The Window of Tolerance: The Wisdom of Trigger Avoidance

Many personal growth and self-help programs encourage people to lean into their pain in order to transmute it. While it’s true that sometimes “the way is through,” at other times we merely re-injure and re-traumatize ourselves by pushing too hard through the pain. The psychological concept of the Window of Tolerance explains why the avoidance of triggers can be an important part of the healing process.

To illustrate this point, I’d like to share two cases from my practice, one of which seemingly has little, if anything, to do with psychology. On the surface these cases have little in common, but they both illustrate the therapeutic importance of taking a break from triggers.

 

The Case of the Leaky Gut

Amber came to see me for help with digestive troubles that began when she got sick with dysentery while working as a Peace Corps volunteer. She’s can’t say whether it was the infection itself or the several rounds of antibiotic and anti-parasitic medications she took to treat it, but for several years since that time Amber has struggled with abdominal pain, reflux, and loose stools – all of which are significantly aggravated by eating dairy and wheat. In addition to these digestive symptoms, Amber had also developed the new ailments of eczema and migraine headaches.

It was immediately clear to me that if I was going to help Amber reclaim her health that I had to help her heal the lining of her digestive tract.

I used a healing method known as the 4 R’s Program – which stands for Remove, Replace, Repair, and Reinoculate.

In the first phase of healing, Remove, we removed as many triggers as we could from Amber’s diet and lifestyle. Amber already knew that dairy and wheat were triggers, and food intolerance testing showed additional high reactivity to eggs, all gluten-containing grains (not just wheat), pineapple, garlic, and almonds. My own understanding of digestive health also led me to advise Amber to avoid deep-fried foods, artificial sweeteners, and alcohol.

“Do I have to avoid all of these foods forever!?” Amber asked, clearly overwhelmed. “Probably not,” I told her. “But for at least a couple of months, yes, it would be best if you strictly avoided all of these things.” In its injured state, Amber’s torn up gut lining was reacting to many different food proteins, but I suspected that once her gut lining was healed it would be able to handle most if not all of these common triggers. After all, if Amber had a broken leg, any doctor (or person with common sense) would advise her not walk on it. Sure, a healthy leg should be able to bear weight, but a broken leg is not a healthy leg yet – and one of the best ways to heal a broken leg is to avoid stressing it. I used this analogy to explain to Amber that she had a “broken” gut and that we needed to let it rest for a while.

The second phase of the 4 R’s program is Replace. In this phase of treatment, we substituted Amber’s diet with digestive enzymes and hydrochloric acid (stomach acid) to help digest her food. I suspected that once Amber’s health was restored her body would make its own digestive agents, but while she was healing her body likely needed a little help in these departments.

The Repair phase of treatment consisted of using herbs, nutrients, and other strategies to actively soothe and heal the gut lining. In Amber’s case specifically, I prescribed two scoops of collagen powder mixed in water daily, 30mg of zinc carnosine twice daily, and castor oil packs applied to the abdomen at least three nights per week. Note that this phase of treatment usually takes at least three months to work: it takes time! This is the active “healing” stage of the protocol, but it does not work without the aforementioned Remove and Replace phases.

In the final phase of treatment, Reinoculate, we ensured a healthy microbial milieu in Amber’s digestive tract by adding in a good quality probiotic supplement and adding more fiber into her diet.

After much patience and diligence, Amber’s gut lining was healed. Within two weeks the abdominal pain and reflux went from three times a day (after every meal) to once every other day. After eight weeks on the restricted diet, Amber’s skin was clear and she only experienced digestive problems once or twice a week, and she was always able to link the flare to a clear trigger (eg: she accidentally ate something on the “do not eat” list). At the three-month follow up I asked about the migraines and Amber looked at me with a mix of confusion and joy: “Oh! I totally forgot about those. I can’t even remember when I had the last one.”

But it wasn’t all smooth sailing: Amber made significant sacrifices for the sake of her health. After a few weeks on the Remove phase of the treatment plan, Amber called me to express feelings of frustration. “It’s so hard to eat in a restaurant. All my friends went out for pizza and beer after work and I sat there feeling so lame,” she cried. Co-workers chided her for her restrictive diet, telling her that “eating a little gluten is good for you,” and “if you don’t eat dairy you might get osteoporosis” (neither of which is true, by the way). “It just isn’t normal,” her father said, “you should be able to come over for dinner and eat what your mother cooks,” implying that Amber was being disrespectful by avoiding her triggers. The hardest phase of the treatment program was by far and away the Remove phase – the phase in which Amber had to avoid her triggers. But it was worth it in the end.

Nowadays, Amber is healthy, happy, and strong. She carefully re-introduced her trigger foods one at a time and found that she could successfully eat dairy, eggs, gluten-free grains, pineapple, garlic, and almonds with no negative reactions. She gets a mild bellyache and looser stools for a couple of days if she eats gluten, so now she decides when it’s worth it for her to eat her trigger food. She put her foot down with her family and now her mother has a small repertoire of gluten-free dishes for when Amber comes over for dinner. Her skin is healthy and smooth, she hasn’t had a migraine in over a year, and she’s tapered off of the digestive enzymes and hydrochloric acid supplement. For all intents and purposes, Amber is cured.

As a healthcare provider and functional medicine specialist, I have treated many patients like Amber. I have tried all kinds of protocols with all kinds of patients, and frankly, I am absolutely convinced that Amber could not have achieved these results without avoiding her triggers for an extended period of time.

 

The Case of the Broken Heart

Can we superimpose Amber’s physical healing journey after gastrointestinal “injury” onto psychological health as well? Absolutely.

The body and the brain are not all that different.

Take, for instance, the case of Sergei. Within a three-month period, Sergei endured some significant mental/emotional injuries. After 11 years of working at a multinational technology corporation, Sergei was laid off when the company fell into financial hardship and let go of 12,000 people. Shortly after losing his job, Sergei discovered that his wife was having an affair with a colleague and that she intended to file for divorce. Suddenly he was without career, partner, and sense of identity. After getting drunk in a bar he went home with a stranger, from whom he contracted genital herpes. For the first time in his life, Sergei experienced panic attacks, insomnia, and general “edginess.”

When we started working together, I asked Sergei to make a list of all of his triggers – the things that made him feel anxious, angry, or sad. The list was long and included obvious things like driving past the street he used to live on, listening to Radiohead (one of his first dates with his wife was a Radiohead concert), not getting enough sleep, dating (he didn’t know how to talk about his new herpes diagnosis), thinking about the logistics of a divorce, and seeing the logo of the company he used to work for. There were some seemingly random triggers, too, like sunset (his anxiety was generally worse at night), his mother’s general victimhood about the separation (featuring such comments as “Oh my, how will I ever explain this to my friends? Isn’t there a way you two can work this out?”), and logging onto the Netflix account he still shared with his wife and seeing her name on the welcome page.

I should mention that up until this rough patch, Sergei generally identified as an “ass kicker” and a “winner” in life. He worked out at a Cross Fit gym several times a week, listened to Joe Rogan, read everything ever written by Tim Ferris, completed the Ice Bucket Challenge, and generally “worked hard and played hard,” as he put it. This “injury” of the job loss and marital trouble – and Sergei’s emotional response to these events – really tested Sergei’s perception of himself.

Sergei decided to turn to his usual “ass kicking” strategies to cope with his new struggles. He signed up for a biodynamic breathwork workshop, which entailed using a breathing technique to flood the brain with oxygen and induce a primal state of emotion during which Sergei re-experienced old wounds from childhood. Sergei reported that the technique caused him to scream and cry. This release of emotion was not a catharsis that left him feeling relieved, but rather a shock to his system that resulted in a worsening of his anxiety, leaving him “feeling like I’d somehow done further damage to my psyche.”

Sergei then signed up for an ayahuasca ceremony with a famous shaman at a fancy retreat center, but that too seemed to hurt more than help: the night after the intense ceremony he started grinding his teeth in his sleep to such intensity that he cracked a tooth and wound up needing a medical procedure to fix it.

Sergei then read an article about “Exposure Therapy” and began meditating before a photo of his wife every day, trying to send her metta (lovingkindness), but it only made him cry and feel anxious every day. By the time he came to see me, Sergei felt desperate.

If these extreme therapies couldn’t help him, nothing else could – or so he feared.

Except I knew it wasn’t true. I knew the therapy that could help Sergei was likely the one that would challenge his ego the most: leaning away from his triggers; not into them. In other words: the 4 R’s program, but for the mind.

The first part of Sergei’s healing plan – Remove – included eliminating and avoiding as many of these triggers as possible. This meant driving a different route, even though it entailed adding another ten minutes to his daily commute, erasing all Radiohead albums off of his phone, and deleting all dating apps. I also encouraged Sergei to cover up the logo of his former employer with various decals. (Perhaps we couldn’t snuff out every logo out there in public, but we certainly could control what Sergei let into his home and private space.) Sergei invested $10 a month into his mental health by creating a separate Netflix account for himself. As for his mother, I suggested to Sergei that he tell her, “Mom, I’m going through a very rough patch right now. I know it’s hard for you too, but I need to ask you to turn to other people for support around that. I can’t be strong enough for us both right now.” He thought for a moment and said, “No, she won’t get it. It’ll just freak her out more.” “Okay then,” I said, so how do we avoid that trigger? “I just need to push her calls to voicemail.” And that’s exactly what he did. His mom didn’t understand but frankly, we couldn’t let that be Sergei’s problem just yet. And the photo of his wife was put in a box and stored in the closet.

The second R in the 4 R program is Replace. In Sergei’s case, the mechanisms that allowed him to feel safe and calm were injured, so we needed to provide him with some buffer. For this reason I prescribed to Sergei a benzodiazepine medication, with instructions that he only take it in one of two circumstances: (1) if he felt an acute panic attack coming on, and/or (2) if he knew he would be exposed to a trigger and he absolutely couldn’t avoid it (eg: if he had a meeting with his attorney to discuss his options for divorce). I also prescribed to him an L-theanine supplement to take daily, a guided visualization exercise to do at sunset, and an herbal sleep support aid to help him wind down at night. As with Amber’s digestive enzymes and hydrochloric acid supplements, I was confident Sergei would have no problems in weaning off the benzodiazepine once he was through the hardest patch of his treatment program.

Sergei, however, fought with me over my rationale. “I don’t want to bypass my work,” he insisted. “If I need to feel all of this pain to grow, so be it.” “Fair enough,” I said.

“But do you think daily panic attacks and cracked teeth are truly the direction of healing?”

Sergei drew in a deep breath and I saw his eyes glaze over. “No. But I don’t want to be a numb zombie,” he whispered. And that’s when I shared with Sergei the same analogy I shared with Amber: the one of the broken leg. “If you had a broken leg and I told you not to walk on it until it was healed, would you tell me that doing so would be a bypass and that what you really needed to do was march into the pain to save yourself?” Sergei looked up as a tear fell down his cheek as he shook his head no.

“Well, you have a broken leg,” I said. “Only it isn’t your leg: it’s your heart. So let’s be gentle with it, because it’s a precious thing and it’s hurting right now.”

Sergei drew in a deep breath, nodded his head “yes,” and sobbed.

The third phase of healing, Repair, is truly a remarkable one when it comes to mental/emotional healing. This looks dramatically different for every individual, but as with Amber’s gut ailments, the repair phase works best when preceded by the removal of triggers and the replacement of mechanisms that are (temporarily) out of service. The repair phase for both physical and psychological ailments also requires a special ingredient: time. Not days, not weeks – but usually months, and even sometimes years.

For Sergei, the repair phase had a lot to do with convincing his nervous system that he was safe.

The “heroic” approaches that Sergei associated with “ass kicking” were all pushing his boundaries – in an unhealthy way.

And although many of Sergei’s “gurus” would say that boundary pushing is a good thing, it was clearly exacerbating and exasperating Sergei’s over-stimulated nervous system – in turn setting him back. Pushing into the pain in Sergei’s case was about as productive as it would have been for Amber to go out for pizza and beer to try and heal her torn up gut lining.

This idea is echoed in the concept of the “Window of Tolerance.”

 

The Window of Tolerance

“Window of tolerance” is a term coined by Dr. Dan Siegel and incorporated into the work of such famous trauma therapists as Dr. Paul Levine and Dr. Bessel van der Kolk. It describes the zone of arousal in which a person can most effectively function. When we stay within the window of tolerance, our brains work optimally and we are able to receive new information and make choices wisely. During periods of extreme stress, however, we’re at risk of becoming either “hypo aroused” (feeling numb) or “hyper aroused” (experiencing anxiety, panic, and racing thoughts). This “hyper aroused” state describes the response of Sergei’s nervous system to the shock of his life changes. Hyper arousal is also the “fight or flight” nervous system response; frankly a terrible state to be in – unless you’re actively running from a tiger, that is.

When we’re hyper aroused (outside of the window of tolerance), we’re more likely to perceive danger and threat during safe/neutral activities. This was the case with Sergei and the panic he felt upon seeing the logo of a certain company.

It isn’t logical, necessarily, but our brains literally think our lives are at danger when we’re out of the window of tolerance.

Every person’s window of tolerance is unique to them, which is why one person might be able to drive by their old street without pain, while doing the same gives freshly-fired-freshly-dumped Sergei a panic attack. In general, people are more likely to remain within the window when they feel safe and supported, whereas experiencing traumatic or highly stressful events (such as a layoff or a divorce) can push a person out of their window of tolerance.

 

Image courtesy of https://www.nicabm.com/trauma-how-to-help-your-clients-understand-their-window-of-tolerance/

 

Although programs like biodynamic breathwork, ayahuasca ceremonies, and other such strategies are powerfully healing for some, they’re likely to aggravate those with a narrower window of tolerance and those who are already outside of their window of tolerance. The programs Sergei tried before coming to see me were all great ideas, but attempted at the wrong time, as Sergei was already outside of his window of tolerance before attempting these arousal-enhancing approaches.

He wasn’t breaking through so much as breaking down.

Fortunately, it’s possible to widen one’s window of tolerance. This mainly entails using therapies and approaches that reinforce feelings of safety, security, and present-moment awareness, such as bodywork, mindfulness practice, body scanning, yoga, T’ai chi, psychotherapy, and, in certain situations, medication. There’s another important remedy for widening the window of tolerance after an acute shock to the system, one that’s all too often overlooked: time.

Some things just take time.

 

Repairing the Broken Heart

Sergei’s Repair phase consisted of a daily meditation practice, moderate exercise regimen, and weekly sessions with a psychotherapist. During these sessions, Sergei and his therapist often stayed mindful of the window of tolerance, and were committed to keeping Sergei “regulated” and “within the window” as they broached challenging topics. Through this period of time Sergei minimized his exposure to triggers and took his medications and supplements as prescribed.

The Reinoculate phase was an important and joyful step in Sergei’s recovery. In this phase, Sergei created a healthy milieu for himself by picking up a new hobby of building model airplanes and joining a dodge ball league, where he made new friends. He created some new habits as well, like starting each day by reading an entry out of a book of inspirational quotes and pampering himself with a juicy steak dinner every Friday night. With time, the “ecology” of Sergei’s life found a new and happy equilibrium.

As with Amber’s journey, Sergei’s process was bumpy at times. A few months into working with me, Sergei sent me a message through the patient portal. He was very confused and agitated after seeing a meme pop up on Instagram, which read:

“Avoiding triggers isn’t healing. Healing happens when you are triggered and you are able to move through the pain, the pattern, and the story and walk your way to a different ending.”

This quote sent Sergei into a bit of a tailspin, in which he began questioning the entire thrust of our treatment plan. “Why am I avoiding all these triggers when I should be moving through them!? WTF is wrong with me that I can’t even drive by Tillia Drive anymore without flipping my shit!?”

“Sergei,” I typed in reply, “this meme is hogwash. Healing is not one-size-fits-all.

“Would you tell somebody with a broken leg that by resting they’re being lazy or enabling their pain? Would you tell them to just to walk their way to a different ending?

“Of course you wouldn’t. You are entirely on the right path. Keep breathing. Keep protecting that gentle, tender heart of yours. Keep doing your healing homework. You’ve got this. You are not running and hiding; you are stepping away to heal. By pairing trigger avoidance with the healing steps you’re taking, you will actually come to transmute those triggers. The ‘no pain no gain’ approach is toxic. ‘Work smarter, not harder’ is your mantra right now. Trust me. That meme is true for certain situations, but not for yours right now.”

Today, Sergei works for a local startup. As I suspected, the context of a carefully designed and executed care plan made it very easy for Sergei to taper down off the benzodiazepine drug I prescribed to him when he first came to see me. He reports that it still “pangs” a little to drive by his old street, but with some deep breaths the pain passes. He can now see his former employer’s logo and laugh, saying, “I’m so glad I don’t work in that cesspool/stress-pool anymore.” He’s dating, talking to his mother, sleeping well at night, enjoying sunsets, and even sending his ex-wife metta from time to time. By avoiding his triggers and working on healing within his window of tolerance, Sergei was able to regain his health.

And you can heal, too.

 

 

Photo by Adeolu Eletu on Unsplash

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