Barriers to Habituation
Stephen M. Nagler, M.D.
Habituation of tinnitus, the process whereby over time you tend to become less and less bothered by your tinnitus and whereby as a consequence you tend to become less and less aware of your tinnitus (unless you purposely seek it), is a completely natural phenomenon. It happens automatically unless there are barriers blocking your way. Eliminate your barriers to habituation - and as I see it, you are absolutely home free. Habituation certainly does not happen overnight, but it does happen. Eliminate the barriers and habituation of tinnitus will happen as assuredly as sunrise follows sunset.
The problem, then, comes down to identifying your barriers, removing the barriers that are under your direct control, and (when needed) adopting some sort of strategy for facilitating the removal of those barriers that are not under your direct control.
The challenge lies in the fact that sometimes it is not so easy to identify all of your barriers to habituation. Moreover, since you are (obviously) not in control of the barriers you do not control, even a best effort can fall short. And when that happens, it's nobody's fault. Certainly not yours!
What follows is not some sort of scientific treatise. Rather, it is the way I personally have come to view things after more than twenty years "in the trenches" - first as a tinnitus sufferer and subsequently as a tinnitus clinician and tinnitus advocate.
The barriers to habituation fall into two main categories: external barriers and internal barriers.
The external barriers to habituation are those factors that are largely under your own control and result in your attending to your tinnitus more than is absolutely necessary. I cannot give a comprehensive listing, and clearly every tinnitus sufferer has his or her own external barriers. But here are some examples ...
Keeping tinnitus diaries. Most everybody does it at first in order to try to "figure out" his or her tinnitus. But once you have figured out that you cannot figure out your tinnitus, which takes a week or two at most, then why continue the diary? Indeed continuing to keep a tinnitus diary serves only to force you to think about your tinnitus more instead of less.
Talking about your tinnitus once, twice, three times or more a day with your spouse or partner. Turns out that it is very rare that at any given time tinnitus presents a true emergency. It is more typical that there are huge non-emergent swings in tinnitus-related distress (due to any number of factors), and whenever you are having a bad time of it, you naturally want to discuss it with your spouse or partner, a person who has a vested interest in your well-being. Bad idea, in my opinion. Because when you are discussing your tinnitus, you are attending to it, which is precisely what you do not want to be doing. My suggestion would be to make "tinnitus dates" with your spouse or partner. Every Monday and Thursday from 6PM to 7PM (for instance), your spouse or partner agrees to be unconditionally available to you to discuss your tinnitus, should you wish to do so. This system has the added advantage that he or she will not be blind-sided by your wanting to talk about it at other times, times when he or she might have other important things to do. In a similar vein, your spouse or partner agrees never to bring the subject of your tinnitus up to you. The time for discussing your tinnitus is during your tinnitus dates, and then only if you bring up the subject.
Searching for perfection. Perfect does not exist. Perfect is a fairy tale. Perfect is a myth. The challenge lies in the fact that tinnitus sufferers not infrequently see themselves as terribly damaged; and in their effort to achieve meaningful relief, there is a tendency to look past predictably effective strategies in their search for the perfect strategy, so they will no longer feel damaged. The search for perfection comes from a place of emotion rather than a place of reality. Here is the reality to keep in mind in terms of external barriers to habituation: PERFECT is the enemy of GOOD. And in searching for perfection you are absolutely attending to your tinnitus more than is absolutely necessary.
Internet tinnitus support boards.
Tinnitus support boards can be a very good thing. They can provide information. They can provide understanding and reassurance. And they can provide camaraderie. But they can also potentially serve as huge external barriers to habituation. So participation on such boards, regardless of how well they are moderated, can be a real balancing act. What kind of barriers, you might wonder ...
(1) While tinnitus support boards do provide information, not all of it is good information. And just because a piece of information makes good sense, that does not by any means make it good information. If your goal is habituation, I respectfully suggest that unrecognized bad information is not going to be your greatest ally.
(2) Tinnitus support boards tend to be dominated by individuals who have not yet overcome their tinnitus ... or they wouldn't be there in the first place. So you need to ask yourself how healthy it is to be continually exposed to postings from those who have not yet managed to figure out how to achieve for themselves precisely that which you desire to achieve for yourself. More than that, many are absolutely convinced that for one reason or another it cannot be achieved at all! To me, this self-defeating mindset can make for a particularly toxic environment given your goal.
(3) The camaraderie can be addicting. It is natural to want to be around folks who are all "in the same boat" as you. But your goal is to get out of that boat - so perhaps you might be better off spending time with individuals with whom you share a bond that has absolutely nothing to do with tinnitus!
I could go on and on, but my overall message is this: Tinnitus sufferers spend enough time necessarily
attending to their tinnitus as it is. If your ultimate goal is habituation, then in my opinion you should strictly limit the amount of time you unnecessarily
attend to your tinnitus. It is you and only you who can determine where that limit lies. I suggest that if you are going to spend a whole lot of time on tinnitus support boards, the one you really want to be on is ...
... but unfortunately that site does not exist. So by default you wind up spending your time (in some cases a lot
of your time) sharing ideas with and moreover identifying with individuals who have not done well! Indeed, one noted authority has referred to tinnitus support boards as "reservoirs of negativity." Now I am by no means telling you to totally avoid tinnitus support boards. What I am saying is that you should attempt to strike some sort of balance where such boards are concerned, lest they become external barriers blocking your own path to habituation.
Which brings us to the internal barriers to habituation, those factors over which you have little, if any, direct control. As with the external barriers, I cannot offer a comprehensive listing. But that said, the internal barriers tend to fall into two main categories: the limbic and the autonomic.
Limbic factors. The limbic system is a major emotional seat of the brain, but the limbic consequences of tinnitus go far beyond "fearing" your tinnitus or viewing it as a threat. Frustration due to the loss of control, sadness because the loss of silence, concern regarding the future, and resentment over what has happened to you are but some of the ways the limbic system commonly finds expression in the daily lives of tinnitus sufferers. And simply telling yourself over and over again not to be so viscerally upset about such a cataclysmic course of events, well that strategy simply will not work.
Autonomic factors. As profound as the limbic factors might be, they are dwarfed by the autonomic factors - and by the interplay between the limbic and autonomic factors. Your autonomic nervous system plays a vital role in protecting you from danger, and (as is the case with your limbic system) you have little, if any, direct control over it. For instance, in a dark room the pupils of your eyes will dilate to let in as much light as possible in order to protect you from what might be lurking in the shadows. You do not tell your pupils to dilate; that function is controlled by your autonomic nervous system. And try as you might, you simply cannot make your pupils constrict in a dark room. Well, as a tinnitus sufferer you have the guest from hell in your head, the uncle who invited himself and simply will not leave. So what does your autonomic nervous system do in response to this omnipresent amorphous intruder? It does exactly what it is supposed to do - it continually monitors your tinnitus. In other words, your autonomic nervous system is acting in powerful opposition to your goal (which is to stop monitoring your tinnitus), and there is nothing you can directly do to change that state of affairs, not unless you can figure out a way to cause your pupils to constrict in a dark room!
So where does that leave us? Well, we need to do our very best to recognize our external barriers to habituation and eliminate them. These barriers are indeed largely within our direct control as noted earlier. In some instances we might need the assistance of an experienced and objective eye in identifying them, but we can do much of it on our own. It is the internal barriers to habituation, the ones over which we have no direct control, that present the real problem. If identifying and directly addressing your external barriers to habituation does not get you where you need to go, then in my opinion you should seriously consider indirectly addressing your internal barriers to habituation, those limbic and autonomic factors over which you have no direct control, through the use of Tinnitus Retraining Therapy (TRT) or Cognitive Behavioral Therapy (CBT). Both approaches are highly clinician-dependent, however, and if you would like some individualized guidance from me personally in terms of selection of approach and clinician that takes into account your own tinnitus and circumstances, you might want to think about possibly arranging for a Telephone or Skype Consultation before moving ahead.
Dr. Stephen Nagler
Atlanta Tinnitus Consultants, LLC