How does training the mind to be present in the here and now help patients with troublesome tinnitus? James Jackson discusses mindfulness and its place in tinnitus management.
Although definitions can be more complex, tinnitus is the perception of sound in the absence of external stimuli. Commonly described as ‘ringing in the ears’ tinnitus can also be heard as roaring, whistling and buzzing noises. It is a common condition, with perhaps one in seven adults having tinnitus. It affects many millions worldwide and poses a significant challenge for audiologists and patients alike.
Recently, mindfulness has emerged as a promising approach to managing tinnitus symptoms. Tinnitus distress is strongly linked to clinical depression, anxiety, and poor sleep quality. This article delves into the principles of mindfulness and its online application in alleviating tinnitus distress.
But just what is mindfulness? The most common definitions describe mindfulness as a way of paying attention, but to this moment, and to only attend to whatever thoughts, feelings, and sensations we are currently experiencing, whether it is the wind in our face, the socks on our feet, or the gentle thrum of a nearby motorway. The aim is to stop reacting to things, and to observe our world. Mindfulness has only become popular in the West over the last 30 years or so, but stems from Eastern philosophy, particularly Buddhism.
Imagine you are walking though a beautiful forest, following a simple path, enjoying the fresh air and the flowers without thinking about anything in particular. You come to a fast-flowing stream and the only way across is by using stepping stones. Rather than being hesitant, focusing on every movement you make, testing each stone, and worrying about falling in, the mindful way forward is to stop midstream on a larger stone, then try to relax and consider the world around you. (Yes, this stream is a metaphor for our daily life). Notice the rushing water, the birds singing, your own breath and faster heart rate. You look around, you notice you are looking around, and you’re aware of being perched on a rock in the middle of a river. You realise this is a bit difficult, you’re worried about getting wet, but you accept this is how things are. Wishing for things to be different is unhelpful, so you accept the situation you are in. This is mindfulness.
"Hundreds of research articles have been published on the benefits of mindfulness meditation, and it has been proven to be effective in treating tinnitus and depression"
Currently, there is no cure for tinnitus. However, the 2020 NICE guidelines for tinnitus management (https://www.nice.org.uk/guidance/ng155) do recommend psychological interventions for tinnitus distress, suggesting cognitive behavioural therapy (CBT) first, whether group-based or individual, and delivered by psychologists. However, they also note that mindfulness-based interventions (MBIs) and acceptance and commitment therapy (ACT) are effective in managing tinnitus-related distress.
CBT is the most common form of psychological therapy for tinnitus that we see. It is used to challenge irrational, unrealistic, and illogical thoughts and reframe them into rational, realistic, and logical ones. Interventions tend to span eight to 12 weekly sessions, covering topics such as attention bias, applied relaxation and distraction techniques, though greater success is seen when interventions are tinnitus-specific [1]. MBIs are becoming increasingly acceptable as a treatment for tinnitus. Hundreds of research articles have been published on the benefits of mindfulness meditation, and it has been proven to be effective in treating tinnitus and depression [2]. Mindfulness is not a quick fix for powerful emotions but, practised over time, it becomes more likely that emotional reactions will not be as strong as before. Low trait mindfulness is known to predict catastrophising and rumination, resulting in ineffective coping strategies (i.e. avoidance) and poor mental health and wellbeing.
Developing higher levels of trait mindfulness through practice enhances the ability of individuals to positively appraise and accept their condition [3]. With regards to tinnitus, CBT and MBIs have considerable overlap since they share some underpinning theory. However, they target the thought process in demonstratively different ways. CBT challenges negative thoughts about tinnitus, whereas MBIs seek to mitigate that thought. The best interventions will incorporate strong psychoeducational aspects of what tinnitus is and how it affects individuals, but both CBT and MBIs encourage patients to coexist with their tinnitus rather than ‘fighting it’ [4].
Illustrating visual accessibility/imagery of mindful resources [5].
Accessibility of interventions for tinnitus management is also problematic. My own research (in prep) suggests that 46% of patients seeing their GP specifically with regards to tinnitus (n=356) are referred onwards to audiology, whereas only 8% of such patients are referred to psychological intervention. Additionally, psychological interventions require input from psychologists who may not be available, while many individuals seeking a cure for their tinnitus are reluctant to seek psychological help for what they believe to be a physical condition. When travel, time restrictions and costs are considered, it is no surprise that individuals are further deterred from seeking psychological support. This makes the online space more attractive, especially when coupled with a desire to remain anonymous. Furthermore, the journey to tinnitus habituation is more likely to rest upon proactive self-management of the condition and many self-help resources are available in the public domain – though it is worth noting that these are rarely tinnitus-specific, so moderately less useful. If evidence-based, these can be effective in reducing anxiety and depression – key comorbidities of chronic tinnitus.
"In the absence of accessible psychological interventions, a structured programme of online mindfulness resources can be recommended for individuals with tinnitus as an effective and low-cost self‑help tool"
In our most recent paper, we took a number of readily available and open-source mindful body scan exercises and hosted them online at Leeds Trinity University as part of an eight-week programme of guided online mediations [5]. Fifty-two participants were sent one exercise per week for eight weeks, and were asked to watch at least one exercise, twice per week. In comparison with our waiting list control (n=48), one-third of our intervention sample saw clinically meaningful reductions in tinnitus distress at the end of the two-month intervention period, also reporting fewer negative thoughts about their tinnitus, and a greater tendency towards mindful thought – both of which are important for tinnitus habituation. As such, in the absence of accessible psychological interventions, a structured programme of online mindfulness resources can be recommended for individuals with tinnitus as an effective and low-cost self-help tool.
There is more work to be done – and we have recently launched a new study looking at the same resources over a longer period of time, measuring other variables to better understand who gains the most from this kind of intervention. Patient-centred outcomes are key and, as mindfulness becomes increasingly fashionable, it is also worth noting that mindful practice is not a perfect cure-all. Indeed, formal mindfulness practice requires us to sit still and witness our own thoughts, feelings, and bodily sensations. Mindfulness is not a substitute for proper psychological support and therapy. Instead, it should be seen as an opportunity to reconnect with life, to understand yourself and to stop worrying about the future. Anxiety is a future-orientated emotion based around fear of what is to come. To spend time in the moment, enjoying it, is hugely beneficial for all of us.
Evaluation of an online mindfulness approach to manage tinnitus distress
Leeds Trinity University (UK) and the University of the Witwatersrand (SA) are seeking individuals with tinnitus to participate in a new study. For more information or to volunteer, please visit https://app.onlinesurveys.jisc.ac.uk/s/ltu/evaluation-of-an-online-mindfulness-approach-to-manage-tinnitus.
References
1. Landry EC, Sandoval XCR, Simeone CN, et al. Systematic review and network meta-analysis of cognitive and/or behavioral therapies (CBT) for tinnitus. Otol Neurotol 2020;41(2):153–66.
2. McKenna L, Marks EM, Vogt F. Mindfulness-based cognitive therapy for chronic tinnitus: Evaluation of benefits in a large sample of patients attending a tinnitus clinic. Ear Hear 2018;39(2):359–66.
3. Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clin Psychol Rev 2017;51:48–59.
4. Marks E, Smith P, McKenna L. Stop Fighting It! An Interpretative Phenomenological Analysis of patient experiences of Mindfulness Based Cognitive Therapy for tinnitus. Front Psychol 2020.
5. Jackson JG, Woolmer CD. An 8-Week Online Body Scan Meditation Intervention for Tinnitus: Accessibility, Adherence, and Rates of Clinically Meaningful Success. Mindfulness 2024;15(5):1176–87.
Declaration of competing interests: None declared.
