Trigger Warnings and The Need for Evidence-based Interventions on University Campuses
Research Report on Trigger Warnings: Harry Chu, Biology Major February 13, 2018...
February 13, 2018
Trigger Warnings and The Need for Evidence-based Interventions on University Campuses Harry Chu Biology Major For better or worse, the debate over trigger warnings across university campuses has changed the perception of public universities. This change in perception is important because the general public funds these universities through their tax dollars and there is genuine concern that universities are not fulfilling their purpose of graduating mature adults who are capable of thinking critically, entering the workforce and contributing positively to society. Pertaining to these goals, ensuring positive mental health outcomes for students is an issue that has been in the spotlight, but a disconnect between the situation on university campuses and public perception exists when it comes to mental health and the use of trigger warnings. This is in part because the current state of trigger warnings on universities campuses has become an enigma for those on the outside looking in. It is evident from a public perspective, that articles informing the trigger warning debate have brought to view the polarized ends of rationales supporting or opposing the use of trigger warnings in university classrooms. For example, Gina Barreca an English professor at the University of Connecticut asserted that trigger warnings “encourage you to interrupt or suppress responses before you encounter any representation, action, idea or emotion you suspect might make you uncomfortable” (para. 6) undermining the purpose of authentic education which requires evocation and disturbance of one’s emotional and intellectual faculties (Barreca, 2016). She went on to assert that she would quit her teaching position if the warnings were ever mandated, echoing the hard stance that many instructors have taken on not using trigger warnings in their courses. Advocates of trigger warnings, such as George S. Bridges, president of Evergreen State College, suggested the University of Chicago’s rejection of trigger warnings was, “either completely tone deaf to the academic and developmental needs of many students or is launching its own counterattack on what it perceives as an unwarranted assault on political correctness on campus. Or both.” (Bridges, 2016, para 4). Bridges (2016) contends that trigger warnings are a way for universities to address historically ignored issues such as sexual violence and is a valuable tool for promoting personal and academic success. This paper hopes to put together the pieces towards a more complete picture through exploration of the controversial issue of trigger warnings and the its potential implications on mental health. Rationales for and against the implementation of trigger warnings on university campuses are summarized along with desired outcomes for trigger warnings in classroom settings. The goal of this paper is to move the discussion of trigger warnings forward—from rationales for their implementation, their current state and predictions of their effect on student mental health outcomes to exploring unanswered questions and offer a framework for pursuing empirical evidence for their supposed efficacy. In addition, this paper provides recommendations for existing evidence-based interventions that universities should consider when it comes to equipping students with the coping skills to handle psychological distress.
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1. Why Trigger Warnings? The rationale for implementing trigger warnings is clear—Godderiss and Root (2016) asserts that, “It is not about civility; it is about compassion…the goal is to respect a student’s right to not be surprised by content that may cause distress.” (p.5) This right is inherent in what Godderiss and Root (2016) calls “consent” (p.5), consent which provides “survivors of childhood abuse, intimate partner violence, sexual violence, colonialism, institutionalized police violence, racism, homophobia, transphobia, genocide, and war, with the power to make decisions in their lives,” (p.5) and to take ownership of their participation in the classroom. Laguardia et al. (2016) states that trigger warnings allow students to make necessary preparations for potentially distressing material, thus enabling them to “participate in all content, rather than being accidentally, biologically, and uncontrollably removed from class activities” (p.16). Carter (2015) claims that trigger warnings are “not about safety but about access,” access which allows “us [traumatized individuals] to enter the conversation, just like automatic doors allow people who use wheelchairs to more easily enter a building” (para. 20). Carter (2015) suggests that when trigger warnings are viewed as tools for access, they “do not provide a way to opt out of anything, nor do they offer protection from the realities of the world,” (para. 20) but rather empower students to “opt in” (para. 20) by dampening the shock of potentially distressing materials and giving autonomy to traumatized individuals to deal with their trauma. Those who speak out against the use of trigger warnings, including Lukanoff and Haidt (2015) contend that using triggers warnings as a way of avoiding trauma re-activation from potentially distressing material may do more harm than good for students in the long run. Lukanoff and Haidt (2015) suggest that the classroom is a “safe place for students to be exposed to incidental reminders of trauma,” and to renegotiate associations with these reminders because “a discussion of violence is unlikely to be followed by actual violence” (p. 6). In 2014, The American Association of University Professors published a report on trigger warnings citing concern that a if controversial topics such as, “sex, race, class, capitalism, and colonialism,” (para. 3) are associated with trigger warnings, faculty might choose to avoid potentially triggering topics for fear of offending students or having complaints levelled against them (AAUP, 2014). In 2015, the University of Chicago took a clear-cut stance on academic freedom by asserting that, “it is not the proper role of the University to attempt to shield individuals from ideas and opinions they find unwelcome, disagreeable, or even deeply offensive,” (Zimmer, 2014, para. 6) and in a letter to incoming freshman in 2016 reiterated that, “our commitment to academic freedom means that we do not support so-called ‘trigger warnings’” (Ellison, 2016, para. 3). Stallman et al. (2017) suggests that the concept of trigger warnings assumes that students are incapable of anticipating potentially distressing content based on the nature of the course and that they possess inadequate coping skills to deal with distressing course content. The biological symptoms of trauma in PTSD diagnosis are rarely disputed, but there are contrasting perspectives on the definition of trauma. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) defines trauma in as “exposure to actual or threatened death, serious injury or sexual violence” or learning of such trauma from close friends or family members (as cited in Boysen, 2017, p. 5). It has been noted 2
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that under the DSM-5 definition, non-occupational exposure to related details of traumatic events through “electronic media, television, movies, pictures,” or through “literature that depicts violence,” (p. 3) would not qualify as events that could cause trauma (Veraldi and Veraldi, 2015). These concerns were raised following a now-retracted draft Sexual Offence Resource Guide at Oberlin College which urged professors to flag content in their syllabi which might “disrupt a student’s learning” or “cause trauma” (Veraldi and Veraldi, 2015). It’s unclear if the Oberlin draft was based on a working definition of trauma but the draft did note, “Be aware of racism, classism, sexism, heterosexism, cissexism, ableism, and other issues of privilege and oppression. Realize that all forms of violence are traumatic and that your students have lives before and outside your classroom, experiences you may not expect or understand” (Medina, 2014, para. 15). Carter (2015) conceptualizes trauma outside the bounds of the medical model of disability and refers to trauma as an, “embodied, affective structure that regulates an individual (or population) outside of hegemonic notions of normative subjectivity” (para. 12). From this perspective, trauma, “no longer resides in the minds or bodies of individuals but in the built environments and social patterns that exclude or stigmatize particular kinds of bodies, minds and ways of being” (Carter, 2015, para. 12). As we move forward with this discussion of trigger warnings, it’s important to take note of different definitions of trauma put forth and that the contentions that revolve around them. For the purposes of this paper, any recommendations put forth refers to the DSM-5 definition of trauma and accompanying physiological distress when the word trauma is referenced. It should also be noted that this paper makes an effort not to loosely interchange the terms trauma and PTSD as one is a clinically defined condition while the other describes one or many events that can lead to PTSD depending on the threshold of psychological distress. The “constituents” that define trauma can also vary dramatically, as noted above. The prevalence of individuals who have experienced exposure to traumatic events and individuals who suffer from PTSD are also vastly different as shown later on.
2. Current State of Trigger Warnings in Universities Since the migration of trigger warnings from the virtual realm into university classrooms, the general public has relied on individual articles on reported incidents and anecdotes from professors and students to inform themselves on the state of trigger warnings on university campuses. While snapshots are useful for creating general impressions of how instructors use trigger warnings, several surveys have emerged to inform us on the attitudes of instructors who are in the position to issue such warnings and the prevalence of their usage. From a 2015 National Coalition Against Censorship (NCAC) survey of 800 members of the Modern Language Association and College Art Association, 15% of instructors reported that students had requested warnings in their courses and 12% noted student complaints to faculty or administration about the lack of trigger warnings (NCAC, 2015). More recently, a 2016 NPR ED survey found that out of 829 responding undergraduate instructors, 51% had used trigger warnings in their classrooms with 64.7% reporting that they had done so on their volition because they "thought the material needed one" (para. 13). Only 3.4% of instructors reported that students had 3
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requested trigger warnings and 1.8% cited that their universities had any official policies on trigger warnings (Kamenetz, 2016). To examine the attitudes of professors who regularly teach courses with material on suicide, trauma, and sex, Boysen et al. (2016) surveyed 131 Abnormal Psychology professors and found that 49% reported that they did not use trigger warnings, 31% did, and 20% were unfamiliar with the term. Of the 80% who were familiar with trigger warnings, 40% were neutral on the outcome of trigger warnings, 34% believed they would be helpful, and 25% believed that they would be harmful (Boysen et al. 2016). In 2016, an Inside Higher Ed Survey of College and University Chief Academic Officers found that on the topic of trigger warnings, of the 539 responding provosts and chief academic officers, 35% replied that trigger warnings "are a useful tool for faculty members to use (Jaschik and Lederman, 2016 p. 18). In addition, 72% believed that they "may discourage students from encountering important works of literature or art" (p. 18) and 58% believed trigger warnings are "part of trend[s] on campuses to shield students from things that may make them uncomfortable" (Jaschick and Lederman, 2016, p. 18). Taken together the information from these surveys suggest that there is no clear consensus on the use of trigger warnings from administrators and instructors in the position to issue them. Few universities have any formal policies on trigger warnings, meaning instructors are free to implement them as they see fit. Compared to previous surveys, the 2016 NPR Survey seems to indicate an increasing prevalence of trigger warning usage. Also, the survey shows that instructors who issue trigger warnings are often doing so on their volition, due to their experiences with students and their moral intuition as suggested by Proctor (2017). What warrants a trigger warning?
In the virtual realm, trigger warnings are issued for a multiplicity of topics, including but not limited to: misogyny, racism, homophobia, PTSD, slavery, victim-blaming, self-injury, child abuse, discussion of "isms", discussions of sex (including consensual), corpses, blood and "anything that might inspire intrusive thoughts in people with OCD" (Filipovic, 2014, para. 3). Below are reported examples for subject areas, and specific materials which trigger warnings have been issued or requested in university classrooms. These subject areas should be of interest to the general public, students and instructors alike because in contrast to online warnings, warnings in the classroom are related to learning materials within the student's discipline and have an impact on subsequent career outcomes. Law faculty at Oxford University issued trigger warnings about potentially distressing content before lectures on sexual offenses and gave students the opportunity to excuse themselves if they saw fit (Broun, 2016). For his International Law class, Patrick Keenan, a law professor at the University of Illinois issues verbal warnings about the horrific details of sexual violence during war and notes that, "I wouldn't invite someone to my house and say we're going to watch Finding Nemo and then show them a snuff film” (Pettit, 2016, para. 16). These warnings follow a 2014 article by Jeannie Suk, a Harvard law professor who observed an increasing apprehension of students towards rape law, and noted that "individual students often ask teachers not to include the law of rape on exams" (Suk, 2014, para. 3) due to concerns that these sensitive topics would decrease performance. Suk (2014) recalls that in one case, a professor received a request to stop using the word "violate" during lecture because the student felt it was triggering (para. 3). It is 4
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interesting to note that from a recent survey by Legal Cheek, a British-based legal news website, it appears that law students are as divided on being exposed to trigger warnings as professors, and university administrators are on implementing them. The survey found that of 419 respondents which included academics, barristers, paralegals, and students, 59% did not support trigger warnings while 31% did (King, 2017). Of the students in the sample, 52% preferred not to be subjected to warnings, while 48% did, highlighting a closer gap (King, 2017). Philip N. Cohen, who teaches Sociology at the University of Maryland added warnings to his contemporary family issues lecture after a student excused herself from the classroom and later all discussions of abortion after Cohen presented a statistic stating that 32% of pregnancies among unmarried couples end in abortions compared to 6% among married couples (Wilson, 2015). Cohen suggests that it would be a "malpractice" to exclude discussions of abortion statistics and while he included trigger warnings in the course syllabus, he asserts that "we can’t function if we have to warn everybody about every traumatic topic [throughout the semester]” (Wilson, 2015, para. 18). Neil Gilbert, a professor of Social Welfare and Social Services at the University of California, Berkley dropped a lecture on abortion from his master's level social- welfare policy course, citing implications of student sensitivity on administrative review of professor performance (Wilson, 2015). Ismail Muhammad, an instructor at the University of California, Berkeley added this trigger warning: "Content Notice: This semester our objects of study deal with issues like race, class, gender, sexuality, bigotry, and violence. As a result, this class will be a space to think deeply about explicit and, in some cases, disturbing texts…" to his course syllabus after he noticed the soured expression on the face of an Asian-American student following the screening of the 1974 film Chinatown (Smith, 2016, para 6). Similarly, Susannah Heschel a Jewish Studies professor at Dartmouth College added warnings to her syllabus following student complaints about upsetting content in the documentary, Night and Fog (1955) describing the liberation of Nazi Concentration Camps (Zhou, 2016). Rani Neutill who taught a course in Representation of Sex in American Cinema describes on multiple occasions how students left the classroom in tears following viewings and discussions related to Melvin Van Peebles', Sweet Sweetback's Badasssss Song, which depicted statutory rape (Neutill, 2015). Neutill describes how despite issuing warnings before every scene she screened in class; a student had requested that she send emails before class outlining a list of potentially distressing scenes that would be screened as not to single out survivors if they had to excuse themselves (Neutill, 2015). This last example highlights a challenge for instructors wishing to utilize warnings for movies and films where any number of scenes may come off as triggering to individuals susceptible to trigger-based distress. Trigger warnings have also started to turn up in English Literature where many texts containing specific themes, scenes and words that some students may find potentially distressing. Chinua Achebe's Things Fall Apart (racism, colonialism, religious persecution, violence, suicide), F. Scott Fitzgerald’s Great Gatsby (suicide and domestic violence), Virginia Woolf’s Mrs. Dalloway (suicide), Alison Bechdel’s Fun Home: A Family Tragicomic (pornographic depictions), Emma Donoghue’s Room, Junot Diaz's This Is How You Lose Her (domestic violence and misogyny), Ovid’s, Metamorphoses (rape), Shakespeare’s King Lear (violence against women, suicide) and Merchant of Venice (anti-Semitism) are among a growing list of literary works drawing calls for trigger warnings (Filipovic, 2014; Flaherty, 2015b; and Carr, 2017). English Literature students at 5
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Cambridge University received warnings for sexual violence in a lecture titled, “Control and consequence; when do we laugh at violence, and why? Credulity and sympathy,” centered around Shakespeare’s Titus Andronicus and The Comedy of Errors, Sarah Kane’s Blasted and Phaedra’s Love and Euripides’ Hippolytus and The Bacchae (Turner, 2017). The University of Kentucky reading program attached physical copies of trigger warnings to each copy of Picking Cotton: Our Memoir of Injustice and Redemption (sexual assault and racial dynamics), and suggested that students "may elect to only read Ronald Cotton’s chapters of Picking Cotton (except pages 127 and 131)” (Common Reading Experience, 2015, para. 2). Students at Duke University requested trigger warnings on Alison Bechdel’s Fun Home: A Family Tragicomic on the basis of moral incompatibility, with one student reportedly saying, “I am a Christian, and the nature of Fun Home means that content that I might have consented to read in print now violates my conscience due to its pornographic nature” (Flaherty, 2015a, para. 6). It is interesting to note that reported examples of trigger warnings have been limited to mainly to the Humanities: Gender Studies, English Literature, History, Film Studies, and Law and have yet to be commonplace in the Sciences: Biology, Chemistry, Computer Science, Engineering, Math and Physics. At Ohio University, a survey of 259 medical students found that 11.2% were familiar with the term trigger warnings, and after explanation, 31% supported the use of trigger warnings, 39.2% were on the fence, and 29.7% were against it (Beverley et al. 2018). Stallman et al. (2017) suggest that the impact of avoiding distressing material may amount to a loss of learning opportunity for Arts students, but students from health disciplines who miss critical and often potentially disturbing material may be inadequately equipped to navigate complex high-stress situations in patient care. Rebecca Stringer a Gender Studies professor who teaches a course in Critical Victimology at Otago University, suggests that students at Otago have been requesting trigger warnings in other disciplines and that they are more likely gain exposure to the concept of trigger warnings in Gender Studies. Springer attributes this to Gender Studies as a discipline, that doesn't strive to, "maintain a tradition of disciplinary masculinism forged in tweed and emotionless rationality" (Stringer, 2016, p.4). Stringer (2016) goes on to suggest that when we view the issue of trigger warnings from the equality of access to education perspective, the discipline of Gender Studies stands to facilitate the implementation of trigger warnings across all disciplines. For the time being though, it appears that outside of the Humanities, a sizable number of academics and students in the Sciences and Health-Related Fields (i.e., Medicine) have yet to be exposed to the concept of trigger warnings, warnings in practice and questions related to their efficacy.
3. Where is the evidence? Currently, research cited in the trigger warning conversation are merely supporting or refuting the assumptions of trigger warnings. Rob Whitley Ph.D., an assistant professor at McGill University's department of psychiatry and researcher at Douglas Hospital Research Centre, suggests that a review of the psychiatric literature yields no studies that demonstrate the effect of trigger warnings on short or long-term mental health outcomes (Whitley, 2017). Similarly, studies on the efficacy of trigger warnings in the classroom have not been published thus far (Boysen, 2017). Vatz (2016) contends that when it comes to trigger warnings, appeals to mental health are predictions, given 6
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the lack of empirical evidence demonstrating the effect, if any effect of trigger warnings on measurable mental health outcomes. Together, these perspectives highlight the absence and need for empirical evidence showing the efficacy of trigger warnings on student mental health outcomes. Below are five preliminary questions that warrant exploration through research, if we are to determine the efficacy of trigger warnings in the classroom setting. The following sections don't provide the answers but offer a starting point for thinking about trigger warnings in the context of coping, efficacy, and trauma within student populations. 1. How do students with trauma respond to trigger warning?
Despite the scarcity of research on this question, one case study at the University of Minnesota, including the perspectives of five students, two teaching assistants and one professor in a Gender Studies classroom showed that trigger warnings didn't change student appraisals towards course materials. Instead, student appraisals towards the professor became more favorable (Horton, 2017). More research is needed to address one of the fundamental questions surrounding trigger warnings which concerns the actions students take after exposure to trigger warnings. The multiplicity of outcomes following in-class trigger warnings include but are not limited to: leaving the classroom and not returning, leaving the classroom and returning once the upsetting material has passed or staying for the discussion following mental preparation. For warnings outside of the classroom, strategies may include: skipping over the upsetting material, skipping the material entirely, reading after mental preparation, reading with the support of others or requesting alternative readings or assignments. Collecting this data is without challenges, as there may be inter-disciplinary and individual differences in the ways instructors use trigger warnings. There will also be limitations in the ability of instructors for large classes to keep track of student responses to trigger warnings. For these reasons, similar surveys on student experiences with trigger warnings should be included. Given the adequate sample size of surveys, this data would move beyond anecdotal support. This data would begin to provide support for theories of academics like Laguardia et al. (2016) who claim that, "far from allowing students to skip content, the warning enables students to participate in all content," and Lukanoff and Haidt (2015) who suggest that the concept of trigger warnings is misguided because it helps students avoid their fears instead of confronting them in a safe classroom setting. Slaughter and Newman (2016) suggest that the distinction needs to be made between three types of warnings that are often used interchangeably: advisory (inappropriate content by age), content (offensive and graphic content) and trigger warnings (caution for sufferers of trauma). Manne (2015) suggests that trigger warnings are similar to advisory warnings frequently observed in movies and television shows. Similarly, Godderiss and Root (2016) conceptualize the warnings they give as "advisory warnings" where students are "advised" about the nature of course content as opposed to being warned about triggers. For Laguardia et al. (2016), "content warnings" provide a form of informed consent towards engaging with potentially distressing content. The overview from Section 2 highlights the difficulty in discerning whether professors are giving advisory, content or trigger warnings without going into the specific wording of the warning. This paper
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suggests that the nature of warnings (e.g., type, frequency, and format) should be included as categories for data collection. Although there is no research documenting measurable outcomes from exposure to trigger warnings (i.e., anxiety levels), there is limited research on the effect of advisory warnings in media. For television warnings, studies have shown that viewership and viewer interest increased in the presence of advisory warnings (Ingold, 1999; Bahk, 2000; and Bushman and Stack 1996). Bahk (2000) found that in a sample of undergraduate students, viewership interest for movies and television that carried advisory warnings for sexuality and violence increased in men, and increased in women for sexuality warnings but decreased for violence warnings. These results suggest that advisory warnings may have unintended effects of increasing viewership desire in some cases. The use of limited research on television advisory warnings in informing the trigger warning conversation should be tempered because television warnings are far removed from classroom warnings. These differences can be categorized as: motivation of the participant (learning vs. leisure), nature of the content (academic vs. recreational), frequency of warnings (before content delivery vs. throughout content), content of the warnings (general warning vs. picking out specific scenes, themes and words) and delivery medium (written vs verbal). Regardless of the type of warning, research should explore the physiological changes and responses resulting from the student's choice of action. Only then can we begin to establish whether these warnings have a positive effect or any effect at all on short and long-term student mental health outcomes. Boysen (2017) proposes a basic experiment for testing the effectiveness of trigger warnings by exposing subject groups containing students who are randomly assigned trigger warnings or no trigger warnings, to a range of potentially trigger topics. On a preliminary level, differences in measures for anxiety, arousal and mood recorded pre and post-exposure should provide a primary indication of whether trigger warnings have a positive effect (Boysen, 2017). Bridgland and Nakarangi (2017) have started a project on Open Science Framework, which seeks to examine whether a warning for potentially distressing memory tasks, will allow the individual to channel inner resources (e.g., spontaneous coping strategies) to help process the memories with minimal distress compared to those without warnings. Measures for mood, state of anxiety, the details of memory, the centrality of memory to their identity, the impact of the memory (i.e., intrusive), and reported coping strategies are recorded twice, two weeks apart at points after individuals perform memory tasks (Bridgland and Nakarangi, 2017). The findings of this study will shed some light on the impact of trigger warnings in cases where students choose not to excuse themselves and carry on with engaging with the potentially distressing material. Taken together, the research methods proposed by Boysen (2017), Bridgland and Nakarangi, (2017) along with qualitative data on the student choices following warnings, should serve as a starting point for approaches to testing the question of whether trigger warnings work to their intended effect as postulated by their advocates.
2. Do individuals with trauma cope using the same methods?
Bannano (2004) suggests that resilience, characterized by, “the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event such 8
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as the death of a close relation or a violent or life-threatening situation to maintain relatively stable, healthy levels of psychological and physical functioning, as well as the capacity for generative experiences and positive emotions" (p. 20-21), is common in individuals following exposure to trauma. Bannano (2004) suggests the assumption that a majority of people will have prolonged distress and impaired functioning following a traumatic event should be challenged, and that the diverse pathways to building resilience include but are not limited to hardiness, self-enhancement, repressive coping, positive emotion, and laughter. Studies have shown that resilience is not uncommon following traumatic events such as sexual victimization and subsequent revictimization. Walsh et al. (2012) estimate that of re-victimized populations, 72% of adolescents, 55% of house-residing women and 40% of college women did not report lifetime PTSD symptoms while 86% of adolescents and house-residing and 68% of college women did not report past 6month PTSD symptoms. These findings highlight that resilience following sexual victimization and re-victimization is not uncommon. Increased resilience as measured by the Connor-Davidson Resilience Scale (CD-RS) has been shown to be predictive of a higher prospect of recovery in PTSD patients (Davidson et al. 2005). Banyard and Cantor, (2004) found that among college students who were trauma survivors, those with an active internal locus of control over external events and greater optimism towards trauma as an opportunity for growth were shown to be more resilient based on measures of academic, social and personal-emotional adjustment. For coping strategies, Campbell-Sills et al. (2006) found that in a sample of college students, task-oriented coping was indicative of higher resilience as measured by the CD-RS compared to emotion-oriented coping which was characteristic of low resilience. Schnider et al. (2007) reported that avoidant emotional-coping as a significant predictor of complicated grief and PTSD in college students following the traumatic loss of someone close. Repressive coping characterized as individuals with self-reported, high defensiveness, low traitanxiety and high anxiety-related arousal (Weinberger et al. 1979) is a common coping mechanism among victims of child sex abuse (CSA) and sexual assault. Alston et al. (2013) suggest that repressive copers may be motivated by self-protection to avoid anxiety-inducing experiences. Previous research has shown that repressive copers demonstrated significantly greater ability in suppressing negative autobiographical memories (Dickson et al., 2009; Geraerts et al., 2012), thoughts (Geraerts et al. 2006, 2007) and self-related materials (Myers and Derakshan, 2004) compared to non-repressive copers. Koole (2010) suggests that because repression is an unconscious process, repressive copers can alleviate distress without burning significant cognitive resources, leaving them with greater capability of employing problem-solving, over emotionfocused strategies in dealing with traumatic events. Repressive copers have been demonstrated to use active coping strategies (positive thoughts) in high threat situations and passive (attentional avoidance) in low threat situations (Langens and Morth, 2003). Compared to repression, suppression defined by the DSM as, “defense mechanism in which a person intentionally avoids thinking about disturbing problems, desires, feelings or experiences” (as cited in Szentagotai and Onea, 2007, para. 3) is a conscious process commonly employed in avoidant coping. Szasz (2009) found that depressive rumination, the process in which, “one turns one’s attention to the causes and consequences of depressive symptoms," (p. 1) mediates the impact of thought suppression. Szasz (2009) suggests that when attempts to alleviate depressive rumination by thought suppression fails, ruminative thoughts may increase in frequency. Thus, 9
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engaging in chronic thought suppression may ironically increase sensitivity to ruminative thoughts (Szasz, 2009). Burwell and Skirk (2007) differentiate two dimensions of rumination: passive brooding characterized by strategies such as avoidance, denial, and fleeing, compared to active self-reflection which is reflected in problem-solving and cognitive restructuring. Burwell and Skirk (2007) found that passive brooding was predictive of depressive symptoms in adolescence while active self-reflection did not, providing support for the suggestion that brooding falls within the category of maladaptive coping strategies. Experiential avoidance defined as the "attempt to alter the form, frequency, or situational sensitivity of private events even when doing so causes behavioral harm," (Hayes et al. 2006 p. 7) is categorized as an emotional regulation strategy (Harris, 2006). Hayes et al. (2006) suggests that while experiential avoidance is perpetuated and reinforced through cultural contexts which places the focus on "feeling good" (Hayes et al. 2006, p. 7) and avoidance of pain, the functional significance of avoided events is amplified as efforts for emotional control begin to interfere with daily functioning. Individuals whose primarily motivators are pain avoidance and feeling good may experience a narrowing of behavior repertoire and may find it constraining to act following what their environment affords. Indeed, Kashdan et al. (2006) found that experiential avoidance mediated the effects of maladaptive coping on anxiety-related stress (i.e., anxiety sensitivity, trait anxiety, suffocation fears, and body sensation fears) and emotional regulation (suppression and reappraisal) on negative and positive experiences in daily life. Experiential avoidance was associated with less positive affective experiences, healthy life appraisals, positive events and greater frequency of negative affective experiences and negative life events (Kashdan et al. 2006). Studies sampling adult (Wright et al. 2007), college (Ullman and Filipas, 2005 and Fortier et al. 2009), treatment-seeking (Johnson et al. 2004), incarcerated (Huang et al. 2008), and veteran (Merrill et al. 2013) CSA victims, found that those who employed avoidant coping strategies over the long term indicated a greater likelihood of developing PTSD symptoms and other problems such as substance abuse. Sikkema et al. (2013) demonstrated that the reduction in the use of avoidant coping strategies over a one year period in participants with HIV and CSA histories resulted in a significant decrease of traumatic stress. Together, the studies above, highlight the diversity and complexity of coping strategies along with some of their advantages and drawbacks. Data on the different actions that students take following trigger warnings will determine the role of trigger warnings within a landscape of scientifically demonstrated adaptive and maladaptive coping strategies. It is unclear if trigger warnings promote resilience because there is no data on the mental health outcomes of students who use trigger warnings as a method to aid in coping in both classroom and non-classroom settings. It's also important to consider whether the arbitrary implementation of trigger warnings on a material to material basis undermines what Bannano and Mancini (2012) describes as, "the natural heterogeneity of human stress responding" (p. 3) by assuming that all students with trauma in their classrooms will benefit from and wish to be subjected to warnings for potentially distressing material. Regardless of whether they choose to ignore the warning, individuals with trauma who do not want to be subjected to warnings in the first place may see this as an encroachment on their autonomy in dealing with their trauma. 3. Do individuals have potential to develop reliance towards trigger warnings?
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Studies have suggested that over-reliance on maladaptive coping strategies is not beneficial for trauma recovery, especially for those with high reactivity towards reminders of trauma (Pineles et al. 2011 and Littleton et al. 2007). A possible explanation for the increase in utilization of coping behaviors regardless if they’re adaptive or maladaptive lies in behavioral psychology. Jacofsky et al. (2018) suggest that based on the principles of operant conditioning, an individual learns to avoid unpleasant experiences through trying different behaviors. Once a behavior is successful in alleviating the negative experience, the frequency of that behavior will increase when a potentially stressful situation presents itself in the future. This is true even if the alleviation of distress is temporary. Maladaptive operant conditioning is an implicit emotional regulation strategy that can be characterized by strategies such as social avoidance and externalization of causes and consequences of behaviors onto others (Westen and Blogav, 2011). In contrast, implicit adaptive operant conditioning may include strategies such as reinforcement of prosocial behavior intended to help others and less harmful defensive processes such as defensive humor (Westen and Blogav, 2011). Explicit maladaptive emotional regulation strategies include suppression and rumination (Westen and Blogav, 2011). Jacofsky et al. (2013) suggest that if we do not allow ourselves to remain in stress-inducing situations for the duration it takes for anxiety to subside naturally, we miss opportunities to unlearn and dissociate the paired associations between the situation that triggers the response and associated symptoms of distress. Johnson and Lynch (2013) found that among a sample of CSA survivors, self-blame, emotional dysregulation and distress are associated with the use of maladaptive coping strategies. Johnson and Lynch (2013) suggest that the relationship between CSA and maladaptive coping may be explained by the fact that CSA was predictive of self-blame, self-blame was associated with emotional dysregulation and greater emotional dysregulation predicted greater utilization of avoidant coping strategies. Also, Littleton et al. (2011) suggest that psychological distress before and after exposure to traumatic events predicted maladaptive coping and that individuals with psychological distress before a traumatic event may have been more likely to appraise the event as unmanageable. Appraising the event as an unmanageable one, individuals may heavily employ avoidance strategies to cope with the distress, and as a result, this may prevent them from breaking the cycle of avoidance, withdrawal, and unproductive appraisals (Littleton et al. 2011). Given the findings suggesting the role of appraisals in maladaptive coping cycles, research should explore the impact of trigger warnings on student appraisals towards potentially distressful materials. Trigger warnings, according to Laguardia et al. (2016), allows students to "take responsibility for, and control of, their well-being and their education…by mustering their own emotional resources and reminding themselves of possible counseling services or support networks" (p.9). In theory, it is not unreasonable for Laguardia et al. (2016) to suggest that warnings give students the autonomy to cope as they see fit but in reality, many questions remain as to how students are coping and whether they're utilizing adaptive or maladaptive strategies. It's not unreasonable to question the role of trigger warnings in facilitating adaptive coping or maladaptive coping cycles. Research needs to examine whether exposure to trigger warnings increases utilization of avoidant coping behaviors and if so, whether these behaviors persist over time. Descriptive studies should look at whether in-class trigger warning use predicts use out of class (i.e., social media) or vice versa and whether exposure to trigger warnings increases or decreases a student's threshold for potentially distressing materials. Finally, researchers should collect information on changes in student appraisals towards potentially distressing materials following exposure to trigger warnings. The 11
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relationship between changes in appraisals and subsequent coping strategies utilized should also be looked at. If we are to question whether trigger warnings facilitate adaptive or maladaptive coping then we must in turn look at the potential downsides of exposure to potentially distressing materials in the classroom. In the classroom setting, are materials in the form of readings, stories of fictional and non-fictional characters, images and statistics capable of inducing biological responses comparable to that of direct engagement with one’s traumatic experiences in clinical settings? 4. The gap between materials presented in the classroom and reliving your trauma in a clinical setting?
Some practitioners in the field of trauma recovery have offered their opinions on this gray area in the trigger warning conversation. Debra Kaysen clinical psychologist, professor, and director of the Trauma Recovery Innovations Program at the University of Washington suggests that while certain words may elicit emotional responses given their historical context, there doesn't seem to be any evidence to suggest that hearing such words would result in PTSD-like symptoms (Waldman, 2016). Similarly, Edna Foa indicates that a "therapeutic distance" exists between confronting one's past trauma and reading about the traumatic experiences of fictional characters (para. 25). Darby Saxby an assistant professor in Psychology at USC who holds a Ph.D. in Clinical Psychology suggests that while flashbacks may result in a degree of temporary discomfort, trigger warnings convey the message that language on its own can damage us regardless of whether we allow it to do so (Waldman, 2016). From a clinical psychology perspective, Saxbe contends that “PTSD symptoms won’t hurt you... they won’t shatter the integrity of your body or your mind” (Waldman, 2016, para. 54) reiterating the belief that language only possesses as much power as granted by us. Advocates of trigger warnings tend to focus intently on the nature of trauma triggers. Laguaradia et al. (2016) remind us not to be confused by the vague nature of "intrusive reliving of the event" (p. 6) compared to the medically relevant consequences of trauma triggers. Laguardia et al. (2016) cite biological evidence of the sensitized hyperarousal response from the trigger, subsequent hormonal cascade and resulting consequences such as feelings of helplessness and panic. The end result according to Laguardia et al. (2016) is a student who may have just vividly relived their traumatic experience and may be frozen in a state of panic as their natural fight or flight response has kicked into gear, preparing the body for the imminent threat of danger. Manne (2015) suggests that a common response for individuals with PTSD is a panic attack which can leave individuals temporarily short of breath, disorientated, nauseated and unable to focus. For Carter (2015), trauma triggers run far deeper than discomfort and injury. When an individual is triggered, the psychological and physiological reactions of the re-traumatization results in an unredressable state of disability on one's body-mind (Carter, 2015). Carter (2015) contends that this state of disability is not comparable to, "the discomfort that comes with confronting one's white privilege, or the feeling of personal injury that may come when someone challenges your belief system," (para. 8) further emphasizing the difference between re-traumatization and injured feelings. Carter (2015) suggests that misconceptions about trauma in the context of trigger warnings, "is telling, though not surprising" (para. 10) due to the ableist structures that predominate society. These ableist
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structures label individuals as overcomers and survivors of victimization with no acknowledgment of the systems of oppression that perpetuate this victimization (Carter, 2015). To these descriptions of re-traumatized students in the classroom, a host of questions remain. Among these: the prevalence of such responses among students in the classroom, the duration of responses and quantifiable impacts on learning need to be examined. Researchers should also attempt to disseminate the severity and intensity of response at different levels (e.g., specific words, topics or themes) and types of material (e.g., written word, imagery or video). This data is needed before we can assert that the responses described by both Laguardia et al. (2016) and Carter (2015) are both prevalent and homogenous amongst students. More importantly it would shed light on whether materials presented in the classroom induces the types of psychological distress that occurs in clinical settings.
5. Are certain topics worthier of trigger warnings?
To this issue, Manne (2015) suggests that common sense should inform us on which topics and warrant trigger warnings (i.e., sexual trauma) compared to those that wouldn't (i.e., political sensibilities). Procter (2017) suggests that the arbitrary choices of materials deemed worthy of trigger warnings by instructors based on their moral intuitions result in a "hierarchy of trauma" (para. 26) which privileges certain types of trigger-based distress over others. Procter (2017) argues that "for trigger warnings to be truly equitable, diverse and inclusive, then every single text and practice taught at colleges and universities would need to be branded as potentially traumatizing" (para. 26). In addition to PTSD, common mental health conditions with triggerbased distress include but are not limited to agoraphobia, bipolar disorder, depression, eating disorders, anxiety disorders, obsessive-compulsive disorder and social phobia (Brewin et al. 2010 and Friedman et al. 2011). Boysen (2017) suggests that if the purpose of trigger warnings is to accommodate those with mental illnesses and psychiatric disorders, students with phobias, which are twice as common as PTSD, also have reasonable ground for receiving warnings. An epidemiological study that surveyed 813 college students found that common phobias included: fear of spiders, public speaking, snakes, heights and injections (Seim and Spates, 2009). Like Proctor, Boysen (2017) suggests that given the wide range of mental conditions with triggered based distress, the choice of using trigger warnings to accommodate students with trauma might be political or personal. Accommodating students with past trauma (or PTSD) and phobias differently "would suggest the privileging of one form of distress over another" (Boysen et al. 2017, p. 10). Carter (2015) contends that trauma in itself is "unequivocally political" (para. 14) and that, "while traumatic experiences can certainly be accidental, the vast majority of potentially traumatizing experiences are rooted in systems of power and oppression" (para 14). For Carter, the feminist slogan "the personal is political" (para. 14) allows educators and students to view trauma in the classroom alongside other disabilities collectively as, "a potential site for a collective reimagining [education]" (para. 14). Laguardia et al. (2016) suggest that limited research shows that the biological effects of discrimination affect student's ability to learn, by citing a study which examined the impact of perceived racial discrimination (PRD) on diurnal cortisol rhythms in adults. Adam et al. (2015) 13
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studied the diurnal cortisol rhythm against PRD over a 20-year span in 112 adults from the Maryland Adolescent Development in Context Study and found that higher PRD predicted lower average cortisol and a less dynamic cortisol profile, both of which have been linked to negative mental health outcomes. Adam et al. (2015) also found that higher cumulative discrimination predicted lower cortisol awakening response (CAR) on average. CAR which is an increase in cortisol levels (up to 50-60% above waking levels) during a short period after waking, has been linked to the mechanism by which the body prepares for the anticipated stress of the upcoming day (Clow et al. 2010 and Adam et al. 2006). Abnormal or chronic elevations and depressions of the CAR has been linked to negative short and long-term health outcomes (Adam et al., 2006). Exposure to chronic stress has been hypothesized to decrease the responsiveness of the CAR anticipated stress mechanism, leading to decreased cortisol levels over time (Heim et al. 2000). Factors that have been linked to low CAR and hold relevance to the university context include: loss of loved one (Meinlschmidt, and Heim, 2005), introversion (Hauner et al. 2008), shyness (Beaton et al. 2013), mild to moderate depression (Stetler and Miller, 2005), burnout (Oosterholt et al. 2014) and PTSD (Wessa et al. 2006). Elevated CAR has been linked to loneliness (Doane and Adam, 2010), Major Depressive Disorder (Adam et al. 2010) and general life stress (Chida and Steptoe, 2009). The current body of research on diurnal cortisol and CAR sheds light on the variety of physiological conditions and stressors that have potential to influence the fundamental ways in which students learn as suggested by Laguardia et al. (2016). Extrapolation of these findings to abnormal CAR in university students should be tempered, due to limitations such as the use of a non-representative sample as noted in the Adam et al. (2015) study. Studies examining the differential CAR profiles of university students are needed to gain a better understanding of the physiological (CAR and cortisol stress response) conditions of students entering the classroom. Research on the effect of trigger warning exposure on CAR profiles of students, while controlling for other variables, may be a starting point for providing support for whether trigger warnings are productive and suitable accommodations for these challenges. However, due to the vast range of indicators associated with CAR, there is a long way to go before we can begin to think about using CAR as a benchmark for determining if particular psychiatric conditions with trigger-based distress are worthier of warnings over others.
4. Current Interest in Finding this Evidence As it currently stands, few academics who have voiced their opinions in support of trigger warnings have emphasized the need for finding out how they are impacting their students. Even with the lack of empirical evidence, the acceptance of trigger warnings as a pedagogical practice and in some cases "best practice" by those who support their usage, is clear. Laguardia et al. (2016) suggests that universities should provide training sessions on the prevalence of trauma, risks of trauma to learning and expects that "most professors, given a briefing on the biology of triggers and just how limited a content notification can be," (p. 20) would be open to thinking about how warnings might fit into their courses. Godderis and Root (2016) suggest that active dialogue among administration and faculty is needed to determine best practices for trigger warnings (e.g., the method of delivery, appropriate content, social context) in the classroom. Manne (2015) views "the willingness to use trigger warnings" (p.4) as a component of best practices within the 14
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classroom. This paper suggests that before we can begin to discuss best practices for trigger warnings, we must first establish whether trigger warnings are best practice. In a section titled, "Do the Research," (p. 21) Laguardia et al. (2016) contend that criticisms suggesting that students use trigger warnings to avoid offensive speech "undermines speech," (p. 21). The authors suggest that researchers should explore the harms of certain types of speech (i.e., racist) and their impacts on student learning (Laguardia et al. 2016). While Carter (2015) offers that the effectiveness and limitations of trigger warnings should be explored, the author suggests that the trigger warning debate has remained on a literal level and should shift towards addressing the underlying needs preceding requests for trigger warnings. These are described as 1) recognition as whole persons with full humanity, 2) language that recognizes their full humanity by attending to embodied pain and suffering and, 3) learning that acknowledges relevancy to student overall life experiences. Carter (2015) argues that by adopting the Feminist Disability Studies pedagogy, an integrated approach to teaching about disability and ableism, "the conversation shifts from whether educators should incorporate trigger warnings into pedagogical practices, to why trauma itself must be understood as an imperative social justice issue within the classrooms" (para. 3). Likewise, those who oppose the use of trigger warnings have been persistent in citing the lack of empirical evidence but have neglected directly calling for advocates and users to provide it. Proctor (2017) suggests that given that trigger warnings are not supported by research demonstrating their efficacy, a "fully democratic debate drawing upon evidence-based research, not the fears and anxieties of academic staff, students and corporate management" (para. 32) is sorely needed. Proctor (2017) reconciles that universities should be safe environments for all members including vulnerable groups but asserts that individuals, "do not have the right not to be offended" (para. 30) as Salman Rushdie once posited. Further, Proctor (2017) contends that opposing trigger warnings is not the same as implying that students be strapped to lecture seats and forced to take in violent material—they possess the autonomy to decide on removing themselves from the situation if they so choose. Lukanoff and Haidt (2015) suggest that universities should officially discourage the practice trigger warnings and endorse the premise of the AAUP report which states that, "The presumption that students need to be protected rather than challenged in a classroom is infantilizing and anti-intellectual" (p. 2). Lukanoff and Haidt (2015) propose that teaching students the basics skills of cognitive behavioral therapy would equip students with a repertoire of skills to navigate, "a world full of words and ideas that they cannot control" (p. 8). Similarly, Stallman et al. (2017) propose that promoting resilience through developing student coping skills would better prepare them for challenges during their university careers and beyond.
5. Evidence-Based Mental Health Investment Evidence-based support for mental health and trauma is essential on campuses. Kilpatrick et al. (2013) surveyed 2953 U.S adults and found that 90% of respondents experienced reported a history of exposure to one or more traumatic events under the DSM-5, but PTSD prevalence was low with lifetime PTSD (8.3%), past 12-months (4.7%) and past 6-months (3.8%). For colleges, Read et al. (2011) surveyed 3014 college students from two U.S universities and found that 66% reported a history of exposure to a DSM-5 traumatic event while 9% met the criteria for PTSD. The frequency 15
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of traumatic events that were reported by college students in Read et al. (2011) were lifethreatening illness (35%), death of a close one (34%), natural disaster (26%), physical violence (24%), other events (20%), sexual assault (7%) and combat (1%). These findings suggest that prevalence of PTSD over time is low compared to the high prevalence of exposure to a variety of traumatic events. In addition, these studies inform us of the broad range of issues that students deal with in addition to stressors resulting from the rigors of university coursework. Certain types of traumatic experiences have been demonstrated to be linked with a high likelihood of meeting criteria for PTSD. Breslau et al. (2013) analyzed data collected from 34,653 respondents through The National Epidemiologic Survey on Alcohol and Related Conditions and found that of the 8.7% who reported experiencing sexual assault, 40.2% (3.5% of the total) developed PTSD. Walsh et al. (2012) found that in a sample of 2000 college women, of the 12.5% who reported experiencing sexual victimization, 50% (6.3%) experienced sexual re-victimization and of those who reported re-victimization, 40% (2.5%) met criteria for past 6-month PTSD and 58.4% (3.7%) met criteria for lifetime PTSD. Across all samples groups, Walsh et al. (2012) found that re-victimization increased the likelihood of developing PTSD with 40% and 55% of revictimized women meeting the criteria for past 6-month and lifetime PTSD respectively compared to 19% and 34% for women who did not experience re-victimization. Walsh et al. (2012) also note that in their study, rates of victimization, re-victimization, lifetime PTSD and past 6-month PTSD were not significantly different between college and non-college women. Laguardia et al. (2016) contend that in the classroom, traumatized students are not uncommon by citing estimates that "one in five women will experience rape or attempted rape in college" (p. 8) based on the National Institute of Justice Report on Sexual Victimization of College Women. The survey found that of 4,432 college women surveyed during the spring of 1997, 2.8% experienced completed rape (1.7%) or an attempted rape incident (1.1%). The paper proposed that assuming victimization rates remained stable over a woman’s college career, the projected rate over a one year period would be 5% and over a five-year degree period upwards of 25% (Fisher et al. 2003). A more recent study from the Bureau of Justice Statistics, surveyed 23,000 undergraduate students (approximately 15,000 females and 8,000 males) at nine post-secondary institutions and found that during the 2014-2015 academic year, the average frequency of completed rape for female students was 4.1%, ranging from 2% to 8% across schools (Krebs et al. 2016). For sexual assault, the average was 10.3% ranging from 4.2% to 20% across schools. For male students, the average frequency of completed rape was 0.8% ranging from 0.3% to 1.4% and for sexual assault an average of 3.1% ranging from 1.4% to 5.7% (Krebs et al. 2016). It is also important to note that across four-year schools, an average of 25.1% ranging from 12.5% to 50%, of senior females reported unwanted sexual contact since entering college. However, the authors note that for incidents before the 2014-2015 academic year, no descriptive information about the frequency of incidents, type of unwanted nonconsensual sexual content, on or off campus, severity, and other details (Krebs et al. 2016). Krebs et al. (2016) note that the data obtained from the study are not intended to serve as a national average and that, "each school needs to understand the magnitude and nature of the problem at their school or university if they are going to effectively address it." (as cited in RTI, 2016, para. 8). Aside from sexual assault and other traumatic experiences, students are also dealing with a variety of mental health challenges. Eisenberg et al. (2013) surveyed 14,175 students across 26 campuses 16
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in 2007 and 2009 and found that common mental health problems included depression (17.3%), non-suicidal self-injury (15.3%), generalized anxiety (7.0%), suicidal ideation (6.3%) and panic disorder (4.1%). In the American College Counselling Association's 2014 National Survey of Counselling Centers, 275 centers representing 3.3 million eligible students were surveyed, and 94% of directors reported increases in students with mental illnesses and psychological problems over the past five years (Gallagher, 2015). A varying percentage of center directors noted increases in different areas related to: anxiety disorders (89%), immediate crisis (69%), psychiatric medical issues (60%), clinical depression (58%), learning disabilities (47%), sexual assault (43%), selfinjury (35%), and prior sexual abuse (34%) (Gallagher, 2015). In addition, the directors reported that center clients with severe psychological issues rose from 44% in 2013 to 52% in 2014 with 8% having impairments that impeded their ability to continue with college (Gallagher, 2015). On a positive note, 65% of responding clients reported that counseling aided them in remaining at their respective institutions and 64% reported that counseling had a positive impact on their academic performance (Gallagher, 2015). These numbers highlight the trend of increasing mental health issues among students and the need for quality counseling services across university campuses. Evidence-Based Paths and Potential for Integration into the Classroom
If there's one thing that even the advocates of trigger warnings can come to a consensus on, it is that trigger warnings are not the solution. Trigger warnings are neither a solution to the mental health challenges that students face or the needs of individuals recovering from trauma. Carter (2015), suggests that "traumatized individuals know that trigger warnings will not save us," (para. 21). For Laguardia et al. (2016), trigger warnings are, "not a solution but an aid" (p. 10) to help students with post-traumatic stress to gain access and engage in the classroom. The authors suggest that trigger warnings, "are not meant to solve the problems traumatized students face, nor can they," and that "the most trigger warnings can do is allow students time to muster whatever resources are needed to enable confronting the relevant material." (Laguardia et al. 2016, p. 18). Godderis and Root (2016) suggest that trigger warnings are not intended to prevent all students from experiencing re-traumatization, but rather they have potential to serve as advisory statements which help foster a culture of informed learning where students can consent to their learning environments. Given that the rationale for trigger warnings is more about consent, as suggested above, and less about helping students deal with psychological distress this report indicates that there are evidencebased paths that universities and instructors can consider in equipping students with adaptive coping skills. Below are three interventions that have bodies of existing research demonstrating their efficacy in improving the life of individuals with PTSD symptoms and other psychiatric conditions. This report suggests that with the slew of unanswered questions on how trigger warnings facilitate adaptive or maladaptive coping strategies, the following evidence-based interventions can be considered when it comes to developing services and best practices for individuals with trauma. This section will provide a brief overview of each intervention, the mechanisms by which they operate, and their potential for integration into classroom settings or co-curriculum.
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1. Prolonged Exposure Therapy (PE) Prolonged exposure (PE), Acceptance and Commitment Therapy (ACT) are two interventions with a common goal of aiding trauma victims achieve greater daily functioning and improvements in quality of life. These outcomes are achieved using different approaches in PE and ACT. In PE, the fundamental framework of the intervention is built around acknowledging and working through experiential avoidance that results from traumatic experiences. In most cases, the first few sessions are devoted to constructing a hierarchy of avoided behaviors along with an action plan that includes exercises, techniques, and homework geared towards helping individuals distinguish memories from the actual traumatic event and associated distress (Schnurr et al. 2007). For example, for individuals dealing with sexual trauma, the process may include: contacting the original experience through imagination while orally ascribing the events to past tense, repeating this process with awareness to emotional states, and engaging with tape recordings of the narrative to aid in-vivo homework exercises (Schnurr et al. 2007). Complementary components include using psychoeducation to help patients disseminate the nature of their trauma in the context of prolonged exposure and teaching controlled breathing skills to help patients deal with traumaassociated anxiety (Foa et al. 2013). a. Overview of Effectiveness Studies have demonstrated the efficacy of PE in improving the quality of life for individuals with PTSD. Rothbaum et al. (2005) noted that in a sample of adult rape victims, following PE, 95% no longer had symptoms meeting the criteria for PTSD and improvements were observed six months after treatment. Among a sample of military veterans, PTSD and depressive symptoms were reduced by 42% and 31% respectively following PE (Goodson et al. 2013). Schnurr et al. (2007) found that in a sample of female veterans with PTSD, following PE, self-reported significant reductions in PTSD symptoms, along with secondary outcomes such as reduced depression, anxiety, and improved quality of life. Similarly, Eftekhari et al. (2013) found that of 1931 combat veterans participating in the PE Training Program, the percentage of individuals meeting the criteria for PTSD decreased from 87.6% to 46.2% following treatment. Foa et al. (2005) found that in a sample of assaultive violence victims (e.g., rape, non-sexual assault, and CSA) with chronic PTSD, reductions in PTSD and depression symptoms were observed following PE. Reductions in PTSD and depressive symptoms were also noted in a sample of adolescent CSA survivors (Mclean et al. 2017). Taken together, these provide support for the efficacy of PE for populations that are significantly more vulnerable to developing PTSD. Studies comparing the efficacy of PE to other interventions such as EMDR (Rothbaum et al. 2005) and present-centered therapy (PCT) (Schnurr et al. 2007, Roach et al. 2015), found that PE was equally or more effective in reducing PTSD symptoms. Mclean et al. (2017) found that patients in the PE showed greater improvement in PTSD and depressive symptoms than those in the supportive counseling group and that the difference in improvement was observable at 12 months post-intervention.
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b. Biological Mechanism Within the brain, when fearful memories are formed, two subsequent outcomes for these memories include extinction and reconsolidation (Quirk and Mueller, 2008). Reconsolidation of memories occurs when memory constituents are maintained and stabilized for future retrieval, compared to extinction where recalled memories of an event no longer contain relevant information (i.e., sensory information of intense fear) to current circumstances (Quirk and Mueller, 2008). Fear extinction, defined as, "the ability to learn to suppress a fear response to a previously conditioned stimulus" (Helpman et al. 2016, p. 2) and the ability to recall learned fear extinction memory, plays a central role in the natural habituation of common fears. The areas of the brain associated with the fear extinction learning process include the amygdala, ventromedial prefrontal cortex (vmPFC), dorsal anterior cingulate cortex (dACC) and hippocampus (Helpman, 2016). A quantitative meta-analysis by Hayes et al. (2012) found that individuals with PTSD demonstrated greater activation in the amygdala and less in the vmPFC during emotional processing and cognitive tasks compared to healthy control groups. A previous study using skin conductance response (SCR) as a measure for extinction recall showed that the ability to recall fear extinction memory was impaired in individuals with PTSD (Milad et al. 2009). Milad et al. (2009) found that in addition to having an impaired recall of extinction memory, the PTSD group also exhibited less hippocampus and vmPFC activation and greater dAAC activation. Helpman et al. (2016) examined the role of PE in influencing neural circuits associated with the process of fear extinction in PTSD and trauma-exposed healthy control (TENC) groups. The authors found that the PTSD group exhibited a significant decrease in right anterior cingulate cortex (rAAC) activation during extinction recall tasks following PE treatment and noted that changes in rACC activation correlated with enhanced function coherence with ventral prefrontal regions including the vmPFC (Helpman et al. 2016). The authors suggest that findings indicate the potential effect of PE on the extinction recall pathway operating through the rACC and vmPFC leading to downregulation of fear circuitry resulting in corresponding improvements in PTSD symptoms (Helpman, 2016). Reduced activation of fear circuitry in individuals with PTSD may normalize ventral neural systems involved in fear identification and reactivity resulting in improved ability to recall fear extinction memory (Helpman, 2016). Similarly, Hauner (2012) found that following a single of session of exposure therapy for individuals with phobias of specific objects, increases in prefrontal activity and decreases in amygdala and vmPFC activity were observed. Cisler et al. (2014) found that following repeated exposure to trauma memory (RETM), increases in functional connectivity between the hippocampus and striatum and between the amygdala, mPFC, and anterior insular cortices were observed. The authors suggest that strengthened connectivity in these respective regions implicates the influence of RETM in fear extinction learning since both the striatum and anterior insular cortices have been shown to influence the tracking of prediction errors (Cisler et al. 2014). Prediction errors are discrepancies between expectations of the brain stemming from previous experiences and memories compared to outcomes in reality. The process of learning and adaptation involves tracking and correcting errors so that discrepancies that lead to maladaptive consequences not persist in the midst of everchanging environments. Cisler et al. (2014) suggest that for individuals with PTSD, strengthened connectivity between circuitry for fear extinction recall and prediction error processing as 19
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observed in the study may result in increased fear extinction learning (i.e., traumatic memories do not predict actual traumatic event). The authors suggest that this is aided by an increased ability to track prediction errors which may in turn help with retention and recall of learned fear extinction memory (Cisler et al. 2014). Helpman (2016) notes that although PE produces changes in neural pathways associated with fear extinction recall the mechanism between these changes and improvements in PTSD symptomology is complex and further research is needed to build on existing findings. The relationship between PE and cortisol response have also been examined. Rauch et al. (2015) noted significant differences in CAR pattern between veterans who exhibited low or high response to PE or PCT treatment. For responders, an initial spike in cortisol was observed during a trauma narrative task pre-treatment session, levels were high during the imagery tasks mid-treatment session, but no significant differences were noted post-treatment session compared to the nonresponder group who exhibited cortisol profiles that remained at a non-responsive and minimal state throughout different stages of treatment sessions for the non-responder group (Rauch et al. 2015). A subsequent study by Rauch et al. (2017) found that cortisol data for all patients from mid to late sessions of treatment indicate that cortisol reactivity was not related to treatment outcomes. The authors noted that veterans with lower reductions in PTSD symptoms showed greater overall increases in cortisol over the course of treatment compared to those with larger reductions in symptoms (Rauch et al. 2017). For non-responders, these increases were observed during imaginal exposure tasks suggesting possible HPA-axis mediation (Rauch et al. 2017). A previous study by Gerardi et al. (2010) found that in adult rape victims with PTSD who received PE or EMDR treatment, significant decreases in cortisol levels compared to baseline were observed in responders to treatment after completion of all sessions. The differences in cortisol levels change observed in the three studies could potentially be explained by the collection time points for cortisol samples. Gerard et al. (2010) suggest that decreases in cortisol levels after the entire treatment process could be reflective of decreased avoidance of the traumatic experience due to improved emotional processing or cognitive restructuring. This is possible given that the authors noted a trend pointing towards significant increases in treatment non-responders possibly due to an inability in processing the traumatic experience (Gerardi et al. 2010). Rauch et al. (2015) suggest that the spike in cortisol following a descriptive trauma script task and high levels during image tasks may indicate that the HPA axis is more active when individuals are more engaged with treatment activities. Rauch et al. (2015) suggest that rises in cortisol levels for individuals with blunted cortisol profiles may "open a window of plasticity" (p. 6) for fear extinction learning and retention to occur. However, Rauch et al. (2017) note that increases in cortisol and associated HPA response at different stages of treatment may have different implications, given their findings showing that higher levels of cortisol during mid to late sections were associated with reduced therapeutic outcomes. Further studies exploration the mechanisms underlying the relationship of cortisol at different points in therapy, should seek to seek to increase time points of cortisol collection and continue to track any associated symptom changes. Several studies have investigated the relationship between CAR and therapeutic outcomes. A study has found that elevated CAR on the day of exposure therapy was related to greater improvements in avoidance behavior, threat appraisal and perceived control during treatment (Meuret et al. 2015). 20
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The authors suggest that elevated CAR on treatment day, compared to non-treatment days, may signal a greater preparedness for upcoming stressors and learning opportunities in therapy, resulting in better outcomes (Meuret et al. 2015). Like the Rauch et al. (2015) study, the findings seem to indicate a cortisol facilitated window for learning. One difference between observed increases in cortisol is that the Rauch et al. (2015) findings reflected acute elevations before exposure onset while Meuret et al. (2015) noted increases in awakening cortisol suggesting a more preparatory elevation. In addition, studies have noted that exogenous administration (Surís et al. 2010) or endogenous increases (Lass-Hennemann and Michael, 2014) of cortisol seem to indicate enhanced outcomes for exposure-based treatments. Despite research demonstrating the impact of administered cortisol, Rauch et al. (2017) noted that the mechanisms by which they influence the patient during treatment are not yet clear. Previous research has found that receptors for cortisol are located in regions of the brain (e.g., amygdala, hippocampus, and cerebral cortex, etc.) central to fear extinction and learning (Bentz et al. 2010) but future study on how these areas change following administered cortisol in therapy. That being said, these studies do provide a potential pathway by which the manipulation of cortisol levels either exogenously or endogenously prior to treatment may enhance patient outcomes. c. Potential for Integration One present limitation for PE in a clinical context is low tolerability, resulting from the reluctance or outright refusal of patients in engaging with past traumatic experiences even in a controlled setting (Frye and Spates, 2012). Low tolerability for individuals who have severe PTSD may be regulated by the individual's anxiety sensitivity defined as, "the fear of anxiety-related sensations, which arises from beliefs that sensations will have harmful physical, cognitive or social consequences" (Wald and Taylor, 2007, p. 2). Frye and Spates (2012) found that in a case study of a 19-year old college student with PTSD, incorporating mindfulness and emotional regulation components decreased anxiety sensitivity helped the individual engage with PE exercises. The emotional regulation component utilized interospective exposure which involves a series of exercises (i.e., breathing through a straw for 30 seconds) to help individuals understand fear sensations do not have the impact an individual expects. Currently, a body of research exists demonstrating the effectiveness of interospective exposure on decreasing anxiety sensitivity (Boswell et al. 2013; Broman-Fulks and Storey, 2008; and Wald, 2008). Future research should explore if interospective exposure is effective among student populations given that physiological fear responses and associated consequences on learning are often cited as justification for trigger warnings. That being said, the research demonstrating the efficacy of interospective exposure in reducing anxiety sensitivity has significant implications for the integration of exposure-based therapies into existing university counseling practices. Research on clinical applications of PE and anxiety sensitivity are a signal that integration of PE into classroom settings is most likely impractical. Edna B. Foa, the founder of the treatment, suggests that without controlled clinical conditions such as the presence of trained professionals to help clients work through distress that comes with directly recounting and confronting one's memory, classroom environments may not be conducive for helping students take control of the fears associated with their traumatic experiences (Waldman, 2016). However, Foa adds that a "therapeutic distance" exists between confronting one's past trauma and reading about the traumatic experiences of fictional characters and states that "I do not appreciate this idea that 21
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people should always decide whether or not they will be made upset. If we act as though they cannot handle distressing ideas, we communicate the unhelpful message that they are not strong" (Waldman, 2016, para 25). This report suggests that while PE may not be an appropriate fit for integration into the classroom, it should be made available students who seek treatment for PTSD and PTSD-like symptoms. Universities should consider adding PE to diversify their repertoire of available resources and existing counseling services. It makes intuitive sense given the high number of trauma victims on university campuses as postulated by trigger warning advocates and users. Cook et al. (2009) found that empirical evidence of treatment efficacy was not a strong determinant of practice compared factors such as the role of mentors, previous training and feedback from colleagues. The authors also noted that the degree to which new interventions could be integrated with existing practices and endorsement from respected practitioners were most influential in determining willingness of practitioners to take on new approaches (Cook et al. 2009). In addition, Foa et al. (2013) suggest that lack of training is a major reason why utilization of PE is low despite having been shown to be highly effective in helping individuals with PTSD. These are factors that administrators should consider when evaluating current practices and potential for integrating new ones at their respective institutions. 2. Acceptance and Commitment Therapy (ACT) Acceptance and Commitment Therapy (ACT) is theoretically grounded in Relational Frame Theory which posits that "the core of human language and cognition is the learned ability to arbitrarily relate events, mutually and in combination, and to change the functions of events based on these relations" (Hayes et al. 2006 p. 5). Through the ACT lens, the destructive side of human language plays out in processes such as rumination, where language reinforces and amplifies psychological distress, a byproduct of vicious cycles of experiential avoidance and anxiety (Harris, 2006). When individuals are caught in these cycles, language tools available for them to navigate present environmental contexts become increasingly narrow and rigid due to an over-focusing on eliminating psychological distress over time (Hayes et al. 2006). Several contexts in which the inflexibility of language frameworks play out include: literality (i.e., the thought of danger becomes perceived as actual danger), reason-giving (i.e., excessive focus on attributing responsibly of one's suffering to others) and emotional control (i.e., feeling good becomes the measuring stick for quality of life) (Hayes et al. 2006). ACT is designed to target psychological flexibility defined as," the ability to stay in contact with inner experiences, allow them to be there when useful, see thoughts as just thoughts, have strong sense of life direction, and pursue things that are meaningful” (Bean et al. 2017, p. 8). ACT does this through promoting awareness of different contexts in which language perpetuates psychological distress and by altering them to reduce the impacts of unhelpful language structures. ACT differs from other interventions in that instead of focusing on symptom reduction as a goal, symptom reduction occurs as a byproduct of fostering psychological flexibility through the development of mindfulness skills. These skills allow individuals to function effectively with what their environment affords and be productive towards short and long-term goals. The six core principles of ACT can be broken down into four mindfulness-acceptance and two commitment22
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behavioral components (Hayes et al. 2006). Each of these core principles can be observed through different exercises, metaphors, and techniques used in ACT. The four mindfulness and acceptance components include, Acceptance, Defusion, Being Present, and Self as Context (Hayes et al. 2006). Acceptance is characterized as an act of experiencing internal stimuli without actively trying to alter them. An example of an acceptance exercise might focus on treating unproductive anxiety like your child who is throwing a temper tantrum at the grocery store (Bean et al. 2017). Like the screaming child, the anxiety that lashes out in our minds will eventually subside if we give it the time without reactively trying to mute it, which in turn results in greater psychological distress. Defusion is characterized by the separation of internal stimuli and functional labels imprinted on these stimuli by the mind (i.e., a racing heart is equated to immediate danger) (Bean et al. 2017). Defusion exercises focus on altering contexts to lessen the impact of fused thoughts. For example, an individual might thank their mind for reminding them that the image they saw in class was potentially dangerous, instead of immediately appraising the situation as literal danger which leads to further psychological distress. In this example, the individual has altered the context of the reminder through from appraisal of danger into a gratuitous acceptance of the reminder. Being Present refers to the process of non-judgmental contact with our inner experiences, allowing us to actively shift our present attention towards functionally relevant stimuli (i.e., our breath) and away from functionally irrelevant stimuli (i.e., head spinning) (Bean et al. 2017). In its simplest form, a grounding exercise for staying present involves planting one's two feet on the ground and bringing undivided attention to the physical sensation of ground and feet. Finally, Self as Context refers to the process of defusing literal interpretations of unproductive self-evaluations (Bean et al. 2017). Simple meditation exercises help cultivate recognition of the self as an observing entity, an observer of one's thoughts (i.e., self-evaluations) as they arise. When individuals are able to think, observe the thought before reacting, no thought that arises is inherently threatening or controlling, without the allowance of the observer (Harris, 2006). The commitment and behavioral change components include: Values and Committed Action. Values can be characterized as qualities identified by individuals as motivators for purposeful action (Hayes et al. 2006). For example, for an individual who identifies full classroom engagement as a value, the therapist may frame behavioral exercises as taking the client one step closer to returning to the classroom. Committed Action involves orientation towards a pattern of behavior in line with identified values and ACT principles (Hayes et al. 2006). Committed action can be facilitated in a variety of methods including goal setting, on-going homework, and selfauthoring. a. Overview of Effectiveness Although large studies examining the efficacy of ACT in treating PTSD have yet to be conducted, a number of case studies have yielded promising results for individuals with sexual trauma (Hiraoka et al. 2016; Burrows, 2013 and Prins et al. 2016) and PTSD (Twohig, 2008; Batten and Hayes, 2005). Studies have also found that culturally adapted CBT (CA-CBT) which includes the core ACT framework of mindfulness and acceptance towards fostering psychological flexibility, improved PTSD symptom for individuals from refugee populations (Hinton et al. 2013 and Hinton 23
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et al. 2011). Woidneck (2014) found that in a small sample of adolescents (aged 12-17) with PTSD, following a 10-session ACT intervention, self-reported and practitioner-determined PTSD symptoms were reduced by 73.7% and 58.8% on average, respectively. Decreases in PTSD symptoms was correlated with decreases in experiential avoidance and thought fusion (Woidneck, 2014). In addition to reducing PTSD symptoms, Yadavaia and Hayes (2012) found that an ACT intervention reduced the negative impact of self-stigma for individuals who identified with samesex sexual orientations. These findings suggest that ACT may be a viable intervention for approaching the types of issues that are currently relevant to university student populations. Woidneck (2012) found that reductions in PTSD symptoms following ACT intervention were comparable to TF-CBT and PE for adolescents. Similarly, ACT compared to CBT for mixed anxiety disorders (e.g., panic disorder, social anxiety disorder, OCD, or generalized anxiety disorder) demonstrated equal effectiveness in reducing anxiety symptoms but with ACT having greater impact for psychological flexibility outcomes. (Arch et al. 2012). b. Biological Mechanism To gain a better understanding of psychological inflexibility, the mechanisms by which ACT targets this process, and the changes that occur in the brain, it may be helpful to briefly review the neural underpinnings of cognitive flexibility in healthy individuals. It’s important to note that psychological flexibility is used to describe a measured outcome for therapies in clinical contexts while cognitive flexibility refers to a way of characterizing executive functioning in the brain in research contexts (Whiting et al. 2017). Both share similar characteristics regarding their, influence on behavior, underlying neurological mechanisms and consequences following impairment (Whiting et al. 2017). Bassett et al. (2011) found that functional connectivity of brain activity following learning and mastery of a motor skill reflected a dynamic pattern of functionally compartmentalized communities that, “manifested consistently over the scale of days, hours, and minute” (p.3) and also exhibited sequential dependence. Bassett et al. (2011) also noted that during engagement with the motor task, low flexibility nodes that functioned in the maintenance of community integrity and high flexibility nodes that actively shifted between communities, were distinguished. The degree of flexibility that was observed in individuals was predictive of improvements in task learning. This finding led the authors to suggest that an individual's cognitive flexibility at any given time could inform us on when they would be most suited for task learning and how we can achieve those conditions (Bassett et al. 2011). In a later study, Braun et al. (2015) found that during a working memory task, reconfiguration characterized by the degree to which nodes changed allegiance was most prominent in frontoparietal (FPN) and frontotemporal networks and that these networks had the highest degree of interactivity with other networks in the brain. Previous studies have also demonstrated the extensive interactivity of the FPN suggesting the role it plays as a major communicator between different brain networks (Cole et al. 2013 and Power et al. 2011). These findings are consistent with findings that suggest the FPN is a major component of adaptive control processes that act to maintain homeostasis and regulate functional distribution in the presence of external stressors (Cole et al. 2014). Cole et al. (2014) also note that in addition to the 24
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FPN, the cingulo-opercular portion (time-dependent control processes), the dorsal attention region (attention to external stimuli) and default network (system at resting state) also work in conjunction, together as an integrated adaptive control system. Alterations in control systems and pathological consequences have been examined in a number of studies. Blair et al. (2013) found that for individuals with PTSD, recruitment of the FPN was impaired in the presence of emotional distractors potentially due to a heightened emotional response to stress cues. Sylvester et al. (2012) noted that in anxiety disorders, pathology was associated with patterns of decreased functioning in the FPN and increased functioning of cinguloopercular and ventral attention regions. Cole et al. (2014) suggest that impairment of the adaptive control system may be a "common cutting factor" (p.4) across mental illnesses despite unique neurological mechanisms and pathways in each condition. Cole et al. (2014) present the example of social phobia, where impairments in the adaptive control system may result in reduced effectiveness in searching and recruiting fear-reduction strategies in the presence of heightened anxiety. In therapy, improvements in anxiety detection and providing the necessary conditions to improve control strategy recruitment can be targeted through introduction of specific skills. The authors suggest that skills or temporarily lost skills such as controlled breathing can be relearned and reintegrated into adaptive control systems through instruction, much like how they are learned early in life (Cole et al. 2014). In ACT, the mindfulness and acceptance components act to increase psychological flexibility through facilitating necessary pre-conditions for effective recruitment of fear-reduction strategies by the adaptive control system. It has been shown that during mindfulness meditation, components of the adaptive control system are active, but that activation and activity are reduced with extensive practice (Chiesa et al. 2013). Cole et al. (2014) suggest that the result of extensive practice may be an active control system that recruits a mindful state as a fear-reduction strategy. The long duration of practice likely plays a role in solidifying retention for the connective networks of mindful states within adaptive control systems. The neurobiological mechanisms and potential pathways for the mindfulness components of ACT will be explored along with Mindfulness-based Stress Reduction (MSBR) in the following section. On a behavioral level, the remaining components of ACT act to encourage individuals to make commitments towards undertaking tasks that are congruent with the goal of cognitive flexibility. In turn, a committed effort to undertaking such tasks would likely result in positive changes on a network connectivity and adaptive control system level over time. The observable changes in cognitive flexibility and adaptive control systems during specific tasks can also serve as an avenue for investigating the impact of trigger warnings. Braun et al. (2014) observed that an oscillatory pattern of reconfiguration as the participants transitioned between tasks suggesting that brain network flexibility that occurs with cognitive demand of the given task can be tracked. In addition, Cole et al. (2013) demonstrated that connectivity between FPN and other brain networks across 64 tasks could be identified by distinctive connectivity patterns and that this relationship held true for both practiced and novel tasks. Perhaps it would be worthwhile to investigate whether the presence of trigger warnings alters flexibility in the FPN network and connectivity patterns between the adaptive control system and the rest of the brain during specific tasks. The findings would give us a better indication of whether trigger warnings belong to categories of interventions that either facilitate increases in cognitive flexibility or perpetuates inflexibility. 25
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c. Potential for Integration Compared to PE, ACT has considerably higher potential for integration into the classroom and cocurriculum. Specific skills targeting increases in psychological flexibility can be integrated into a variety of preventative mental health modules and can be delivered using web-based platforms. Several studies have demonstrated the potential for ACT to be a useful guided self-help tool for individuals with moderate levels of anxiety and depression. Fledderus et al. (2012) found that individuals who utilized an internet-based self-help ACT module with either extensive or minimal email support had significant reductions in depression, anxiety, and experiential avoidance and increases in mindfulness. In addition, these improvements were observable at 3-months follow up (Fledderus et al. 2012). Similarly, in a sample of individuals with chronic pain, Trompetter et al. (2015) found that following an internet-based ACT intervention, reductions in pain intensity, interference with daily functioning were observed. Importantly, in line with ACT's target of reducing psychological inflexibility, improvements in psychological flexibility and pain catastrophizing were also noted. Testing the feasibility of a supplementary web-based ACT program at university counseling centers, Levin et al. (2015) found that counselor and student user satisfaction was high and improvements for psychological flexibility were noted. Although completion rate of the entire ACT module was low (38%), individuals who displayed high engagement perceived the module as helpful. Similarly, Levin et al. (2016) noted lower program completion and satisfaction for an ACT prevention prototype compared to a more traditional mental health education website intervention. These findings suggest while integration of ACT as a stand-alone self-help resource or as a supplement to existing counseling services is achievable, the challenge, as seen in many other mental health services, lies in maximizing student engagement. In addition to utilizing ACT in a therapeutic context, ACT training in the workplace offers another potential route for integration with higher potential for engagement. ACT training often referred to as ACTraining, aimed at decreasing burnout, stress and increasing psychological flexibility have been shown to be effective in many professional populations including early childhood special needs educators, media personnel, mental health workers, government employees and university workers (Moran, 2015). One potential explanation for the efficacy of ACTraining in reducing burnout could be due to the role of increased psychological flexibility in more efficient distribution of cognitive resources towards constructive goals (i.e., academic coursework) rather than overly heavy investments on emotional regulation (Moran, 2015). Despite a lack of therapeutic component in ACTraining, training that utilizes the core principles of ACT and skills designed to promote psychological flexibility can benefit students in a number of ways. An increase in psychological flexibility may directly lead to reduction of psychological distress or act indirectly through alleviating burnout from the academic rigors of university coursework. The delivery format of ACTraining either in the form of classroom workshops, training workshop or ongoing student development throughout the term, would be highly accessible to both faculty and students. If university administrators are to consider integrating ACTraining into the classroom or cocurriculum, they should consult existing templates within professional populations.
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3. Mindfulness-based Stress Reduction a. Overview of Effectiveness Kimbrough et al. (2010) found that an 8-week Mindfulness-based Stress Reduction (MBSR) intervention for a sample of adult CSA survivors, reduced depressive and PTSD symptoms. These PTSD symptoms take many forms: avoidance, numbing, hyperarousal and re-experiencing (Kimbrough et al. 2010). Reductions in these symptoms were observed, along with significant improvements in mental health-related quality of life post-treatment in a sample of MBSRparticipating veterans although these gains were not statistically significant at four-month followup (Kearney et al. 2013). Improvements in PTSD symptoms that were maintained 3 months posttreatment were observed in veterans with a history of mild traumatic brain injury and PTSD (Cole et al. 2015). In addition to reducing PTSD-like symptoms, Serpa et al. (2014) found that suicide ideation (i.e., suicidal thoughts) was also reduced in veterans following participation in MSBR. Another study on MSBR in veterans with PTSD demonstrated that MSBR was more effective in reducing PTSD symptoms than present-centered therapy (Polusny et al. 2015). Examining the feasibility of MSBR in a sample of low-income African American women with PTSD and a history of intimate partner violence, Dutton et al. (2013) noted self-reported improvements in acceptance, hyperarousal, self-care, and self-empowerment among participants. Similarly, Gallegos et al. (2015) found that in a sample of women with PTSD symptoms and a history of interpersonal violence reductions in PTSD symptoms, depressive symptoms, perceived stress, emotional dysregulation were observed. Together, these findings suggest that MSBR is a potentially viable option for reducing PTSD symptoms and psychological distress in vulnerable populations. There is a body of literature supporting the effectiveness of MBSR in university populations. Goodman and Schorling (2012) found that an eight-week MBSR-based course resulted in significant improvements for burnout and mental well-being in health practitioners such as physicians, nurses, psychologists and social workers from university and community settings. For students, Bonifas and Napoli (2014) found that graduate social work students who took a Quality of Life: Development of Mindfulness module (3 hours per week, 16 weeks total) experienced increases in health and functioning (e.g. more energy, fewer worries, greater control over life, etc.) despite no changes in levels of perceived stress. Medical school programs have had positive results incorporating mindfulness training modules. Positive outcomes following mindfulness-based training for medical students included self-reported reductions in psychological distress and anxiety (Shapiro et al. 1998), perceived stress (Warnecke et al. 2011) and increases in selfregulation (i.e. staying on track) and self-compassion (i.e. less self-criticism) (Bond et al. 2013). In addition, de Vibe et al. (2013) found significant improvements in mental distress, study stress and well-being in female participants only, indicating a potential gender difference in responses to MBSR interventions. de Vibe et al. (2013) suggests that positive outcomes were a result of increases in mindful acceptance and greater ability to regulate automatic responses to stimuli. Many authors noted however that due to lack of comparison groups it could not be established if mindfulness modules caused improvements in health and functioning observed in students versus improvement due to other uncontrolled factors (Bonifas and Napoli 2014; Bond et al. 2013; Fourtney et al. 2013 and Kimbrough et al. 2010). Nevertheless, improvements in psychological distress compared to baseline were observed in each study.
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There are a variety of indicators that may explain why mindfulness-based interventions are effective in reducing psychological distress in student populations. Palmer and Rodger (2009) found that among a sample of first-year students, those who had higher mindfulness scores based on the Mindfulness Attention/Awareness Scale (MAAS) had lower levels of perceived stress. Higher mindfulness scores were positively associated with rational coping and negatively with emotional and avoidant coping (Palmer and Rodger, 2009). The authors suggest that these findings provide support for the role of mindfulness in facilitating adaptive coping and that the MAAS may be a useful tool in evaluating student coping skills and psychological condition. In addition, Thompson and Waltz (2010) found that in a sample of undergraduate students who reported exposure to trauma, mindfulness in the form of non-judgment characterized by acceptance of one's experiences was the strongest predictor of experiential avoidance. Experiential avoidance in the form of inability to recognize distressing emotions and thought suppression were found to be the strongest predictors of PTSD avoidance symptoms. The authors suggest that these findings provide support for the role of mindfulness, especially nonjudgmental acceptance of experiences, in helping traumatized individuals engage meaningfully with traumatic experiences and reducing the use of avoidance over time (Thompson and Waltz, 2010). On a functional level, Kearney et al. (2013) observed that PTSD symptoms such as avoidance, guilt, emotional numbing and intrusive memories often rose to the surface during mindfulness exercises and that instruction was given to help veterans bring attention to and navigate those feelings. To some extent, the same mechanism may be present wherein mindfulness instruction aid students with arising feelings associated with anxiety, burnout, and self-criticism. b. Biological Mechanism A body of scientific literature exists on how mindfulness changes the brain. These findings offer potential explanations for the observed changes in patients following mindfulness-based interventions. Hölzel et al. (2011) showed that in brain scans of patients following 8-week MBSR, gray matter density increased in the left hippocampus, an area of the brain responsible for emotional regulation and learning. Increases in grey matter were also observed in the posterior cingulate cortex, temporoparietal junction and cerebellum areas associated with introspective and empathic awareness, spatial congruency between the self and body, attention to the desires, goals, and intentions of others and perception of alternative views (Hölzel et al. 2011). Hölzel et al. (2009) found that following 8-week MSBR, decreases in perceived stress predicted the amount of decrease in grey matter density in the right amygdala an area of the brain associated with fear, negative emotion, and automatic stimulus detection. The density changes observed were specific to the right but not left amygdala which has been associated with discriminating between different stimuli (Hölzel et al. 2009). These findings are consistent with previous research indicating dispositional mindfulness was associated with decreased grey matter in the right amygdala even after controlling for a number of factors including age, depression, neuroticism and total grey matter volume (Taren et al. 2013). The findings of this study suggest that interventions such as MSBR could potentially benefit individuals who have strong initial responses to distressing stimuli due to heightened responsiveness and activation of the amygdala. Hölzel et al. (2009) suggest that through the process of re-conditioning existing responses to distressing emotions, interventions such as MSBR can induce changes in areas of the brain associated with stress, even in the absence of significant changes to the individual's external environment (i.e., university campus).
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Patterns of brain activation during meditation practice were observed to be central in the ACC and dorsal medial prefrontal cortex (dmPFC) (Hölzel et al. 2007). This finding is consistent with a large number of studies that have found PFC and ACC activation during mindfulness meditation (Chiesa and Serretti, 2011). Lieberman et al. (2007) found that labeling negative emotions and thought as they are, increased activation of the right ventrolateral prefrontal cortex and decreased in the amygdala. In conjunction, research has found that mindfulness in the form of emotional and experiential acceptance involves deactivation of the ACC, mPFC (Kross et al. 2009), and PCC (Taylor et al. 2011) in response to distressful stimulus. These findings seem to suggest that during mindfulness meditation, core regions of the default network (mPFC, PCC, ACC) are active and that as we begin to observe, label, and accept internal experiences as they arise, activations in these areas decreases. Boyd et al. (2017) suggest mindfulness meditation may facilitate more effective recruitment of the default network when required (i.e. self-perception processes) and greater control over it when not required (i.e. mindful acceptance processes). Increased connectivity between the PCC and the ACC and dmPFC have also been observed following mindfulness-based exposure therapy (MBET) (King et al. 2016b). This finding is supported by previous research which found that meditators have greater functional connectivity between default network and mPFC at rest compared to non-meditators (Jang et al. 2010). In addition, the findings of attentional improvements in King et al. (2016a) study seem to suggest that decreases in PTSD symptoms following MBET could be due to positive changes in the adaptive control system and improved recruitment of stress adaptation functions (i.e., shifting attention). The mechanisms underpinning MBET are highly complex, due to potential interactions between both mindfulness and exposure components. Future studies should examine differential outcomes in neural correlates for prolonged exposure therapy versus mindfulness-based exposure therapy. It’s also worth noting that the mPFC and ACC are both involved in the process of fear extinction, as shown in our exploration of fear extinction in PE. The significance of these regions in both exposure therapies and mindfulness meditation could be explained by Tang et al. (2015) who suggest that mindfulness meditation acts as a form of exposure in that directing one’s attention towards internal stimuli (i.e. traumatic memory) is also central to exposure therapies. The authors suggest that mindfulness meditation may enhance fear extinction learning and retention through its overall effect on brain regions in fear circuitry (Tang et al. 2015). In addition, during the process of acceptance, activation in the amygdala decreased, likely, as a result of a lowered fear response. The Hölzel al. (2011) study also found increased functional connectivity between the amygdala and PFC regions post MSBR treatment suggesting that meditation facilitates greater functional communication between these regions of the brain. King et al. (2013) found that following mindfulness-based cognitive therapy, combat veterans experienced reductions in PTSD symptoms and notably, reductions in unproductive trauma-related cognitions such as self-blame and perception of the world as threatening. The decreases of trauma-related cognitions in this study along with the previously observed patterns of ACC and dmPFC activation during meditation suggests a potential pathway through which mindfulness meditation, activates regions of the brain involved in fear extinction, laying the preconditions for effective fear extinction learning and resulting in overall PTSD symptom reductions. c. Potential for Integration
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In addition to having previous success in reducing psychological distress in student populations, there are three additional qualities of MSBR interventions that make viable for integration into curriculums or classrooms: flexibility in delivery length, lasting duration of positive outcomes and ability to master core skills post-intervention through practice. Thus far, the studies presented have utilized 8-week MBSR interventions, but limited research has suggested positive outcomes following abbreviated programs of shorter duration. Duration is an important factor to consider when assessing the feasibility of integrating mindfulness-based interventions into the curriculum or classroom because longer durations may interfere with class hours or be a de-motivator for commitment. In a sample of primary care physicians following an abbreviated 8-week MBSR intervention significant decreases in burnout, depression, and stress were found (Fortney et al. 2013). Similarly, for a sample of nurses, following a shortened 4-week MBSR intervention, reductions in emotional exhaustion, depersonalization, and increases in relaxation were observed (Mackenzie et al. 2006). Carmody and Baer (2009) reviewed a sample of MSBR studies and found no significant difference between hours delivered in MBSR interventions and measures of psychological distress indicating that abbreviated MBSR may be just as effective in alleviating psychological distress as conventional 8-week interventions. Carmody and Baer (2009) suggest that future research should investigate whether total hours may determine measures other than psychological distress such as reduced rumination, fear of emotion and the maintenance of these factors over time. Studies have observed the extended durations of post-intervention improvements. Early et al. (2015) found that at 2.5 years follow-up from MSBR intervention for child sex abuse survivors, significant decreases in anxiety and PTSD symptoms persisted. In the Kimbrough (2010) study, improvements in PTSD and depressive symptoms remained statistically significant at 24 weeks from the start of the intervention, with the largest effect size for reduced depressive symptoms at eight weeks. Krasner et al. (2009) noted that in a sample of primary physicians, following an 8week MBSR intervention, reductions in burnout (i.e., emotional exhaustion and depersonalization) and improvements to mood (i.e., anger and fatigue) were observed over a 15month period. For 4-week abbreviated MBSR, Fortney et al. (2013) found that the reduction in burnout, depression, and stress was observed over a 9-month period from the beginning of the intervention. The effect duration of mindfulness for weeks and months post-intervention may play a preventative role for traumatized individuals by acting as a buffer to additional stressors (i.e., midterms) during school terms. Finally, while mindfulness-based interventions revolve around several core principles, in practice modules are composed of a set of skills that can be taught, learnt, refined and mastered with repetition. In Krasner et al. (2009), the mindfulness meditation component used guided exercises intended to enhance awareness and acceptance of internal and external experiences instead of the labels and judgments attached to them. These exercises included: body scan (bodily sensations), sitting meditation (thoughts and emotions), walking meditation (natural movement and experiential awareness) and yoga (mindful movement). The University of Montreal's Health Enhancement and Mindfulness Programme for medical students utilizes 15 -minutes of lecture time and 15 minutes of practice time for guided body scans and mindful breathing within each 30minute session. A total of ten 30-minute sessions were distributed over the duration of the 5-year medical program (Dobkin and Hutchinson 2013). Several programs have utilized the concept of 30
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breathing space which involves putting down tasks at hand and engaging in 3-minutes of mindful breathing (Gallego et al. 2014 and Dutton et al. 2013). Taken together, these activities and the skills they seek to enhance have potential to be utilized by students in a variety of settings (i.e., home practice or classroom situations) following classroom instruction or through co-curriculum. Together, this section has laid out three different evidence-based interventions each with variable degrees of potential for integration into the classroom and co-curriculum. This report suggests that it may be useful for university administrators to review existing counseling services at their respective institutions to determine whether current practices are meeting demands from both clinician and student standpoints. If demand is inadequately met, it may be useful to consult respected practitioners and researchers in the field of trauma and PTSD to determine if integration of new evidence-based practices is appropriate. While it is ultimately on each institution to decide where their needs lie and the steps they take towards meeting these needs, administrators and instructors should not let the presence of trigger warnings (not evidence-based) deter them from pursuing evidence-based interventions in the process of tackling mental health challenges inside and outside the classroom.
6. Recommendations Teaching Coping Skills
This paper suggests that one approach to tackling mental health and trauma on campus is to incorporate the teaching of pro-active coping skills in the classroom and through co-curricular modules. Arming students with adaptive coping skills will go a long way in helping students become adult learners whom Stallman et al. (2017) characterizes as having the ability to: "effectively interact with a diversity of people, learn content relevant to the program of study they choose to enroll in and tolerate diverse and often contradictory opinions of others" (p.2). SontagPadilla (2016) found that in the CalMHSA Student Mental Health Campus-Wide Survey, the group with the highest utilization of on and off campus mental health services or a combination of both, were characterized as having active coping skills. Compared to students with inadequate coping skills, this relationship was consistent at comparable levels of academic impairment and current psychological distress (Sontag-Padilla, 2016). This finding suggests that equipping students with a repertoire of adaptive coping skills may help them with the utilization of available mental health resources. In addition, learned adaptive coping skills could be carried on throughout the student's university careers for present and long-term benefits. Universities should consider drawing on the existing framework of MSBR modules in medical and social work programs to develop similar modules in disciplines that view reduction of trauma symptoms and psychological distress in their students as pressing need. Presented at the start and throughout the year, instruction and skills in these modules will equip students with resources to draw from pre and post-exposure to difficult material. There is potential for instructors to work collaboratively with MSBR practitioners to tailor curriculum and incorporate core mindfulness exercise towards the specific course and student needs. Also, making ACTraining accessible as 31
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workshops or co-curricular training sessions throughout the year would be consistent with the goal of equipping students with adaptive coping skills. Outside of the classroom, universities who identify the need to increase services for students dealing with trauma and mental health issues (based on information and statistics collected for their institution) should consider expanding the total number of available practitioners and diversifying current services with a repertoire of evidence-based interventions that have demonstrated effectiveness in reducing PTSD symptoms (ie. PE and MSBR) and unproductive anxiety (ie. ACT). Students would also benefit from reviewing available information on evidencebased interventions, so they are well equipped in lobbying the university for more funding into counseling and mental health services. Personalizing Warnings
Given the wide range of potentially distressing materials, Boysen et al. (2017) suggest that trigger warnings may need to be personalized to best serve the needs of individuals with diverse experiential, psychological and physiological makeups. Personalization of trigger warnings can be accomplished through university online learning systems. Laguardia et al. (2016) suggest that "adding the option to place content notifications and links to support resources [through online learning systems] would seem like a natural, and simple solution" (p.19). By tailoring built-in features in online learning systems to include an option for showing or hiding trigger warnings, individuals who do not wish to be subjected to trigger warnings in a course that uses them have the choice opting out. Also, having the option of selecting trigger warnings as on, off or customizable, at any point during the course enables individuals to control the way they engage with materials (with, without, or with select warnings) at different stages of the course and mental health treatment. The resulting flexibility is in line with the goal of respecting the autonomy of individuals with trauma who carry with them diverse coping skill sets and may not necessarily wish to be subjected to trigger warnings in the coping process. Trigger warnings delivered in this manner, would to some degree, alleviate the concerns put forth by Sarah Roff as quoted in Lukanoff and Haidt (2015) who suggests that trigger warnings will impact, “not just those who have experienced trauma, but to all students, creating an atmosphere in which they are encouraged to believe that there is something dangerous or damaging about discussing difficult aspects of our history” (p. 6). If warnings are personalized, students can choose whether or not they want to be exposed to labels for subjective concepts such as disturbing, offensive, cis-sexism, sexism, misandry, and misogyny. They can engage with aspects of course material without exposure to the pre-judgements cast by these warnings. Note that, degrees of separation between a clear-cut image depicting rape, the subjective interpretation of cis-sexism from a passage in a novel, and a statistic on abortion should be kept in mind. Individuals should have the choice to interpret the text without any explicit pre-supposition of how they might react to certain scenes in the text or pieces of information. By handing students, the responsibility of reviewing their personalized warnings beforehand, professors could start course or individual lectures by engaging in brief discussions about topics such as "the necessity of discomfort in learning about difficult material," "differences between personal discomfort and institutionally sanctioned epistemic violence" and "disagree[ing] without demeaning or disrespecting one another" as suggested by Carter (2015, para. 28). 32
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Ensuring the Equity and Inclusivity of Accommodations
Thirdly, instructors who utilize trigger warnings should make sure such accommodations are equitable and inclusive as possible. As such, when adopting warnings, instructors should seek to avoid what Proctor (2017) refers to as a “hierarchy of trauma” (para. 26) which results in the privileging of certain forms of trauma over others when materials deemed worthy of warnings are selected on an arbitrary basis. If trigger warnings are not personalized—the only way to ensure the accommodation is truly equitable and inclusive would be to label all materials as potentially traumatizing. In the Horton (2017) study, 3 of 5 (60%) interviewed students suggested that not providing warnings for "all content that could be traumatic" (p.24) demonstrates a lack of commitment on the part of the professor and decreases the effectiveness of the warnings. Future studies should examine whether the perspectives from the students in the Horton (2017) study are prevalent. Regardless, universities who have mandates for equity and inclusion are obligated to make every attempt at making trigger warnings an equitable practice. One way to ensure adequate coverage of conditions with trigger-based distress is to compile a comprehensive document for teachers and university administrators. For psychiatric conditions ranging from phobias to PTSD, the DSM-5 and related scientific literature should be consulted. In addition, a review of past topics from self-help and feminist forums would round out the list of topics. The forums from which trigger warnings first originated would supply a valuable list of topics not included in the DSM-5 and perhaps unfamiliar to academic settings, some of which include: acephobia (fear of asexuality), animals in wigs, alcoholism, emetophobia (fear of vomiting), finger snapping, pregnancy, sizeism, slut-shaming, the rapper Chris Brown (domestic violence), and trypophobia (fear of small holes) (Jarvie, 2014). Additionally, in the process of document creation, student consultation and consideration of multicultural perspectives on triggerbased distress should be included in the spirit of diversity, equity, and inclusion.
7. Implications In this report, the exploration of trigger warnings reveals two things: 1) the notable absence of empirical evidence supporting the efficacy of trigger warnings and 2) a perceived lack of interest in obtaining this evidence. As shown earlier, there is no empirical evidence for the efficacy of trigger warnings on mental health outcomes in either classrooms, message boards, or psychiatric settings. The reason for the absence of empirical evidence on the impact of trigger warnings on student mental health outcomes could be as Laguardia et al. (2016) suggests that trigger warnings have not been in classrooms long enough to be studied. It's been three years since trigger warnings first migrated from online message boards into university classrooms, and given the increased prevalence of usage as indicated by the surveys presented in, “The Current State of Trigger Warnings on University Campuses” and the growing mental health crisis on university campuses—the time to produce research and collect data on trigger warnings is now. Implementing trigger warnings is easy— finding out how they're impacting students is challenging work. The onus is on advocates and users
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of trigger warnings (or their permutations) to take the initiative and begin exploring the consequences of the warnings they're issuing. This paper suggests that while the biological of triggers are well established, using them as a justification for trigger warnings falls short in convincing those who challenge the use of trigger warnings without any evidence of their efficacy. The biological nature of trauma triggers is merely an underlying assumption used to justify trigger warnings and the lack of attempts that have been made at evaluating the outcomes of warnings on student mental health is concerning. Given that trigger warnings provide students the choice of avoiding distressing content (regardless of their intent), it's not unreasonable to suggest that if trigger warnings are taken as cues to utilize avoidance behaviors and if these behaviors are subsequently learned and maintained over time, it has major implications for the ability of students to cope with trauma and other mental health issues. In addition, due to the existence of alternative interventions with supporting evidence for positive outcomes in practice (beyond theory), some may feel that the reasons for implementing trigger warnings are political and are not conducive to helping students deal with trauma and psychological stress in the long run. This paper suggests that there are two things advocates of trigger warnings can do to move closer towards providing a convincing argument that trigger warnings are indeed part of best practices in the classroom and have positive outcomes on students: 1) produce research and data to support impact on student mental health and other desired outcomes and 2) increase transparency for pedagogical practices that lack supporting research and evidence. As it stands, the theory that trigger warnings are meant to be tools of access for traumatized individuals, have observable impacts on these individuals and positive outcomes on mental health have as much scientific validity as religious postulations as suggested by Vatz (2016). Scientific validity is not everything—but is necessary, if trigger warning advocates wish to present a convincing argument to the scientific community including academics, researchers, psychologists, practitioners that trigger warnings are indeed impacting students in ways that have been suggested. Outside of universities, stakeholders along with others who hold the scientific validity of practices to high regard and make evidence-based decisions will also need some convincing. Advocates who seek to provide support for the efficacy of trigger warnings using the scientific method should work towards developing appropriate or drawing on existing measures for evaluating trigger warning outcomes (i.e., CD-RS for Resilience). Studies should be designed with control groups, participant randomization, and setup replicability in mind. Findings would be the first of their kind and provide a starting point for future research on the efficacy of trigger warnings. This research would also add to the existing body of scientific research on trauma triggers, coping strategies and evidence-based interventions (i.e., MBSR). In complement, quantitative data which can shed light on the measurable outcomes of trigger warnings (e.g., anxiety, coping, psychological distress, experiential avoidance, resilience measures). Quantitative data can provide in-depth information on the changes in appraisals towards potentially distressing materials pre and post-exposure, changes in thresholds of distressing materials over time and the increased "access" for traumatized students. If Gender Studies as a discipline, stands to take the lead in facilitating the use of trigger warnings across disciplines as Stringer (2016) suggests, the onus is on them to start looking at producing research exploring descriptive measures above. Qualitative research offers several points of compatibility 34
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with the fundamental feminist framework of Gender Studies programs as referenced in Social Research Methods (Bryman, 2015). According to feminist researcher Maria Mies, these include: 1) Promoting women’s voices, as opposed to “ignoring them or submerging them in a torrent of facts and statistics” (as cited in Bryman, 2015 pg. 403), 2) Alleviating “control” over variables, thereby not perpetuating masculine concept of control, and 3) Avoiding exploitation of female subjects as objects of research with nothing in return for their experiences and knowledge (as cited in Bryman, 2015). First and foremost, research on the efficacy of trigger warnings must be produced before we can even begin to think about them alongside other evidence-based practices. Once initial research is published, it is then up to academics, researchers, scientists, and students to break down strengths, limitations and suggest improvements for future studies. The involvement of students in this process through careful reading, discussion, and analysis of the works published is critical to ensuring these works meet the standards of academic rigor and scholarship. One study only begins to scratch the surface of the unanswered questions about trigger warnings (or their permutations —but it is a start towards building bodies of research similar to those of evidence-based interventions and pedagogical practices. If advocates of trigger warnings reject the notion that trigger warnings need to be scientifically validated the least they could do is increase the transparency of such practices given their controversial nature. There are many ways that this can be accomplished, so long as the motivation to undergo these tasks is adequate. For syllabus and content warnings, advocates should seek to produce a comprehensive public document that lays out: an up-to-date list of topics that have warranted warnings, specific materials corresponding to the topics listed, topics that have been requested but were not granted warnings and collection of detailed sample warnings along with rationales. Researchers should face few barriers collecting this information as many professors have been open in sharing their warning practices in articles on the trigger warnings debate. For verbal warnings given in-class on a material-by-material basis, advocates would serve well to upload recorded lectures demonstrating trigger warnings in a live setting given that students consent for participation. In conjunction, open panel discussions and information sessions should be held so that questions and concerns about the nature of warnings in the videos can be explored by stakeholders and members of the university community. Thus far, the trigger warning conversation has centered exclusively around faculty and students and rightfully so. However, this paper suggests that there are additional groups who stand to benefit from evidence-based research on the outcome of trigger warnings and greater transparency on their usage. Counsellors and Mental Health Practitioners With the heavy demand of mental health resources often outpacing availability on university campuses – some students are often turning to off-campus resources for support. Sontag-Padilla et al. (2016) suggested that off-campus service usage could be more prevalent among students who lived off-campus based on proximity. In the California survey, 10% of students reported having used off-campus services, but the authors suggested that this was an underestimate given that students have potential to utilize both on and off-campus services at different or same points in 35
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time (Sontag-Padilla et al. 2016). It's imperative that mental health practitioners for off-campus services are fully informed about the use of trigger warnings in university classrooms and their impacts on the students they're seeing. Trigger warning advocates may also wish to consider the perspectives of practitioners who have extensive experience working with PTSD and trauma victims. Metin Basoglu the founder of Trauma Studies at the Institute of Psychiatry, King's College London, suggests that while the biological effect of being triggered and infinite multiplicity of potential triggers are very real for trauma victims, "exposure to trauma reminders provides an opportunity to gain control over them" and to build resilience (Waters, 2014). Basoglu and his colleagues have demonstrated success in treating people living with PTSD by rehabilitating avoided behaviors using exposure as a core principle. To the contention that integrating the concept of exposure into the classroom is not suitable given that they are not clinical settings, Basoglu answers, "many people discover the benefits of exposure for themselves. I've seen people who have said, ‘If I hadn't started driving soon after the accident, I'd have never driven again" (Waters, 2014, para. 30). This perspective echoes the sentiment of Lukanoff and Haidt (2015) who suggest that individuals might discover the classrooms are spaces where reminders of violence are typically not followed by violence. Dr. Suzanne Pineles a clinical psychologist at the US Department of Veterans Affairs' National Centre for PTSD, suggests that avoidance of potential triggers, "prevents the natural habituation or extinction that happens to people over time" (para. 4) which has implications for student mental health beyond the classroom (Hovet, 2016). Psychiatrist, Sarah Roff also suggests that PTSD symptoms are amplified and maintained through maladaptive adaptive coping strategies such as avoidance. To summarize, Hovet (2016) suggests that from a psychological perspective, regardless of their intention, trigger warnings foster a culture within universities where “avoidance coping is supported, encouraged, and justified,” (para 5) and the result is the creation of a “mass breeding ground for PTSD,” (para. 7) and PTSD symptoms for individuals without PTSD. These perspectives raise questions as to whether clinically-relevant trauma is best engaged within controlled clinical settings and whether materials presented in the classroom are likely to elicit the type of trauma symptoms requiring clinical treatment. If avoidance behaviors are undertaken on a consistent basis and maintained towards materials that may not result in trauma symptoms warranting clinical treatment, this may negatively affect an individual's ability to take control of their trauma, in on-going treatment and over the long term. These concerns are raised due to the role trigger warnings may play in acting as cues and justifications for maladaptive avoidant coping behaviors which have been shown to contribute to the amplification and maintenance of PTSD symptoms. Until we have research demonstrating the outcomes of trigger warnings on students, the perspectives of individuals with extensive experience dealing with trauma victims should not be overlooked in efforts directed towards the common goal of ensuring positive mental health outcomes for students. It would benefit users of trigger warnings to consult clinical professionals and experts in the field of trauma on the potential risk of trigger warnings contributing to the mental health problem on university campuses. International Students
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According to statistics from Student and Exchange Visitor Information System (SEVIS) there are currently 1,184,735 active international students studying in the United States as of May 2017 (SEVP, 2017). In Canada, number of international students should exceed 400,000 given there are 414,946 active study permit holders as of December 2016 (ICEF, 2017). Notably, estimates for students coming from Asia (i.e., with a majority from China and India) were 77% for the U.S (SEVP, 2017) and 63% for Canada (ICEF, 2017). As it pertains to trigger warnings, universities should ensure that incoming students are fully informed about the nature of warnings and their intended purpose. Making an effort to explain the reasoning behind giving warnings makes intuitive sense given that the implementation of trigger warnings has been limited to institutions in Australia, Canada, U.K and the United States. Even within the U.S, the students in the Horton (2017) noted that instructors never explained why the warnings were given before presenting materials and that their knowledge of these warnings came from interacting with them on social media platforms such as Facebook. A teaching assistant in the study suggested that instructors should offer rationales for warnings as they relate to specific content, before they are explicitly given, to ensure that students are informed (Horton, 2017). The voice of international students in the discussion of trigger warnings is invaluable given their diverse histories and experiences with trauma and cultural differences in coping strategies. As a hypothetical example, a student coming from a country having suffered under an oppressive regime may realize that engaging in sensitive material here most likely won't result in threats of physical violence. This student may welcome engagement with sensitive materials given the absence of imminent threats and wish to do so without warnings possibly for a variety of reasons (i.e., cultural) or they may embrace the warnings. University administrators and faculty who are in the position to issue such warnings have no way of knowing unless they have student input. This paper suggests that it would be wise for universities to proactively engage with and be inclusive of all international student voices (regardless of agreement) on controversial and important issues such as trigger warnings at a classroom and institutional level. Alumni and Employers Alumni who have gone through the rigors of a university degree and are familiar with the inner workings of their respective universities have a role to play in the trigger warning conversation. Recent graduates who've had exposure to trigger warnings in the classroom in recent years, starting around 2014 have a significant role to play given their experience. For alumnus who seek to hold our home universities accountable to their international reputations as top research-based institutions, writing and speaking out helps propel the conversation of trigger warnings from the realm of students and academics towards stakeholders and other groups with interest in positive student mental health outcomes. One such group, are employers who have traditionally strived to maintain relationships with universities (and vice-versa) through partnerships, grad-hiring programs, and annual surveys. These surveys function as a channel for exchanging feedback related to student employment and serves as a way for both parties to gauge mutual understanding on major (i.e., mental health) and controversial (i.e., trigger warnings) issues related to student success. With the current situation on university campuses, universities may be well served to have employers on the same page when 37
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it comes to, the current mental health crisis on campuses, approaches respective universities are taking to these issues and up-to-date information on the use of trigger warnings. Employers may benefit from being informed on the way these warnings are impacting students and student expectations for the use of warnings in the workplace since trigger warnings have for the most part been relegated to university campuses and online settings. Likewise, universities and their constituents would benefit from knowing employer perceptions on these issues and taking note of any discrepancies between their expectations and employer perceptions from survey responses. There are many resources that have the capability of delivering quality surveys on this issue. These include, but are not limited to organizations such as the Chronicle of Higher Education, Inside Higher Ed, NPR Ed and The Association of American Colleges and Universities who have delivered informative surveys that have shed light on the state of trigger warnings on university campuses. Together, the Inside Higher Ed's, " 2016 Survey of College and University Chief Academic Officers (Jaschick and Lederman, 2016) and NPR ED’s survey (Kamenetz, 2017) provided new information on the perceptions of head university administrators on the use of trigger warnings at their institutions, prevalence of usage among instructors and rationales for usage. Perhaps the next step would be to survey employers, adding another dimension to the trigger warning conversation.
Conclusion As discussions of trigger warnings and mental health progress, it’s imperative for those on the peripheries of university campuses to stay informed. As individuals who are genuinely concerned about finding solutions to the mental health challenges on university campuses, we need to take a nuanced approach towards issues with complex assumptions and no empirical evidence. Advocates and users of trigger warnings should seek to produce evidence to justify their practices if they wish to take the lead in advocating for warnings across all disciplines. Transparency for practices that lack evidential support is both beneficial and critical for maintaining a nuanced discussion on the issue. University administrators should continue to pursuing evidence-based interventions in the process of tackling mental health challenges in and out of the classroom. If the motivation for undertaking such tasks is adequate, progress can be made in determining whether trigger warnings are productive in tackling mental health challenges or are making things worse. It’s been three years since trigger warnings have migrated into classrooms. The time to produce research and collect data on their outcomes on mental health is now.
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