Table 1 Comparison of tinnitus retraining therapy and standard care in the TRTT

Goal of counseling

Introduce the concept of habituation to facilitate habituation of reaction and secondly, habituation of perception. The goal is for the participant to move to a state where tinnitus is no longer an issue.

Reduce negative cognitive, affective, physical and behavioral reactions to tinnitus; improve the participant’s wellbeing and quality of life.

Short-term goals

Reframe the way the participant views the tinnitus problem by understanding what it is and what it is not; neutralize negative emotional associations by understanding the mechanisms that provoke the emotional reaction to the tinnitus.

Empathize with and validate the participant’s feelings, provide reassurance, promote self-efficacy and engage participant in tinnitus management.

Baseline interview and factors that exacerbate tinnitus

Review completed TRT Interview Form, which informs counselor about impact of tinnitus or decreased sound tolerance on such activities as concentration, sleep, quiet recreational activities, work, restaurant use, sports, concert attendance, or socializing. This information is then discussed during counseling and at follow-up appointments.

Elicit participant’s ‘story’ to identify problem areas.

Description of the anatomy and physiology of the normal and impaired auditory system

Explain structures of outer, middle, and inner ear with special attention to the cochlear structures, function of inner and outer hair cells, and afferent and efferent nerve fibers, using three-dimensional model of an ear, diagrams, and photos. Emphasize that hearing is perceived at the brain, not at the ear, which serves only as a transformer, changing mechanical into electrochemical energy that the brain processes as sound.

Describe in general terms outer and inner ear and some description of nerve pathways.

Processing at the level of the brain

Explain that the cortical area of the brain is responsible for the perception of sound, with monitoring by at least five pre-cortical or subconscious lower levels to filter out irrelevant sounds and enhance new or dangerous signals based on personal characteristics and situation. Describe, with examples, ways in which the brain processes signals, including sensory contrast, selective perception, prioritization, and relationship with tinnitus.

Not described.

Explanation of tinnitus

Explain key points of Jastreboff’s neurophysiological model of tinnitus, using basic charts, to demonstrate the importance of the activation of subcortical, limbic and autonomic systems in tinnitus becoming intrusive.

Provide general description, with assurances that tinnitus is common, does not predict hearing loss, and does not damage health.

Sound therapy

Implement sound therapy with sound generators with low-level, relatively broad-band, sound set to level where sound just begins to mix with tinnitus sound. Recommend environmental sound and to ‘avoid silence’ at all times.

Recommend environmental sound.

Hearing protection

Recommend use of appropriate noise protection in hazardous situations, with caveat that participant should not overuse sound protection. Advise an increase in the volume of the sound generator in slightly noisier settings or the wearing of muffs over sound generators to avoid silence.

Recommend use of appropriate noise protection in hazardous situations. No recommendation for or against routine sound protection.

Sleep

Recommend use of environmental sound throughout the night with tabletop sound machines or sound pillows that have neutral sound that can be adjusted to soft, but audible, volume (not television or talk radio). Discuss etiology of sleep disorders as they relate to tinnitus.

Discuss general guidelines for sleep health and, if necessary for sleep health, recommend use of environmental sound, if an issue. If not an issue, not discussed.

Concentration

Discuss, if an issue.

Discuss ways to shift attention, increase attention span, and avoid distraction, if an issue; if not an issue, not discussed.

Stress

Discuss, if an issue.

Discuss methods to facilitate relaxation, if an issue; if not an issue, not discussed.

Setting goals with individual patient

Discuss making progress towards habituation, making sure the patient understands that it is important not to try to control the process or actively monitor it on a daily basis.

Discuss coping mechanisms that have worked in the past for the participant, including use of environmental sound devices, and strategies to deal with sleep, stress, and concentration. Recommend or decide upon specific strategies for problem areas.

Written materials

Provide written summary of tinnitus counseling and guidelines for sound generator use.

Provide leaflets on tinnitus facts; environmental sound devices; and tips for enhancing sleep, relaxation, and concentration, if these are problem areas; provide list of websites with additional information.