As school counsellors, many of us know the challenges of working with undiagnosed students or students awaiting a diagnosis for various challenges. We may also have experienced the frustrations of working with undiagnosed students facing mood or personality related challenges, as these diagnoses tend to not happen during school years despite the presence of symptoms for assorted reasons and circumstances.
In this four-part series, I aim to explore a need-based approach for offering care to students experiencing mood or personality challenges while they are on the waiting list.
Introduction
As school counsellors, we work in what I sometimes call a distinct clinical space. By working in a school setting, we experience different clinical realities than we would if we were somewhere else – which in turn often require a distinct approach. One of these realities is working with undiagnosed students, who are often on waitlists to be diagnosed but still need support at school. The challenge with these students is it can throw us off our typical training, where we assess, treat, and monitor outcomes. If we do not have access to a psychologist for clinical assessment, sure we do the best we can to assess the problem, but we can easily be thrown off. In this article, I hope to share my own reflections and growth around navigating this challenge of working with students who are undiagnosed and are often on long waitlists. As the first part in our four-part series, I want to focus on the shift in approach which may help us as school counsellors from focusing on assessment to focusing on the student’s needs. Once this groundwork is present, we can concentrate on the needs of undiagnosed students presenting mood and personality challenges moving forward.
Beyond the Diagnosis
With students on waitlists and still requiring support from school counselling departments, it is easy to get discouraged. As school counsellors we work with and intervene with these students who have changes in mood, struggle with maintaining stable relationships, avoid stress and perceived stress like the plague, and other behaviors or challenges that can affect their success at school. Numerous times I have seen myself or colleagues get stuck when we are working with a student who is starting to have complex problems and behaviors at school. We try to identify the problem, but it is not easy, se we refer to a psychology service for diagnosis so that they can tell us what the problem is so we can address it at school. So, our student gets on a waitlist, and we hope things happen fast so we can figure out how to support this student. The issue is waitlists for psychological diagnosis are becoming less and less fast – especially in rural areas such as where I currently work. In short, this older model of doing things is starting to be less effective for educational settings as far as I see it. This means that one way or another, we need to find a different approach in these cases so that we do not feel stuck waiting while our students still require support at school. We need to find a way to offer proper support without a clinical diagnosis – something that we are not always trained to do.
What has helped me is looking at ways to change my approach with students on waitlists. If not having a diagnosis is the problem, then developing an approach and skills which move beyond diagnosis is relevant. In my own wrestling with this challenge and research, I noticed two things which helped me to make the needed shift.
- Remembering that a diagnosis is a tool not a cure. At the end of the day, having a clinical diagnosis does not automatically fix anything in a school context, and relying on it has its limitations. For example, Irvin D. Yalom calls us to avoid diagnosis, as it can sometimes be counterproductive to what we are trying to achieve in counselling (Yalom, 2017). What supports students is not necessarily diagnosis, but the care and support we provide. Thus, we do not need the diagnosis right aways to provide evidence based and competent support.
- Several therapeutic modalities do not rely on diagnosis to function. The more I research different counselling theories to find the right fit for school counselling, the more I realize how many of them do not rely on diagnosis. For example, in Solution Focused Brief Therapy (SFBT), diagnosis is not really used much. “In our approach, we overtly say there is no need to diagnose your clients. That tactic doesn’t produce change. Although the symptoms of the various disorders may be present (and, therefore, a diagnosis may be relevant), Treatment from and SFBT perspective is not contingent upon understanding the presence of the symptoms or relevant diagnosis” (Connie and Froerer, 2023). This does not mean we do not discern or asses our client’s needs, it just means that we don’t need a clinical diagnosis to think critically about how to support clients (Connie and Froerer, 2023). SFBT is not alone in this position and the hope is to share some of these other theories in future articles in this series. Thus, learning from these modalities and evidence-based approaches can help us in school counselling regarding undiagnosed students.
To me it is clear, working and supporting undiagnosed students is a reality which requires a bit of a mindset shift for us as school counsellors. A large part of that shift involves a change in the way we approach care and counselling. It is challenging work as it causes us to reflect and think critically about the way we do things in our schools, which is uncomfortable. Yet it is necessary to have effective solutions to address undiagnosed students presenting complex challenges.
A Need-Based Approach
Part of the shift for me was – considering some of the theories mentioned above – moving to a need-based approach rather than an assessment-based approach. What do I mean when I say a need-based approach? Well, I mean that in school counselling regardless of what is going on, our role is to respond to student needs. This is true on a basic level where we offer the opportunity for students to learn, grow and build relationships. Whether it is giving the student who forgot their lunch a snack or teaching a student math, schools are all about providing students with what they need to grow and develop. Thus, our approach in school counselling can also focus on student needs.
But how do we describe needs, as that word can be used to mean a lot of things? In the words of Richard Dayringer, “Every person has certain inherent needs… these things are not optional; they are necessary for survival and well-being” (Dayringer, 2008). This is a powerful reminder to me that we can do things differently as school counsellors. We can use classic tools such as Maslow’s hierarchy of needs to help facilitate our understanding and our shift in approach as well (Dayringer, 2008). Or, if we need something a bit more robust, we do well to remember that Maslow is not the only person to reflect on the psychology of need. Richard M. Ryan and Edward L. Deci also remind us of the power of focusing on satisfying basic psychological needs. For Ryan and Deci, the basic psychological needs of autonomy, competence and relatedness are essential to supporting well-being and facilitating healthy psychological development and function (Ryan and Deci, 2018). All this to say, there is an evidence base to paying less focus on diagnosis, and more energy on discerning our student’s needs. Making this switch I believe is an essential first step to working with undiagnosed students, and it has proven helpful in my school counselling work thus far.
Back to Basics
In many ways, using a needs-based approach is about getting back to basics in counselling and psychosocial care. I know when I started trying to shift from needing a diagnosis to a more need-based approach, I felt a little off kilter. I felt like I was not treating the problem. Though that is the point, isn’t it? If I am focusing on responding to my students’ needs through counselling and other support, then I may not be treating the problem, but I am responding to their request for stability or improved function in their life and at school. Thus, a need-based approach is responding in hope to requests for stability and function in our students, and we do not need a diagnosis to do that. This means I am doing a lot of basic counselling skills, empathetic listening, asking good questions, being non-judgmental, and focusing on bringing hope into my counselling with students. If in doing this I look out for needs which are unmet and work to respond to those needs, I have found that to be more fruitful in working with undiagnosed students – and in fact, students in general.
Perhaps you are unsure about switching to a more need-based approach in your school counselling practice. If so, that is perfectly natural, rethinking is challenging after all. That said, going back to basic counselling skills when working with undiagnosed students is also a great strategy to help get unstuck, or to provide effective care while our students are on the waitlist. Basic counselling skills are not basic in the sense that they are supposed to be surpassed by advanced techniques after all. Basic counselling skills are called such because they are both simple and essential to all psychological care. Thus, even if we are unsure about switching to a need-based approach, a strategy we can use with working with undiagnosed students is going back to basic counselling skills.
Making the BEDS
I recognize that the first part of our series is more general and really trying to lay the groundwork which will help make sense of some of the concrete interventions I use with undiagnosed students moving forward. Working with students who present complex challenges, or challenges surrounding their mood or personality can be particularly scary if we rely heavily on diagnosis to work with these students. Yet, it does not have to be scary, and I have found switching to a need-based approach to be particularly helpful for working with students having mood and personality challenges.
On a more practical note, however, having a starting point to identify potential student needs facing mood or personalities challenges is helpful. Thus, I share the following as a starting point moving forward. Though not scientific by any means, I noticed that students facing mood and personality challenges also have common needs. That is why I developed a quick list to help me identify them quickly in the counselling room. This list is not exhaustive, but it is a start on the road of identifying possible needs these students may experience and allow us clarity in reflecting on how to satisfy those needs in future articles in this series. In acronym form; these students tend to need BEDS:
- Boundaries
- Emotion regulation
- Decision making
- Safe compassionate space
Between now and our next article in this series, I encourage us to reflect on our students who are undiagnosed and their needs. I encourage us to reflect on BEDS when we are working with students experiencing mood or personality challenges and see if this helps us not panic so much when we do not have a diagnosis right away. The goal is not trying to solve problems but respond to needs ethically to support our students who are undiagnosed.
Conclusion
In this article we begin to reflect on a challenge we face as school counsellors, working with undiagnosed students. We have explored some of the shifts we can make as school counsellors to facilitate working with undiagnosed students. We also ended this article by briefly describing the BEDS acronym as we begin to look at the needs of undiagnosed students experiencing mood and personality challenges. The goal in future articles is to unpack the BEDS acronym in more detail and reflect on some strategies and interventions I use with students presenting mood or personality challenges using the need-based approach described in this initial article. I believe that in school counselling, we are working in a distinct clinical space which faces distinct challenges and thus requires a distinct approach. Focusing on student needs for stability and function is a way we as school counsellors can respond to all students, even those who are undiagnosed.
Bibliography
D Yalom, I., M. D. (2017). The Gift of Therapy, an open letter to a new generation of therapists and their patients. HerperCollins.
Dayringer, R., ThD. (2008). The heart of pastoral counseling, healing through relationship (Revised). Routledge.
E Connie, E., & S Froerer, A. (2023). The solution focused Brief Therapy Diamond, a new approach to SFBT that will empower both practicioner and client to achieve the best outcomes. Hay House, Inc. M Ryan, R., & L Deci, E. (2018). Self-ditermination Theory, basic psychological needs in motivation, development, and wellness. The Guildford Press.
ABOUT THE AUTHOR:
Justin Bertrand, M.Div. is a counsellor in academic training at the high school level as well as a part time student in the MA in counselling & spiritual care program with McMaster Divinity College. He has over ten years of experience in various counselling settings and is passionate about offering adolescents compassionate and professional care.
