Pacing CBT4T

Pacing is at the core of the CBT4T process

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 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

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

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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

To view the CBT4T full programme Outline - you can enrol here too: https://courses.tinnituseprogram.org/cbt4t-2025

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