Tinnitus | March 2018 Hearing Review
Helping patients to rise above self-defeating personal explanations for their tinnitus
Since tinnitus is not directly observable and its causes remain an enigma,1 patients often create their own explanatory narratives. In some ways, tinnitus can come to resemble a verboten Rorschach inkblot that patients may keep private from hearing care professionals (HCPs).
Hearing care professionals know that factors like noise exposure, ototoxicity, or other physical traumas are responsible for tinnitus. However, the tinnitus patient can internalize more personal—and often negative and self-denigrating—explanations. And, sometimes, these explanations can get in the way of positively addressing the symptoms of tinnitus. This article looks at ways to bypass or overcome patients’ negative narratives and help them embark on the journey to better hearing care.
For example, John told me that he was trying to forgive himself for having tinnitus, as he was convinced that the clanging in his ears was divine punishment for having committed a transgression against God in a past life (an extramarital affair). Therefore, he compulsively prayed, often several times an hour. He hadn’t told this to his audiologist because “She would think I’m nuts.” As another example, Sue reported that “My audiologist told me that contributing factors to my tinnitus could be anxiety, ototoxic medicines, trauma to my ears or head, or a medical condition, but I know the real cause—my repressed anger.” Therefore, she began indiscriminately unleashing her anger at the slightest provocation.
Although many tinnitus sufferers accept the oft-cited “etiology unknown,” a subset of patients adopt self-blame explanatory narratives. Although these may cause feelings of guilt and shame, paradoxically, the perceived clarity of such narratives may be psychologically comforting.
For example, it is common for parents to blame themselves for having a disabled child, as in the case of a mother who was convinced that “My ambivalence about being pregnant caused my baby’s cerebral palsy. I feel horrible for this, but at least I know the reason.”
Self-blame explanatory narratives may also provide patients with a sense of control. To the extent that an individual believes oneself to have caused tinnitus, that individual may also attribute to oneself the power to actualize a cure, for example, by praying or expressing anger.
One’s stance of self-perceived empowerment is in contrast to common feelings of helplessness when learning that there is no cure. While up to 90% of tinnitus sufferers can obtain some relief, unfortunately, there is not yet a cure for tinnitus.1 Hence, the prevailing bottom-line advice to tinnitus sufferers is that they must accept the impossibility of eliminating the phantom sounds in their ears.
Simply providing that well-meaning and cogent advice may be psychologically inadequate, at best, to help patients manage their tinnitus. I asked Sue whether she told her audiologist about the “real cause” of her tinnitus.
“No way,” she responded. “I nodded politely until he was finished lecturing me, because I didn’t want to hurt his feelings.”
A common patient psychological dynamic from their perspective:
- The doctor explains how treatment will help, but points out there is no cure.
- This makes me angry and scared, but I cannot show it because that will make the doctor talk more.
- So, I’ll nod my head and plan my escape.
A common healthcare provider psychological dynamic from their perspective:
- It’s clear that this patient needs help.
- If I explain this thoroughly enough and convey my expertise, then the patient will trust me and accept my help.
- I know I’m succeeding at this because the patient is nodding in agreement.
I doubt that Sue would have hurt her audiologist’s feelings. Instead, the audiologist perhaps would have countered her interpretation by citing medical evidence-based research, and then she would have continued to nod her head politely.
An important caveat: It is frequently impossible to disprove patients’ explanatory narratives, even though they may be medically indefensible. As human beings, we not only have the ability, but typically assert our right, to choose what we think—specifically how we story our experience.
The ways in which health-related maladies are understood and interpreted—the storyline—make a considerable difference to their effects in a person’s life.2 This principle has important ramifications for the psychological management of tinnitus. According to a cognitive-behavioral framework, what we think determines how we feel, which then determines how we behave. In the examples cited above, both persons would have suffered significantly less had they not storied their tinnitus with themes of self-loathing. John attributed his tinnitus to divine punishment; he felt guilty, so he compulsively prayed. Sue attributed her tinnitus to suppressed anger; she felt internally “blocked,” so she spewed anger at every opportunity. However, the most debilitating psychological effect was their self-denigration when their strategies failed; they admonished themselves for not trying hard enough and then tried more. This became a vicious cycle that not only failed to provide relief, but caused increased stress, anxiety, and depression which, in turn, exacerbated their experience of tinnitus.
In my experience, patients are often reluctant to disclose their unsubstantiated tinnitus-related narratives to the HCP, but will more readily disclose these narratives to a psychotherapist.3-5 As one patient put it, “With my shrink, I’m supposed to talk about weird things.” Since John and Sue had only shared their private narratives with me, not their audiologists, one treatment goal would be to help them to allow their audiologists into their private hell instead of politely nodding their heads and planning their escape. This would improve rapport and pave the way for them to benefit by adhering to audiologic recommendations. And then, in collaboration with their audiologists, the goal would be to help John and Sue modify their debilitating explanatory narratives.
Author Toni Morrison stated this goal more succinctly in her book Song of Solomon: “Wanna fly, you got to give up the shit that weighs you down.”
Helping Tinnitus Patients Modify Their Negative Explanatory Narratives
1) Elicit a patient’s explanatory narrative. In addition to providing patients with evidence-based information about tinnitus, help patients feel comfortable sharing their personal, non-evidenced-based explanatory narratives. For example, you can say, “I’ll tell you about the causes and treatments, but many people have their own kind of personal theories—which may even seem silly or embarrassing—about the why and what to do about it. It would be important for me to know your ideas about this. Would you share them with me?”
2) Emphasize that one has the ability to choose a particular narrative. I think, therefore I am. Emphasize that, as human beings, we have the ability to choose what we think, how we story our experience, including about tinnitus. When there is no empirical truth out there to be found, we construct our own reality, or we “re-author” our life stories.2
As an illustration of this dynamic, you can tell a patient about a child who was learning how to be an umpire and asks three umpires for their advice. The first umpire says, “I call them as they are.” The second umpire says, “I call them as I see them.” The third umpire says, “They are as I see them.” We are all “third umpires.”
3) Validate a patient’s narrative. This is important even though a patient’s narrative may be medically indefensible, unsubstantiated, and even seem preposterous. However, this does not mean you need to agree with it.
I once made an error with a patient who informed me he was scared because there were Martians behind the couch. I tried to prove him wrong by tiptoeing to the couch and quickly moving it. Although he admitted there were no Martians there, he said,“They obviously saw us coming and ran away!” In order to have validated his feelings, I should have said, “If you believe there are Martians behind the couch, you must be scared.” However, if he had asked me whether I agreed with him, I would have said no, and we would have agreed to disagree.
In the case of John, had he disclosed to his audiologist that his tinnitus was due to a past- life transgression, she could have validated it with, “Obviously, I cannot prove you right or wrong—I wasn’t there [smile]—but it sounds like you’ve thought a lot about it. I can now understand more why you pray so much.” (For a humorous illustration of validating one’s narrative, readers may access https://www.youtube.com/watch?v=XIJYO4u5iug&feature=youtu.be).
4) Introduce the concept of a useful narrative. If the veracity of a particular explanatory narrative cannot be proven, it behooves one to choose a narrative that is psychologically useful. As psychologist Deborah Khoshaba advised, “Be sure the story you wish to tell about what happens to you gives you many options from which to carve out the next chapter of your life.”6 John’s audiologist could have safely ventured into the domain of his emotional functioning with a “bounded open-ended question” that would not have derailed the session and risked inadvertently “opening up a can of worms.” For example, “Could I ask you to give me a glimpse, a snapshot, in the short time we have, about how your belief about a past life event causing your tinnitus has affected you?” (As described in previous publications,4 emphasizing the boundaries of time can be an effective way to prevent HCPs from inadvertently getting too deep into affective issues which should occur in a mental health setting.)
John disclosed to me how initially his explanatory narrative had given him a sense of control and offered him a cure for tinnitus by prayer. Feeling validated by me, he then chronicled how that initial comfort had morphed into him feeling “besieged” by an endless cycle of praying and self-condemnation for not praying hard enough or long enough. He admitted that this cycle took over his marriage, his parenting, his free time—in short, how it had subjugated his life.
I admitted that I did not have the wisdom, ability, or moral right to disagree with his narrative, but then I asked the key question: “Given that it can’t be proven or disproven, would you be willing to come up with a better one that’s more useful to you; one that would help you live a more fulfilled life?” He nodded his head.
This article advocates that hearing care professionals ask patients if they have personal explanations for why they have tinnitus in addition to providing them with evidence-based research. In some cases, simply providing that well-meaning and cogent information may be psychologically inadequate, at best, to help patients manage their tinnitus. It’s often what you don’t talk about that impedes treatment.
A reader response may be a version of “We have enough to do within our limited appointment times and those discussions are more appropriate within the rubric of psychotherapy.” My counter-response: The HCP eliciting and validating tinnitus patients’ explanatory narratives may:
- Improve your rapport and therefore increase adherence to your recommendations;
- Provide a non-threatening impetus for patients to meet with a psychotherapist in order to elaborate and understand more how such narratives help or thwart their lives and to modify them accordingly;
- Be an antidote to the patient head nodding/planning-an-escape syndrome, and
- Requires minimal time.
John came into my office one day with a beaming smile. He told me that he “took a deep breath” before finally telling his audiologist that he used to think his tinnitus was divine punishment for having had an extramarital affair in a past life. She did not exude a demeaning attitude, as he had feared, but instead validated his feelings with, “I now understand why you disagreed that it was probably caused by a severe blow to your head.” John then told me that he and his audiologist had “the best session ever” and agreed on a revised tinnitus narrative: that its cause was “a severe head trauma that happened in one of my past lives.”
Most importantly, John no longer felt culpable and therefore no longer viewed tinnitus as a just punishment. Toward the end of that “best session ever,” he informed his audiologist that he would begin the Tinnitus Retraining Therapy (TRT) that she had suggested many times before.
Citation for this article: Harvey MA. A psychological tool for managing tinnitus: Creating useful narratives. Hearing Review. 2018;25(3):22-24.
Mazevski A, Beck DL, Paxton C. Tinnitus issues and management: 2017. Hearing Review. 2017;24(7):30-36.
White M, Epston D. Narrative Means to Therapeutic Ends. New York City, New York: W.W. Norton & Company;1990.
Harvey MA. What your patients may not tell you. Hearing Review. 2010;17(3):16-20.
Harvey MA. The psychological benefits of audiologic care. ADA Feedback. 2005;16(3):10-13.
Harvey MA. How to refer patients successfully to mental health professionals. Hearing Review. 2008;15(7):20-24.
Khoshaba D. Turn your hard time into a good story that moves you forward. February 26, 2012. http://www.psychologyineverydaylife.net/2012/02/26/turn-your-hard-time-into-a-good-story-and-move
Michael A. Harvey, PhD, ABPP, is a clinical psychologist who works in private practice in Framingham, Mass. His most recent books are The Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss, both published by DawnSignPress.
CORRESPONDENCE can be addressed to HR or Dr Harvey at: [email protected]