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The effectiveness of bibliotherapy in alleviating tinnitus-related distress
Journal of Psychosomatic Research 68 (2010) 245 – 251
The effectiveness of bibliotherapy in alleviating tinnitus-related distress John M. Malouff ⁎, William Noble, Nicola S. Schutte, Navjot Bhullar University of New England, Australia Received 19 September 2008; received in revised form 10 July 2009; accepted 28 July 2009
Abstract Objective: The present study examined the efficacy of bibliotherapy in assisting individuals experiencing distress related to tinnitus. Methods: One hundred sixty-two tinnitus sufferers from Australia participated in a study designed to examine the effectiveness of a cognitive–behaviorally based self-help book in reducing distress. To maximize the ecological validity of the findings, we excluded no individuals interested in treatment for tinnitus-related distress. Results: The experimental condition lost 35% of participants at postassessment, compared to 10% in the control group. In an analysis of participants who completed postintervention assessment, those assigned to the intervention condition, who received a tinnitus self-help book, showed significantly less tinnitus-related distress and general distress 2 months later compared to those assigned to the waiting list control condition. The intervention group's reduction in tinnitus-related
distress and general distress from preintervention to postintervention 2 months later was significant, and these participants maintained a significant reduction in distress on follow-up 4 months after they received the tinnitus self-help book. A long-term follow-up of all participants, who at that time had received the book at least a year previously, showed a significant reduction in tinnitus distress. Although these group differences and pre–post changes were significant, effect sizes were small. Intention-to-treat analyses showed no significant effect for between-groups analyses, but did show a significant effect for the 1-year follow-up pre–post analysis. Conclusion: Information on the effectiveness of using a self-help book, without therapist assistance, in alleviating distress is important, as bibliotherapy can provide inexpensive treatment that is not bound by time or place. © 2010 Elsevier Inc. All rights reserved.
Keywords: Bibliotherapy; Cognitive–behavioral therapy; Distress; Self-help; Tinnitus
Introduction Tinnitus involves the perception of a persistent sound, in the absence of an acoustic source, that is often described as ringing, buzzing, whistling, or chirping. Approximately 14% of the adult population experiences tinnitus symptoms persistently [1], and 20% of those with such symptoms experience substantial distress because of their tinnitus [2]. Recent reviews of approaches to treatment for tinnitus indicate that no effective pharmacological treatment is available [3,4], nor is there yet an accessible physical treatment [5]. Cognitive–behavioral therapy (CBT) delivered by therapists tends to be effective in alleviating distress associated ⁎ Corresponding author. Psychology, University of New England, Armidale NSW 2351, Australia. E-mail address: [email protected] (J.M. Malouff). 0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.07.023
with tinnitus [6,7]. A Cochrane review [8] indicated that this procedure used in tinnitus treatment can have a beneficial effect on quality of life compared to a waiting list control (SMD=0.7; 95% confidence interval=0.33–1.08). However, the review found no significant effect on subjective tinnitus loudness or depression. The Cochrane review found that cognitive–behavioral interventions in relation to tinnitus commonly use several of the following techniques: provision of information about tinnitus and its causes, changing overly negative appraisals of the tinnitus condition, building better control of attentional processes, management of sleep, and positive imagery and relaxation training [6,7]. One limitation of CBT as it has been used to help tinnitus sufferers is that it involves seeing a mental health professional, which may be associated with significant expense, delay, travel, and feared embarrassment. One possible way around these problems involves providing the treatment via a self-help book.
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The bibliotherapy approach Self-help books exist for a wide variety of psychological problems. Studies of their value indicate that they can help individuals make substantial improvements [9,10], on average about as much as psychotherapy [11–14]. Metaanalyses of the efficacy of bibliotherapy have shown treatment effect sizes (Cohen's d) of .56 for bibliotherapy across a range of psychological problems [13]. Studies of Internet-administered treatment showed similar effect sizes, although these were slightly lower than the effect sizes for bibliotherapy [15]. The finding that bibliotherapy can be effective in alleviating distress may reflect the fact that theoretically grounded psychological treatments tend to have positive effects. Meta-analytic reviews have shown that therapistdelivered psychotherapies with a sound theoretical basis are substantially more effective than waiting list or placebo control conditions in the treatment of mental disorders [16]. Self-help books, including tinnitus self-help books, based on a theoretically sound basis may have treatment effects roughly equal to the effects of other types of psychological treatment. The finding that bibliotherapeutic approaches can have a positive effect on depression [15,17] has special implications for tinnitus-related distress. A number of studies have found an association between tinnitus-related distress and depression, and improvements in tinnitusrelated disability and depressive symptoms covary [7]. Tyler et al. [18] have suggested that tinnitus distress and depression may have a common cause. There are a number of tinnitus self-help books [19–22], and these offer information and strategies to help people with tinnitus better deal with the condition. As cognitive– behavioral techniques for tinnitus-related distress have been found effective when delivered by therapists, a selfhelp book based on such techniques would seem to hold promise. One published study [23] has examined the effectiveness of a bibliotherapeutic approach, in combination with support by a therapist, in reducing tinnitus-related distress. Kaldo et al. [23] conducted an intervention in which they provided Swedish participants with a cognitive–behaviorally based tinnitus self-help guide prepared for the study, together with telephone calls by therapists with clinical psychology training. During the calls, which occurred weekly over a 6-week period, therapists evaluated treatment progress and provided advice to participants on how to progress. Participants in the intervention condition showed significant reductions in tinnitus-related distress, depression, and anxiety from pretest to posttest compared to participants in the waiting list control condition. Participants who were initially in the control condition were later provided with the self-help guide and less intensive contact with a therapist; under this condition, the therapists had only one telephone session with the participants and, in this
session, therapists and participants created treatment plans and goals. Participants in this less intensive therapy contact condition also showed significant reductions in tinnitusrelated distress and psychological distress, although not quite as much reduction in tinnitus distress and anxiety as those who had the more intensive therapist contact. The study did not examine the effect of using a self-help book with no additional support, as an individual acquiring a tinnitus self-help guide from a bookstore or library might do. The purpose of the present study was to evaluate the effect of using a self-help book without therapist assistance to treat individuals who seek help for tinnitus-related distress. In order to maximize the ecological validity of the study, we used no exclusionary criteria. Kaldo-Sandstrom et al. [24] examined the effects of an Internet- and email-focused CBT on tinnitus-related psychological symptoms and found improvement from preintervention to postintervention in a group of individuals selected to have serious tinnitus and no psychiatric or social problems that might interfere with Internet treatment. Kaldo et al. [25] studied a CBT intervention delivered as an Internet-focused treatment for tinnitus-related distress and found that this treatment was as effective as group in-person treatment.
Method Participants Participants were recruited from throughout Australia through postings on tinnitus support Web pages, announcements at in-person tinnitus support groups, postings in audiology practices, and media releases. Of the 219 individuals who initially indicated interest in participating, 162 completed a mail-in questionnaire that assessed the variables of interest. We used no exclusionary criteria. All of these individuals had some symptoms of tinnitus, as assessed by items on the Tinnitus Severity Scale [27]. We did not collect data on other types of hearing problems, specific medical conditions, or other demographic characteristics of the sample. Sixty-nine percent of the participants reported constantly hearing tinnitus noise, with another 27% reporting the noise as being usually present. Seventy-three percent of participants reported that tinnitus noise interfered with their detection of sounds, and 72% reported that tinnitus noise interfered with their understanding of speech. Design and procedure The study consisted of a randomized controlled trial with premeasures, postmeasures, and follow-up measures. Individuals with tinnitus who volunteered to participate in the project were sent premeasures assessing tinnitus severity, tinnitus-related distress, general distress, and several other measures that are not the focus of this report. Participants who sent back completed questionnaires were matched on
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the severity of tinnitus distress. After matching for the level of tinnitus distress, we tossed a coin to determine which condition to assign to each member of closely matched pairs. This process led to slightly uneven numbers in each group. Those in the intervention group were immediately sent the Henry and Wilson [20] tinnitus self-help book. We asked the participants in the book condition to complete the book within 2 months. We chose that time frame in the hope that they would complete about one chapter every 5 days. After 2 months, participants in both groups were asked again to complete the measures of tinnitus-related distress and general distress. Participants who did not respond received three weekly emails encouraging them to complete the assessment. Participants in the intervention group were asked to report what percentage of the book they had read and to what extent the book led them to change their situations, cognition, and behavior. Those in the control condition then also received the book. Two months after this (i.e., 4 months after commencing participation in the project), participants were asked to complete a follow-up assessment of tinnitusrelated distress and general distress. All participants who completed the pretest were also invited to complete a 1-year follow-up assessment of tinnitus-related distress. At postintervention assessment and follow-up assessment, we encouraged participants to complete the assessment; if they did not do so, we encouraged them again. If we still did not receive the information, we encouraged them a third and final time. Assessment Tinnitus severity The Tinnitus Severity Scale [26,27] is a measure of the strength of the perceptual aspects of tinnitus severity such as loudness of tinnitus noise and how much it interferes with an individual's ability to assess from where external sounds originate. The response format varies among the items, and we followed the usual method of calculating scale scores [27]: standardizing each item and then summing. The measure has evidence of good reliability, with a Cronbach's α of .84 [27]. In the current study, the internal consistency at pretest, as measured through Cronbach's α, was .84. Tinnitus-related distress The Tinnitus Reaction Questionnaire [28] is a measure of psychological distress specifically associated with tinnitus. This was the main outcome measure in the study. Sample items are “My tinnitus has made me feel irritable” and “My tinnitus has interfered with my enjoyment of life.” Different items have different numbers of response options, so the usual way to calculate a total score involves standardizing responses to each item and summing them [28]. We followed this method. This measure has evidence of good reliability (with a Cronbach's α of .96) and validity [28]. In the current study, the internal consistency at pretest was .95.
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General psychological distress The General Health Questionnaire-12 [29] is a measure of general psychological distress that has been used extensively in research. Sample items ask participants whether they “felt they couldn't overcome their difficulties” and whether they have “been feeling unhappy and depressed.” Studies of the scale showed Cronbach's α values of. .82 to .90, as well as good sensitivity and specificity with regard to psychiatric case identification through diagnostic interview schedules [29]. The scale has also been found to be sensitive to treatment-induced reduction in distress [30]. In the current study, the internal consistency at pretest was .90. Involvement in bibliotherapy As a manipulation check, participants were asked what percentage of the book they had read. Participants were also asked to indicate on a 7-point scale to what extent the book led them to change their situations, cognition, and behavior. In a previous bibliotherapy study, this scale had a Cronbach's α of .85 and evidence of validity through an association with level of improvement [9]. In the present study, the internal consistency for these three items at posttest was .89. Participants were also asked to provide free narrative descriptions of changes that the book prompted and what was most helpful about the book. Intervention material Participants received the book Tinnitus: A Self-Management Guide for the Ringing in Your Ears. This self-help book by Henry and Wilson [20] is based on cognitive–behavioral principles, including educational information on tinnitus, cognitive reappraisal and restructuring, relaxation and stress management techniques, attention control techniques, use of self-instruction, making lifestyle changes, and maintaining gains. The book provides guidelines for specific exercises such as progressive muscle relaxation and personalizing selfinstructions. The book is derived from an effective standard clinical psychological intervention project [7]. Accompanying the book was a brief letter asking participants to read the book and to follow the suggestions contained in it during the subsequent 6 weeks. No specific directions were provided in the letter, and no further contact was made with participants until the time of postassessment.
Results Table 1 shows the flow of participants. Of the 162 participants, 84 (51% men) were randomly assigned to the intervention condition, and 78 (60.3% men) were assigned to the control group. The mean age of participants in the intervention group was 57.3 years [standard deviation (S.D.)=13.7], and the mean age of participants in the control condition was 57.8 years (S.D.=13.3). The age and gender compositions of the groups were not significantly different.
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Table 1 Flow of participants (162 participants entered the study; no one was excluded)
Randomly assigned Completed postassessmenta Completed follow-up Completed 1-year follow-up
Experimental
Control
84 55 44 45
78 70 – 39
No reasons for loss were ascertained.
One hundred twenty-seven participants completed the postquestionnaire, of which 55 (60% male) were in the treatment condition and 70 (53% male) were in the control condition. Table 2 shows the means and S.D. for tinnitus symptom severity, tinnitus distress, and general distress at pretest for all participants and separately for participants who were assigned to the intervention and control conditions. At pretest, there were no significant differences in symptom severity, tinnitus distress, and general distress between those assigned to the intervention condition and those assigned to the control condition (see Table 2). Of the 84 individuals assigned to the experimental group, 55 (65%) completed postintervention assessment. Of the 78 individuals assigned to the control group, 70 (90%) completed the postassessment. This difference in the completion rates of the postquestionnaire was significant (χ2=13.51, P=.001). We tested age and sex as potential predictors of completion in the experimental condition, but neither variable provided significant prediction. All participants in the intervention condition who completed the 2-month posttest reported having read at least some of the tinnitus self-management guide. Participants, on average, reported reading 82% of the book. Using the 7-point scale (7=extremely, 1=not at all), participants rated the extent to which reading the book led them to change their thinking, behavior, and situations. The mean scores for these three items were 3.03 (S.D.=1.60), 2.67 (S.D.=1.59), and 2.23 (S.D.=1.68), respectively, indicating slight to moderate changes. Effectiveness of bibliotherapy intervention in reducing distress Tinnitus distress An analysis of covariance, using 2-month postscores for tinnitus distress as outcome and tinnitus distress prescores as
covariate, showed that the tinnitus distress scores (see Table 3) of those assigned to the intervention condition who completed the postassessment were significantly lower than the tinnitus distress scores of those who completed the postassessment in the control condition [F(1,122)=6.23, P=.01, d=.28]. However, a more conservative betweengroups intention-to-treat evaluation of tinnitus distress, which involved imputing posttest scores for those who did not complete the postassessment by assigning them the score they had at pretest, was not significant [F(1,159)=3.28, P=.07]. Individuals in the intervention condition who completed the postassessment experienced a significant reduction in tinnitus distress from preintervention to postintervention [t(54)=4.18, P=.0001]. Participants in the control group, who received the book after completing the postquestionnaire and again completed the questionnaire 2 months after receiving the book (n=41), showed a nonsignificant trend towards reduction in tinnitus distress between the time of postmeasure (mean=21.00, S.D.=17.59) and follow-up 2 months later (mean=19.05, S.D.=16.69) [t(40)=1.16, Pb.25]. Following the lead of Kaldo et al. [23], we considered a decrease in tinnitus-related distress scores of at least 50% as clinically significant. Fourteen of 55 individuals in the experimental group who completed postintervention assessment (25%) achieved a reduction in tinnitus-related distress of at least 50%; 10 of 70 individuals in the control group (14%) achieved that level of reduction. The between-groups difference in the rates of reliable change, although in the hypothesized direction, was not statistically significant (χ 2 =2.48, P=.15). Conducting the same analysis on the basis of intention-to-treat also leads to a nonsignificant result (χ2=0.47), with 14 of 84 (17%) reaching clinically significant improvement in the experimental condition and with 10 of 78 (13%) reaching clinically significant improvement in the control condition. Forty-four of the participants in the intervention condition completed the follow-up (2 months after posttest and 4 months after receiving the self-help book). With a mean score of 15.43 (S.D.=15.02) on tinnitus distress, these participants maintained a significant reduction in tinnitus distress on follow-up in comparison to their distress at pretest [t(43)=2.93, P=.005]. Eighty-four of the original participants completed the 1year follow-up by rating their tinnitus-related distress on the Tinnitus Reaction Questionnaire. All of these participants
Table 2 Means and S.D. for variables at pretest Total sample (N=162)
Intervention (n=84)
Control (n=78)
Variables
Mean
S.D.
Mean
S.D.
Mean
S.D.
Tinnitus symptom severity (Z-score) Tinnitus distress General distress
0.00 21.63 11.54
6.92 18.83 5.31
88 21.75 11.83
7.34 19.20 5.73
−0.95 21.50 11.23
6.34 17.63 4.85
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Table 3 Means and S.D. for tinnitus distress and general distress at pretest and posttest for participants who completed posttest measures Intervention group (n=57) Pretest
Control group (n=70) Posttest
Pretest
Posttest
Variables
Mean
S.D.
Mean
S.D.
Mean
S.D.
Mean
S.D.
Tinnitus distress General distress
21.73 11.75
18.88 5.64
15.55 9.91
15.02 3.94
22.36 11.23
17.01 4.96
20.67 11.14
16.51 3.76
had received the book 12–18 months prior to the follow-up data collection. The mean tinnitus distress score at pretest for these 84 participants was 19.93 (S.D.=16.50). Their mean score at 1year follow-up was 15.24 (S.D.=14.89). This lessening in tinnitus distress from pretest to 1-year follow-up was significant [t(83)=3.09, P=.003]. An intention-to-treat analysis, which involved carrying forward the last reported tinnitus distress score to impute that score for individuals who did not complete the 1-year follow-up data collection, also showed a significant lessening of tinnitus-related distress [t(161)=4.18, P=.0001], with a mean score of 21.63 (S.D.=18.83) at pretest and a mean score of 17.64 (S.D.=17.10) at 1-year follow-up. General distress An analysis of covariance, using 2-month postscores for general distress as outcome and general distress prescores as covariate, showed that the general distress scores (see Table 3) of those assigned to the intervention condition who completed the postassessment were significantly lower than the general distress scores of those in the control condition who completed the postassessment [F(1,119)=5.41, P=.02, d=.26]. Those in the intervention condition who completed the postassessment experienced a significant reduction in general distress from preintervention to postintervention [t(54)=2.05, P=.04]. On follow-up, 44 participants in the intervention condition provided information on their general distress. With a mean score of 9.76 (S.D.=4.51) on general distress, these participants maintained a significant reduction in general distress on follow-up [t(43)=2.37, P=.02]. Relationships between amount of book read and changes made with decrease in distress The percentage of the book that participants reported reading was not related to the decrease in tinnitus distress from pretest to posttest [r(54)=.12, P=.37] or to the decrease in general distress from pretest to posttest [r(54)=.26, P=.06]. The composite measure of cognitive, behavioral, and situational changes made in response to reading the book was related to the decrease in tinnitus-related distress [r(54)=.29, P=.03] and the decrease in general distress [r(54)=.39, P=.004]. The relationships of the specific changes to change in tinnitus distress were as follows: change in cognition [r(54)=.15, P=.27, ns]; change in
behavior [r(54)=.29, P=.03]; and change in situations [r(54)=.35, P=.01]. The relationships of the specific changes to change in general distress were as follows: change in cognition [r(54)=.33, P=.01]; change in behavior [r(54)=.35, P=.01]; and change in situations [r(54)=.39, P=.004]. The correlations were not α-corrected. Narratives related to changes made and helpfulness of the book The comments that participants made in relation to cognitive, behavioral, or situational changes prompted by the book varied from general to specific. The comments included the following: “The book gave me a clearer understanding, and it [tinnitus] no longer frightens me,” “This is something I have to and can learn to manage,” “I use a sound machine now to get to sleep,” “Relaxation really does help,” and “[I] stop negative thoughts using the ABC and coping mechanisms.” Some participants commented that they were already familiar with the change strategies offered by the guide.
Discussion With the use of an experimental design, the study examined the efficacy of bibliotherapy in alleviating tinnitus distress. Completer analysis results indicated that a cognitive–behaviorally based tinnitus guide book helped participants experience significantly less tinnitus-related distress and less general distress compared to participants in the waiting list control condition. The intervention produced a small effect size for tinnitus-related distress (d=.28) and general distress (d=.26). Of those participants in the self-help book intervention condition who completed the postassessment, 25% showed a clinically significant reduction in tinnitus-related distress, compared to 14% in the control group. This reduction involved a reduction of at least 50% in scores on the relevant measure of distress. One way to look at the effect is to calculate NNT, the number of individuals who need to be treated, on average, in order to produce one more case of a clinically significant change in the treated group than in the control group. The formula for NNT is 1/(proportion of E group achieving reliable change −proportion of C group achieving reliable change). Here, the NNT was 1/(0.25−0.14)=9.09, meaning that about nine clients would need to receive the treatment in order for one
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more person to achieve a reliable change than they would without treatment. The results of the present study support and extend the findings of Kaldo et al. [23]. Kaldo et al. [23] found that Swedish tinnitus suffers who received a self-help guide, in conjunction with therapist support, experienced reductions in tinnitus distress, depression, and anxiety. The present study partially replicates these findings with Australian tinnitus sufferers and extends the findings to testing the effectiveness of a bibliotherapy intervention without therapist support. The best evidence for replication comes from the results of the comparisons of the intervention and control groups in the present study. The significant improvements found from pretest to posttest for individuals in the intervention condition also provide evidence, although based on a weaker part of the design, of the effectiveness of bibliotherapy. The promise of pre–post improvement finding for the experimental group was tempered somewhat by the finding that, for control group participants who received the intervention after having completed the postassessment, there was only a nonsignificant trend towards lessening of tinnitus distress. The 1-year follow-up assessment of tinnitus distress, which included participants in both the original intervention group and the control group, all of whom had received the book at least 1 year previously, showed a significant reduction in tinnitus distress compared to distress at pretest. Although the 1-year follow-up results are also based on a weaker part of the design, they provide some tentative evidence of the longterm effectiveness of a bibliotherapy intervention. For some individuals, contacts with a therapist may encourage the use of bibliotherapeutic material or may provide other important assistance. Hence, the findings of the study of Kaldo et al. are most relevant to the effects of the use of bibliotherapy mixed with phone therapy; the present findings are more relevant to the effects of self-help books, as individuals most often use them without therapist involvement. However, the present results were found in the context of the study, creating the possibility that any bona fide experimental intervention would have prompted participants to improve. The present study of CBT-based Internet treatment for tinnitus distress found that, on an intention-to-treat basis, 14 of 84 (17%) treated individuals who did not have any therapist contact achieved clinically significant improvement —a reduction of at least 50% in tinnitus distress (TRQ) scores. The results of previously published CBT-based online interventions for tinnitus distress showed, on intention-to-treat analyses, that 10 of 26 (38%) treated participants who also received weekly email contact with a therapist [25] and 11 of 34 (32%) treated participants who also received weekly phone calls from therapists [23] achieved clinically significant improvement, measured in the same way as in the present study. If we combine the two groups that had weekly therapist contacts, we find that 21 of 60 individuals achieved clinically significant improvement, a
proportion significantly higher than that of 14 of 84 individuals in our study with no therapist contact (χ2=6.39, Pb.02). Hence, there is some reason to think that weekly therapist contact may add to the effects of an Internet-based intervention for tinnitus distress. However, various other differences between studies could explain the differences in outcome. For instance, the participants in the study of Kaldo et al. [23] had a much higher pretreatment level of tinnitusrelated distress, with a mean TRQ score of about 39, than the participants in the present study, with a mean of about 22. Hence, the participants in that study may have had more room to improve. On the other hand, the participants in the study of Kaldo et al. [25] had a mean TRQ of 27, close to that in the present study. The finding that a bibliotherapeutic approach may help reduce tinnitus-related distress is important because self-help books tend to provide inexpensive treatment that, in theory, can be available anywhere and anytime. The finding adds to prior findings indicating that cognitive–behaviorally based self-help books can provide effective treatment for depression, panic disorder, and various other psychological problems [9–11,14]. However, the small effect size suggests that this type of intervention has only some practical impact. In the present study, the percentage of the book read was not significantly associated with reduction in either type of distress; however, the correlation with general distress reduction was very close to significant. The average amount read was 82%, so there may have been a ceiling effect that restricted the correlation. The amount of change made altogether in thinking, behavior, and situations was significantly associated with the level of reduction in both tinnitus-related distress and general distress. This finding, although only correlational, is consistent with the view that making changes in thinking, behavior, and situations plays a role in reducing distress. There was greater loss of participants in the experimental group at postintervention assessment than in the control group. Using a self-help book independently and effectively likely requires adequate time, reading ability, self-confidence, and self-discipline. Whether the individuals who dropped out of the self-help book condition would have done better in face-to-face treatment is unknown. Nevertheless, because the dropout rate was higher in the experimental condition, the size of the treatment effect may be lower than apparent in our between-groups comparisons of individuals who completed the postintervention assessment. One implication of the higher participant loss rate in the book condition versus the control condition is that an intention-totreat analysis with preintervention scores imputed at postassessment for all lost participants shows no significant effect of treatment. The participant loss rate in the experimental condition was 35%. This was slightly higher than the loss rate in the CBT-based online tinnitus treatment study of KaldoSandstrom et al. [24], which lost 23 of 77 participants (30%). It was higher than the loss rate in a study of treatment
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for tinnitus by a self-help book [23], which reported a treatment dropout rate of 20% but a postintervention assessment data loss of only 7%. It could be that the weekly therapist phone calls in that study contributed to the willingness of the participants to complete the postintervention assessment. In the study of Kaldo-Sandstrom et al. [24], participants received some therapist emails and had the opportunity, rarely used, to have face-to-face sessions. In the present study, the participants did not have any therapist contact. The significant reduction in distress experienced by the self-help book group continued to exist on follow-up, 2 months after the intervention ended and 4 months after participants received the book. However, only about half of the participants assigned to the experimental condition completed the follow-up assessment. The finding of a continuing effect is common in the traditional face-to-face treatment of anxiety and depression [14]. In a study of the effectiveness of a self-help guide, in conjunction with therapist contact, Kaldo et al. [23] also found a long-term reduction in tinnitus distress. The finding of a similar pattern with the self-help book in this study is important because it suggests a continuing benefit from an inexpensive and convenient alternative form of treatment. We did not collect data on any other treatment obtained by participants during the study. Hence, it is possible that the results were affected by other treatments. Future studies could examine further which tinnitus sufferers benefit the most from self-help book interventions. Studies could also collect additional information on the most important elements of the improvement process. Acknowledgments We would like to express our appreciation to the American Tinnitus Association for providing the grant that made this project possible. References [1] Preece JP, Tyler RS, Noble W. The management of tinnitus. Geriatr Aging 2003;6:22–8. [2] Andersson G, Kaldo V. Internet-based cognitive behavioral therapy for tinnitus. J Clin Psychol 2004;60:171–8. [3] Dobie RA. Clinical trials and drug therapy for tinnitus. In: Snow JB, editor. Tinnitus: theory and management. Hamilton (ON): BC Decker, 2004. p. 266–77. [4] Robinson SK, Viirre ES, Stein MB. Antidepressant therapy for tinnitus. In: Snow JB, editor. Tinnitus: theory and management. Hamilton (ON): BC Decker, 2004. p. 278–93. [5] Noble W. Treatments for tinnitus. Trends Amplif 2008;12:236–41. [6] Andersson G. Psychological aspects of tinnitus and the application of cognitive–behavioral therapy. Clin Psychol Rev 2002;22:977–90.
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[7] Henry JL, Wilson PH. The psychological management of chronic tinnitus: a cognitive behavioral approach. Boston: Allyn and Bacon, 2001. [8] Martinez Devesa P, Waddell A, Perera R, Theodoulou. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev 2007, doi:10.1002/14651858 article no. CD005233, CD005233.pub2 2007. [9] Green F, Malouff J. Processes involved in improvement associated with reading self-help books for psychological problems. Aust e-J Adv Ment Health 2007;6. www.auseinet.com/journal/vol6iss1/green.pdf. [10] Malouff J, Rooke S. Empirically supported self-help books. Behav Ther 2007;30:129–31. [11] Carlbring P, Westling BE, Andersson G. A review of published selfhelp books for panic disorder. Scand J Behav Ther 2000;29:5–13. [12] Gould RA, Clum GA. A meta-analysis of self-help treatment approaches. Clin Psychol Rev 1993;13:169–86. [13] Marrs WR. A meta-analysis of bibliotherapy studies. Am J Community Psychol 1995;23:843–71. [14] McKendree-Green NL, Floyd M, Scogin FR. Self-administered treatments for depression: a review. J Clin Psychol 2003;59:275–88. [15] Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems. J Behav Med 2008; 31:169–77. [16] Lambert MJ, Ogles BM. The efficacy and effectiveness of psychotherapy. In: Garfield SL, Bergin AE, editors. Handbook of psychotherapy and behavior change, 5th edNew York: Wiley, 2004. [17] McDermut W, Miller IW, Brown RA. The efficacy of group psychotherapy for depression: a meta-analysis and review of the empirical research. Clin Psychol Sci Pract 2001;8:98–116. [18] Tyler RS, Coelho C, Noble W. Tinnitus: standard of care, personality differences, genetic factors. ORL J Otorhinolaryngol Relat Spec 2006; 68:14–9. [19] Habets B. The tinnitus handbook: a self-help guide. Encinitas, CA: United Research Publishers, 1996. [20] Henry JL, Wilson PH. Tinnitus: a self-management guide for the ringing in your ears. Boston: Allyn and Bacon, 2001. [21] Hogan K. Turning the volume down. 2nd rev. ed. Eagan, MN: Network 3000, 2003. [22] Vernon JA, Sanders BT. Tinnitus: questions and answers. Boston: Allyn and Bacon, 2001. [23] Kaldo V, Cars S, Rahnert M, Larsen HS, Andersson G. Use of a selfhelp book with weekly therapist contact to reduce tinnitus distress: a randomized controlled trial. J Psychosom Res 2007;63:195–202. [24] Kaldo-Sandstrom V, Larsen HC, Andersson G. Internet-based cognitive–behavioral self-help treatment of tinnitus. Am J Audiol 2004;13:185–92. [25] Kaldo V, Levin S, Widersson J, Buhrman M, Larsen HC, Andersson G. Internet versus group cognitive–behavioral treatment of distress associated with tinnitus: a randomized controlled trial. Behav Ther 2008;39:348–59. [26] Meikle MB, Griest SE, Stewart BJ, Press LJ. Measuring the negative impact of tinnitus: a brief severity index [Abstracts]. Assoc Res Otolaryngol 1995:167. [27] Sirois FM, Davis CG, Morgan MS. “Learning to live with what you can't rise above”: control beliefs, symptom control, and adjustment to tinnitus. Health Psychol 2006;26:119–23. [28] Wilson PH, Henry JL, Bowen M, Haralambous G. Tinnitus Reaction Questionnaire: psychometric properties of a measure of distress associated with tinnitus. J Speech Hear Res 1991;34:197–201. [29] Goldberg D, Williams P. A user's guide to the General Health Questionnaire. Windsor, Berkshire, UK: NFER-Nelson, 1988. [30] Alford W, Malouff JM, Osland K. Effects of emotional expression on workers in stressful jobs. Int J Stress Manage 2005;12:177–87.
The effectiveness of bibliotherapy in alleviating tinnitus-related distress John M. Malouff ⁎, William Noble, Nicola S. Schutte, Navjot Bhullar University of New England, Australia Received 19 September 2008; received in revised form 10 July 2009; accepted 28 July 2009
Abstract Objective: The present study examined the efficacy of bibliotherapy in assisting individuals experiencing distress related to tinnitus. Methods: One hundred sixty-two tinnitus sufferers from Australia participated in a study designed to examine the effectiveness of a cognitive–behaviorally based self-help book in reducing distress. To maximize the ecological validity of the findings, we excluded no individuals interested in treatment for tinnitus-related distress. Results: The experimental condition lost 35% of participants at postassessment, compared to 10% in the control group. In an analysis of participants who completed postintervention assessment, those assigned to the intervention condition, who received a tinnitus self-help book, showed significantly less tinnitus-related distress and general distress 2 months later compared to those assigned to the waiting list control condition. The intervention group's reduction in tinnitus-related
distress and general distress from preintervention to postintervention 2 months later was significant, and these participants maintained a significant reduction in distress on follow-up 4 months after they received the tinnitus self-help book. A long-term follow-up of all participants, who at that time had received the book at least a year previously, showed a significant reduction in tinnitus distress. Although these group differences and pre–post changes were significant, effect sizes were small. Intention-to-treat analyses showed no significant effect for between-groups analyses, but did show a significant effect for the 1-year follow-up pre–post analysis. Conclusion: Information on the effectiveness of using a self-help book, without therapist assistance, in alleviating distress is important, as bibliotherapy can provide inexpensive treatment that is not bound by time or place. © 2010 Elsevier Inc. All rights reserved.
Keywords: Bibliotherapy; Cognitive–behavioral therapy; Distress; Self-help; Tinnitus
Introduction Tinnitus involves the perception of a persistent sound, in the absence of an acoustic source, that is often described as ringing, buzzing, whistling, or chirping. Approximately 14% of the adult population experiences tinnitus symptoms persistently [1], and 20% of those with such symptoms experience substantial distress because of their tinnitus [2]. Recent reviews of approaches to treatment for tinnitus indicate that no effective pharmacological treatment is available [3,4], nor is there yet an accessible physical treatment [5]. Cognitive–behavioral therapy (CBT) delivered by therapists tends to be effective in alleviating distress associated ⁎ Corresponding author. Psychology, University of New England, Armidale NSW 2351, Australia. E-mail address: [email protected] (J.M. Malouff). 0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.07.023
with tinnitus [6,7]. A Cochrane review [8] indicated that this procedure used in tinnitus treatment can have a beneficial effect on quality of life compared to a waiting list control (SMD=0.7; 95% confidence interval=0.33–1.08). However, the review found no significant effect on subjective tinnitus loudness or depression. The Cochrane review found that cognitive–behavioral interventions in relation to tinnitus commonly use several of the following techniques: provision of information about tinnitus and its causes, changing overly negative appraisals of the tinnitus condition, building better control of attentional processes, management of sleep, and positive imagery and relaxation training [6,7]. One limitation of CBT as it has been used to help tinnitus sufferers is that it involves seeing a mental health professional, which may be associated with significant expense, delay, travel, and feared embarrassment. One possible way around these problems involves providing the treatment via a self-help book.
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The bibliotherapy approach Self-help books exist for a wide variety of psychological problems. Studies of their value indicate that they can help individuals make substantial improvements [9,10], on average about as much as psychotherapy [11–14]. Metaanalyses of the efficacy of bibliotherapy have shown treatment effect sizes (Cohen's d) of .56 for bibliotherapy across a range of psychological problems [13]. Studies of Internet-administered treatment showed similar effect sizes, although these were slightly lower than the effect sizes for bibliotherapy [15]. The finding that bibliotherapy can be effective in alleviating distress may reflect the fact that theoretically grounded psychological treatments tend to have positive effects. Meta-analytic reviews have shown that therapistdelivered psychotherapies with a sound theoretical basis are substantially more effective than waiting list or placebo control conditions in the treatment of mental disorders [16]. Self-help books, including tinnitus self-help books, based on a theoretically sound basis may have treatment effects roughly equal to the effects of other types of psychological treatment. The finding that bibliotherapeutic approaches can have a positive effect on depression [15,17] has special implications for tinnitus-related distress. A number of studies have found an association between tinnitus-related distress and depression, and improvements in tinnitusrelated disability and depressive symptoms covary [7]. Tyler et al. [18] have suggested that tinnitus distress and depression may have a common cause. There are a number of tinnitus self-help books [19–22], and these offer information and strategies to help people with tinnitus better deal with the condition. As cognitive– behavioral techniques for tinnitus-related distress have been found effective when delivered by therapists, a selfhelp book based on such techniques would seem to hold promise. One published study [23] has examined the effectiveness of a bibliotherapeutic approach, in combination with support by a therapist, in reducing tinnitus-related distress. Kaldo et al. [23] conducted an intervention in which they provided Swedish participants with a cognitive–behaviorally based tinnitus self-help guide prepared for the study, together with telephone calls by therapists with clinical psychology training. During the calls, which occurred weekly over a 6-week period, therapists evaluated treatment progress and provided advice to participants on how to progress. Participants in the intervention condition showed significant reductions in tinnitus-related distress, depression, and anxiety from pretest to posttest compared to participants in the waiting list control condition. Participants who were initially in the control condition were later provided with the self-help guide and less intensive contact with a therapist; under this condition, the therapists had only one telephone session with the participants and, in this
session, therapists and participants created treatment plans and goals. Participants in this less intensive therapy contact condition also showed significant reductions in tinnitusrelated distress and psychological distress, although not quite as much reduction in tinnitus distress and anxiety as those who had the more intensive therapist contact. The study did not examine the effect of using a self-help book with no additional support, as an individual acquiring a tinnitus self-help guide from a bookstore or library might do. The purpose of the present study was to evaluate the effect of using a self-help book without therapist assistance to treat individuals who seek help for tinnitus-related distress. In order to maximize the ecological validity of the study, we used no exclusionary criteria. Kaldo-Sandstrom et al. [24] examined the effects of an Internet- and email-focused CBT on tinnitus-related psychological symptoms and found improvement from preintervention to postintervention in a group of individuals selected to have serious tinnitus and no psychiatric or social problems that might interfere with Internet treatment. Kaldo et al. [25] studied a CBT intervention delivered as an Internet-focused treatment for tinnitus-related distress and found that this treatment was as effective as group in-person treatment.
Method Participants Participants were recruited from throughout Australia through postings on tinnitus support Web pages, announcements at in-person tinnitus support groups, postings in audiology practices, and media releases. Of the 219 individuals who initially indicated interest in participating, 162 completed a mail-in questionnaire that assessed the variables of interest. We used no exclusionary criteria. All of these individuals had some symptoms of tinnitus, as assessed by items on the Tinnitus Severity Scale [27]. We did not collect data on other types of hearing problems, specific medical conditions, or other demographic characteristics of the sample. Sixty-nine percent of the participants reported constantly hearing tinnitus noise, with another 27% reporting the noise as being usually present. Seventy-three percent of participants reported that tinnitus noise interfered with their detection of sounds, and 72% reported that tinnitus noise interfered with their understanding of speech. Design and procedure The study consisted of a randomized controlled trial with premeasures, postmeasures, and follow-up measures. Individuals with tinnitus who volunteered to participate in the project were sent premeasures assessing tinnitus severity, tinnitus-related distress, general distress, and several other measures that are not the focus of this report. Participants who sent back completed questionnaires were matched on
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the severity of tinnitus distress. After matching for the level of tinnitus distress, we tossed a coin to determine which condition to assign to each member of closely matched pairs. This process led to slightly uneven numbers in each group. Those in the intervention group were immediately sent the Henry and Wilson [20] tinnitus self-help book. We asked the participants in the book condition to complete the book within 2 months. We chose that time frame in the hope that they would complete about one chapter every 5 days. After 2 months, participants in both groups were asked again to complete the measures of tinnitus-related distress and general distress. Participants who did not respond received three weekly emails encouraging them to complete the assessment. Participants in the intervention group were asked to report what percentage of the book they had read and to what extent the book led them to change their situations, cognition, and behavior. Those in the control condition then also received the book. Two months after this (i.e., 4 months after commencing participation in the project), participants were asked to complete a follow-up assessment of tinnitusrelated distress and general distress. All participants who completed the pretest were also invited to complete a 1-year follow-up assessment of tinnitus-related distress. At postintervention assessment and follow-up assessment, we encouraged participants to complete the assessment; if they did not do so, we encouraged them again. If we still did not receive the information, we encouraged them a third and final time. Assessment Tinnitus severity The Tinnitus Severity Scale [26,27] is a measure of the strength of the perceptual aspects of tinnitus severity such as loudness of tinnitus noise and how much it interferes with an individual's ability to assess from where external sounds originate. The response format varies among the items, and we followed the usual method of calculating scale scores [27]: standardizing each item and then summing. The measure has evidence of good reliability, with a Cronbach's α of .84 [27]. In the current study, the internal consistency at pretest, as measured through Cronbach's α, was .84. Tinnitus-related distress The Tinnitus Reaction Questionnaire [28] is a measure of psychological distress specifically associated with tinnitus. This was the main outcome measure in the study. Sample items are “My tinnitus has made me feel irritable” and “My tinnitus has interfered with my enjoyment of life.” Different items have different numbers of response options, so the usual way to calculate a total score involves standardizing responses to each item and summing them [28]. We followed this method. This measure has evidence of good reliability (with a Cronbach's α of .96) and validity [28]. In the current study, the internal consistency at pretest was .95.
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General psychological distress The General Health Questionnaire-12 [29] is a measure of general psychological distress that has been used extensively in research. Sample items ask participants whether they “felt they couldn't overcome their difficulties” and whether they have “been feeling unhappy and depressed.” Studies of the scale showed Cronbach's α values of. .82 to .90, as well as good sensitivity and specificity with regard to psychiatric case identification through diagnostic interview schedules [29]. The scale has also been found to be sensitive to treatment-induced reduction in distress [30]. In the current study, the internal consistency at pretest was .90. Involvement in bibliotherapy As a manipulation check, participants were asked what percentage of the book they had read. Participants were also asked to indicate on a 7-point scale to what extent the book led them to change their situations, cognition, and behavior. In a previous bibliotherapy study, this scale had a Cronbach's α of .85 and evidence of validity through an association with level of improvement [9]. In the present study, the internal consistency for these three items at posttest was .89. Participants were also asked to provide free narrative descriptions of changes that the book prompted and what was most helpful about the book. Intervention material Participants received the book Tinnitus: A Self-Management Guide for the Ringing in Your Ears. This self-help book by Henry and Wilson [20] is based on cognitive–behavioral principles, including educational information on tinnitus, cognitive reappraisal and restructuring, relaxation and stress management techniques, attention control techniques, use of self-instruction, making lifestyle changes, and maintaining gains. The book provides guidelines for specific exercises such as progressive muscle relaxation and personalizing selfinstructions. The book is derived from an effective standard clinical psychological intervention project [7]. Accompanying the book was a brief letter asking participants to read the book and to follow the suggestions contained in it during the subsequent 6 weeks. No specific directions were provided in the letter, and no further contact was made with participants until the time of postassessment.
Results Table 1 shows the flow of participants. Of the 162 participants, 84 (51% men) were randomly assigned to the intervention condition, and 78 (60.3% men) were assigned to the control group. The mean age of participants in the intervention group was 57.3 years [standard deviation (S.D.)=13.7], and the mean age of participants in the control condition was 57.8 years (S.D.=13.3). The age and gender compositions of the groups were not significantly different.
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Table 1 Flow of participants (162 participants entered the study; no one was excluded)
Randomly assigned Completed postassessmenta Completed follow-up Completed 1-year follow-up
Experimental
Control
84 55 44 45
78 70 – 39
No reasons for loss were ascertained.
One hundred twenty-seven participants completed the postquestionnaire, of which 55 (60% male) were in the treatment condition and 70 (53% male) were in the control condition. Table 2 shows the means and S.D. for tinnitus symptom severity, tinnitus distress, and general distress at pretest for all participants and separately for participants who were assigned to the intervention and control conditions. At pretest, there were no significant differences in symptom severity, tinnitus distress, and general distress between those assigned to the intervention condition and those assigned to the control condition (see Table 2). Of the 84 individuals assigned to the experimental group, 55 (65%) completed postintervention assessment. Of the 78 individuals assigned to the control group, 70 (90%) completed the postassessment. This difference in the completion rates of the postquestionnaire was significant (χ2=13.51, P=.001). We tested age and sex as potential predictors of completion in the experimental condition, but neither variable provided significant prediction. All participants in the intervention condition who completed the 2-month posttest reported having read at least some of the tinnitus self-management guide. Participants, on average, reported reading 82% of the book. Using the 7-point scale (7=extremely, 1=not at all), participants rated the extent to which reading the book led them to change their thinking, behavior, and situations. The mean scores for these three items were 3.03 (S.D.=1.60), 2.67 (S.D.=1.59), and 2.23 (S.D.=1.68), respectively, indicating slight to moderate changes. Effectiveness of bibliotherapy intervention in reducing distress Tinnitus distress An analysis of covariance, using 2-month postscores for tinnitus distress as outcome and tinnitus distress prescores as
covariate, showed that the tinnitus distress scores (see Table 3) of those assigned to the intervention condition who completed the postassessment were significantly lower than the tinnitus distress scores of those who completed the postassessment in the control condition [F(1,122)=6.23, P=.01, d=.28]. However, a more conservative betweengroups intention-to-treat evaluation of tinnitus distress, which involved imputing posttest scores for those who did not complete the postassessment by assigning them the score they had at pretest, was not significant [F(1,159)=3.28, P=.07]. Individuals in the intervention condition who completed the postassessment experienced a significant reduction in tinnitus distress from preintervention to postintervention [t(54)=4.18, P=.0001]. Participants in the control group, who received the book after completing the postquestionnaire and again completed the questionnaire 2 months after receiving the book (n=41), showed a nonsignificant trend towards reduction in tinnitus distress between the time of postmeasure (mean=21.00, S.D.=17.59) and follow-up 2 months later (mean=19.05, S.D.=16.69) [t(40)=1.16, Pb.25]. Following the lead of Kaldo et al. [23], we considered a decrease in tinnitus-related distress scores of at least 50% as clinically significant. Fourteen of 55 individuals in the experimental group who completed postintervention assessment (25%) achieved a reduction in tinnitus-related distress of at least 50%; 10 of 70 individuals in the control group (14%) achieved that level of reduction. The between-groups difference in the rates of reliable change, although in the hypothesized direction, was not statistically significant (χ 2 =2.48, P=.15). Conducting the same analysis on the basis of intention-to-treat also leads to a nonsignificant result (χ2=0.47), with 14 of 84 (17%) reaching clinically significant improvement in the experimental condition and with 10 of 78 (13%) reaching clinically significant improvement in the control condition. Forty-four of the participants in the intervention condition completed the follow-up (2 months after posttest and 4 months after receiving the self-help book). With a mean score of 15.43 (S.D.=15.02) on tinnitus distress, these participants maintained a significant reduction in tinnitus distress on follow-up in comparison to their distress at pretest [t(43)=2.93, P=.005]. Eighty-four of the original participants completed the 1year follow-up by rating their tinnitus-related distress on the Tinnitus Reaction Questionnaire. All of these participants
Table 2 Means and S.D. for variables at pretest Total sample (N=162)
Intervention (n=84)
Control (n=78)
Variables
Mean
S.D.
Mean
S.D.
Mean
S.D.
Tinnitus symptom severity (Z-score) Tinnitus distress General distress
0.00 21.63 11.54
6.92 18.83 5.31
88 21.75 11.83
7.34 19.20 5.73
−0.95 21.50 11.23
6.34 17.63 4.85
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Table 3 Means and S.D. for tinnitus distress and general distress at pretest and posttest for participants who completed posttest measures Intervention group (n=57) Pretest
Control group (n=70) Posttest
Pretest
Posttest
Variables
Mean
S.D.
Mean
S.D.
Mean
S.D.
Mean
S.D.
Tinnitus distress General distress
21.73 11.75
18.88 5.64
15.55 9.91
15.02 3.94
22.36 11.23
17.01 4.96
20.67 11.14
16.51 3.76
had received the book 12–18 months prior to the follow-up data collection. The mean tinnitus distress score at pretest for these 84 participants was 19.93 (S.D.=16.50). Their mean score at 1year follow-up was 15.24 (S.D.=14.89). This lessening in tinnitus distress from pretest to 1-year follow-up was significant [t(83)=3.09, P=.003]. An intention-to-treat analysis, which involved carrying forward the last reported tinnitus distress score to impute that score for individuals who did not complete the 1-year follow-up data collection, also showed a significant lessening of tinnitus-related distress [t(161)=4.18, P=.0001], with a mean score of 21.63 (S.D.=18.83) at pretest and a mean score of 17.64 (S.D.=17.10) at 1-year follow-up. General distress An analysis of covariance, using 2-month postscores for general distress as outcome and general distress prescores as covariate, showed that the general distress scores (see Table 3) of those assigned to the intervention condition who completed the postassessment were significantly lower than the general distress scores of those in the control condition who completed the postassessment [F(1,119)=5.41, P=.02, d=.26]. Those in the intervention condition who completed the postassessment experienced a significant reduction in general distress from preintervention to postintervention [t(54)=2.05, P=.04]. On follow-up, 44 participants in the intervention condition provided information on their general distress. With a mean score of 9.76 (S.D.=4.51) on general distress, these participants maintained a significant reduction in general distress on follow-up [t(43)=2.37, P=.02]. Relationships between amount of book read and changes made with decrease in distress The percentage of the book that participants reported reading was not related to the decrease in tinnitus distress from pretest to posttest [r(54)=.12, P=.37] or to the decrease in general distress from pretest to posttest [r(54)=.26, P=.06]. The composite measure of cognitive, behavioral, and situational changes made in response to reading the book was related to the decrease in tinnitus-related distress [r(54)=.29, P=.03] and the decrease in general distress [r(54)=.39, P=.004]. The relationships of the specific changes to change in tinnitus distress were as follows: change in cognition [r(54)=.15, P=.27, ns]; change in
behavior [r(54)=.29, P=.03]; and change in situations [r(54)=.35, P=.01]. The relationships of the specific changes to change in general distress were as follows: change in cognition [r(54)=.33, P=.01]; change in behavior [r(54)=.35, P=.01]; and change in situations [r(54)=.39, P=.004]. The correlations were not α-corrected. Narratives related to changes made and helpfulness of the book The comments that participants made in relation to cognitive, behavioral, or situational changes prompted by the book varied from general to specific. The comments included the following: “The book gave me a clearer understanding, and it [tinnitus] no longer frightens me,” “This is something I have to and can learn to manage,” “I use a sound machine now to get to sleep,” “Relaxation really does help,” and “[I] stop negative thoughts using the ABC and coping mechanisms.” Some participants commented that they were already familiar with the change strategies offered by the guide.
Discussion With the use of an experimental design, the study examined the efficacy of bibliotherapy in alleviating tinnitus distress. Completer analysis results indicated that a cognitive–behaviorally based tinnitus guide book helped participants experience significantly less tinnitus-related distress and less general distress compared to participants in the waiting list control condition. The intervention produced a small effect size for tinnitus-related distress (d=.28) and general distress (d=.26). Of those participants in the self-help book intervention condition who completed the postassessment, 25% showed a clinically significant reduction in tinnitus-related distress, compared to 14% in the control group. This reduction involved a reduction of at least 50% in scores on the relevant measure of distress. One way to look at the effect is to calculate NNT, the number of individuals who need to be treated, on average, in order to produce one more case of a clinically significant change in the treated group than in the control group. The formula for NNT is 1/(proportion of E group achieving reliable change −proportion of C group achieving reliable change). Here, the NNT was 1/(0.25−0.14)=9.09, meaning that about nine clients would need to receive the treatment in order for one
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more person to achieve a reliable change than they would without treatment. The results of the present study support and extend the findings of Kaldo et al. [23]. Kaldo et al. [23] found that Swedish tinnitus suffers who received a self-help guide, in conjunction with therapist support, experienced reductions in tinnitus distress, depression, and anxiety. The present study partially replicates these findings with Australian tinnitus sufferers and extends the findings to testing the effectiveness of a bibliotherapy intervention without therapist support. The best evidence for replication comes from the results of the comparisons of the intervention and control groups in the present study. The significant improvements found from pretest to posttest for individuals in the intervention condition also provide evidence, although based on a weaker part of the design, of the effectiveness of bibliotherapy. The promise of pre–post improvement finding for the experimental group was tempered somewhat by the finding that, for control group participants who received the intervention after having completed the postassessment, there was only a nonsignificant trend towards lessening of tinnitus distress. The 1-year follow-up assessment of tinnitus distress, which included participants in both the original intervention group and the control group, all of whom had received the book at least 1 year previously, showed a significant reduction in tinnitus distress compared to distress at pretest. Although the 1-year follow-up results are also based on a weaker part of the design, they provide some tentative evidence of the longterm effectiveness of a bibliotherapy intervention. For some individuals, contacts with a therapist may encourage the use of bibliotherapeutic material or may provide other important assistance. Hence, the findings of the study of Kaldo et al. are most relevant to the effects of the use of bibliotherapy mixed with phone therapy; the present findings are more relevant to the effects of self-help books, as individuals most often use them without therapist involvement. However, the present results were found in the context of the study, creating the possibility that any bona fide experimental intervention would have prompted participants to improve. The present study of CBT-based Internet treatment for tinnitus distress found that, on an intention-to-treat basis, 14 of 84 (17%) treated individuals who did not have any therapist contact achieved clinically significant improvement —a reduction of at least 50% in tinnitus distress (TRQ) scores. The results of previously published CBT-based online interventions for tinnitus distress showed, on intention-to-treat analyses, that 10 of 26 (38%) treated participants who also received weekly email contact with a therapist [25] and 11 of 34 (32%) treated participants who also received weekly phone calls from therapists [23] achieved clinically significant improvement, measured in the same way as in the present study. If we combine the two groups that had weekly therapist contacts, we find that 21 of 60 individuals achieved clinically significant improvement, a
proportion significantly higher than that of 14 of 84 individuals in our study with no therapist contact (χ2=6.39, Pb.02). Hence, there is some reason to think that weekly therapist contact may add to the effects of an Internet-based intervention for tinnitus distress. However, various other differences between studies could explain the differences in outcome. For instance, the participants in the study of Kaldo et al. [23] had a much higher pretreatment level of tinnitusrelated distress, with a mean TRQ score of about 39, than the participants in the present study, with a mean of about 22. Hence, the participants in that study may have had more room to improve. On the other hand, the participants in the study of Kaldo et al. [25] had a mean TRQ of 27, close to that in the present study. The finding that a bibliotherapeutic approach may help reduce tinnitus-related distress is important because self-help books tend to provide inexpensive treatment that, in theory, can be available anywhere and anytime. The finding adds to prior findings indicating that cognitive–behaviorally based self-help books can provide effective treatment for depression, panic disorder, and various other psychological problems [9–11,14]. However, the small effect size suggests that this type of intervention has only some practical impact. In the present study, the percentage of the book read was not significantly associated with reduction in either type of distress; however, the correlation with general distress reduction was very close to significant. The average amount read was 82%, so there may have been a ceiling effect that restricted the correlation. The amount of change made altogether in thinking, behavior, and situations was significantly associated with the level of reduction in both tinnitus-related distress and general distress. This finding, although only correlational, is consistent with the view that making changes in thinking, behavior, and situations plays a role in reducing distress. There was greater loss of participants in the experimental group at postintervention assessment than in the control group. Using a self-help book independently and effectively likely requires adequate time, reading ability, self-confidence, and self-discipline. Whether the individuals who dropped out of the self-help book condition would have done better in face-to-face treatment is unknown. Nevertheless, because the dropout rate was higher in the experimental condition, the size of the treatment effect may be lower than apparent in our between-groups comparisons of individuals who completed the postintervention assessment. One implication of the higher participant loss rate in the book condition versus the control condition is that an intention-totreat analysis with preintervention scores imputed at postassessment for all lost participants shows no significant effect of treatment. The participant loss rate in the experimental condition was 35%. This was slightly higher than the loss rate in the CBT-based online tinnitus treatment study of KaldoSandstrom et al. [24], which lost 23 of 77 participants (30%). It was higher than the loss rate in a study of treatment
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for tinnitus by a self-help book [23], which reported a treatment dropout rate of 20% but a postintervention assessment data loss of only 7%. It could be that the weekly therapist phone calls in that study contributed to the willingness of the participants to complete the postintervention assessment. In the study of Kaldo-Sandstrom et al. [24], participants received some therapist emails and had the opportunity, rarely used, to have face-to-face sessions. In the present study, the participants did not have any therapist contact. The significant reduction in distress experienced by the self-help book group continued to exist on follow-up, 2 months after the intervention ended and 4 months after participants received the book. However, only about half of the participants assigned to the experimental condition completed the follow-up assessment. The finding of a continuing effect is common in the traditional face-to-face treatment of anxiety and depression [14]. In a study of the effectiveness of a self-help guide, in conjunction with therapist contact, Kaldo et al. [23] also found a long-term reduction in tinnitus distress. The finding of a similar pattern with the self-help book in this study is important because it suggests a continuing benefit from an inexpensive and convenient alternative form of treatment. We did not collect data on any other treatment obtained by participants during the study. Hence, it is possible that the results were affected by other treatments. Future studies could examine further which tinnitus sufferers benefit the most from self-help book interventions. Studies could also collect additional information on the most important elements of the improvement process. Acknowledgments We would like to express our appreciation to the American Tinnitus Association for providing the grant that made this project possible. References [1] Preece JP, Tyler RS, Noble W. The management of tinnitus. Geriatr Aging 2003;6:22–8. [2] Andersson G, Kaldo V. Internet-based cognitive behavioral therapy for tinnitus. J Clin Psychol 2004;60:171–8. [3] Dobie RA. Clinical trials and drug therapy for tinnitus. In: Snow JB, editor. Tinnitus: theory and management. Hamilton (ON): BC Decker, 2004. p. 266–77. [4] Robinson SK, Viirre ES, Stein MB. Antidepressant therapy for tinnitus. In: Snow JB, editor. Tinnitus: theory and management. Hamilton (ON): BC Decker, 2004. p. 278–93. [5] Noble W. Treatments for tinnitus. Trends Amplif 2008;12:236–41. [6] Andersson G. Psychological aspects of tinnitus and the application of cognitive–behavioral therapy. Clin Psychol Rev 2002;22:977–90.
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