Crisis & safety Severe DID without specialized training Severe conduct disorder (without parent component) Severe dissociation (stabilize first) Severe mental illness Severe untreated dissociation Medical instability Needs immediate stabilization Ongoing abuse (safety first) Ongoing domestic violence Active family violence Active risk requiring intervention Active substance use (treat first) Active unaddressed infidelity Acute crisis needing stabilization Acute individual crisis needing stabilization Acute safety crisis Acute suicidality (stabilize first) Frequent crisis Active psychosis Acute psychosis Acute suicidality Active suicidality Suicidal behavior Acute crisis
Clinical Severe cognitive impairment Severe cognitive impairment (adapt or refer) Severe cognitive limitations Significant dementia (use sensory reminiscence instead) Cognitive decline / dementia adjustment
Symptom Severe personality pathology Stress Low distress phase Mild-to-moderate issues Personality disorder Primary cognitive disorder Chronic dysregulation PTSD OCD Specific phobia Contamination fear Checking Intrusive thoughts Rumination Anxious rumination Performance anxiety Recurrent depression Chronic low-grade depression Acute severe depression Depressive relapse risk Bipolar depression Bulimia Eating disorders Emotional dysregulation Chronic emptiness Phobia Exposure-responsive anxiety Health anxiety Borderline features OCD patterns Perfectionism Social anxiety Depression Self-harm
Couples & family Severe unprocessed caregiver trauma (caregiver needs own therapy) Unwilling system Caregiver involved Caregiver unable/unwilling to participate (address first) Couples conflict Family conflict Relationship conflict Relationship chaos Parenting conflict Blended family stress
Trauma Severe unprocessed trauma (needs trauma-focused work) Severe unprocessed trauma (without modification) Trauma Unprocessed trauma without containment Neglect background Developmental trauma Stuck trauma memories Freeze/dissociation Startle/bracing Body-held stress Somatization Unprocessed trauma needing a different protocol Trauma-based inner critic Religious trauma / spiritual abuse Acute dissociation Single-incident trauma Complex trauma
Motivation & stage Skill deficit not ambivalence Unwillingness to practice Unwillingness to tolerate discomfort Pushed too hard in past therapy Resistance to looking back (consider present-focused work) Ambivalent about change Pre-contemplation Motivation is the bottleneck Mandated or reluctant Resists directive approaches Resists behavioral structure Refuses emotional frame Demoralized by therapy Already motivated
Treatment response Symptom relief didn't address the why Cbt-resistant
Need & frame Time-limited Circumscribed skills-responsive distress Client seeks symptom-focused protocol (consider CBT) Experiences interpretation as invasive Experiences non-directive as withholding Finds parts metaphor alienating Health behavior change Invisible strengths Needs concrete symptom management Needs hope and agency Needs relational space Non-relational work Parts language resonates Primary need is concrete skills (add CBT/DBT modules) Primary need is concrete symptom management Primary need is insight Resource-starved Acute symptom management Needs concrete skills first Needs coping skills first Needs behavioral activation first Needs to feel understood first Needs trust before technique Needs relational depth over processing Clear goals Existing strengths Time-limited context
Existential Unfinished business Freedom and responsibility Life transition Meaning-making Philosophical distress Role change Role strain Mortality concerns Life transitions Grief Meaning concerns
Self & shame Compassion feels destabilizing Exhausted by control strategies Internal conflict Self-criticism Chronic self-criticism High shame Shame narratives Shame-driven avoidance Fear of self-compassion Conditional worth Problem-saturated identity
Relational Conditional love history Disengagement Entrenched patterns Interpersonal deficits Lifelong relational patterns Rigid contact styles Attachment-driven individual patterns Repetitive relational patterns Repeating relational loops Pursue-withdraw Attachment wounds Attachment insecurity Isolation Enmeshment Relational rupture patterns
Structure High structure need (child/parents) Needs structure before processing High structure need Low structure tolerance
Defense Highly defended Defense-driven Splitting
Identity & power Identity concerns Identity exploration Identity diffusion IPV survivor Reproductive concerns People-pleasing / self-silencing Postpartum Body image / body shame Motherhood / mothering Fatherhood / fathering Men Men's shame Provider pressure Chronic pain Disabled Marginalized identity Chronic illness Gender-based oppression Caretaking overload Boundary difficulty Women Self-blame
Cognitive style Rigid rule-following All-or-nothing patterns Insight without change Insight without felt change Knows but doesn't feel Cut off from feelings Highly intellectualizing Catastrophic thinking Abstract thinker Rigid thinking
Developmental Adolescent (developmentally past play) Child/adolescent presenting Children and adolescents Late life / aging Children / early childhood
Emotional processing Body alienation not yet addressed Can't tolerate affect Severe alexithymia Bodily disconnection Emotionally flat Alexithymic Somatic complaints Emotionally reactive
Substance & addiction Active substance use Addictions
Culture Cultural narratives Intergenerational conflict Cultural identity salient Racial trauma Immigrant Acculturation stress
Relationship Intimacy avoidance
Gender Masculinity norms Restrictive emotionality Gender dysphoria Trans clients Gender questioning Nonbinary
Sexuality Sexual performance / inadequacy Sexual shame Queer clients Sexual minority Coming out Non-traditional relationship
Neurodivergence Masking burnout Neurodivergent Sensory sensitivities PDA profile ADHD Autistic
Coping Value drift Chronic avoidance Rigid coping Substance use
Attachment Disorganized attachment Anxious attachment Avoidant attachment
Insight Low insight capacity High insight capacity
