Where are there differences between CBT4T and CBT for Anxiety
Be aware that CBT is far from being a set procedure, using the same “tools” to procure behaviour change through challenging negative automatic thoughts (NATs). When potential psychologists and psychotherapists are initially introduced to CBT as students, it can seem that way – but just as when learning other disciplines, what is taught at the beginning is just the tip of an iceberg. It is so much more interesting as your understanding deepens over the years. As students learning the CBT ropes as it were, they are taught enough to be able to work with a few hand-picked clients/patients but always under the direct supervision of a long experienced psychologist/psychotherapist. Their training is not only the 4-6 years spent at university to qualify, but they are also still working under close supervision and regulated by one of the psychology or psychotherapy professional bodies depending on the training route they have taken.
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.
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!
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