Why TRT Fails People ...

Discussion in 'Support' started by Dr. Nagler, Oct 8, 2014.

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    1. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Hi All –

      In response to a question @Lisa88 posed on the Doctors' Corner, I gave the four factors Dr. Jastreboff listed that might account for a decreased probability of success in TRT: medical-legal issues, Category 4, high doses of benzodiazepines, and flag-waving. In thinking about that post some more last night, it came to my mind that Dr. Jastreboff's list is really only half the story. Of equal importance to the question of why people might fail TRT, indeed very possibly of greater importance, is the question of why TRT might fail people!

      So here are some of my own thoughts in that regard ...
      • Expectation mis-match. I lay this one squarely at the feet of the TRT clinician, who might encourage a patient to embark upon TRT without first clearly explaining to the patient what TRT can and cannot offer in the way of treatment outcome. If a patient goes into TRT expecting that his or her tinnitus will get softer or possibly even go away, that patient will be sorely disappointed at the conclusion of treatment. It is incumbent upon the TRT clinician to thoroughly evaluate the patient and his or her expectations to make sure that the protocol will meet those expectations.
      • Poor communication. Again I lay this one squarely at the feet of the TRT clinician. TRT involves in-depth counseling. You don't just hang a couple of devices on the patient's ears and call it a day. TRT counseling is equally important as sound therapy. And TRT counseling involves a lot of communication. Some clinicians simply do not have those skills. They might know how to talk, but they do not know how to listen.
      • Lousy TRT. By this I mean that many clinicians (and I mean many) claim to be doing TRT, but whatever it is that they are doing ... it isn't TRT. I addressed this issue and the lack of credentialing in another post – so I'll just copy it below:
      "With TRT, since the name is not trademarked, what you see is in many cases not what you get. And to my way of thinking, that represents an enormous problem for the tinnitus community. Anybody can call himself or herself a "TRT clinician." Moreover, since there is no credentialing or standardization in TRT, even if a clinician has read Dr. Jastreboff's book and taken his course, there is no assurance that he or she has retained the material or even understood it in the first place."

      And finally, everything can be perfect – ideal patient, knowledgeable experienced clinician, all the stars in alignment – and still the outcome might be disappointing. So clearly there are factors that we do not understand.

      In my opinion what's important to realize in talking about the 15% who for whatever reason do not do well with TRT is that 85% succeed. And my personal favorite statistic is that 100% of those who do ultimately succeed are pretty well convinced at the outset that with their luck they'll wind up in the 15% who do not do well ... until they start getting better!

      Dr. Stephen Nagler
       
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    2. nogood
      Torn

      nogood Member Benefactor

      Tinnitus Since:
      04/2014
      Cause of Tinnitus:
      ototoxicity/infection
      Trt or cbt is just a means to train once brain to ignore the t. At least that is how i see it.
      Its tool for adopting to so called new normal.
      When it comes to adoptablity it boils down to the motive or reason for adopting.
      I often interact with many cultures at given day. Sometimes i feel lost cause of all the differences in culture, language and body language. Nothing made sense, didnt know how to handle that kind of situations. survival now for me is to go along with unknown, Or say i quite and go back to my home country where everything is familiar. I choose to stay and go along with unknown. Kerping in mind that i Still have choice of going back to my home country.
      But for this f**k T i dont have a choice. So here i am try to adopt to this new normal which is unknown to me.

      Why trt fails .. people keep wanting to go back to their home where everything is familiar. Unfortunately T is a one way, no way to return back to home.
       
    3. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      So you're blaming the patient?

      I really don't see it that way.

      Dr. Stephen Nagler
       
    4. nogood
      Torn

      nogood Member Benefactor

      Tinnitus Since:
      04/2014
      Cause of Tinnitus:
      ototoxicity/infection
      I am not blaming the patient.
      Let me rephrase. ..
      What ever approach they are using is not reaching to the patient's mind.
      For many its Just not convening enough.
       
    5. bwspot

      bwspot Member

      Tinnitus Since:
      06/13/2014
      @Dr Nagler
      I wish you could give us more specifics about the TRT you practice, but I understand you had your own reasons no to do so on the forum. I was wondering if this would help us understand it better. It seems like there is lots of confusion on the forum recently about TRT and too many fights over it. Many people don't believe in it and the whole Jastreboff model. Maybe with better understanding with more specifics we could settle down a little?
       
    6. LadyDi
      Busy

      LadyDi Member Benefactor

      Location:
      Florida, USA
      Tinnitus Since:
      06/2013
      Cause of Tinnitus:
      Barotrauma/airplane
      Thank you for your post, @Dr. Nagler. I would say that many of the points you make also would be true with Neuromonics. The clinician is critical, and realistic expectations must be emphasized from the beginning. IMHO: There also are plenty of Neuromonics programs out there where they just hand you the device, give you the instructions, and walk away. Large ENT practices are latching onto Neuromonics as a revenue generator, so be careful where you go. Having said that: I have been pleased with the quality of my Neuromonics counseling and program, but I went to a university-based research institute.

      A question for @Dr. Nagler: What would you define as "success" regarding TRT? I am referencing the below.
      In my opinion what's important to realize in talking about the 15% who for whatever reason do not do well with TRT is that 85% succeed.

      And @bwspot, I suspect there will continue to be arguments about TRT on this board as long as the topic is posted. There also are people who believe Neuromonics, cognitive behavioral therapy (CBT) and other treatments are bunk. They have a right to their opinion. There are no large, independent, scientific studies (yet) proving effectiveness of any tinnitus treatment -- including ones that shoot drugs, or shine lasers, into your ears. For now, you just need to decide what you think is the most promising, what you can afford, and go with it. Or not. You also can just hang in there and see if habituation does its trick.
       
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    7. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      The studies quoting an 85% success rate will specify the criteria for success employed in each of those studies respectively. For myself, I define success as the achievement of meaningful lasting relief to the patient's satisfaction.

      Dr. Stephen Nagler
       
    8. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      @bwspot, I tried to answer your question one way, but ran afoul of the rules of the board. So with apologies to all, I'll try a different tack.

      Regarding the TRT I practice, there is one and only one TRT. It is the TRT described in detail in Dr. Jastreboff's book and taught in his courses. Any other "TRT" is not TRT at all. The TRT I practice is Dr. Jastreboff's TRT, which is the only TRT.

      Dr. Stephen Nagler
       
    9. kmohoruk
      Nerdy

      kmohoruk Member

      Tinnitus Since:
      07/2005
      Cause of Tinnitus:
      Loud Noise, Ear Infection, TMJ
      Thank you shedding more insight regarding this Dr. Nagler, it's very interesting!

      Out of curiosity @Dr. Nagler , if one were to fall into that 15% category of what would be considered a non-success. Is there a chance that if they were to take a break, and come at it again and try TRT again, that they would be able to achieve a more successful result?

      I know that is a bit of a loaded question. But I guessing for many of those people it would have to be to deal with their depression, anxiety or some physical issues first (Like hyperacusis), before they are able to truly be able to reach that successful point.

      Haha, I guess i'm just trying to find a positive angle in all of this as well. (Like I've seen you and other people say before, a positive attitude can go along way, even in the presence of a set back.)
       
    10. bwspot

      bwspot Member

      Tinnitus Since:
      06/13/2014
      Thx for the answer. That was easy.
      So if I want to learn more the book should give me enough details.
      And just to be 100% sure this is the one:
      http://www.amazon.com/dp/0521088372/?tag=tinntalk-20
       
    11. MattK

      MattK Member

      Tinnitus Since:
      2/13/2014
      In my opinion, some people just don't want to accept that their tinnitus is here to stay. Any solution other than getting rid of it will be viewed with skepticism.
       
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    12. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Yes. Depends on the reason for non-success.

      Dr. Stephen Nagler
       
    13. LadyDi
      Busy

      LadyDi Member Benefactor

      Location:
      Florida, USA
      Tinnitus Since:
      06/2013
      Cause of Tinnitus:
      Barotrauma/airplane
      In my opinion, some people just don't want to accept that their tinnitus is here to stay. Any solution other than getting rid of it will be viewed with skepticism.

      I think in some cases, you are correct, @MattK. Acceptance is a bear. I still am struggling with it. But for me, it's been crucial for being able to continue to live a life worth living. Everyone is different, though. And if a viable treatment comes along, I'll be first to grab onto it.
       
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    14. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Yes. If you want to understand TRT, that book would be the best source.

      But if you want to actually do TRT, the book would be completely inadequate.

      Dr. Stephen Nagler
       
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    15. bwspot

      bwspot Member

      Tinnitus Since:
      06/13/2014
      Does it mean that the TRT is still the mystery and no books explains how to do it?
       
    16. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      No. It means you can't do TRT without the one-on-one bi-directional TRT counseling. The principles of TRT counseling are outlined in considerable detail in the book. But the book is completely inadequate in terms of the execution of TRT counseling.

      @bwspot, perhaps look at it this way ...

      TRT is of course nowhere near as serious as, say, open heart surgery. But the analogy still holds. You can read a book about the principles of open heart surgery. There is no mystery at all. It is totally transparent. But for the execution of open heart surgery, you really do need a surgeon. More than that, I suspect you'd prefer a knowledgeable and experienced surgeon with a few thousand cases under his or her belt. I doubt that you'd choose to see somebody fresh out of residency training.

      Dr. Stephen Nagler
       
      • Like Like x 1
    17. bwspot

      bwspot Member

      Tinnitus Since:
      06/13/2014
      Thank you. Few more thoughts:

      So basically one cannot do TRT to him self.

      If I would try to ignore Tinnitus and get positive attitude towards together with applying few techniques listed here:
      "http://www.tinnitus.org/exercises.html" would I be doing TRT?

      I wonder if I would give the book to my dear wife or friend would they be able to apply the TRT to me?
      Would they still require more training to learn how to do it from people like you or dr. Jastreboof as information in the book regarding applying TRT in practice is not in the book and can only be gained through practice and lessons from those who know it?
       
    18. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Right. But some folks try it anyway.

      To them I say, "More power to you." The only thing I ask is that if they succeed, as a few of them do, they not consider it to be a TRT success. And if they fail, as the overwhelming majority do, they not consider it to be a TRT failure. Why? Because "self-TRT" is not TRT at all.

      You cannot imagine the number of folks around who claim that TRT "didn't work" for them - but who when questioned about what they did and for how long they did it wind up admitting that whatever it was that didn't work for them, it wasn't TRT.

      I am going to back out of the thread at this point.

      Best to all -

      Dr. Stephen Nagler
       
    19. attheedgeofscience
      Uninvolved

      attheedgeofscience Member Hall of Fame

      Location:
      Denmark
      Tinnitus Since:
      Childhood
      Cause of Tinnitus:
      Head Injury
      Dr. Nagler, could you please explain to the forum what exactly it is about two days of counselling in total which makes such a difference to the outcome of TRT. Actually - strike that - it is just one day of counselling (because day #1 is spent doing "audiology" tests).

      Even if TRT was done by the world's best psychologist/TRT clinician, I don't see how just one day of counselling could have such a profound effect on the final outcome. Can you?
       
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    20. ampumpkin
      Amused

      ampumpkin Member Benefactor

      Location:
      Montreal
      Tinnitus Since:
      Onset: 12/2007 Increase: 04/2014
      Cause of Tinnitus:
      2007: Meds(Antidepressant) 2014: Meds(Antibiotics)
      Ateos, there is a wonderful function called EDIT and I've just used it :)

      I hate your attitude. I find it very sad. You have such ANGER in you....
       
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    21. Michael2013
      Happy

      Michael2013 Member

      Tinnitus Since:
      September 2013
      Personally I think Ateos is asking a great question here. I would love to understand the answer myself.
       
    22. ampumpkin
      Amused

      ampumpkin Member Benefactor

      Location:
      Montreal
      Tinnitus Since:
      Onset: 12/2007 Increase: 04/2014
      Cause of Tinnitus:
      2007: Meds(Antidepressant) 2014: Meds(Antibiotics)
      Ateos, I thank you for forwarding to me privately some very disturbing things about Dr. Nagler. I do not care about it and it doesn't change anything at all.

      To answer to your comment, I have had very few interactions with Dr. Nagler. I do not support him nor do I not support him. I am neutral, either way.

      I am very tempted to invite you to get a life. Get that anger out of your heart and learn to let go.
       
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    23. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      What question, Michael?

      If it's important to you, let me know what it is ... and I'll try to help.

      Dr. Stephen Nagler
       
    24. Michael2013
      Happy

      Michael2013 Member

      Tinnitus Since:
      September 2013
      It's essentially wanting to know why DIY TRT is so difficult. I am a DiY'er. I read books and built my own deck. I do all my own automotive repairs without anybody but the internet teaching me. I am restoring a car from the ground up (with help, but not professional help). And I don't do any of that for a living and have no professional training on it. Why couldn't I do TRT myself? I am not saying I need TRT right now because I am doing well...I just don't understand what this missing link is that prevents it from being successful.

      -Mike
       
    25. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Let me guess, ATEOS is using the board's private messaging platform to send you some unsubstantiated "he said she said" newsgroup posts from ten-plus years ago when there was a purposeful campaign mounted by a couple of Internet miscreants in an attempt to destroy my reputation. I found one post where I supposedly threatened to break some guy's legs.

      Swell.

      Dr. Stephen Nagler
       
    26. SweetPeach

      SweetPeach Guest

      attheedgeofscience also sent me disturbing links about dr nagler :unsure:
       
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    27. ampumpkin
      Amused

      ampumpkin Member Benefactor

      Location:
      Montreal
      Tinnitus Since:
      Onset: 12/2007 Increase: 04/2014
      Cause of Tinnitus:
      2007: Meds(Antidepressant) 2014: Meds(Antibiotics)
      I wonder why such gesture is tolerated around here. Makes me very disappointed.
       
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    28. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      TRT requires sound therapy consistent with TRT category and bi-directional counseling consistent with TRT category. Regarding the TRT counseling, typically there is an initial intensive session followed by three or four one-hour follow-up sessions (in person or via phone or teleconference) spread out over a year's time. And between these sessions there is a good bit of back-and-forth communication between clinician and patient as various issues inevitably come up with the protocol. When I had lunch with Dr. Jastreboff yesterday, he mentioned one case in particular where he and his patient exchanged 50+ e-mails over a two to three month period. All that sort of thing comes under the umbrella of TRT counseling.

      I'm not saying that you cannot do a bunch of research and ultimately succeed with a DIY habituation program. I'm just saying that since bi-directional TRT counseling consistent with your TRT category is such a crucial element in TRT, that if you do succeed in a DIY effort, you shouldn't attribute that success to TRT. And similarly, if you fail, you shouldn't attribute that failure to TRT.

      Dr. Stephen Nagler
       
    29. Dr. Nagler

      Dr. Nagler Member

      Location:
      Atlanta, Georgia USA
      Tinnitus Since:
      04/1994
      Folks, I see my role here in terms of my ability to answer your questions on a wide variety of tinnitus-related issues, my ability to explore and address some of the myths about TRT and other approaches, and my ability to bear personal witness to the fact that tinnitus can indeed be overcome. It takes Strategy, Determination, Flexibility, and Insight. But it can be done. And if I can do it, you can do it. (Moreover, nowhere in that four-step formula do you see reference to TRT.)

      That said, the events of the past several days have saddened me greatly. I do not like being a punching bag.

      I'm going to take some time off and try to regroup.

      Best to all who are of good heart -

      Dr. Stephen Nagler
       
    30. MattK

      MattK Member

      Tinnitus Since:
      2/13/2014
      [QUOTE="LadyDi, post: 69466, member: 1437
      I think in some cases, you are correct, @MattK. Acceptance is a bear. I still am struggling with it. But for me, it's been crucial for being able to continue to live a life worth living. Everyone is different, though. And if a viable treatment comes along, I'll be first to grab onto it.[/QUOTE]

      Me too. It is a bear, but unfortunately, it's all we have. Of course, if I had the choice between habituation vs a real cure (so long as that cure didn't have some side effect worse than tinnitus), then of course I'd take the cure.

      But what I don't get is that some people on here get so hostile at the thought of habituating. I understand that it sucks to have to do that, but we live in the real world. Not everything as of yet is curable, and unfortunately tinnitus is one of those things.
       

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