S2E12 Trigger Warnings

Have you been given a trigger warning before? In the service of increasing sensitivity and awareness to the struggles of others, trigger warnings have gained popularity by letting someone know that what’s about to be shared could be distressing. In this episode, Dr. Pete and Dr. Rubin discuss how this well-intentioned approach actually runs counter to the behavioral science behind exposure therapy, and how it’s impossible to avoid all triggers and avoid all distress. The docs identify how practicing compassionate awareness of others’ distress while also facing triggers can exist dialectically, and how this results in increasing psychological resilience. Tune in to learn more.




Pete: I learned something this year and maybe I'm just behind the times, but we're going to talk about trigger warnings. Hey, Nikki.

Nikki: Hey Pete. Yeah, you just learned that phrase or…

Pete: Isn't that bad, is that bad?

Nikki: It's not bad. I'm surprised, frankly, I was surprised you never heard that phrase.

Pete: Well, in my defense, I trained psychologists and I believe that there are no such thing as trigger warnings in the human behaviorism. I mean, I don't know that. In that regard, it's a new construct. Have you ever been given a trigger warning in life?

Nikki: I have not, though I will say, I often say, I'm sure we've got some younger folks listening that are already feeling mad at us which is okay, I'm like, that's okay. That's alright to honor that. But I always sort of like make the joke when I'm working with some younger patients that they, I don't know, like how it comes up. And if we talk about trigger warnings, I'll say to them, “do you want to know what cognitive behavioral therapists think about trigger warnings?” And they're like, “Yeah, what do you guys think?” I'm like, “hate ‘em”. And I think it's hard for them to understand though, like how we can hate them while we're also often preaching compassion and empathy.

Pete: I mean, I love empathy. I love multiculturalism. I love fairness and passion. These are all…

Nikki: Accurate perspective taking.

Pete: [inaudible 1:42] and curiosity. I mean, they're all a part of my life. They're a part of that profession. They're a part of my career, so I'm not trying to say that… And we'll talk about some of the history of this, and where we're at today with it. So a trigger warning, because we love my definitions,

Nikki: Bring it on, yeah.

Pete: A statement at the start of a piece of writing or video, alerting the reader or viewer to the fact that it contains potentially distressing material? So, I wouldn't be against that. I mean, I guess that's like PG 13 and R.

Nikki: Yeah. I mean, it's like in… let's start with, like why people would want that. Because it's like, yes, on paper that seems like a potentially useful construct. So what would you say, like what's the kernel of truth in using a trigger warning, what would you say?

Pete: Well, part of the history was that I understand is that the advent of trigger warnings began with some feminist websites, around violence against women. And so in that regard, that makes sense to me. If I am, say in this example, I'm a woman who is interested and curious about feminism, and perhaps I've had violence against me or a loved one. I think it makes sense that we then say, ‘hey this might be really alarming to you as you come and get involved in our community, because of x y & z’, makes total rational to me.

Nikki: Makes total sense. And it comes from that place of perspective ticking, which Pete and I talk a lot about on this podcast, which is that you're trying to… and perspective taking, of course, related to empathy, put yourself in the shoes of somebody else. And imagine how something might impact somebody. So that's very helpful to consider.

Pete: Well, isn't that the definition of empathy?

Nikki: I mean, you can dig into Merriam Webster and see a [inaudible 3:42] it's like… yeah, empathy is feeling something as if it's happening to you.

Pete: Yeah, walking inn someone's shoes.

Nikki: Yeah, exactly. So we need that, because that's going to help us understand someone's experience and also help us be sensitive and compassionate to the distress pain suffering of another human right, so absolutely.

Pete: Yeah. And if it comes to like, again, I think I feel rational around it, when it comes to sexual assault, in that example. I feel less compassionate about it when it comes to some other issues, I think that's where I get a little righteous around this. Because actually, part of the definition is it's widely recognized that any sight, sound, smell, taste, touch, feeling or sensation could be a trigger. So it's like, we may have to live in a bubble, to have these experiences.

Nikki: Yeah, and I think that's where it's going to be… Actually, I think, pretty important for us to explain to listeners to talk about exposure therapy, because I think…

Pete: Well that's why, yeah. Go ahead,

Nikki: Yeah, so I think that's going to help people understand that, again, big dialectic coming here. That being compassionate and empathic to the experience of another person is not antithetical to also learning to come into contact with what is distressing to us. And I think that's where trigger warnings have become very problematic, because even using sexual assault as an example, of course, you want to be mindful of that, and compassionate to somebody. And exposure therapy is the standard of care, well, for PTSD. So stop being something that people often experience PTSD in response to. And what we do is we have the person come into contact with memories that are scary to them, or words that might be scary or passing a place. And that's not the same thing as, and I think people get confused with, and again, we'll define this more clear in a moment here, it can get very confused about re traumatizing somebody, they don't understand the difference between that, so…

Pete: Well, the re traumatization, I love that you brought that up, because also that's important for the provider. So for us as CBT clinicians, one of the things that we see in the literature around working with trauma is the re traumatization, that it can also cause to us, as the provider, so I think, creating space for that. So I think what I hear you also, so maybe we'll talk a little bit more exposure therapy, because I think like in the sexual assault example, if that person wants to have a child, or continue on a sexual pathway, they need to come into contact with their trauma in order to gain a healthier perspective of that. And that is, I guess, where my righteousness comes in of like, I believe in systematic desensitization, because research tells us that it works, I believe in exposing to experiences that are uncomfortable, because that's how we grow. And, right?

Nikki: Well, right,

Pete: So a listener is going to be saying, “but a trigger warning allows me to choose whether or not I then engage with the material that I'm about to click on”.

Nikki: Well, and so let's get to that in a moment, because that's the part, like where we… Because I think that I would say, that's where we talk about, like where mindfulness comes in. And about like we've talked a lot about here, like, we don't know what's going to happen on the other side of this moment, we don't control, we own the process, not the outcome. So maybe we could take a moment and actually explain how exposure works from a functional standpoint, from a behavioral science standpoint. And I can even share a little about there's different types of exposure therapy…

Pete: Take the lead, go.

Nikki: Alright, here I go. So, and these are by the way, these are specialties of mine, that I do a lot of exposure work.

Pete: She's a better teacher than me, though. That's why she's going to teach, go.

Nikki: That's not true at all. But I will jump in and say this part. Okay. So I'm from a behavior... And I'll start by saying exposure therapies are some of the most well studied things in psychology, we've studied this for, like, more than 40 years or something, 50 years, long time. So we have a lot of research around it. And basically, what exposure means is coming into contact initially around anxiety disorders with a feared stimulus. So a simple example would be someone is afraid of heights. Someone's afraid…

Pete: Let’s say even more simple, like a spider.

Nikki: Okay, shall I? Alright, fine. I was going to say it’s actually the same thing. Let me go to my heights example. So someone's afraid of heights. And you can ask anyone on the street, they're going to be like, how do you treat fear of heights, I'm just going to go, you got to do the heights. That's right. But we're going to do it in what we call graded exposure for the most part, which means you're going to like maybe first look at a picture of a tall building. And you're going to look at that picture until that picture no longer elicits a fear response. And then maybe the next thing on what we call a fear hierarchy. So it's like a ladder of things we're afraid of. The next thing is like, I'm going to go stand in the lobby of a tall building, and you work your way up the hierarchy. So maybe like, Pete on the East Coast here, maybe you're going to the top of the Empire State Building.

Pete: Fun,

Nikki: Fun, right, yeah. So this is really effective. And what it does is it allows the brain to emotionally regulate the anxiety decreases in intensity. It's like there's like, sometimes we'll say it's like gravity, like, what goes up must come down. But what people will do is they'll avoid these things that they're afraid of, because they're afraid either, maybe with the buildings, they're afraid something bad is going to happen to them, or they're afraid that they're not going to be able to tolerate the emotion. Okay, anything you would add in there?

Pete: Obviously, not.

Nikki: Okay, so there are different types of exposure. So there's like a type of social called flooding, flooding means going to the top of the hierarchy, it would be that…

Pete: Right away,

Nikki: We're going to take you to the top of the Empire State Building, it actually works. It's my opinion, very cruel. Most people as a high…

Pete: Well, I think we should acknowledge that because I think any other non CBT practitioners, even with the data that says this works do feel that exposure therapy can be cruel, no matter how you do it, even graded.

Nikki: Right, because…

Pete: Let's just own that.

Nikki: That's so true, yes. Because they think it's cruel to come into contact with freedom. It's like, well, flooding, yes, most people don't want to do flooding, I certainly wouldn't want to do flooding. It does work though. If you stay in that situation long enough, the brain will regulate. But most of us do graded exposure, because it's like building a muscle, like you're not going to tell somebody to bench press 100 pounds if you've never done it, you're going to build the muscle up to…

Pete: I got 100 easily come on,

Nikki: Really? Not. I mean, I guess I could get there. No, I couldn't, that would never happen. That would never happen. Okay, so other types of exposure. So Pete mentioned, systematic desensitization, that's actually one of the older ones systematically desensitization was under the theory that you pair relaxation techniques with graded exposure, because the theory was, you can't be relaxed and anxious at the same time. But research has actually shown that it's not as effective as regular graded exposure, because the relaxation gets in the way of contacting the emotion. And what mindfulness research teaches us is that when we contact, and by the way, any emotions, it's not just anxiety, shame, sadness, anything, when we allow ourselves to feel emotions pass more quickly. So other types of exposure, prolonged exposure, that's the type of exposure used in trauma, where you expose yourself to telling the narrative you're telling, actually listening to tapes of a story of a trauma that you experienced. And then cognitive processing therapy, which is very similar CPT, which I'm not actually personally trained in, but it functions similarly to prolonged exposure, there's like a writing story.

Pete: And the common theme here is coming into contact with the emotion. And in a systematic way, or in a graded way.

Nikki: Graded way, sure.

Pete: To allow for, like I like to say, building the relationship with that experience or with the fear. And so I think that's where that, so that ultimately, is the whole idea as to why we as CBT practitioners really are not a big fan are not big fans of trigger warnings.

Nikki: So maybe you can, so now that we've got this like base about like how exposure therapy works, maybe you can then kind of weave back to like, so what would we say to somebody then, who's like coming in from, doesn't… maybe it's trauma, maybe it's, again, maybe I don't know, phobia, or something, like with a height? It's like, why would we not want to say like a trigger warning about, again, something as simple as like, you're going to, I don't know, you're about to watch a movie where the person's being dangled off of a building or something? I don't know. Why wouldn't we do that?

Pete: But we wouldn't want to do it? Well, so let's back it up.

Nikki: Okay. Sure.

Pete: The thing about say graded exposure, or any kind of exposure therapy is we do provide education to the client. So it's not like we just set up the fear hierarchy. We do that with the client, we educate them on that. We say, “hey, let's build, here's how this works, we're going to start small, we're going to start by looking at a picture. And ultimately, we're getting to going up to the Empire State Building. And then along the way, we're going to work together”. So things that I've done, like, say, living where I live, is people are afraid of tunnels. So I may eventually say, one day, we're going to drive through a tunnel together, or bridges, we're going to drive a bridge together. And again, that's not your traditional CBT. Or that's not your traditional psychotherapy, because we're outside of a couch in a room, and that's the thing about us, CBT practitioners with exposure, is that we're doing this in vivo, we're doing it in the person's environment. So I thought that it was important to…

Nikki: Absolutely. And I think that, yes… So that's interesting, what you're bringing up, because the psycho ED part's important that that might be where we're saying we're teaching and we're giving someone information about how their brain works, how the therapy is going to go and how they're going to be able to step into a difficult situation. Though we're also not saying you're never… we want you to be 100% prepared, every time you go into situation like to know whether you're going to be triggered or not. We actually say we can't control for triggers.

Pete: We don't know.

Nikki: We don’t know, right.

Pete: And we're trying to control and I think the American Association of University Professors, they've been really adamant against trigger warnings, because what they're saying is, where do you balance this need to protect students rather than challenging them?

Nikki: Yeah, and from an emotional standpoint, when we're not practiced at tolerating the challenges, it's actually not helpful for our brains. Now, like to that point, like if, let's say, I don't know, if we can balance this concept of exposure, and like, I'm going to use this behavioral term of coping ahead. If somebody is, let's say, like I keep using the example of sexual assault, a sexual assault survivor, and there is a course being taught at their university, or let's say they're in law school that's about cases related to sexual assault, based on where that person is in their own journey in terms of treatment, for example, taking that course at that time, that might not be helpful. It might be too triggering. It actually might overwhelm their brain, like that is true. But we would not say to that person, I want you to never be able to do that.

Pete: Yeah. And actually in, I think, was 2019, there was a study that found that trigger warnings were useless, that they were not helpful and actually created more harm for people that were experiencing trauma.

Nikki: Well, and say more about that, because it's like, I'm not surprised to hear that, but I bet you people listening might go like, “that doesn't make any sense”.

Pete: Well, and so I'm mindful that like, my bias might be that those are the kind of studies that I am more geared towards. However, it was in the Journal of Clinical Psychological Science. So it's a peer reviewed journal. What that means is that there can be a negative effect of using trigger warnings, because the people are not able to experience that emotional state. And that's a lot of what we've just went into with explaining how exposure therapy works. You have to learn how to feel,

Nikki: Yeah, because you don't know when like, I was just like, we just don't know, when we're going to get triggered, like, we can cope ahead for some, and we might say, this isn't going to work for me, that's going to overwhelm my system, I'm not going to put myself in that situation right now. And you could get triggered, someone could say something that you don't anticipate, you can see something on TV that you don't anticipate. And if you don't have the psychological tools in your toolbox to tolerate that, that's going to actually, yeah, like you're saying, negatively impact you.

Pete: I think it's what you were saying too, like, if I'm afraid of heights in that example that you gave I, if I'm watching TV, I might just all of a sudden have a movie that shows that, or if I'm on YouTube, it might just automatically do that. Or if I'm driving cross country, I might all of a sudden be on like a really high hill or mountain. So there are lots of things that happen. Now I could plan like, I could map out something, and try and avoid bridges and tunnels or whatever it is that I'm trying to avoid. But that avoidance actually creates it as a reinforcer to your anxiety or the trauma. And that's our take home message there. Right, Nikki?

Nikki: Well, yes, and I would say and there's another one woven in there, which is what you're describing is, then there's so much effort being put into controlling…

Pete: It's all control,

Nikki: Outcomes. It's all control that, Pete and I talk about flexibility all the time here, that in order to create expansiveness in our life, and again, the geeky behavioral thing, increase our behavioral repertoire. It's about being able to show up to whatever moment we're in, and adapt and respond as effectively as we can.

Pete: Well, I'm also going to say that listeners like to just, because we've all put our foot in our mouth, have you put your foot in your mouth?

Nikki: Have I put my foot in my mouth? The answer would be yes.

Pete: Yeah. And I think that that's the other thing that's like humbling is that we're going to misspeak. And so sometimes I'll have like, people say to me, like, if I'm giving a talk, or coaches are saying, like that'd be like, “how do I say this?” Or. “how do I say that”, I said, “I don't know. And I went to school for 13 years to figure out what to say”. Because there's just not always the right thing to say, and I think just being mindful that there are going to be moments in our lives when we're going to misspeak. And we might say something that's uncomfortable and inappropriate, in today's world, we might have someone we're conversing with, who then really is responding to us in an emotional way that then we don't know how to respond. And we could simply just sit in that discomfort too, and just embrace and accept that you have misspoke, because that is also part of the human condition. And, I don’t know, you have anything to add to that?

Nikki: Oh, I was just going to say I think what you're getting at there too, is that I think trigger warnings. There can be such a righteousness in them of like, if somebody misspeaks or says something that triggers, it's like as if that they're not there, there's mal intent, and it's like, no, this is back to the human stuff. Like we're all going to trigger somebody sometimes like, it doesn't mean… It's just going to happen. I mean, it doesn't mean you're a bad person.

Pete: It just is.

Nikki: Yeah, it just is.

Pete: I talked to people about dogs, it's like well my dog just doesn't like, it's like well don't you know like at school have maybe there were other people you got along with better than others, that's the same for dogs. Like if you go to a dog park, my dog acts all weird with small dogs and not big dogs. Well, he doesn't like small dogs. That’s okay because…

Nikki: The nature of different things.

Pete: It’s the nature of life, and I think so… Lastly, the last point I want to make is like, as an educator, I have felt my righteousness has come in of like, especially an educator within an Applied Psychology, clinical world. I have never once given a trigger warning in session. And I worked in inner cities. I've worked with really pathologized and traumatic individuals. And I think that that's for me is where I get really uncomfortable because I have been cursed at, I have been called sexual terms. I have been sexualized, there's been a lot of experiences I've had in session and none of them was I warned for, and I had to then deal with it in the moment feel uncomfortable. And then I brought it to supervision later, and then found ways…

Nikki: To process it.

Pete: Yeah, to process, yeah.

Nikki: Well, I going to say, because what you're bringing in again, is that like, the moment to moment stuff, I think it'd be really helpful for listeners to hear like, what do you think some of the Eastern traditions would say about trigger warnings?

Pete: I have no clue.

Nikki: Well, I would imagine probably, like, isn't that like, antithetical to like, it would be like controlling outcomes though.

Pete: [inaudible 20:38] future oriented,

Nikki: Because like, we don't impact like, suffering is a part of being alive, right?

Pete: Yeah. And you have the option, so that if you as the person are on the receiving end, who has been the victim of something really traumatic or uncomfortable, and you do click on something, you have the option to click off. And I think that that's empowering. And I think that's really where, again, there's a place for this. I could see where the advent of it makes sense. But as we think about the world that we live in, we need to consider directly contacting this moment, at any moment and any feeling because all feelings are not wonderful. And just to be mindful about the experiences that we have and that not everything's going to be great and that we may feel triggered and that's okay.

Pete: This has been When East Meets West. I'm Dr. Pete Economou.

Nikki: And I'm Dr. Nikki Rubin. Be present. Be brave.

Pete: This has been When East Meets West all material is based on opinion and educational training of doctors Pete Economou and Nikki Rubin.

Nikki: Content is for informational and educational purposes only.