TRT for Tinnitus¶
Tinnitus Retraining Therapy is a clinical standard combining directive counseling with sound therapy. It provides the conceptual framework for Naluma's Sounds tab and the overarching habituation narrative.
Evidence Summary¶
- Developed by Jastreboff & Hazell; widely adopted in audiology clinics
- Two pillars: directive counseling (psychoeducation) + sound therapy (enrichment)
- Evidence base more clinical/observational than RCT-driven (compared to CBT/ACT)
- Habituation model provides the most intuitive patient-facing explanation of tinnitus improvement
- Westin et al. trial showed ACT outperformed TRT at 18 months, but TRT remains the standard for sound therapy guidance
Core Concepts¶
The Neurophysiological Model¶
Tinnitus is a neural signal that the brain can learn to filter out (habituate), similar to how you stop noticing the hum of a refrigerator. The goal is not to eliminate the signal but to reclassify it as neutral — not threatening, not important.
Two levels of habituation:
- Habituation of reaction — emotional/stress response diminishes first
- Habituation of perception — conscious awareness of tinnitus decreases over time
Five Patient Categories¶
| Category | Profile | Treatment Focus |
|---|---|---|
| 0 | Mild tinnitus, minimal impact | Counseling only |
| 1 | Significant tinnitus, no hearing loss | Counseling + broadband sound enrichment |
| 2 | Significant tinnitus + hearing loss | Counseling + hearing aids with sound generators |
| 3 | Hyperacusis (with or without tinnitus) | Desensitization protocol + pink noise |
| 4 | Hyperacusis + significant tinnitus | Combined protocol (hyperacusis first) |
The Mixing Point¶
The mixing point is the volume level where background sound starts blending with tinnitus perception:
- Below mixing point → tinnitus clearly audible above background
- At mixing point → tinnitus and background sound begin to merge; brain starts reclassifying
- Above mixing point (masking) → tinnitus inaudible; NOT recommended by TRT because the brain never learns to habituate
The key insight: sound enrichment should be set at or just below the mixing point, not used to mask tinnitus completely.
Mapping to Naluma¶
| TRT Component | Naluma Feature | Implementation |
|---|---|---|
| Directive counseling | Today tab — psychoeducation sessions | Chat explains neurophysiological model, habituation concept |
| Sound enrichment | Sounds tab (S30) — soundscape player | Nature sounds, white/pink noise, layered soundscapes |
| Mixing point guidance | Sounds tab (S30) — volume slider with mixing-point indicator | Slider with labeled zone: "mixing point" marker + educational tooltip |
| Patient categorization | Onboarding (S00–S06) | Severity assessment maps to content recommendations |
| Habituation tracking | Progress tab (S50–S51) | Weekly tinnitus awareness/reaction ratings over time |
Design Implications¶
- Mixing-point slider is the key TRT UI element — the Sounds tab volume control should educate, not just adjust volume. A labeled zone or gentle coaching prompt reinforces the concept.
- "Don't mask" is counterintuitive — patients instinctively want to drown out tinnitus. Naluma needs to explain the mixing-point concept early and reinforce it in the Sounds tab UI.
- Habituation is the overarching narrative — even though Naluma uses CBT/ACT techniques, the patient-facing story is TRT's habituation model: "Your brain can learn to tune it out."
- Sound therapy + counseling together — TRT insists both components are needed. Naluma should link Sounds tab usage to chat sessions (e.g., "Try using your rain sounds tonight — I'll check in tomorrow").
Source¶
Henry et al. — TRT counseling and sound therapy (PMC8632517)