Level 5 Individualized Support

Individualized support is needed by relatively few 

patients. Level 5 Individualized Support involves 

use of the same principles of using sound and coping techniques to manage tinnitus that are presented in Level 3 Group Education. However, at 

Level 5 some patients use ear-level noise/sound 

generators or combination instruments, and the 

education and support is provided in a one-on-one 

format with more intense and individualized assistance. Also, Level 5 counseling is less structured 

and allows for flexibility in what is covered during the sessions. The individual counseling should 

reinforce the Level 3 principles, but the clinician 

has latitude to modify or expand on the counseling information as needed. Level 5 intervention 

normally requires up to six months of repeated 

appointments with an audiologist and/or a mental 

health provider.

Level 5 Standard Protocol for 

Audiologists

Level 5 Appointments

At each Level 5 appointment with an audiologist: 

(a) the functioning and proper use of ear-level 

instruments is verified (if applicable); and (b) oneon-one PTM counseling is conducted—focusing on 

updating the Sound Plan Worksheet (see Appendix N) to ensure that the patient is optimizing the 

use of therapeutic sound to address tinnitus-problem 

situations. If the clinician feels that it is necessary, the 

patient’s progress is evaluated, and current needs are 

assessed using any of the questionnaires that were 

administered at the Level 4 evaluation, including 

the Tinnitus Handicap Inventory (see Appendix F), 

9
78	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Tinnitus and Hearing Survey (see Appendix D), 

Hearing Handicap Inventory (see Appendix G), and 

the Tinnitus Interview (see Appendix R). If the Tinnitus Interview is used, then it is best to select individual questions that are relevant to the patient’s 

complaints rather than administering the entire 

interview. Audiometric testing is repeated only if 

the patient reports a significant auditory change.

Schedule of Appointments

Following the initial Level 5 appointment, return 

counseling appointments normally are scheduled 

at 1, 2, 4, and 6 months.

Why Are Return Appointments Important?

Return appointments are an essential, but often 

neglected, aspect of ongoing management for patients 

who have a severe problem with tinnitus. It is 

unreasonable to expect these patients to accomplish 

all management objectives without the guidance and 

support of a tinnitus specialist. Consequently, they 

require repeated appointments on a prescribed schedule until their problem is sufficiently resolved and/

or they are capable of performing self-management 

effectively.

From a health education perspective, patients 

need to return for repeated counseling because they 

recall only about half of the information, and some 

of the health information is remembered incorrectly (Margolis, 2004; Shapiro, Boggs, Melamed, & 

Graham-Pole, 1992). It also has been reported that 

patients immediately forget as much as 80% of the 

information (Kessels, 2003).

Repeated appointments are required for all 

Level 5 patients to ensure that they are using their 

ear-level devices properly and that they remember 

the key points of counseling (J. A. Henry, Trune 

et al., 2007a; P. J. Jastreboff & Hazell, 2004). Return 

visits also are necessary to ensure that patients are 

(a) implementing their individualized sound plans 

developed at previous visits, and modifying the 

plans to optimize their efficacy; and (b) using the 

specific coping skills that are taught by the mental health provider. Compliance with a schedule of 

periodic appointments optimizes the potential to 

achieve successful results.

Adherence to the Appointment Schedule

Adherence to the recommended schedule requires 

motivation and commitment on the part of the 

patient. Normally, only patients with the most 

problematic tinnitus are so inclined. Patients who 

live at a distance may not be able to return to the 

clinic as often as advised. These patients should at 

least be counseled via telephone, using the self-help 

workbook How to Manage Your Tinnitus: A Step-byStep Workbook (J. A. Henry et al., 2010a) as a general 

guide to implementing self-help strategies.

Six-Month Appointment

The appointment at six months is the final appointment for most patients receiving Level 5 services. 

If this is the final appointment, then the same procedures are conducted as for the standard protocol 

that is recommended for all of the Level 5 appointments (see Level 5 Appointments above). In addition, 

the Tinnitus Handicap Inventory (see Appendix F) 

and the Tinnitus and Hearing Survey (see Appendix D) should be administered and results compared to previous responses to evaluate the patient’s 

progress through all levels of PTM. If problems 

were reported on the Tinnitus Interview (see Appendix R), then it would be important to repeat any 

pertinent questions from the interview.

Exceptions to the Level 5 Standard 

Protocol for Audiologists

Final Appointment

The patient’s final Level 5 appointment may 

be earlier or later than six-months. Regardless 

of when the final appointment takes place, the 

procedures described above for the six-month 

appointment should be performed during the final 

appointment.

Making the Decision to End Intervention 

Before or After Six Months

The decision to end intervention should be made 

jointly between the clinician and patient. Ideally, 
Level 5 Individualized Support 79

this decision would be corroborated by the patient’s 

responses to outcome questions on the Tinnitus 

Handicap Inventory (THI) (see Appendix F) and 

Tinnitus and Hearing Survey (see Appendix D) 

(although such corroboration is not essential). As a 

reference, it has been reported that a 20-point 

reduction in the THI index score reflects “clinically 

significant improvement” (C. W. Newman & Sandridge, 2004). When intervention is complete, 

patients should be advised to telephone the clinician whenever questions or issues arise, and to 

request special appointments if needed.

Extending Intervention Beyond Six Months

If the patient requires intervention beyond six 

months, then the progress made to this point 

should be reviewed with the patient along with 

discussion of the potential benefit of further intervention. Multiple issues can be discussed as potentially contributing to a lack of sufficient progress:

n The patient’s tinnitus problem was 

so severe that more time and support 

are needed for the patient to be able to 

adequately self-manage reactions to 

tinnitus.

n Effective sound plans (using the Sound 

Plan Worksheet—Appendix N) have not 

yet been identified.

n The patient (for any reason) has not 

implemented the sound plan(s) from the 

Sound Plan Worksheet.

n A psychological component has not been 

properly managed through help from a 

mental health professional.

Every possible contributing factor should 

be explored, and referrals to other services may 

be indicated more strongly at this point. If, after 

thorough review with the patient, there is agreement that further intervention may be helpful, then 

Level 5 appointments can be extended beyond six 

months. It is critical for these patients to know 

that further services are accessible and available 

if needed.

Telephone Counseling

Patients may not be able to attend the recommended 

series of return appointments because they live at 

a distance or for other reasons. These patients can 

be counseled adequately over the telephone if they 

have the self-help workbook (J. A. Henry et al., 

2010a) to refer to during the counseling.

Self-Help Workbook

At the initial Level 5 appointment, patients should 

be asked if they have a copy of the workbook (How 

to Manage Your Tinnitus: A Step-by-Step Guide, J. A. 

Henry et al., 2010a), which normally is dispensed 

at the beginning of Level 3 Group Education. If not, 

then a new copy should be provided. The workbook should be reviewed with the patient and 

portions of the workbook that are most applicable 

should be discussed. Patients should be aware that 

the key PTM counseling principles are described 

in the workbook, along with step-by-step instructions for developing plans to manage their tinnitus 

problem using both therapeutic sound and coping 

techniques. They should be encouraged to read the 

workbook and adhere to its recommendations.

PTM Level 5 Counseling

The education provided by audiologists to patients 

at all levels of PTM is designed primarily to help 

patients develop, and experience success using, 

self-management strategies that address the situations when their tinnitus is most problematic 

(using the Sound Plan Worksheet—Appendix N). 

The main difference at Level 5 is the one-on-one 

setting that facilitates direct interaction between 

patient and clinician. Some patients do better by 

receiving ongoing individualized attention from a 

caring and knowledgeable clinician. Some patients 

also need the opportunity to resolve any questions 

or concerns about their tinnitus in a private setting 

where they can express feelings and concerns that 
80	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

they might not have been comfortable discussing 

in a group setting.

A patient counseling guide (Progressive Tinnitus Management: Counseling Guide, J. A. Henry 

et al., 2010b) is used during the Level 5 appointments. The counseling guide is used like a flip 

chart, but laid flat on a table between clinician and 

patient. When the book is open, one side faces the 

clinician and the other side faces the patient. The 

clinician’s pages contain bulleted counseling 

points, and the patient’s pages show simplified 

bulleted points and illustrative graphics. The counseling guide was designed to be used primarily by 

audiologists. A similar guide is in development that 

will be intended primarily for use by mental health 

providers.

The Level 5 patient counseling guide includes 

three sections: an introductory section, follow-up 

section, and supplemental sound tolerance (hyperacusis) section. The first two sections correspond 

with the Level 3 PowerPoint presentations (Managing Your Tinnitus: What to Do and How to Do It) that 

are included on the CD in the back of this handbook. Using the counseling guide, most patients 

at Level 5 will start with the follow-up section 

(because the material covered in the introductory 

section was already covered during Level 3 Group 

Education). The introductory section normally is 

used only with patients who have not completed 

Level 3. The introductory section, however, serves 

as a resource for fundamental PTM counseling 

information that can be accessed as needed during 

counseling sessions.

Demonstrating Personal Listening 

Devices and Stationary Devices

Appropriate use of augmentative sound can be 

very effective for helping to manage reactions to 

tinnitus. Unless the various personal listening 

devices and stationary devices are demonstrated 

in the clinic, however, patients may not appreciate their full value. There is no formal protocol for 

demonstrating these devices—they simply should 

be available in the clinic and demonstrated as 

appropriate during the Level 5 appointments.

Level 5 CBT

The Level 4 Interdisciplinary Evaluation informs 

the intervention provided by a mental health provider at Level 5. The mental health services at 

Level 5 involve a review of the CBT coping techniques taught during Level 3 Group Education 

(and included in the self-help workbook that is provided to patients at Level 3) and an individualized 

examination of patients’ unique achievements and 

challenges so far during PTM. Further integrating 

coping skills by attending to challenges patients 

face when implementing the skills allows themes 

to emerge. Patients learn more about setting and 

achieving goals with 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 scale from 0 to 10 is an effective way to quantify 

the patient’s response to stress and observe change 

as a result of modification 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.

In order to provide CBT, clinicians must be 

trained by another professional experienced in 

this modality of psychotherapy. Mental health clinicians may or may not have received this training, thus the involvement of mental health at this 

level will depend on the availability of CBT-trained 

mental health providers. A mental health provider 

who is experienced in providing CBT is skilled 

in explaining the process of CBT to patients, possesses skill in conceptualizing underlying themes 

that arise for individuals, and assists patients in 

developing their skills to problem solve. Such clinicians refer to themselves as “psychotherapists,” 

which is a title regulated by state licensing boards 

based on qualifications and training. A psychotherapist has received years of training and supervision on establishing a good working relationship 

with patients (also known as rapport). Psychotherapists adhere to a code of ethics and guide patients 

through the therapeutic intervention. Psychotherapists who specifically provide CBT understand the 

importance of behavioral and cognitive theories 
Level 5 Individualized Support 81

of the intervention. They assist the patients in learning ways to evaluate and change their thoughts 

and behaviors.

During Level 5 CBT, psychotherapists help 

patients understand their tinnitus as it relates to 

the entire mind-body system. Often, tinnitus is 

accompanied by symptoms of depression such as 

increased or decreased appetite, problems falling 

or staying asleep, and decreased pleasure when 

doing activities that once were pleasurable, among 

other symptoms. By simultaneously addressing 

a patient’s reactions to tinnitus and depressive 

symptoms, the patient recognizes the importance 

of addressing both the mind’s reactions to physical 

symptoms, and the physical symptoms that might 

influence emotions.

Occasionally, patients place more emphasis on the problem of tinnitus than on other more 

difficult emotional problems, such as unresolved 

trauma. Perhaps because tinnitus adds to frustration that already exists for some patients who 

struggle when negative emotions arise or because 

tinnitus is something that can be described physically, learning ways to cope with tinnitus may be 

how patients prefer to begin looking at the way 

they cope with stress, emotions, and problems in 

general. Nonetheless, several patients during one 

of our studies (see Chapter 2, Fifth Study) who 

began using CBT to cope with tinnitus realized that 

their tinnitus was just one problem among many in 

their lives. CBT for tinnitus for these particular 

patients offers an introduction to positive thoughts, 

behaviors, and attitudes in what might be perceived as a less formidable environment than what 

would be required to address the “other problems.” 

Such patients are then primed to use these coping skills in other areas of their lives. Level 5 CBT 

gives patients the opportunity to start using the 

skills of CBT on a concrete, diagnosable, physical problem (tinnitus) from which they can apply 

the skills to more global emotional problems and 

behaviors.

Case Study: Sam

Sam has received ongoing Level 5 Individualized Support fom an audiologist and psychologist for three months. He reports that his 

combination instruments have been helpful, but 

lately has been finding that he has to turn up 

the noise generator higher and higher to completely “mask out” the tinnitus. He also reports 

that once he has set the noise generator to a 

high level, sometimes the tinnitus returns after 

several minutes. He also feels like he is carrying around his own portable noisy environment 

and believes he cannot hear as well when the 

noise is on.

 Sam needs to be reminded that the goal of 

using sound is never to mask the tinnitus. The 

three types of sound (soothing, interesting, and 

background) should be reviewed. It should be 

clarified that the sound generator portion of the 

combination instrument can be used as soothing 

sound or background sound, neither of which 

requires masking. It may also be helpful to point 

out that the hearing aid portion of the device can 

make it easier for him to understand interesting 

sounds—like speech. It also can be explained 

that when hearing is the predominant need, he 

can turn the noise to either a very soft level or 

turn it off completely.

 The audiologist should summarize the contents of the meeting with Sam and make it available to the psychologist providing Level 5 

support to ensure that the psychologist is aware 

of Sam’s difficulties with using sound.

Beyond Level 5 

Individualized Support

If a patient does not make satisfactory progress 

after about six months of Level 5 Individualized 

Support, then a different approach can be considered. Options for extended intervention at Level 5 

include further PTM audiologic counseling (modified as necessary), further CBT counseling (including the addition of different components of CBT 

that may not have been covered to this point), tinnitus masking, tinnitus retraining therapy, and neuromonics tinnitus treatment. There is no definitive 

evidence that any one of these behavioral methods 

is more effective than any other.
82	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

Cognitive-Behavioral Therapy

The objectives of CBT are to identify negative 

behaviors, beliefs, and reactions in patients and to 

assist them in substituting appropriate and positive reactions (see Chapter 7). CBT initially was 

used as an effective treatment for depression and 

anxiety. A standard CBT protocol as adapted for 

tinnitus involves up to ten sessions. These sessions 

can be conducted with individual patients or with 

groups of patients.

CBT normally is performed by mental health 

providers. It can, however, be administered by 

other health care providers who have received the 

proper training. Training to conduct CBT for tinnitus is not offered on any routine basis for nonmental health clinicians, but must be obtained from 

a professional who has this expertise. Books are 

available that describe CBT clinical procedures in 

detail (J. L. Henry & P. H. Wilson, 1998, 2002).

Tinnitus Masking

The method of tinnitus masking (TM) became available as a clinical technique in the late 1970s (Vernon, 1977). It was popular through the 1980s and 

continues to be used (Schechter & J. A. Henry, 2002). 

The main objective of TM is to use broadband noise 

to provide a sense of relief from tension or stress 

caused by tinnitus. Because of the label “masking,” 

however, the main objective has commonly been 

misunderstood to be to cover up or “mask” the tinnitus (J. A. Henry, Schechter, et al., 2002). Maximizing a sense of relief is accomplished with complete 

masking for some people, partial masking for others, 

and sometimes even with no masking effect (J. A. 

Henry, Rheinsburg, & Zaugg, 2004).

TM patients normally are fitted with ear-level 

instruments (“maskers”) that present wide-band 

noise to the ears. Patients are instructed to adjust 

the noise to the level that provides the greatest 

sense of relief. With respect to the PTM combinations of sound (see Figure 7-1), TM is an example of 

using environmental sound as soothing sound. Patients 

also are advised to use various sound-producing 

devices to achieve relief, including CDs, tabletop 

fountains, sound machines, sound pillows, and so 

forth. Counseling is used with TM, but the use of 

therapeutic sound to induce a sense of relief is the 

primary mode of intervention. There is no training 

program available for TM. Clinicians must learn 

TM on their own or be trained by an individual 

who has expertise in this method.

Tinnitus Retraining Therapy

The method of tinnitus retraining therapy (TRT) 

has two basic components: educational (“directive”) counseling and “sound therapy” (J. A. Henry, 

Trune, et al., 2007a, 2007b; P. J. Jastreboff & Hazell, 

2004). Unlike TM, the use of therapeutic sound 

with TRT is not meant to give a sense of relief (J. A. 

Henry, Schechter, et al., 2002). With TRT the patient 

should hear the tinnitus clearly, but with constant 

sound in the background. The background sound 

reduces the contrast between the tinnitus and the 

quiet environment, thus making the tinnitus less 

likely to attract attention (passive attention diversion). Patients are supposed to use sound in this 

way every day to eventually achieve habituation, 

that is, reduction or elimination of tinnitus reactions and perception.

Evaluation of patients for TRT results in their 

placement into one of five categories: 0, 1, 2, 3, and 

4. Patients in all categories are counseled to “enrich 

their sound environment” at all times with soft, 

pleasant, or neutral background sound. Category 

0 patients have tinnitus that is not severe enough 

to warrant the use of ear-level devices, thus they 

receive TRT counseling only. Category 1 patients 

are severely bothered by their tinnitus, and earlevel instruments (sound generators, combination 

instruments, or hearing aids) are advised for use 

each day for at least one year. With respect to the 

PTM combinations of sound (see Figure 7–1), the 

use of broadband noise with TRT is an example of 

using environmental sound as background sound.

Category 2 patients also have a severe tinnitus 

problem, but in addition they have hearing loss 

requiring amplification. These patients are fitted 

with hearing aids or combination instruments, 

and sound therapy is conducted as for Category 1 

patients. Patients in Category 3 require primary management for hyperacusis, which involves special 
Level 5 Individualized Support 83

desensitization procedures using sound to increase 

tolerance levels (J. A. Henry, Trune, et al., 2007a, 

2007b). Category 4 refers to patients whose tinnitus 

is exacerbated by exposure to certain sounds. These 

latter patients require judicious use of sound to systematically reduce their reactions to sound.

The originators of this method contend that 

it is necessary to attend their training courses in 

order to properly conduct TRT. However, books 

are available that describe TRT clinical procedures 

in detail, and numerous clinicians who are trained 

and experienced in conducting TRT may be available to provide training and clinical supervision.

Neuromonics Tinnitus Treatment

Neuromonics tinnitus treatment (NTT) is unique 

among tinnitus therapies in that providers who 

offer this technique work directly with a company to receive all training, materials, therapeutic 

devices, and support. After a provider has received 

training, company representatives attend the provider’s first appointments with patients to ensure 

that all clinical procedures are conducted according to the prescribed protocol. The method cannot 

be implemented without the company’s endorsement and support.

Intervention with NTT involves six months 

or more of using a proprietary, wearable listening device 2 to 3 hours per day (P. B. Davis, 2006). 

The device is similar to an MP3 player and plays 

baroque and new age music that is specially selected 

for having relaxation-inducing qualities. For each 

patient, the device is customized by the company 

so that the sound output is adjusted (equalized) for 

any hearing loss. The device is used to implement 

desensitization to the tinnitus in two stages as the 

prescribed protocol. During the first two months 

of treatment (stage 1) wide-band noise (“shower 

sound”) is added to the music. The objective of 

stage 1 is to attain a sense of relief and control over 

the tinnitus—generally to reduce anxiety. Relative 

to the combinations of sound as described for PTM 

(see Figure 7–1), the use of sound during stage 1 of 

NTT is an example of using a combination of music 

and environmental sound as soothing sound. During the next four months (stage 2) the wide-band 

noise is removed from the audio signal. Patients 

are instructed to gradually reduce the volume of 

the music. The objective of stage 2 is essentially the 

same as for TRT: less awareness of, and less reaction to, the tinnitus. The use of sound during stage 

2 of NTT is an example of using music as soothing 

sound, transitioning to using music as background 

sound (see Figure 7–1) prior to discontinuing daily 

use of the device.

Conclusion

All audiologists routinely encounter patients who 

complain of tinnitus. Different methods of intervention for tinnitus have been available to audiologists 

for years. However, relatively few audiologists 

have received adequate training in providing clinical services for tinnitus. Audiologists need the skills 

to evaluate patients and provide the needed level 

of care. The method of PTM is a definable program 

of care that is based primarily on goal-oriented 

counseling of various uses of sound for managing 

reactions to tinnitus, and the provision of specific 

coping skills fundamental to CBT.

Standardized clinical guidelines for managing 

reactions to tinnitus are unlikely to be established 

in the near future for audiologists. Training in tinnitus clinical services is highly variable among 

audiology graduate programs (J. A. Henry, Zaugg, 

et al., 2005a). Any training that exists reflects biases, 

which is understandable because research does not 

conclusively support any one form of management. 

There are four broad areas that require consensus to 

achieve standardization. These include: (a) defined 

clinical procedures; (b) research evidence to support clinical procedures; (c) audiology graduate 

training; and (d) patient educational programs. 

PTM establishes basic procedures that can be used 

by audiologists until more formal standardized 

techniques are developed and validated.

The effectiveness of intervention with PTM 

depends on the effectiveness of the education that 

is provided to patients. It is essential that evidencebased methods of patient education are utilized. 

Previously, we have reviewed a variety of learning theories that have particular relevance to PTM 
84	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

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

This review shows that PTM adheres to a number of principles that have been demonstrated to 

optimize effective patient learning of skills for selfmanagement of health.

We recognize that counseling for facilitating 

health behavior change presents challenges that 

can result in frustration for patients and clinicians 

alike (Rollnick, Mason, & Butler, 1999). Behavioral 

changes do not come easily, especially when the 

target behaviors and their underlying cognitions 

are long-standing, sometimes even lifelong habits. However, counseling with PTM is a patientcentered method that addresses the uniqueness 

of each patient and his or her particular tinnitusproblem profile. This patient-centered approach 

has been shown to greatly enhance individual 

motivation for making adaptive changes for 

improving health (Stewart et al., 2000). In PTM, 

patients participate in the process of defining the 

problem and identifying specific behavior changes 

for managing the problem. Each patient becomes 

an active participant in making decisions and 

ultimately is in charge of making lifestyle adjustments to mitigate his or her own tinnitus problem. Understanding that the patient is an expert 

in his or her own life circumstances, problems, 

resources, and abilities is the key that enables this 

collaborative tinnitus self-management approach 

to succeed.