In the previous entry (Coping Effectively with Trauma: Part I), I discussed how trauma cannot be defined objectively: it is an eye-of-the-beholder experience. I also discussed the major symptoms of PTSD, such as re-experiencing (symptom #1), hyperarousal (symptom #2), avoidance (symptom #3), and changes in beliefs (symptom #4). This blog entry will discuss how to cope effectively with these symptoms and how to assist those we love who may be struggling.
Where am I?: Finding a Window of Safety
I often talk with my patients about something called “the window of tolerance.” (Briere & Scott, 2015). The window of tolerance is a place where a person can feel his or her emotions, but the emotions are tolerable and regulated. Here’s one way to think about it. Imagine a box or a window. Below this window is a state of numbness where a person feels dead inside or detached (symptoms 3 and 4). Above the window is a state of hyperarousal where feelings are too intense (symptoms 1 and 2). In contrast to numbness or hyperarousal, when you’re inside the window of tolerance, you can feel emotions, know what you’re feeling, and regulate or influence those emotions. Yet, many people who have experienced trauma are either below or above this window on a frequent basis. As a result, they “ping-pong” back and forth between states of hyperarousal and states of numbness (see below).
Finding the Window of Tolerance
Hyperarousal (Examples of Symptom Clusters 1 and/or 2):
Can’t think clearly
Hypervigilance/ Startle response
Intrusive thoughts/ Images
Within the Window of Tolerance
Feel emotions but in workable range
Can feel more than one emotion
Numbness (Examples of Symptom Clusters 3 and/or 4):
Don’t know how you feel
Blunting of emotions
Goes on “autopilot” (i.e., does the same thing again and again, while expecting different results)
Appears sleepy/ slow thinking or movement
Wanders Aimlessly or Without Purpose Through Life
Difficulty tracking what is going on inside
Disengaged from life and relationships
Arousal is like a wave that comes and goes. Some people are more aware of their emotions; they know when arousal is high and when it is low. Because of awareness, such fortunate persons can “ride the wave” of arousal. In other words, they can gently influence their stress level to keep themselves more or less within the window of tolerance. When the person’s arousal level is going up, she does not deny or ignore her feelings. She also does not give herself a hard time for having them (“I’m horrible for feeling upset….”). Instead, she intuitively takes her psychological temperature and makes small course-corrections to reset her emotional thermostat.
Yet, if someone has been raised in an invalidating environment, has been repetitively traumatized, or is forced to maintain a pressure-cooker-like lifestyle, he or she may develop a more-narrow window of tolerance. Consequently, she may “ping-pong” between states of hyperarousal and numbness. The person either judges herself harshly (“I shouldn’t be upset…”) or tries to ignore her feelings (“I’m fine…”). Rigid control, harsh self-criticism, or emotional denial all guarantee a never-ending game of psychological ping-pong.
“Where do drug and alcohol use fit in?”
With time and practice, a person can expand or enlarge the window of tolerance – despite his or her inborn temperament or tragic past. Yet, as mentioned in the previous blog, avoiding arousal and seeking numbness is where drug and alcohol problems typically happen. During hyperarousal, a person may experience flashbacks or feel like they’re going insane. Instead of riding the wave of arousal, the person impulsively uses alcohol or substances to force themselves back into a state of numb detachment. This seems to work for a short while… until the Xanax wears off. Once it wears off, the person experiences symptoms of withdrawal, which the body mistakes for anxiety (“Something is wrong again!”). Once the body mistakes withdrawal for anxiety, the mind quickly finds something to be anxious about. In a sense, the body does a Jedi-like mind-trick and convinces us that imagined or exaggerated dangers are real… mainly because they feel so real. The person then experiences a compulsion to take more medication, and the cycle of tolerance and withdrawal repeats itself – all while being justified by a doctor’s prescription.
It is important to remember, however, that this ping-pong cycle isn’t limited to drug or alcohol use; it can happen with any addictive or compulsive behavior, like excessive pornography consumption, self-harm behaviors (e.g., cutting), binge eating, or OCD-like handwashing ₁. With each compulsion, we preempt the wave. We escape before we learn the truth, which is that the wave – like all waves in nature – eventually recedes. But we don’t believe that because we haven’t allowed ourselves to experience it. Instead, we believe that if we tolerate our distress our heads will explode (or something else equally disastrous will happen). Soon, we become intolerable of ourselves because we’ve become intolerable of our experiences, and the window of tolerance narrows precipitously.
“How do I Cope Effectively?”
“Yeah, yeah… but what am I supposed to do?” you may be asking yourself. The problem with answering this question, however, is that there is no single, fool-proof coping skill that you must use every time you have symptoms. Coping with trauma is a lot about knowing – psychologically speaking – where you are. If you are above the window of tolerance (i.e., you’re experiencing symptoms 1 and/or 2), you need to do one set of techniques. If you are below the window of tolerance (you’re experiencing symptoms 3 and/or 4), you need to do a completely different set of techniques. This requires the person to be able to monitor and reflect on his or her emotional state at any given moment of time, which is no easy task when you are desperately trying not to feel. But, again, finding the window of tolerance is not about not feeling. It is about being able to acknowledge your feelings without reacting to them ₂.
Here are a few simple, pragmatic techniques to use if you find yourself above or below the window of tolerance:
If you are above the window of tolerance (i.e., hyperarousal)…
- Grounding: Grounding is being connected to the sensory experience of the present moment without judgment. Instead, we just notice the present moment, like: “Now I’m hearing the ticking of a clock… now I can feel my feet in my shoes… now I can see light reflect off of my computer screen as a write.” The idea behind grounding is to bring a person back from a state of hyperarousal and harsh self-judgment to within the window of tolerance. A qualified mental health provider can help if this feels too difficult to do on your own, but the exercises of Peter Levine can also be helpful (one such exercise can be found at: http://www.new-synapse.com/aps/wordpress/?p=234).
- Lowering general stress. People with high levels of anxiety frequently hover around their “boiling point.” Such persons need to participate in relaxing activities to lower their general level of stress. Practices such as deep breathing, muscle relaxation, and/or yoga can all be helpful. Frequent participation (not just “one-and-done” participation) helps make us less reactive to small triggers. Over a period of time, the window of tolerance grows. In contrast, continuing to plow straight ahead doesn’t work. We must consciously take time to be well, or we’ll most definitely have to take time to be ill. Lowering your general stress level may also mean that you have to let go of some things for a while so that you can have a more balanced lifestyle. Anyone will start to ping-pong if they live in a constant pressure cooker.
- Set limits on yourself/ Give yourself time. Don’t make any decisions when you know you are above the window of tolerance. This includes using drugs or alcohol. When it comes to dealing with people, instead of saying something impulsive, you can say something like, “I’m getting overwhelmed and need some time to think. Let’s talk later.” Saying this doesn’t mean you’re wrong or that the other person is right. It just means you’re wise enough to know where you are. No one problem-solves well when they are above the window of tolerance. Just because something feels urgent, doesn’t mean it actual is urgent. Set aside a time to solve the problem later.
If you are below the window of tolerance (i.e., numb)…
- Connecting with People. If you are going to say, “let’s talk later” (see above) then you have to actually talk later. The last thing I want someone with trauma to do is to shut themselves off from supportive others. While you don’t need to be the life of the party (Remember: some people also use excessive socializing as a way to avoid), it’s important to connect to others and get support, such as joining a group from an organization like the US Department of Veteran Affairs (VA).
- Connecting with Activities. Get started on some activities that give you a sense of connection and purpose. Many of the recommendations I typically give my depressed patients can be helpful when you are below the window of tolerance (see 7 Ways to Manage Depression without Medication).
- Connecting with Yourself. Mindfulness is a form of meditation borrowed from Buddhism that persons of any religion (or no religion) can do to strengthen their inner peace and self awareness (see Developing Mindfulness).
It’s worth repeating that successfully coping with trauma is about knowing where you are. If you’re hyperaroused or above the window of tolerance right now, some healthy distraction may be just fine. In contrast, if you’re numb or below the window of tolerance right now, you need to engage through connection. (Endless distraction ain’t going to help you.) Just remember that our goal is not a Xanax- or pot-like numbness; it is being able to experience our emotions without judging them or getting swept up in them.
There is always a danger in oversimplifying what is actually complex advice, but, if I were forced to summarize the recommendations above, I would say “When above the window, wait and ride (the wave). When below the window, connect and get going.”
Your symptoms, while understandably disturbing and probably undeserved, are temporary. Keeping in mind the impermanent nature of our symptoms is helpful; they won’t last forever. One of the only things we are guaranteed of in this life, other than death and taxes, is change. If you can keep this in mind without over-using trite phrases, like “This too will pass,” then you’ll be able to ride the wave of arousal and your window of tolerance will eventually expand. It’s important to remember that you’re not your trauma. Your history doesn’t define you, unless you allow it to by escaping or reacting every time you’re triggered. It depends a great deal on the story we tell ourselves. (see Redefining Your Past).
Treatment for trauma has come a long way. We may have to confront some ghosts, but aren’t we tired of running from them? Exorcising these ghosts is possible. But the exorcism comes through acceptance of the self – not through resistance of the self. We cannot escape our ghosts completely because we cannot escape ourselves completely … no matter how much we may try. Instead of resisting our pain by endlessly pushing our traumas away, we can nullify their power by accepting and working through them.
But What if it isn’t My Trauma? What if I’m Worried about Someone Else?
What if you aren’t the one who is traumatized, but you’re worried about someone who might be? How do you approach a loved one you’re worried about?
I recommend finding a good moment and planning out what you’ll say ahead of time. You don’t want to have a talk during an argument or right after a blow up. (“See! This is why you need to see a therapist!!!!”) Shame is a very powerful emotion, particularly for men or anyone who considers him or herself to be a warrior, like our returning veterans. When someone is being reactive, usually the emotion underneath the reaction is shame. Perhaps they feel ashamed that they can’t seem to “control” their feelings, or they feel guilty because they assume their family is disappointed in them. If we can be aware of the power of shame, we may become less frustrated and reactive ourselves. In other words, you have to lead the way. You’re going to have to regulate your own window of tolerance before you’re going to effectively lead someone else to do so.
Keeping this in mind, here’s a way to frame what can be a difficult conversation:
- Ask permission and keep the conversation to 2-3 minutes. Try something like, “Hey I’m concerned about you because it seems like a couple things have changed. Can you give me two minutes to tell you what I’ve noticed?”
- Tell them what you’ve noticed without judgment or labeling. “It seems like you’re really tense, and I’m worried about you. It might be worth talking with your doctor or a therapist for a couple sessions. I don’t want to wait until something bad happens.”
- It is important that your facial expression and tone of voice match the concern behind your words. Deep sighing, eye-rolling, yelling, or overt signs of despair aren’t going to be interpreted correctly by someone who is prone to being either numb or reactive. As the wife of one of my patients yelled at her husband during a couple’s counseling session, “Would you just get your ass back in the window, please!!!!!” (As you may suspect, they were both military.)
Having a talk might not feel successful at the moment, but if you approach your loved one with care, you might sow some seeds. Part of having trauma is wanting to avoid talking about trauma, so if you can choose a positive time to talk, they may be more receptive.
₁ When I explain the window of tolerance idea to some patients, I have many of them say, “But I’m never in the window of tolerance!” or “I’m both above and below the window at the same time!” This seems especially true for patients that were raised in invalidating environments. For such patients, I recommend starting a mindfulness practice (see Developing Mindfulness). Such persons need the nonjudgmental awareness that mindfulness cultivates. I also strongly recommend working with a qualified mental health provider. Other signs that you need to discuss trauma in therapy is if you dissociate. Dissociation is where you completely “blank out” where you are, who you are, or what you are doing. You may even lose track of time.
₂ This is part of the reason why some people exchange addictions and compulsions like they change underwear: one day they overuse alcohol, the next day they overuse work; one week they are really into pot, the next week they are really into online gaming; for a few months they try their hand at compulsive gambling, only to replace it later with multiple, impulsive sexual exploits. Any way you slice it, it’s all about escape.
Briere, J. & Scott, C. (2015). Principles of Trauma Therapy, 2nd Edition.
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