Acceptance and commitment therapy (ACT) and mindfulness-based therapy reduce tinnitus distress in randomised trials, but the evidence is smaller and less settled than for CBT, and the 2024 VA/DoD guideline calls it insufficient.
This page is the evidence page for the whole family: the trials, the systematic reviews and the guidelines. For what a mindfulness course involves week to week, and a breathing exercise with a small trial of its own, see meditation for tinnitus.
How ACT and mindfulness differ from CBT
Standard CBT for tinnitus works substantially through cognitive restructuring — identifying and changing unhelpful thoughts about the tinnitus. ACT, grouped with mindfulness-based approaches under the label "third-wave" therapies, instead emphasises psychological flexibility: learning to notice tinnitus-related thoughts and sensations without automatically reacting to them, clarifying what matters to you in life, and taking action toward those values while the tinnitus is present, rather than waiting for it to go away first. In practice, sessions include mindfulness exercises, "defusion" techniques for stepping back from unhelpful thought patterns, and values-based goal setting.
The mindfulness programmes are structured courses rather than a general instruction to meditate. Mindfulness-based stress reduction (MBSR) is a set protocol of intensive mindfulness training; mindfulness-based cognitive therapy (MBCT) combines that training with elements of cognitive therapy; and tinnitus-adapted versions add education about tinnitus itself.
What all of them share is the target. None tries to remove the sound; they try to change how much it governs your attention, mood and choices.
The head-to-head trial against TRT
The most striking result in this literature comes from Westin and colleagues in Sweden, published in 2011 in Behaviour Research and Therapy. They randomised 64 people with normal hearing and tinnitus to one of three arms: ACT, tinnitus retraining therapy, or a waiting list.
The two treatments asked for very different things. ACT was 10 weekly one-hour sessions. TRT was one 150-minute session, one 30-minute follow-up, and wearable sound generators recommended for at least 8 hours a day for 18 months. Assessments ran at baseline, 10 weeks, 6 months and 18 months.
- Against the waiting list, at 10 weeks, ACT improved tinnitus impact with a large effect (Cohen's d = 1.04), along with problems with sleep and anxiety.
- Against TRT, across all the assessment points, ACT did better on tinnitus impact (d = 0.75) and on sleep problems.
- At 6 months, 54.5% of the ACT group showed reliable improvement on the main outcome, against 20% of the TRT group.
- The improvement was mediated by tinnitus acceptance — the process the therapy sets out to change, which is some evidence that it worked for the reason it was supposed to.
This is a comparison against an established active treatment rather than against nothing, which is rarer in tinnitus research than it should be. It is also one trial, of 64 people split three ways, all with normal hearing. It does not tell you how ACT compares with TRT for people whose tinnitus comes with hearing loss, and a single small trial is where a finding starts rather than where it settles.
ACT against CBT, delivered online
The closer comparison is with CBT itself. In a 2012 trial in the Journal of Consulting and Clinical Psychology, Hesser and colleagues randomised 99 people significantly distressed by tinnitus to guided internet-delivered CBT (32), internet-delivered ACT (35), or a control group using a monitored online discussion forum (32).
On the Tinnitus Handicap Inventory, both therapies beat the control after the 8-week programme, by almost the same margin: d = 0.70 for CBT and d = 0.68 for ACT. The difference between the two was not significant (d = 0.16). Both groups kept large improvements through one-year follow-up (d = 1.34), though that figure is a before-and-after change within the groups rather than a comparison with the control. The authors concluded that acceptance-based procedures may be a viable alternative to traditional CBT techniques.
A later analysis of the same trial, by Hesser, Westin and Andersson in 2014, asked what drove the change. One part of acceptance — continuing to engage in activities despite the tinnitus — carried the improvement in both therapies. The other part, giving up attempts to suppress the tinnitus, carried it in ACT only. So the line between the two therapies is less sharp than their labels suggest: accepting the sound appears to be part of how CBT works as well. That also connects this family to internet-based CBT, which is where most people will meet a structured psychological programme for tinnitus.
What the mindfulness trials found
Four studies carry most of the weight for mindfulness programmes specifically.
- MBCT against relaxation, 2017. McKenna and colleagues randomised 75 adults with chronic, distressing tinnitus to MBCT or intensive relaxation training, each delivered as 8 weekly 120-minute sessions — an active comparison matched for time and attention, which is a harder test than a waiting list. Both groups improved on tinnitus severity and loudness, distress, anxiety, depression and disability. MBCT reduced tinnitus severity more: a mean difference of 6.3 points on the Tinnitus Questionnaire (95% CI 1.3 to 11.4), and 7.2 points six months later, a standardised effect of 0.56. The benefit did not depend on initial severity, duration or hearing loss.
- Mindfulness meditation against relaxation, 2017. Arif and colleagues recruited 86 patients to five sessions of either approach. Only 61 completed — 34 in the mindfulness group and 27 in the relaxation group. Both improved on the Tinnitus Reaction Questionnaire and most secondary measures, and the change was greater with mindfulness.
- Mindfulness after education, 2012. Philippot and colleagues gave everyone a single session of education about tinnitus, then two months later six weekly sessions of mindfulness or relaxation. The gains from the education session were maintained or enhanced by mindfulness and eroded with relaxation over follow-up.
- MBCT in routine care, 2018. McKenna, Marks and Vogt followed 182 adults through an 8-week MBCT group at a London tinnitus clinic. After the course, 50% showed reliable improvement in tinnitus-related distress and 41.2% in psychological distress, and the changes tracked increases in acceptance and mindfulness. There was no comparison group, so this shows what happened in a real clinic rather than what the course caused.
The pattern across these is consistent with the ACT trials. Against relaxation training, which is itself an active treatment, mindfulness tends to come out ahead on distress, by a modest margin.
What the systematic reviews conclude
Three reviews have pooled or summarised this literature, and they agree more than they differ.
Rademaker and colleagues, 2019. Seven studies of mindfulness-based interventions with 425 patients, including three randomised controlled trials. Two of the three trials found a clinically relevant drop in tinnitus distress straight after treatment compared with controls. The review found no effect on depression or anxiety in tinnitus patients, and called the long-term effects uncertain.
Wang and colleagues, 2022. Fifteen studies — six randomised trials and nine before-and-after studies — with 750 people, most of them about tinnitus. ACT and mindfulness-based interventions improved hearing-related distress against controls and other treatments at the end of treatment, and ACT also improved depression and anxiety against controls. But the gains were either not maintained or not examined at follow-up, there was no evidence of improvement in quality of life, and the studies were mostly of poor to moderate quality with small samples. The authors' conclusion is that the evidence is insufficient to recommend these therapies generally, with some evidence that they help tinnitus distress in the short term.
Ungar and colleagues, 2023. A meta-analysis of ACT alone, with three studies. Tinnitus Handicap Inventory scores were 17.67 points lower with ACT than in untreated control groups (95% CI −23.50 to −11.84). That is a large difference, but it is three studies measured against no treatment, which is the easiest comparison to win.
So individual trials report benefits still present at six months, while the reviews, looking across the literature, could not establish that the gains last. Both can be true: a few good trials followed people up, and most of the literature did not.
What the guidelines say
The US Department of Veterans Affairs and Department of Defense guideline, published in June 2024, addresses this family directly. Recommendation 15 states that there is insufficient evidence to recommend for or against ACT, mindfulness-based therapies or MBSR, by a trained provider, for adults with bothersome tinnitus — listed together and unranked.
The reasoning is set out in the full guideline. Only one systematic review met its methods for this question, the Wang review above. The work group rated its confidence in the evidence as very low, citing a limited number of studies, small samples and predominantly poor-to-fair methodological quality, and noted that for ACT the treatment gains were not maintained at 6- and 12-month follow-up. It judged that the benefits slightly outweighed the potential harms.
Set that beside Recommendation 14, which suggests CBT by a trained provider (weak for). The guideline's confidence in the CBT evidence was also very low, but CBT has the most studies and more consistent findings. That is the real difference between the two verdicts: the amount of evidence, rather than a finding that one works and the other does not. The same document notes that in combined sound-and-CBT programmes, elements such as mindfulness and relaxation training could be delivered by other disciplines to ease the load on mental health providers. The VA/DoD guideline in plain English covers all 25 of its recommendations.
"Insufficient evidence" is the accurate reading of this literature, and it is a statement about the trials rather than about the therapies.
What has not been tested yet
The question most people would ask — is mindfulness as good as CBT? — has been designed as a trial more than once, and not yet answered.
- The MinT trial, whose protocol was published in 2020, set out to randomise 54 patients to MBCT or CBT and test whether MBCT is no worse than CBT on the Tinnitus Functional Index at 12 months after therapy ended, using a 13-point margin.
- A Lithuanian three-arm trial, whose protocol was published in 2023, compares internet-delivered CBT with an internet-delivered mindfulness-based tinnitus stress reduction course and a waiting list, with follow-up at 3 and 12 months.
A PubMed search in September 2026 found both protocols but no results paper for either. Until one reports, "as good as CBT" rests on Hesser's single online comparison of ACT, and for mindfulness on no direct comparison among the studies described here.
If other treatments have not helped
A 2025 case series from Japan followed five people whose tinnitus had not responded to tinnitus retraining therapy through an ACT programme. Four completed six-month follow-up, and three of them showed a clinically meaningful drop on the Tinnitus Handicap Inventory; those without hearing loss improved more on some psychological measures. With five people and no comparison group, that is a reason to consider ACT after TRT rather than evidence that it will work.
Who this tends to suit
ACT and mindfulness-based approaches may suit people who have found that CBT's focus on directly challenging thoughts does not resonate, or who are drawn to a more experiential, present-moment style of therapy. The claim is not that they outperform CBT — both aim to reduce distress and improve functioning rather than eliminate the sound — but the route is different, and some people engage better with one framework than the other.
They are also a reasonable next step when CBT is not available locally, provided you choose a structured programme. A general meditation app is a different, much less studied thing, as the practical meditation page linked at the top explains.
Finding it
ACT for tinnitus specifically is less widely available than general CBT. Ask an audiologist or psychologist directly whether they offer ACT or a mindfulness-based tinnitus programme, or can refer you to someone who does. As with CBT, experience with tinnitus matters more than general familiarity with the approach, and a course with a fixed structure — a set number of weekly sessions and practice between them — is closer to what was tested than open-ended sessions.