierarchical levels of clinical services with PTM. 

The hierarchy of services starts with Level 1 Triage at the bottom of the flowchart. Level 1 Triage 

provides guidelines for all clinics where patients 

with tinnitus are likely to be encountered. Level 1 

Triage on the flowchart includes a large rectangular text box that describes the criteria for referring 

patients who complain of tinnitus. Depending on 

the patient’s symptoms and other diagnostic factors, there are four possible referrals (as indicated 

by the four columns in the text box): (1) Refer to 

audiology; (2) Refer to ENT (i.e., refer to otolaryngology) for a nonurgent appointment; (3) Refer to 

emergency care or ENT for an urgent appointment 

that will take place on the same day the symptoms 

are reported; (4) Refer to mental health or emergency care for further assessment of concerning 

mental health symptoms.

Level 2 of PTM is the Audiologic Evaluation, during which it is determined whether or 
Overview of PTM	 27

not the patient will participate in Level 3 Group 

Education. During the Level 2 evaluation, patients 

also are screened for severely reduced tolerance 

to sound (hyperacusis). If they fail the screening, 

then they should participate in the sound tolerance 

evaluation and management (STEM) protocol, as 

indicated on the figure. The STEM protocol should 

resolve the hyperacusis problem, at which time the 

patient should be evaluated to determine if further 

tinnitus services are needed. If so, then the patient 

is advised to participate in Level 3 Group Education (shown on the flowchart by the arrow leading 

from the STEM box to Level 3).

Patients who need clinical services beyond 

Level 3 can schedule an appointment for a Level 4 

Interdisciplinary Evaluation. The Level 4 evaluation (ideally performed by an audiologist and a 

psychologist) will be used to determine if Level 5 

Individualized Support is warranted.

Level 1 Triage

Level 1 is the triage level for referring patients 

at the initial clinic point-of-contact.

“Tinnitus triage guidelines” were developed for 

nonaudiologist health care providers who encounter patients complaining of tinnitus. Patients complain of tinnitus in many different clinical settings. 

Health care providers often do not know how to 

refer these patients appropriately—or whether to 

refer them at all. The tinnitus triage guidelines can 

be used to help guide referral practices for clinicians 

encountering patients reporting tinnitus. The guidelines are consistent with accepted clinical practices 

(Harrop-Griffiths, Katon, Dobie, Sakai, & Russo, 

1987; J. A. Henry, Zaugg, et al., 2005a; J. L. Henry & 

P. H. Wilson, 2001; Wackym & Friedland, 2004).

Level 2 Audiologic Evaluation

Level 2 is the audiologic evaluation, which 

includes a brief assessment of the impact of 

tinnitus on the patient’s life.

The primary objective of the Level 2 Audiologic 

Evaluation is to assess the potential need for a 

medical examination and/or audiologic intervention (audiologic intervention can include intervention for hearing loss, tinnitus, and/or reduced 

sound tolerance). Sometimes it also is appropriate to screen for mental health conditions that can 

interfere with successful self-management of reactions to tinnitus. Screening methodology is available, but not required, at this level to determine 

if a patient should be referred for a mental health 

assessment. When indicated, brief questionnaires 

can be administered to assess the potential need 

for referral to a mental health clinic. Patients’ primary care providers should be notified when their 

patients report feeling sad, isolated, agitated, or 

anxious. This information should be documented 

in the medical record along with behavioral observations such as crying or angry outbursts.

The Level 2 evaluation always includes a standard audiologic evaluation and brief written questionnaires to assess the relative impact of hearing 

problems and tinnitus problems. Patients who require 

amplification are fitted with hearing aids, which 

often can result in satisfactory reduction in reactions to tinnitus with minimal education and support specific to tinnitus (J. A. Henry, Zaugg, Myers, 

& Schechter, 2008c; J. A. Henry, Zaugg, et al., 2005b; 

Searchfield, 2005). Patients who report any degree 

of a tinnitus problem following these basic services 

are advised to attend Level 3 Group Education.

Patients who report a severe problem with 

reduced sound tolerance are scheduled for STEM, 

which then becomes the focus of clinical management. (STEM is described fully in Chapter 6, and a 

brief summary is provided below.)

Patient Self-Help Workbook

The self-help workbook provides a description 

of key information that is covered during 

Level 3 Group Education.

A special workbook (How to Manage Your Tinnitus: 

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

has been developed that provides patients with the 
28	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

core PTM counseling information that is offered 

both in Level 3 Group Education and Level 5 

Individualized Support. The workbook provides 

detailed information and instructions for developing individualized action plans to self-manage 

reactions to tinnitus using therapeutic sound and 

coping techniques. Videos and a sound demonstration CD are included in the workbook to supplement the written material.

Although the workbook is designed to be 

used by patients to learn the different self-help 

techniques, it has been our experience that many 

patients have difficulty benefiting from the workbook without at least some guidance and support 

from a clinician. Indeed, some patients can receive 

full benefit from using the workbook without additional intervention. However, patients are more 

likely to benefit from the workbook if it is provided 

in the context of a group with guided activities 

led by a clinician. We recommend providing the 

workbook to patients when they attend their first 

Level 3 workshop—for reasons that are explained 

in Chapter 5.

Sound Tolerance Evaluation and 

Management (STEM)

STEM provides adjunct procedures to evaluate 

and treat a severe sound tolerance problem.

During the Level 2 Audiologic Evaluation, patients 

are screened for a sound tolerance problem (hyperacusis and/or misophonia) using the Tinnitus and 

Hearing Survey (see Chapter 5). The survey includes 

two questions specific to reduced sound tolerance, 

which generally are adequate to determine if the 

patient has a severe problem with reduced sound 

tolerance. These patients are considered special 

cases and their progress through PTM is temporarily suspended while they undergo STEM. Some 

patients also may express a strong desire to simply 

concentrate on addressing sound tolerance problems rather than tinnitus. These patients should 

have the option of attending the STEM program.

The STEM protocol starts with an assessment of the problem, which relies mainly upon 

a special sound tolerance interview (see Chapter 

6). Testing for loudness discomfort levels can be 

performed, but is not required. If treatment for 

reduced sound tolerance is needed, then the use of 

ear-level devices (noise generators or combination 

instruments) is a consideration. Special procedures 

have been developed to evaluate patients for these 

devices. The STEM protocol continues for as long 

as reduced sound tolerance is a significant problem 

for the patient. Once the sound tolerance problem 

is under control, then it is determined whether the 

patient should continue to receive tinnitus-specific 

clinical services. If so, then the patient normally is 

advised to participate in Level 3 Group Education.

Level 3 Group Education

Level 3 provides group education workshops

for patients who require tinnitus-specific 

intervention.

Level 3 Group Education is for patients who have 

attended the Level 2 Audiologic Evaluation and feel 

that they need additional clinical services to learn 

how to manage their reactions to tinnitus. Level 3 is 

the first level within PTM for which patients receive 

focused intervention for a tinnitus problem. The 

group education is presented as classroom-style 

sessions of PTM counseling that are facilitated by 

the use of PowerPoint presentations. (Note that the 

PowerPoint files for these presentations are provided on a CD that is attached to the back of this 

handbook.) As mentioned above, patients should 

receive a copy of the self-help workbook at the start 

of the first session. The normal intervention within 

Level 3 is for patients to attend two sessions facilitated by an audiologist, combined with three sessions facilitated by a psychologist or other mental 

health provider.

In general, there are several advantages to a 

group education format (Mensing & Norris, 2003; 

S. R. Wilson, 1997): (a) Group sessions are both costeffective and time-efficient. Education and support 

can be provided to more patients in less time, maximizing available resources; (b) When education is 

the primary intervention modality, group educational intervention can be equally or more effective than providing the education on an individual 
Overview of PTM	 29

basis because of the group-interaction dynamic; 

(c) Patients often are more motivated to attend 

group rather than individual sessions because of 

the encouragement and support that they receive 

from each other; and (d) Patients who participate 

in groups tend to form a sense of camaraderie that 

further motivates them to attend the sessions.

Recent evidence supports the use of group 

education as a basic form of tinnitus intervention. 

Group education has been shown to be effective as 

part of a hierarchical tinnitus management program 

at a major tinnitus clinic (C. W. Newman & Sandridge, 2005; Sandridge & C. W. Newman, 2005). 

In addition, we completed a randomized clinical 

trial (see Chapter 2) evaluating group education 

for tinnitus in almost 300 patients that showed significantly more reduction in tinnitus severity for 

patients in the education group as compared to two 

control groups (J. A. Henry, Loovis, et al., 2007).

PTM group education has been carefully developed to assist patients in directly addressing those 

life situations when their tinnitus is problematic. 

The counseling focuses on facilitating self-efficacy 

and was developed using well-documented principles of patient education and health literacy (J. A. 

Henry, Zaugg, Myers, Kendall, et al., 2009). PTM 

counseling thus does not just educate patients about

tinnitus—it is designed to teach patients how to selfmanage their reactions to tinnitus. These patients are 

empowered to make informed decisions about selfmanagement, protecting their ears, and further tinnitus intervention options.

During the first session with the audiologist, 

the principles of using sound to manage reactions 

to tinnitus are explained, and participants use the 

PTM Sound Plan Worksheet (J. A. Henry, Zaugg, 

Myers, & Kendall, 2009; J. A. Henry et al., 2010a) to 

develop an individualized “sound plan” to use to 

manage their most bothersome tinnitus situation. 

They are instructed to use the sound plan until the 

next session with the audiologist (approximately 

two weeks later), at which time they discuss their 

experiences using the plan and its effectiveness. 

The audiologist facilitates the discussion and 

addresses any questions or concerns. Further information about managing reactions to tinnitus is then 

presented, and the participants revise their sound 

plan based on the discussion and new information. 

By the end of the second session with the audiologist, the participants should have learned how to 

develop, implement, evaluate, and revise a sound 

plan to manage their most bothersome tinnitus situation. They are encouraged to use the Sound Plan 

Worksheet on an ongoing basis to write additional 

sound plans to address other bothersome tinnitus situations. Additional group sessions with the 

audiologist can be scheduled if needed.

The group education sessions led by a psychologist focus on teaching three cognitive-behavioral therapy (CBT) coping techniques: relaxation, 

cognitive restructuring (“changing thoughts”), 

and attention diversion (“planning pleasant activities”). During the first of three sessions with the 

psychologist, the principles of CBT are explained, 

and participants use the PTM Changing Thoughts 

and Feelings Worksheet (J. A. Henry et al., 2010a). 

The provision of CBT for chronic problems other 

than tinnitus often involves six to eight sessions (J. 

L. Henry & P. H. Wilson, 2001). For PTM, only certain components of CBT are taught to minimize the 

number of group sessions and because other components of CBT, such as education about tinnitus, 

are provided elsewhere during Level 3 and Level 5.

Patients should 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. During Level 5 Individualized Support, all 

CBT modules including psychoeducation, prevention, and planning for relapse and flare-ups are 

presented in detail according to results of the Level 

4 Interdisciplinary Evaluation.

Level 4 Interdisciplinary Evaluation

Level 4 involves in-depth evaluation of 

patients who require services beyond Level 3 

Group Education.

Patients who are unable to satisfactorily manage 

their reactions to tinnitus following completion of 

PTM Levels 2 and 3 require a full evaluation to 

determine their needs for further intervention. Such 

an in-depth evaluation is not warranted for the great 

majority of patients who are able to self-manage 
30	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

reactions to tinnitus with the information and support provided in Levels 2 and 3.

The Level 4 Interdisciplinary Evaluation should 

include assessments by both an audiologist and a 

psychologist (or other mental health provider). The 

audiologist should discuss use of devices and determine if individualized support from an audiologist 

is warranted. The psychologist’s assessment should 

include screening for psychological conditions that 

may need to be addressed and a determination 

if individualized support from a psychologist is 

warranted. Thus, two appointments normally are 

required at this level—one with an audiologist and 

one with a psychologist. Ideally, after both evaluations the audiologist, psychologist, and patient will 

come to agreement concerning if and how Level 5 

intervention should be conducted.

The audiologic tinnitus assessment includes 

written questionnaires, a structured interview, 

and, optionally, a psychoacoustic assessment of 

tinnitus perceptual characteristics. The questionnaires and interview are the key to determining 

how the tinnitus impacts the patient’s life and if 

individualized support from an audiologist is 

indicated. Special procedures have been developed for selecting sound-generating devices for 

tinnitus management using therapeutic sound, 

including ear-level noise generators and combination instruments, and personal listening devices. 

The audiology portion of the Level 4 evaluation is 

used to determine if Level 5 Individualized Support from an audiologist is needed. However, 

patients who are fitted with ear-level noise generators or combination instruments must progress to 

Level 5 to ensure proper utilization of the devices.

Screening for symptoms of mental health disorders is considered a requirement at Level 4 if 

the patient is not already receiving mental health 

services. Such screenings would include inquiries 

about depressive and anxious symptomatology, 

sleep problems, and significant life stressors that 

may be contributing to one’s inability to cope. It 

is best for the mental health evaluation to be performed by a psychologist or other mental health 

care provider who is qualified to conduct diagnostic evaluations. If assessment by a mental health 

care provider is not possible, basic screening for 

these symptoms can be conducted by any clinician 

who has been properly trained to use screening 

tools and who has resources for responding to the 

outcomes of these screeners. In instances where 

audiologists (or other nonmental health care providers) are performing screening for referral to 

mental health, collaborations with primary care 

are essential to allow for immediate referrals and 

follow-up as warranted based on mental health 

screeners. Medical centers and outpatient clinics 

vary in the types and availability of mental health 

clinicians. When appropriate mental health care providers are unavailable, collaboration with primary 

care is necessary to ensure patients receive the best 

care available at that site.

It should be mentioned that these Level 4 evaluations should take into account patients’ impressions about the education they received from the 

Level 3 classes. It is important to know how useful 

the information was to patients to focus on building skills that are most likely to provide benefit. 

Taking this patient-centered approach can help 

patients feel that they are part of the decision-making process, and increases the likelihood that intervention will be successful.

Level 5 Individualized Support

Level 5 is the provision of one-on-one support

for patients who require longer-term intervention from an audiologist and/or a psychologist.

Level 5 Individualized Support involves repeated 

appointments with an audiologist and/or a mental health provider (typically a psychologist) who 

provide one-on-one individualized support to the 

patient. If ear-level devices are involved in the 

management program, then appointments with an 

audiologist are essential to ensure that the devices 

are working properly and that the patient is using 

the devices in a manner that is optimal for tinnitus 

management. Any psychologist providing Level 5 

Individualized Support should have experience or 

adequate training in providing CBT. This foundation is essential to provide effective care.

The audiologic counseling information is 

essentially the same as what was covered during 

Level 3 Group Education. However, for Level 5, the 
Overview of PTM	 31

audiologist uses a book to facilitate the counseling 

(Progressive Tinnitus Management: Counseling Guide) 

(J. A. Henry, Zaugg, Myers, & Kendall, 2010b). The 

book is laid flat on a table between clinician and 

patient, and works like a flip chart to guide both 

the audiologist and the patient through the counseling protocol. Patients should attend at least two 

Level 5 appointments, but they can attend as many 

as needed. The typical schedule includes appointments at 1, 2, 4, and 6 months following the Level 4 

Interdisciplinary Evaluation.

The psychological counseling at Level 5 

involves a review of the techniques taught during Level 3 Group Education (and included in 

the self-help workbook) and an individualized 

examination of the patient’s unique achievements 

and challenges so far during PTM. Patients learn 

more about setting and achieving goals via behavioral modification by tracking their progress using 

clearly defined measures of change. For example, 

if a patient is having difficulty managing stress, 

charting stress on a 1-to-10-scale can be effective 

for quantifying the patient’s response to stress and 

observing change as a result of modifications in 

behavior. During Level 5, patients learn how to 

accept their individual strengths and weaknesses 

while gaining a sense of control in the event that 

change is realistic and obtainable.

During Level 5 the audiologist and psychologist 

should collaborate with each other and with the 

patient to determine what is necessary to provide 

adequate benefit to the patient. Occasional appointments with both providers may be helpful for clarifying the goals of the interventions and emphasizing 

a team approach to providing tinnitus care. Options 

for the patient beyond six months of Level 5 include 

ongoing psychological symptom management (if 

warranted), further audiologic intervention (counseling and/or use of ear-level instruments), or other 

forms of tinnitus intervention that can be provided 

by an audiologist (tinnitus masking, tinnitus retraining therapy, or neuromonics tinnitus treatment). 

Some patients may require psychiatric management to address persistent or more serious mental 

health symptoms that may become evident at any 

level of PTM. If a psychologist is collaborating then 

that clinician should make such a referral to psychiatry or the primary care provider.

Conclusion

The five levels of PTM provide a logical, sequential means of working collaboratively with patients 

to best determine their needs and to provide only 

the level of care that is needed. It is a basic philosophy of PTM that educating the patient is the 

most important concern. Thus, patients receive 

only basic audiology services and self-help education through Level 3. Included in that education 

is a thorough explanation of the different ways 

that sound can be used to manage reactions to tinnitus. And, as part of that explanation, patients 

are taught how sound is used with other soundbased methods of tinnitus management (e.g., tinnitus retraining therapy). Patients should have this 

understanding before potentially committing to an 

additional clinical protocol that may be expensive 

and time-consuming. An important reason why 

fitting ear-level noise generators or combination 

instruments is not advocated until Level 4 is that 

patients need to be fully informed before making 

such decisions.

Additionally, there continues to be great 

stigma associated with psychological interventions. 

Audiologists must be on the frontlines educating 

patients about the use of psychological interventions for health conditions. Audiologists can help 

patients with tinnitus feel less concerned about this 

stigma if they explain the goals of CBT. CBT has 

been effective in helping patients deal with chronic 

pain (patients who receive CBT for pain even report 

decreased levels of pain) (B. M. Hoffman, Papas, 

Chatkoff, & Kerns, 2007). The analogy between 

pain and tinnitus is especially useful in introducing the goals of psychological management for tinnitus. Patients should be reassured that clinicians 

do not think tinnitus is a psychological disorder 

nor do we think it is “in their heads.” It may be 

important for some patients to hear that clinicians 

believe their tinnitus is real and very disturbing to 

them as a validation of their concerns and distress 

upon introducing the psychologist’s role.

If a patient reaches Level 5, then one-on-one 

support is needed for the patient to better understand the concepts and receive help in trying to 

learn how to self-manage reactions to tinnitus. 
32	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

(This is a skill patients likely will need for the rest 

of their lives so it is important that they fully grasp 

the concepts.) Furthermore, tinnitus is a dynamic 

symptom that may change dramatically over the 

course of the patient’s lifetime. If none of the efforts 

expended through Level 5 works for the patient, 

then the logical next step is to attempt to modify 

the procedures, or to try other forms of therapy. As 

a result of participating in PTM, patients become 

fully educated about the different uses of sound, 

and are in a position to make informed decisions 

about committing to another form of therapy.

PTM is a program that is efficient for audiologists and psychologists and is designed to work in 

the best interest of patients to help them learn how 

to self-manage their reactions to tinnitus without 

getting involved in expensive therapy. If a clinician is committed to one of these other methods, 

then the framework of PTM can be helpful to more 

systematically make decisions about the need for 

a high level of intervention. The interdisciplinary 

approach of PTM can be modified based on a particular clinic’s resources and staffing. Some clinics 

employ health psychologists or clinical psychologists who specialize in auditory disorders, and 

who may be especially adept at responding to the 

psychological needs of patients with tinnitus. Other 

clinics do not have such clinical resources.

The PTM model is designed for implementation at any clinic that desires to optimize resourcefulness, cost efficiency, and expedience in working 

with patients who complain of tinnitus. Use of these 

recommendations should lead to more widespread 

and consistent tinnitus assessment and intervention by clinicians. Each level of PTM is described 

in detail in this book.

Case Studies

The following case studies illustrate the PTM 

approach employed for three patients (Sam, Betty, 

and Joe). These are somewhat random examples, 

but they illustrate the range of problems reported 

by patients and the adaptive nature of PTM to 

address individual needs.

Case Study: Sam

n Level 1: Sam was referred to audiology 

by primary care for tinnitus and hearing 

loss complaints.

n Level 2: Audiologic evaluation revealed a 

high frequency sensorineural hearing loss 

bilaterally. Sam was advised and agreed 

to be fitted with hearing aids. The brief 

tinnitus assessment revealed clinically 

significant tinnitus. Sam’s primary care 

provider and a mental health provider 

were immediately notified due to his 

statement “I’m not sure how much I can 

go on living with this tinnitus.”

n Level 3: Sam attended group education 

sessions with the audiologist and psychologist and reported that the education was 

not enough—he was still very troubled by 

his tinnitus and wanted more assistance.

n Level 4: Sam returned for an interdisciplinary evaluation. The hearing aids 

were returned for credit and combination 

instruments were ordered. He and 

the psychologist agreed that further 

psychological intervention had potential 

to be helpful.

n Level 5: Sam received individualized 

ongoing intervention with an audiologist 

to optimize the use of his combination 

instruments and to more fully understand 

the PTM techniques. He met individually 

with a psychologist to optimize the use of 

coping techniques based on CBT.

Case Study: Betty

n Level 1: Betty was referred to audiology 

by primary care due to a report of 

intermittent tinnitus bilaterally.

n Level 2: Audiologic evaluation revealed 

that Betty had normal hearing bilaterally. 

Assessment of impact of tinnitus revealed 

that Betty was mildly impacted by her 

tinnitus. Betty was counseled regarding 

the test results and her tinnitus. She 
Overview of PTM	 33

was invited to attend Level 3 Group 

Education.

n Level 3: Betty participated in the 

group education workshops conducted 

by an audiologist. She obtained the 

information needed to self-manage her 

reactions to tinnitus by optimizing her 

lifestyle and using low level sounds in 

her environment when the tinnitus was 

bothersome. She deferred instruction on 

CBT education or further referral and will 

contact the clinic if changes or problems 

are noted.

Case Study: Joe

n Level 1: Joe was referred to audiology by 

his psychologist due to reports that he

“dislikes” hearing sound and has very 

bothersome tinnitus. He stopped socializing last year and avoids all activities that 

involve moderate levels of sound. The

psychologist has been treating him for PTSD.

n Level 2: Audiologic evaluation revealed 

that Joe had moderate hearing loss in his 

left ear but normal hearing in his right 

ear. (Referral to otolaryngology and 

subsequent imaging with MRI indicated 

no lesions or malformations.) The 

brief assessment of tinnitus and sound 

tolerance revealed that Joe was severely 

impacted by both of these conditions. 

Because of his severe sound tolerance 

problem, Joe was advised to participate in 

the STEM program (see Chapter 6).

n STEM: The evaluation determined 

that Joe’s sound tolerance problem 

involved hyperacusis, misophonia, 

and phonophobia. Treatment therefore 

required counseling and support by 

both an audiologist and a psychologist. 

In addition, he was fitted with a 

combination instrument in his left ear 

and a noise generator in the right ear, 

and sound was added very gradually via 

these devices and in his environment. 

His sound tolerance recovered over 

a six-month period to the degree that 

tinnitus became the primary problem. 

He was advised to attend Level 3 Group 

Education.

n Level 3: Joe participated in all of the 

group education workshops conducted 

by both the audiologist and psychologist. 

Joe learned from the audiologist how 

to use sound to decrease his awareness 

of tinnitus and to continue increasing 

his tolerance to sound. During the CBT 

workshops he learned the importance 

of staying active to distract himself from 

his tinnitus. He became less isolated 

and began meeting with friends again. 

The referring psychologist learned 

about tinnitus from the PTM team 

and incorporated skills taught during 

PTM into his PTSD treatment. Joe 

continues to receive regular follow up 

from his psychologist. It was decided 

to not schedule him for a Level 4 

Interdisciplinary Evaluation from the 

audiologist. However, the psychologist 

and audiologist will consult in 

approximately 3 months to determine if a 

Level 4 evaluation is warranted.