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Cognitive behavioral interventions are the most widely used psychological strategies for coping with tinnitus. The goal of the therapy is to alter maladaptive cognitive, emotional, and behavioral responses to tinnitus and not to abolish the sound itself.
There are two main components to this approach: (a) Cognitive restructuring and (b) Behavioral modification. Treatment programs comprise of techniques like relaxation training, cognitive restructuring, attention control techniques, imagery training, and exposure to difficult situations.
The combined approach assists patients in identifying and modifying maladaptive behavior and promotes habituation to tinnitus. The collaboration of patient and therapist is a prerequisite for a positive outcome of therapy. In the history of tinnitus research and treatment, many attempts have been directed toward abolishing or minimizing tinnitus.
Most interventions in reducing tinnitus-related distress are predicated on cognitive theories of behavior regulation. A general cognitive framework as shown in Picture 1 asserts that the emotional and behavioral consequences of an event or situation experienced by a person are modified by the way a person thinks about it. A comprehensive model for the chronification of tinnitus, including various dysfunctional cognition and behavior, is described by Kroener-Herwig [4] based on the assumptions regarding tinnitus tolerance made by Hallam and Jakes [5].
This model describes the vicious cycle of tinnitus distress and demonstrates how different cognitive, emotional, and behavioral factors interact and create positive feedback loops generating and maintaining tinnitus-related annoyance and discomfort. The origin of cognitive behavioral therapy goes back to the 1950s and 1960s when Wolpe and Lazarus [6] developed new techniques for changing behavior – in particular in patients with anxiety disorders – based on experimental psychology. Cognitive behavioral therapy was developed mainly as a treatment for affective disorders such as depression and anxiety. Treatment programs comprise of techniques like relaxation training, cognitive restructuring, attention control, imagery training, and exposure to difficult situations. Relaxation methods were one of the earliest psychological treatments applied to patients with tinnitus [20]. Despite the popularity of relaxation training in clinical practice, research shows that relaxation seems to be of limited value for most tinnitus patients when used as the sole treatment [21].
In general, cognitive therapy involves the identification of dysfunctional beliefs and negative thoughts, which occur in response to life events or sources of distress. The therapist helps the clients to challenge and test the validity of their automatic thoughts and to learn ways to substitute them with more constructive ones.
Imagery techniques are used to change the negative associations related to tinnitus either by “masking” the noises or by integrating them into positive scenes. In clinical practice, these approaches are rarely used as sole therapeutic methods, but are incorporated into relaxation training or cognitive restructuring interventions. Brussels, cold and blustery on a summer day and we were on the fag end of a glorious holiday in Europe. The Comic Strip Centre is housed in an Art Nouveau building by Victor Horta which was built in 1906 and served as a textile warehouse for the longest time but had been lying neglected since 1970. The appeal of graphics to tell a story is as old as cave paintings but it is in the comic strip museum that you appreciate the sweep of the medium across age groups, languages and themes. The Pratham Books Champions blog covers inspiring stories sent by champions from the field. Despite all these efforts, until now no treatment has been found to successfully eliminate tinnitus permanently.
In other words, emotions and behavioral reactions are the result of appraisals of an event and are not the result of the event itself. It is made clear that mainly the thoughts, beliefs, and expectations about tinnitus are creating the problem.
They are convinced that the tinnitus is “making” them depressed, anxious, and worried and that their ways of dealing with tinnitus are of no account. Regardless of the cause of tinnitus, “suffering” is a function of how the patient reacts to tinnitus – how he or she copes with it.
In the early phases, therapy (then called behavior therapy) was dominated by techniques like operant conditioning [7], systematic desensitization [8], or aversion therapy [9], which were directed at overt behavior change.


Patients are taught methods of challenging those thoughts and substituting their catastrophic, unrealistic thoughts with more constructive ones (cognitive restructuring).
Furthermore, strategies to specifically manipulate the acoustical environment are recommended. In imagery exercises, a patient may be asked to imagine that the tinnitus is masked by the sound of a waterfall or the waves of the sea.
Tinnitus for them is an acceptable solution or “a legitimate excuse” for avoiding these situations.
The meta-analysis of Anderson and Lytthens [21] showed that psychological treatments are very effective regarding the reduction of tinnitus-related distress. Kroener-Herwig, B, Biesinger, E, Gerhards, F, Goebel, G, Greimel, KV and Hiller, W (2000) Retraining therapy for chronic tinnitus A critical analysis of its status.
Hallam, RS and Jakes SC (1987) An evaluation of relaxation training in chronic tinnitus sufferers In: Proceedings of the Third International Tinnitus Seminar. Wolpe, J and Lazarus, AA (1966) Behavior therapy techniques: a guide to the treatment of neuroses. Hallam, RS (1984) Psychological aspects of tinnitus In: Contributions to medical psychology pp. Andersson, G, and Lyttkens, L (1999) A meta-analytic review of psychological treatments for tinnitus. Jastreboff, PJ and Hazell J (1993) A neurophysiological approach tinnitus: clinical implication.
Wilson, PH, Henry, JL, Anderson, G, Lindberg, P and Hallam RS (1998) A critical analysis of directive counselling as a component of tinnitus retraining therapy.
Martinez Devesa, P, Waddell, A, Perera, R and Theodoulou M (2009) Cognitive behavioral therapy for tinnitus.
Amid the overkill of hellenistic busts, roman antiquities and renaissance art in museums and soaring churches, this was a bright squiggle that invited and intrigued- The Belgian Comic Strip Centre in Brussels.
Tastefully restored now, it is full of light and space for a foyer which houses Herbie, known for going bananas, and Tintin's famous lunar expedition rocket.
Belgium is said to have more than 700 comic strip artists and given its size, this would be a pretty dense population of practitioners of the Ninth Art. You can stick your head in and get photographed in a cut out, you can see the sceptre used as a reference for King Ottokar's Sceptre, you can see the different hats used by Thomson and Thompson, you can see how Tintin's very simple face takes on different expressions with deft use of minimal lines whereas Captain Haddock's face registers excessive contortions.
Another exhibition on British artist Posy Simmonds landed you smack in England in the liberal landscape of adult graphic novels.Her graphic novels Gemma Bovery and Tamara Drewe were presented along with hitherto unseen exhibits from her teenage years, audio recordings of her interviews of her growth as a story teller and artist. As a consequence, increasing efforts have been undertaken by behavioral scientists and psychologists to eliminate or at least ameliorate psychological symptoms associated with tinnitus. Furthermore, if the patient thinks that there is nothing that can be done to alleviate the symptoms, he or she will likely become hopeless and depressed. Focusing attention on tinnitus, accompanied by specific dysfunctional cognitive processes of appraisal like catastrophic thoughts and rumination, leads to negative emotional consequences. In the 1970s, increasingly cognition-centered theories of behavior regulation were established and, consequently, cognitive interventions were implemented into therapy.
A cognitive behavioral approach was first applied in the treatment of patients with tinnitus in the 1980s [13–16]. Cognitive restructuring helps patients think differently and adopt a different attitude about their problem. Cognitive behavioral therapy (CBT) encourages patients to expose themselves to those situations in order to realize that they can cope without major negative consequences. There had been enough teasers strewn all around Brussels where you could round a corner and find a wall fully painted with a comic-book frame. The staircase is the model for the much loved Marlinspike Hall staircase where we have seen Captain Haddock miss a step many times. You can watch a utterly charming pre-disney animated cartoon of Gertie, the dinosaur done by Winsor McCay on friendly touch screens. She has also done Fred for children which was adapted in 1996 as an animation short and received an Oscar nomination. The aim of psychological interventions is not to “cure” or to eliminate the inner noise but to reduce tinnitus-related distress and increase quality of life.


This assumption can be illustrated by the fact that the majority of individuals permanently afflicted by tinnitus – even if they describe it as loud – do not feel distressed by it. Blaming a situation or person for the onset of tinnitus will create anger and hostility (see Picture 2). The goal of the therapy is to alter maladaptive cognitive, emotional, and behavioral responses to tinnitus and not the sound itself. Beck [2] has been most influential in introducing cognitive interventions into therapeutic strategies. Nowadays, it is one of the most widely used and accepted psychological strategies for coping with intractable disorders [17–19]. In this technique, a person is shown how to decrease muscular tension and to achieve states of relaxation in a very brief period of time after detecting tension. It is used as a method to guide patients recognize and subsequently abandon rigid, unhelpful thinking patterns and replace them with constructive cognitions and thoughts.
These behavioral “experiments” must be well prepared and these new skills should be frequently practiced. In these cases, patients have to become aware of the underlying problem and are assisted in finding adaptive problem solutions. Her journey exemplifies how the visual narrative has tremendous appeal in the age of television and its evolution as a sophisticated art form.
If patients are no longer bothered by their inner noises and the question of how tinnitus can be removed, they might become secondary. Nevertheless, the therapist should make it explicitly clear that he or she knows that the tinnitus is real, not imagined, and that the patient’s response to the abnormal tinnitus perception can be well understood. In accordance with this trend, Ellis [10] introduced Rational-Emotive Therapy (RET) based on his A-B-C model. The therapist instructs patients how to sequentially tense and relax various muscle groups, moving from practice in comfortable settings to practice in real-life situations such as sitting at a desk, watching television, etc. This is different from simple “positive thinking” or from “directive counseling,” a treatment component of tinnitus retraining therapy [22], because in cognitive restructuring the therapist and patient collaborate in identifying, testing, and challenging dysfunctional thoughts, beliefs, attitudes, or attributions [4, 23]. If you wish to explore based on your preference of artists, you could read their potted biographies and even see some of their research materials and favoured art materials.
As long as tinnitus itself cannot be eliminated, the main intention of all therapeutic interventions is to alleviate suffering from tinnitus. Meichenbaum [11] introduced the notion of the specific importance of self-talk and self-instructions for behavior regulation. Relaxation techniques may be helpful in assisting people in learning a way of coping with tension and anxiety related to tinnitus. It is theorized that for patients with tinnitus, the source of distress is not the sound itself, but the way in which the person evaluates and interprets the sound.
Patients might be instructed to imagine walking through a landscape by listening to the singing of birds or lying on a blooming field and hearing the noises of bumblebees, cicadas, and other insects.
Bandura [12] states in his social learning theory that self-efficacy beliefs play a most important role in guiding behavior. Furthermore, it is commonly reported by patients that stress exacerbates tinnitus or causes a person to experience the tinnitus more intensely, and that a reduction in stress levels may reduce loudness and annoyance. Alternatively, a patient may imagine a cold and snowy winter day, sitting comfortably in front of the fire place, hearing the sizzling of a teakettle, and looking forward to enjoying a cup of hot tea. Artists such as Bob De Moor, Marten Toonder give you a real sense of the passion that they felt for this medium and how tenaciously they built it up. Also, listening to one’s tinnitus in a relaxed state can foster habituation and retain serenity in the presence of tinnitus. It is the centenary year of Marten Toonder (the creator of Tom Puss, loved by children and adults alike) and the special exhibition on him was fascinating with details of his family of artists where his seafarer father, brother, wife and son were all involved in similar work.



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