Thompson, Dean Mark
(2018)
Defining components and measuring the effects of audiologist-delivered counselling for tinnitus.
PhD thesis, University of Nottingham.
Abstract
Psychological treatment is effective at alleviating tinnitus distress when delivered by a psychologist. In the United Kingdom (UK), best practice guidance for tinnitus advises that audiologists should deliver Cognitive Behavioural Therapy (CBT) and other counselling techniques where psychologists are unavailable. However, there is a lack of evidence for the effectiveness of audiologist-delivered psychological tinnitus treatment, and no consensus among clinicians and researchers on what form, if any, this should take. Furthermore, training in CBT and other counselling techniques is not a part of standard audiologist training in the UK. The aims of this PhD were to define the components and measure the effects of an audiologist-delivered psychological tinnitus treatment for people with tinnitus.
Potential treatment components to include were identified in two studies. The first study was a comprehensive scoping review in which components were extracted from 64 records on psychological tinnitus treatment delivered by psychologists. The components were predominantly extracted from studies of CBT. The second study was a Delphi survey of a panel of 39 patients and clinicians who were asked to rate the importance of 160 different treatment components for an audiologist-delivered psychological tinnitus treatment. These data were used to inform the development of a treatment manual, underpinned by a cognitive behavioural model of tinnitus distress. The manual comprised tinnitus education, psychoeducation, relaxation, graded exposure, thought challenging, physical exercise, sleep hygiene, an introduction to acceptance and defusion techniques, and sound enrichment, which could be implemented flexibly according to patient need.
To measure the effects of the psychological tinnitus treatment, appropriate outcome domains and instruments were identified by applying template analysis to the treatment manual. Potential domains were selected from a list constructed by grounded theory using existing questionnaires. Outcome instruments were identified if they were responsive to therapeutic change and possessed good content validity and internal consistency. It was predicted that the treatment would affect tinnitus-specific emotional impact and negative thoughts. Based on current evidence, the Tinnitus Functional Index (TFI) and the Tinnitus Cognitions Questionnaire (TCQ) were identified to best measure these domains.
A feasibility randomised controlled trial (RCT) was conducted over six months to determine the feasibility of a definitive RCT of audiologist-delivered psychological tinnitus treatment. Nineteen patients were recruited to the trial. Attrition rates were high, though all patient withdrawals occurred before their first appointment. The trial indicted that a definitive RCT of audiologist-delivered psychological tinnitus treatment is not feasible due to poor site compliance with returning questionnaires, and low recruitment rates in smaller trial sites.
Patients and audiologists were invited to attend post-treatment semi-structured interviews to explore treatment fidelity and experience. Patients reported that the treatment was acceptable and effective in reassuring them about their tinnitus. Audiologists reported focusing on psychoeducation with limited use of specific techniques such as thought challenging and graded exposure. Patients and audiologists thought that the TFI and TCQ comprehensively measure the important tinnitus domains and are useful for planning treatment and encouraging discussion about patients’ negative thoughts. A lack of confidence due to the brevity of training was given by audiologists as a reason they avoided implementing certain treatment components.
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