I triggered my audience while lecturing on PTSD. Here's what I learned
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Version 0 of 1. Last week I presented an academic paper on combat trauma and the post-war experience of veterans – a dramatically underexplored area of research. As I spoke, I wondered whether I ought to have given a trigger warning. Let me explain. My talk was the most recent in a series of arguments I’ve presented for why we need to be careful about psychopathologising the complex experiences of military veterans during and after tours of duty. Related: 'You don't ever get over it': meet the British soldiers living with post-traumatic stress disorder Activist groups have done a wonderful job of bringing attention to the real issues faced by veterans in Australia, and a number of ethicists have started to explain the social responsibilities owed by a community to their veterans. But moral philosophy, I argue, can do more. It can help to explain the nature of those veterans’ suffering; something that is ordinarily considered the domain of psychology. In a sense, it is the domain of psychology – nearly everyone is familiar with post-traumatic stress disorder, or PTSD – just not exclusively. A number of psychologists, trauma experts, chaplains, philosophers, and veterans have begun to express dissatisfaction at the use of PTSD as a cover-all diagnosis for the difficulties faced by veterans. In response, some have proposed the existence of a separate condition – “moral injury” – marked by a slightly different set of symptoms and different causal triggers. The differences, in short, are as follows. PTSD begins with a threat to one’s safety, or the safety of loved ones. After the threat subsides, it is natural to be guarded and cautious for a while, until one can be confident the world is safe again. At that stage we can start to re-ground ourselves. However, PTSD occurs when – for whatever reason – the person isn’t able to accept that the world is safe anymore. The paralysing fear and horror, pervasive intrusion symptoms and subsequent withdrawal, and the alienation from loved ones and society are devastating to a person’s flourishing. Moral injury (which is still a hotly contested term, and hasn’t yet been accepted into any iteration of the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychological disorders) presents a different story. Moral injury happens when a person performs, witnesses, or is victim to a betrayal of deeply-held moral values. When a person is morally injured, they don’t view the world as unsafe, but as morally unreliable. Morality is, amongst other things, a way in which we understand the world and our relationship to it – when our concept of morality is damaged, the consequences are drastic. Diagnostically, moral injury differs from PTSD in that it lacks the hyperarousal symptoms that popular culture frequently associates with veterans: paranoia, suspicion, and sensitivity to unexpected sense experiences. Morally injured veterans won’t be triggered by a car backfiring, or the smell of burned rubber, because they’re not in a state of fight-or-flight in the way that PTSD sufferers are. Their injury is one of trust. So far, so good. But I’m sceptical about whether a diagnostic approach can allow us to fully appreciate the differences between the experiences of PTSD and moral injury. I think we can use moral philosophy to add some substance to the useful outline of moral injury that psychologists have proposed. More importantly, perhaps, we can challenge some of the assumptions that come from viewing trauma and veterans’ experiences through what I call the “therapeutic gaze” implicit in some strands of psychology. By using moral philosophy, we can understand the evaluative content of emotions such as guilt and shame – common occurrences in the proposed diagnosis of moral injury - and how they might be responded to morally. We can understand a person’s emotions as more than externally-determined events that they are subject to but as informative human experiences that might be better processed with assistance. Most psychologists do this anyway, but philosophy adds another level of evaluation: if a veteran is feeling guilty or ashamed, perhaps he is right to. Perhaps he has learned something from his experience of war that we’ve yet to understand through living entirely in a peacetime environment. Furthermore, we can start to see that moral injury is actually an experience of the self as judge: as judge of one’s environment and as judge of oneself. It is an experience of radical self-authority and responsibility for the actions one has been involved in. Knowing this, we can start to understand how profoundly moral concepts, like forgiveness or even punishment, might have an important role to play in healing moral injuries if they are applied appropriately. We can also see how moral injury is partly about a fragmented moral self: it’s about a failure to integrate a single experience into one’s self-concept. This isn’t to say that psychology is a farce, or that those suffering from combat trauma don’t require mental health care. Rather, it’s to say that those administering that care need to be able to understand the experiences of veterans on a case-by-case basis, rather than through a restrictive diagnostic lens. It is never going to be a philosopher who sits with a veteran in the therapy room, but that doesn’t prohibit therapy from being a little philosophical. It’s interesting to note that all of the approaches to healing combat trauma – whether moral injury or PTSD – advocate exposure to triggers as a way of integrating the traumatic experience into one’s identity, rather than allowing the self to remain fragmented. It is the return to triggers, rather than the avoidance of them, that provides closure. During my talk a couple of members of the audience became noticeably uncomfortable. Each seemed to be dealing with emotional baggage, which aspects of my talk had awakened for them. One spoke freely in the Q&A, explaining his own history with PTSD as a product of a car accident. He still experiences intrusions when he smells burned rubber, and candidly described the way his life was changed and the difficulties he and his wife face living with his condition. A second woman was less familiar with her condition. Clearly distraught, she struggled to give voice to what troubled her. She associated with the symptoms I’d detailed, and alluded to a complex family history, but couldn’t – or wouldn’t – offer any more detail. This wasn’t for fear or her own privacy, but because of a constant concern that her story was an imposition. Through her tears she apologised profusely for sharing her feelings, and no amount of reassurances could leave her comfortable enough to sit with her feelings. I spoke at length with each after the talk, encouraged them to seek professional help, and hope to remain in contact. The severity of PTSD and other conditions has prompted an ongoing discussion about trigger warnings. At Columbia University an extended campaign by student activists seeks to make trigger warnings compulsory in classes that may awaken difficult experiences, and trigger warnings on news stories dealing with some mental health issues has become the industry standard. Whilst undoubtedly well-motivated and aimed at avoiding the potentially catastrophic consequences of genuine psychological triggers, I wonder whether this sends a deeper message – precisely the same one that I’ve spoken against in the veterans’ space. Namely, that negative experiences exist outside of the genuine self; that emotions are pathological intrusions from our environment into our psyches. When we respond to a troubling news story, we feel a range of emotions that might not be comfortable. These are rarely the product of trauma; they are authentic human experiences to be nurtured. When we feel, we haven’t been triggered; we’ve responded to a situation in our own way. I worry that the over-use of trigger warnings undermines this. When conversations aren’t only opportunities to learn, but potentially harmful triggers, we also reinforce the idea that one must be painstakingly careful about what one says. But the fear of harming others and the belief that one’s testimony isn’t welcome in civil company is one of the great obstacles to enabling veterans to speak about their experiences, to receive the closure and communal acceptance that many desperately need. It was also the obstacle that the woman in my talk encountered. The belief that her emotional vulnerability could be an inconvenience to me. Something to apologise for. If we aren’t judicious regarding when trigger warnings are necessary, we risk the pathologising of feeling, when negative emotional experiences are no longer a natural part of getting to know oneself and the world, but conditions that we are made victim to by our environment. “Better safe than sorry” might be helpful legal advice when publishing articles dealing with difficult subject matter, but it’s the same thinking that reinforces the damaging cycle of trauma: fear, avoidance, withdrawal, alienation. |