1. Managing Your Tinnitus: Changing Your Thoughts and Feelings (Session 1 of 3) Version date: June 5, 2012

2. This workshop was developed by researchers at: The VA RR&D National Center for Rehabilitative Auditory Research (NCRAR), located at the Portland, Oregon VA Medical Center The VA Connecticut Healthcare System in West Haven, Connecticut This workshop was developed by researchers at: The VA RR&D National Center for Rehabilitative Auditory Research (NCRAR), located at the Portland, Oregon VA Medical Center The VA Connecticut Healthcare System in West Haven, Connecticut

3. Introductions Please share the following with the group: What is tinnitus like for you? Do you also have hearing loss? How we should communicate as a group? How do you deal or “cope” with your tinnitus? Please share the following with the group: What is tinnitus like for you? Do you also have hearing loss? How we should communicate as a group? How do you deal or “cope” with your tinnitus?

4. Remember: Tinnitus cannot be cured “Cure” = eliminate or reduce the tinnitus No cure yet – research underway It can’t be cured, but you can learn to manage your reactions to it [Note: “managing tinnitus” really means “managing reactions to tinnitus” – you can’t change the sound of the tinnitus, but you can change how you react to the sound] “Cure” = eliminate or reduce the tinnitus No cure yet – research underway It can’t be cured, but you can learn to manage your reactions to it [Note: “managing tinnitus” really means “managing reactions to tinnitus” – you can’t change the sound of the tinnitus, but you can change how you react to the sound]

5. Remember: Goals of Tinnitus Management (All Methods) Negative emotional reactions are reduced Stress is reduced Little, if any, attention is given to tinnitus Tinnitus does not negatively affect any life activities in a major way Further help for tinnitus management is not needed or wanted Negative emotional reactions are reduced Stress is reduced Little, if any, attention is given to tinnitus Tinnitus does not negatively affect any life activities in a major way Further help for tinnitus management is not needed or wanted

6. These goals can be reached even if the sound of your tinnitus doesn’t change!

7. Understand what “CBT” means Learn about stress and tinnitus Learn two relaxation exercises: 1.Deep Breathing 2.Imagery Learn about “distraction” (by keeping your mind off of your tinnitus using pleasant activities) Start using the Changing Thoughts and Feelings Worksheet Understand what “CBT” means Learn about stress and tinnitus Learn two relaxation exercises: 1.Deep Breathing 2.Imagery Learn about “distraction” (by keeping your mind off of your tinnitus using pleasant activities) Start using the Changing Thoughts and Feelings Worksheet Goals of Today’s Workshop

8. ■Tinnitus is not a mental health disorder ■CBT is used to change thoughts, behaviors, or emotions ■CBT helps you think more positively about your tinnitus ■CBT also helps people who have pain and other health problems ■Tinnitus is not a mental health disorder ■CBT is used to change thoughts, behaviors, or emotions ■CBT helps you think more positively about your tinnitus ■CBT also helps people who have pain and other health problems Introduction to Cognitive Behavioral Therapy (CBT)

9. The CBT Cycle Beliefs Emotion Behavior & Thoughts

10. The CBT Cycle Behavior, emotions, and thoughts/beliefs are related If you change one of these then you can change all of these Behavior or thoughts can lead to negative feelings about tinnitus TODAY: You will work on behaviors that can help you think more positively and help you feel better Behavior, emotions, and thoughts/beliefs are related If you change one of these then you can change all of these Behavior or thoughts can lead to negative feelings about tinnitus TODAY: You will work on behaviors that can help you think more positively and help you feel better

11. Ground Rules… Time is limited, so we will follow the agenda We will stay focused on learning ways to manage reactions to tinnitus Time is limited, so we will follow the agenda We will stay focused on learning ways to manage reactions to tinnitus

13. Today’s Agenda 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities

14. Tear out a blank Changing Thoughts and Feelings Worksheet: Take a moment to…

15. Learning How to Use the Changing Thoughts & Feelings Worksheet Use this Worksheet to take notes while you learn skills to manage your reactions to tinnitus Use a new Worksheet for each bothersome tinnitus situation This Worksheet help guide you as you practice the new skills What you put on the Worksheet will change as you figure out what works best for you

16. How do I fill out #1 on the Changing Thoughts & Feelings Worksheet?

17. #1 on the Changing Thoughts & Feelings Worksheet The first step in completing a Changing Thoughts and Feelings Worksheet is to write down a bothersome tinnitus situation You already identified a bothersome tinnitus situation last week when you met with the audiologist using the Tinnitus Problem Checklist on page 29 Does everyone have a bothersome tinnitus situation to write for #1? The first step in completing a Changing Thoughts and Feelings Worksheet is to write down a bothersome tinnitus situation You already identified a bothersome tinnitus situation last week when you met with the audiologist using the Tinnitus Problem Checklist on page 29 Does everyone have a bothersome tinnitus situation to write for #1?

18. Remember from first Workshop with audiologist the Sound Plan Worksheet: 1. One bothersome tinnitus situation

19. How do I fill out #2 on the Changing Thoughts & Feelings Worksheet?

20. During the workshops with the mental health provider, you will learn the CBT skills shown on #2 of the Worksheet

21. Today you will learn these two CBT skills to manage your tinnitus:

22. Write down details about the skill you will use to manage your reactions to tinnitus #3 on the Worksheet

23. After you try the skill, write down how helpful that skill was in helping you feel better #4 on the Worksheet

24. Write down a comment describing how you feel after trying this skill #5 on the Worksheet

25. Today’s Agenda 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group

26. Stress and Tinnitus

27. Many people say stress makes their tinnitus worse Reducing stress can help your tinnitus Think of stress as a “challenge” instead of a “threat” Healthy living will help you manage stress Things you can do to reduce stress: Plan ahead for stressful events Exercise and eat right Get enough sleep Meditate or learn yoga Do relaxation exercises – there are many kinds Reducing stress can help your tinnitus Think of stress as a “challenge” instead of a “threat” Healthy living will help you manage stress Things you can do to reduce stress: Plan ahead for stressful events Exercise and eat right Get enough sleep Meditate or learn yoga Do relaxation exercises – there are many kinds

28. Today’s Agenda 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group

29. Why learn relaxation exercises?

30. Relaxation Exercises: Why do they help? They help you take a break from stress They slow down your breath and heart rate They distract you from your tinnitus They help you take a break from stress They slow down your breath and heart rate They distract you from your tinnitus

31. Relaxation Exercises: How do they help? By slowing down your body By helping you get your mind off of your tinnitus By helping you feel relaxed and calm so you: Feel a sense of relief from tension and stress caused by your tinnitus Think more clearly Feel better over By slowing down your body By helping you get your mind off of your tinnitus By helping you feel relaxed and calm so you: Feel a sense of relief from tension and stress caused by your tinnitus Think more clearly Feel better over

32. Relaxation Exercises: When should I use them? Any time you feel stressed or tense Practice everyday between group sessions Share with the group next session Any time you feel stressed or tense Practice everyday between group sessions Share with the group next session

33. How to prepare before a Relaxation Exercise ■Find a place where you won’t be disturbed ■Tell others you need privacy ■Loosen tight clothing or change clothes ■Sit with feet flat on the floor or propped up ■Place your hands in your lap or on chair arms ■Turn on soothing sound or soft music ■Avoid silence when practicing relaxation exercises ■Find a place where you won’t be disturbed ■Tell others you need privacy ■Loosen tight clothing or change clothes ■Sit with feet flat on the floor or propped up ■Place your hands in your lap or on chair arms ■Turn on soothing sound or soft music ■Avoid silence when practicing relaxation exercises

34. Relaxation Exercise #1: Deep Breathing - A Step-by-Step Guide Step 1: Prepare using the information above. Step 2: Put one hand on your stomach and one on your chest. Notice which hand moves. Move your stomach hand more for a deeper breath. Step 3: Close your eyes or focus on a thing in the room. Step 4: Breath through your nose for 3 seconds – count in your head “one-two-three.” Step 5: Hold that breath for 2 seconds (count “one-two”) & release the breath for 3 seconds (count “one-two-three”). Step 6: Repeat Steps 4 and 5 for five to ten minutes. Step 7: When you are done, think about where you are, wiggle your hands and feet, and open your eyes. Step 1: Prepare using the information above. Step 2: Put one hand on your stomach and one on your chest. Notice which hand moves. Move your stomach hand more for a deeper breath. Step 3: Close your eyes or focus on a thing in the room. Step 4: Breath through your nose for 3 seconds – count in your head “one-two-three.” Step 5: Hold that breath for 2 seconds (count “one-two”) & release the breath for 3 seconds (count “one-two-three”). Step 6: Repeat Steps 4 and 5 for five to ten minutes. Step 7: When you are done, think about where you are, wiggle your hands and feet, and open your eyes.

36. When you are done, choose the amount of relief you feel Choose either 0, 1, 2, 3, 4, or 5 Be ready to share your rating with the group When you are done, choose the amount of relief you feel Choose either 0, 1, 2, 3, 4, or 5 Be ready to share your rating with the group Deep Breathing Let’s try it!

37. The Relief Scale:

38. Raise your hand if you felt no relief from the stress or tension caused by your tinnitus

39. Raise your hand if you felt slight relief from the stress or tension caused by your tinnitus

40. Raise your hand if you felt mild relief from the stress or tension caused by your tinnitus

41. Raise your hand if you felt moderate relief from the stress or tension caused by your tinnitus

42. Raise your hand if you felt nearly complete relief from the stress or tension caused by your tinnitus

43. Raise your hand if you felt complete relief from the stress or tension caused by your tinnitus

44. Deep Breathing Track your progress on this chart

45. What is Imagery? Imagery is imagining you are some place calming and peaceful Some people call this their “happy” place Choose a place that feels safe to you Think about each of your 5 senses to get a good picture of the place: Sight Smell Sound Touch Taste Imagery is imagining you are some place calming and peaceful Some people call this their “happy” place Choose a place that feels safe to you Think about each of your 5 senses to get a good picture of the place: Sight Smell Sound Touch Taste

46. Imagine… Picture a safe, calming, and peaceful place

47. Relaxation Exercise #2: Imagery - A Step-by-Step Guide Step 1: Prepare as you would for any relaxation exercise. Step 2: Take several deep breaths. Step 3: Choose a calming and peaceful place to imagine. Imagine the place as you close your eyes or focus on a thing in the room. Do this for five to ten minutes. Step 4: When you are done, think about where you are, wiggle your hands and feet, and open your eyes. Step 1: Prepare as you would for any relaxation exercise. Step 2: Take several deep breaths. Step 3: Choose a calming and peaceful place to imagine. Imagine the place as you close your eyes or focus on a thing in the room. Do this for five to ten minutes. Step 4: When you are done, think about where you are, wiggle your hands and feet, and open your eyes.

48. When you are done, choose the amount of relief you feel Choose either 0, 1, 2, 3, 4, or 5 Be ready to share your rating with the group When you are done, choose the amount of relief you feel Choose either 0, 1, 2, 3, 4, or 5 Be ready to share your rating with the group Imagery Let’s try it!

49. Raise your hand if you felt no relief from the stress or tension caused by your tinnitus

50. Raise your hand if you felt slight relief from the stress or tension caused by your tinnitus

51. Raise your hand if you felt mild relief from the stress or tension caused by your tinnitus

52. Raise your hand if you felt moderate relief from the stress or tension caused by your tinnitus

53. Raise your hand if you felt nearly complete relief from the stress or tension caused by your tinnitus

54. Raise your hand if you felt complete relief from the stress or tension caused by your tinnitus

55. Practice the Imagery exercise at home: Track your progress page 43

56. Tell me in your own words: Why might Relaxation Exercises help you feel better? Explain the concept rather than giving an example HINT:

57. Record your progress and try the DVD in the back of the Workbook:

58. Today’s Agenda 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group 1.Changing Thoughts & Feelings Worksheet 2.Discuss stress and tinnitus 3.Learn and practice two relaxation exercises: Deep Breathing and Imagery 4.Learn to plan pleasant activities 5.Other topics suggested by the group

59. Planning Pleasant Activities: Distraction

60. Planning Pleasant Activities What are pleasant activities? Activities you enjoy Activities you like to do but do not have to do How can they help you manage your tinnitus? Helps you have more positive feelings Distracts you from your tinnitus Helps you feel better overall What are pleasant activities? Activities you enjoy Activities you like to do but do not have to do How can they help you manage your tinnitus? Helps you have more positive feelings Distracts you from your tinnitus Helps you feel better overall

61. Step 1: Track Your Activities Use the Activity Planning worksheet to see how many pleasant activities you have in your daily routine If you don’t have “2’s” (pleasant activities) everyday you may need to add them Sometimes we forget to make time for ourselves Pleasant activities can keep your mind off your tinnitus Pleasant activities also can keep you feeling positive about life Use the Activity Planning worksheet to see how many pleasant activities you have in your daily routine If you don’t have “2’s” (pleasant activities) everyday you may need to add them Sometimes we forget to make time for ourselves Pleasant activities can keep your mind off your tinnitus Pleasant activities also can keep you feeling positive about life

62. Planning Pleasant Activities Step 1: Track Your Activities

63. Planning Pleasant Activities Step 2: List of Activities

64. Plan at least one pleasant activity each day Ask yourself (keep a journal): Did I do all of my scheduled pleasant activities each day? What prevented me from doing my pleasant activities? Might more activities help? Planning Pleasant Activities Step 3: Schedule Pleasant Activities

65. Record your progress:

66. Tell me in your own words: Why might planning more pleasant activities help me manage my reactions to tinnitus? Describe the concept rather than giving an example

67. Summary of Today’s Homework Changing Thoughts and Feelings Worksheet (See the back of your Workbook)  Relaxation exercises  Planning pleasant activities  Wait to complete the Changing Thoughts section Relaxation  Practice: Deep Breathing and Imagery  Record your progress: Deep Breathing and Imagery Planning Pleasant Activities  Step 1: Track Your Activities  Step 2: Make a List of Pleasant Activities  Step 3: Schedule Pleasant Activities Changing Thoughts and Feelings Worksheet (See the back of your Workbook)  Relaxation exercises  Planning pleasant activities  Wait to complete the Changing Thoughts section Relaxation  Practice: Deep Breathing and Imagery  Record your progress: Deep Breathing and Imagery Planning Pleasant Activities  Step 1: Track Your Activities  Step 2: Make a List of Pleasant Activities  Step 3: Schedule Pleasant Activities

68. Remember: Continue to work on your Sound Plan Worksheet for your next session with the Audiologist

69. Other agenda items?

70. Questions?