by Richard S. Tyler, Najlla O. Burle and Patricia C. Mancini
Patients with tinnitus often seek help from audiologists when it disrupts their thoughts and emotions, sleep, concentration and/or hearing. This can have dramatic effects on their quality of life. Some of the patients can be very distressed, and there are no pills or surgery for sensorineural tinnitus. Unfortunately, many healthcare professionals choose not to help them. Audiologists are qualified to provide counselling, but reimbursement is difficult. The evidence is sufficient for reimbursement for counselling— period. Counselling can also be performed by a wide variety of other health care professionals, including physicians, nurse practitioners, and psychologists.
Tinnitus patients usually have hearing difficulties, caused by a hearing loss or their tinnitus. We can provide counselling as our training in aural rehabilitation includes the understanding of the psychological consequences of hearing loss, tinnitus, and other such auditory conditions. If emotional consequences become severe, we can and should refer to other professionals. Sometimes we receive referrals from psychiatrists and psychologists who need our help with their tinnitus patients. While these professionals can help with the emotional aspects, they are not trained regarding tinnitus and hearing loss and their consequences. Thus, many refer their patients for an audiologist's help.
Audiologists can help patients understand their tinnitus—how it affects their hearing, thoughts and emotions, sleep and concentration, and how they react to it. We suggest ways they might change their behaviour to help manage challenges. In fact, several counselling and sound therapy treatments were designed by and taught by audiologists.
As most of these patients have hearing loss, we can be reimbursed for diagnosing and measuring their hearing loss, and provide hearing aids. This is an important contribution. Which services get reimbursed and the reimbursement rate is influenced by many factors, including lobbying by organisations. Audiology services are valuable and should be reimbursed appropriately. However, because of the limited reimbursement, many cannot justify helping tinnitus patients.
The effectiveness of any counselling largely depends on the individual interactions between the patient and the clinician. Systematic strategies can help, but the outcome is strongly influenced by the individual clinician. Even following the same counselling protocol, some patients will see relief of symptoms, but not others. Recently, a study challenged the effectiveness of cognitive behaviour therapy (CBT) generally, and this has been applied to CBT for tinnitus. The study concluded that the individual clinician is the main factor in the outcome of the CBT. Each patient with tinnitus experiences different symptoms, and research should focus on individuals, not groups. Unfortunately, this rarely occurs in research studies.
Many argue in favour of the need for “evidence-based" research studies to support treatments. With respect to tinnitus, CBT is promoted as a strategy to treat patients. Interestingly, for smoking cessation and weight management, evidence (and reimbursement) is available for counselling, but it does not have to be CBT counselling for weight management; it is just “counselling for weight management."
While some tinnitus patients benefit from reading online information or those from patient handouts, others may not find these resources helpful and need personalised. Millions of dollars can be spent on each study documenting each variation of counselling for tinnitus patients. The government should direct money for counselling. While some patients may choose to independently seek out health care information on tinnitus, many ask for individualised, patient-centred care. Unfortunately, the current health care reimbursement landscape is a barrier to audiologists performing this type of patient-centred care.
In the evolution of Tinnitus Activities Treatment (TAT), we saw the benefit of (and included) Progressive Muscle Relaxation and Guided Imagery. Audiologists ask patients to focus, at the moment, without judging. Our TAT includes helping patients to “accept," “own" their tinnitus.
Hearing loss is not just about hearing but also about how we use our hearing for communicating, interacting with friends, enjoying life, and planning for the future. Smoking cessation and weight management are reimbursed by government health care and insurance agencies—so why not hearing loss and tinnitus? Audiology services are valuable and should be reimbursed appropriately. Clinicians must make choices about how to spend their time and resources. Because of the limited reimbursement, many cannot justify helping tinnitus patients.
Our professional organisations need to work collaboratively with legislators and take this on as the most important focus of our profession. It is necessary to conduct solid research not only on the effectiveness of counselling but also its cost-benefit analysis compared to other reimbursable procedures. We need the help of audiology professional organisations to speak up—as well as the help of people with tinnitus, including those committees and legislatures, since they can appreciate the consequences and be helpful.
Audiologists can provide counselling to help with the psychological consequences of hearing loss and tinnitus (and hyperacusis). A reasonable, driving force, behind our ability to help these patients depends on reimbursement for our audiological services.
Richard Tyler, PhD, is a professor of otolaryngology–head and neck surgery and of communication sciences and disorders at the University of Iowa. Najlla O. Burle is a speech therapist affiliated with the Post-Graduate Program in Speech Therapy Sciences at the Universidade Federal de Minas Gerais in Brazil, where Patricia C. Mancini, PhD, is an associate professor in the university's department of speech-language pathology and audiology.