Do We Need "Trigger Warnings" for Depictions of Drug Use?

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May 31 2016

Do We Need “Trigger Warnings” for Depictions of Drug Use?

June 1st, 2016

Atop many of my articles and columns, you will see images of needles—many, many images of needles, either in containers, loose or, perhaps worst of all, puncturing someone’s vein. I don’t choose these photos. Like headlines, they are usually created by someone other than the writer and often, I don’t see them until my work has been published.

But while there has been much discussion about “trigger warnings” for pictures and other media that could upset trauma survivors, far less coverage has been given to the abundance of potential media triggers that may harm people with addiction, who often, of course, have also experienced a great deal of trauma. Far too frequently, these images appear alongside the very stories people with addiction are most likely to want to read.

This presents a thorny issue to readers and editors: Should these images be avoided entirely or should “trigger warnings” be presented before they appear?

In general, I’m of two minds on trigger warnings. While it is clear that people should not be exposed to graphically violent, gory, disgusting and sexually explicit media without advance notice, it’s also true that avoiding trauma triggers can make them more powerful, rather than less—and this can exacerbate post-traumatic stress disorder (PTSD), instead of helping. The same is true for relapse cues in addiction.

And, in both cases, even if everyone provided warnings on obvious potential triggers, for most people, what sets them off can be highly individual and unpredictable, even to themselves. Pictures of spoons, for example, in the case of IV drug use. Or baking soda, for freebasers. With trauma, triggers are often extremely specific: the smell of the aftershave a rapist wore, or the slant of light at the time of year when an assault occurred.

Moreover, many folks find being treated as though they will respond without thought, like Pavlov’s dogs to the bell that signals a juicy steak, to be insulting and disempowering, rather than respectful. And treating drug images as though they are pornographic can actually increase stigma, by linking them with the illicit and forbidden.

So, what should be done?

I don’t advocate enforced censorship, but I certainly think it’s fair and easy for media outlets to voluntarily warn people about obviously extreme material, particularly in audiovisual form that tends to capture attention and cannot be quickly escaped; the issue is far less clear with written media, where you can simply close the book or navigate away before there’s much exposure.

For each of us, the question of when we should choose to avoid such material and when we should try to face it needs to be answered carefully, on a highly individualized basis.

But I think there are a few general conclusions that can be made and are worth considering.

For one, the media has nothing to lose from cutting back on its use of needle imagery, particularly close-ups of people injecting. It’s undoubtedly true that if you have been addicted to IV drugs, in early recovery these images are hard to take and can induce craving. And the same is true for realistic images of drugs (though the ones that use obviously fake powders or ridiculously large needles may be more likely to make addicted people laugh than crave.) Pictures of drinking, smoking and gambling-associated images should also be used with care—again, not censored, but used thoughtfully and with the recognition that at least one in 10 viewers has some personal experience of addiction.

Craving can truly be an overwhelming experience, which is hard to describe to those who haven’t been addicted. But basically, it’s quite similar to randomly hearing a song that reminds you of someone you are desperately trying to forget, or being offered your favorite dessert when you are seriously hungry and attempting to diet. It’s visceral, and creates strong emotion that has the potential to seriously interfere with rational thought.

There are good biological reasons for this: Anything the brain perceives as a threat to survival or to a critical opportunity for feeding or reproduction is probably too important to be left to the slow, deliberate pathways that encode rationality.

Indeed, if our ancestors spent too much time deliberating about whether to fight or flee a bear, or whether or not to eat a peach, or try to engage in a relationship with a willing and desirable partner, chances are, they wouldn’t have become our ancestors.

At the same time, however, we are not simply the routines that have been wired into our habitual brains, no matter how urgent the desires they create may feel. As psychologist and Holocaust survivor Victor Frankl notably put it, “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Much of recovery, in fact, is reclaiming this space from the habitual and unconscious patterns of behavior that we learned and ingrained during addiction. However, here, there’s a real difference between people who are newly recovering—certainly, in their first few months or years—and those who have much more distance from problematic use. Experience matters.

In my own case, I remember being worried about how I would respond to covering needle exchange as a journalist, which I did when I had just a year or two of abstinence from IV heroin and cocaine. Many people would—and did—tell me to steer clear of such direct contact with both active IV drug users and needle availability.

But I knew it was important to tell the story of needle exchange, which, back in the early ’90s was still illegal—and that my own personal experience made me uniquely suited to do so in a way that would reach people and hopefully, debunk myths and help stop the spread of AIDS.  I also knew that many people who did needle exchange were in recovery themselves—and this helped them reach participants.

And so, I did it—being careful to ensure that I had social support and that I made clear to everyone involved that I was in recovery, which would have made it at the very least extremely embarrassing if I had behaved otherwise. It was important to me to know that I wasn’t just a slave to my urges, that I could, for an important cause, overcome them.

And what I found was that—just as research on trauma shows —with exposure, over time, my emotional responses to needles dramatically diminished. At first, I’d react with anxiety and stress and even a taste of withdrawal symptoms; these responses are unconsciously physiologically conditioned to cues, which is part of why they can be so powerful.

But over time, seeing needles became a perfectly ordinary experience. By the time I later had to inject myself as part of medical treatment, I had no problem with it.

Read more from The Influence:

Why the “Disease Model” Fails to Convince Americans That Addiction Is a Health Issue

The Anatomy of a Heroin Relapse

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In fact, one of the most effective treatments for PTSD is exposure therapy—gradually increasing exposure to trauma triggers in a safe environment until the emotional response is desensitized. That’s because the more these experiences are avoided, the more powerful the response becomes when they can’t be—and the more likely avoidance is to spread, making it difficult to live a full life. (Unfortunately, however, many PTSD sufferers are not able to endure the anxiety this treatment provokes.)

With addiction, this kind of exposure to cues can bring other dangers—most obviously, of relapse. However, learning to deal with these cues is essential to recovery: Until you can manage to react to things that make you want to get high without responding by relapsing, your recovery won’t be secure. This is part of why long-term inpatient treatment often isn’t the best approach: The artificial environment doesn’t prepare you to respond in the real world, which you will have to do eventually.

The key here is common sense—and moving slowly from dealing with mild cues in low doses to being able to manage intense cues in difficult situations. Challenging yourself for the sake of doing so is likely to set you up to slip. But moving out into the world in a way that allows you to create that space between stimulus and response is actually the path to freedom.

Ideally, the media would reduce its use of injection imagery. For one thing, it’s by now an overwhelming cliché. Secondly, it tends to dehumanize people with addiction, reducing us to bloody arms and faceless shame. But since this is unlikely to happen on a large scale any time soon, the best response for those of us affected may be to use them as an opportunity to start desensitization by exposure.


Maia Szalavitz is a columnist for The Influence. She has written for TimeThe New York TimesScientific American Mind, the Washington Post and many other publications. She has also authored six books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). Her latest book is Unbroken Brain: a Revolutionary New Way of Understanding Addiction. Her last column for The Influence was “The Rehab Industry Needs to Clean Up Its Act. Here’s How.” You can follow her on Twitter: @maiasz.

  • I saw an ad for cereal this morning. Unfair! Usually I can go til noon without thinking about food. This triggered my cravings for breakfast. Yet I didn’t think about shooting up. Why? Because cereal is legal and I can go to the store and buy it any time. As in literally 24 hours a day. Oxy? Not so much.

    “With addiction, this kind of exposure to cues can bring other dangers—most obviously, of relapse.” Sorry to see you are still peddling this crap. As in, it literally hurts my heart. But hey that’s probably one of those defects and disorders that served an evolutionary purpose so I’ll just suck it up.

  • Kenneth Anderson

    There have been a number of studies of cue exposure therapy for addiction such as “Cue Exposure Therapy for the Treatment of Opiate Addiction: Results of a Randomized Controlled Clinical Trial;” however, they have not generally been helpful and there is some evidence they may increase relapse compared to treatment as usual. My own take is that people may need a year of recovery before cue exposure starts being beneficial–but it seems no one has tested this experimentally–all the tests seem to be on people currently in treatment.