CBT is not a single therapy. It encompasses a variety of distinct therapies, most of which are listed in the umbrella diagram.

Cognitive Therapy combined with one or more CBTs has long been recognised as effective psychological therapy for many, if not all the different types of anxiety.

This would be a very lengthy article indeed were it to cover each and every type of anxiety; so for the purposes of this article, let’s just bring in two of the most common types of anxiety:

• GAD (generalised anxiety)

• Health anxiety

When discussing CBT for tinnitus distress, I am referring to the levels of tinnitus distress for which the CBT4T programme was developed – Tinnitus Functional Index (TFI) & Tinnitus Handicap Inventory (THI) categories 4 and 5.

Where it is possible to do so, I will explore some commonalities and differences for CBT for tinnitus, GAD and health anxiety.

To begin, let’s consider what is important – more important than what CBT is, or what GAD or health anxiety is:

What has brought a person to the point where they’ve decided they need help?

Most of you reading this article here in the CBT4T Substack know what it was that brought you to the CBT4T programme, and at least some of your experiences will be recognisable to you in a previous Substack post “How you got here”.

Most people, by the time they recognise they need help, are already unwell. They are fearful.

Think back to when you began the CBT4T process: I asked you to write Impact Statements. There are three of them: the Past, the Present, the Future.

One aspect of what you and others write about in those Impact Statements is undeniable: when people are living in a distressed state, they find themselves fearful of a future that, prior to tinnitus-onset was a future they looked forward to; and even if they already had most of what they wanted, they had a future that looked at least “ok”.

One of the earliest hurdles for many, if not most people, is to learn that CBT for tinnitus is not “for tinnitus” at all – it’s for tinnitus distress; that the problem is the reaction to tinnitus; that hearing tinnitus and reacting to tinnitus are two different things. For the vast majority of people, at least initially, understanding there is a difference between the two is non-existent, impossible.

Whether tinnitus is recent onset or has been distressing for a long time, I think it takes a significant leap of faith for someone to accept there is a difference between the two.

How is anyone likely to react to information their mind tells them doesn’t make any sense? Their thinking is likely to be along the lines of: “Of course I’m reacting to it – the noise is horrible and there’s no escape from it!”

For anyone reading this who doesn’t have tinnitus, or perhaps if they do and it has never been a problem for them, this inability to entertain the idea they’re conflating hearing tinnitus and reacting to tinnitus is a genuine and common dilemma I have seen in my clinics for all 30+ years, as well as from people embarking on the CBT4T online programme ever since I started it in 2009.

I learned 30 years ago that the only way people are able to begin to realise the difference is when they begin to experience the difference for themselves. Before that happens, it really is a matter of trust and taking that important leap of faith. For those that take the leap of faith, the next most important thing is for that person to start experiencing a difference in how they feel within the first two weeks.

Any longer, and most of us lose the faith which is only ever on loan for a short time. The difference that is experienced doesn’t need to be huge; but it does need to be definitive – a genuine experiential difference. From here, there is something real to build on, and trust can and does grow.

There is no room for complacency though. Any difference experienced not only has to continue; it has to become ever more apparent if the person is to grow confidence in what they are being asked to do.

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Are there commonalities and differences between GAD (generalised anxiety) and tinnitus distress?

First, let’s explore some of the differences.

As a psychotherapist working with someone with anxiety, for example someone with the most common type being GAD (generalised anxiety), I see a fairly consistent improvement of anxiety symptoms relatively quickly over a relatively short period of time, certainly over 4-6 weeks.

Those first weeks begin with gaining an understanding of the Autonomic Nervous System (ANS) and using breath work and relaxation routinely, just as you do when you begin CBT4T.

4-6 weeks in, they are already able to begin challenging negative thoughts that provoke anxiety symptoms. Prior to therapy, these thoughts used to repeat as though in a loop, over and over. But because they’ve already learned they can control the physical symptoms and sensations of anxiety (there’s a list of 17 in the ASQ), their ability to catch the negative thoughts, challenge them and turn them around, improves exponentially. Physical anxiety symptoms are significantly reduced.

GAD symptoms are countered significantly after 6-8 weeks (measurable with the GAD-7 & ASQ). Appropriate CBT therapies suitable for the individual person and their presenting issues are selected including those that help address thoughts/meaning that used to drive the already significantly reduced symptoms. Confidence is re-building and newly discovered control continues to improve and be maintained. In a case of non-complex GAD, a person can usually be ready for discharge from care after 10-12 weeks.

This is NOT the case for people with distressing tinnitus. The noise is still there, albeit distress levels somewhat reduced by Stage 4 of the CBT4T process (measurable with TFI & ASQ) , and reduced further still by Stage 6 (TFI and all measures repeated).

After a similar length of time (10-12 weeks), for those with tinnitus distress, tinnitus is still very much in awareness even though reduced (TFI Q1); the person is still reacting to the tinnitus > leading to negative thoughts > leading to increased physical anxiety symptoms that in turn exacerbates tinnitus loudness perception.

There are occasions when a GAD diagnosis has overshadowed or overlooked underlying or additional issues, so GAD is certainly not always dealt with as straightforwardly as I have described above. Just as can happen for people with distressing tinnitus, additional issues can arise and those too need to be addressed either through the therapy process or expedited in another way. It is common, for example, for one or more challenging issues to arise during the process – such as being faced with another health issue, or changes in a personal or work situation. Such occurrences are common, so the CBT4T process needs to be flexible to allow for newly arising challenges to also be addressed. CBT4T won’t change a situation, but using the CBT4T practices and tools does throw light on how you might react to it.

What about health anxiety?

Health anxiety involves having a perpetual worry of impending illness. It’s the ingrained belief of impending serious illness triggered by tiny physiological/body changes that sets off the anxiety reaction. The UK NHS website describes it thus:

“Health anxiety is when you spend so much time worrying you’re ill, or going to get ill, that it starts to take over your life. It’s related to obsessive compulsive disorder (OCD).”

Just as an observation, I see many people with distressing tinnitus who also have health anxiety – the two are not unrelated. To clarify though, someone who has health anxiety is to be counted as one of the “1-in-7” (prevalence of tinnitus in the UK population) should s/he later have tinnitus onset. There is no link the other way around i.e. that someone with tinnitus would develop health anxiety.

As I see it – based on my own experience of working with patients with health anxiety - the main difference between health anxiety and being distressed by tinnitus is that most people with health anxiety know that their worries are probably unfounded, often as high as 90-99% imagined. Tinnitus is not imagined – it is a noise that a person can most definitely hear.

Someone with health anxiety and distressing tinnitus is likely to add to their distress by ruminating, looking to link tinnitus to another aspect of their health e.g. “my tinnitus is very bad, so it could mean that I have x, y, z....”

Fortunately, although I have come across many people who do have both health anxiety and tinnitus, overwhelmingly most people with tinnitus DO NOT have both.

It is worth noting there is a significant difference between noticing physical symptoms that worry you sufficiently to contact your GP and “health anxiety”. All anxiety disorders including health anxiety need to be formally diagnosed by a qualified medical professional. Self-diagnosis (or diagnosis-by-internet or AI) is strongly advised against. A person diagnosed with health anxiety who has physical symptoms that worry him/her should always contact their GP. Their GP will know them well, and know how to help them. More often than not, the help given is reassurance.

As it is for GAD, CBT is extremely beneficial for addressing health anxiety, particularly after being taught how to control physical anxiety symptoms through regulating the nervous system. Learning to counter the repetitious negative thoughts through identifying in particular the repetitious “predicting the future”, “all or nothing” and “emotional reasoning” are commonly occurring cognitive distortions in health anxiety.

Some final words about the CBT4T process and what went in to its development

By its very nature once triggered, tinnitus is a noise that is heard if/when we think of it. It is true that when our thoughts are elsewhere, we don’t hear tinnitus.

Dissecting the components that contribute to tinnitus distress has been fundamental to developing the processes integrated in to what in 2026 is the CBT4T process. The significant improvements that people make through following the CBT4T programme are clear from the clinical Outcomes (TFI, THI, GAD-7, PSS, ASQ + HSQ & HAQ). The TFI Outcomes along with comprehensive feedback and reviews from individuals as they progress through the CBT4T process are published on the website.

A few years ago, I broke down the components of the CBT4T programme as follows – it is in the main CBT4T courses website and copy/pasted here:

“The issues around tinnitus distress are complex. Resolution isn’t found by treating any single aspect of tinnitus distress, but through a process that addresses all the aspects involved. This is precisely what CBT4T provides for those with tinnitus distress.

The CBT4T process draws from 5 fields of expertise:

• Hearing Therapy & Audiology - Debbie Featherstone is a qualified (HT Dip), experienced Hearing Therapist (30+ years) specialising in tinnitus & hyperacusis

• Psychotherapy – Debbie Featherstone is a fully trained, qualified (PG Dip, MSc), experienced Psychotherapist (21 years) specialising in tinnitus & hyperacusis, specifically developing effective (measurable) CBT processes, practices and tools - predominantly 3rd wave CBT - for tinnitus & hyperacusis patients/clients

• *Clinical physiology & related neuroscience, in particular how trauma affects brain-processing, impact of dysregulation of the nervous system and how to recover a regulated nervous system

• *Neuropsychotherapy - an integrative approach to therapy that takes into account the dynamic interplay between the mind, body, social interaction, and the environment on a person’s well-being with a focus on neuroscientific research

*Hundreds of psychotherapy CPD training hours over 21 years

Rather than predict and believe how good or bad your day might be... depending on what tinnitus does or doesn’t do... CBT4T trains you back to living your life without being under the influence of tinnitus.”

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I hope you have found this article interesting. I love reading your comments and am always happy to answer questions if you have them in the comments below.

It is a rather lovely, sunny and warm Bank Holiday Monday here, so I’m off out now to enjoy the sun while it’s still here!

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Here are some useful links:

Main CBT4T course website: https://courses.tinnituseprogram.org

CBT4T Enrolments to view the CBT4T programme and join if you haven’t already: https://courses.tinnituseprogram.org/cbt4t-enrolments

CBT for Tinnitus Distress (Audiologists): https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

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Who is CBT4T Substack for?

The aim is for the CBT4T Substack to be a useful resource to anyone interested in CBT (Cognitive Behaviour Therapy) and how it is used in the CBT4T programme. As such, it is for:

• Anyone with tinnitus, whether they are already using the CBT4T programme or not yet enrolled

• Anyone supporting others who have tinnitus, such as Audiologists, Hearing Therapists, and those in a tinnitus supporting/advisory role

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Any of you enrolled in the CBT4T programme already know the importance of the “little and often, regular and consistent” breath work that begins from day 1 in the CBT4T programme.

In fact, any one of the thousands of patients I’ve worked with in the last 30+ years heard the same from me: “little and often, regular and consistent” breath work and relaxation!

I know I sound like a stuck record, but I don’t apologise because the benefit “little and often, regular and consistent” breath work and relaxation practice brings to the nervous system is enormous. By the end of Stage 4 of CBT4T having completed CBT4T Element 1 (Preparation) and begun Element 2 (Moving Forward), these daily practices produce a MINIMUM reduction by one full Tinnitus Functional Index (TFI) category and one full Anxiety/stress Symptoms (ASQ) category.

A couple of weeks ago, completely by chance, I came across a really interesting, informative little book.

The front cover of the book entitled Breath proudly states: “The Sunday Times Bestseller”.

First published by Penguin Life in 2020, the edition I have was published in 2021, and authored by James Nestor.

It turns out Breath wasn’t the kind of read I expected it to be.

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What I hadn’t expected was that it would be such an interesting read; rather than it having a formal text-book like style, Breath is presented in a story-style. The author relates his experiences during a time he is taking part in a formal 20 day research project at the Stanford Department of Otolaryngology Head and Neck Surgery Centre to monitor the effects of mouth breathing (10 days) versus nose breathing (10 days).

He interjects with conversations he has with a fellow research project participant, along with easy to follow explanations of the physiology of breathing, and the impact the way we breathe has on major systems in the body such as the autonomic nervous system. You will be familiar with this already if you are part of the CBT4T programme.

The way we breathe impacts other major systems in the body too: much of this knowledge was studied, accepted and practiced in the past, and somehow has been allowed to be forgotten.

The core learning from Breath is:

• We breathe too much and need to “breathe less”

• Breathe in and out slowly through the nose

• Mouth breathing is bad – nose breathing is good

• Ideally, each in-breath for 5.5 seconds, each out-breath for 5.5 seconds

The physiology behind this is explained in understandable language in the 214 page book, plus the appendix contains a good variety of breathing methods and exercises.

I recommend you read the whole book yourself. However, here are a couple of short cuts that are intended to help you straightaway:

ONE:

Coherent Breathing: Here is a YouTube video with Dr Richard Brown leading you through a practice of “Coherent Breathing”. The video is 12 minutes 26 seconds long.

TWO:

I recommend a downloadable App (Android and iOS) called Pocket Breath Coach. You can use it usefully for free, and if you want to access the whole selection of breath work practices and wider choice of accompanying sounds, it costs £6.99 for a year’s subscription.

NOTE: My first choice of exercise in the Pocket Breath Coach is the ‘1:1 ratio’ category: 5.5 breaths/minute because of what I learned from reading Breath. I recommend you do the same, and then by all means, try out some of the other practices in the Pocket Breath Coach app.

For those of you in Stages 1-6 of CBT4T, you may want to use one or two of these new exercises in place of one or two of the six times daily 2-3 minute breathing exercises. I’ll add them to the Relaxation Log so you can let me know when you use them.

For those of you beyond Stage 6 in Elements 3 or 4, these new breath work exercises offer you even more variety. Mix them up with your Autogenics or guided relaxation practices.

Happy breathing!

Let us know how you get on in the comments!

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Useful Links

Complete a Tinnitus Functional Index (TFI)

CBT4T Enrolments at a glance

CBT4T Feedback & Reviews

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The aim is for the CBT4T Substack to be a useful resource to anyone interested in CBT (Cognitive Behaviour Therapy) and how it is used in the CBT4T programme. As such, it is for:

• Anyone supporting others who have tinnitus, such as Audiologists, Hearing Therapists, and those in a tinnitus supporting/advisory role

• Anyone with tinnitus, whether they are already using the CBT4T programme or not yet enrolled

I found these at the bottom of the main course site while reviewing its content this morning. These snippets are from people who enrolled on CBT4T in 2020-21 following its launch as the CBT for Tinnitus E-Programme in July 2020.

Reading them again, I realised that recent CBT4T users and visitors to the site probably don’t even see these, so I’ve decided to give them a fresh airing!

I collected them long before the more detailed feedback and reviews were requested as they are currently.

I am frequently told by people enrolled in CBT4T that they often revisit the feedback and reviews, because reading about others helps them enormously - how so many others – just like them - were worried and afraid, but “got their lives back” through using the CBT4T programme.

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Snippets of feedback from 2020-21

“This course has been life transforming for me. Before I started the course, I was constantly focused on the tinnitus (March 2021 onset) and had taken time off work for associated anxiety. Now it rarely comes to mind and when it does, it has no emotional impact on me and I fairly quickly forget about it.”

“The Tinnitus E-Programme is a quality on-line programme for actively learning how to manage tinnitus. It is a game changer!”

“This course and all the support has really helped me to live with my tinnitus and I feel my life is now getting back to normal. I know that I couldn’t get to where I am now without this programme. I feel ok now about my tinnitus. I can still hear the hissing sound sometimes but it doesn’t really concern me.”

“CBT going well. Really like reading module 3 as this nicely focused the CBT towards tinnitus.”

“I am particularly impressed with the depth of the recorded relaxation programs. They do exactly what they are intended to do. I am also very satisfied with the responses to my emails I get from Debbie and her depth of skill and knowledge of working with people with tinnitus.”

“I have been concerned about long-standing insomnia issues and how they impact on CBT for tinnitus. Debbie gave me reassurance that I was on track with the program and was making incremental progress in line with those who are currently taking and those who have taken the program.”

“Now I understand the tinnitus more than ever, how to relax and I’m able to observe my thoughts. After using the breathing exercise and the relaxation (recordings), I feel different - quiet and relaxed”

“I have found the Tinnitus E-Programme to be great! Especially to understand why and how to be more rational about tinnitus, and less stressed about why I have it”

“Debbie explains everything thoroughly and simply. I use the breathing exercises and relaxation everyday”

“This course has done exactly what Debbie (Featherstone) told me it would do. My thanks to Debbie - it has been a life-saver being shown that there is a “way out”, a way of dealing with tinnitus, and also dealing with stress in general which is on-going.”

“A well thought out course which covered many aspects of the cause of tinnitus and management of it.”

“I find the switching between listening to the tinnitus and not listening very helpful”

“Over the past 10 weeks, again I have had a lot of stress with different circumstances. But even so, I amazed to see my (TFI) score come down from 46 to 29. I know I will benefit more from working with Debbie using more CBT.”

“Being able to talk to Debbie about tinnitus and her fully understanding the problems and impact it causes helped me a great deal.”

“It helped me to relax more and helped me to get to sleep easier. I don’t feel as isolated and realise other people have the same feelings about having tinnitus.”

“I particularly like having the four relaxation recordings to download and keep. Having 4 of them allows a good choice. I now have a much better understanding of the problem and realise how to deal with it.”

“Has been beneficial and I can now relax a lot easier which therefore helps with getting to sleep which was one major problem for me!”

“Debbie has been most helpful answering queries and giving clear explanations. Her whole manner is relaxing in itself which generates a feeling of well-being. She shows great empathy.”

“I love the way you write and how hopeful I feel after reading these modules. I’m hopeful, uninterested in tinnitus, very still.”

“I’ve been falling asleep in less than 10 minutes. I find that I’ve become more bored of my tinnitus. I worry for a second ‘what if I hear it again?’ then I think of something else (automatically not forced) and give it no more thought. It just seems like my brain is finding it harder to focus on the tinnitus sounds.”

“I feel a lot less anxious about the future living with tinnitus. I found the course very easy to cope with and enjoyed it!”

“The course was helpful. I feel less anxious now I have more information regarding the way tinnitus works.”

Useful Links

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

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The aim is for the CBT4T Substack to be a useful resource to anyone interested in CBT (Cognitive Behaviour Therapy) and how it is used in the CBT4T programme. As such, it is for:

• Anyone who supports others who have tinnitus, such as Audiologists, Hearing Therapists, and those in a tinnitus supporting/advisory role

• Anyone with troublesome tinnitus & interested in Cognitive Behaviour Therapy (CBT) & related Neuroscience, including when already enrolled in the CBT4T programme

Today’s post is an article previously published in the CBT4T Bulletin 18^th March 2020 (www.tinnituseprogram.org) updated with a short final section “Five Years On”

Listening to and monitoring tinnitus

I chose a weekend to MONITOR my tinnitus. Just to observe what it did in terms of loudness. I used a simple scale of 1-10, 1 = very quiet, and 10 = as loud as I believe it can possibly be.

Something I find really interesting is....

When I happen to mention to patients that I too have tinnitus, they are often quite surprised. Mine began in 1993 and hasn't stopped since. Lucky for me I knew what it was (once I'd sussed it wasn't a noise from "outside") and I never attached any emotion to it. I wasn't scared of it, I didn't "hate" it - it was just something that was there that I'd prefer wasn't, but as there was nothing I could do other than ignore it, that's what I did.

As a result, I became one of the 85% (of the 1 in 10* of the population who has tinnitus), and 'habituated' to it being there, unnoticed most of the time. It is a different story for 15%, who struggle to live with tinnitus.

*At the time of writing, prevalence was reported as 1 in 10 of the population has tinnitus. In 2025 according to Tinnitus UK, prevalence is 1 in 7

A commonly learned prediction that many people form and use daily is that on waking, if their tinnitus is "loud" - it means (to them) they are in for a bad day; whereas if the noise is “quiet” – it means (to them) they might have a better day, but it wouldn't last.... and sure enough, their 'prediction' usually came true.

On-waking monitoring > predicting is VERY common, and of course leads to more frequent monitoring, that becomes habitual (habit-formed). It is a typical element of maladaptive neuroplasticity discussed in a previous CBT4T Substack: How you got here

Monitoring (listening for and listening to) tinnitus is frequently the last habit behaviour that changes (changing from maladaptive > adaptive neuroplasticity) by the end of a habituation process.

I decided to carry out a personal experiment. I can't think why I had never thought of doing it before, but sometimes these ideas come to us, and we wonder "why didn't I think of this before?"

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THE EXPERIMENT

I chose a weekend, a time of the week for me that has less likelihood of there being any unexpected stress around, to MONITOR my tinnitus. My intention was just to observe what my tinnitus did in terms of loudness. I used a simple scale of 1-10: 1 = very quiet, and 10 = as loud as I believe it can possibly be.

First day - Saturday 25 January 2020:

12:30pm: Tinnitus loudness: 3/10 Mainly left ear and head

I have no more entries for the Saturday because I forgot to monitor it!

Second day - Sunday 26 January 2020:

09:55am: Tinnitus loudness: 6/10 Left and right ears, and head with pulsing

15:15pm: Tinnitus loudness: 8/10 Left and right ears, and head; piercing

17:50pm: Tinnitus loudness: 4/10 Left and right ears

21:55pm: Tinnitus loudness: 7/10 Left and right ears

Prior to this mini-experiment, I had been aware that my tinnitus varied in loudness, but my assumption was it varied day-to day. I hadn’t realised how much it varied throughout a day. As I mention above, being one of the 85% having tinnitus but not bothered by it, my mind has no reason to think of it most of the time, so I don’t hear it most of the time.

The experiment had shown how much variability there was with my own tinnitus! In fact, a thought popped in to my head when I did the 15:15 monitoring..... "How on EARTH was I NOT noticing that?????" It was so shrill and piercingly LOUD!

I had recorded those results, and must admit, it did cross my mind at the time "I hope this doesn't trigger me off "monitoring"!

And indeed, as belatedly anticipated, the experiment DID have an after-effect. It wasn't until 4 days later - the Thursday - that I realised I had stopped monitoring! Monday and Tuesday, my mind kept thinking about the tinnitus, Wednesday less so, and I realised on the Thursday evening that I hadn't thought about it all day - other than the usual times which is when I am talking to a patient about their tinnitus, and I do occasionally internally-relate to my own - which causes me to notice my tinnitus.

I don't "notice" when I stop noticing of course! It's not until the next time I "notice" it, I realise I've not noticed it.... That's just the way it works!

This after-effect led me to consider why it takes a long time for the patients to 'stop monitoring'. I only did it for a day, and it took 4 days to stop monitoring. Plus, I really don't care about 'my tinnitus'.... I consider myself one of the 85%, fully habituated and although I have tinnitus, it has no effect on my life. Other than occasionally tinnitus having been a good teacher that over the years has allowed me to be cognisant of what it is to experience a 'phantom noise', by which I mean a noise that I can hear, but has no external source of origin.

And lucky for me, because tinnitus has never carried any strong negative meaning for me, I don’t care about it. My mind doesn't care about it, has no interest in what it's doing, doesn't go in to overdrive or overwhelm about it.

27 years later, I look back at a career that has been spent helping others to achieve what came so easily to me. They have had to work harder than I ever did to change, but change they have, and they continue to do so. That career has been my share in helping "the 15%" become part of “the 85%” which, of course, is why I still do it!

Five Years On

It’s now July 2025 - five years on from the self-inflicted experiment. I have never been tempted to repeat the experiment and I would seriously caution anyone against experimenting themselves! I did it before I had the level of understanding that I have now about neuroplasticity.

However, I learned two main things that I have since been able to pass on to others:

1. Other than a very few exceptions, one being when tinnitus has been caused through whiplash injury, where impacting a nerve in the neck results in an unchanging loudness level of tinnitus, tinnitus varies A LOT - both in loudness (how loudly we perceive it to be) and in what it sounds like. There is what might be referred to as a baseline i.e. what it usually sounds like, such as a hiss, or droning, or whistling… (there are many different tinnitus sounds), but it can and does vary in loudness and in the sound itself. If you are interested in understanding more about ‘What does tinnitus sound like’, the Tinnitus UK website is a great place to start! There is also a recording of synthesised tinnitus sounds in a previous CBT4T Substack 8th June 2025

2. I spent ONE day monitoring my tinnitus, and it wasn’t until FOUR days later that I had stopped. And I was not stressed, I had no anxiety, I wasn’t depressed, worried or fearful. Everyone coming to the CBT4T programme has already had tinnitus for a significant length of time. A few find the programme early-on either through Tinnitus UK or an internet search; however, well over 90% of those coming to CBT4T have been struggling for many months, and indeed, years when they enrol. Most also have significant stress, and anxiety; they are often fearful and worried, and sometime feel low, even depressed. As brilliant as neuroplasticity is, and as certain as it is that maladaptive-neuroplasticity is changeable to adaptive-neuroplasticity through repeated practice, changes won’t turn around in a few days. The process to bring about adaptive-neuroplasticity is a PROACTIVE process, undertaken stage by stage over time as set out in the CBT4T process. The average time taken from start to finish is 6-8 months; as a rule of thumb, the lower the initial TFI category (Tinnitus Functional Index), the less time it is likely to take.

Thanks for reading! I hope you’ve found the article helpful.

PLEASE do comment below - I can only know if you are finding the content I’m publishing here in the CBT4T Substack interesting if I hear from you!

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CBT4T Programme

CBT4T Enrolment choices/options: https://courses.tinnituseprogram.org/cbt4t-enrolments

Recordings - A new section for CBT4T

New Progressive Relaxation with Debbie Featherstone: https://courses.tinnituseprogram.org/progressive-relaxation-with-debbie-featherstone

CBT4T Packs for Professionals

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

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29th July 2025

As well as a highly experienced Audiologist and a Speech & Language Therapist, my previous team in Birmingham had included a clinical psychologist; however, there was no psychology input available to my new hearing therapy patients in Lancashire…. In a nutshell, this was the reason I sought additional training as a psychotherapist. As luck would have it too, the first year of the training I opted for was clinical hypnosis, and I must say, over the years it has certainly had its uses!

The reason for mentioning this little bit of history is by way of introduction and to give context to this Progressive Relaxation recording.

About the recording

It was through the clinical hypnosis training that I learned to pace delivery of relaxation during the first year of my training as a psychotherapist.

This recording is NOT hypnosis, nor is it hypnotherapy!

The recording is progressive relaxation: in the context of a hypnotherapy session, progressive relaxation such as this could be used as stage 1 of a four or 5 stage hypnotherapy process.

Towards the end of the 30 minutes, there is a period of approximately one minute to enjoy a short visualisation, after which the session is ended using a 5-4-3-2-1 countdown.

There is a (quiet) background of sea waves behind my voice throughout the recording.

NOTE: although the progressive relaxation ends at approximately 31 minutes, the background sea waves continues for up to a further 27 minutes.

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New equipment & software – requesting your help

I am using new recording equipment and software I recently purchased with the purpose of creating a variety of relaxation recordings. The Progressive Relaxation recording presented here is the first of those. My intention is to record several others, of varying length and type.

Because this is my first attempt using new equipment and software, I would really appreciate feedback from you - particularly those of you enrolled in the CBT4T programme, as you are already familiar with at least some of the relaxation recordings used in CBT4T, depending on where you are in the CBT4T process. Please listen to the recording and leave your feedback in the comments – thank you so much!

Before you begin, choose a time when you will not be disturbed for at least half an hour. Find a comfortable space either seated in a comfortable chair or laying down.

I hope you enjoy ….

To download this recording

From 27th July 2025, if you have enjoyed this progressive relaxation and would like the convenience of having your own copy (price £10.00 GBP) on your phone, tablet or computer, the recording is now available to download to your computer or mobile device: Go to details

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The aim is for the CBT4T Substack to be a useful resource to anyone interested in CBT (Cognitive Behaviour Therapy) and how it is used in the CBT4T programme. As such, it is for:

• Anyone supporting others who have tinnitus, such as Audiologists, Hearing Therapists, and those in a tinnitus supporting/advisory role

• Anyone with tinnitus, whether they are already using the CBT4T programme or not yet enrolled

Setting explicit goals is an important aspect of achieving successful outcomes. Setting clear goals is fundamental when we wish to achieve any form of change and is an integral part of any process to help us achieve change. How will we measure we have achieved or not achieved what we set out to do, when we are unclear about where we are going?

If we are unclear about what we intend to achieve, we are likely to end up being disappointed.

Goal setting is part and parcel of any process intended to lead to change, including a Cognitive Behaviour Therapy (CBT) process; yet the task of goal setting is often one of the most challenging to us when we are in the midst of already challenging and difficult experiences.

Goal setting in CBT aims to make goals EXPLICIT i.e. “stated out loud” metaphorically speaking. If NOT made explicit, implicit assumptions lurk in the subconscious and cause lack of clarity, even confusion.

When do we formally set goals?

I remember all too well in my earlier days of clinical practice, eager to set my patients off on “the right track” following their assessment, goal setting was the first task to take a patient through. It was ALWAYS difficult!

The reason they found it difficult is not complicated. It was because they struggled to cope with the tinnitus noise, and wanted it gone! Hardly surprising then that the most frequently stated goal was something along the lines of “For tinnitus to go!”

Of course, both they and I knew this to be highly unlikely, so the goal immediately failed two of the SMART goal rules: “Achievable” and “Realistic”.

SMART goals are:

• Specific

• Measurable

• Achievable

• Realistic

• Timely

Not only did this initial failure cause the goal setting task to seem “too difficult”; it undermined people’s confidence, adding to frustrations and fears they were already suffering.

To be useful, goal setting should be approached at the right time in the process. In the CBT4T process, goal setting begins in Element 2 where the Cognitive therapy component of the process begins, following the early re-regulation of the Autonomic Nervous System that has begun to take effect throughout Element 1 (Stages 1-3).

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How do we go about setting goals that are most likely to be successful?

• We define clearly the direction we want to go

• We make EXPLICIT what we want to achieve

• We ensure our chosen goals are SMART

To meet the ‘Timely’ component of SMART, it is helpful to use a framework – the simple framework I use is:

• Short term goals

• Medium term goals

• Long term goals

Consider these broadly in terms of weeks and months. You are setting these goals for yourself; you are allowed to be flexible with them. For example, it may be you choose something as a medium term goal, find you enjoy the activity you set yourself, achieve it sooner than you expected so it turns out to be a short-term goal!

Things can work out the other way too. None of us can predict the future, so it may be that something you believed could be achieved short term (just a few weeks) is taking longer. As long as you have largely followed your action plan to meet the goal, there is nothing wrong with making an adjustment, re-evaluating the goal as medium or long term.

When you are beginning to set goals, choose at least one of each when you begin, and preferably more short term than medium and long term goals as you continue. This way, success comes quite quickly, giving you confidence to build on “the wins” feeling motivated and confident about achieving your medium and long term goals.

A good way to identify several short term goals, is to work out how to break a wanted goal down in to easily achievable stages.

Popular goals around listening and reading

“Listening” is a commonly identified goal – be that listening to music, listening to a favourite radio or TV show; “reading” is another – maybe reading a book, or a favourite magazine or newspaper.

Set short, achievable times for “listening” or “reading”.

For example: “Listen to music/radio/TV for 5 minutes every day”

Perhaps every day may prove difficult due to home or work responsibilities. So be fair to yourself, for example: “Listen to music/radio/TV x number of times a week” (where feasible, be even more definitive e.g. on Monday, Wednesday, Friday, Saturday).

Once you’ve met your goal of 5 minutes consistently several times over, extend the time period to what you believe to be achievable – it may be 10 minutes for example, and this would become your next short term goal.

If your goal is about reading a book, set yourself a goal of reading a specific book that you want to read, but break it down in to small sections, depending on what you think might be achievable as a first goal.

For example: “Read one page of x book every day”, or “Read one page of x book at least 4 days a week/on Tuesdays, Wednesdays, Thursdays and Fridays in the evenings (or whenever you think is your best time for reading).

And it doesn’t matter how limited you need to make the goal. Keep it REALISTIC, For example, where reading was once an enjoyable past time, and has become an activity you haven’t done because of difficulty concentrating because of tinnitus (this is very common indeed!), even a page might feel too much! Have a single paragraph as your initial goal. You can extend beyond a single paragraph as your next goal.

Values Based Action

One of the most useful – and logical – ways of identifying and successfully achieving a goal is to choose goals that you personally value. Listening and reading are probably the most common past times that people choose because they miss having them in their life. Cycling is another very common activity that people have enjoyed for years but have stopped doing – sometimes because they’ve felt too depressed (because of tinnitus); sometimes because they worry it will “make tinnitus worse”, either because of wind noise, sometimes because physical activity increases arousal and they fear the impact on their tinnitus. A first step, short term goal would be to go for a very short (5-10 minute) bike ride X times every week. Include where you will ride in the goal, e.g. “Ride down X street and back”. It would be similar when choosing walking as a goal.

Start off small > achieve success > extend a little > achieve success > extend some more.

Choosing activities that you enjoy is a concept known as Values Based Action, and comes from one of the third wave Cognitive Behavioural Therapies: Acceptance & Commitment Therapy (ACT). The tools for Values Based Action goal setting is detailed in the CBT4T course content (Stage 5b).

Goal Setting & Action Planning Framework

Reference: Scobie, Dixon, Wyke (2011) Goal setting & action planning in the rehabilitation setting: Development of a theoretically informed framework, Clinical Rehabilitation, 25, 468-482

Particularly where goal setting and planning how to meet goals is new to you, a template is really helpful. This is the referenced framework used in the CBT4T programme.

Choose goals that pertain to your wellbeing rather than be focused around tinnitus

Bear in mind that reduced conscious awareness of tinnitus is the objective of the CBT4T process.

However, although it may feel counter-intuitive, choosing goals that explicitly use tinnitus as the locus to change, is likely to delay progress rather than be of help.

To better understand why, consider the perspective you would be bringing to the goal.

The definition of perspective (noun) is:

“A particular perspective is a particular way of thinking about something, especially one that is influenced by your beliefs or experiences”

(Ref: https://www.collinsdictionary.com/dictionary/english/perspective)

Let’s examine the perspective you are bringing to a goal that has tinnitus as the locus to change, for example: “To not hear tinnitus”, or “To become less aware of tinnitus”.

Immediately, tinnitus is central and significant, due to the meaning attributed to tinnitus because of the negative experiences it has brought in to your life - so much so that you needed to seek help. Simply because you are thinking of tinnitus as you are thinking about the “tinnitus goal”, the likely effects are that your tinnitus sounds louder (than it was before you thought of the goal), your attention is taken up by it and you find yourself monitoring it. I even hesitate to include this paragraph, as it’s likely this is happening even as you read it!

So moving quickly on…. Neither of those goal statements meet SMART criteria either:

• “To not hear tinnitus” – implies to not hear tinnitus AT ALL – fails three of the five SMART criteria - Achievable, Realistic, Timely

• “To become less aware of tinnitus” – how much less aware? by when? – fails three of the five SMART criteria - Specific, Measurable, Timely

Always make your goals about activities you enjoy!

Past examples of Goal & Action Planning

To conclude, below are three examples of goal action planning sent in by past users of CBT4T.

Short term example:

Medium term example:

Long term example:

Additional links that may be of interest

CBT4T website: www.tinnituseprogram.org

Tinnitus Functional Index: www.tinnituseprogram.org/tfi.html

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

26/6/25

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The aim is for the CBT4T Substack to be a useful resource to anyone interested in CBT (Cognitive Behaviour Therapy) and how it is used in the CBT4T programme. As such, it is for:

• Anyone supporting others who have tinnitus, such as Audiologists, Hearing Therapists, and those in a tinnitus supporting/advisory role

• Anyone with tinnitus, whether they are already using the CBT4T programme or not yet enrolled

For a multi-component process to be of use to a wide range of individual people, there needs to be in-built flexibility, allowing for each person to use the process at a pace that fits their needs (including what they require clinically) and responsibilities (including family, work etc). Excellent health care is “person-centred”.

In circumstances where the expectation is that the person must fit a multi-component, inflexible process for them to benefit, the expectation is unlikely to be met.

Person-centred care is widely acknowledged as being integral to successful health outcomes, and is advocated by health providers including the NHS in the UK. A quick internet search evidences this to be the case. Here is an example publication:

Person-centred care: What is it and how do we get there (2016) (NIH - National Institutes of Health)

CBT4T: The one thing everyone has in common is tinnitus distress

No two people come to CBT4T with the same histories, the same thoughts, feelings, beliefs, the same nervous systems, the same neural pattern formations. The one thing everyone has in common is “tinnitus distress”. However:

• Tinnitus differs from one person to the next

• There is a host of causes of tinnitus, and frequently even the cause remains unclear

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What does tinnitus sound like?

Here are a few examples that demonstrate a variety of tinnitus descriptions from CBT4T new starters answering the question ‘What does your tinnitus sound like?’

It can be difficult for people to describe what their tinnitus sounds like, because frequently, tinnitus doesn’t sound the same as anything familiar. It’s why descriptions of tinnitus often begin with “it sounds a bit like….” Bear in mind too, for example, that when someone describes their tinnitus as “ringing” or other descriptor, someone else will not really know exactly what the other person’s “ringing” (or other descriptor) sounds like, because we each have our own internalised interpretation of what “ringing” (or other descriptor) is to us.

Listen to a recording of a range of synthesised tinnitus sounds…. (do not have the volume of your device set too high!)

Please note that the telephone number given at the end of the recording is out of date! The recording was made by the British Tinnitus Association, now known as Tinnitus UK. You’ll find their up to date details on their website www.tinnitus.org.uk

What caused tinnitus?

The causes of tinnitus vary too. Here are some examples from CBT4T new starters answering the question ‘Do you either know or suspect why tinnitus started?’

The examples listed are but a tiny few, and overall it is common for people not to have been given a definitive cause.

How long someone has had tinnitus is another factor, although more to the point: how long someone has been troubled by tinnitus. It is common for people to have had tinnitus for longer than they’ve been troubled by it.

How problematic is tinnitus?

The Tinnitus Functional Index (TFI) is the main measure used at the beginning, during and on completing CBT4T to quantify how problematic tinnitus is:

• Category 1: small problem (0-17%)

• Category 2: small problem (18-31%)

• Category 3: moderate problem (32-53%)

• Category 4: big problem (54-72%)

• Category 5: very big problem (73-100%)

The TFI is the main measure used in CBT4T, but it is not used in isolation. The Tinnitus Handicap Inventory (THI) is used as a secondary tinnitus measure, plus there are clinical measures for anxiety, for stress and separately for symptoms of anxiety and stress.

There are two useful aspects to the Tinnitus Functional Index:

• Total TFI score

• Eight subscales within the TFI

The total TFI score is a good reflection by category of how problematic tinnitus is at the time (over the past week); however, the eight subscales reflect very useful information in terms of how a person’s experience is changing as they make their way through the CBT4T process.

The eight subscales are:

1. INTRUSIVE (unpleasantness, intrusiveness, persistence)

2. SENSE OF CONTROL (reduced sense of control)

3. COGNITIVE (cognitive interference)

4. SLEEP (sleep disturbance)

5. AUDITORY (auditory difficulties attributed to tinnitus)

6. RELAXATION (interference with relaxation)

7. QUALITY OF LIFE (QOL) (quality of life reduced)

8. EMOTIONAL (emotional distress)

All eight subscales are impacted by the Autonomic Nervous System operating dysfunctionally. Subscales 1-3 are also impacted by Cognition (more so than the other 5); hence subscales 1-3 are frequently the later of the eight to reduce.

CBT4T Substack 22 May 2025: Your Autonomic Nervous System

More varying factors

There are more variables from person to person too, based on individual needs and responsibilities. These encompass a range of changeable circumstances such as general health & wellness, family, work, financials, social life. Life is dynamic – we are constantly influenced by what happens around us. Being adaptable as we navigate our way through life can be challenging.

Adapting to the dynamic world of which we are a part can be described in an analogy from Heraclitus:

Heraclitus, an ancient Greek philosopher in the 6th century, is quoted as saying:

“No man ever steps in the same river twice, for it's not the same river and he's not the same man.”

He spoke of Two Worlds:

• An External World where a river never stays the same, is forever changing and is in constant flux

• An Internal World where the “you” that steps into the river today is not the same “you” that steps into the river tomorrow

***************

To summarise the differences referred to so far:

• What tinnitus sounds like

• What caused the tinnitus

• How much of a problem tinnitus is overall (TFI)

• How much of a problem tinnitus is in eight identifiable areas (TFI subscales)

• Health – including physical and psychological

• Family, work, financial responsibilities

• Social - recreation, leisure interests

• Adaptability and ability to navigate change

This modest list of differences barely scratches the surface. Beneath the veneer of each is the detail, embedded in our individual life experiences that shape what we think, what we believe and what we feel about our Past, our Present, and our Future. However, the list highlights why it is that no person should be expected to fit a process – rather, a process MUST be flexible to fit the person.

CBT4T Framework

CBT4T has a framework that enables you to set your own pace to accommodate your individual needs and responsibilities. Your pace will almost certainly vary throughout.

CBT4T framework:

1. Four Elements

2. Stages within each Element

3. Sections within each Stage

Element 1: Build strong foundations

• CBT4T Element 1: Preparation

• CBT4T Stages 1-3

Element 2: Action - Making changes

• CBT4T Element 2: Moving Forward

• CBT4T Stages 4-6

Element 3: Reinforcement – Embedding changes

• CBT4T Element 3: Meaning & Beliefs

• CBT4T Stage 7: 4 modules

Element 4: Maintenance - Maintaining changes

• CBT4T Element 4: Consolidation & Completion

• CBT4T Stage 8: 2 modules

There is a minimum number of days recommended to spend at each Stage. Each person spends *as long as they need in each Element and Stage before moving to the next.

*It is worth noting that many people starting the course want to rush through the content, being eager to make changes happen quickly! Sadly, the human brain and nervous system doesn’t work like that!

Once in Element 2, an early check is made to compare two of the measures completed at the beginning of the process: the TFI (Tinnitus Functional Index) and ASQ (Anxiety/stress Symptoms Q) Both measures are repeated, acting as quantitative check of readiness to continue Element 2.

The next time a comparison is made is at the end of Element 2 when all clinical measures are repeated:

• TFI (Tinnitus Functional Index)

• THI (Tinnitus Handicap Inventory)

• GAD-7 (anxiety measure)

• PSS (Perceived Stress Score)

• ASQ (Anxiety/stress Symptoms Q)

These are also repeated later in the process/on completion.

In-built mechanisms to support individual pacing

There are also mechanisms that support individual pacing within the framework:

• Daily relaxation logs

• Weekly SITREPs – www.tinnituseprogram.org/sitrep.html

• End of Stage Progress Checks

Beyond these, there is email support and of course, the face to face appointments via Zoom included in enrolment.

Feedback from CBT4T Users about pace

To conclude, here are some example responses to a question asked of people when they send in their feedback at the end of Element 2:

How have you found the pace of the course generally?

“I think the course offers a flexible timeline for people with different paces to complete each stage. The content is also very diverse and covered almost everything I needed to know about my brain and tinnitus. So far, I'm able to follow every reading and every stage with the suggested end day (referring to the starting day of every new date).”

“The course is at the right pace as I can control the speed I am going at and introduces new areas of learning at the appropriate times.”

“The pace has been fine for me and the content about right. Early on, I wanted more information sooner, but I think patience is the key.”

“I wanted to rush through and appreciated the feedback via email to slow down. Also useful that the next stage of the course opens in stages.”

“You can follow the course at your own pace. I have spent at least 2 weeks on each Stage so far, so as to fully absorb the learning at each step and really get to grips with the practical exercises.”

“I have found the pace of the course just right as you can take as much time as you wish to complete it.”

Additional links that may be of interest

Feedback/Reviews from CBT4T Users: https://www.tinnituseprogram.org/reviews.html

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (due to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

8/6/25

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Fundamentally, a return to a natural Window of Tolerance is reliant on achieving re-balance between limbic/amygdala and prefrontal cortex (PFC) activity of the Autonomic Nervous System.

Here is a diagram representation of the Nervous System, its many component parts and the Autonomic Nervous System (ANS) indicated by the red arrow:

There are strong links between tinnitus intrusiveness and loudness perception, and arousal (stress and anxiety). Arousal is the term used for Sympathetic Nervous System activity, consisting higher than normal levels of neurotransmitters (chemicals and hormones) including adrenaline and cortisol (see HPA Axis below).

How do you even BEGIN to bring about the necessary “re-balancing” when your ability to reason and think logically is inhibited?

Indeed, the harder you try to “think through what is happening to you” in an attempt to solve the predicament because you want some certainty over uncertainty, the more UN-certain, fearful, anxious and stressed you are likely to feel, and the more intrusive and loud the tinnitus is perceived to be.

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Here’s how…

There is a need to regulate what has become a dysregulated nervous system, specifically by re-regulating the Hypothalamic-Pituitary-Adrenal Axis (HPA Axis)

Regulating a dysregulated nervous system (re-balancing) has to be undertaken in stages.

Just as your Window of Tolerance didn’t suddenly shrink – your Autonomic Nervous System (ANS) via the HPA Axis didn’t suddenly become dysregulated/imbalanced. These changes have occurred over time, not suddenly, not overnight.

The Goal

Ultimately, we are aiming to free-up the prefrontal cortex (PFC) so it can return to keeping the amygdala in check, thus calming limbic activity. It is done broadly in two stages:

1. Physically activate the suppressed parasympathetic nervous system (PNS) to begin lowering hyperactivity in sympathetic nervous system (SNS). This draws the two counter-activities closer together

2. Once PNS and SNS activities draw closer together, the PFC increases its capacity for reason and logic. This renewed PFC capacity is now able to begin to redress anxiety and stress provoking automatic-negative-thoughts.

The second stage (2) is achieved through Cognitive Therapy. For now, we are focusing on (1):

How to physically activate the suppressed parasympathetic nervous system (PNS) to begin lowering hyperactivity in sympathetic nervous system (SNS)

The limbic system – including the amygdala – cannot be communicated with through talking to it! The limbic system is “non-verbal”.

Interaction with the limbic system is “communicated” at the physiological level; it is our emotional centre. When we are stressed and/or anxious, SNS activity increases. Increased SNS activity (stress/anxiety) suppresses (disengages) PNS activity (rest/digest).

Mastering your Autonomic Nervous System

The most effective way to re-engage parasympathetic activity (PNS) is through the practice of regular and consistent breathing and relaxation exercises, building up their ROUTINE use starting with “little and often”. The routine is as important as the exercises themselves, because routine = dependable, and dependable = safe.

All the detail of what the specific exercises are, how often to do them, what they do, establishing a routine - how and why - etc is laid out throughout the CBT4T programme.

Dipping a toe in to Artificial Intelligence (AI)

AI is not something I have previously “embraced”… I don’t understand it, I’ve never used it, and I freely admit, I don’t trust it!

However, I had this article in the planning, and a few days ago, the idea popped in to my mind to “test it out”. Asking a question about something I already know the answer to seemed like a good idea… I am glad I did too - see my verdict at the end!

Asking Grok

First, I used Grok – my question: “What do breathing exercises do to the human nervous system?”

Well, to say I was impressed is an understatement! Here is Grok’s answer (in italics to differentiate from my own content):

[Start Grok] “Breathing exercises influence the human nervous system by modulating the autonomic nervous system (ANS), which regulates involuntary functions like heart rate, blood pressure, and digestion. The ANS has two main branches: the sympathetic nervous system (SNS), which activates the "fight or flight" response, and the parasympathetic nervous system (PNS), which promotes "rest and digest." Breathing exercises primarily enhance PNS activity, leading to relaxation and reduced stress, while also affecting brain function and emotional regulation.

Here’s a detailed breakdown:

1. **Activation of the Parasympathetic Nervous System**:

- Slow, deep breathing (e.g., diaphragmatic or box breathing) stimulates the vagus nerve, a key PNS component. This increases acetylcholine release, slowing heart rate and reducing blood pressure.

- Studies show that controlled breathing at 6–10 breaths per minute maximizes heart rate variability (HRV), a marker of PNS dominance, promoting relaxation and resilience to stress.

2. **Reduction of Sympathetic Activity**:

- Rapid, shallow breathing can trigger SNS activation, increasing cortisol and adrenaline. Conversely, deliberate slow breathing lowers SNS activity, reducing stress hormones.

- Research indicates that techniques like alternate nostril breathing decrease sympathetic markers, such as galvanic skin response, in as little as 15 minutes.

3. **Impact on Brain Function**:

- Breathing exercises alter brainwave patterns, increasing alpha waves (associated with relaxation) and reducing beta waves (linked to alertness/stress). EEG studies show this shift during practices like mindfulness-based breathing.

- They enhance activity in the prefrontal cortex, improving emotional regulation and decision-making, while reducing amygdala activity, which drives fear and anxiety responses.

4. **Regulation of the Hypothalamic-Pituitary-Adrenal (HPA) Axis**:

- Slow breathing reduces cortisol release by calming the HPA axis, the body’s stress response system. This helps mitigate chronic stress effects like inflammation and immune suppression.

- A 2018 study found that 20 minutes of daily breathing exercises lowered cortisol levels significantly over 8 weeks.

5. **Improved Oxygenation and CO2 Balance**:

- Controlled breathing optimizes oxygen delivery and carbon dioxide expulsion, stabilizing blood pH. This reduces physiological stress signals that could activate the SNS.

- Techniques like coherent breathing align respiratory and cardiovascular rhythms, enhancing autonomic balance.

6. **Neuroplasticity and Long-Term Effects**:

- Regular practice of breathing exercises can rewire neural pathways, strengthening connections between the prefrontal cortex and limbic system. This enhances emotional resilience over time.

- Longitudinal studies suggest that consistent practice (e.g., 10–20 minutes daily for 12 weeks) increases vagal tone, improving stress recovery and mood stability.

**Practical Examples**:

- **Diaphragmatic Breathing**: Inhale deeply through the nose for 4 seconds, hold for 4, exhale for 6–8. This maximizes vagal stimulation.

- **4-7-8 Breathing**: Inhale for 4, hold for 7, exhale for 8. It rapidly reduces acute stress by boosting PNS activity.

- **Alternate Nostril Breathing**: Balances left and right brain hemispheres, reducing SNS activity and enhancing focus.

**Caveats**:

- Effects vary by individual and technique. For example, fast-paced breathing (e.g., Wim Hof method) may initially activate the SNS before inducing relaxation.

- People with respiratory or cardiovascular conditions should consult a doctor before starting.

- Overdoing certain techniques (e.g., hyperventilation) can cause dizziness or alkalosis, disrupting nervous system balance.

In summary, breathing exercises shift the nervous system toward parasympathetic dominance, reduce stress, and enhance emotional and physiological regulation. Regular practice amplifies these benefits, making them a powerful tool for nervous system health. If you want specific techniques or a demonstration, let me know!” [End Grok]

ChatGPT answer to the same question

I then went to ChatGPT and decided to include it here too: My question: “What do breathing exercises do to the human nervous system?” (ChatGPT answer in italics)

[Start ChatGPT] “Breathing exercises have a significant and well-documented impact on the human nervous system. Here's a breakdown of what they do:

1. Activate the Parasympathetic Nervous System (PNS)

• Mechanism: Slow, deep breathing—especially exhalation—stimulates the vagus nerve, which is a key part of the PNS.

• Effects:

  • Slows heart rate

  • Lowers blood pressure

  • Promotes relaxation and recovery

  • Reduces stress hormones (like cortisol)

2. Regulate the Autonomic Nervous System (ANS)

• The ANS controls involuntary functions like heart rate, digestion, and respiration.

• Breathing is unique because it's both involuntary and voluntary—this makes it a powerful tool to consciously influence autonomic function.

• Controlled breathing can shift the balance from sympathetic (fight or flight) dominance to parasympathetic (rest and digest) tone.

3. Improve Heart Rate Variability (HRV)

• HRV is a measure of the variation in time between heartbeats, and it reflects nervous system balance.

• Higher HRV is associated with better stress resilience and cardiovascular health.

• Breathing exercises (especially coherent breathing at ~5-6 breaths/min) help improve HRV.

4. Reduce Sympathetic Nervous System Overactivity

• In stressful situations, the sympathetic system ramps up—raising heart rate, tightening muscles, increasing alertness.

• Chronic overactivation is linked to anxiety, hypertension, and burnout.

• Breathing exercises help dampen this overactivity, calming the body and mind.

5. Enhance Emotional Regulation and Focus

• By calming the nervous system, breathing exercises reduce amygdala reactivity (linked to fear and anxiety).

• This leads to improved:

  • Emotional control

  • Cognitive clarity

  • Decision-making under stress

Summary Table

If you're interested, I can suggest specific breathing techniques like box breathing, 4-7-8 breathing, or resonance breathing, each with unique nervous system effects.” [End ChatGPT]

My Verdict?

AI has saved me a lot of typing for this article! I take no issue with either of the explanations - other than one thing: I err on the side of caution regarding the use of “deep breathing” - instead, I advocate using “natural” breathing, albeit still from the diaphragm i.e. diaphragmatic/abdominal breathing, as opposed to shallow clavicular breathing.

When someone is highly stressed, and they attempt breathing exercises, breathing deeply CAN induce hyperventilation that, in turn, CAN lead to a panic attack. Natural diaphragmatic/abdominal breathing used attentively still engages the PNS, and as the person gains confidence in the exercise, the breath naturally becomes deeper given time. There is a short video (YouTube) included in the course notes where I explain how to use the breathing exercise.

Additionally, anyone who has been stressed over a lengthy period of time, has high levels of tension in their body - to the point where being tense has become their “normal”. This makes using a breathing exercise more difficult for them to do than it would otherwise be. Therefore, for a high proportion of people coming to the CBT4T programme, I advise they use the 9 minute physiological relaxation exercise (instructions are in the course notes) PRIOR to two or three of the 6 x daily two-to-two and a half minute breathing exercises. They can then usually forego the physiological relaxation after 2-4 weeks of use, and fully benefit from the breathing exercise.

There are further relaxation exercises throughout the CBT4T process, including a 6 part mini-course in Autogenic Relaxation starting from Stage 6. There are also four longer (30 minute) guided relaxation recordings - originally chosen by over 100 patients I worked with while I was in the NHS; they are introduced at various stages throughout the process. I am currently planning to record a variety of relaxation exercises - varying in type and length - to add to the collection!

I admit I will continue to be wary of using AI for anything I don’t already know or understand; however, this was indeed a promising “first time”!

I’ll be interested to hear from any reader about your experiences of using AI too! Being such a newbie to it, I’ll be interested to hear from you!

And do please let me know your thoughts about this Newsletter article by commenting below. I can see from the numbers of people reading my Newsletter articles so far there are lots of you reading them.

Next Planned Newsletter Article

The next intended Newsletter concerns the importance of using CBT4T programme at a pace that suits your individual needs and responsibilities.

However, if you have additional topics to suggest, or a question burning away in your mind, let me know in the Chat.

Additional links that may be of interest

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

22/5/25

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The statement may immediately make sense to you – or maybe you hadn’t thought about it before. In either case, here are some thoughts for you to consider in relation to what brought you to the CBT4T Substack, whether you are already enrolled on the CBT4T programme as many of you are, or if you are considering enrolling, or you are a professional or support worker helping people struggling with tinnitus.

To be able to genuinely understand how and why we got to where we are, our understanding has to be explored in a dispassionate way. For pretty much everyone coming to the CBT4T programme, thinking back over the time since tinnitus first began causing a problem is going to be nigh impossible to explore “dispassionately”.

How can you reason objectively when your mind and body is doing the opposite – your mind being muddled and emotional, and your body reacting by being tense and fatigued through stress, anxiety, fear and worry? Rather than having an ability to be objective, that ability is massively reduced to a different type of reasoning – subjective reasoning. It is the process within the CBT4T programme that enables you to understand the how and the why.

Subjective “emotional reasoning” is one of the very common Cognitive Distortions we experience when we are distressed. They don’t come along one at a time – several of them invariably run concurrently: further common examples are:

• predicting the future

• minimising the positive while maximising the negative

• all or nothing thinking

• self and other blaming

….. to name just a handful of them. They come about because consciously and unconsciously, we are attempting to make sense of what is happening to us. Human beings like certainty, and feel threatened by uncertainty. The less sense we can make of what is happening, the worse we feel, and we have less ability to tolerate the situation we find ourselves in.

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Window of Tolerance

If you are living in the UK, unless you have been living under a rock recently, you have more than likely come across the term “the Overton Window” or “shifting the Overton Window”. Unlike the Overton Window that itself moves (shifts) with the tide of public opinion (commonly depicted as moving left to right or right to left), the Window of Tolerance we experience as an individual, expands and contracts.

When we feel calm, are fit and healthy in mind and body, the more expansive is our Window of Tolerance:

Diagram: National Institute for the Clinical Application of Behavioral Medicine (NICABM)

As indicated in the diagram:

“When you are in your Window of Tolerance, you feel like you can deal with whatever’s happening in your life. You might feel stress or pressure, but it doesn’t bother you too much. This is the ideal place to be.”

However, when stress and pressure increase to a point beyond your ability to feel like you can cope with what is happening in your life, your Window contracts.

The more you feel unable to cope, the more stressed and anxious (hyper-arousal) you feel, and your mood becomes suppressed leaving you feeling low and depressed (hypo-arousal)

As the Window of Tolerance contracts, the area:

• above the window (hyper-arousal - too much arousal) expands, and

• below the window (hypo-arousal - too little arousal) expands

Hyper-arousal and/or hypo-arousal significantly impacts our ability to think clearly, emanating from an imbalance of action happening in the brain.

When we are calm vs when we are stressed/anxious

• Pre-frontal cortex (PFC) – reasoning and logic

• Limbic/amygdala – threat focused/emotionally reactive

When we are calm, there is a good balance of bottom>up (limbic/amygdala > pre-frontal cortex) and top>down (pre-frontal cortex > limbic/amygdala) brain action

When we are stressed/anxious, the limbic/amygdala activity over-powers the pre-frontal cortex (PFC), significantly reducing our ability to reason and think logically

So, back to understanding the answer to the question of how you got here…

Everyone has their own individual story about their journey, likely beginning with “my tinnitus started because…” or “I don’t know what started my tinnitus”.

However, what each does have in common is:

• increased bottom>up / decreased top>down brain activity

• a reduced Window of Tolerance

Indeed, a reduced Window of Tolerance is CAUSED through increased bottom>up / decreased top>down brain activity.

The answer to the question is therefore:

1. Re-balance bottom>up / top>down brain activity to re-engage the pre-frontal cortex (PFC)

2. Expand your Window of Tolerance

How to bring about (1) is tackled from the outset and continues throughout the CBT4T programme. Re-balancing this fundamental area of brain activity begins to expand (2) the Window of Tolerance. This re-balancing frees the pre-frontal cortex (PFC) to take advantage of the brain’s natural ability to grow and strengthen new neural firing patterns through adaptive neuroplasticity.

Adaptive & Maladaptive Neuroplasticity

You may well have heard of “brain plasticity” (the colloquial term for neuroplasticity). When we are stressed, anxious, depressed, struggling in life, brain plasticity hasn’t stopped!

Earlier in this article, I mentioned Cognitive Distortions, and how “They come about because consciously and unconsciously, we are attempting to make sense of what is happening to us.”

As we strive to make sense of what is happening to us, but struggle to do so due to feeling emotional – scared, worried, frustrated, angry etc., brain plasticity is on-going.

Billions of neurons continue firing, forming millions of inter-connections throughout the entire brain and nervous system. What we think, what we come to believe and what we feel is reflected in those patterns of firing neurons, making it predictable that we will continue to feel – and think – the same over and over again.

Brain plasticity is always at work, but when we are going through difficult times in life, rather than being adaptive plasticity, this is maladaptive brain plasticity. You may have read an earlier article in the CBT4T Substack: “Two Arrows”, explaining how it is the second and subsequent arrows that cause “suffering”. Suffering is maladaptation in a small, contracted Window of Tolerance at work!

Expanding the Window of Tolerance

The goal is to return to your natural Window of Tolerance where:

“… you feel like you can deal with whatever’s happening in your life. You might feel stress or pressure, but it doesn’t bother you too much. This is the ideal place to be.”

When you have already made a great start by improving the balance of top>down and bottom>up brain action, you are able to change the way brain plasticity is functioning – away from being maladaptive (problem-oriented and unhelpful) towards being adaptive (recovery-oriented and helpful).

In Summary

How and why did we get here in the first place?

• By attempting to make sense of what was happening

• Trying to counter uncertainty with certainty

• Thinking became more subjective than objective

• Increased bottom>up / decreased top>down brain activity

• Brain plasticity became maladaptive

• Window of Tolerance became smaller

To understand ‘how and why we got here in the first place’, enables us to see there are clearly explainable reasons for it.

More than that, is the realisation that so much of what’s changed for us “because something happened” – usually something that was beyond our control anyway – is not insurmountable as we believed it to be.

Knowing it is in our purview to change what we previously believed to be unchangeable, provides us with the means to a better, healthier future.

Some additional links that may be of interest

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists and Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

13/5/25

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Of course, the one we are discussing here – cognitive behaviour therapy (CBT) - is one of the most widely recognised by name by the public at large, and one of the most commonly used psychotherapies in the last 20+ plus years. In the UK, CBT became widely heard about by the public in general probably because of its widespread adoption within the NHS. And there are literally thousands of books about CBT – including self-help books but also tomes for professional therapists – that are available. I haven’t counted the number of CBT books that are in my personal library, but at a guess, I must have in the region of at least 50-60 of them purchased over the past 20 years or so!

Why therapy anyway – be it CBT or other type?

Something I’d really like to briefly address before I discuss anything more about CBT here, is the idea that a psychological therapy was proposed to be helpful for tinnitus in the first place!

Definition of tinnitus (Tinnitus UK):

“[Tinnitus] is the sensation of hearing a sound when there is no external source for that sound. Someone with tinnitus may hear ringing, buzzing, hissing, whistling or other noises. Tinnitus can be there all the time or come and go. The volume of someone’s tinnitus can vary from one episode to the next.”

So, having tinnitus is a physical experience – no different to any other physical experience, from having a headache to having a broken leg.

However, what can and does happen for so many people (around 15% of the 1 in 7 people that “have tinnitus”), is they become overwhelmed by the experience of tinnitus to a point of being really distressed by it.

Were a person become overwhelmed by a headache – there’s an antidote: they can take analgesics that at least gives them some respite from the headache, or may get rid of the headache altogether. It’s similar with a broken leg – extreme pain yes, but painkiller medications help, plus eventually, the broken leg heals.

There is no such antidote to very distressing tinnitus; there is no antidote to tinnitus (that in itself is a huge cause of frustration for many); however, there IS an “antidote to the distress reaction” by learning to replace the distress reaction to tinnitus with a neutral reaction to tinnitus.

Not all “CBT” is the same

Anyone not in the psychotherapy field can be forgiven for assuming that “CBT is CBT”; that all CBT therapists use the same practices as each other, so when choosing a therapist to work with, the only difference would be whether or not you feel comfortable with the individual therapist.

In fact, “CBT” has become an umbrella term for many different forms of psychological therapies, and each of those different types of therapy that fall within the CBT umbrella are specialities in and of themselves, where therapists specialise in one or more of the Cognitive Behavioural therapies.

So, in fact, ALL CBT IS NOT THE SAME, and most certainly, every CBT therapist does not work in the same way, using the same “tools” as every other CBT therapist, for every different issue that every different person undertaking therapy is seeking help to address. There is a wide range of cognitive behavioural therapies, and therapists train extensively in their particular area of specialism and interest. The clinical areas that are well covered in the formal training of CBT therapists are those that present the most widely across the population, so these are predominantly depression and the multiple types and forms of anxiety.

What this ultimately means for patients is they can look for and usually find a suitable therapist to help them if they need help for depression or anxiety.

Unfortunately, this is not the case when you are a patient seeking help for distressing tinnitus!

A couple of baffling examples

Over the years, I have worked with many thousands of patients who have found themselves in the dire situation of experiencing tinnitus that causes them significant distress. Some of them have done some research, learned that CBT is the recommended treatment, have looked in their locality for a CBT therapist, started working with the therapist, only to discover that their tinnitus doesn’t improve, and in numerous if not most cases, felt worse than they did before they began what they believed to be “CBT”!

By the time they find me, their understandable opinion is that “CBT doesn’t work for me”.

When this happens – and it continues to happen on occasion unfortunately – I always ask them the same question: “Can you describe to me what the therapist has been asking you to do?”

It has been happening for years – I have been a Hearing Therapist working with tinnitus patients for 30 years, and specialised using CBT for tinnitus distress since I qualified in psychotherapy in 2005. Their descriptions have never ceased to astound, and even shock me!

Example 1: A recent example from someone enrolled in CBT4T is in a lady’s Mini-history who’s CBT therapist (apparently a specialist in OCD) advised her - and I quote:

“I was given advice to try and go towards the head sensations (tinnitus and head pressure) and make them worse as an exposure to not be worried by it. I was told not to try and relax, to do things like spinning in a chair to make them worse etc.”

This was probably one of the most shocking examples I have ever heard of!

And although example 2 might be less worrying overall, I have always failed to see the point of it:

Example 2: However, here is a much more common example I have seen so many times over the years. A patient with distressing tinnitus has gone to a CBT therapist who tells them to visit their local supermarket several times per week, instructing them to stay there longer on each visit, no matter how loud/intrusive the tinnitus becomes.

This second example I find baffling and yet I have had multiple patients report to me they have been instructed to do it. It is another example of “Exposure Therapy” – but the commonly used “supermarket” (a busy place with lots of people) exercise used supposedly to help with social anxiety.

What is profoundly obvious from these examples – and others that I have been told of over the years – is there are CBT therapists working at best ineffectively for patients with distressing tinnitus.

A quick internet search: “Will CBT work for me”

I haven’t spent hours researching this, but very near the top of the search came: https://www.psychologytoday.com/us/blog/true-self-empowerment/202301/why-cbt-might-not-be-working-for-you

It gives a clear outline of what “CBT” is intended to do, and its limitations.

The “Will CBT work for me” question and how I can best answer that question in relation to CBT4T

If you are a human being born on the planet Earth – this ensures your physiology is the same as any other human being – and you follow the CBT4T process, yes it will work for you! All you need to do is follow the process. Oh yes – and the course is currently only available in English! People from all walks of life have used the programme, so you don’t need a doctorate in philosophy either!

There is plenty of Users’ Feedback on the website – including their quantitative clinical Outcomes.

The process employed in CBT4T has been specifically developed (by Debbie Featherstone) for people with tinnitus who are highly distressed by it. So, the process within CBT4T has not been copied from elsewhere. There is one piece of work included in the CBT part of the CBT4T process that is the work of another therapist, and that is the Core Belief work in the latter stages (Element 3) of the CBT4T process, where Christine Padesky’s Core Belief work is included and referenced in full.

Even more significantly, the CBT4T process is NOT LIMITED TO CBT. The process is informed by and from 30+ years of Hearing Therapy and Psychotherapy clinical practice:

1. Knowledge and understanding of tinnitus and hearing

2. Relevant areas of neuroscience: neurobiology, neurochemistry, neuroplasticity

3. Polyvagal theory including the Autonomic Ladder

4. Consciousness studies

These four are in addition to the bespoke CBT, carefully combined and woven in to a Four Part (Four Elements) multiple staged process to be used by each individual AT A PACE that suits their own individual needs and requirements.

CBT4T is not an academic exercise where as long as you read each section, you’ll “get it” and as if by magic, changes come about! Were there to be such a means of changing human physiology including neurophysiology, I’m sure it would be great, and we’d all welcome it!

Like the rest of CBT4T, the practical “doing” aspects of the process are woven in to and throughout the process. And practices begin at Element 1: Stage 1. The easiest way of describing this is for you to go to the CBT4T Supplement. Where you are already enrolled on the course, you will already be familiar with the breath work and physiological relaxation practices, building a new daily routine of activities from the outset including the logs.

Some additional links that may be of interest

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists, Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

The process in CBT4T consists of FOUR elements that reflect the Stages of Change:

• Element 1: Preparation (Build strong foundations)

• Element 2: Moving forward (Action: Making Changes)

• Element 3: Meaning & Belief (Action: Meaning & Beliefs)

• Element 4: Consolidation & Completion (Maintaining changes)

I intend to cover Element 1 in future articles. It is, after all, foundational to all that is built upon it.

However, the first “Cognition tool” used in the CBT4T process is the Two Arrows exercise (Element 2: Stage 4B Section “Cognitive Fusion 2”). I have chosen to include it as an early CBT4T Substack post for three main reasons:

1. The Two Arrows exercise is frequently described by those using the CBT4T programme as having “a lightbulb effect”

2. The Two Arrows concept also lends itself well to those “suffering” with tinnitus due to the wide use of the word within the tinnitus community, for example: “tinnitus sufferer”, “suffering from tinnitus”

3. How we experience an event (our emotional response) is “Second Arrow”; only the event itself is “First Arrow”. The First Arrow is rarely a choice, because it is an experience that happens to us. Second and subsequent arrows, however, are LEARNED RESPONSES that we can TRAIN OURSELVES TO CHANGE

There are three types of response we can have to an event

• Pleasant

• Unpleasant

• Neutral

Two Arrows Explained

The Two Arrows teaching purportedly comes from the teachings of Buddha some two thousand years ago, where the First Arrow (the event) is pain; the Second Arrow (unpleasant response) and subsequent unpleasant “arrows” is suffering.

Watch and listen to the following YouTube video that explains it well:

Distress Tolerance & Pain Without Suffering

After watching the video

You can write about and send in an example of a recent experience that you now realise may have led to “Second Arrow” suffering. Your example can be related to tinnitus, but it can be any recent experience that caused you to feel ‘unpleasant’ emotions (2nd and subsequent arrows).

Two Arrows Practice Exercise (Click the link to go to the exercise in the CBT4T website)

Note: After you press Send, you should receive a copy of what you have sent by return email. Please check your Spam email if it doesn't arrive in your inbox.

A Note for CBT4T Users already enrolled*

*You may be beyond this stage in the CBT4T course! If so, perhaps you would leave a comment below this article about the Two Arrows exercise - for example, what help did it give you when you were in Stage 4; what has its impact been since continuing to later stages in the CBT4T process? REAL EXPERIENCES are important - thank you!

Some additional links that may be of interest

CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

To view CBT for Tinnitus Distress for Audiologists, Hearing Therapists https://courses.tinnituseprogram.org/cbt-for-tinnitus-distress

To view CBT for Tinnitus for Advisors & Support Workers (soon to be updated) https://courses.tinnituseprogram.org/tinnitus-advisors

After two, or maybe three months’ experience of Substack, I began thinking that maybe I could start a Substack too?

Emergence of Procrastination > Sabotage

There followed a period of several weeks spent procrastinating, doing my UNCONSCIOUS best to sabotage the idea altogether. Self-sabotage is not a deliberate or conscious act that we are aware of at the time. Reading excellent Substacks by others was certainly one thing that reinforced my self-sabotage – pondering how good they were, how well they were written and how I couldn’t possibly “come up to the mark”, all contributed to a wariness of trying to start my own Substack.

Of course, I had self-sabotaged before! Recently too!

Something else I managed to self-sabotage was the planning and preparation of CBT4T 2025 – a fifth “life” of the CBT for Tinnitus E-Programme, and something that was particularly important to me.

Although the previous versions had proven successful for those using them, I was aware there were still improvements that I could make. But each time I sat at my desk to work on those improvements, I confused myself – most frequently because of “over-thinking” what I wanted to do. It would have been around mid-October 2024 when I first decided it was time to make some changes….

I completed and published CBT4T 2025 around a week before Christmas!

And, of course, I used Christmas and the New Year period procrastinating, leading to further delay starting the Substack…

Realisation

It was mid-January, following an appointment with one of my patients enrolled on the CBT4T programme, that the “procrastination-penny” dropped! We had been discussing issues she was experiencing that, as an outside observer, I could clearly see was self-sabotage behaviour.

Just to reiterate and be very clear here, self-sabotage is not a conscious, purposeful act. It’s something called “a defence mechanism” that is created subconsciously.

It isn’t as though self-sabotage is a rare thing; on the contrary, it’s really common, and a discussion I frequently have with patients.

The “Hack”

You know how sometimes we hear or see something “at just the right time”?

Just a couple of days following the discussion with the lady about her self-sabotage, I was participating in an online conversation with a group of people (from one of the Substack groups I belong to in fact!), and of all things, the topic of procrastination came up. One of them started talking about what he referred to as a hack he used when he found himself putting off doing something he knew he had to do – even wanted to do (or sometimes didn’t want to do!).

The hack is…. tell yourself you can “Do it badly”.

I could see the benefit of using this straightaway! It was just the gift I needed at that particular time, and I have indeed made a start on my new Substack!

It has taken a while (and many hours) to fathom all the settings needed to create this Substack; however, it was “the hack” that helped me to start!

Giving myself permission to “do it badly” was enough to help me make a start, and here I am, paying “the hack” forward!

Giving myself permission to “get things wrong” cancelled out any need for a defence mechanism. I could delete what I’d written if it was so bad, I could change what I’d written if I didn’t like it after I’d written it. It wouldn’t be the end of the world, and once I was happy with the article, I could publish it on Substack. In fact, I learned after publishing my first post earlier today - only to discover I had made an error with one of the images that looked an absolute eyesore (I’d used the wrong size) – I was able to un-publish the post, make the necessary correction, and republish.

All is good with the world! Disaster avoided!

I have used “the hack” several times over since learning about it. Such a simple “permission to do it badly” helps you to start something. So many of us have an over-developed perfectionist streak. Perfectionism is frequently behind procrastination, and thus behind both not starting and not finishing something!

Next time you find yourself putting off doing something that you know needs to be done, give yourself permission to “do it badly”.

You won’t do it badly at all – but you will make that much needed start (or finish!)

I see others do the same time and again. For example….

Self-sabotage frequently manifests as procrastination as I have described above for me!

I also see it frequently before someone enrols on the CBT4T programme.

It’s not unusual for someone to contact me about help – usually by email or through sending in their Tinnitus Functional Index (TFI) – and I then hear nothing more from them for several weeks and even months in some cases.

In some of these cases, they have spent the intervening weeks/months putting off enrolling. In other cases, I have seen people enrol on the course, not start it, and then weeks or months later, email to ask if they can still start the course (which of course, they can).

There can be many reasons for this; however, here are the TWO most common ones:

Thinking thoughts such as:

• What if I can’t do it?

• What if I’m the exception to everybody else and it doesn’t help?

I recognise “what if’s” in myself all too well. Being a psychotherapist doesn’t prevent me from procrastinating!

So, the next time you find yourself “putting off doing something you want to do” – use “the hack”!

And if you do use “the hack”?

Do leave a comment to let us know how you got on!

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CBT4T Substack - The Basics

Just a short post to start with, to give you an overview of the CBT4T Substack

1. Why I started this Substack

In recent years, a number of people including psychotherapy colleagues with an interest in tinnitus - some having tinnitus themselves and have used the CBT4T programme for themselves - here’s a great example, hearing therapists, audiologists and indeed, numerous patients and users of the CBT4T programme, have asked:

“When are you going to write a book about this?”

My answer is always the same: “As soon as it’s published, it will be out of date!”

Just as I do with the CBT4T programme itself, the great thing about running a Substack is I can keep everything up-to-date!

2. Who is CBT4T Substack for?

• For you if you are considering CBT4T enrolment yourself

• For you if you have a professional, helping, supporting or advising role with people with troublesome tinnitus

• Even for you if you are already enrolled on CBT4T

3. What’s included in CBT4T Substack?

A mix of content including (though not limited to):

• CBT4T back-stories - some common, some less common - real experiences of “what changed” for CBT4T programme Users

• Why having some understanding of neuroscience (particularly brain plasticity), trauma, polyvagal theory, and elements of consciousness studies integrated in to the CBT4T programme process significantly impacts the effectiveness for users of the programme

• Answers to commonly asked questions – some you might have thought about, some you might not!

As time progresses, I expect to be covering many aspects of the component parts of the bespoke CBT4T programme process.

4. Become a CBT4T Substack Subscriber

Subscription to this Substack is free. As a Subscriber, new content uploaded to the Substack will also arrive in your email Inbox. The CBT4T Substack is for anyone with an interest in understanding more about how the bespoke CBT in the CBT4T programme, elements of neuroscience (particularly that related to brain plasticity), consciousness studies, trauma and polyvagal theory that all contribute to the CBT4T programme helps people change how they deal with tinnitus.

As well as there being plenty of room for your comments on published posts/articles that are available in your Substack Inbox, there is also “Chat” that some Substacks make use of, and others don’t. A popular way of using the Substack Chat is for topic suggestions, and I encourage you to use the Chat to suggest ideas for new editorial content.

5. Where to find the CBT4T course

• The CBT4T programme/course site: https://courses.tinnituseprogram.org

• CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

• Course content is the same for each enrolment. Introduction sections are previewable

6. Some helpful links

• CBT4T Enrolment: https://courses.tinnituseprogram.org/cbt4t-enrolments

• Feedback/Reviews from CBT4T users www.tinnituseprogram.org/reviews.html

• Case Study www.tinnituseprogram.org/case-study.html

• Information website www.tinnituseprogram.org

7. The best thing you can do before enrolling?

Complete your Tinnitus Functional Index (TFI):

• www.tinnituseprogram.org/tfi.html

8. Links if you have a professional, helping, supporting or advising role with people with troublesome tinnitus

• Audiologists & Hearing Therapists: CBT for Tinnitus Distress

• Tinnitus support/advising role: CBT for Tinnitus E-Programme for Advisors

9. Brief History of CBT4T

CBT4T began its online life in 2009 as the Tinnitus E-Programme:

• 2009-2018 Tinnitus E-Programme: Internet-based, self-directed 6 module programme of tinnitus management. Suitable for up to mid-moderate tinnitus distress (Tinnitus Handicap Inventory/THI category 3: 38-56%)

• 2018-July 2020 Tinnitus E-Programme: Internet-based, therapist-supported 6 module programme of tinnitus management. Suitable for up to mid-moderate tinnitus distress (TFI/THI category 3)

• July 2020-present CBT for Tinnitus E-Programme – became CBT4T in 2024: Internet-based, therapist-supported comprehensive staged-programme using Cognitive Behaviour Therapy, specially developed for those with a Tinnitus Functional Index (TFI) category 5 (73-100%) and category 4 (54-72%). Also suitable for those with a TFI mid-max category 3. Full range of TFI category 3: 32-53%

The current 2026 programme is the 6th version, the programme having been updated/revised annually. The most recent version is CBT4T Online

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