Abstract
Background:
Tinnitus is a complex experience characterized by sound perception in the absence of an acoustic source, which can accompany or result in psychological distress. Cognitive Behavioral Therapy (CBT) and counseling are two of the most prominent tinnitus therapy methods. CBT is a psychotherapy typically undertaken by psychologists. CBT considers that tinnitus distress results from distorted thinking and resultant maladaptive behaviors. CBT clinicians often employ restructuring techniques to change maladaptive thoughts and behaviors. Tinnitus counseling, commonly in the form of psychoeducation, is frequently used in tinnitus practice by audiologists. Tinnitus counseling aims to reduce the negative impact that tinnitus has on patients' lives. Counseling uses empathetic conversation and psychoeducation to help people understand their tinnitus and, through demystification, reduce distress. Insufficient availability of psychologist consultations and the strong evidence base for CBT have led to audiologists seeking to practice CBT. Although audiology-led counseling and CBT share some methodologies, the practice of CBT by non-psychologists is controversial.
Methods:
In this study, we review the literature to determine if therapy outcomes differ between CBT and counseling, various therapy durations, and different therapy providers. From the initial 210 articles chosen based on title relevance, eight studies were selected for data charting.
Results:
Three studies reported greater efficacy for CBT; in 1 study, counseling was superior, and in four, the outcomes were equivalent. There was a significant amount of variability in content, both between and within the methods used. Studies varied in terms of who provided the therapies and the duration of therapy.
Discussion:
The literature surveyed is characterized by ambiguity. Both CBT and counseling are helpful, but there is no clear evidence that one is superior to the other. It is also unclear what elements of CBT or counseling contribute the most benefit. A distinction needs to be made between CBT and CBT-informed counseling. Current scope of practice guidelines indicate that psychologist-led CBT may include cognitive restructuring psychotherapy, while CBT-informed counseling by audiologists (aCBT) should not.
Conclusion:
There is currently equivocal evidence for the efficacy of CBT and counseling for tinnitus management. Extending audiology practice to include CBT may not be a productive approach.
1 Introduction
Severe tinnitus is the result of a complex interplay between auditory and emotional neural processing () influenced by psychosocial factors (). Tinnitus can range from a slight nuisance to a disorder impacting life quality (). Tinnitus disorder may result from, or in, anxiety, depression, and stressful events (). In the absence of effective pharmacotherapy, tinnitus has been primarily managed through audiological or psychological approaches that have included counseling and Cognitive Behavioral Therapy (CBT) (). These approaches have placed a high emphasis on managing the negative impact of tinnitus on the sufferer's life, rather than eliminating the tinnitus sound (). CBT and counseling fall on a continuum as opposed to being dichotomous methods (). Psychologists will be familiar with approaches ranging from empathetic listening to CBT (Figure 1).
Figure 1
CBT is a structured psychological intervention aimed at changing a person's unhelpful patterns of thinking and behavior (). Within tinnitus management, CBT conceptualizes the disorder as arising and being maintained by distorted thinking and maladaptive behaviors. CBT has high-quality evidence to support its use (). CBT is regarded as the benchmark against which other psychological approaches are compared (). CBT psychotherapists have specific education and many hours of supervised practice (). Counseling is a term that encompasses a range of approaches designed to provide support and information, thereby improving an individual's coping and wellbeing (). Audiologist-based tinnitus counseling typically takes the form of patient-centered, empathetic conversations, psychoeducation (discussion of tinnitus, ear and brain physiology, hearing and sound therapies), and goal-based counseling (). Audiology counseling approaches include aspects of adjustment counseling, motivational interviewing, and Solution-Focused Therapy to help build self-efficacy (). Some counseling methods heavily draw on cognitive-behavioral models. Although CBT and audiologist tinnitus counseling content can be similar, the delivery methods, theoretical foundations, and training of psychologists and audiologists differ significantly ().
Some audiologists have argued for a long time that CBT for tinnitus should fall within the audiology scope of practice (). The debate has increased with more audiologists advocating for CBT () and its internet-based form, iCBT (). Motivating factors for this argument include the higher quality of evidence supporting CBT for tinnitus compared to audiology-based therapies, as well as the shortage of psychologists. However, there is little evidence for the effectiveness of audiology-led CBT () and in many jurisdictions, CBT requires formal education in psychology with postgraduate CBT-specific training (diploma or certificates) and supervised clinical experience using CBT (). Tinnitus counseling by audiologists is frequently bundled with sensory management through hearing aids and the use of sounds with many different applications (). Extracting counseling benefit from audiological management as a whole is difficult. The relative effectiveness of CBT and counseling have not been widely reviewed. The goal of this paper is to review the current literature comparing CBT to counseling, discuss their similarities and differences, and debate the merits of audiologists incorporating these interventions within their scope of practice.
2 Methods
A scoping review of the literature was undertaken between December 2024 and February 2025 using a six-step framework () following PRISMA guidelines (, Figure 2). The primary research question was “Do the outcomes of tinnitus therapy using CBT and counseling differ?”. Cognitive behavioral therapy (CBT) was defined as skills-focused treatment focusing on altering the thoughts and behaviors of patients to reduce maladaptive emotional responses (). Counseling was defined as the communication of knowledge and skills needed to understand and manage tinnitus, including general coping strategies (). Secondary questions were: “Did the length (number of sessions/time) or delivery (in person/digital) result in different outcomes?” and “Did results depend on who provided the therapies?”
Figure 2
The key search terms were cognitive behavioral therapy [OR cognitive behavioral therapy OR CBT OR cognitive therapy] AND counseling [OR counseling OR talk therapy OR psychotherapy] AND tinnitus OR ringing in the ears OR chronic tinnitus were extensively searched on four databases: Scopus, PubMed, Google Scholar, and psycArticles. Reference lists of the articles were reviewed, and hand searching was conducted to identify any additional relevant studies. Articles were excluded if they were not written in English or were unavailable in full text. From the initial 210 articles chosen based on title relevance, 26 studies were shortlisted based on relevancy of the abstracts, use of keywords, and meeting inclusion criteria (journal articles with an experimental methods and results section published after 1990 to maintain relevancy), with hand-searching resulting in the addition of a further 10 articles. Of the 36 articles, 29 were able to be fully reviewed (access was restricted for three articles, and four were excluded on the basis of being study proposals with no results). After reviewing the articles fully, eight studies were chosen for charting the data. One of the articles was reviewed as a pre-publication, the final article was published, and this was the version referenced.
3 Results
Outcomes of the scoping review were summarized to provide an overview of the included studies (author, year, therapy type, therapy provider(s), method, study size, outcome, Supplementary Table 1). The earliest publication included in the review dated back to 1996; the median publication date for research was 2011. The sample sizes ranged from 56 to 461 participants, with a mean of 155.6 participants across the publications (SD ± 147.5). The search captured a broad scope of CBT applications, including studies delivered via the internet, group sessions, and individual therapy, with interventions administered by both psychologists and audiologists. Counseling typically comprised psychoeducation, offering information surrounding the auditory system and tinnitus causes, assessment, and management, delivered via mobile applications or internet-based online platforms, in-person (individual or group counseling sessions), or through booklets or written resources. Of the eight studies reviewed, only in two papers was CBT/counseling solely delivered by audiologists.
3.1 Direct comparisons: CBT vs. counseling
Eight studies were identified that directly compared the therapeutic outcomes of cognitive behavioral therapy (CBT) with those of counseling. investigated the effectiveness of CBT-oriented Tinnitus Coping Training (TCT) in contrast to two minimal contact (MC) interventions (Minimal Contact-Education and Minimal Contact-Relaxation), as well as a waitlist control. TCT is described as a form of CBT adapted specifically for tinnitus management. Patients were randomized to either the TCT group (n = 43) to receive therapy in a group over a period of 11 sessions, Minimal Contact-Education (n = 16) to take part in two group sessions in which education and self-help strategies around tinnitus were presented, Minimal Contact-Relaxation (n = 16) to receive music-supported relaxation in addition to education over a period of four sessions, or waitlist control (n = 20). The study reported that the TCT showed highly significant improvements in comparison to the control group and was somewhat superior to both MC interventions in diary variables, coping, and subjective change ratings. There was no significant difference in disability reduction between TCT and MC. Larger changes in psychopathology, as measured by the General Symptom Index (GSI) of the Symptom Checklist (SCL-90R) and the Allgemeine Depressionsskala ADS (German version of the Center for Epidemiologic Studies Depression Scale (CES-D)) depression questionnaire, were found for the MC groups than for TCT. MC intervention outcomes did not differ significantly from each other but were superior to the waitlist control in a few domains of outcome (disability, psychopathology, and subjective change) (). A subsequent study by contrasted the effects of TCT to a habituation-based treatment (based on Jastreboff's neurophysiological model of tinnitus, ) and an educational intervention (active control group). TCT (n = 27) was implemented in a group format over 11 sessions, habituation-based treatment (n = 30) was delivered in five group sessions, and the educational intervention (n = 20) was presented in a single group session. Data assessments included follow-ups up to 21 months post-treatment. The study revealed that TCT and the habituation-based treatment both significantly outperformed the education intervention, with TCT being slightly superior to the habituation-based treatment on the basis of prolonged treatment effects (sustained benefit 18 months post-treatment vs. 12 months for the habituation group) as well as greater improvement in general wellbeing and adaptive behavior (). TCT, as a form of tinnitus-specialized CBT, was also adopted by in a study evaluating the effects of three different CBT-informed provisions (internet self-management, bibliotherapy, and group training) compared to an information-only control in 304 patients with acute tinnitus. The results demonstrated that internet and group-based CBT led to significantly more improvement in tinnitus distress relative to information-only control, with participants being highly satisfied with the CBT ().
There is evidence to suggest that the superiority of CBT over counseling in offering tinnitus relief might be a short-term effect. examined the effects of a combined cognitive educational program, education alone, and a waitlist control. Participants (n = 60) in the two treatment programs attended one weekly 90-min group session for 6 weeks. The cognitive coping skills training drew on some of the hallmark features of CBT, including teaching patients to approach the issue of tinnitus in more adaptive and constructive ways, regarding their reaction to tinnitus as manageable and modifiable. Additionally, attention-diversion techniques were implemented to re-focus attention from tinnitus (an internal signal) to an external signal. Several other methods, including imagery training, identification and challenging negative automatic thoughts, and cognitive restructuring, were also employed. The education program was presented as a written manual containing information about tinnitus, covering topics such as the auditory system, audiological assessment, causes of tinnitus, its history, theories, and medical treatments. The authors reported that following treatment, patients in both training programs improved significantly more than those in the waitlist group on measures of frequency of use and benefits derived from coping strategies, irrational beliefs, and knowledge about tinnitus. Those in the combined cognitive educational program achieved significantly greater reductions in dysfunctional thinking, as well as distress and handicaps associated with tinnitus, in comparison to those in the education-only group. However, therapeutic effects were acute; there were no significant pre-treatment to 12-month follow-up differences on any of the Group by Time contrasts for any of the dependent variables ().
Two studies found that CBT and counseling lead to similar outcomes for tinnitus (). conducted a cluster-randomized trial to evaluate the effectiveness of internet-based CBT (iCBT) vs. information-only counseling for alleviating tinnitus distress. Participants (n = 56) were randomized to either an iCBT group (n = 32), which included homework assignments and weekly diaries, or the information-only counseling program (n = 24), which included weekly content-based multiple-choice quizzes. While the authors stated that iCBT failed to show superiority over information-only counseling, neither intervention seemed to offer significant improvement with respect to tinnitus distress, with a repeated measures MANOVA on the Tinnitus Reaction Questionnaire, Depression, Anxiety, and Stress Scale, and World Health Organization Quality of Life Questionnaire scores revealing no significant main effects or interactions. Participants in both groups experienced significant improvements in personal relationships and a reduction in tinnitus loudness and annoyance. conducted a randomized, multi-center, non-inferiority clinical trial to explore the effectiveness of guided iCBT compared to face-to-face tinnitus information counseling in 92 adults. Patients in the iCBT group participated in an 8-week interactive e-learning program consisting of 16 recommended modules and 5 optional modules, while those in the face-to-face group received a mean of 2–3 individualized counseling appointments (60 min) targeted at providing information about tinnitus and its management, including negative thought analysis, sleep hygiene, and relaxation strategies. The study reported that the two therapies were equally effective in reducing tinnitus distress and most tinnitus-related issues. A clinically significant improvement in tinnitus distress (as defined by at least a 13-point change in the Tinnitus Functional Index, TFI) was achieved by 57% at T1 (immediately after undertaking the therapy) and 54% at T2 (2-month follow-up) in the iCBT group, compared to 41% at T1 and 46% at T2 in the face-to-face group ().
When directly considering patient views on the effectiveness of management strategies on tinnitus, counseling outperformed several popular therapies (). reported the outcomes of a UK-wide cross-sectional service education survey evaluating patients' views on the effectiveness of several tinnitus and hyperacusis therapies offered at a specialist UK National Health Service (NHS) audiology department. Patients were asked to rank a number of treatments, including education, client-centered counseling, CBT, hearing aids, and sound therapy, on a scale from 1 (no effect) to 5 (very effective), leaving those treatments they had not tried blank. The survey found that while patients were generally reasonably happy with all of the interventions, those receiving counseling responded most positively to the management of their tinnitus and hyperacusis, followed by education and CBT. A recent international, multicenter, parallel-arm, superiority randomized controlled trial by compared the efficacy of several established tinnitus therapies (CBT, hearing aids, structured counseling, and sound therapy) applied either in isolation or as a combination of two treatments. Chronic tinnitus patients (n = 461) were stratified by their hearing and tinnitus distress levels and randomly assigned to one of 10 treatment arms to receive single or combination interventions over a 12-week period (those without a hearing aid indication were not randomized to treatment groups utilizing hearing aids). CBT content was informed by principles of exposure therapy and grounded in the fear-avoidance model, with trained psychologists and psychotherapists delivering the therapy in weekly 1.5–2 h face-to-face group meetings. The structured counseling program was developed by a team of psychologists to provide structured patient education, counseling, and tinnitus coping advice through a series of 12 chapters delivered daily via a mobile application. All treatments resulted in an improvement in THI scores from baseline to week 12, which was sustained at follow-up (36 weeks post-baseline). Overall, the combination of structured counseling and hearing aids yielded the largest change in THI (20 points). Of the individually administered interventions, CBT and hearing aids had the largest THI changes (16.9 and 14.4 points respectively), which were superior to structured counseling (THI 12 points). Although CBT, structured counseling, and hearing aids performed better than sound therapy, the differences in therapeutic efficacy between these treatments were not statistically significant ().
3.2 Therapy sessions and durations
The duration of intervention, number, and length of sessions were compared within studies, with a view to determining if the nature of therapy delivery (as an alternative to therapy type) explained outcomes. The mean number of CBT sessions attended by patients was 7.4 (n = 8, SD ± 3.9) lasting 95 min (n = 6, SD ± 22.6) per session, while the mean number of counseling sessions attended by patients was 2.6 (n = 7, SD ± 2.4) lasting 75 min (n = 2, SD ± 21.2); 6 studies did not report the counseling time duration. While the majority of studies made efforts to ensure treatment delivery was comparable across interventions, a variety of research designs were used. In the randomized controlled trial conducted by , participants in the iCBT group completed 6 modules at a rate of one module per week, while those in the counseling group similarly completed 6 weeks of a Tinnitus Information Program with weekly multiple-choice quizzes about content knowledge. In a similar study by , three self-managed therapies had an allotted 3-month completion period, while the in-person CBT group sessions consisted of four weekly appointments, each lasting 2 h. Other studies followed entirely different protocols across interventions (; ; ). For example, the study by prescribed 11 sessions (90–120 min in duration) for the CBT group, 4 sessions (of unspecified duration) for the relaxation group, and 2 sessions (of unspecified duration) for the counseling group. Similarly, participants in the iCBT group of the study by completed an 8-week course consisting of 16 recommended modules and 5 optional modules, while those in the counseling group attended a mean of 2–3 in-person individual appointments (mean duration of 137 min).
In some cases, while session frequency and duration were comparable across interventions, delivery was not. In the international multi-center randomized controlled trial by , participants underwent 12 weeks of treatment regardless of whether they were randomized to the CBT or structured counseling group; however, CBT involved the active participation of a psychologist or psychotherapist through weekly 1.5–2 h sessions, whereas structured counseling, although developed by a team of psychologists, was self-administered with minimal or no clinician contact time.
3.3 Professions delivering the therapy
Of the studies evaluated in this review, 5 described counseling and/or CBT to be delivered by psychologists only, 2 by audiologists only, 1 by psychologists and psychotherapists (Supplementary Table 1). A substantial proportion of the reviewed studies did not report whether all therapies were administered by the same clinician(s), nor did they clarify which clinician(s) were responsible for delivering each type of therapy. CBT and/or counseling were reported as being provided by psychologists in several studies (; ; ; ; ). Two studies specified that CBT was provided either by psychologists who had completed or were in the process of completing CBT training (; ), while other studies did not detail specialized CBT knowledge () or mentioned unspecified ‘training and supervision' (; ). In the study conducted by CBT was delivered by trained psychologists or psychotherapists, while counseling was developed by a team of psychologists but self-administered by patients via a mobile application. Of the 8 studies reviewed, only 2 provided counseling and/or CBT services solely delivered by audiologists (; ) of these, the randomized clinical trial conducted by Beukes et al. offered CBT as a series of online modules (iCBT) with supervision and guidance from audiologists.
4 Discussion
The primary research question was “Do the outcomes of tinnitus therapy using CBT and counseling differ?”. Secondary questions were: “Did the length (number of sessions/time) or delivery (in person/digital) result in different outcomes?” and “Did results depend on who provided the therapies?” Collectively, the literature surveyed is characterized by heterogeneity and ambiguity. Three studies reported better outcomes for CBT (; ; ), for two studies counseling was superior (), and in four the outcomes were equivalent (; ; ; ). Considerable methodological variation was observed both within and between counseling and CBT, with substantial areas of overlap. Studies varied in who provided the therapies and therapy duration. Both CBT and counseling are helpful, but there is no clear evidence that either CBT or counseling is superior to the other. It is also unclear what elements of CBT or counseling contribute the most benefit. In this section, we discuss the results and, where evidence is lacking, provide informed opinions.
4.1 CBT vs. counseling
The literature showed mixed results, with some studies reporting greater efficacy for CBT (; ; ), another indicating counseling to be more effective (), and several reporting comparable benefits between the two therapies (; ; ; ). The outcomes were equivalent; however, this simple metric is limited by the considerable heterogeneity in methods used, which in turn complicates the evaluation of study quality.
Meaningful comparisons of outcomes across studies require that the therapies being compared are equivalent. A recurring challenge in categorizing the literature was the inconsistency of treatments labeled under the same term (e.g., counseling), with considerable variation in the professionals delivering the interventions and, at times, in their duration. The issue commonly encountered when evaluating the literature concerned with counseling was the great variability in definitions, descriptions, and protocols used under the umbrella term of “counselling.” Given that this review adopted a psychoeducational definition of counseling, the majority of studies utilized this approach, typically involving explanations of key features of the auditory system and information on tinnitus, its causes, assessment, and management (; ; ; ; ; ; ). Some studies delivered psychoeducation via internet-based online platforms or mobile applications (; ), others offered in-person counseling typically delivered in a group setting (; ; ) or one-on-one (), and some used booklets or written resources solely (). The study by was the only study that explicitly compared psychoeducation vs. client-centered counseling.
CBT was similarly subject to varied descriptions. In many instances, adaptations or modifications of CBT were classified under the same label, irrespective of the extent or magnitude of the modifications. Several studies adapted CBT to better suit the context of tinnitus management (; ; ). Cognitive Coping Skills Training, as used by , incorporated core elements of CBT, including cognitive restructuring and techniques for identifying and challenging negative automatic thoughts. Similarly, Tinnitus Coping Training (TCT), employed by and , addresses thoughts, emotions, and physiological responses to tinnitus, with a focus on modifying both functional and dysfunctional cognitions, as well as reframing the emotional context of tinnitus, among other components.
The classification of substantially adapted or tailored interventions under the CBT label raises fundamental definitional concerns: to what extent can an intervention be regarded as CBT if it departs from core theoretical principles, omits key procedural components, or includes only selected elements of established CBT protocols? Such variability complicates the synthesis of evidence, undermines comparability across studies, and risks conflating distinct therapeutic approaches under a single umbrella term. While CBT in its entirety may be too extensive for routine application in tinnitus therapy, it remains essential to establish a clear rationale for the selective inclusion of specific components, and to reach consensus on what constitutes CBT vs. what should more accurately be described as CBT-informed or CBT-based therapy.
In addition to the discrepancies in definitions across studies, variability in the details surrounding delivery and duration of therapy stands as a secondary hurdle to straightforward interpretation of results. Over half of the studies either prescribed different durations for each intervention or provided detailed information for only one of the treatment arms (; ; ; ; ). In the study conducted by , participants in the CBT group received substantially more contact time, with 11 sessions lasting 90–120 min each, compared to those in the habituation-based treatment (5 sessions lasting 90–120 min) and counseling (1 session, duration unspecified). The study reported that CBT was superior to both habituation training and counseling; however, the CBT group received considerably more sessions than the other groups. Similar inconsistencies in therapy duration were seen in other studies (; ). In other cases, therapies with clinician contact were compared to counseling without clinician engagement (; ). Such comparisons are reasonable at a study level when methods are compared and details are provided, but care needs to be taken when broad definitions are applied. For example, is it fair to label an information-based therapy without clinical engagement as counseling and then compare it to an extensive clinician-engaged therapy labeled as CBT? We cannot say with certainty that the increased contact time did not confer an advantage in terms of therapeutic support, thereby making it unclear whether the observed effects were attributable to the specific components of a therapy or simply to the greater amount of therapy provided. Studies that controlled both clinician and intervention duration found that counseling and CBT produced comparable outcomes (; ). If the aim of these studies is to determine whether one therapy offers greater benefit than another in the context of tinnitus management, it is essential to control for factors that could inadvertently influence outcomes, including therapeutic alliance. Standardization is not easy at an individual therapeutic level because most approaches place the person at the center of conversation and select therapy components according to needs; however, there is an evident need for more nuanced methodological groupings and clearer definitions. The limited number of suitable publications prevents a finer grained analysis at this time.
4.2 Role delineation in psychological therapies for tinnitus
While a range of clinicians delivered interventions across the studies reviewed, psychologists and audiologists emerged as the primary providers of therapy. Given the distinct disciplinary backgrounds of audiology and psychology, with each drawing on different knowledge bases, skill sets, and clinical practices, it raises an important question: who is best suited to deliver psychological therapies for tinnitus management? Audiologists are healthcare professionals who specialize in hearing and balance, including the evaluation, diagnosis, management, and treatment of related disorders such as tinnitus; their expertise and training enable them to provide informed and appropriate care for tinnitus patients (). Psychologists bring specialized expertise in the mental health aspects of tinnitus and are well-positioned to deliver counseling within a multimodal therapeutic framework, typically involving CBT and related CBT. The limited availability of psychologists providing CBT for tinnitus has previously prompted questions regarding the capability of audiologists and other health professionals to deliver appropriate and effective CBT (). While CBT allows flexibility in certain aspects, such as mode of delivery (e.g., group sessions, one-on-one, online, apps, telephone) and session frequency (typically between 6 and 20 sessions), the inclusion of both behavioral and cognitive interventions remains essential and forms the cornerstone of the therapy (). This was reflected in the studies reviewed; despite variability in CBT format and delivery across studies, a consistent emphasis on cognitive and behavioral change mechanisms was maintained. Some CBT content overlapped with counseling approaches surveyed, and certain counseling interventions were informed by CBT principles. While there is clear overlap, the distinction between these methods warrants consideration: is it an important clinical differentiation, a matter of semantics, or merely professional territoriality? We argue that this distinction is crucial, particularly in the domain of psychotherapy targeting thoughts and behaviors. CBT-informed counseling remains counseling—while it incorporates cognitive principles (e.g., Beck's framework), it does not involve active modification of core cognitions by the clinician. Engaging in these more advanced aspects of CBT carries the potential risk of unearthing deep-seated emotional issues, including self-harm or suicidal ideation, which audiologists are not typically trained to manage. Although these risks are low, they must not be underestimated.
We believe that reaching a consensus on who should provide various therapies is a crucial goal for the tinnitus community. Clinician skills and worldviews will influence the way therapy is delivered to and received by the patient. Ideally, tinnitus management would be delivered in a coordinated, multidisciplinary setting. However, such collaboration is not always feasible, as audiologists frequently work in community settings that are distant from large, multidisciplinary hospitals. Consequently, audiologists often need to provide comprehensive primary care for tinnitus. Experts in tinnitus must therefore possess knowledge that spans both auditory perception and psychological distress and be prepared to refer patients to other professionals when appropriate. Audiologists seeking to practice in tinnitus management should continue to develop their counseling skills; however, current evidence does not support audiologists practicing CBT independently. Audiologists could train as psychologists, but when practicing in this dual mode, they should be transparent about which regulatory or endorsing body they practice under. Best practice involves the judicious application of relevant knowledge and clinical skills. Recognizing individual training backgrounds, strengths, limitations, and professional perspectives can help determine the most appropriate counseling style ().
4.3 Limitations of the reviewed studies
Beyond the evident variability in intervention content and implementation, which affects the overall interpretation and generalizability of results, some studies also presented limitations specific to their individual methodologies. Studies by and were limited by high attrition rates (39% and 50% respectively). Additionally, due to the industrial population from which participants were recruited, 96% of individuals in the study were male. The authors suggest that the high dropout rate likely reflects the characteristics of this sample—primarily middle-aged (mean = 53 years) men working in industry who may have faced challenges such as work-related travel, which limited both internet access and time to engage with the program. Comparatively, acknowledged the low compliance rate, noting that although it is comparable to other studies, it may reflect several factors, including participants losing interest as their tinnitus distress decreased prior to study completion, or perhaps the lack of therapeutic contact provided.
4.4 Recommendations for implementation and future research
A substantial body of evidence supported the use of counseling in the effective management of tinnitus, with multiple studies demonstrating its potential to reduce tinnitus-related distress (), annoyance (), and loudness (), as well as improve personal relationships (). While counseling may be viewed as a more straightforward or less intensive approach compared to CBT (Figure 1), it equips patients with a clear understanding of their tinnitus, demystifying the phantom percept and alleviating fears driven by insufficient information, in turn reducing maladaptive thoughts and emotional responses (), and fosters a greater sense of control over tinnitus. These attributes support the authors' position that counseling should be considered a sufficient initial step in the management of tinnitus.
There is a need for greater clarity in research reporting. We recommend that studies provide detailed descriptions of their intervention protocols. This would facilitate the identification of which components of CBT and counseling are effective, thereby enabling the development of appropriately tailored interventions for tinnitus management based on empirical evidence. Such transparency could be achieved through the inclusion of extended methods sections or detailed research protocols. A consensus on therapy definitions is needed. CBT and counseling are “omnibus” treatments containing many components; there needs to be greater clarity in clinical and research descriptions. Counseling is a “broad church,” and the methods used across studies ranged from providing information to CBT-informed counseling. We suggest using “CBT” when referring to a comprehensive, manualized psychological treatment grounded in cognitive-behavioral theory, delivered by a therapist trained and supervised in CBT. “CBT-based” (or CBT-informed) counseling is an intervention that uses selected techniques from CBT, but without delivering the full model. Where iCBT sits depends on whether psychologists are supervising the delivery or not. The evolution of AI assistants may shift unsupervised iCBT from being CBT-informed counseling toward CBT. Given internet CBT is identified as iCBT, we recommend CBT provided by audiologists be identified as aCBT. The use of the acronym “aCBT” may reduce the potential misconception that CBT provided by audiologists is the same as that provided by psychologists. Researchers and clinicians should carefully consider how they use these terms so as not to mislead the public.
5 Conclusions
Counseling and CBT of various forms are beneficial; however, there is insufficient head-to-head evidence at this time to differentiate benefits. Given the current equivocal evidence, we conclude that there is insufficient justification, or in fact, a need for audiologists to independently practice CBT. Furthermore, it is unclear whether clinicians are, in fact, delivering “true CBT” or rather CBT-informed counseling (or aCBT). The literature on this issue is ambiguous, but available evidence suggests that audiologists typically provide counseling informed by CBT principles, focusing on psychoeducation rather than active cognitive restructuring or psychotherapy. We are concerned that the label “CBT” is being used in an injudicious manner. Taking all of the considerations into account, we endorse previous assertions that the extent to which audiologists provide psychological support should align with their professional training and scope of practice ().
Statements
Author contributions
GS: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. DV: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. BC: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. CS: Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing.
Funding
The author(s) declared that financial support was received for this work and/or its publication. BC received a University of Auckland Summer Scholarship to undertake this review.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author GD declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fauot.2025.1690547/full#supplementary-material
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Summary
Keywords
tinnitus, counseling, Cognitive Behavioral Therapy (CBT), therapy, review
Citation
Campbell B, Vajsakovic D, Swindale C and Searchfield GD (2026) Counseling and Cognitive Behavioral Therapy for tinnitus—The same but different: a scoping review. Front. Audiol. Otol. 3:1690547. doi: 10.3389/fauot.2025.1690547
Received
22 August 2025
Revised
16 November 2025
Accepted
28 November 2025
Published
06 January 2026
Volume
3 - 2025
Edited by
Prashanth Prabhu, All India Institute of Speech and Hearing (AIISH), India
Reviewed by
Stefan Schoisswohl, University of Regensburg, Germany
Fatih Bal, Sakarya University, Türkiye
Updates
Copyright
© 2026 Campbell, Vajsakovic, Swindale and Searchfield.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Grant D. Searchfield, g.searchfield@auckland.ac.nz
Disclaimer
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