Psychosocial Assessment, Support and Counseling

Recovery

The process of performing a psychosocial assessment and providing support in the context of another culture is fraught with many possibilities of making “mistakes.” Recovery after a mistake allows the session to be restored to where it was before a setback. A perceived barrier to the process of the psychosocial assessment is the risk of invoking client discomfort. For example, counselors may be uncomfortable opening a discussion of spiritual factors due to concern that they will not be able to adequately address any revealed spiritual turmoil (Reis et al., 2007). However, it is inevitable that mistakes will be made; even highly skilled professionals make mistakes. According to Paul B. Pederson of the University of Hawaii Department of Psychology, “If you are not making mistakes while working with a client, especially if that client comes from a culture that is unfamiliar to you, then you may not be taking enough personal risks.” Proper training can help you prevent and recover from mistakes with increased rather than diminished effectiveness. Counselors should acknowledge and attend to the mistake for the best possible outcome.

►Exercise

Review the following recovery skills developed for psychologists by Dr. Pederson. Consider which of the following techniques could you use to facilitate psychosocial assessment and counseling in genetic counseling sessions?

Recovery Skills (adapted from Pederson, 1999)

1. Change the topic. Redirect the interview appropriately following a controversial interaction.

2. Focus. Refocus the interview on the basic problem instead of on the controversial issue.

3. Silence. Tolerate quiet time for both counselor and client to gather their thoughts and self-reflect.

4. Role reversal. Solicit consultation from the client to generate solutions and alternative responses to the crisis.

5. Challenging. Confront the client with his or her own perception of what is really happening in the crisis.

6. Referral. Refer the client to another counselor in a culturally appropriate way and at an appropriate time.

7. Termination. Terminate the interview prematurely in a culturally appropriate way.

8. Arbitration. Brings in a third person or “cultural-broker” to mediate a dispute in a culturally appropriate way.

9. Metaphorical analysis. Describe the crisis as a microcosm of a larger macro situation to gain insights about the larger picture.

10. Positioning. Identify an area of unmet need or opportunity not yet recognized by the client, and build on it to the client’s advantage.

 

Redirecting the Need for Directive Counseling

It is not uncommon for an Asian American, or any, client to explicitly ask the genetic counselor what he or she should do in the situation. Asian American culture directs great respect towards authority and elders (Chang, 1992). This respect can extend to health care professionals who may be regarded as authority figures (Jung, 1996). Asian American clients often come into a genetic counseling session with specific role expectations for the counselor. When this is the case, the counselor’s nondirective counseling perspective may contradict the client’s expectations. A client’s request for direct guidance can be due to cultural issues. However, it may also be due to other issues such as confusion, a sense that the genetic counselor is being emotionally distant, a disagreement between the client and her partner, or because the client wants to know how others have dealt with the same or similar situations (Weil, 2001). If the basis of the request is culturally rooted, it may be due to the misconception that genetic counseling is mandatory or due to the client’s overarching respect for the counselor as an authority figure. A genetic counselor’s widely accepted professional role is to promote client autonomy and provide nondirective services. However, strict adherence to nondirective counseling can leave a client feeling confused, disrespected and/or completely unsure about what to do (Weil, 2001).

If a client asks for direct guidance, it is the responsibility of the genetic counselor to attempt to determine why the client is asking and then attempt to provide some direction so that the client can formulate his/her personal path. Counselors can frame a suggestion for the client based on assessment of the values the client expressed in the session (e.g., “Based on what you have told me, it seems that you are leaning towards…”) (Weil, 2001). While there are some barriers to this method of overcoming directive counseling, the client may feel more capable of coming to a decision when the counselor offers a suggestion that is rooted in the client’s expressed values and beliefs. One should be tentative when offering suggestions.

►Exercise

In the following scenarios, consider why the client may be asking directive questions and respond to the client in a nondirective manner. State what you believe is the client’s motivation for asking you to be directive. Read the first example as a model for completing the remaining examples.

Example:

Scenario:  A 25-year-old woman comes into the Hereditary Cancer Clinic for cancer risk assessment. Based on the family history, it is appropriate to offer the woman testing for BRCA. You believe that there is a high likelihood she will have a mutation. After explaining the test to your client, she asks you, “I should probably get the test, right?”

Redirect: “Let’s talk about what having conclusive test results would mean for you.”

Motivation:  The client is confused and overwhelmed about having the testing. She wants you to agree that she is making the right decision. Or, she wants you to state that her risk is not really so high (magical thinking).

Additional Scenarios and Responses:

Scenario:

A couple comes to the Prenatal Clinic after learning their baby is affected with Trisomy 18. When you are explaining the possible options for this pregnancy, the woman turns to you and asks, “What would you do if you were in my situation?”

Redirect: ____________________________________________________________

Motivation: ____________________________________________________________

 

2. Scenario:

A woman comes to the Prenatal Clinic to talk to you about her advanced maternal age. She states that her doctor told her to have an amniocentesis. Therefore, that is the testing procedure she says she wants. She asks you, “Have you ever had an amniocentesis?”

Redirect: _________________________________________________________

Motivation: _________________________________________________________

 

3. Scenario: A couple has just delivered a baby that the doctors believe has Down syndrome. As you begin counseling the couple about Down syndrome, you notice that the wife has been crying. The husband is sitting next to the window, staring out into the trees. The husband suddenly turns to you and asks, “Would you keep a baby with Down syndrome?”

Redirect: __________________________________________________________

Motivation: __________________________________________________________

 

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