ACT for Tinnitus¶
Acceptance and Commitment Therapy is a complementary approach to CBT that focuses on changing the relationship to tinnitus rather than changing cognitions directly. Strong evidence with large effect sizes sustained at 18-month follow-up.
Evidence Summary¶
- Westin et al. RCT: ACT showed large effect sizes for tinnitus distress reduction
- Effects sustained at 18-month follow-up (superior to TRT in this trial)
- Changes mediated primarily by tinnitus acceptance — the degree to which patients stop struggling against the sound
- Complementary to CBT: ACT targets experiential avoidance; CBT targets cognitive distortions
Core Processes¶
ACT is built on six interconnected processes (the "hexaflex"):
| Process | Definition | Tinnitus Application |
|---|---|---|
| Acceptance | Willingness to experience tinnitus without trying to control or eliminate it | "Can you sit with the sound for 30 seconds without reacting?" |
| Cognitive Defusion | Seeing thoughts as mental events, not facts | "I notice I'm having the thought that this will never stop" |
| Present-Moment Awareness | Contacting the here-and-now rather than dwelling on tinnitus | Mindfulness exercises anchored to non-tinnitus sensory input |
| Self-as-Context | "I am not my tinnitus" — observing self vs. experiencing self | Perspective-taking exercises |
| Values Clarification | Identifying what matters most, independent of tinnitus | "What would you do today if tinnitus wasn't a factor?" |
| Committed Action | Taking values-aligned steps even in the presence of tinnitus | Setting small behavioral goals; tracking in Progress tab |
Key Techniques for Naluma¶
- Defusion language pattern — "I notice I'm having the thought that..." Transforms relationship to catastrophic thoughts. Can be implemented as chip-guided reframing.
- Leaves on a stream — Visualization exercise where thoughts (including tinnitus awareness) are placed on leaves floating downstream. Maps to guided audio session (S20).
- Titchener's repetition — Repeating a word until it loses meaning; applied to tinnitus-related words to reduce emotional charge. Novel technique for chat interaction.
- Values card sort — Selecting personal values from a list and connecting daily actions to them. Natural fit for chip-based interaction.
- Willingness scale — Rating willingness to experience tinnitus on 1–10 scale. Maps to Progress tab check-ins.
Mapping to Naluma¶
| ACT Component | Naluma Feature | Session Type |
|---|---|---|
| Acceptance exercises | Today tab — guided mindfulness + chips | Practice |
| Cognitive defusion | Today tab — "I notice..." reframing via chips | Reflection |
| Values clarification | Today tab — chip-based values card sort | Reflection |
| Committed action | Progress tab — goal setting + tracking | Check-in |
| Present-moment awareness | Session player (S20) — guided mindfulness audio | Practice |
| Willingness scale | Progress tab — weekly check-in dimension | Check-in |
Design Implications¶
- ACT sessions are more reflective than CBT — fewer "right answers," more open-ended exploration. Chip options should reflect this (e.g., multiple valid perspectives rather than correct/incorrect).
- Values work is highly personal — the values card sort is one of the most engaging chip interactions. Consider making it a memorable onboarding moment.
- Acceptance is counterintuitive — many patients expect "fix it" solutions. Psychoeducation about acceptance needs careful framing to avoid seeming dismissive.
- 18-month effect sizes suggest ACT content should be introduced early and reinforced throughout, not saved for later modules.