2018 ATRR: Mindfulness and tinnitus Introduction Mindfulness, integrated with psychological therapy, is an increasingly popular treatment approach for a range of conditions. There is now a body of evidence showing that such approaches can significantly reduce the impact of disease as well as generally enhancing well-being. This review begins by discussing why psychological treatments more generally are important in tinnitus management. It moves on to define mindfulness and consider how and why it relates to psychological approaches to tinnitus management. It concludes with a summary of the evidence for mindfulness as a treatment for tinnitus published over the last year. <h2>Download ATRR_2018_Tinnitus_and_mindfulness_FINAL.pdf Tinnitus and psychological treatments When tinnitus causes emotional distress, it tends to be more persistent and disabling, and the emotional impact of tinnitus may even distort the perception of tinnitus. Psychological treatments were developed as a way of reducing the emotional impact of tinnitus, and this effect is associated with less intrusive and distressing tinnitus. Until now, the best evidence for effective tinnitus treatment has been for cognitive behavioural therapy (CBT). CBT is a psychological approach based on the theory that the way we think about tinnitus affects how we feel about it (our emotional state) and how we react to it (our behaviours). CBT helps people to learn to think differently about tinnitus, and to react to it in a more helpful way. As a result, the emotional reaction lessens, tinnitus becomes less problematic and quality of life improves. There is strong evidence that CBT can lead to significant benefits for people suffering with tinnitus. An important concept within the psychological treatment of physical symptoms, such as tinnitus, is that of acceptance. When used by psychologists, this is a technical term that is slightly different from the everyday use of this word. In psychological thinking, acceptance refers to not ‘fighting’ with or ‘struggling against’ tinnitus. This is an important point, because the struggle against tinnitus (and other distressing experiences) is thought to actually make the suffering that arises with tinnitus worse. Acceptance is not about ‘giving in’, rather it is about recognising our struggles and choosing to step away from this habitual process and focus instead on more productive and helpful thoughts and behaviours. Just as in CBT, acceptance, involving particular ways of thinking and behaving, is a central idea to mindfulness based therapies (including Mindfulness Based Cognitive Therapy / MBCT). What is mindfulness? Mindfulness is an ancient form of meditation, but its underlying message of acceptance sits equally well within modern psychological theory. Perhaps one of the best definitions comes from Jon Kabat-Zinn: Mindfulness is what arises from … paying attention, on purpose, in the present moment and without judgment. Jon Kabat-Zinn introduced a programme of mindfulness into Western medicine  for people with chronic pain and illness. This group of people had not benefited sufficiently from the usual medical interventions. They did however show significant improvements in things like emotional state and quality of life following the mindfulness programme. Since then, hundreds of research studies have demonstrated the benefits of mindfulness in a range of conditions (depression, anxiety, chronic pain, diabetes, cancer), as well as general benefits in healthy populations. As for tinnitus, there is evidence that mindfulness leads to reductions in distress and disability, with recent brain imaging studies showing a helpful shift in brain functioning in people with tinnitus . How can mindfulness help tinnitus? Jon Kabat-Zinn’s definition of mindfulness presents a challenge. It invites one to ‘pay attention’, a curious invitation when tinnitus is intrusive, and when the hope for treatment is probably that it will achieve the exact opposite. However, trying not to pay attention to something is often unsuccessful. Some strategies may help, particularly at first such as distracting with other things, keeping busy, etc. Using an avoidance strategy to cope with tinnitus often doesn’t work well, and has two big problems: it takes a lot of energy, and if this is the only coping strategy then it is likely to lead to exhaustion; and there can be a paradoxical rebound effect of tinnitus suppression. The paradoxical rebound effect of suppression When we experience something which demands our attention, our efforts to not think about it may result in us paradoxically thinking about it more. You can try this with the following thought experiment: “For the next minute, whatever you do, please don’t think of a pink elephant”. What did you notice? Most people end up thinking about elephants! This is because when the brain attempts to suppress an experience, the natural consequence is that it pops up in awareness. This is just how the brain works, ‘what we resist, persists’ and this applies to tinnitus. The more effort put into ignoring, suppressing and avoiding tinnitus the more intrusive tinnitus may become. Well-intentioned advice to ‘try to ignore it’ will not always work; when it doesn’t then another way is needed. Mindfulness practice presents an interesting experiment, viz. to see what happens when one stops resisting tinnitus. How to pay attention to tinnitus: on purpose Purposeful attention is a very particular type of attention, and is central to mindfulness. When tinnitus is a problem, then the person is usually aware of it in spite of their best efforts to avoid it. Failure to avoid tinnitus then causes distress. Turning this approach on its head, and choosing to notice tinnitus on purpose can provide a very different experience. This can lead to less struggle, or fight, with tinnitus. This is a big step towards ‘allowing’ tinnitus. By ‘not fighting it’, the person with tinnitus has a new opportunity to discover what really happens if tinnitus is ‘allowed’ into experience. The outcome is not always the result predicted by the anxieties that led them to avoid it in the first place. How to pay attention to tinnitus: in the present moment Purposeful attention is challenging. People may find that at first, tinnitus and stress become more apparent, because they are focusing on it. This is where the second part of Kabat-Zinn’s definition is important: present moment attention. Most people who struggle with tinnitus talk about how it affects them from the perspective of the past or the future. They might think “My life was great and tinnitus has ruined it” or “It will be a disaster if this continues for another twenty years” or “It’s going to get worse, and then I won’t cope”. These ruminative and catastrophic thoughts make the person feel terrible. Mindfulness teaches us that these thoughts are just thoughts, mental events about the past or future, but the past and the future are not actually happening right now. Attending to the present moment teaches us that this moment is, in fact, the only moment we are alive in. The present moment is the only one we have to get through. The past is no longer here; the future is yet to come. A focus on the present moment is usually much more manageable than attempting to cope with things that are not currently happening. How to pay attention to tinnitus: without judgement These thoughts also relate to the third part of the definition: paying attention without judgement. Human beings make judgment all the time. When we notice something we automatically judge it. We may judge it as pleasant, or unpleasant or in some other way. These judgements influence how things are perceived. When an experience is judged as ‘bad’, the resulting emotions are unhappy and stressed, and the experience will seem increasingly threatening and intrusive. Mindfulness teaches us how to notice both our experiences and our judgements. We learn to ‘step back’ from these things without automatically reacting. We learn to notice the physical nature of tinnitus, without getting caught up in thoughts about how terrible it is. This offers most people a new (and much less stressful) way of noticing tinnitus. When put together with purposeful and present-moment awareness, it is easier to notice things in a less judgemental way. As we become less attached to negative thoughts about tinnitus, the need to fight it lessens too. Over time it will become smaller, less threatening and a less significant part of life. Letting go of attempts to control tinnitus frees one from it. Mindfulness as a treatment Few people actually pay attention mindfully in their daily life. Most of us run on ‘automatic pilot’, acting and reacting to the world, without really noticing what is happening. Mindfulness-based treatments teach us how to develop this quality of mindful attention. Approaching our experiences more mindfully slows things down a bit, and gives us a chance to step away from automatic, habitual thoughts and behaviours, which are often the cause of distress. This creates a new way to engage not only with tinnitus, but with the whole of life. Mindfulness-based treatments (including MBCT) recognise that everyone has challenges. We all experience powerful thoughts and emotions, both positive and negative, no matter who we are. By seeing these experiences as normal, mindfulness teaches us how to respond to experiences with kindness, rather than criticism. Mindful attention teaches us that all experiences, even difficult ones, ebb and flow. When we see how things change on their own, we can feel more confident about noticing experiences without always having to change them immediately. When we see how thoughts are just patterns in the mind, we can learn to let go of these too, so we are less caught up by the powerful thinking patterns that fuel anxiety, depression and tinnitus distress. Learning mindfulness Learning mindfulness takes time and requires regular, daily practising of meditation. It is this practice that teaches one how to pay mindful attention. Reading about mindfulness will help you understand what it is about, but the only way to learn it is to practise it for oneself. It is probably easiest to do this with the support of a therapist, and as part of a group of people who are learning mindfulness. Some people are anxious about the idea of joining a group but many things, like exercising or learning a new hobby, are easier and more rewarding when done in a group. Being in a group with other people with tinnitus can be very supportive too. Structured interventions such as MBCT involve weekly attendance at a group for eight weeks. Recent evidence for mindfulness as a treatment for tinnitus Mindfulness-based interventions have been tested in tinnitus populations over the past few years. This has produced evidence that it can reduce the distress associated with the symptom (tinnitus distress), and lower levels of anxiety and depression as well as improving quality of life. Since the current review aims to provide an update on the most recent evidence, it is limited to that published in 2017. A literature search was therefore conducted in Scopus and PubMed using the search terms ‘tinnitus’ AND ‘mindfulness’ in title, abstract and key word, and published in 2017. Three articles reporting on primary data from mindfulness interventions were identified. The findings are summarised below. MBCT for tinnitus Prior to 2017, a number of articles had been published that demonstrated emerging evidence in support of mindfulness as an approach to managing tinnitus. These were mainly uncontrolled studies with small sample sizes. The three articles published in 2017 add significantly to the evidence base, with large sample sizes and two randomised controlled trials (RCTs). All studies were UK based. Two studies have focused on the benefits of a structured intervention: MBCT for tinnitus. One reports on a RCT of MBCT compared to relaxation training for chronic tinnitus  and the other on a naturalistic evaluation of MBCT over several years . Both studies involved the completion of eight weeks of a two-hour group-based MBCT for tinnitus course, developed and delivered by the first authors of the studies. The RCT included 75 participants and clearly demonstrated that MBCT was significantly more effective than intensive relaxation training in alleviating tinnitus distress. Furthermore the benefits persisted in the long term (6 months), with a large standardised effect size (0.56). MBCT also led to improvements in psychological distress, anxiety, depression and disability. Effects occurred regardless of tinnitus severity or comorbidity (hearing loss, hyperacusis etc), suggesting this treatment is broadly applicable to tinnitus sufferers, with effect sizes comparable to CBT. The naturalistic study evaluating MBCT involved a very large sample of 182 patients attending a routine clinic for treatment . Similar outcomes were reported, and reliable improvements in tinnitus distress were detected in 50% of patients following intervention. Both of these studies also found associated increases in tinnitus acceptance, mindfulness and reduced negative, catastrophic thinking about tinnitus, which may point towards mechanisms of change underpinning mindfulness. Arif et al reported on a RCT comparing mindfulness meditation to relaxation therapy . Treatment here involved five, 40-minute individual face-to-face sessions with the emphasis on learning mindfulness or relaxation (rather than a structured psychological treatment such as MBCT). They included 86 participants and again found that both treatments led to improvements in tinnitus distress, but that these improvements were greater in the mindfulness group. Conclusion With two RCTs and a large naturalistic study published in the last year, evidence in support of mindfulness-based interventions for tinnitus is growing. Our own clinical and research work has focused on developing a more standardised treatment for tinnitus (MBCT for tinnitus) that includes elements of CBT and psychological theory as well as teaching mindfulness as a meditation technique. The success of these interventions, and their focus on learning to ‘allow’ tinnitus rather than ‘fighting it’ may offer an alternative approach to tinnitus management that may benefit individuals who have not responded so well to traditional treatment approaches. Future research should focus on exploring the underpinning mechanisms of change and consider how mindfulness is best delivered to patients who wish to try this new approach. References  Kabat-Zinn J, Lipworth L and Burney R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioural Medicine. 1985: 8: 163–190  Schmidt SA, Carpenter-Thompson J and Husain FT. Connectivity of precuneus to the default mode and dorsal attention networks: A possible invariant marker of long-term tinnitus. NeuroImage: Clinical. 2017: 16: 196-204. doi:10.1016/j.nicl.2017.07.015  McKenna L, Marks EM, Hallsworth CA and Schaette R. Mindfulness-based cognitive therapy as a treatment for chronic tinnitus: a randomized controlled trial. Psychotherapy and Psychosomatics. 2017: 86(6):351-61.doi: 10.1159/000478267  McKenna L, Marks EM and Vogt F. Mindfulness-based cognitive therapy for chronic tinnitus: evaluation of benefits in a large sample of patients attending a tinnitus clinic. Ear and Hearing. 2017 Sep. doi: 10.1097/AUD.0000000000000491  Arif M, Sadlier M, Rajenderkumar D, James J, and Tahir T. A randomised controlled study of mindfulness meditation versus relaxation therapy in the management of tinnitus. The Journal of Laryngology & Otology. 2017 Jun: 131(6):501-7 About the authors Dr Liz Marks Clinical PsychologistRoyal National Throat, Nose & Ear Hospital, London LecturerUniversity of Bath Dr Liz Marks is a chartered clinical psychologist who works at the Royal National Throat Nose and Ear Hospital, London. She is an accredited CBT practitioner and trained mindfulness teacher, and has been delivering MBCT for tinnitus for the past six years. Liz is also a lecturer in clinical psychology at the University of Bath. Her clinical and research interests focus on how to help people manage chronic and persistent physical conditions (such as tinnitus) and their associated impact, using CBT and mindfulness. Dr Laurence McKenna Clinical PsychologistRoyal National Throat, Nose & Ear Hospital, London Dr Laurence McKenna has worked as a clinical psychologist at the Royal National Throat Nose & Ear Hospital for over 30 years on the study and psychological management of tinnitus and other audiological disorders. He qualified as a clinical psychologist from the University of Liverpool in 1983. His PhD focused on psychological aspects of tinnitus and hearing loss. He trained in cognitive behaviour therapy at the University of Oxford and in Mindfulness Based Cognitive Therapy (MBCT) with the Bangor University. He has been using MBCT in tinnitus management for almost ten years. He is the author or co-author of many academic papers in psychology and audiological medicine.