80-90% of tinnitus patients have some evidence of hearing loss
10 - 20% of tinnitus sufferers seek medical attention
Cognition: maladaptive cognitive strategies “The reaction is the key to whether a person with tinnitus becomes a tinnitus patient” (Sweetow, 1986; 2000)
Habituation: intolerance results from individual’s failure to adapt (Hallam et al, 1984; 2006)
Attention: failure to shift attention away from tinnitus (Hallam and McKenna, 2006)
Enhanced tinnitus perception is learned response resulting from “negative” emotional reinforcement involving limbic system and autonomic activation (Hallum;Jastreboff and Hazell, 1993; McKenna, 2004)…..de-emphasizes connection with peripheral hearing loss
N = 12, 166 ; N with tinnitus) = 2,024 (16%)
N = 12, 166 ; N with tinnitus) = 2,024 (16%)
Each year of age increased the odds ratio of tinnitus by about 3%.
Men generally showed a higher risk for tinnitus compared with women.
Exposure to noise and stress were important for the probability and level of discomfort from tinnitus. However, for the transition from mild to severe tinnitus, stress turned out to be more important.
Reduction of likelihood of tinnitus if noise is removed = 27%, if stress is removed =19%), if both removed = 42%.
Conclusions: Stress management strategies should be included in hearing conservation programs, especially for individuals with mild tinnitus who report a high stress load.
Baigi, et al; Ear and Hearing 2011. 32, 6:787-789
Disruption of auditory input (e.g., hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
Disruption of auditory input (e.g., hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
Decrease in inhibitory (efferent) function
Over-representation of edge-frequencies (cortical plasticity)
Dysfunctional gating in basal ganglia
Other somatosensory influences (cervical disturbances, etc.)
Increased attention related to reticular activating system involvement
Association with fear and threat (limbic system)
Tinnitus is associated with abnormal EEG-patterns, showing enhanced activity in the δ band and reduced activity in the α band (Weisz, Moratti, Meinzer, Dohrmann, & Elbert, 2005)
Tinnitus is associated with abnormal EEG-patterns, showing enhanced activity in the δ band and reduced activity in the α band (Weisz, Moratti, Meinzer, Dohrmann, & Elbert, 2005)
MEG data indicating that subjects with tinnitus
< 4 years have gamma network predominantly in the temporal cortex; but subjects with tinnitus of a longer duration show a widely distributed gamma network into the frontal and parietal regions (deRidder, 2011)
auditory
auditory
attentional
emotional
Tinnitus Severity Scale - Sweetow and Levy
Tinnitus Severity Scale - Sweetow and Levy
Tinnitus Handicap Inventory - Newman et al
Tinnitus Handicap Questionnaire - Kuk, et al
Tinnitus Effects Questionnaire - Hallam, et al
Tinnitus Reaction Questionnaire - Wilson, et al
Tinnitus Cognitive Questionnaire (TCQ) - Wilson and Henry
Tinnitus Functional Index – Miekle, et al
time
time
behaviors affected
attitudes and thoughts
what affects the tinnitus?
Physical (viral, medication, hearing loss (imbalance between excitatory and inhibitory neurons), neurotoxicity from noise, somatic influences)
Physical (viral, medication, hearing loss (imbalance between excitatory and inhibitory neurons), neurotoxicity from noise, somatic influences)
CDs (e.g. Personal Growth Tinnitus Relief, Petroff DTM)
Of the nine tinnitus treatment methods assessed, none were tried by more than 7% of the subjects.
Of the nine tinnitus treatment methods assessed, none were tried by more than 7% of the subjects.
Treatment methods rated with substantial tinnitus amelioration were hearing aids (34%) and music (30%).
Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols.
This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus. This fact should be more widely acknowledged in both the audiological and medical communities.
Kochkin S., Tyler R., Born J. MarkeTrak VIII: The Prevalence of Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review. 2011;18(12):10-27.
Greater neural activity allows brain to correct for abnormal reduced inhibition
Greater neural activity allows brain to correct for abnormal reduced inhibition
Enriched sound environment may prevent maladaptive cortical reorganization
Alter production peripherally and/or centrally
Reduce contrast to quiet
Partially mask tinnitus
Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
The majority of tinnitus sufferers have at least some degree of hearing loss
Complete masking
Complete masking
Partial masking
Mix
Habituate
Distract
Suppress
the process of "ignoring" (or becoming accustomed to) a stimulus without exerting any conscious effort.
the process of "ignoring" (or becoming accustomed to) a stimulus without exerting any conscious effort.
from a psychological perspective, it is defined as the adaptation, or decline of a conditioned response, to a stimulus following repeated exposure to that stimulus.
The brain can sort out meaningful stimuli from those which are not
The brain can sort out meaningful stimuli from those which are not
Attention is directed toward "salient" or information-bearing stimuli
Ring on your finger
Ring on your finger
Clothing
Refrigerator humming
Rear end (buttocks) in your chair
Somatosensory
Somatosensory
Auditory
How brain (limbic system) determines importance of external stimuli
low level noise interferes with pattern recognition by increasing neuronal activity
low level noise interferes with pattern recognition by increasing neuronal activity
this makes tinnitus more difficult to detect
gradually increasing input could decrease gain over an extended time
Some (Jastreboff) suggests 24 hours a day, 7 days a week
Others (Neuromonics) claim 2-4 hours adequate
Jastreboff
Jastreboff
Tyler
the signal used to facilitate suppression is softer than the tinnitus perception
the signal used to facilitate suppression is softer than the tinnitus perception
time course …..Masking of tinnitus is instantaneous, while suppression of tinnitus requires from several seconds to several minutes to both occur and then decay.
this suggests different neural mechanisms for the two methods.
maskers typically have similar spectral and temporal properties to the tinnitus, whereas the most effective suppressor may have distinctly different spectral and temporal properties than the perceived tinnitus.
suppression is a physiologic process in which sounds may modulate the activity of the auditory cortex and interrupt tinnitus generation.
Subjects who experienced suppression reported louder tinnitus (db SL) at baseline
Subjects who experienced suppression reported louder tinnitus (db SL) at baseline
Best stimuli were amplitude modulated pure tones with carrier frequencies between 6K and 9K
White noise is ineffective as a suppressor
For subjects with any suppression, AM and FM pure tones were more likely to yield total suppression compared to un-modulated pure tones
Moses/Lang CD7, (1993)
Moses/Lang CD7, (1993)
noise bands covering seven different frequency ranges —user selects most effective band
(Johnson,1998; Vernon and Meikle, 2000)
Dynamic Tinnitus Mitigation (DTM-6a)
Petroff Audio Technologies, Inc. (Marina Del Rey,CA; petroffml@aol.com)
E- water (dynamic)
E- water (dynamic)
E- air
E- nature (dynamic)
White noise
Personal Growth high frequency relief
DTM sounds use proprietary “dynamic” (changing) sound formats that are intended to enhance masking and distract attention away from tinnitus.
DTM sounds use proprietary “dynamic” (changing) sound formats that are intended to enhance masking and distract attention away from tinnitus.
“Dynamic” acoustic technology refers to proprietary semi-random, short-term amplitude and frequency domain modulation signal processing
E-Nature and E-Water, have been “dynamically” processed to provide expanded amplitude peaks on the order of 5 to 15 dB, over corresponding time durations on the order of 10 to 500 msec.
E-Air = E-Nature when measured in 2 dimensions (amplitude/frequency)
E-Air = E-Nature when measured in 2 dimensions (amplitude/frequency)
When measured in 3 dimensions E-Nature is dynamic
E-Water is significantly rolled-off in high-frequency amplitude relative to E-Air, so we would expect E-Air to provide better masking.
E-Air should have performed at least as well if not better but this didn’t happen; perhaps because E-air was dynamic????
Presentations lasted from 3-30 seconds
Presentations lasted from 3-30 seconds
Study was done in a sound booth
Hearing loss amongst subjects varied
TDH 50s, which have significantly reduced amplitude from ~ 7-13KHz, were used
McKinney, et al; 1999
Counseling only; 72% showed “improvement” (N=54)
Counseling with sound generators at just audible level; 75% showed “improvement” (N=72)
Counseling with hearing aids; 85% showed “improvement” (N ~ 35)
Counseling with sound generators; 83% showed “improvement” (N ~ 30)
My conclusion….not definitive proof….yet 70% of TRT users get them! But, these were done with white noise.
Both TRT and general counseling without additional sound therapy are effective in reducing the annoyance and impact of tinnitus.
Both TRT and general counseling without additional sound therapy are effective in reducing the annoyance and impact of tinnitus.
The largest effect on overall tinnitus handicap was observed in the TRT participants, with an effect size of 1.13. However, a clinically significant effect was also observed in the control group, with an effect size of 0.78.
Effect of Tinnitus Retraining Therapy on the Loudness and Annoyance of Tinnitus: A Controlled Trial; Bauer, Carol A.; Brozoski, Thomas J. Ear & Hearing: March/April 2011 - Volume 32 - Issue 2 - pp 145-155
Group analysis assumes all are the same
Group analysis assumes all are the same
Some individuals show large changes, but these are diluted in group analysis
There is not likely a single treatment which confers universal benefit
Subjects who do not want a device, but who are randomized to a device group are less likely to show benefit
Tyler, 2010
Number of beats per minute
Number of beats per minute
High frequencies (alerting) vs low frequencies (soothing)
Rhythm = duration of a series of notes and how they group together to form a unit (in mother’s womb)
Tempo = overall speed or pace of the piece
Contour = shape of the melody
Timbre = tonal color from overtones distinguishing one sound from another
Loudness (Japanese study)
Pitch
Spatial location
Reverberation
Consonance vs dissonance
All of the above are separable and can vary without affecting the other attributes
Music has been shown to activate the limbic system and other brain structures (including the frontal lobe and cerebellum) and has been shown to produce physiologic changes associated with relaxation and stress relief.
Music has been shown to activate the limbic system and other brain structures (including the frontal lobe and cerebellum) and has been shown to produce physiologic changes associated with relaxation and stress relief.
Home
Home
Work
Celebrations
Advertising
Romance
Movies
Athletic locker rooms
Shopping malls
Hospitals
Therapies
Relaxation
Home stereo
Home stereo
iPod
Neuromonics
Hearing aids
Slow onset, long, quiet sounds – calming
Music with a slow tempo (i.e. near natural heart rate (60 – 72 beats per minute) - relaxing
Repetition - emotionally satisfying
We don’t like the unexpected
We don’t like the unexpected
But certain rules have to be followed
Active listening may arouse, passive listening may soothe
For tinnitus patients, active listening may draw attention to the tinnitus, passive listening may facilitate habituation
a bit of cognitive therapy
a bit of cognitive therapy
A bit of TRT
Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
Rhythm
Hearing instrument algorithm (equal sensation level) for hearing loss compensation
2 stage program
expensive
N= 56; 6 month trial
N= 56; 6 month trial
Both groups (SG and NTT) demonstrated a significant reduction in tinnitus for SG and NTTs. However, there were no differences in the SG or NTT treatment groups.
Conclusions: Both protocols (SG and NTT) yielded significant improvements with regard to quality of life (HRQoL) issues, based on the THI improvements
SG appears to be more cost efficient than NTT. “The cost per unit of improvement (treatment utility) on the THI (scale from 1–100 points) measured in “quality-adjusted life years” was $604 per point for the sound generator treatment compared to $1,771 per point for the neuromonics treatment. The implication here is that equivalent gains might be obtained at a lesser cost to the patient.”
Newman CW, Sandridge SA. (2012) A Comparison of benefit and Economic Value Between Two Sound Therapy Tinnitus Management Options. Journal of the American Academy of Audiology 23:126–138.
Forty-seven patients initiated treatment with the Neuromonics device during the 2 year study period.
Forty-seven patients initiated treatment with the Neuromonics device during the 2 year study period.
Fourteen patients completed treatment, and another 18 were actively undergoing treatment at the end of the study period.
The mean pure-tone average (N 47) = 23.4 dB for the involved ear.
Of those who completed the treatment, the mean posttreatment TRQ score was significantly lower than the pretreatment score ( p ~ .001).
Fifteen patients (31.9%) returned the device or did not complete treatment.
Across all 47 patients, 48.9% achieved a successful reduction of 40% or greater in TRQ score.
No correlation among pure-tone average, initial TRQ score or duration of use, and percentage change in TRQ score for those with at least one follow-up test.
Goddard JC, Berliner K, Luxford WM. Recent Experience with the Neuromonics Tinnitus Treatment. Int Tinnitus J. 2009;15(2):168-173
Frequency shaping
Frequency shaping
Loudness balance
Compression
"Harpsichord Concerto in F Minor," by J.S. Bach
"Harpsichord Concerto in F Minor," by J.S. Bach
"Concerto No.10 in F Major from Twelve Concerti Grossi," by A. Corelli
"Winter" from "The Four Seasons," by A. Vivaldi
"Canon in D," by Pachelbel
"Adagio in G Minor for Strings," by Albinoni
Read more: http://www.articlesbase.com/stress-management-articles/the-best-relaxation-music-541489.html#ixzz1TLaTSXjT Under Creative Commons License: Attribution No Derivatives
Sounds (including music) affects people in different ways, due to inherent, learned (and cultural) preferences
Sounds (including music) affects people in different ways, due to inherent, learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting, negative, or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms?
For relaxation
For relaxation
Music with a rhythm slower than your natural heart rate (72 beats per minute) is useful to many people
Lower pitches are more calming than higher pitches, generally speaking
For focus and concentration
No distraction
Personal preference
Few emotional tags
For tinnitus
Active listening (distraction)
Masking (covering up)
Passive listening (habituation, desensitization)
"a rough or fragmented geometric shape that can be split into parts, each of which is (at least approximately) a reduced-size copy of the whole”
"a rough or fragmented geometric shape that can be split into parts, each of which is (at least approximately) a reduced-size copy of the whole”
Properties include self-similarity and a simple and recursive definition
Examples include:
Examples include:
clouds, rivers, fault lines, mountain ranges, craters, snow flakes, crystals, lightning, cauliflower, broccoli, blood vessels, ocean waves and DNA
Fractal tones create a melodic chain of tones that repeat enough to sound familiar and follow appropriate rules, but vary enough to not be predictable.
Fractal tones create a melodic chain of tones that repeat enough to sound familiar and follow appropriate rules, but vary enough to not be predictable.
Fractal technology ensures that no sudden changes appear in tonality or tempo
An optional listening program in certain (Passion, Mind, and Clear) Widex hearing aids that plays adjustable, continuous, chime-like tone complexes using fractal algorithms.
An optional listening program in certain (Passion, Mind, and Clear) Widex hearing aids that plays adjustable, continuous, chime-like tone complexes using fractal algorithms.
The chimes are generated based on an understanding of the properties of music that would be most relaxing (Robb et al., 1995):
Ability to self select music.
Tempo near or below resting heart rate (60-72 bpm).
Each Zen program can be individually adjusted to loudness, pitch and tempo preferences
Each Zen program can be individually adjusted to loudness, pitch and tempo preferences
The fractal tones (or the noise) should be audible, but relatively soft
It should never interfere with conversational speech
The annoyance level of the tinnitus should just begin to decrease (i.e., tinnitus can still be audible)
Sweetow & Henderson-Sabes, The use of acoustic stimuli in tinnitus management. JAAA 21,7, 461-473, 2010
Sweetow & Henderson-Sabes, The use of acoustic stimuli in tinnitus management. JAAA 21,7, 461-473, 2010
Kuk F, Peeters H, Lau CL. The efficacy of fractal music employed in hearing aids for tinnitus management. Hearing Review. 2010;17(10):32-42.
Herzfeld and Kuk, Hearing Review, 2011; 18,(11), 50-55.
Would fractal tones (and/or noise) delivered through hearing aids be:
Would fractal tones (and/or noise) delivered through hearing aids be:
Perceived as relaxing to tinnitus patients?
Reduce short term tinnitus annoyance in the lab?
Lower subjective tinnitus handicap and reaction scores in a 6 month field trial?
Fractal tones were effective as a tool in promoting relaxation and reducing annoyance from tinnitus
Fractal tones were effective as a tool in promoting relaxation and reducing annoyance from tinnitus
Both fractal tones and noise reduced tinnitus annoyance, but the fractal tones were preferred by subjects for longer term use
an integrated program addressing all 3 major components of tinnitus distress; auditory, attention, and emotion.
an integrated program addressing all 3 major components of tinnitus distress; auditory, attention, and emotion.
many patients will be adequately served by counseling and sound therapy (hearing aids, fractal tones, or noise) alone
patients with nnegative reactions treated with a comprehensive program integrating cognitive-behavioral concepts and relaxation exercises along with the counseling and acoustic tools.
is to ensure that the tinnitus does not negatively impact the patient's quality of life!
is to ensure that the tinnitus does not negatively impact the patient's quality of life!
it is not designed to be a cure, or to suppress tinnitus (though it sometimes produces that effect).
Counseling to educate the patient and assist the limbic system to alter its negative interpretation of the tinnitus via cognitive and behavioral intervention;
Counseling to educate the patient and assist the limbic system to alter its negative interpretation of the tinnitus via cognitive and behavioral intervention;
Amplification (binaurally, when appropriate) to stimulate the ears and brain in order to discourage increased in central activity (overcompensation) and maladaptive cortical reorganization;
Fractal tones binaurally delivered to the patient in a discreet, inconspicuous and convenient manner, designed to both relax and provide acoustic stimulation;
Relaxation strategy program highlighted by behavioral exercises and sleep management strategies.
Instructional
Instructional
Adjustment-based
Instructional counseling helps educate the patient about aspects of the tinnitus itself. For example, it addresses…………..
Instructional counseling helps educate the patient about aspects of the tinnitus itself. For example, it addresses…………..
the basic anatomy and physiology of the auditory (and central nervous) system,
why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss),
how the limbic system affects the tinnitus perception and how the patient’s reaction impacts the ability to cope with or habituate to the tinnitus.
Helps the patient recognize aspects about how the tinnitus is affecting him or her, and the cognitive and behavioral implications. It is designed to :
Helps the patient recognize aspects about how the tinnitus is affecting him or her, and the cognitive and behavioral implications. It is designed to :
address the emotional sequelae of tinnitus, including fear, anxiety and depression;
identify and correct maladaptive thoughts and behaviors;
understand the relationship between tinnitus, stress, fear, behaviors, thoughts, and quality of life.
is designed to identify the unwanted thoughts and behaviors hindering natural habituation, challenge their validity, and replace them with alternative and logical thoughts and behaviors.
is designed to identify the unwanted thoughts and behaviors hindering natural habituation, challenge their validity, and replace them with alternative and logical thoughts and behaviors.
the objective is to remove inappropriate beliefs, anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs, it is the patient's reaction (and all reactions are subject to modification).
The basic processes in cognitive-behavioral intervention are :
identify behaviors and thoughts affected by the tinnitus;
list maladaptive strategies and cognitive distortions currently employed;
challenge the patient to identify negative thoughts;
identify alternate thoughts, behaviors, and strategies.
Ask “what will make this encounter or therapy successful in your mind?”
Ask “what will make this encounter or therapy successful in your mind?”
Remember that tinnitus patient management is a journey, remind patients of the ups and downs to be expected
Tell patient that 1st thought upon recognizing tinnitus should be…..
Progressive Muscle Relaxation
Deep breathing
Guided imagery
Perform the exercises while sitting in a comfortable chair in a quiet place with no distractions;
Perform the exercises while sitting in a comfortable chair in a quiet place with no distractions;
Do the exercises while listening to the Zen tones, but if you are too distracted, turn off the tones;
Remove your shoes and wear loose, comfortable clothing;
Don't worry if you fall asleep;
After finishing the exercise, close your eyes, relax for a few minutes, breathe deeply and rise up slowly.
* NOTE: IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
PMR consists of alternating deliberately tensing muscle groups and then releasing the tension. Focus on the muscle group; for example, your right foot. Then inhale and simply tighten the muscles as hard as you can for about 8 seconds. Try to only tense the muscle group that you are concentrating on. Feel the tension. Then release by suddenly letting go. Let the tightness and pain flow out of the muscles while you slowly exhale. Focus on the difference between tension and relaxation.
PMR consists of alternating deliberately tensing muscle groups and then releasing the tension. Focus on the muscle group; for example, your right foot. Then inhale and simply tighten the muscles as hard as you can for about 8 seconds. Try to only tense the muscle group that you are concentrating on. Feel the tension. Then release by suddenly letting go. Let the tightness and pain flow out of the muscles while you slowly exhale. Focus on the difference between tension and relaxation.
head (facial grimace)
neck and shoulders
chest
stomach
right upper arm
right hand
left upper arm
left hand
buttocks
right upper leg
right foot
left upper leg
left foot
Relax for about 10-15 seconds and repeat the progression. The entire exercise should take about 5 minutes.
DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
This is the simplest of the relaxation procedures. It simply requires you to follow the five suggestions above and to add deep, rhythmic breathing. Specifically, you should complete the following cycle 20 times:
This is the simplest of the relaxation procedures. It simply requires you to follow the five suggestions above and to add deep, rhythmic breathing. Specifically, you should complete the following cycle 20 times:
Exhale completely through your mouth;
Inhale through your nose for four seconds (count "one thousand one, one thousand two, one thousand three, one thousand four");
Hold your breath for seven seconds;
Exhale through your mouth for eight seconds;
Repeat the cycle 20 times
The entire process will take approximately 7 minutes.
Maintain a standard bedtime for each day.
Maintain a standard bedtime for each day.
Set your alarm for the same time each day.
Walk or exercise for ten minutes a day, but not right before going to sleep.
Set thermostat for a comfortable bedroom temperature.
Use a fan or white noise machine to interfere with your tinnitus.
Close your curtains/drapes and maintain a bedroom dark enough to sleep.
Change the number of pillows you use. This also may impact somatic contributors to tinnitus.
Don't watch TV, eat or read in bed. Use your bed for sleep and sex.
Sleep on your back or on your side, try to avoid sleeping on your stomach.
Take prescription medicines as directed, but only if required.
…..helps establish realistic, time-based expectations, provides methods of assessing progress, and creates a follow up schedule.
…..helps establish realistic, time-based expectations, provides methods of assessing progress, and creates a follow up schedule.
In addition, the information is demonstrated with the use of case examples.
Reduction in the number of episodes of awareness
Reduction in the number of episodes of awareness
Increase in the intervals between episodes of awareness
Increase in quality of life
Not necessarily a reduction in perceived loudness
Effect may NOT be immediate
Establish realistic, time-based expectations
Tinnitus is not unique to that one patient.
Tinnitus is not unique to that one patient.
Tinnitus is not a sign of insanity or grave illness.
Tinnitus may be a “normal” consequence of hearing loss
Tinnitus probably is not a sign of impending deafness.
There is no evidence to suggest the tinnitus will get worse.
Tinnitus does not have to result in a lack of control.
Patients who can sleep can best manage their tinnitus.
Tinnitus is real, and not imagined.
Tinnitus is real, and not imagined.
Tinnitus may be permanent.
Reaction to the tinnitus is the source of the problem.
Reaction to the symptom is manageable and subject to modification.
If significance and threat is removed, habituation or "gating" of attention can be achieved.
Stay off the internet!
Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds, a broad frequency response, and flexible options for acoustic stimuli
Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds, a broad frequency response, and flexible options for acoustic stimuli
Tailor the therapy to the patient’s functional and financial needs
Sound therapy without counseling is not likely to work
