Advance knowledge is power: Exposing the true nature of exposure therapy

This is the third in a short series on engagement and trigger warnings.
Part 1: A trip to the dentist
Part 2: The banality of trigger warnings
Part 4: A strange hill to die on

Content note: this post discusses mental illness and psychiatry, PTSD, phobias and snakes, mentions rape.

A daytime chat show:  the topic is phobias. The host promises that his guest therapists will cure these phobias, right in front of our eyes, using exposure therapy. A guest, a young woman, talks about her phobia of snakes, and how it prevents her going outside.

The host then calls a man to the stage. He enters from the back, walking up the aisle between the audience for maximum effect. They whoop and cheer, because he is carrying a large snake on his shoulders. The woman on stage pales and begins to shake as she sees him coming towards her. As he gets closer, she vibrates more and more.

The man plonks the snake around her shoulders and she screams and cries, because she has a phobia of snakes. The audience is delighted by this spectacle. Their whooping intensifies with her screaming: there is something almost medieval about it. She screams until she can scream no longer. I turn off the TV, disgusted.

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The scene described above is what too many people think is meant by the term “exposure therapy”, which is usually the justification given to lend a scientific veneer to the argument against trigger warnings.

Trigger warnings, it is argued, are unhealthy. The main source for this argument is the infamous Atlantic article, which was written by a psychologist. Which, yes, it was written by a psychologist, but not one who specialises in anything clinical–or even one who fully understands the behavioural model on which exposure therapy is based. He’s a “moral psychologist”, who naturally therefore views these things throw a moral lens, rather than anything else. As the old saying goes, when all you’ve got is a hammer, everything looks like a nail.

Exposure therapy forms the core of the supposedly scientific argument against trigger warnings, but everyone putting this across is wrong. 

Exposure therapy isn’t simply randomly exposing people with anxiety disorders to their anxiety triggers, and assuming they’ll eventually get better and grow some resilience. Exposure therapy is a wide term for a number of different approaches which all involve exposing the client to the thing that causes their anxiety under controlled circumstances. In some approaches, the person might be trained in coping mechanisms before being exposed to their trigger in a safe space. In others, there might be a stepped exposure to the trigger with the support of the therapist–using the example of snakes, that might be first looking at a picture of a snake, then touching a bit of snake skin, eventually working up to holding a snake over the course of the therapy. Some approaches might even use virtual reality or visualising the trigger, and so forth. Crucially, though, exposure therapy isn’t just exposing someone to their trigger and assuming they’ll just get over it and become a stronger person: the exposure happens in controlled circumstances–and usually in a manner which the person controls (indeed, in PTSD, exposure therapy is more effective when it’s self-controlled rather than therapist-controlled).

Exposure therapy is more commonly-used in treating phobias: when used for PTSD, the most common form involves a combination of visualising and processing traumatic memories with the help of a therapist, and taking a hierarchical approach to exposing oneself to triggers in real life. Again, trigger warnings are not at odds with this: hell, providing information about content could help someone undergoing exposure therapy undertake their week’s task of, say, watching a rape scene in a film, by having been told in advance that the rape scene is there!

The fundamental lack of understanding of exposure therapy is perhaps a driving force in the peculiar belief that not allowing survivors control over their engagement with triggering material is somehow for their own good.

Far from being at odds with various therapeutic models, trigger warnings can be congruent. It means that exposure occurs in circumstances which are controlled by the person rather than just at random. Exposure therapy is hardly the only model for treating PTSD, and may not necessarily be the best: however, I have not managed to identify a treatment for PTSD which is incompatible with trigger warnings.

Of course, the other primary conjecture used against trigger warnings is that they cause avoidance. The only attempt to systematically research it I’ve found is an abstract for an unpublished undergraduate dissertation with a tiny sample size of twenty and rather a lot of tests run on that very small data set (including dividing it into subsets!).  If there’s any evidence of the effect of trigger warnings on avoidant behaviour, I’d love to see it. Note exactly what I asked for. I am not asking for you to leave a screed in the comments about how your feelings suggest this is so (you can call it “common sense” if you like, but it isn’t).

If warnings about content were actually harmful, we would expect to see psychologists coming out against the banal, everyday content warnings that you see on TV, or before films. We don’t.

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So, trigger warnings aren’t going to harm anyone. Are they actually helping anyone?

Sadly, we don’t know, because there is an unwillingness to provide the data which could identify whether they’re effective. Given how politically-charged the issue is though, there sadly aren’t any large-scale studies on the impact of using trigger warnings in higher education, which is a primary battleground in this debate. There don’t seem to be any quality studies at all.

This is likely because very few institutions have tried, despite it being fairly easy to pilot. What we do know is that dropping out of college happens more if you’ve experienced violence. We also know that a frighteningly large portion of the population has experienced sexual violence. With this happening, what exactly do lecturers have to lose by piloting whether trigger warnings improve retention rates?

Of course, some may wonder how this all fits into practice, while teaching traumatic content. An article in The Criminologist, the American Society of Criminology’s newsletter offers some evidence-based suggestions. Criminology, of course, necessarily features teaching subject matter which can be heavily traumatic. Trigger warnings are recommended as one aspect in teaching about victimisation:

Warning early and often via multiple mediums provides students maximum opportunity to engage in informed decision-making and feel that they are in control. The first trigger warning should be on the first day of any course that includes information with the potential to emotionally trigger students. Trigger warnings should be given in at least the two classes before the presentation of potentially triggering material (or engagement with it outside of class, if that is the case), as well as at the beginning of the day when the material is presented. If an assignment is going to be shared with others, include that detail ahead of time (e.g., Hollander, 2000), so students can control how much of their experiences they share. These steps allow students time to think about what they need to do for self-care (see below) and give them an opportunity to talk to the instructor about their concerns and possible alternate arrangements.

Meanwhile, an article in the American Psychological Association’s Monitor on Psychology, suggests the following guidance, emphasising the point about how trigger warnings actually involve taking responsibility on the part of those who require trigger warnings:

Some professors, including Zurbriggen, encourage their psychology students to start doing so by taking responsibility for their reactions at the beginning of a course. She asks students to create a list of coping practices and people they can consult if they are affected by course material.
…
“The way the story is framed [in the media] sometimes is that students are so vulnerable or that they need to toughen up, and that’s not the issue,” says Zurbriggen. “Most trauma survivors have a lot of resilience. Providing information to students always makes the class a better experience and prepares them to dive into the material in a way that promotes learning.”

Despite all this, the evidence is sparse: the question becomes political, and therefore the objections, too, are political, and largely driven by emotion. It’s therefore only fitting that tomorrow’s conclusion to this series will also be political and largely driven by emotion and my own experiences.

Part 4: A strange hill to die on

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