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On Trigger Warnings and “Scientific Arguments”

In case you haven’t noticed, the fires of the Great Trigger Warning Debate are burning high again, this time in the halls of academia. Students at UCSB have called for trigger warnings in course syllabi, prompting the New York Times to equate dissociative spells, nightmares, and anxiety attacks with “squirming”. Now, along comes Pacific Standard with an article that tells us science says we shouldn’t give sexually assaulted students with PTSD even the same consideration we give television viewers who don’t like nudity on their screens.

As the article was written by Dr. Richard J. McNally, who directs clinical training for Harvard, I didn’t expect to find fault with the science he cited. This turned out to be mostly true. I found the argument presented in the article pretty appalling, however.

On a side note before I get to the arguments: You may well have the impression that “trigger” is a concept unique to post-traumatic stress disorder. If you do, you’re not alone. I saw someone on Twitter just a few days ago suggest that a broad view of trigger warnings was somehow appropriating the experience of PTSD sufferers. Reading the article won’t disabuse you of this notion–it’s entirely a discussion of PTSD–but this isn’t true.

Think of a trigger the way you’d think of a stimulus in classical behavioral psychology. It is an event that provokes a response over which someone has very little control. Pavlov’s bell was a salivation trigger in his dogs.

Of course, we’ve moved on a good bit from strict behavioral psychology, and people aren’t dogs. “Trigger” these days describes an event to which we react in a way that is significantly but not entirely automatic or beyond our conscious control. Suppressing a reaction to a trigger requires cognitive and emotional resources, executive function, but it can be done. “Trigger” now applies to events that provoke a wider variety of maladaptive responses as well, such as bingeing in someone with eating disorders or self-hatred in someone with depression.

But on with the article.

There are five studies presented to support points of argument in the article. The first three essentially constitute a prevalence argument. Stringing the numbers given by McNally together, we’re left with a statement that about 3% of women and about 0.2% of men experience long-term (greater than three months) PTSD associated with sexual assault. Applying that number to college students doesn’t account for greater rates of sexual victimization in populations that are also less likely to attend college, but it also doesn’t account for the fact that college campuses themselves pack a lot of sexual assault into a short period of time, making only long-term incidence measures less appropriate.

At a college like Harvard, with 7,200 undergraduates, that gives us a minimum of 110 students at any given time for whom trigger warnings solely about sexual assault could be useful on a long-term basis. Do those 110 students not deserve that accommodation? Because let’s face facts: PTSD is a disability that educational institutions have a duty to accommodate. Or is McNally arguing that they should have to individually identify themselves as having a history of sexual assault and mental illness to each of their professors in order to receive that accommodation? Do they need to face each professors idiosyncratic thoughts on the legitimacy of both sexual assault and PTSD in order to be accommodated?

Frankly, I don’t think McNally has thought this through. It is far, far easier to get faculty to print simple content notices about the subject matter they’ll be covering, particularly in a syllabus, where they’re already discussing the subject matter they’ll be covering, than it is to ensure that all your faculty will respond appropriately in one-on-one situations with students talking about sexual assault and mental health. These are not subjects and situations where colleges and universities really want tenured faculty applying their “academic freedom” at will, at least not if they have the best interests of their students in mind. There are too many misconceptions and outright prejudices common to our society that don’t magically dry up when someone receives an advanced degree.

I’m going to skip to McNally’s fifth argument here, because it’s almost as simply dealt with by thinking it through.

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.

This is an very simple correlation vs. causation issue. Do people whose trauma is central to their identity suffer worse PTSD? Do those people who suffer the worst, longest-term PTSD feel that the trauma that won’t leave them has come to dominate and define their lives? Or does ongoing, severe PTSD perhaps limit people’s lives in such a way as to make continued PTSD more likely?

The study McNally cites, on which he was also an author, (available as a pdf) cannot address the question. The study occurred decades after the abuse and the onset of PTSD, and getting a chicken or egg answer could only be done in the immediate aftermath of the trauma (if at all). This should have been mentioned in the paper as an obvious limitation, but it wasn’t.

It should certainly be mentioned when any policy recommendations are made based on its conclusions. If the severe PTSD comes first rather than as a result of how trauma is viewed, this provides even stronger incentives for dealing with it compassionately and effectively up front.

This brings us back to McNally’s fourth point, which is that PTSD is not cured by avoidance. This is true, as far as it goes. It is also irrelevant to the argument at hand.

While PTSD is not cured by avoidance, it is also not cured by dumping people back into the soup. If it were, it would have taken us longer to discover PTSD as a disorder. If sending “shell shocked” soldiers back to the front had worked in WWI to do anything other than get people killed, we wouldn’t have spent so much time and effort figuring the problem out. Abrupt reimmersion into trauma isn’t helpful and may make someone’s PTSD worse.

PTSD is actually treated through a very controlled desensitization process. Triggering stimuli are introduced on a gradually escalating basis, and drugs and techniques for coping with stress. One level of stimuli is conquered before the next is introduced. The person with PTSD has a hand in planning the treatment and assessing its effects.

Most importantly, the person with PTSD does not have triggers thrown at them without warning. This, however, is what McNally is advocating for in his article. In suggesting we eliminate avoidance, because it doesn’t cure PTSD, he is advocating for surprise triggers, which also don’t cure PTSD. Neither avoidance nor surprise will cure PTSD.

The argument over trigger warnings is not about curing a mental illness. It is about accommodating it so that people who have that mental illness don’t have another barrier to full participation in society.

McNally’s avoidance argument misses another important point about trigger warnings on campus. This misunderstanding is common to many if not most of the people I see arguing against them, however, especially those who argue against trigger warnings as a way of championing literature. (I follow a lot of writers.) If you’re one of these people, please stop and take a moment to let this sink in: Trigger warnings are not about avoiding triggers.

I know that seems counterintuitive, but it’s true. Maybe this post from a college instructor will help:

My position is influenced by having spent some years in the feminist blogosphere audience, and my reading of trigger warnings has always been that they are simply warnings so that readers know what they’re about to get into. Perhaps someone who knows that reading about sexual assault will set of a strong emotional reaction will put off reading that story on their lunch break at work, and instead pick it up again at home. Someone else may not care at all, and can click through to read right away. Posts on difficult subjects have not disappeared from feminist blogs since the advent of trigger warnings, and a skim through comments sections on some such pieces will often show readers who were viscerally reminded of their own experiences.

From an instructor’s point of view, I consider that students may be doing their homework at home–or in downtime at a workplace, in a public area like a library or cafeteria, side by side with friends or teammates in a group study session, or any number of other environments. They might be planning to go to work, or sleep, or a high-stakes exam after studying. If the reading I assigned might prompt a student to be overcome by a memory of being assaulted, to be taken with rage or sadness (whether from personal experience or not) at reading in depth about genocide, then would it be such a bad thing for the student to know that in advance and be able to plan their reading schedule accordingly?

People with disabilities choose to do things that hurt all the time. If you have disabled friends, chances are good you’ve heard the phrase, “Oh, I’m going to pay for this tomorrow.” People with disabilities choose to do things that take energy they don’t really have to spare. They choose to walk when they could, and maybe should, sit. They choose to eat and drink things they know may cause problems.

They choose to engage with triggering material. People with PTSD are no different than people with any other disability in that respect. Read the comments on those blog posts with sexual assault trigger warnings. You’ll find people who have PTSD from sexual assault. You’ll find people whose PTSD was triggered. They saw the warning. They still read the post.

Why do people with disabilities do all these things? Because they don’t want to be shut out of worthwhile things by their disability. Because they want to have what everyone else has. Because choosing a small amount of pain beats the alternative. Because having a disability doesn’t suddenly stop someone from that very human impulse to live beyond their limits. Because they know the right amount of ambition can bring improvement.

Trigger warnings on syllabi won’t make people stop reading literature or taking classes on racism or war or genocide. What they will do is help people decide when and where to deal with the material, to take a propranolol first or make sure there’s someone around to talk to afterward. Trigger warnings will help people deal successfully with material that is traumatic for them without being retraumatized, which is the goal for PTSD treatment.

McNally knows this, or he should. This isn’t a good argument against trigger warnings any more than his other four, which just goes to show that you need more than science to make a compelling argument. McNally didn’t.

Comments

  1. August Berkshire says

    As you say, trigger warnings are not censorship: they are responsible behavior. Movies have ratings: G, PG, PG-13, R, NC17, etc. TV show are sometimes rated: L (language), V (violence), etc. It’s not like college courses are a suspense novel where you don’t want to give away the ending. Trigger warnings are not spoiler alerts – though they do function in much the same way: be forewarned of what’s coming so you can make a more fully informed decision as to whether or not you want to proceed. It’s like the color yellow in a traffic light. Nobody thinks we should do away with that, do they?

  2. says

    What I always wonder 100% when this comes up is this: what harm is done to people who don’t need a trigger warning, that they get so angry about it? It is that they didn’t get a spoiler warning, in which case the two sort of cancel each other out? Or is it that they are furious when they are reminded that other people exist, and those other people need a little more than they do? Because that seems to be a cultural trend lately.

  3. says

    Most importantly, the person with PTSD does not have triggers thrown at them without warning. This, however, is what McNally is advocating for in his article.

    Of course the accepted method for dealing with a child who has an irrational fear of spiders is to give them a large hairy one in a gift-wrapped box for their birthday. The adequate treatment for a child who’s afraid of the dark is to randomly turn off the light. The adequate cure for a peanut allergy is to make them eat a PB&jam sandwich.

    Joe

    What I always wonder 100% when this comes up is this: what harm is done to people who don’t need a trigger warning, that they get so angry about it?

    the only reason I can think of is that it forces them to remember that bad things happen to good people all the time.

    +++
    If I were a college instructor or admininistrator, I would want my students to go through their classes as smoothly as possible. Therefore students who drop out of a class because they were triggered unexpectedly should be a bad thing I don’t want to have. Therefore things that allow students to decide whether they feel able to handle a class (because yes, sometimes avoidance might be the only sensible thing to do) and that give other students the tools to handle the class should be good things, right?

  4. Kate Donovan says

    3% of women and about 0.2% of men experience long-term (greater than three months) PTSD associated with sexual assault

    I don’t have this paper in front of me, but PTSD isn’t *technically* (and my assumption is that research was aiming for technical/by the book definitions of the disorder) something that can be called PTSD until six months after the causal incident. The idea is to have a firm deadline of ‘adaptive reaction to shitty things’ and ‘maladaptive reaction to shitty things’.

    So, I’d hazard a guess that you’ve got the 110 students you mention, plus a significant number of those who have recently had an incident and have natural-trauma-but-not-yet-PTSD issues going on. There’s a diagnosis for this, acute stress disorder, but I doubt many of them have gotten it–they’re busy dealing with the current life fallout! They know why things are bad!

  5. says

    I think it still becomes PTSD at one month. We’re supposed to be very resilient, I guess. To be fair, a great many of us are.

    I wonder whether ASD is excluded as a consideration in these discussions because people are just supposed to be useless wrecks withdrawing from the world shortly after trauma. There’s no difference that I know of between ASD and PTSD in avoidance, but lay perceptions get in the way of these things all the time.

  6. Pen says

    On a somewhat related issue, my university presented us with warnings about the material we were studying twice: once for descriptions of the Roman ‘games’ and once for the primary sources relating to slavery in Jamaica. I think they were right to do so both times. My middle school on the other hand, found it a social duty to spring Auschwitz footage on thirteen year olds. That traumatised me all by itself. Some material doesn’t need a student’s personal history to deserve a warning.

  7. dickspringer says

    The problem is that the outside world does not come with trigger warnings and the presumed purpose of an education is to prepare people to deal with the world as it is. Filling a cocoon with soft feathers may be comforting but it isn’t educational.

    Having improved university mental health services can help those with PTSD of whatever origin cope with the world, which they eventually will have to do.

    College students are adults and should be treated as such.

  8. says

    The “outside world”, at least in the U.S., comes with the Americans with Disabilities Act, which comes with a requirement for reasonable accommodations. Why should students get less?

    You do know that “toughen them up” is reality-denying bullshit, right?

  9. Ankur Chakravarthy says

    Hi Stephanie,

    I also have a problem with this statement by McNally

    “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”

    That would only be a valid argument against trigger warnings if trigger warnings directly hinder that process, even if it is directly relevant to the timeframes seen with college sexual assault. Even then – his suggestion reeks of patronisation in that he is saying that people who refuse to use trigger warnings are doing it for the survivors’ own good.

    _____________________________________________________________________________

    Additionally, Dickspringer,

    The real world does come with empathy and these students *are* being treated as adults by being given informed choices in terms of how they prepare to engage with material based on trigger warnings. I concur with Stephanie that the toughen them up bullshit doesn’t work – PTSD flashbacks are pretty much involuntary and can be crippling.

    Best,
    Ankur.

  10. zombiemoogle says

    To be honest, the trigger warning debate, well, triggers a gut reaction with me. There seems to be a growing cultural trend, at least on the farther ends of ideological spectrums, that we need to be “protected” from information. It’s the reason segments of broadcasts of Cosmos that dealt with evolution were “accidentally” removed. It’s the reason religious fanatics squawked like startled chickens when they were “forced” to see Michael Sam kissing his partner on ESPN. It’s an insistence that the universe fit their prejudices & is counterproductive to the intellectual progress of society
    That said, the author makes an undeniable point that adding trigger warnings to syllabi wouldn’t detract from the classes themselves & could be helpful to people who have a difficult time with certain stimuli, but perhaps didn’t realize that said stimuli was being introduced.
    My only concern is with potentially introducing a “filter bubble” to academia (for anyone unfamiliar, Filter Bubble is a a term used to refer to when search engine algorithms tailor results to a specific user, prioritizing results to their tastes & excluding those that differ, thus bottle-necking the users access to information). Perhaps I’m being pessimistic, but my nagging suspicion that many would prefer not to be exposed to new or difficult ideas gives me pause on this subject.
    I can only speak from personal experience, of course, but the most positive aspect of my brief time in academia was being forced to expose myself to information & ideas that I most certainly would have avoided or rejected prior (I was raised very conservative). While I fully acknowledge the benefit trigger warnings would have for people with sensitive psychological states & agree that amenities should be made for them, I am still concerned about the potential harm of truncating the flow of knowledge to young minds

    But hey, I don’t run the colleges, so do what you think is best & let’s see what shakes out

  11. theobromine says

    The problem is that the outside world does not come with trigger warnings

    I beg to differ: Discussion of things that cause discomfort to others is frequently avoided in polite adult society. For example though I’m not a medical professional myself, I am quite happy to discuss graphic details of surgeries, dissections, or body parts, at a matter of fact level that would make many people (including my spouse) feel queasy. If everyone else in such a discussion is a medical professional, I might just assume that it is fair game to go ahead, but otherwise I try to remember to ask others if they are comfortable with that sort of discussion, and if not either change the subject, or move the graphic discussion elsewhere.

  12. Onamission5 says

    Shorter Dickspringer: the outside world* comes with freeways, so let’s drop people in front of speeding cars unwarned and unawares.

    The people who are asking for trigger warnings– namely, victims of violence, bigotry, and rape– are well aware that the world at large has a way of kicking one’s feet out from under them. But thanks for ‘splaining that, elsewise we’d never have known that the world can be a dangerous, unforgiving, and harsh place to live.

    *Outside of what, exactly? Are colleges not part of the world in the same way that the internet supposedly isn’t real life?

  13. shari says

    It’s interesting because the trigger warning is an act of responsibility for awareness of content. Basically, saying, “this material is on the explicit end of things. This material is worth preparing yourself for.” Not to run away from. Not to silence. But certainly allowing those who struggle with PTSD to make informed decisions.

    Why is it so hard to explain that informed consent and informed decisions are a Good Thing?

  14. says

    It’s really kind of macho, this “toughen up, the world can’t coddle you forever” argument against trigger warnings. Toxic masculinity for all!

  15. shari says

    The bitch I would end up being if I toughened up as directed…..half of north america would move!!!

    (not that I would blame them, mind!!)

  16. blf says

    (Cross-posted, with edits, from Brute Reason here at FtB.)

    Trigger warnings on books aids and abets self-censorship.

    Who decides what labels are to be applied? For instance, some people claim the Harry Potter books promote witchcraft. Some people are bothered by that, and have attempted traditional censorship; i.e., removing them from libraries or similar. Should Harry Potter books have a label? If so, What does the label say? And Who reached these decisions, and How?

    Warning about your own writing, or a link or quote you providing, is one thing; namely, clearly your own opinion. Which is fine. Slapping a label / sticker on book is not equivalent, possibly excepting the authour her- or him-self doing it.

  17. says

    Oh, noes! People will make decisions about what to read! We can’t have that! Everyone must read ALL THE THINGS! Get thee to the slime pit now!

    Yeah, your comment is bullshit in both places. It’s bullshit in part because Miri and I both individually addressed the argument already. See above where I pointed out that people do actually try to lead “normal” lives around their disabilities. See Miri’s point that being prepared to read triggering things makes for better comprehension. See the instructor we both quoted talking about how things really work in class.

    It’s also bullshit because we have systems of warnings now, with actual people making those decisions. See Jason’s post I linked to up top about viewer warnings. The world has not ended. Our media has not become significantly more restricted. If warnings were some kind of slippery slope toward media restriction, Game of Thrones would not be the phenomenon is it.

  18. biogeo says

    As I understand it, a trigger warning is nothing more than a prior notice that a text or discussion includes reference to certain topics, so that a potential reader/participant can decide whether to engage. For college classes, the course summary and course syllabus are intended to constitute a comprehensive description of the topics that will be included so that a potential student can decide whether to enroll. The idea of including trigger warnings in a course syllabus seems entirely compatible with standard academic practice.

    In fact, a well-written syllabus should already include the same information that a trigger warning would include. Colleges already set policies for what a syllabus should include as guidelines to instructors. This proposal seems like just another such policy, geared toward ensuring that the syllabus provides students with a reliable set of expectations for the course. Additionally, asking the instructor to consider what, if any, material may be acutely stressful for certain students ahead of time provides the instructor with an opportunity to plan for how to best help a student who has an adverse response to such material, and review university policy for such cases.

    If the ideal for course syllabi is working well at UCSB, then at worst this proposal is redundant, and adopting it should be easy and painless while alleviating the concerns of the students who raised it. If there were specific problems that prompted the proposal, then it’s a good strategy for improving standard practice. Either way, it should be a no-brainer.

    It really seems like people objecting to this proposal are really just objecting to the idea that students might want to consider their emotional as well as intellectual preparedness when deciding whether to engage with certain material.

  19. theobromine says

    blf:

    I don’t see why it would be a problem if an accurate, objectively descriptive label or other warning is applied to a book by someone other than the author. What is the problem with saying that Harry Potter books contain scenes of witchcraft? Or that To Kill a Mockingbird contains depictions of racism? Or that a website, or blogpost contains material that might not be suitable for most people to view at their workplace? Or that an item contains a depiction of violence that some may find upsetting/disturbing (which is just a longwinded way to say “trigger warning”). I would certainly appreciate knowing if something I see/hear/read is going to keep my up all night. If I had young children, I would definitely appreciate having such advance information, so I can decide if it’s something they can watch/hear/read on their own, or if a parent should be with them, or if they should be given advance information, or simply wait until they are older.

  20. says

    “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”

    Not allowing [one’s abuse] to dominate one’s sense of self”.

    Isn’t this:
    A) utterly useless advice, as someone capable of just willing such issues out of their mind must already have the mental resilience this would supposedly foster, and
    B) akin to telling a depressed person to “stop dwelling on their misery and cheer up”?

  21. shari says

    @21 Kagato – In reading your comment, it seems you are mis-stating this. You can’t ‘will’ issues out of your mind. My understanding of the therapy is that it DOESN’T leave your mind, but you acknowledge the event, and build your sense of self apart from your experience/identity as a victim.

    B. absolutely the opposite. You aren’t telling someone how to feel, you are counseling them in ways of building a strong sense of self, one that is, incidentally, less attractive to manipulative abusers.

    Stephanie’s background in psychology is better suited to answering this than mine though, hopefully she will weigh in if I am incorrect in my understanding.

  22. Forbidden Snowflake says

    There is something about these statements of “the world won’t coddle you, you need to be exposed to these things” that is just so patronizing. The students sign up for acquiring knowledge in a school, not for a reeducation camp to be forced to work through issues they weren’t planning to work on in that setting.

    If warnings were some kind of slippery slope toward media restriction, Game of Thrones would not be the phenomenon is it.

    This reminded me that I had wanted to ask your opinion about the representation of PTSD on GoT (if you watch the show and have an opinion). It’s been in the show’s limelight recently, again.

    [I wrote the same thing in an earlier comment that doesn’t appear now. I didn’t verify that it appeared before, so I don’t know whether it was deleted or never sent. If the former, then I apologize]

  23. shackleram says

    I believe in absolute freedom of speech. I also believe in trigger warnings. Not for me because I have a thick skin but for those less privileged or fortunate than myself who may not have the same degree of emotional resistance to compromising content. Because sometimes it is not about oneself but about others and if something as simple a trigger warning is sufficient to enable them to make an informed choice about the probability and / or degree of negative reaction that a particular work might provoke then what right have I to complain ? None whatsoever and so I do not and it really is as simple as that

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