Trauma, Gaming and Healing Part 2: Triggers and Trigger Warnings

In part one of this series, I provided a general overview of PTSD and some gamers who have it, as well as a summary of some of the successes and challenges the video game community is facing in being inclusive to gamers with PTSD. Now I’d like to dig into the gaming community debate surrounding “trigger warnings”. I’m going to stay away from the explosively controversial university campus trigger warning debate and focus on the issue of triggers and video games. The Escapist is a video game culture site. Hooray for staying on topic! Furthermore, the goal here is not to make a definitive judgement on trigger warnings. My goal is to weigh the pros and cons and offer some analysis and suggestions while attempting to remain objective. There are no easy answers here.

Trigger warnings sit at an intersection point between feminist activism and mental health accessibility principles. A “trigger” is a sensory input that triggers a flashback or anxiety attack in a person with PTSD. Decorated Iraq veteran Michael Stevens provides this example of a trigger episode.

battlefield 4 helicopter

“You’ll be in a car on a long, empty stretch of highway, and suddenly there are no trees, no buildings, only desert for as far as you can see. You blink and you’re back to reality.”

Trigger warnings are a form of content advisory that gives readers or viewers advanced warning that a piece of media contains known common triggers. Some believe that trigger warnings serve to warn trauma survivors away from potentially triggering material, but according to pro-trigger warning advocate Philip Wythe, that’s not accurate. “I think the warning lets gamers with these triggers ‘plan’ for experiences.” They explain. (Wythe prefers a gender neutral pronoun.) “That is, instead of playing a game in public, I’ll play at home. That way if I have an anxiety attack, well, I’m at home and a little more comfortable — less likely to feel socially anxious about it.”

Knowing what to label as a trigger can be difficult. It’s most commonly done for depictions of sexual assault, but every website or other organization decides for themselves what to label. Conversely, combat-related PTS triggers like the sound of helicopters, gunfire, or fireworks are in numerous games, but they’re rarely prefaced by warnings. “Under certain circumstances, the audio engine in Battlefield with a nice headset can get my blood pressure up a bit, but I enjoy it. It’s not something I ‘fear’.” Explains decorated Iraq veteran with PTSD Michael Stevens. “A game like DayZ or H1Z1 with an ability to create tense confrontations between players can have a similar effect, but I revel in that stuff. I think a lot of veterans do. As far as the mere discussion of video games acting as a ‘trigger’, no, that’s absurd.”

Speaking about military experiences and reintegration issues can, however, lead to a displaced feeling. Mike, a Canadian Forces veteran, needed to recenter himself after I interviewed him. This involved having a “quiet” moment and listening to a specific very loud song. He apologized if he “appeared rude” – he didn’t – but a short time later he was back to discussing the awesomeness of South Park: The Stick of Truth. People with PTSD who are receiving the proper treatment can manage their symptoms with a minimum of disruption.

Outlast Screen

I myself have been triggered by games, including the game Outlast. I love horror games, but I had to stop playing Outlast a few times because my heart was racing unpleasantly, my chest hurt, and I was having trouble breathing. These weren’t normal responses for me, but since I had to review the game and didn’t want to admit to the anxiety attacks, I pushed through by watching Let’s Plays before navigating through levels myself. In doing so, I discovered PewDiePie. YOLO!

I ended up quite enjoying Outlast. Trigger episodes do not mean that companies should stop making scary or intense video games. Should there be greater sensitivity in marketing these games, however? That’s a different question.

In a trade show setting, I thought Bethesda struck a good balance last year with their E3 demo stations for The Evil Within. The gameplay was extremely gory — full of body horror, dismembered limbs, screaming, jump scares, and even a guy ripping open his own scalp. But in order to get into the room with those demo stations you had to sit through a presentation about the game, and this presentation was full of clear content warnings. If you didn’t want to partake, you could skip it. I fell in love with the game – like I said, I love horror games — but other people passed. That’s the way things should work.

Some people, however, don’t believe in making any such allowances for sensitive souls. Some of that is just a lack of empathy, but not all of it. In researching this article, I came across four primary reasons that conscientious people opposed trigger warnings.

Gamephobias page

We already have the ESRB ratings

Anything can be a trigger:

“It’s true that anything can be a trigger.” Wythe says. “But there are also certain issues in our society and culture that might be experienced because they are prominent traumatic issues people experience in life. While certain triggers simply cannot be warned for, for example, colors, others might be more specifically experienced by a wide group of gamers. Perhaps those who experienced emotional/physical abuse, or served in combat.”

While these groups definitely make up a large number of people with PTSD, even people in these groups don’t necessarily have triggers that are that direct.

“I could work with adults who had experienced trauma such as my own, I could be around blood, I could be around crying children, none of that triggered me, but a simple pop song could turn me into a crying mess in a matter of seconds.” Recalls Stacey Washington. “I would have a full blown flashback attack. And there was no way to prepare for that…. So trigger warnings are great, if you know you’re talking to an audience of rape survivors about rape. But PTSD is so much more complicated than that.”

To address this, Wythe directed me to Gamephobias.com. a wiki style site that details various things people may want to avoid in the interactive entertainment they consume. It’s searchable by type of phobia – snakes, spiders, animal cruelty, body horror, etc – as well as by game, so players can make informed choices. This site wouldn’t help with songs, it does cover a lot of other bases. Like cat phobias. The internet must be a terrible place for people with a fear of cats.

ESRB Ratings

Because triggers are so varied and people’s responses are so different, it’s important to remember that trigger warnings are a courtesy and not a reason to crucify someone when they don’t include one. That being said, the reality that anything can be a trigger doesn’t totally refute the argument that it’s kind to consider common ones in cases of graphic descriptions or depictions.

The ESRB is a great system, but it was designed to determine age ratings for games more than to inform adult buying decisions. For instance, the “sexual violence” warning is used extremely rarely by the ESRB — it’s apparently only been put on two games. I think we can all agree that sexual violence has appeared in more than two games, so things are slipping through the net.

“The ESRB tells me about “intense violence,” but what does that mean?” Wythe asks. “Trigger warnings are more specific and detail what might be in a game. They don’t have to be in-your-face, just accessible for those who need it.”

Furthermore, ESRB content advisories highlight some harmful behaviors like alcohol use, drug use, and gambling, but not other things that studies have shown to have social contagion effects like suicide, eating disorders, and self-harm. Studies have indicated that prominent, specific, and dramatic reports or portrayals of suicide do have a link to copycat behavior while there is no causal link between violent media and violent actions. Despite this, suicide is bundled into the “graphic violence” ESRB category. Eating disorders and self-harm aren’t listed at all.

In one study over 56% of people with PTSD reported some type of suicidal thoughts or behaviours. So, we need to talk about suicide prevention. A person in a state of despair shouldn’t have to avoid M-rated video games altogether because games have insufficient content advisories.

victor zsasz arkham asylum

For another example, a person trying to stop self-cutting might not want to play Arkham Asylum because of Victor Zsasz, a character who carves a tally mark on his skin for each person he kills. The ESRB rating for that game includes cautions of blood, violence, torture, “provocative outfits” and “deep cleavage”, but no reference to a self-harming character. Breasts are apparently a worse example for kids than a dude who carves up his own skin.

It seems odd, in light of the available scientific documentation, to leave self-destructive behaviors with a proven influence out of game content advisories. Some claim that these acts should be left out of content advisories to avoid spoilers, but since ESRB descriptions already contain things like “a scene takes place in a strip club” or “the central character is depicted in bed with his girlfriend”, I’m not sure how “depiction of suicide” is any more of a plot spoiler. It doesn’t say who dies by suicide, or how relevant it is to the story. It just says it’s there.

Avoidance of triggers doesn’t help in the long run:

Avoidance behavior is a key symptom of PTSD, hence the belief that things like trigger warnings enable the disorder. However, that doesn’t mean it’s okay to deliberately antagonize someone by triggering them if you’re not a therapist. Ideally, people with PTSD face our traumas, but the timeline for that is different for everyone.

Skip Rizzo USC

Trauma therapy isn’t just about repeated exposure. It also carries with it a component of cognitive restructuring that takes time to develop. Sometimes you just need a break, because dealing with that stuff is tiring. Every person should be able to set their own boundaries so they can sample entertainment products like video games in a way they find, you know, entertaining?

A researcher like Dr. Skip Rizzo at USC is trained to induce anxiety in a therapeutic way. “We don’t have people run screaming from the room.” He says of his highly-successful VR exposure therapy. Rizzo’s work takes place in a contained, controlled, supervised, clinical environment. A less controlled environment like a launch event or press conference won’t necessarily feel safe enough for someone with PTSD to expose themselves to triggers in a manageable way. If PTSD was that easy to control, it wouldn’t be considered a disorder.

Some widely-distributed video game trailers use deliberately shocking imagery to grab attention. Gamers love visceral experiences, it’s true, but there should be more to a marketing campaign than shock tactics. Blood and screaming can indicate “this is a horror game”, but it doesn’t do anything to explain why that particular game is worth $70. Publishers may need to be more vigilant in cautioning viewers of livestreamed events that upcoming content may be disturbing, especially during omnibus press briefings at major trade shows like E3. Someone tuning in for news on Halo or LittleBigPlanet shouldn’t be forced to watch a graphic trailer for a survival horror game as well.

I want to be clear that being disturbed by something and being triggered aren’t the same thing, and you can’t spend your life hiding from potentially scary things. But no one should attempt to force someone with PTSD to do something “for their own good”, unless they’re a professional. As Stevens, who is personally against trigger warnings, puts it “Unless you have [PTSD], you don’t really ‘get it,’ and I get a kick out of couch commandos who try to tell veterans anything about how they should feel or what they should do when it comes to this subject.”

E3 staged event

Some people with PTSD find trigger warnings helpful. Some think they’re downright stupid. But no one should be forced to confront upsetting things before they’re ready because some “couch commando” has a different opinion.

The absurdity of modern trigger warnings actually increases stigma of PTSD. This complaint came up a lot in interviews with people with PTSD. Names have been removed from the following quotes in the interests of discretion.

“When we put a trigger warning on everything, people lose the meaning of trigger warning.”

“I actually had to look up what a Trigger Warning was.”

“I hate it when people use this for many many many years without taking the effort for any sort of therapy and learn to live with their past.”

“Taking every imaginable precaution to avoid being “triggered” isn’t living.”

“The media has made ‘triggering’ a complete joke at this point.”

“It becomes like the NSFW tag. It becomes overused. Everything is tagged… for the obvious stuff, we can really do without…. We don’t need to have ‘point away from face’ on a bazooka.”

“We need to learn how to handle ourselves instead of expecting the world to try and prevent uncomfortable situations from happening. It takes therapy, sometimes medication and time but if we’re constantly coddled we’ll never get past it.

It’s undeniable that trauma triggers sometimes get taken to an absurd extreme, like this wiki entry on trauma triggers that contains a trauma trigger. Many people with PTSD don’t want to be associated with what they consider silly extremes because stigma and negative stereotyping are major concerns. This is especially relevant for military personnel. Military ethics center around strength, bravery, and not letting people down. You don’t walk to the medic. You’re carried there. People with this sort of ethical code don’t want to associate with anything resembling coddling.

ESRB M Rating

I think gamers share an element of this “tough” identity. We’re all about “git gud”. So we can’t dismiss the concern that the extreme fringe of trigger warning usage has the potential to increase stigma and therefore discourage some people from getting help.

For what it’s worth, I think we could quiet down the trigger warning debate through an evolution of the ESRB based on sound scientific consensus to help inform all gamers, not just parents. Regarding articles or discussions of games, I think every website still needs to decide for itself what it’s comfortable doing regarding content warnings, since attitudes are so divided. Websites like gamephobias.com will, of course, continue to serve gamers who need information beyond the scope of the ESRB.

So there’s a brief look at the trigger warning debate in gaming, and I admit that I’m glad to have that part of the PTSD and gaming discussion out of the way. In the next part of this series, we’ll look at more fun stuff: some games that already deal with PTSD… some without even intending to! Plus, a more in-depth look at the USC Virtual Reality Prolonged Exposure Therapy program!

Part 3 on the art and science of PTSD an video game technology will appear next Wednesday.

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