Trigger Warnings

Pacific Standard has a piece by Harvard prof and anxiety research giant Rich McNally, suggesting that trigger warnings can actually serve to make PTSD worse.

A trigger warning (summarized here in Slate) is a notice that a speaker is about to say something that may aggravate symptoms among those who have a psychological disorder. UC Santa Barbara stirred controversy when they required that professors provide such warnings on their syllabi, so as to avoid triggering episodes of PTSD among their students. (In case you’re wondering, UCSB’s trigger warning flap occurred before the Isla Vista shooting, and not in response to it.)

PTSD is an anxiety disorder (well, sort of. At least it used to be), and McNally suggests that trigger warnings, while well intended, can paradoxically aggravate PTSD symptoms.

Trigger warnings are designed to help survivors avoid reminders of their trauma, thereby preventing emotional discomfort. Yet avoidance reinforces PTSD. Conversely, systematic exposure to triggers and the memories they provoke is the most effective means of overcoming the disorder. According to a rigorous analysis by the Institute of Medicine, exposure therapy is the most efficacious treatment for PTSD, especially in civilians who have suffered trauma such as sexual assault. For example, prolonged exposure therapy, the cognitive behavioral treatment pioneered by clinical psychologists Edna B. Foa and Barbara O. Rothbaum, entails having clients close their eyes and recount their trauma in the first-person present tense. After repeated imaginal relivings, most clients experience significant reductions in PTSD symptoms, as traumatic memories lose their capacity to cause emotional distress. Working with their therapists, clients devise a hierarchy of progressively more challenging trigger situations that they may confront in everyday life. By practicing confronting these triggers, clients learn that fear subsides, enabling them to reclaim their lives and conquer PTSD.

This idea, that avoidance amplifies symptoms and prolongs suffering, is central to our understanding of PTSD and all other anxiety disorders.

Here’s an extremely stripped-down, basic, model of PTSD: You witness or experience something terrible, such as a car accident. You then develop a conditioned response to things that are related to the accident, such as the song that was on the radio, or the part of town where it occurred.

Because this conditioned emotional reaction is so extreme and hard to handle, you begin to avoid things. You not only avoid the street where the accident occurred, you avoid the neighborhood, then the city, then driving altogether. You paradoxically become sensitive to more and more triggers.

A similar cycle of conditioning occurs in panic disorder (substitute panic attack for traumatic event), and in OCD (substitute distressing thoughts for traumatic event, and compulsion for avoidance). These disorders can look very different, but the underlying mechanism is similar: Anxiety leads to a behavior that reinforces anxiety. 

In all these cases, cognitive-behavioral therapy presents a way of learning to handle the emotional response, to turn toward the pain in a safe way, and to gently but firmly reverse the momentum. Gradually, you reclaim the ground that you'd ceded to avoidance.

It may sound somewhat cold and detached to talk about trauma or panic in such a clinical, detached, way. I know that it feels like hell in when you're in it. But the science is clear. We understand these disorder, and we know how to treat them. Treatment works, as long as you trust the process and stick with it.