Counseling Triage: Where to Begin with Complex Struggles

March 21, 2016

Brad Hambrick

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Brad Hambrick

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).

1. Safety

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.

3. Trauma

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.

4. Character

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.

5. Skill

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?

Brad Hambrick

About Brad Hambrick

Brad is Pastor of Counseling at The Summit Church in Durham, NC. He also serves as an adjunct professor of biblical counseling at Southeastern Baptist Theological Seminary. Brad has been married to his wife, Sallie, since 1999.

6 thoughts on “Counseling Triage: Where to Begin with Complex Struggles

  1. Where is sin, sinner, Jesus, grace, gospel, God, Holy Spirit, faith, repentance, justification, holiness/sanctification, loving God and neighbor, and the glory of God in all of this? Should we just ignore doctrine and its practical application concerning who we are as sinners and who God is as the only
    holy, just, and righteous God? Should we “follow” your advice or levels of “triage” instead of
    pointing people to Jesus as our only hope, help, and perfect, righteous sacrifice?

  2. I agree with you Harold. The author of this post says, “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.” What is “hopefully”, supposed to mean? No need for grace and no need for Jesus, but just try harder while relying on the advice of a mere man? While justification is monergistic, sanctification is synergistic so it is not devoid of the Holy Spirit. If someone truly possesses faith in Christ, they will change no matter if the change is minuscule at first. However, tips and tricks of the trade from the “experts” do not cleanse and forgive us of our sins and enable us to return to the worship of a Holy God in new obedience. This only occurs by one who abides in Christ by obedience to His commands (i.e. not adherence to the “five points of man”) through the grace and power of the Holy Spirit.

  3. Instead of deleting and ignoring guest comments, can you answer on the following?

    Where is sin, sinner, Jesus, grace, gospel, God, Holy Spirit, faith, repentance,
    justification, holiness/sanctification, loving God and neighbor, and the glory
    of God in all of this? Should we just ignore doctrine and its practical
    application concerning who we are as sinners and who God is as the only holy,
    just, and righteous God? Should we “follow” your advice or levels of
    “triage” instead of pointing people to Jesus as our only hope, help,
    and perfect, righteous sacrifice?

  4. The author of this post says, “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.” What is
    “hopefully”, supposed to mean? No need for grace and no need
    for Jesus, but just try harder while relying on the advice of a mere man?
    While justification is monergistic, sanctification is synergistic so it is not
    devoid of the Holy Spirit. If someone truly possesses faith in Christ,
    they will change no matter if the change is minuscule at first. However,
    tips and tricks of the trade from the “experts” do not cleanse
    and forgive us of our sins and enable us to return to the worship of a Holy God
    in new obedience. This only occurs by one who abides in Christ by
    obedience to His commands (i.e. not adherence to the “five points of
    man”) through the grace and power of the Holy Spirit.

  5. Meeting people in their pain/understanding their context & helping THEM understand their context can be incredibly helpful IN ORDER to more effectively, point them to Jesus. Doctrine absolutely matters, yes. Everything you mentioned (sin, grace, sanctification, etc.) speaks into EVERYBODY’S situation, no matter what it is and should be applied, I 100% agree! But in walking alongside people in their pain, there is an appropriate time and place to help them apply these doctrines. I don’t know that you start there. You want to get there and finish there, for sure- the end goal is that they would know God and worship Him more. All of life is about that- glorifying Him. But the process is much more complex than you make it to be. It takes time and wisdom. Misapplying doctrine in ministering to someone in pain can be very harmful…

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