Motivational interviewing for genetic counseling: A unified framework for persuasive and equipoise conversations

Abstract

Genetic counselors (GCs) have traditionally been trained to adopt a position of equipoise or clinical neutrality. They provide information, answer questions, address barriers, and engage in shared decision‐making, but generally, they do not prescribe a genetic test. Historically, GCs have generally been trained not to persuade the ambivalent or resistant patient. More recently, however, there has been discussion regarding when a greater degree of persuasion or directionality may be appropriate within genetic counseling (GC) and what role MI may play in this process. The role for “persuasive GC” is based on the premise that some genetic tests provide actionable information that would clearly benefit patients and families by impacting treatment or surveillance. For other tests, the benefits are less clear as they do not directly impact patient care or the benefits may be more subjective in nature, driven by patient values or psychological needs. For the former, we propose that GCs may adopt a more persuasive clinical approach while for the latter, a more traditional equipoise stance may be more appropriate. We suggest that motivational interviewing (MI) could serve as a unifying counseling model that allows GCs to handle both persuasive and equipoise encounters. For clearly beneficial tests, while directional, the MI encounter can still be non‐directive, autonomy‐supportive, and patient‐centered. MI can also be adapted for equipoise situations, for example, placing less emphasis on eliciting and strengthening change talk as that is more a behavior change strategy than a shared decision‐making strategy. The core principles and strategies of MI, such as autonomy support, evocation, open questions, reflective listening, and affirmation would apply to both persuasive and equipoise encounters. Key issues that merit discussion include how best to train GCs both during their initial and post‐graduate education.

Defining orienting language in the genetic counseling process

“…The category of Guidance has implications for the long‐standing discussions in the field about the appropriate use of a spectrum of directiveness. The conversation has evolved beyond the tenet of non‐directiveness to a goal of increasing patient autonomy (Kessler, 1992) and using techniques, such as shared decision making (Elwyn et al, 2000; Shugar & Shuman, 2020) and motivational interviewing (Resnicow et al, 2022), to aid clients in making informed decisions that improve their health and the health of their families while incorporating their own personal values. Such techniques are compatible with the range of guidance identified in our study, which found many examples of genetic counselors providing guidance, ranging from subtle language to strongly worded health promotion (for example, see Table 2 in sections on Guidance as Strategy and as Purpose).…”

Creation and beta testing of a “choose your own adventure” digital simulation to reinforce motivational interviewing skills in genetic counseling

“…While goal-oriented and directional, MI is autonomy supportive rather than directive (Resnicow et al, 2022).…”

“…The widely accepted, short definition of MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2012). While goal‐oriented and directional, MI is autonomy supportive rather than directive (Resnicow et al., 2022).…”

“…MI is designed to help individuals resolve their ambivalence (Miller & Rollnick, 2012). In cases where genetic testing would lead to clear medical benefits, a directional approach is warranted (Jamal et al., 2020; Resnicow et al., 2022). For example, the National Comprehensive Cancer Network (NCCN) guidelines (National Comprehensive Cancer Network, 2023) support offering genetic testing for children ages 10 and above when a parent has familial adenomatous polyposis (FAP) and a known pathogenic variant.…”

Behavioral Changes after Psychiatric Genetic Counseling: An Exploratory Study

“…While genetic counseling encompasses a risk communication component, it should extend beyond this information to provide personalized psychotherapeutic support counseling that may more effectively influence behavior [21]. It has been shown that genetic counseling, under these conditions, leads to an increased sense of perceived personal control and greater intention of engaging in positive health behaviors [22, 23].…”