In life and counseling, finding the starting point can be difficult. Life is fluid enough that identifying where to begin with a life-dominating or complex struggle can feel like finding the beginning of a circle. In order to help you with this very important question, a five-level triage progression is outlined below.
As you consider these levels, keep in mind that a struggle in one of the higher categories may have many expressions or contributing causes in the lower categories. For example, someone who is suicidal (a level one safety concern) may need to learn how to manage her finances better (a level five skill concern), because pending bankruptcy fuels a sense of hopelessness.
However, unless the upper level concerns are addressed first, efforts at change have a low probability of lasting success. The individual above needs to be stabilized before she would be able to implement a budget or debt-reduction plan. Similarly, a person with a substance abuse problem (a level two addiction concern) may have anger management issues (a level four character concern), but until the abuse of a mind altering substance is removed attempts at learning emotional regulation and how to honor others in times of disappointment will be short-lived.
This is why the higher concerns are recommended to be addressed first and significant progress should be made in those areas before beginning to focus on the lower level concerns.
There is one final point before we examine these five levels of triage. In the higher categories denial is likely to be a stronger complicating factor. For example: abusers (level one), addicts (level two), and those who have been traumatized (level three) are very prone to deny or minimize the impact of their struggle. The benefit of this tool is that it provides a reasonable system to appeal to in order help these individuals see why it is not sufficient to just “be nicer” (level four) and learn to “do better” (level five).
When the basic requirements of safety are not present, then safety takes priority over any other concern. Safety is never an “unfair expectation” from a relationship. If safety is a concern, then you should immediately involve other people (e.g., pastor, counselor, or legal authorities).
This category includes: thoughts of suicide, violence, threats of violence (to people or pets), preventing someone from moving freely in their home, destruction of property, manipulation, coercion, and similar practices.
2. Substance Abuse / Addiction
After safety, the use of mind or mood altering substances is the next level of priority concern. Substance abuse makes an individual’s life situation worse and inhibits any maturation process. The consistency and stability required for lasting change are disrupted by substance abuse.
This category includes: alcohol, illegal drugs, prescription drugs not used according to instructions, inhalants, driving any vehicle with any impairment, and similar activities.
Past or present events resulting in nightmares, sleeplessness, flashbacks, a sense of helplessness, restricted emotional expression, difficulty concentrating, high levels of anxiety, intense feelings of shame, or a strong desire to isolate should be dealt with before trying to refine matters of character or skill. Trauma is a form of suffering that negatively shapes someone’s sense of identity and causes them to begin to expect or brace against the worst constantly.
This category includes: any physical or sexual abuse, significant verbal or emotional abuse, exposure to an act of violence, experience of a disaster, a major loss, or similar experience.
This refers to persistent dispositions that express themselves in a variety of ways in a variety of settings. Because both the “trigger” and manifestation change regularly and hide when convenient, it is clear that the struggle lies within the core values, beliefs, and priorities of the individual. Skill training alone will not change character.
This category includes: anger, bitterness, fear, greed, jealousy, obsessions, hoarding, envy, laziness, selfishness, pornography, codependency, depression, social anxiety, insecurity, and similar dispositions.
With skill level changes there usually will be a high degree of self-awareness that change is needed in the moment when it is. However, confusion or uncertainty prevents an individual from being able to respond in a manner that it is wise and appropriate.
This category includes: conflict resolution, time management, budgeting, planning, and similar skills.
Hopefully, after reading these five points, you will have less of a “jump in anywhere and try anything” mentality towards your struggles or the struggles of your friends. Change is hard, but knowing where to starts helps to establish confidence. Remember, you are not alone. Christ will meet you and the church will walk with you at any of these five points.
Join the Conversation
Have you used a “triage” process for dealing with complicated cases in your counseling? What did you do?