TRT or CBT

[Katarina]

Just one more question, dr. Nangler.

As I explained in my previous question to you, there are no hearing therapists in my country who specialize in the treatment of patients with H and T. I have tried self help but 4 years have passed and I am still struggling with these conditions. There have been good and bad times, but now the situation is so bad that I have decided to seek out proper treatment once and for all. Even if it means traveling to a different country and paying lots of money for the treatment.

I am thinking of the UK and I know that you highly recommend Jacqui Sheldrake as the no. 1 therapist/audiologist who treats these conditions. I have contacted her but the initial assessment in her office costs 350-400 GBP! That is a lot of money for me and I am not entirely comfortable about paying it. I have emailed Jacqui a question about reducing the cost by running all the necessary audiological exams in my country, buying the necessary sound generators here, and just presenting myself for the counseling sessions - she did not even bother to reply (I did not like that - more than the cost of her treatment). I come from an ex-communist country, where all health care was accessible to all and is STILL accessible to all. I guess this is the reason why I view private practises with suspicion - hard to tell when a specialist is "in it" for the money rather than for helping people ...

The UK has a pretty good national health service and excellent counseling services. I contacted the British Tinnitus Association and enquired about TRT on the NHS system and was told that TRT is no longer offered in its pure form as it is generally considered outdated. I have been sent links to hospitals which offer services to T and H patients, including counseling, by reputable and knowledgeable specialists like Laurence McKenna, the author of a book on coping with H and T using CBT (congnitive behavioural therapy) technique.

My question is: in your experience, is TRT the BEST way to conquer T and H or is it just one of the ways that can be tried? In your experience, do some patients respond better to CBT than TRT or vice versa?

Or can one employ elements of TRT in a self-help mode (eg by listening to low level white/pink noise, day and night) and get counseling (explanation of how the ears work, how to protect oneself and how to react) alongside this?

I assume that you get patients with different experiences, so have formed an opinion about this. I'd appreciate if you could share it ...

Thank you again for all your help.

 

[Dr. Nagler]

My question is: in your experience, is TRT the BEST way to conquer T and H or is it just one of the ways that can be tried? In your experience, do some patients respond better to CBT than TRT or vice versa?

I honestly do not think that there is any one "BEST" approach. I think rather that the treatment approach needs to fit the individual. As you may know, I have a "1 to 10" scale that I sometimes use, a scale that I explain to each prospective patient, who then places himself or herself on the scale at whichever point seems most appropriate. A "1" is a person who has tinnitus and would prefer not to have it, but who largely does not care one way or another because his or her tinnitus is not bothersome. At the other end of the spectrum is a "10," which is a person who has tinnitus and for whom that tinnitus has totally and irrevocably destroyed his or her life. For 9s and 10s I generally recommend TRT, but I at least leave the possibility of CBT open as an alternative. 8s are sort of a gray area. With people who put themselves at 7 or less, I generally think that CBT, masking, mindfulness, etc. would be the way to go. There are obviously a number of exceptions, but that's my overall philosophy. One caveat that I have mentioned elsewhere lies in the fact that I believe TRT to be totally inappropriate for anybody who is not open to the most remote possibility that there is at least some degree of validity to the Neurophysiological Model of Tinnitus. There are a number of individuals on this board for, for instance, who fall into that category. And under no circumstances would I recommend TRT for them as it would be a waste of their time and money. This is not in any way to denigrate them or "lay the blame" at their feet. It is just to say that if you want to get from Los Angeles to San Francisco and you are 100% convinced beyond a shadow of a doubt that there are no train tracks from Los Angeles to San Francisco, then in my opinion you need to be selecting a mode of transportation other than rail. I hope that clarifies more than confuses, but it's the best I can do without writing a veritable tome on the subject.

Or can one employ elements of TRT in a self-help mode (eg by listening to low level white/pink noise, day and night) and get counseling (explanation of how the ears work, how to protect oneself and how to react) alongside this?

One can of course employ the "elements" of TRT and get some counseling to go along with it, but there are some inherent problems with that approach. First of all without TRT counseling, one cannot get a true appreciation for the elements of TRT, which go far beyond mere sound therapy. And second, I really want to stress that "self-TRT" really isn't TRT at all. TRT is not in any way a do-it-yourself protocol.

Thank you again for all your help.

You are most welcome.

Dr. Stephen Nagler