1. The programme at a glance
Indication. The programme is intended for an adult who has been hearing tinnitus for at least three months (section 8), whose ears have been examined by an ENT specialist with audiometry, and for whom the distress linked to the sound is in the foreground: shortened nights, captured attention, worry, withdrawal. It is suitable when the handicap measured by the Tinnitus Handicap Inventory reaches at least the moderate level (38 or more, section 11), the threshold from which the Haute Autorité de santé (the French National Authority for Health) proposes cognitive behavioural therapy (Haute Autorité de santé, 2026). For milder bother, this manual offers a short version (section 36).
Reference model. The programme rests on cognitive behavioural therapy for tinnitus, the only psychological approach whose efficacy is established in this indication (Fuller et al., 2020; Haute Autorité de santé, 2026). It enriches it with acceptance and commitment therapy and with mindfulness, which have their own trials (Westin et al., 2011; McKenna et al., 2017). Its model is that of McKenna and colleagues (2014), which describes how threatening interpretations, selective attention, physiological arousal and safety behaviours maintain the bother (section 7).
Format. Ten weekly individual sessions of 50 to 60 minutes, the first lasting 75 minutes, then three booster sessions, at one, three and six months. The programme can also be delivered in a group (section 36), and section 16 justifies this format.
Targeted mechanism. The programme does not seek to silence the sound, which the manual does not promise, but to bring about four changes: that the person understands their tinnitus without seeing it as a threat; that their body and their attention stop being on alert around the sound; that they give up the monitoring, the struggle and the unnecessary protection that keep it at the centre; and that they get back their sleep and what the sound had taken from them.
| Session |
Focus |
Session deliverable |
| 1 |
Assess, triage, link with the ENT specialist |
Assessment and risk checked, baseline measures, diary handed over |
| 2 |
Understanding tinnitus |
Explanation restated by the person, sound and bother separated |
| 3 |
The cycle, and what tinnitus has taken |
Cycle drawn, values written, first resumption dated |
| 4 |
Relaxing the body |
Relaxation done in session, daily practice set |
| 5 |
Shifting attention |
Attention experiment done, one check replaced |
| 6 |
Thoughts about tinnitus |
Thoughts rated, written response, experiment planned |
| 7 |
Silence, sounds and protection |
Protection sorted, first exposure done |
| 8 |
Nights |
Sleep plan written |
| 9 |
Making room |
Observation exercise done, values-guided actions dated |
| 10 |
Review, spikes and plan for what comes next |
Measures repeated, plan written |
What the person takes away. Nine printable worksheets, listed in section 38, one of them for those close to the person.
What distinguishes this programme from the other manuals on this site. It begins with the ENT specialist and stays in liaison with them, because tinnitus can signal a condition that can be treated, sometimes urgently. It judges the outcome on the impact, not on the loudness of the sound, which changes little. And it works on the person's relationship with the world of sound itself — silence, noise, hearing protection, devices —, which the neighbouring manuals do not address. It shares with Chronic pain: a therapist's manual the logic of a real symptom whose place, rather than its existence, is what gets treated.
2. Before you begin
The five preliminary decisions
Has an ENT specialist examined the ears and carried out audiometry? If not, or if the tinnitus has changed since, the person makes an appointment before session 2 (section 3).
Is there a red flag? You go through them in session 1, even when the tinnitus has lasted for years (section 3).
Is there a suicide risk? It is asked about explicitly (section 10).
Is another disorder in the foreground? Severe depression, established insomnia, pervasive health anxiety or post-traumatic stress disorder may come before or alongside the programme (section 9).
What is the level of bother? The score on the Tinnitus Handicap Inventory guides the format and serves as the starting point for the response criterion (section 11).
What this programme does not treat
It does not treat the ENT cause of the tinnitus, nor sudden hearing loss, which is an emergency (section 3).
It does not treat severe depression or acute suicide risk on its own. These fall under Treating depression in adults: a therapist's manual and Suicidal behaviour in adults: a therapist's manual, and call for a psychiatric opinion; the programme resumes when the person's condition allows.
It is not meant for children or adolescents, and it treats neither misophonia nor isolated hyperacusis (section 4).
How to use it
Read the whole manual before the first session, in particular sections 3, 6 and 16, then sections 28 to 32 before the sessions that draw on them. Three warnings are specific to this indication.
The first trap is to imply that the sound is psychological. Many people have heard "there's nothing to be done" or "it's your nerves", and believe they are being sent to the psychologist for want of anything better. The first session must show them the opposite: the sound is real, and the work is about the place it has taken.
The symmetrical trap is to make promises. These people have often tried treatments, sometimes expensive ones, that ended in disappointment. The manual says what research establishes: a real effect on the impact, not on the loudness (section 12).
And the sound enters the session. This programme asks the person to stay in quiet, to listen to the tinnitus, to remove a background sound, to go out without earplugs. If these exercises make you uncomfortable, work on them in supervision.
3. What falls to the ENT specialist first: the assessment and the red flags
Why this section comes before everything else
Tinnitus often accompanies hearing loss, but it can reveal a condition that can be treated, sometimes urgently. You do not make a medical diagnosis, but you often see the person more regularly than anyone else, and you are well placed to spot a change. The list below takes up the signs adopted by the British guideline, the Haute Autorité de santé and the Assurance maladie (the French national health insurance); it is used for screening, in session 1 and whenever the person describes a change, and it does not replace the examination.
The assessment that precedes the programme
It includes an examination of the ears and audiometry, recommended in all cases, and, depending on the results, further investigations (Haute Autorité de santé, 2026). The Haute Autorité de santé recommends an MRI scan for tinnitus on one side, hearing loss on one side or asymmetrical hearing loss, fluctuating hearing or vestibular disorders, or pulsatile tinnitus; the British guideline proposes imaging for pulsatile tinnitus and considers it for tinnitus on one side. Both advise against it for tinnitus on both sides that is symmetrical, with no other sign (National Institute for Health and Care Excellence, 2020; Haute Autorité de santé, 2026). This last point helps you respond to requests for repeated investigations (section 30).
What cannot wait: the emergency department or a same-day consultation
The sources do not always set the same timeframe: the Haute Autorité de santé often asks for an examination or imaging without specifying the urgency, whereas the Assurance maladie asks people to seek medical advice immediately. This manual adopts, each time, the shortest timeframe given by any one of them.
A sudden drop in hearing, in one ear or both, with or without tinnitus. It is an emergency for all the sources: the Haute Autorité de santé recommends starting treatment as an emergency, without delay, the British guideline asks for the person to be seen within twenty-four hours when the loss developed over three days or less in the past month, and the Assurance maladie asks people to seek medical advice immediately (National Institute for Health and Care Excellence, 2020; Assurance maladie, 2026b; Haute Autorité de santé, 2026). Tinnitus that appeared after a very loud noise, an explosion or a diving accident belongs to this group as soon as it is accompanied by a drop in hearing or by vertigo.
Sudden neurological signs: weakness or paralysis of the face, difficulty speaking, weakness on one side of the body, violent vertigo, or any sign suggesting a stroke (National Institute for Health and Care Excellence, 2020; Haute Autorité de santé, 2026).
A sudden and unusual headache with tinnitus that appeared in the previous ten days, pulsatile tinnitus that appeared suddenly or is changing quickly, tinnitus that appeared after a blow to the head, or sudden tinnitus accompanied by fever and chills, nausea or vomiting, or impaired consciousness (Assurance maladie, 2026b; Haute Autorité de santé, 2026).
High suicide risk, which calls for an emergency psychiatric assessment (section 10).
What calls for a scheduled ENT opinion
Established pulsatile tinnitus, that is, a sound that beats, often in time with the pulse, which calls for a targeted examination and imaging.
Tinnitus on one side, or tinnitus associated with hearing loss on one side or asymmetrical hearing loss.
Hearing that declines over a few weeks, or an old sudden hearing loss that was never investigated: the British guideline then asks for an opinion within two weeks.
Fluctuating vertigo or hearing, or tinnitus that appeared after acoustic trauma or a diving accident, without a drop in hearing or vertigo.
These four situations are described by the same guidelines (National Institute for Health and Care Excellence, 2020; Haute Autorité de santé, 2026).
What you do
You ask the questions in session 1, saying why: "I'm going to ask you a few medical questions. It isn't my job to make a diagnosis, but I want to be sure we don't miss something that needs a doctor."
You act according to severity. For signs in the first group, the person seeks medical attention the same day, at the emergency department if necessary, and you help them to do so. For those in the second, they make an appointment with the ENT specialist, within two weeks when hearing is declining, and, with their consent, you write to the specialist about what you have observed.
And you do not suspend the programme for nothing. A temporary rise in the usual sound, after a noisy evening or a cold, is not a red flag: it is the subject of the spike plan in session 10. The distinction rests on novelty — a sound that becomes pulsatile, a side that changes, hearing that declines —, not on intensity.
The opposite mistake
Medical vigilance can become a trap: a person who asks for a new investigation at every variation, or reads every change in the sound as the sign of a tumour, falls under the work on reassurance seeking (section 30). A change in the nature of the sound is shown to the ENT specialist; a variation of the usual sound is worked on in the programme.
4. Five presentations not to be confused
1. Tinnitus that does not bother
What you observe. The person hears a sound, sometimes for years, and lives with it without suffering from it.
What points to it. The absence of impact. This is the most frequent situation (section 5).
What it implies. Accurate information is enough.
2. Tinnitus disorder
What you observe. The sound is accompanied by emotional distress, difficulties with attention or concentration, physiological arousal, and the person has changed their life around it.
What points to it. This is the distinction proposed by an international consensus: tinnitus refers to the perception of a sound without an identifiable external source; it becomes tinnitus disorder when it is associated with emotional distress, cognitive difficulties or physiological arousal, which lead to changes in behaviour and functional impact (De Ridder et al., 2021).
What it implies. This is the programme described here.
3. Hyperacusis
What you observe. Ordinary sounds — dishes being put away, a street, children playing — experienced as too loud, unpleasant, frightening or painful. A reference review groups these reactions into four categories: excessive loudness, annoyance, fear and pain (Tyler et al., 2014).
What points to it. The person complains about external sounds, and avoids them or protects themselves from them.
What it implies. When it accompanies tinnitus, it is worked on through graded exposure to sounds (section 31), in liaison with the ENT specialist and the hearing aid audiologist.
4. Misophonia
What you observe. An intolerance of specific sounds, most often produced by other people, such as chewing or breathing, which trigger intense anger, disgust or distress. The consensus that defined it states that the reaction does not seem to depend on the loudness of the sound, but on its particular pattern or its meaning for the person (Swedo et al., 2022).
What points to it. The trigger is a specific sound, not the volume, and the reaction is mainly emotional.
What it implies. It is not the subject of this programme: the exposure to ordinary sounds in session 7 targets hyperacusis, not a reaction to specific sounds. Misophonia calls for a separate assessment, by an ENT specialist or a psychologist familiar with this presentation.
5. Sound that has a meaning
What you observe. The person hears music, voices, words.
What points to it. The definition adopted by the Haute Autorité de santé describes tinnitus as an auditory sensation without external stimulation and without meaning (Haute Autorité de santé, 2026). A structured sound, which has a meaning, is therefore not tinnitus in the sense of this manual.
What it implies. A medical opinion, and a psychiatric opinion if other signs point that way.
The three triage questions
"What exactly do you hear, and does this sound beat in time with your heart?" It separates tinnitus from other perceptions, and identifies pulsatile tinnitus.
"Is it this sound that bothers you, or the noises around you?" It separates tinnitus from hyperacusis and misophonia.
"What does it stop you from doing?" It separates tinnitus that does not bother from tinnitus disorder.
5. What tinnitus is
The definition
According to the definition adopted by the Haute Autorité de santé, tinnitus is an auditory sensation without external sound stimulation or meaning, which reflects a dysfunction of the auditory system or of structures that interfere with it, and which, under the effect of cognitive and emotional processes, may be experienced as unpleasant and affect quality of life (Haute Autorité de santé, 2026). The last part of this definition is the foundation of this manual.
How many people
In a worldwide meta-analysis, about 14% of adults had tinnitus, with no clear difference between men and women; the proportion increased with age, from about 10% before the age of 45 to nearly 24% after 65, and severe tinnitus affected about 2% of adults; the authors estimate that more than 740 million adults have tinnitus, and that more than 120 million experience it as a major problem (Jarach et al., 2022). Most people who hear tinnitus therefore do not seek help.
Where the sound comes from
Hearing loss is a major risk factor, along with certain medications that are toxic to the ear, head injuries and depression (Baguley et al., 2013). It may be mild, limited to the high frequencies, or not show up on the standard audiogram: in people who have tinnitus and a normal audiogram, electrophysiological measures have shown a reduced response of the auditory nerve fibres, which researchers call hidden hearing loss (Schaette & McAlpine, 2011).
The brain compensates. When the ear transmits less information, the activity of the central auditory structures increases, as if the brain were turning up its volume to compensate. This central gain is one of the main hypotheses put forward to explain tinnitus and hyperacusis, and its mechanisms are still debated (Auerbach et al., 2014). You explain it with an image, without claiming to know more.
Habituation is a natural mechanism. The Haute Autorité de santé asks that the habituation process be explained to the person, as a natural neurophysiological mechanism by which the nervous activity linked to a repeated stimulation of no interest gradually decreases, and that it be distinguished from the idea of "putting up with it" (Haute Autorité de santé, 2026). It is this process that distress blocks, and that the programme seeks to encourage.
What the person describes
A whistling, a buzzing, a crackling or a hissing, on one side, on both or "in the head", which varies over the course of the day and has spikes after noise, fatigue, a cold or stress. Silence has become difficult, and so has sleep; attention is captured, mood is often low. And the feeling of not being taken seriously often comes up: the sound cannot be heard by others, cannot be seen, and the tests are often "normal".