Mindfulness Based Tinnitus Stress Reduction: Tinnitus, Brain Functioning, and Mindfulness

 

Hello everyone, and thank you very much for joining us today. My name is Brooke Townsend, and I am the content development audiologist at ReSound, and I am very pleased to introduce our guest speaker for today, Dr. Jennifer Gans.

Dr. Gans is a clinical psychologist in San Francisco, and she specializes in the psychological impact of deafness and hearing on well-being. She is also the CEO and founder of MindfulTinnitusRelief.com, which is an eight-week self-administered skill-building course, and it's to learn how to live comfortably with tinnitus.

Today, Dr. Gans will be providing us information regarding mindfulness and how it can be used to help our patients suffering from tinnitus.

And I just need to go over the objectives for today, and then we'll let her get started.

So, after this course, you will be able to explain how to evaluate research to date on mindfulness as a management tool for tinnitus. You will also be able to describe Mindfulness-Based Tinnitus Stress Reduction and the components of the eight-week course and the online version, MindfulTinnitusRelief.com. And you will be able to describe what is happening in the brain of a person experiencing bothersome tinnitus.

So, Dr. Gans, welcome.

Good morning to all of you people here on the West Coast. I'm calling in from San Francisco, and good afternoon to everybody on the East Coast and all of the times in between.

So I'm really pleased to be here, and the topic that we're going to be talking about today is kind of new in the field—relatively new. It's Mindfulness-Based Tinnitus Stress Reduction, a program that I've designed, and I wanted to talk a little bit about kind of the backbone of the course, but from a tinnitus brain functioning and mindfulness perspective.

So, let us get started here.

And Brooke, thank you so much for your introduction. I think that pretty much says it all.

Just a quick disclosure: I have no commercial or financial relationship with ReSound, but we kind of joined a partnership for this talk with ReSound just in good faith, to expand everyone's knowledge about this topic. And I very much appreciate ReSound and our ability to develop such a good partnership.

The content of today's talk is really the property of mine.

So let's dig into the important stuff.

So, goals for today's talk, just to kind of frame where we're going to be heading:

I'm going to do a very, very brief tinnitus review. I don't have a great sense—there's quite a few people that have called in for this webinar—I don't have a great sense of where people's knowledge is about tinnitus, but I'm going to make some assumptions that if you're calling in about this, that you've kind of gotten your feet wet with tinnitus.

So I'm not going to spend too much time with the review of tinnitus. But then we're going to talk about what is happening inside the tinnitus brain—or let me put it this way: what we think is happening inside the tinnitus brain.

Then I'm going to demystify meditation and mindfulness. I'm guessing, again, it's hard because I don't see you all in person and I can't necessarily ask for a raise of hands for who has had some experience with meditation and mindfulness. But I want to really give us even some experiential education into what meditation even is.

You know, it's a very—it's a sometimes misunderstood word. And so maybe through today's talk we'll be able to give you a good experience with what meditation really is.

So then we're going to talk about how meditation and mindfulness are tools to change the tinnitus brain, and MBTS, which is the acronym for Mindfulness-Based Tinnitus Stress Reduction. We're going to look at the research and we're going to look at some of the findings.

And then we're going to look at the next step in my career goals: the development of MindfulTinnitusRelief.com, which is basically the Mindfulness-Based Tinnitus Stress Reduction course flipped into an online version.

So then we're going to look a bit inside the course and, most importantly, how audiologists can lead and start to really branch out and be providing MBTS courses and information in their own practices.

So let's really get started here.

Tinnitus Reviewed
Now, just again, I think everybody knows somebody or is somebody with tinnitus. I mean, it's hard to—you know, it's hard to avoid it. And certainly all of us in the hearing-related fields, you know, it can be a daily occurrence that we talk with people with tinnitus.

So the stats are that about 50 million Americans experience tinnitus.

Now, that's quite a huge number, but let's make a real distinction here. I really see tinnitus as really falling into one of two categories. There's the people who are bothered by tinnitus, but they're also the people that are not bothered by tinnitus.

And so today's—you know, the 50 million really encompasses all of those people. And what we're really concerned with, and the people that we see in our practices, are the ones that are bothered by tinnitus.

And so here we have this stat that 33 million are not bothered by their tinnitus. 15 to 16 million of the 50 million have a problem enough with their tinnitus that they actually will go to their doctor, will go to their audiologist, we'll go to some professional to say, "Hey, wait a minute. This tinnitus is bothering me. What's going on here?"

And then we have about two to three million Americans—just Americans—that are really debilitated by their tinnitus.

And those are people that are really needing some help. Oftentimes they've tried just about everything, and very little has given them relief.

And so let's—this slide I find really, really interesting.

Again, Brooke, thank you again for your introduction. I am a psychologist, and so many people are like, "Oh, wait a minute. You know, here we're talking about tinnitus. Why would a psychologist be interested in tinnitus?"

And I think this slide pretty much kind of sheds light on why I'd be interested in tinnitus.

So over the years, you know, we've done some looking into the psychoacoustics—the psychoacoustic properties of tinnitus. And it's very interesting because we have these two groups, really: the people who are not bothered by their tinnitus and then the people who are bothered by their tinnitus, in the red and the greenish color here, the ones that are actually bothered by their tinnitus.

And it would stand to reason, you know, to most of us probably, that if you're not bothered by tinnitus, well then your tinnitus must not be very loud, or be perceived as very loud.

And then if you are bothered by your tinnitus, well, gee, you know, the severity of your tinnitus probably is connected to the sound level of the tinnitus sensation.

Well, that's actually not the case.

You know what we're seeing here, if I can use a couple arrows, is that the people who are not bothered by tinnitus, you know, 2 to 20 decibels is about where they say that their tinnitus falls into.

Then we have the ones with the significant problem, the ones who are bothered enough to go to their doctor and say, "Hey, what's this?" But again, we have 2 to 20 dB.

And then here we have, in the third category, the ones who are severely bothered by their tinnitus. Lo and behold, their tinnitus is measured from 2 to 20 dB.

Now, what this tells me is that it's not about the damage or the problems that are going on with hearing functioning. That's really what determines the bother of tinnitus.

And perhaps it's really not even about the ears, and it's more about what's between the ears. Perhaps it's about what's happening in the brain.

And so again, you know, I'm kind of looking for the questions that are raised here. And the fact that, depending pretty much on average—again, on average—we're having similar decibel levels for the tinnitus really points to it's more about what's happening inside the brain.

And so that's really what I want to touch on a little bit today.

All right, some facts about tinnitus, just to kind of wrap up our information on tinnitus being reviewed, and some things that will come into play throughout the rest of this talk.

It's, you know, anybody that's worked with somebody with tinnitus is probably very much aware of this, but the top four complaints of tinnitus are depression, anxiety, sleep difficulty, and concentration problems.

So maybe it's not about so much the tinnitus sensation itself, but the depression, the anxiety, the sleep difficulty, and the concentration problems that kind of wrap tinnitus into a ball of frustration and discomfort and bother.

And then something else that I've certainly observed in my practice, and you know, something you can certainly read about in the research, and again, something I'm sure you've all had contact with, is that really, you know, we don't know everything about tinnitus, but we do know one thing:

Stress increases tinnitus bother. Relaxation decreases tinnitus bother.

So that's a pretty important fact that we'll be taking more into account as we go through this talk.

And so, you know, for most tinnitus, you know, unless there's an MRI that's taken place and there's an acoustic neuroma or a brain tumor on the acoustic nerve, for most tinnitus is really a benign, albeit very unpleasant, body sensation.

So let's move along here.

The Tinnitus Gordian Knot
So what I think is happening with tinnitus is that, you know, you have this benign, albeit very frustrating, body sensation.

But I wonder if it's really about the tinnitus and the body and the body sensation of tinnitus, or the brain sensation of tinnitus, or is it about the emotions, the memories, the thoughts, the feelings, the beliefs, the perspectives—really the stories about the tinnitus—that are the true problem for people with tinnitus?

Okay, and I call this the Gordian knot, actually.

At the end, I believe there's a slide that points to an article that I've recently written for the Hearing Review that talks about this tinnitus Gordian knot.

You know, I see people coming into my practice just wrapped up. The tinnitus is definitely there, but what I'm seeing is their brain—there's just a loss of integration. There's just so much weight put on the emotions, the stories that we create about the tinnitus, that are really wrapping people up into problems, which I think are perhaps the reason why depression, anxiety, sleep difficulty, and these concentration problems are really plaguing people with bothersome tinnitus.

And so, as a clinical psychologist, you know, I'm interested in—I think we all are—but helping our people with their quality of life, you know, as a general statement.

And so, you know, I found that we have these experiences that happen in life and we react to them. We react in a very habitual way.

Like, for example, if you—I don't know if you've experienced this with your clients—but some of my clients, or pretty much most of my clients, will always check for their tinnitus in the morning.

You know, they'll wake up, they'll check to see if their tinnitus is there or not there.

And so when you wake up, you check and you see that your tinnitus is there, all of a sudden a cascade of stories:

"Oh God, I might as well not even get out of bed. This tinnitus is going to make it impossible for me to focus at work."

Or, "Oh God, there's that tinnitus again. You know, this is all my fault. This is from all the years of loud music that I listened to."

Or, "You know, what is this going to mean for my future? What is this going to mean when I'm older? Does this mean that I'm going to lose my hearing? Does this mean that my tinnitus is going to get worse?"

You know, so a person can wake up in the morning, recognize their tinnitus, and all of a sudden their immediate body reaction is to kind of get into that Gordian knot, that ball of frustration.

And so I think that Viktor Frankl—he was actually a Holocaust survivor who then became a psychiatrist, who then wrote a very interesting book, some of you might have read, called Man's Search for Meaning—he was quoted as having said:

"Between every stimulus and response is a space, and within that space lies our freedom and our choice."

So let me say that again:

"Between every stimulus and response is a space, and within that space lies our freedom and our choice."

And people with bothersome tinnitus don't feel like they have freedom and choice. They are locked into this grip, this tight grip around their tinnitus, where life doesn't feel very open. Life doesn't feel like there's choice and freedom.

And so how do we take the stimulus—it may, you know, in this case it would be the tinnitus—and our reaction to the tinnitus, and create a little bit of space there so that we might be able to breathe a little easier and start to give ourselves some time even to choose a new way of relating to tinnitus?

And so, you know, this quote really does say it all for where I think that mindfulness is very, very helpful.

Demystifying Mindfulness and Meditation
So let's get into demystifying mindfulness and meditation.

Again, you know, for all I know, I can see the list of all of you out there. For all I know, you've all been meditating and had experience with mindfulness for the last, you know, 30 years, if you're lucky.

But for those who haven't, I want to take a few moments to demystify mindfulness and meditation.

And one thing that I want to say to start is that meditation, you know, the word meditation has been on the cover of Time magazine and everything. And it's really mindfulness—I hear it, you know, several times a day, especially living here in San Francisco, which feels like the mindfulness Mecca out here.

But still, these are pretty—you know, these are kind of new terms in our culture right now.

Meditation, to many, kind of throws us back to sitting in a cave and, you know, in a lotus posture and sitting and meditating all day.

But I really want to take the "meditation" out of meditation. I want to really break it down so that it can make sense to us that meditation and mindfulness is really about awareness building.

Because let me go back to this slide here, and that, you know, the question is: How do we create that space to give us that freedom and our choice between the stimulus and response?

And my experience and my belief is that awareness—when we become aware of something, we can then start to make some good choices for a healthy future.

So what I see meditation as is a meditation is an awareness-building exercise.

I see some clients where I won't even use the word meditation. I might use the word awareness building instead.

You know, kind of in the same way that we go to the gym to build that bicep muscle, you know, we'll lift up a barbell and we'll pump iron, so to speak, to build a muscle.

What we're doing with a meditation practice is we're really pumping up—and we're going to talk about which parts of the brain we're pumping up—but really strengthening our awareness, building our attention, where we place our purposeful attention.

And that's something that I think the person with tinnitus is really struggling with.

There's a lack of integration in their brain where all of a sudden we have a million and one body sensations at any given moment, but for whatever reason the focus is on that tinnitus to the exclusion of all else that's happening.

So again, a meditation and mindfulness practice helps us to what's called meta-awareness, basically be able to step outside of ourselves and look in and start to say, "Wait a minute. Let me pause for a moment and start to maybe choose to put my attention where I want it to go."

Okay, so let's go to the definition of mindfulness.

It's tough—in a few written words or in a sentence or two, it's very hard to define mindfulness. But I think that Jon Kabat-Zinn, who really was the founder of a mindfulness-based stress reduction program back in the '70s at UMass Medical Center in Boston, I think that he really has done a very, very good job of bringing this concept of mindfulness to us.

So let me just throw out a definition that he's given.

So mindfulness is paying special attention.

Okay, I'm going to pause on that word, "special attention," because it's not just any attention. It's a special kind of attention.

So mindfulness is paying special attention on purpose, in the present, without judgments. And I've added actually in the words, "without clinging to judgments," because, you know, I'm not a big believer in asking somebody to do something that they're not going to be able to do.

And I think that we humans, we're judging creatures. Our minds are going to judge.

And so the slight difference here is that without clinging to judgments means that, you know, we allow the mind to judge because minds are going to judge anyway, but the choice we have is that we don't have to cling to those judgments.

So just to bring it all together, Jon Kabat-Zinn has defined mindfulness as paying special attention on purpose, in the present, without clinging to judgments, to the unfolding of experience moment by moment.

Okay, all right.

So I want to pause here again, and I want to talk about being with and approaching our experience through mindfulness.

Now, we had mentioned before that mindfulness is a special kind of awareness, a special kind of attention.

It's not your average attention where, "Oh, you know, you're—I don't know—you're walking down the street and you're aware of a criticism that you have of some person walking by," or something like that.

It's a special kind of awareness. It's an awareness that has curiosity.

Curiosity meaning you're approaching each moment as though you've never, ever seen a moment like this before.

And in that moment, it could be a tinnitus sensation. While you're experiencing that tinnitus body sensation at that moment with curiosity, you're—it’s a special kind of awareness with an openness to whatever comes in.

Because you know something? The present moment is the only moment that we ever really have. And so we might as well show up for it, and let's be open to whatever this moment has brought.

It's also an acceptance—a special kind of awareness that has an acceptance to it. That, you know what? This is the moment I have.

And compassion. An awareness with compassion.

And another, I guess you could call it a side effect—I call it a side effect of a mindfulness practice—is that it's a process of learning how to become your own best friend.

Okay?

So not only is it helping you to reintegrate the areas of the brain that might be the problem, or that a person with tinnitus is struggling with, but it also is an opportunity to really become our own best friends, listening closely to the dialogue that we have with ourselves and being our own best friends.

Okay, so what's happening inside?

We're just going to give you a bit of a flavor of what's happening inside the person who is meditating.

And then we're going to do a short exercise, which may or may not be hard through a webinar, but I'm going to give it a shot anyway, because it's what I do with my groups when I'm working with them in person.

We're just going to do a quick—I'm not even saying it's going to be five minutes—but a short breathing exercise so that you can have an actual experience of what mindfulness and what meditating really is like.

So I'm going to just go through what might—what is happening inside the brain of the meditator so that when we go into the exercise, you have a framework for how it's going to run.

We start with an awareness on the breath.

Now, there's nothing particularly special about the breath other than the breath is very special. But we focus on the breath because it's a body sensation that everybody has that we can control to some degree.

We can take a deep breath. We can take a shallow breath.

It's, again, something that's with all of us. And also, unless you're having some kind of pulmonary issues, usually the breath doesn't hold a lot of emotional pull, a lot of emotional significance.

So it basically can serve as an anchor for our awareness.

Okay, so let's just choose the breath as the focus.

So when we're focusing on the breath here, our minds have shifted to the body sensation of the breath, and then—boom—our mind wanders off.

Okay, so it's funny. All minds wander, just like I said. All, you know, minds are designed to judge. Minds are designed to also wander.

But when the mind leaves the breath, we note that the mind has left the breath.

We bring awareness to the fact that, "Oh, my mind has gone away from the breath and has gone to a thought. It has gone to another emotion. It's gone to, you know, an idea about the grocery list that we need to get after work today," what have you.

But we note that the mind has left the breath. We note where the mind has gone, but then we let it go, and we gently and with compassion bring our awareness right back to the breath.

And then we focus on the breath, focus on the breath, and then—boom—the mind pops off.

But then we note where the mind has gone, we let it go, and then we come back.

That's simple. It's really as simple as meditating really is.

But it's very simple, but not easy.

And so let's have an experience with a just a very brief mindfulness meditating exercise.

And let's see if you can really watch the mind, watch the mind focusing on the breath, and then noting when the mind should leave the breath, letting go—the thought, the emotion, the whatever comes to mind—letting it go, and then bringing your awareness right back to the breath.

And through that exercise, much like going to the gym and building, you know, the repetition of building that bicep using a heavy weight, we use the wandering of the mind to build certain areas of our brain.

Mindfulness Breathing Exercise
All right, and so for all of you who are listening to this webinar, here's an opportunity for us to sit back in our chair, or wherever we are, sitting back into a very comfortable position.

And closing your eyes, if you feel comfortable doing that.

And right now I'm just going to bring us through a short breathing exercise.

And so, sitting in a comfortable posture, let's just start by becoming aware of your body as a whole.

Maybe noting if you're maybe holding some tension in an area where it's really not serving you.

Perhaps your shoulders are a little bit tense. Perhaps you're even clenching your jaw. Maybe your toes are clenched.

But just take a moment to allow gravity to do what gravity does and just pull you into your chair, pull you into your couch, and just settle into this moment.

Again, settling into this moment with a special kind of awareness—an awareness with curiosity, openness, acceptance, and compassion for yourself.

And now, in a moment, I'm going to ring a bell.

And when you listen to this bell, listen very closely for the waves of air that bring you the sound of this bell, and listening most closely to the last five seconds until you can't hear the sound anymore.

And now let's shift our awareness once again, shifting our awareness away from the waves of air that bring us the sound of that bell to the waves of air that bring us the sensation of just this breath.

Breathing in and breathing out.

Landing your awareness gently on wherever you feel the breath the most.

Maybe it's as you bring in air through your nose. Maybe it's as it hits the back of your throat or enters your belly, and you notice the rise and fall, the rise and fall of your belly.

Bringing the strength of your awareness to rest gently and with compassion on just this wave of breath, moment by moment by moment.

And if, again, you're like most people, your mind is going to wander.

Maybe it's a judgment. Maybe your mind wanders to a judgment thought, like, "Oh, this is stupid. I'm not—you know, I'm not going to participate in this."

Well, just let that thought go and participate anyway.

Or maybe a comparison thought pops into mind, like, "Oh, I bet everybody else on this call is, you know, sitting there with their eyes closed and doing this, right?"

Well, let go of that comparison thought. Let go of the thought and rest your awareness just gently back on the breath.

Breath by breath by breath, and moment by moment by moment.

Showing up for this moment.

Noting and letting go. Noting and letting go, and returning to the breath again and again.

"This being human is a guest house.

Every morning a new arrival:

A joy, a depression, a meanness,

Some momentary awareness comes

As an unexpected visitor.

We welcome and entertain them all.

Even if there are a crowd of sorrows

That violently sweep your house

Empty of all of its furniture,

Still, treat each guest honorably.

He or she may be clearing you out

For some new delight.

The dark thought, the shame, the malice—

Meet them at the door laughing,

And invite them in.

Be grateful to whomever comes.

Be grateful to whomever comes,

Because each has been sent as a guide from beyond."

And when you're ready, gently opening your eyes.

And because I can't really see a raise of hands, I'm going to make some assumptions here that many of you are feeling a lot more relaxed, a lot more—for lack of a better word—more integrated in your mind.

Maybe you're feeling a little bit more balanced. Maybe you've let go of a past thought, something that happened in the past.

Maybe you're able to let go of perhaps something that you think might happen in the future, and really just reintegrate the mind, the brain, and settle into just things as they are with compassion.

And this is something that is very helpful for the person, again, with tinnitus, who spends a lot of time in the past and the future.

"What did I do? What will I do? What did I do? What will I do?"

And it really allows them to just open up their grip on tinnitus and just allow integration and to be able to see it for what it is, so that you can create some space and start to make some choices for yourself that might help with the tinnitus, that might help you release some of the intensity.

So I'm going to skip over this slide because we talked about tinnitus.

You know, in a joking way, I consider a mindfulness practice kind of a boot camp for strengthening that awareness muscle, and we're going to get into now a little bit about what I'm talking about there.

You know, one thing that is important to realize, and for those who aren't aware, is that the brain is pretty plastic. We call it neuroplasticity.

And by that we mean that with experience—with experience and repetition—the neurons of our brain can wire, fire, and grow and strengthen in new directions.

So that's my way of saying that we've shown that up until our very last breath in life, the brain is constantly changing. It's constantly learning, and it's possible to unlearn and then relearn more adaptive ways of functioning.

But, you know, I just think this slide is an important one.

This is really how I see a person with tinnitus. They're holding on with a tight fist onto their tinnitus.

So what a mindfulness practice does is it helps them to basically just open their palm to the tinnitus, just hold it in a slightly more compassionate way.

Now, it doesn't mean the tinnitus is not there.

Now, mindfulness is certainly not a cure for tinnitus, but it is a way to change your relationship to the bother.

So you can allow the tinnitus to be there and also to not be there, and holding it with more compassion.

What Might Be Happening in the Tinnitus Brain
All right, so let's talk about what might be happening in the tinnitus brain.

We're going to—I'm taking an awful lot of time on this part, so I'm going to try to kind of cruise through this.

But we're going to break the brain down into three incredibly simple parts.

First, we have what we call the reptilian brain, and that's the part that's the midbrain here. And that is the first part of the brain to develop in utero.

And it's also a part of the brain that all animals have. That's the reptilian brain.

The things that take care of—or is the part of the brain that takes care of—things like respiration, heart rate, the sleep-wake cycles, the really subconscious, the things you don't need to think about, parts of the brain that are true for all animals.

So then we have the midbrain, and that, some of you might have heard of, is called the limbic system.

And that's the midbrain.

And within the limbic system is the part that I'm interested in really highlighting for you.

Inside the limbic system is an area called the amygdala, and that is really our emotional processing center to a large degree.

And what the amygdala's job is in our brain—and again, this is a very base part of our brain. This is also—the limbic system, or the midbrain, is part of—all mammals have a midbrain, and it's still very subconscious.

It's the second part of our brain in utero to develop, and it's very base. It's very basic. It's our raw emotions and memories and such.

And so the amygdala's job is to take in information and basically its job is to make a decision for us—a split-second decision:

"Is this something I need to pay attention to, or is this sensation something that I can just allow to go into the recesses of my mind? Something I don't need to pay attention to because it's not a threat to me?"

Now, what I think is happening inside the person's brain with tinnitus versus the person who's bothered and non-bothered by tinnitus is that the amygdala in the person with tinnitus is overworking. It's overfiring because it's actually misinterpreting this tinnitus signal.

It's taking in the tinnitus sensation and, lo and behold, it thinks that it's something it needs to pay attention to.

There might be a fear there, like, "Oh my God, what is this?"

And, you know, this person basically—their amygdala is keeping their body on alert, and it's basically saying, "I'm not—maybe, maybe it's saying, 'I'm not quite sure what this is, but I need to pay attention to this because it could be a potential threat.'"

And so the person with that's experiencing bothersome tinnitus might actually have an overactive—or their amygdala is misfiring and misunderstanding this tinnitus signal as being something that it needs to pay attention to, when in fact it's something that it can habituate to, that it could allow to go into the recesses of their thinking, of their brain.

And so the third part of the brain to develop, and really where all the magic, I think, happens in the brain, is this very conscious part of our brain.

I'm pointing to it right here.

This is called the medial prefrontal cortex.

It is the last part—or the cortex in general is the final part—of our brain to develop.

And I'm just going to talk right now about the medial prefrontal cortex, and that's in this area right here. It's the part right behind our forehead.

And that is where the magic happens.

So what's happening inside our medial prefrontal cortex is that's where all of our executive functioning is. It's a very conscious part of our brain.

And this medial prefrontal cortex is in charge of things like—I think I have a list here in my next slide that we can go down—is that our executive functionings involve things like reasoning, our judgment, our ability to regulate our emotion, to have response flexibility.

And I think of response flexibility as being able to kind of modulate how reactive we are or how we respond, basically stopping and thinking before acting.

Also, executive functionings are things like fear modulation, and that's something that's very important.

You know, we talked about with the amygdala in the person with tinnitus—the it's the medial prefrontal cortex that can allow us to basically relax the amygdala.

Now, going back to—let me just finish with the executive functionings here.

Impulse control, you know, again, stopping and thinking before acting.

Reasoning, planning, ability to think about thinking.

They even believe that it's partly involved in our ability to have empathy for self or others, compassion for ourselves or others.

And so—and also sustaining our attention and where we place our attention.

And so these are pretty important factors.

And these are also very conscious parts of our brain.

And so back to this slide here, we have the medial prefrontal cortex here.

And what's really special about this area is that it can send down—we can use our reasoning to send down the fibers down to the amygdala.

And these fibers that are sent down are basically neuropeptides. They're downregulating neuropeptides.

For example, GABA is one of them, one of many, but GABA—gamma-aminobutyric acid—is a neuropeptide that sends down, that can be sent down to the amygdala to basically relax the amygdala, to basically chill it out and say, "You know what? This is not something that I need to be focused on so tightly."

So we can use our medial prefrontal cortex and our reasoning to basically chill out the amygdala.

And if that's what we're needing for people that are struggling with tinnitus, that link there, that connection between our conscious thought and our subconscious fear modulation or fear centers in the amygdala, it's very interesting that perhaps if we can strengthen the areas of our executive functioning in the medial prefrontal cortex, perhaps the person with tinnitus can basically chill out their amygdala, to be able to relax it and, you know, let the tinnitus go into—you know, just be one of many body sensations that we experience at any given time.

Meditation Research
All right, and so, interesting, as I'm doing my research and findings, I'm looking at other areas of research.

And so one area that I want to go over briefly is—I'm going to skip to this.

What we know from the meditation research.

So, for example, a woman named Sarah Lazar, professor at Harvard, and her colleagues wanted to know what is happening in the mind of the meditator.

So what she did was she took experienced meditators and she put them through an fMRI machine, which is a functional magnetic resonance imaging machine, which basically gives us a picture of the activation of the brain and what areas light up under certain conditions.

And what her findings showed were very, very interesting.

She took these experienced meditators, she put them through an fMRI machine, and what she found was very interesting: that experienced meditators had a larger medial prefrontal cortex.

And that became very, very interesting to me because I'm, you know, thinking, "Well, if we can strengthen the medial prefrontal cortex to relax the amygdala, then, you know, how do we do that?"

Well, if she's finding that through meditation the gray matter and the growth of the fibers inside the medial prefrontal cortex are larger, that pointed to me—that showed to me—that, wow, maybe there is an exercise that we can do to help people with tinnitus to strengthen that part of their brain so that they can basically do some fear modulation in their amygdala to relax the reaction around tinnitus, so that it becomes more of a response.

Again, just for the sake of time, I've left many, many slides here, and you can see I get so caught up in the background.

But I am going to—these slides are all going to be available to you, so you can go back through them if you want to learn more about this.

But I am going to skip through a few of these.

So I was curious, after I'm learning about all this stuff, I'm like, "Hmm, I wonder what would happen if we put people with bothersome tinnitus through a mindfulness skill-building program?"

So back years ago, I decided to create this eight-week course called Mindfulness-Based Tinnitus Stress Reduction and did some research with it.

Now, there's not—I mean, you can see from the list here that there's not a ton of research out there on mindfulness and tinnitus, but I do have to say it's growing and growing and growing.

So I encourage all of you who are listening right now, who are researchers, closet researchers, or, you know, have any interest in this area, to explore what mindfulness can do for our people with bothersome tinnitus through doing research.

This is definitely an area that's wide open, and boy, is there—

So perhaps if I give this talk again next year, I can list some of your research up here as well.

So let's go to what I found in my research.

Now, I created this eight-week course, where I'm going to go into what is involved in the course, and it was—I created it in a way that this course is meant to be used in conjunction with excellent audiological care.

I'm a very big believer that it takes a village, so to speak, to help somebody with tinnitus, and that if something works, you know, something is effective, keep using it.

And so participants during the eight-week course are encouraged to continue using any tools or other devices, like sound generators, hearing aids, doctor-prescribed medications, acupuncture, you know, other forms of meditation, relaxation, CBT—the list goes on and on—while they're taking the course.

The MBTS eight-week course is designed to be an adjunct to good audiological care.

And so let's talk about what's involved in this eight-week course.

Now, it's not an eight-week therapy course. It's an eight-week skill-building course, and that's important to note.

But inside this eight-week course, every week the group comes together, or in the online course they come to their computer, but for about a two-hour class.

And during this class, we learn many things about tinnitus: tinnitus education, because we all know that a little bit of tinnitus education can also chill out the amygdala, can also relax a person by understanding what tinnitus is and what tinnitus isn't.

We also go through mindfulness lessons.

There are instructor-led meditations, gentle yoga, or I call it kind of just gentle movement exercises.

There are discussion questions and skill-building activities, calendars, and readings that are done through this two-hour course.

Now, very, very, very important: similar to even an exercise routine, you know, once a week is all fine and good, but we need to keep the practice up.

And so through this home practice exercise, every day the person will, using audio recordings, in the privacy of their own home or wherever they choose to do it, will do a 30-minute mindfulness exercise every single day on the six days in between.

And then between the sixth and seventh week there's an all-day retreat.

So that's what's involved in this Mindfulness-Based Tinnitus Stress Reduction course.

And so I'm aware of time just going by so quickly. I wish I had more time, but so I created this research project at UCSF, in California here.

And with my subjects, it was a small group of eight people. We went through the Mindfulness-Based Tinnitus Stress Reduction eight-week program, and I gave them pre- and post-intervention measures to see if there was any change.

And so we're going to look at that change.

First, some of the measures, just to know what we're looking at. There's the Tinnitus Handicap Inventory, but I'm also curious about, like we had said, depression, anxiety, sleep difficulty, and that nature.

So we also had some secondary measures that measured those areas.

Okay, so what were the findings?

Again, for the sake of time, I am going to flip to the quick-and-dirty explanation of what the findings were.

Basically, what we found was that after the eight weeks, the tinnitus handicap and bother went down, depression scores went down, anxiety scores went down, increased mindfulness scores went up, and quality of life went up.

So what we're seeing in this course in just an eight-week period—and you can see the numbers go down pretty dramatically for, for example, the Tinnitus Handicap Inventory.

Pre, the group, on average, was at 50. Post, their Tinnitus Handicap Inventory scores were down at 39.

And then something very interesting is I was curious, you know, great, so MBTS works great in eight weeks, but how does it work long-term?

And so I got in contact with the group 12 months later and administered the measures again, and we see that even after a year, their THI scores, or their Tinnitus Handicap scores, have gone down even more.

And I had no contact with this whole group through those 12 months.

And so it's very interesting to see that something is really changing in them after a course like this.

Participant Experiences
I want to go through what participants said after the course.

One person at the end of the course wrote:

"Tinnitus doesn't seem like a terrible curse anymore. It's sometimes annoying now, but not insurmountable. I have come to see it, tinnitus, now as just another sensation—typically unpleasant, rarely neutral, never pleasant—but I try to be aware without judging."

Another person said:

"I'm sleeping in a more regular pattern now. When I take medication to sleep, I'm taking half instead of a full dose. It's good to hear."

Another person wrote:

"I can go into the ringing without going towards depression."

You know, and others, you know, it's interesting.

MindfulTinnitusRelief.com
So we're going to quickly talk about the MindfulTinnitusRelief.com course.

I basically took this course that I developed and wanted to get it out to people because there was only one of me who knew how to run this course, and it was very frustrating that not more people could take advantage of it.

So what I did was I took this eight-week course and I created an online version.

And again, because of time, we don't have much time to go into it, but I really encourage you all to look at MindfulTinnitusRelief.com after we're finished here, because this is a course that you can be recommending to patients that you see all over the world, anywhere they have internet connectivity, where they can be taking this course in the privacy of their own home, at any time that they choose, etc.

But anyway, so here's a funny thing.

A couple months ago, this woman wrote to me after taking the online course.

You know, she writes to me, "It's funny. After just a few weeks of starting the course, I'm noticing that my tinnitus doesn't bother me as much anymore, and I'm getting along better with my husband."

And that made me chuckle because, you know, this mindfulness is really—it's not about the tinnitus.

I mean, it is about the tinnitus when we're coming to it because of the tinnitus, but what we're seeing is a change in how we're relating to all things in life, even our husbands.

So, just to finish things up again, I was a little frustrated because, you know, here I can see through the research that this is a program that's really working, and I had no way of getting it out to the people, you know, to people that don't live in the Bay Area.

And so one thing that I decided to do was, "Well, I wonder what happens if I take this same skill-building course and I flip it into an online version, an eight-week course?"

And so the problem that I saw was that few patients will ever see a clinician trained in mindfulness for their tinnitus.

And that was frustrating to me.

And so the answer to that was to create this self-help version of Mindfulness-Based Tinnitus Stress Reduction, administered via the Internet.

And I'm going to skip through the slide, but, you know, everybody knows that Internet interventions are growing and growing, and there's over a hundred studies on Internet interventions out there.

Excuse me, let me go back to that for a moment.

And so we're seeing that they're cost-effective, that they reduce time needing to be spent with the therapist, physician, audiologist, ENT, that it's as effective as face-to-face intervention for the people that are taking it, and it puts healing back into the hands of the patient.

That's something that is very important with tinnitus, because our tinnitus patients are coming—they're looking to us for the cure.

And we all know that there's just no cure for it, and, you know, that we can certainly help them with the management of it.

But what I was curious about through this course is: How can we help a person with tinnitus to also help themselves?

And so, you know, having a course like this really is a nice bridge.

You see them in your practice, you can then send them on their way with this online course, for example, where they can then, you know, you can say, "All right, I'll see you in eight weeks. While you're at home, take this course."

And they can be really helping themselves outside of your practice, and not so much looking to you for the answers, but looking for their own internal resources for healing, which is, I think, a very important part, because, you know, a very important piece of the tinnitus puzzle.

Again, so many slides and so little time here.

So what the eight-week online course really involves is, again, it's worldwide. You have online access to it from a desktop, laptop, tablet, smartphone, everything.

It reaches those people who have limited access to tinnitus care.

There are weekly classes at participants' convenience. Patients can self-refer.

There's privacy. A lot of people don't want to come to in-person groups. They prefer to, you know, do their care from the privacy of their own homes.

So this definitely suits the needs of that person.

It is low-cost.

And again, similar to the in-person version, it involves a two-hour weekly online instructional class.

Then there's homework that is done every single day in between, on those six days in between the two-hour course.

There's up-to-date, advanced tinnitus information and education.

There's mindful movement and yoga video instruction.

More than two hours of downloadable mindfulness awareness-building exercises.

Weekly discussion questions.

Downloadable activities.

Very similar to the in-person, but, you know, again, being able to be done on your computer from your own home.

And this is what these are images of what you might find on the course.

Now, I am doing a little bit of tweaking of the way the course looks with my developer right now, so if you go on there in a month or so and see that it looks very different, that's why.

But, you know, on your own time, go to MindfulTinnitusRelief.com and have a look at what's out there.

There's yoga videos, there's audio—you know, yoga videos, there's audio links.

You can see here that there's, you know, every week you can click on and there's, again, videos, there's audio recordings, and other mindfulness activities that they participate in.

How Can the Practitioner Get Involved?
So how can the practitioner get involved?

And we're just going to end on this note.

You can go to MBTS.edu, you know, in your practice, and invite in groups of your tinnitus patients to meet for about two hours a week.

And then they go home and do their activities, and then they come back and you lead them through the next week's lesson.

So it's basically a way for you to facilitate—you, as the audiologist or hearing health professional—to be able to run groups like this, in-person groups in your practice, if that's what you choose.

So I'm just trying to give some variety to it.

And again, you know, let me point to this: I hope I don't sound like I'm pushing this course, but one problem that we're having is that there is no access—there is not a lot of accessibility to mindfulness for tinnitus.

And so, again, I would be referring you out to, you know, other professionals that have created something like this.

But the problem is nobody has yet.

And so while it sounds like I'm promoting this, which I guess I am, I'm really encouraging you to, you know, go in this direction because this is really the only online course out there of its kind for helping our patients with mindfulness.

And so, going back to this last slide, let's also remember this saying by the Buddha:

"Pain in life is inevitable and suffering is optional."

It's very interesting because people come into our practice with pain. They come in with pain—tinnitus in the form of tinnitus—and that's not something that we can help or cure for them.

But what we can help them with is the suffering.

What we can help them with is how we relate to that tinnitus, and that's something that is in the hands of the person with tinnitus, and it is optional.

So I really—I like how this quote just basically says it all:

"Pain in life is inevitable, but suffering is optional."

And again, I encourage you to, you know, be teaching the people that you see not to hold on to tinnitus in such a tight fist.

And that while the tinnitus might still be there, you can hold it with softness, with compassion, with a way where you can relax the amygdala, take away the fear of the tinnitus, and just see it for what it is—a benign, albeit incredibly unpleasant for some, body sensation.

And I want to thank you all for spending this time with me.

As I'm afraid happens quite often, the hour is up.

However, I am a big fan of questions. It does pain me that I didn't—that we don't have more, like an hour and a half, for this talk today.

But I really, really encourage you to send me your questions, kind of for selfish reasons. I love your questions because they really help me to direct where my work is going to go.

So I really encourage you all to ask any questions that you have, and I will do my best to get back to you and answer them.

And you see here below I've included my email, where again, if you would like to write to me, I'm also happy to, by mail, send out brochures and things like that that you can share with your patients about this program.

Also, in the section here of handouts, I have included a sheet that is a brochure of the MindfulTinnitusRelief.com course that you can share with your patients that gives all the facts and how they can participate in it.

And I really want to thank you all for joining me today, and I hope that this has inspired you to really go out there and learn more about mindfulness for yourself.