Chapter Eleven – Trigger Identification and Intervention

Many of the difficulties that trauma-exposed adolescents experience arise when stimuli or situations in their immediate environment trigger upsetting memories, with their associated thoughts and emotions.

Once these memories are triggered, the adolescent may experience a cascade of thoughts involving, for example, helplessness, imminent danger, betrayal, abandonment, or need for retribution. Along with these may be emotions the adolescent experienced at the time of the trauma, such as fear, anger, shame, or sadness. The end effect of these processes may be an episode of “acting out” or tension reduction as a way for the youth to reduce internal awareness of these experiences. For example, a young man is insulted by a peer, which triggers (often implicit) memories of parental maltreatment and extreme, unfair criticism, which, in turn, activates feelings of low self-esteem and thoughts about “getting even.” These thoughts and memories may then activate anger and motivate an action (e.g., aggression) that is out of proportion to the actual insult by the peer. He has been triggered and now is involved in an act that is more relevant to his childhood than his current situation. Examples of other triggers and responses are (1) the break-up of a dating relationship triggering early memories of abandonment with associated desperation and emptiness, leading to a suicide attempt; (2) a consensual sexual activity triggering flashbacks of childhood sexual abuse, resulting in intense fear or disgust, or (3) criticism at work by an employer triggering physical and psychological abuse memories, resulting in the youth throwing something and quitting his or her job.

This tendency for current events to trigger extreme emotions and behaviors related to childhood maltreatment is a serious problem for some adolescents. The suggested clinical approach to this issue could have appeared under previous chapters on affect regulation training, cognitive interventions, or therapeutic mindfulness, but is outlined separately here because of its importance.

Trigger awareness and intervention can help the survivor maintain internal equilibrium in his or her daily life by teaching him or her how to identify and address triggers in the environment that activate posttraumatic reliving. Successful trigger identification during ITCT-A can facilitate a greater sense of control and better interpersonal functioning by helping the adolescent to avoid or alter situations in which triggering might be likely, or, in the event triggering has occurred, to change his or her experience of – and response to- the associated internal cascade of negative thoughts and/or feelings. The adolescent is supported in learning to (a) identify instances when he or she is being triggered, (b) reframe triggered reactions as archaic, as opposed to contemporary (i.e., “real” versus “not real”), and then (c) respond to these archaic/”unreal” experiences as, in fact, internal events rather than accurate perceptions of the external world. In this way, trigger identification and intervention works in a similar manner as the metacognitive awareness aspect of mindfulness training described earlier: triggered reactions are recontextualized as merely thoughts or feelings, associated with prior events, which may have no actual relevance to the current situation.

Trigger identification and intervention training usually occur during the therapy session, and are then called upon later when the survivor encounters triggers in his or her environment. In other words, it is often difficult to figure out exactly what to do when one has been triggered; it is better to have previously identified the trigger, its meaning, and its solutions in the context of therapeutic guidance and support, and then call upon that information as needed.

In session, the client and therapist work through the Trigger Grid, presented in the Appendix as “What triggers me”. Some clients may easily identify their primary triggers, whereas others may require considerable time before they are able to do so. Typically, the Trigger Grid is revisited at multiple points in treatment, as the youth becomes aware of additional triggers as therapy proceeds.

The goal is for the client to:

learn about triggers, including their historic nature
identify specific instances during which he or she has been triggered,
determine, based on these times,
(a) what seem to be the major triggers in his or her life and
(b) how to identify when he or she is being triggered,
detect the “unreal,” non-here-and-now nature of triggered thoughts and feelings, i.e., that they are more relevant to the past than the present, and
problem-solve strategies that might be effective once triggering has occurred.

In response to the trigger grid, adolescents typically identify a number of trauma-related triggers, including, for example,

interpersonal conflict
sexual situations or stimuli
angry people
intoxicated people
perceived narcissism
seemingly arbitrary criticism or accusations
rejection
perceived abandonment
feeling ignored or dismissed
interactions with an authority figure
people with physical or psychological characteristics that are in some way similar to the client’s past perpetrator(s)
boundary violations
sirens
footsteps
unwanted physical touch
gunshots
the sound of crying

One of the more challenging parts of the trigger grid for the adolescent trauma survivor is the question, “How I Know I’ve Been Triggered?” Some answers are relatively easy; for example, it may not be difficult to recognize an intrusive sensory flashback of a gunshot as posttraumatic. In others, however, the reexperiencing may be more subtle, such as feelings of anger or fear, or intrusive feelings of helplessness that emerge “out of nowhere” during an interpersonal interaction. Among the qualities of triggered as opposed to contemporary (“real”) responses are:

A thought/feeling/sensation that doesn’t fully “make sense” in terms of what is happening around the survivor
Thoughts or feelings that are too intense, based on the current context
Thoughts or feelings carry with them memories of a past trauma
An unexpected alteration in awareness (e.g., depersonalization or derealization) as these thoughts/feelings/sensations occur
A situation in which the adolescent often gets triggered

The section on “What Happened After I Got Triggered?” provides an opportunity for the client to explore the thoughts, feelings, and behaviors associated with each major trigger, so that triggering becomes more obvious to him or her, and his or her responses to the trigger are better understood as reactions to the past, not the present. This exercise may help the client to discriminate triggered states from “real” (i.e., here-and-now) ones, and thus have less reactivity to them.

The final question on the grid is “What I Could Do After I Get Triggered That Would Make It Better and I Wouldn’t Get So Upset or Mad” answered for each of the major triggers that the client has identified earlier. Among possible answers to this section are

changing the scenario or using “time-outs” during especially stressful moments (e.g., leaving a party when others become intoxicated; intentionally minimizing arguments with authority figures; learning how to discourage unwanted flirtatious behavior from others)
analyzing the triggering stimulus or situation until a greater understanding changes one’s perception and thus terminates the trigger (e.g., carefully examining the behavior of an individual who is triggering posttraumatic fear, and eventually becoming more aware of the fact that he/she is not acting in a threatening manner; or coming to understand that a given individual’s seemingly dismissive style does not indicate a desire to reject or ignore as much as it does interpersonal awkwardness)
increasing support systems (e.g., bringing a friend to a party where one might feel threatened, or calling a friend or AA sponsor to “debrief” an upsetting situation)
positive self-talk (e.g., working out beforehand what to say to oneself when triggered, such as “I am safe,” “I don’t have to do anything I don’t want to do,” or “this is just my past talking, this isn’t really what I think it is”)
relaxation induction or breath control, as described in Chapter 7
engaging in physical activity, such as doing exercises, dancing, or yoga
strategic distraction, such as starting a conversation with a safe person, reading a book, or going for a walk, as a way to pulling attention away from escalating internal responses such as panic, flashbacks, or catastrophizing cognitions.

As the adolescent becomes more conversant with triggers and their associated feelings and behaviors, triggered states can be more recognizable as such – as replayed “movies” or ancient computer programs rather than perceptions of the contemporary/”real” world. This increased distance from the triggered experience often serves to reduce the power of the feeling and lessen the likelihood that problematic behaviors will emerge. Further, by working out strategies beforehand, the triggered survivor less often has to figure out what to do – instead he or she can call on the fruits of previous problem-solving and, to the extent it is possible in any given triggering circumstance, respond in a more effective and self-protective manner.