This post is an expansion of an original post by the same title.
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.
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 (level one – safety concern) may need to learn to manage their finances better (level five – skill concern) because pending bankruptcy fuels their 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 they would be able to implement a budget or debt-reduction plan. Similarly, a person with a substance abuse problem (level two – addiction concern) may have anger management issues (level four – character concern), but until the abuse of a mind-mood 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 to be made in those areas before beginning to focus on the lower level concerns.
One final point before we examine 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 to 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 necessary authorities or advisors (i.e., pastor, counselor, parents of a minor, 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.
Until safety is no longer in doubt other concerns should only be as a way of understanding how to create a safe disposition or environment for the individual.
Sample Dialogue: “I hear you talking about how hard it is for you to live realizing how much pain you’ve caused your family. It makes sense why that is so overwhelming and I think it is important for us to discuss how to process the shame and despair you feel. But I want to make sure our conversation does not add to your sense that life is not worth living. Can we take a break from talking about what has happened and what you fear having to do about it in order to remember / talk about why suicide is not an answer?”
Sample Dialogue: “I can tell you’re very upset about the ways you believe your wife disrespects you, but in describing that, you’ve mentioned several things that are concerning: striking her face when she “back-talked,” not allowing a conversation to end when she asked for a break after an hour of escalating argument, and punishing her by not allowing her to have access to transportation or talking to her parents. These behaviors are abusive. They raise concerns of safety which supersede concerns of disrespect. The way you describe her offensive actions as ‘causing’ (and by implication ‘excusing’) your dangerous actions, indicates that your personal lack of self-control is a greater concern than the relational differences that exist in your marriage.”
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 for any distance, and similar activities.
Sample Dialogue: “It is good that you want to learn how to manage conflict better with your spouse, but when you’ve described your arguments they are usually in the evening when you’ve been drinking. It seems you ‘have a drink’ more nights than you do not and this leads to much of the conflict with your spouse. Several times you’ve blamed what you’ve said as being excessive because you ‘had too much to drink that night.’ It is doubtful that you will practice the self-control necessary to engage conflict well as long as you abuse alcohol in the way you do. For this reason, if you are serious about your desire to manage conflict better, then you will need to address your substance abuse problem.”
Sample Dialogue: “I admire the courage you show in wanting to learn how to handle the emotions associated with losing your child in a traffic accident. The fear, anxiety, anger, and confusion you describe are very understandable. But it concerns me how much you are using alcohol to cope with this experience. One of the effects of escaping emotions through alcohol is that it stunts our ability to mature though those experiences. An important part of processing this experience healthily will be to forego the escapist coping mechanism of alcohol.”
Past or present events resulting in nightmares, sleeplessness, flashbacks, 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 constantly expect or brace against the worst.
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.
Sample Dialogue: “I hear what you’re describing about the changes in your marriage and job satisfaction over the last year. But I cannot help but notice how that correlates with when you lost your father, whom you mentioned being very close to. You also mentioned how busy the time around his death was because you were responsible to administrate his will. It seems you may have started ‘being strong because you had to’ (which meant ignoring / turning off your emotions) and now you’re struggling to feel anything for your spouse or job. I think it would be unwise to make any decisions in those areas until you allowed yourself to grieve the loss of your father.”
Sample Dialogue: “I admire your desire to become ‘a more positive person’ and willingness to acknowledge how your pessimism may be impacting the sense of security in your children. But what you’re calling ‘being negative’ or ‘anxiety’ seems to be hypervigilance – a natural response to a trauma like what happened when you lost everything in the house fire last year. I believe the most effective way to shape your character in the way you desire is to understand the impact of the trauma you and your children went through, so that you do not try to ‘just be stronger’ in a way that makes your normal response to a tragedy seem like a moral defect in your 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. If character concerns exist, then teaching skills without addressing the core values of an individual tends to result in change that only lasts as long as the consequences of misbehaving are greater than the probability of misbehaving being seen.
This category includes: anger, bitterness, fear, greed, jealousy, obsessions, hoarding, envy, laziness, selfishness, pornography, codependency, depression, social anxiety, insecurity, and similar dispositions.
Sample Dialogue: “It’s great that you recognize how over-committed you are and how that leads to a great deal of personal stress and sometimes even lying to your friends about what you haven’t done. But learning how to be more efficient with your time is only going to help if you are willing to tell people ‘no.’ I get the sense that you want to become so efficient that you never have to tell anyone ‘no.’ If that’s the case, then I wouldn’t be helping you by teaching you how I approach projects. I think it would be better for us to discuss how I handle the idea of disappointing people.”
Sample Dialogue: “It takes a great deal of courage to admit you need to become a less controlling person. But the kinds of questions you’re asking center on the ‘rules of relationship – what you can and cannot expect from others without being considered controlling.’ If we engage that conversation, I’ll just be helping you become a controlling-person-no-one-is-allowed-to-be-upset-with. It seems to me you are depending too much on those you consider a ‘best friend’ for your sense of security. As long as that is the case, even reasonable expectations will carry too much weight for you and friendship will be strained by your response to the normal short-comings of imperfect people.”
With skill level changes there will usually be a high degree of self-awareness that change is needed in the moment when change is needed. 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.
Sample Dialogue: “I hear your concern that, as a parent, your anxiety may be negatively affecting your children. But you’ve described how your children feel safe bringing their fears to you without feeling like burden to you. You seem to be able to enjoy times of playing with your children and allowing your children to take appropriate risks in their play. For these reasons and until these things change, I think it is sufficient for us to help you identify outlets to discuss and address your anxieties so that you are not ruminating on them.”
Sample Dialogue: “I can understand why you are upset with yourself for frequently being late and upsetting your friends. It’s good that you’re willing to address this pattern, but I’m not sure it means you’re an abusive person or chronic liar. It seems that you’re an extrovert who gets so lost in one moment you lose any sense of what’s next. If this is accurate, then we can begin by learning some scheduling or time management techniques. If this resolves the problem, then this is just a strength-weakness of your personality of which you need to be aware and manage well.”
 The “sample dialogues” for this section will have a different tone because they assume the individual is trying to address the problem as a higher level concern instead of minimizing the problem. Use these dialogues as a sample of how you would speak if a friend was trying to exaggerate one of the mid-level concerns in this triage model.