The word 'tinnitus' comes from the Latin word for 'ringing' and is the perception of sound in the absence of any corresponding external sound. It is not a disease or illness; it is a symptom generated within the auditory system. The noise may be in one or both ears, or in the head, or it may be difficult to pinpoint its exact location. Those who experience tinnitus usually find the noise disrupting and distressing.
How did your career in psychology begin?
My first degree, in Psychology, was at Oxford, and I enjoyed all things about the subject,’ says Lecturer and Clinical Tutor Dr Elizabeth Marks, from her office in the Department of Psychology. ‘I’ve always been interested in how a scientific understanding of human psychology and the brain can empower us to help people who are in real distress.’ After graduating, Liz went to Spain and taught English for a year, exploring life and language in a different culture, but she missed her subject. She realised that she wanted to find a way to put her degree into practice and was drawn to clinical psychology, a place where science and clinical practice meet.
‘I returned to the UK, and began working as a nursing assistant in a mental health trust. It was a really rich experience, and gave me the privilege of working alongside people at the sharp edge of mental illness and distress. I was struck by both the commitment of the staff and the great psychological needs of the patients. As a nursing assistant my own skills were somewhat limited in meeting these needs, and this only strengthened my determination to develop the necessary expertise to do this. I could see that it would lead to a really valuable and fulfilling career, and I worked towards getting a place on a doctoral training course for clinical psychology’.
‘I was lucky enough to be given a job as an assistant psychologist at the Central and North West London NHS Foundation Trust (CNWL), adult mental health outpatients unit. This gave me some great clinical experience, and I began to learn to use Cognitive Behavioural Therapy as a way of enabling people to make real changes to their psychological health. After a year, I was offered a place to train as a clinical psychologist at the Institute of Psychiatry at Kings College London. This training involved teaching and research as well as varied clinical work within the NHS’.
Tell us about your thesis
‘My doctoral research project looked at “information processing styles associated with trauma and anomalous experiences”. We know that the way in which the brain processes traumatic information tends to be less ‘contextualised’ and can lead to more fragmented and intrusive memories about traumatic events. We therefore hypothesised that a tendency to engage in this type of information processing style, particularly in response to traumatic experiences, might be a factor that underpins anomalous experiences. This was supported by our finding that people prone to anomalous experiences reported an information processing style that was less contextually integrated – less tied to time and space – and had more trauma-type memories after watching a mildly traumatic video, compared to individuals without anomalous experiences. This suggested that reduced levels of contextual integration may be common in individuals who have anomalous experiences.
In addition to her interest in trauma, Liz became increasingly fascinated in how psychological distress arises alongside physical health problems, and the relationship between mind and body. She explains: ‘The way we experience the world fundamentally involves the body. Our physical, emotional, behavioural and cognitive experiences are intertwined, and this is particularly evident when it comes to medical conditions. I got really interested in persistent physical symptoms and how they have a profound effect on people’s lives, leading to vicious cycles where the physical and psychological effect each other.’
How did this lead you to work with tinnitus?
‘Tinnitus is a condition where mind and body meet. By the time I qualified, I had decided to specialise in the area of clinical health psychology, and got my first job in a new area for me - Audiovestibular Medicine in an ENT department (Ears, Nose and Throat). The beauty of this role is that we are a small team of psychologists fully embedded in a medical hospital, meaning that we have true multi-disciplinary working. I feel passionately that this model of working is best for everyone. It is better for the medical and psychology teams, as they can learn from one another, better for the NHS, as evidence shows that it is cost-effective and better for the patient, as their care is more holistic, taking into account the biological and psychosocial.’
‘Tinnitus is a real, physical symptom, with a powerful interaction with stress; tinnitus can both be caused by and can cause stress itself. For most, tinnitus is a relatively mild experience, but 10% of tinnitus patients experience severe distress, with anxiety, depression and feelings of hopelessness very common. This leads to significant behavioural changes as people understandably do anything they can to get rid of, or cope with the noise. For example, they might avoid quiet places, or noisy places. They may be unable to concentrate and communication can become more challenging, so their work and social world can change massively. The life impact can be profound.
As Liz puts it, ‘It’s an invisible problem, inaudible to everyone else. Family, friends, colleagues, even healthcare professionals often can’t understand that severe tinnitus is not the same as the occasional ringing most of us get after spending a few hours in a noisy concert or restaurant. The patients I work with have tinnitus that has bombarded them relentlessly for weeks, or months, or years, often with no help, support or advice. It’s no wonder they can get desperate, lonely and isolated.’
What treatments have traditionally been available?
Most people will naturally habituate to tinnitus, meaning that the noise may continue, but it fades into the background and stops being intrusive or bothersome. However, a proportion of people don’t habituate automatically, so tinnitus remains problematic. In such cases, treatment aims to reduce tinnitus awareness, usually by enriching the sound environment by playing background noise or using behind-the-ear noise generators. Hearing aids can be useful when there is associated hearing loss. Another popular treatment is to reduce stress, because high stress levels can increase tinnitus awareness and impede habituation, as such, formal relaxation training is often recommended.
‘For some people audiological and relaxation approaches can work a treat.’ says Liz, ‘More recently, we have also seen that cognitive behavioural therapy (CBT) is effective for tinnitus. There are some high-quality studies on CBT, and we regularly use this treatment approach successfully within our clinic. CBT is based on the idea that it isn’t just the tinnitus that is the problem, but that it is also how one reacts to tinnitus. Because tinnitus can be so unpleasant, people can easily develop certain patterns of negative thoughts, behaviours and attentional focus in reaction to it. Unfortunately these patterns can actually make things worse by setting up a vicious cycle that actually fuels emotional distress, and increases the intrusiveness of tinnitus. CBT helps by enabling patients to identify and then change their thoughts and behaviours in a way that ultimately reduces tinnitus-related distress and enhances habituation.”
‘One of the biggest worries people tell me about is the fear that they will have to live with this distressing noise forever. Luckily, it is possible to assure them that habituation can happen, and that although tinnitus may not disappear, it will get much less intrusive over time, to the point when it is often not a problem at all. This is a natural development with time, but there are also lots of things they can try to support the process and make the problem easier to live with, and mindfulness is one of them.’
Why does mindfulness bring to the table?
‘The credit for introducing mindfulness to the tinnitus community goes to my colleague and Head of Psychology at the Royal National Throat Nose and Ear Hospital, University of London College Hospitals (UCLH), Laurence McKenna. He recognised that the benefits of mindfulness in chronic pain and illness might translate to tinnitus patients. There are clear parallels between tinnitus and pain; both are persistent, intrusive and often disabling, and in many cases there is sadly no medical or surgical fix.
‘When a symptom cannot be completely ‘cured’, mindfulness offers people a new way of learning to live well alongside it.’ The work of Liz and Laurence combines mindfulness with CBT. ‘The aim is not to change the physical symptom, but to help people relate to it differently. Rather than ‘fighting’ the tinnitus by trying to escape, mask, or avoid it, mindfulness teaches people how to allow tinnitus into their awareness, in a non-judgemental way. It isn’t about trying to change things, it’s about paying attention to what’s really happening right now, without having to react to it’.
They tested this treatment in a Randomised Controlled Trial, where they compared Mindfulness Based Cognitive Therapy (MBCT) to an active control treatment (formal relaxation training), both delivered in small groups, over an eight-week period.
‘What we found is that both treatments led to significant improvement, but that the improvements in the MBCT group were significantly greater. What is really encouraging is that this increased benefit lasted in the longer-term too.
We are excited about this. Traditional relaxation treatments can work well for some people however for others where this isn’t so helpful, we can now say that there is good evidence that MBCT can offer them a new and effective treatment. It’s a really hopeful message.
Making tinnitus manageable
‘When I meet someone who’s distressed by their tinnitus, and having a really tough time of things, I’m able to confidently say that there are ways in which we can make it more manageable, and that pretty much everyone with tinnitus can get to a point where it is no longer a problem.
Mindfulness offers a good place to start. It’s quite common, when tinnitus starts, that people get scared that they’ll be like this forever, and they feel unable to cope with it for the next week, month or year. But perhaps this isn’t such a helpful thought. Really, no one can cope with the next year happening all at once, but then again, no one has to - we really only have to get through this present moment. Just this moment. That’s much easier! Rather than tasking oneself to conquer tinnitus forever, we start by allowing it to be present for a moment, and then another moment. And with practice, we realise we can do this, one moment at a time. We also learn how to direct our attention in a gentle way onto tinnitus and then onto other things, and the battle with tinnitus slowly starts to fade.’
‘Another part of mindfulness – and quite a challenge in our culture I think – is learning to see and allow our experience without judging it, and that includes tinnitus. When something’s not right in our body, we automatically say to ourselves “This is awful, so I must struggle to get rid of it”. This struggle is exhausting, fruitless and fuels the negative cycle of thoughts, feelings and behaviours I’ve just described. If we don’t judge our experience so much, then we don’t have to fight so hard, and the vicious cycle of tinnitus distress stops reinforcing itself.
‘In this way, mindfulness has a paradox at it’s centre: If you stop fighting so hard to make things different, then things start to change on their own. This idea is perfectly captured by Carl R Rogers, a renowned humanistic psychotherapist focused on client-centred methods, in his famous words “The curious paradox is that when I accept myself just as I am, then I can change”.’
A revelation
‘This word acceptance can be a tricky one, as people feel it might imply resignation. So I prefer the word ‘allow’. Rather than ‘giving in to’ tinnitus, people learn what it is like to allow it to be here, even if you don’t like it! Mindfulness is a great way of learning to do this, and people can discover that tinnitus doesn’t have to go away for life to be okay. This is what our patients tell us too, and after eight weeks of MBCT, people will say “My tinnitus is still there, but it doesn’t seem to bother me as much. It’s just another sound, or just another part of me and I don’t really notice it very much”.
‘A few years ago, a guy – a teacher – came into the clinic after experiencing long-term tinnitus that hadn’t been a big problem. However, something had changed and it had started bothering him, which is actually quite unusual. He was in a really, really low place, so he did some CBT. This took the edge off but he was still struggling, and so although sceptical about mindfulness he had an open mind, and agreed to give it a go. Within just two or three weeks he had noticed a change: he could sit with this noise, he didn’t have to avoid it and he wasn’t overwhelmed by it, and it was a revelation! As a result, he actually trained in mindfulness and now teaches it to other people, both in schools and for adults. He’s doing incredibly well.
‘I could tell you a lot of stories like this, and I think that’s the main message,’ concludes Liz. ‘It’s important to know that there are things that can help with tinnitus. Even when it feels completely overwhelming, there are treatments you can find that will help you to be okay. The bad times will pass.’ For reliable advice and information about how to get help, Liz recommends the British Tinnitus Association, who have an excellent website.
What does the future hold?
Liz and Laurence are hoping that as evidence for MBCT grows, it will become another treatment option for tinnitus patients, and they are continuing to offer this treatment within their clinic.
They are now focusing their research efforts on developing and testing a new treatment designed to help those patients who also experience insomnia alongside their tinnitus. This clinical trials is now open and they are recruiting participants, to find out more visit the British Tinnitus Association website.