Tinnitus: Counseling strategies to help your patients

The benefits of counseling intervention for patients with bothersome tinnitus is well-established. The American Academy of Otolaryngology strongly recommends counseling and education to help mitigate its functional and emotional health effects.¹

A survey of 93 patients who received tinnitus services in the UK viewed counseling as more effective than amplification or sound therapy alone in helping them better manage their condition.²

In Audiology, counseling refers to the provision of informational and personal adjustment services to patient with hearing problems such as reduced hearing acuity, tinnitus and hyperacusis.³  

Informational counseling

This component of counseling focuses on providing clear, up-to-date, evidence-based, and unbiased information to assist patients and their family in making an informed decision regarding treatment options. The goal is to educate patients on an array of topics such as audiometric test results, associated hearing and health conditions, stress management, and sound enrichment strategies.

Discussion topics:

Correcting misconceptions about tinnitus, its prognosis, and treatment(s)
Sadly, some patients are still being told that “nothing can be done”, their tinnitus will “get worse” and they will eventually have to “learn to live with it”. Research warns that more than a third of them have gone online and retained inaccurate and false information.⁴ Therefore, clinicians gain in educating patients on what tinnitus is and is not.

According to a recent epidemiological study in Canada, subjective tinnitus is a highly prevalent condition affecting more than a third of the general population.⁵ It is most often associated with minor health conditions (e.g., aging, noise exposure, hypertension, anxiety). Audiological management strategies currently available can help reduce its complications such as hearing and communication problems, distraction and concentration difficulties, sleep, and emotional disturbances.

Reviewing the hearing-brain connection
Audiologists benefit in reviewing the anatomy and physiology of the auditory system by centering explanations on the hearing-brain connection. The hallmark symptom of subjective tinnitus is hearing loss.^6,7 It is estimated that up to 90% of tinnitus patients present with elevated high-frequency thresholds.^8,9

Explaining the association between tinnitus annoyance and emotional distress
Adults with tinnitus are more likely than individuals without the condition to report high stress levels, anxiety, and depression.^1,10,15 It is estimated that about 20% of the tinnitus population struggles with bothersome tinnitus.¹¹ Therefore, the link between tinnitus annoyance and emotional distress needs to be examined especially for patients reporting poor levels of well-being.

Several theoretical frameworks, such as the Neurophysiological, Cognitive and Fear-Avoidance models of tinnitus, have been proposed to explain the development of negative emotional reactions among these patients.^11-14 One common assumption found in all these models is that tinnitus-related emotional distress amplifies and maintains the negative experience with the condition.

Additionally, increase in situational stress, such as the COVID-19 outbreak, have been shown to worsen pre-existing tinnitus.¹⁶ Many studies during the pandemic have also identified the need to attend to the emotional burden associated with the experience of tinnitus.¹⁶ A referral to a mental health professional may be necessary for patients with more severe reactions.

Personal-adjustment counseling

This component of counseling focuses on providing emotional support to patients and their family in coping with the psychosocial impact of tinnitus.³

The goal is to address feelings, thoughts, behaviors, and beliefs expressed by patients in the hope of facilitating change and acceptance. The use of effective counseling skills such as empathy, active listening, non-verbal communication habits, and instilling hope has been shown to build trust, reduce distress, boost treatment compliance, and improve outcomes.^17-19

Skills and attitudes:

• Expressing empathy allows patients to feel that they matter as individuals and their well-being is in good hands.
• Taking the time to listen to patients’ struggles, concerns and expectations conveys respect for their own knowledge and promotes self-efficacy.
• Adopting helpful body language habits (e.g., smiling when greeting patients, leaning in when listening, maintaining appropriate eye contact and head nodding, using friendly and calm tone of voice) communicates positive messages to patients such as compassion and competence. Good non-verbal habits are as significant as clear verbal communication skills.
• Providing patients with a sense of hope can help them cope. Over time, it is possible for them to re-claim control over tinnitus with personalized intervention(s). Studies show that patients with greater optimism engage in more adaptive coping behaviors which facilitate management of chronic symptom(s).²⁰

Counseling is not the only audiological strategy – demo amplification

Research shows that amplification and counseling can significantly improve perception of, and reaction to, tinnitus.^1,21,22 A quick hearing aid demo is often the best way to explain the benefits of amplification for tinnitus relief.

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References:

Tunkel, D.E., Bauer, C.A., Sun, G.H., Rosenfeld, R.M., Chandrasekhar, S.S., Cunningham, E.R. Jr., Archer, S.M., Blakley, B.W., Carter, J.M., Granieri, E.C., Henry, J.A., Hollingsworth, D., Khan, F.A., Mitchell, S., Monfared, A., Newman, C.W., Omole, F.S., Phillips, C.D., Robinson, S.K., Taw, M.B., Tyler, R.S., Waguespack, R. & Whamond, E.J. (2014). Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg, 151(2 Suppl), S1-S40.

Aazh, H., Moore, B.C., Lammaing, K. & Cropley, M. (2016). Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments. Int J Audiol, 55(9), 514-22.

American Speech-Language-Hearing Association (2008). Guidelines for audiologists providing informational and adjustment counseling to families of infants and young children with hearing loss birth to 5 years of age (guidelines). Retrieved from Guidelines for Audiologists Providing Informational and Adjustment Counseling to Families of Infants and Young Children With Hearing Loss Birth to 5 Years of Age (asha.org), accessed February 7, 2022.

Lewandowsky, S., Ecker, U.K., Seifert, C.M., Schwarz, N. & Cook, J. (2012). Misinformation and its correction: Continued influence and successful debiasing. Psychol Sci Public Interest, 13(3),106-31.

Ramage-Morin, P.L., Banks, R., Pineault, D. & Atrach, M. (2019). Tinnitus in Canada. Health Rep; 20;30(3): 3-11.

Henry, J., Roberts, L.E., Caspary, D.M., Theodoroff, S.M., & Salvi, RJ. (2014). Underlying mechanisms of tinnitus: review and clinical implications. J Am Acad Audiology, 25(1), 5-126.

Moller, A.R., Salvi, R., De Ridder, D., Kleinjung, T. & Vanneste, S. (2015). Pathology of tinnitus and hyperacusis-Clinical implications. Biomed Res Int, 608437.

Pineault, D. (2020, September 24). Assessing and managing COVID-19 related tinnitus. Phonak Audiology Blog [Clinical Practice]. Retrieved from https://audiologyblog.phonakpro.com/assessing-and-managing-COVID-19-related-tinnitus/, accessed November 30, 2023.

Pineault, D. (2023, November 28). Hyperacusis: What audiologists need to know. Phonak Audiology Blog [Clinical Practice]. Retrieved from https://audiologyblog.phonakpro.com/hyperacusis-what-audiologists-need-to-know/, accessed November 30, 2023.

Lin, C.E., Chen, L.F., Chou, P.H. & Chung, C.H. (2018). Increased prevalence and risk of anxiety disorders in adults with tinnitus: a population-based study in Taiwan. General Hospital Psychiatry, 131-136.

Dobie, R.A. (2004) Overview: suffering from tinnitus. In: Snow JB, ed. Tinnitus: Theory and Management. Lewiston, New York: BC Decker Inc., 1–7.

Jastreboff, P.J., & Jastreboff, M.M. (2000). Tinnitus retraining therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol, 11(3), 162-77.

McKenna, L., Handscomb, L., Hoare, D.J. & Hall, D.A. (2014). A scientific cognitive-behavioral model of tinnitus: novel conceptualizations of tinnitus distress. Front Neurol, 5:196.

Cima, R.F.F., Crombez, G. & Vlaeyen, J.W. (2011) Catastrophizing and fear of tinnitus predict quality of life in patients with chronic tinnitus. Ear Hear, 32(5), 634–641.

Pineault, D. (2021). Impact of COVID-19 Pandemic on Mental Health and People with Hearing Problems, The Hearing Journal, 74(3), 6.

Beukes, E.W., Manchaiah, V., Andersson, G., Allen, P.M., Terlizzi, P.M. & Baguley, D.M. (2018). Situationally influenced tinnitus coping strategies: a mixed methods approach. Disabil Rehabil, 40(24), 2884-2894.

Hashim, M.J. (2017). Patient-centered communication: Basic skills. Am Fam Physician, 1;95(1), 29-34.

Derksen, F., Bensing, J., & Lagro-Janssen, A. (2013). Effectiveness of empathy in general practice: a systematic review. The British Journal of General Practice: The Journal of the Royal College of General Practitioners, 63(606), e76–e84.

Beck, K., & Kulzer, J. (2018). Teaching Counseling Microskills to Audiology Students: Recommendations from Professional Counseling Educators. Seminars in Hearing, 39(1), 91–106.

Amati M, Grignoli N, Rubinelli S, Amann J, Zanini C. The role of hope for health professionals in rehabilitation: A qualitative study on unfavorable prognosis communication. PLoS One, 14(10):e0224394.

McNeill, C., Tavora-Vieira, D., Alnafjan, F., Searchfield, G.D. & Welch, D. (2012). Tinnitus pitch, masking, and the effectiveness of hearing aids for tinnitus therapy. International Journal of Audiology, 51, 914-919.

Araujo Tde, M. & Iorio, M.C. (2015). Effects of sound amplification in self-perception of tinnitus and hearing loss in the elderly. Brazilian Journal of Otorhinolaryngology, 82(3), 289-296.