Hazards Ahead: The Problem With Trigger Warnings, According to the Research

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http://www.psmag.com/health-and-behavio ... arch-81946

Five studies you should read before you deploy a trigger warning.

Resolutions by campus student groups seldom make national news. Yet when the student senate at the University of California-Santa Barbara passed a resolution to mandate that syllabi carry what are called “trigger warnings,” writers across the nation began typing. Professors, the resolution said, must alert their students to course materials that might produce emotional distress. Students should be exempt from portions of a class where “triggering content”—discussion of suicide, sexual abuse, kidnapping, or other disturbing topics—may occur.

Trigger warnings are increasingly being used on websites and blogs to warn readers away from potentially disturbing content. Their rapid spread has sparked loud debate about their use, prompting Slate to christen 2013 “The Year of the Trigger Warning,” and the New York Times to feature the controversy on the front page of a recent Sunday edition.

In the noise, it is easy to overlook that trigger warnings originated in the feminist blogosphere in part to emphasize the frequency of sexual assault in America and the trauma that can come with it. The UC Santa Barbara resolution urges the university to require trigger warnings to affirm its stand “against issues of sexual harassment and violence.” People who have experienced a trauma and developed post-traumatic stress disorder remember their experience all too well, reliving it emotionally in the form of intrusive memories, flashbacks, and nightmares. Warnings on syllabi can enable those who have suffered a traumatic event to avoid reminders that can trigger discomfort. But as the following studies show, these warnings may be counterproductive. The use of trigger warnings doesn’t just underestimate the resilience of most trauma survivors; it may send the wrong message to those who have developed PTSD.

MOST TRAUMA SURVIVORS DON'T DEVELOP PTSD

Experiencing trauma does not mean that one will develop post-traumatic stress disorder. Trauma is common, but PTSD is rare. In a representative survey of 2,181 adults in southeastern Michigan, the epidemiologists Naomi Breslau and Ronald C. Kessler found that 89.6 percent of them had experienced trauma, such as rape, natural disasters, serious accidents, or learning of the sudden, unexpected death of a loved one. Yet only 9.2 percent of the subjects developed PTSD. These findings imply that risk and resilience factors affect whether exposure to trauma results in the disorder.

—“The Stressor Criterion in DSM-IV Posttraumatic Stress Disorder: An Empirical Investigation,” Breslau, N., & Kessler, R. C., Biological Psychiatry, 2001

BUT PTSD ISN'T UNCOMMON AMONG SURVIVORS OF SEXUAL ASSAULT

Not all traumatic stressors are equally likely to produce PTSD, as Naomi Breslau and her colleagues confirmed in a recent study. In a nationally representative sample of 34,653 American adults, interviewers asked respondents, “Were you ever sexually assaulted, molested, or raped, or did you ever experience unwanted sexual activity?” Among the women interviewed, 14.2 percent responded affirmatively, whereas 2.7 percent of men did so, according to Breslau. The lifetime prevalence of PTSD among the female and male sexual assault survivors was 43.2 percent and 17.1 percent, respectively. Compared to sexual assault, severe accidents and natural disasters produced far lower rates of PTSD in both women (16.0 and 6.9 percent) and men (6.4 and 3.5).

—“Influence of Predispositions on Post-Traumatic Stress Disorder: Does It Vary by Trauma Severity?” Breslau, N., Troost, J. P., Bohnert, K., & Luo, Z., Psychological Medicine, 2013

STILL, MANY RAPE SURVIVORS RECOVER WITHIN MONTHS OF THEIR TRAUMA

The clinical psychologist Barbara O. Rothbaum and her colleagues assessed the symptoms of 95 survivors of rape or attempted rape over the course of several months. Although 94 percent of the women met symptomatic criteria for PTSD about two weeks after the trauma, that number dropped to 65 percent after approximately one month and to 47 percent after approximately three months. The data indicate that about half of rape survivors recover naturally from PTSD within three months of the assault.

—“A Prospective Examination of Post-Traumatic Stress Disorder in Rape Victims,” Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., & Walsh, W., Journal of Traumatic Stress, 1992

CONFRONTING TRIGGERS, NOT AVOIDING THEM, IS THE BEST WAY TO OVERCOME PTSD

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.

—“Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence,” The National Academies Press, Institute of Medicine, Washington, D.C., 2008

MAKING TRAUMA CENTRAL TO ONE'S IDENTITY BODES POORLY FOR SURVIVORS

Many women who have experienced sexual assault reject the label victim in favor of survivor. But although the latter term connotes empowering agency, having trauma become central to one’s identity bodes poorly for one’s mental health. The psychologists Dorthe Berntsen and David C. Rubin developed a short questionnaire called the Centrality of Event Scale (CES) that assesses how important a specific event is to one’s personal identity. The CES captures how integrated the event is in one’s autobiographical memory, the extent to which it marks a turning point in one’s life story, and the degree to which it shapes one’s expectations for the future. My Ph.D. student, Donald J. Robinaugh, and I found that among 102 women who reported histories of childhood sexual abuse, the more central their abuse was to their identity—as measured by the CES—the worse their PTSD symptoms. In particular, seeing one’s future through the lens of one’s abuse was especially associated with the severity of PTSD symptoms. These data suggest that acknowledging one’s abuse but not allowing it to dominate one’s sense of self may foster resilience against the long-term psychologically toxic effects of childhood sexual molestation.

—“Trauma Centrality and PTSD Symptom Severity in Adult Survivors of Childhood Sexual Abuse,” Robinaugh, D. J., & McNally, R. J., Journal of Traumatic Stress, 2011