Trigger Warnings Create Fertile Ground for PTSD

The topic of trigger warnings has become divisive in many circles, including on the internet where the phenomenon first began, and in university classrooms where an increasing number of students demand trigger warnings for all applicable course materials and content. Though their intended purpose is a noble one: to alert someone suffering from post-traumatic stress disorder (PTSD) about subject matter that might trigger flashbacks or memories of trauma, trigger warnings simply do not make sense from a psychological perspective. They do more harm than good.

The Difference Between Trigger Warnings and Content Warnings


Before we go any further, it is important to draw a distinction between trigger warnings and content warnings. Content warnings are given before some news stories, television shows, and movies, and are intended for general audiences. Content warnings alert viewers about subject matter that may be upsetting to certain viewers due to age (e.g. young children), moral inclinations, inborn squeamishness and sensitivities, and so on. Trigger warnings, on the other hand, are specifically intended for those with PTSD and other trauma-based anxiety disorders. In other words, trigger warnings presuppose the existence of pathology, whereas content warnings do not.

Do Trigger Warnings Work? 


I recently interviewed Dr. Suzanne Pineles, an expert in PTSD and a clinical psychologist with the US Department of Veterans Affairs' National Center for PTSD. Dr. Pineles specializes in the cognitive, physiological, and neurobiological processes involved in the development and maintenance of PTSD. She explains that a foundational element in the formation and prolongation of PTSD is avoidance coping, or the tendency to avoid anything that serves as a reminder of the initial trauma. These can include memories, specific people or places, certain topics, emotional states, and so on.

This avoidance of trauma triggers, Dr. Pineles says, "prevents the natural habituation or extinction that happens in people over time to help them learn that although it's never going to be fun to think about your trauma, having these memories or thoughts about it is not in itself dangerous."

Individuals and organizations that utilize trigger warnings, she continues, "may inadvertently be sending a message that these materials should be avoided, and the research shows that avoiding memories of the trauma actually might maintain or make PTSD worse."

With trigger warnings and the accompanying expectations that have arisen in "trigger warning culture", an environment has been created where avoidance coping is supported, encouraged, and justified. 

In some circles, this upholding of avoidance coping is seen as compassionate and inclusive. Ironically and against the good intentions of those who support the use of trigger warnings, a mass breeding ground for PTSD has been formed instead.

Psychiatrist, Sarah Roff, explains that exposure to media depicting triggering events has never been known to cause PTSD. What can cause or exacerbate PTSD is developing maladaptive coping mechanisms following a traumatic event that favour turning away from challenging and potentially upsetting experiences, numbing one's emotions, and refusing to open up to others about one's traumatic experiences -- avoidance tendencies that are all supported in trigger warning culture.

Trigger warnings are highly ineffective in other ways. For instance, potential triggers are infinite in number and difficult to pinpoint. Some people are triggered by "positive" scenarios, Dr. Pineles explains, such as stories of happy families. The resulting flashbacks to such material can be just as extreme and disturbing as those triggered by scenes of graphic rape or violence, yet most would never think to provide trigger warnings for such "wholesome" depictions.

Instead of compiling an ever-increasingly long list of potential triggers -- which now include representations or discussions of obesity, racism, insects, anything with multiple holes (for those with trypophobia), and much, much more -- the focus should be on formulating a better approach to how we talk about and confront trauma in ourselves and in others. A good solution is raising awareness of evidence-based treatments for PTSD, and promoting open dialogue about trauma and its potential effects. In the words of sociologist, Frank Furedi, "Compassion and thoughtfulness, not the avoidance of difficult topics, is the way forward."

Dispelling Myths About PTSD


We must also work to dispel myths that abound about both PTSD and PTSD treatments. One common myth is that PTSD is widespread, and a closely-related myth is that we are all at risk of developing the disorder. In a research article for Psychological Science in the Public Interest, PTSD expert Dr. Edna B. Foa and her fellow researchers explain that the majority of individuals experience significant trauma in their lives, but very few go on to develop PTSD. Echoing their claims is Dr. George Bonanno, whose work on psychological resilience shows that the most common human response to trauma is to pull through relatively unscathed and, in some cases, even strengthened.

Another myth is that PTSD is difficult to treat, when in fact, according to Dr. Pineles, it only takes 10-16 therapy sessions to treat a full-blown case. The two most common evidence-based treatments are 1) prolonged exposure therapy, developed by Dr. Foa, which habituates the patient's emotions by having them tell the story of their trauma over and over again in a controlled environment; and 2) cognitive processing therapy, which works by undoing the patient's cognitive distortions, such as blaming themselves for the trauma, thinking of the world as an incredibly dangerous place, and so on.

Yet another myth is that the gold standard treatments for PTSD, the above-mentioned prolonged exposure and cognitive processing therapies, are damaging in themselves and do not work for people who have experienced significant or severe trauma. Though it's well-acknowledged by therapists and researchers working in the field of trauma-based disorders that a small minority of patients with severe and complex cases of PTSD do not always respond well to exposure-based treatments, these treatments have been shown to be safe and effective for even some of the most difficult cases and in situations where the individual with PTSD has co-occurring disorders.

Though many writers, specialists, and educators have come to similar conclusions about the ineffectuality of trigger warnings, it is important to extend understanding and compassion to those who ardently uphold their use. In a world where trauma and the effects of trauma are often overlooked, ignored, or mocked, trigger warnings can feel like signs of a welcome change. They can feel like society declaring to the survivor, "I see you, your struggles are important, and I care about what happens to you."

Unfortunately, trigger warnings will never be able to protect individuals who have been diagnosed with PTSD or are on their way to developing the disorder. The demand for and expectation of trigger warnings have paved the way for a cultural environment where dialogue about difficult subjects is increasingly abandoned, where avoidance is a socially-acceptable and even encouraged behaviour, and where PTSD symptoms can develop and become further entrenched.


References

Avoidance coping. (n.d.). In Wikipedia. Retrieved from https://en.wikipedia.org/wiki/Avoidance_coping

Common trigger warnings. (n.d.). In Kyriarchy & Privilege 101. Retrieved from http://privilege101.tumblr.com/triggers.html

Cornell University. (2010). Rethinking trauma: George Bonanno on resilience. Evidence-Based Living. Retrieved from http://evidencebasedliving.human.cornell.edu/2010/03/28/rethinking-trauma-george-bonanno-on-resilience/

Drew. (2015, April 19). Common exposure therapy mistakes and misconceptions. That Anxiety Guy. Retrieved from http://www.thatanxietyguy.com/common-exposure-therapy-mistakes-and-misconceptions/

Extinction (psychology). (n.d.). In Wikipedia. Retrieved from https://en.wikipedia.org/wiki/Extinction_(psychology)

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: Lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest, 14(2), 65-111.

Furedi, F. (2015, June 29). Trigger warnings are educational suicide. spiked. Retrieved from http://www.spiked-online.com/newsite/article/trigger-warnings-are-educational-suicide/17124#.V2q7Z1QrJdj

Lukianoff, G., & Haidt. J. (2015, September). The coddling of the American mind. The Atlantic. Retrieved from http://www.theatlantic.com/magazine/archive/2015/09/the-coddling-of-the-american-mind/399356/

Pacific Standard staff. (2014, May 20). Hazards ahead: The problem with trigger warnings, according to the research. Pacific Standard. Retrieved from https://psmag.com/hazards-ahead-the-problem-with-trigger-warnings-according-to-the-research-4f220f7e6c7e#.g0xttub00

Roff, S. (2014, May 23). Treatment, not trigger warnings. The Chronicle of Higher Education. Retrieved from http://chronicle.com/blogs/conversation/2014/05/23/treatment-not-trigger-warnings/

Suzanne Pineles, PhD. (n.d.). In National Center for PTSD, U. S. Department of Veterans Affairs. Retrieved from http://www.ptsd.va.gov/about/divisions/womens-health/Suzanne_Pineles_PhD.asp

Trigger warning. (n.d.). In Wikia. Retrieved from http://geekfeminism.wikia.com/wiki/Trigger_warning

Van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012, July 25). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406222/pdf/EJPT-3-18805.pdf

(image 1 by PsycheAnamnesis via DeviantArt; image 2 by Michelle Robinson via Flickr)

A big thank you to Sezin Koehler for engaging with me in an email discussion about trigger warnings and PTSD. Our discussion helped immensely in the formulation of this article. Sezin Koehler is a gifted writer and cultural commentator, whose new book can be found here.