Genetic counselors often are privy to a family’s darkest moments, whether it be informing a couple their pregnancy is affected with a lethal condition, disclosing test results indicating a high risk for cancer, or providing a diagnosis confirming a child will never be like her or his peers. As they engage with patients in navigating a difficult and painful path, genetic counselors likely are affected personally by the experience. Some of their reactions may be described as countertransference (CT), or certain conscious and unconscious emotions, fantasies, behaviors, perceptions, and psychological defenses genetic counselors experience in response to some aspect of the genetic counseling process (Weil 2010). The complex phenomenon of genetic counselor CT is the focus of several theoretical articles and book chapters (e.g., Djurdjinovic 1998; Kessler 1979; McCarthy et al. 2003; Weil 2000, 2010). To date, however, no empirical studies have solely examined genetic counselors’ CT experiences. This study aimed to investigate the nature of clinical genetic counselors’ CT experiences and their strategies for managing CT.

Conceptualizations of Countertransference

Sigmund Freud originated the term countertransference, which may be described as the psychoanalyst’s unconscious emotional responses to the patient stemming from the psychoanalyst’s unresolved psychological issues. He cautioned that CT can be harmful to the patient and counterproductive to the therapeutic process and emphasized that therapists should examine their unconscious reactions, which in turn may help them to better understand their patients (Gelso and Hayes 2007).

The definition of CT has evolved since Freud’s initial conceptualization. Some theorists posit a “totalistic” view that comprises all therapist reactions to the client while others propose a moderate definition of CT as the therapist’s conscious or unconscious feelings, cognitions, and behaviors originating from the therapist’s unresolved issues or maladaptive behaviors in response to the client or other aspects of the counseling relationship. Contemporary theorists and researchers view CT as an inevitable and potentially valuable aspect of clinical interactions (e.g., Gelso and Hayes 2007).

In genetic counseling, definitions of CT generally tend towards a more moderate view. Kessler (1992) introduced the concept of CT in genetic counseling, stating “the unconscious projections of the counselor, consisting of the attitudes, beliefs, anxieties, and fears stimulated by the counselees and the issues with which the counselees are dealing, constitute the countertransference. As long as the countertransference remains unconscious, the counselor is likely to misunderstand and distort the counselees’ needs. Once they are brought into…consciousness, the counselor can begin to use his/her own feelings as a vehicle for understanding the counselees” (p. 195). Kessler asserts that no one is immune to experiencing suffering, and genetic counselors’ experiences with suffering give rise to CT. He identifies two types: associative CT and projective CT.

Associative CT occurs when a patient speaks or behaves in a way that causes the genetic counselor to shift focus from the patient to his or her own internal experience. For example, a patient mentions being diagnosed with cancer at age 28, which is close to the genetic counselor’s current age. The counselor begins to wonder about how s/he would feel to have cancer. This momentary distraction may be beneficial if it enables the genetic counselor to speculate upon her or his own reaction to having cancer, and thus leads to greater empathy for the patient. Conversely, it may be detrimental if the counselor feels too threatened by her or his own possible feelings and responds by emotionally distancing from the patient.

Projective CT is the result of over-identification with the patient due to a similar shared experience (e.g., the patient and the genetic counselor both have a history of infertility). Similar to associative CT, projective CT has the potential to provide greater insight into the patient’s feelings and perspective. On the other hand, the genetic counselor may mistakenly believe her or his feelings are the patient’s feelings. Unrecognized projective CT might lead the genetic counselor to assume a better understanding of the patient’s situation than is actually the case, resulting in a failure to explore differences and subtleties in the patient’s experience. Kessler (1992) asserts that genetic counselors who attempt to recognize and manage their projective CT tend to provide deeper levels of empathy than those who do not do so.

Citing CT as one of the most common disruptions to the genetic counselor-patient working relationship, Djurdjinovic (1998) states CT is “…about imposing an invalid understanding and a response to someone through an unconscious template…Sometimes it can be correct, but most of the time it is simply a projection of a belief or a wish on the part of the person who creates this understanding for another” (p. 144). Similar to Kessler (1992), she considers CT to be both an unconscious and conscious process.

Weil (2010) notes that, when recognized, CT can provide the genetic counselor with better insight, empathy, and guidance into the patient’s experience and result in better services. Alternatively, unrecognized CT may interfere with the genetic counseling process by causing genetic counselors to emotionally distance themselves from the patient or to not follow appropriate lines of inquiry. He emphasizes that genetic counselors should attend to their emotions before, during, and after patient interactions in order to appropriately manage their CT.

McCarthy et al. (2003), in their discussion of CT, note that genetic counselor and patient similarities and differences in factors such as values, behaviors, attitudes, language, physical appearance, age, and gender may affect how the counselor identifies with the patient. Depending on the situation, CT can result in over-identification, where genetic counselors have difficulty distinguishing between patient emotions and their own emotions, or it can result in extreme dis-identification. They assert that a primary negative consequence of unrecognized and unmanaged CT is its interference with empathy for the patient. They further state that “generally speaking, any behavior, thought, feeling, or attitude that is either out of character for you or is considered by others (e.g., your supervisor, the client) to be ineffective or inappropriate could signal countertransference” (p. 250). They propose several behaviors that may indicate CT: compulsive advice giving; unusually strong feelings toward a particular client; “rescuer” fantasies; dreading or being overly eager for a session with a particular patient; feeling sleepy; or avoiding patient feelings, especially negative ones, that are directed at the genetic counselor.

Weil (2010) describes four circumstances that are likely to evoke CT: (1) patient characteristics, especially when they are expressing particularly strong emotions; (2) if the genetic counselor feels a sense of vulnerability when facing situations of disease, disability, and loss which can lead to anxiety or fear; (3) diversity issues, particularly if the patient is from an ethnicity, culture, religion, sexual orientation, socioeconomic status and/or disability that differs from the counselor; and (4) challenging situations such as giving bad news, providing genetic counseling to children and adolescents, providing genetic counseling for cancer or neurogenetic disorders, encountering ethical dilemmas, suicide attempt or completion by former patients, and when a genetic counselor experiences a personal disability, trauma or loss.

Research on Countertransference

Psychotherapy Research

Research on CT is limited, due in part to a lack of standardized measures. In response to this issue, Gelso and Hayes (2007) developed a comprehensive, five-component framework for conceptualizing CT consisting of the origins, triggers, manifestations, effects, and management of the CT experience. Origins refers to the therapists’ unresolved conflicts, often developed in childhood. Triggers refers to events or client characteristics that cause the therapists to have a reaction. Manifestations refers to the emotions, behaviors, or cognitions of the therapist in reaction to the trigger. Effects of CT, particularly unmanaged CT, may include the therapist avoiding client feelings, inaccurately interpreting session content, or becoming overly involved; when managed appropriately, however, CT may be deeply beneficial to therapy by building better rapport and increasing empathy. Management refers to actions the therapist takes to recognize and appropriately handle CT. Gelso and Hayes (2007) propose five factors that aid in managing CT: self-insight, self-integration, empathy, anxiety management, and conceptualization skills.

Hofsess and Tracey (2010) asked experienced psychologists to review a list of therapist behaviors and rate their level of agreement that each behavior is indicative of CT. The behaviors rated highest by psychologists related to sexual feelings towards a client, excessive thoughts about a client, loss of neutrality, rejecting a client, and engaging in too much self-disclosure.

Using the Gelso and Hayes (2007) framework, Hayes et al. (2015) interviewed 18 therapists and drew these conclusions about CT origins, triggers, manifestations, effects, and management strategies: Origins consisted mainly of the therapist’s unresolved personal and professional issues. Triggers were client resemblance to therapist or to others, differences between client and therapist, client behaviors, and client characteristics Manifestations were pleasant feelings (warmth, caring, compassion), unpleasant feelings (anger, worry, self-doubt), cognitions (confusion, misconceptualization), and behaviors (colluding, working too hard, relaxing boundaries). Effects included facilitating (e.g., a stronger working relationship), and hindering (e.g., a weaker working relationship). Management included caution/vigilance, in-session reminders (e.g., to stay calm and be present), out-of-session behaviors, and self-insight.

Genetic Counseling Research

Although a few personal accounts contain discussions of CT (cf. Anonymous 2008; Hyatt 2012; Likhite 2000; Mathiesen 2012; Woo 2002) no empirical studies have been performed for the sole purpose of examining genetic counselors’ experiences with CT. Some articles address CT within the context of disability and with respect to self-disclosure in genetic counseling. Hodgson and Weil (2012a) conducted a focus group with genetic counselors and other attendees at a professional genetic counseling meeting and concluded some participants have difficulty discussing Down syndrome in a prenatal setting due to personal biases regarding disability. In a commentary to that article, the authors emphasize the importance of understanding a genetic counselor’s personal attitudes towards disability and how countertransference might manifest when providing counseling about genetic conditions (Hodgson and Weil 2012b). Peters et al. (2004) surveyed genetic counselors about the effects on their practice of personally receiving genetic counseling services. Close to half of the sample noted increased empathy and connection from having personally received genetic counseling. A number of respondents reported self-disclosing to patients about their receipt of genetic counseling services, which might be due to associative CT (i.e., similarity to patient vis a vis having genetic counseling). Redlinger-Grosse et al. (2013) similarly speculated that self-disclosure may result from associative CT and potentially shift focus to the genetic counselor.

Purpose of the Study

Countertransference is thought to be an inevitable part of genetic counseling, comprised of certain conscious and unconscious reactions of the genetic counselor in response to the patient or other aspects of the genetic counseling session. To date, however, no studies have solely investigated the extent to which genetic counselor are inclined to experience CT and the nature of their CT experiences. This study explored the extent to which clinical genetic counselors’ perceive themselves as inclined to experience CT, gathered examples of CT they have encountered in clinical situations, and assessed strategies they’ve used to effectively manage CT.

Methods

Participants

After obtaining approval from the University of Minnesota Institutional Review Board, an email invitation was sent to full members of the National Society of Genetic Counselors (NSGC) in December 2014 (~N = 2969). An email reminder was sent 2 weeks later. Inclusion criteria were a certified or board eligible genetic counselor who currently, or at one time, provided post-degree genetic counseling services directly to patients. These criteria were established as it was thought that currently practicing genetic counselors and those who have had direct patient contact would be more likely to experience CT. One-hundred fifty-three individuals returned surveys (5.2% conservative estimated response). Of these, 129 surveys were complete, and of the completed surveys, 127 individuals met inclusion criteria.

Instrumentation

We developed a four-part survey. The first section contained Weil’s (2010) definition of CT: “conscious and unconscious emotions, fantasies, behaviors, perceptions, and psychological defenses that the genetic counselor experiences as a response to any aspect of the genetic counseling situation” (p. 176). Given the lack of a standard definition of countertransference in the genetic counseling literature and the lack of empirical data concerning the phenomenon, we elected to use a relatively inclusive definition. This definition allowed us to capture a wide range of clinical examples. We included a question asking respondents to rate their agreement with the definition (Scale: 0% = completely disagree to 100% = completely agree) in order to assess the extent to which they were working from a similar definition when completing the survey.

The second section contained 11 demographic questions. The third section contained 28 items adapted from a questionnaire designed to measure CT propensities (Teyber and McClure 2000). The original questionnaire is part of a workbook intended for individuals in training to be psychotherapists. The items were modified slightly to make them more applicable to genetic counseling. For example, the word “client” was changed to “patient,” and 5 items were omitted because they do not apply to genetic counseling. For 27 of the items respondents indicated the extent to which each statement is characteristic of them (Scale: 1 = Little/Not at All Characteristic, 2 = Somewhat Characteristic, 3 = Characteristic, 4 = Very Characteristic). They rated an additional item, I often think about ways in which my own issues could impact the therapeutic relationship, on a frequency scale: (1 = Never/Rarely/Not at all, 2 = Sometimes, 3 = Often, 4 = Very often).

The fourth section of the survey contained a multi-part, open-ended question: Have you ever been in a genetic counseling situation in which you believe you experienced countertransference with a patient? Please describe the situation and how you felt. What aspect of the session made this countertransference? How did you handle the situation at the time, and what, if anything, do you wish you had done differently?

The survey was piloted with one practicing genetic counselor and 11 genetic counseling students. Their feedback resulted in a few minor revisions to clarify wording.

Data Analysis

Quantitative Analyses

Descriptive statistics (means, standard deviations, percentages) were calculated for survey items. An internal consistency reliability analysis was conducted on the 28 CT items to determine an overall Cronbach’s alpha; this analysis was done because the items had been modified to make them more applicable for genetic counselors. An exploratory factor analysis using principal axis factoring with promax rotation was conducted on the 28 items. This type of factor analysis groups items according to those which respondents tended to answer similarly.

Qualitative Analyses

Responses to open-ended items were analyzed by the first author using thematic analysis (Silverman 1993). She manually coded responses into conceptually similar groupings and assigned each a label reflecting the underlying concept. She organized her groupings of responses to the question regarding genetic counselors’ personal experiences with CT according to four of the five components of Gelso and Hayes’ (2007) CT framework: trigger, manifestation, effects, and management of the CT experience. The fifth component, origins of CT, was not used, as this information was not elicited from respondents. The second author served as data auditor, and disagreements were discussed to reach concordance.

Results

Sample Demographics

The participants’ demographic characteristics are summarized in Table 1. The majority were female (99%), and the most common primary specialty areas were prenatal (46%), cancer (37%), and pediatric (25%). Most were employed at either a university medical center (37%), public hospital/medical facility (29%), or private hospital/medical facility (17%). Ninety-one percent were providing genetic counseling services directly to patients at the time of the study. Eleven participants had provided genetic counseling services directly to patients in the past (Range: < 1 year to 16 years). Participants reported working an average of 40 h per week when seeing patients (Range: 8 to 60+ hours), and seeing an average of 11.5 patients per week (Range: 1 to 30). Eighty-three percent reported formal training on the topic of CT, 10% had never received formal training, and 7% were unsure. The mean percentage of agreement with the definition of CT was 88.8% (SD = 17.3%); the median agreement was 95%.

Table 1 Participants’ demographic information
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Genetic Counselor Countertransference Propensities

Participants rated the CT items in terms of how characteristic each is of them. Mean ratings, shown in Table 2, ranged from 1.43 (I tend to find myself in power struggles or subtle control battles with my patients) to 3.43 (I usually remain accepting and engaged with patients who make choices that disagree with my values). A reliability analysis done on the 28 CT items yielded a Cronbach’s alpha of .76, suggesting the items as a whole have acceptable internal consistency reliability.

Table 2 Summary of principal axis factor analysis with promax rotation, along with item means, standard deviations, and observed ranges
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Factor Analysis of CT Items

An exploratory factor analysis using principal axis factoring with promax rotation yielded four factors (Table 3), which account for 38.5% of the response variance. The four factor solution was based on visual analysis of the scree plot, higher internal consistency reliability of the factors (as compared with a three factor solution), and the stronger theoretical consistency of the items loading together (as compared with a three factor solution). The Cronbach’s alpha for each factor is 0.74, 0.71, 0.51, and 0.32, respectively. Factors 3 and 4 have only a small number of items, which tends to lower reliability. Two items, I tend to have difficulty accepting patients’ genuine expressions of warmth toward me, and I find myself wanting to temper my comments or dilute the emotional impact of my interventions to avoid having too much influence or impact on my patient’s lives, did not load to any factors, based on the factor loading cutoff score of .25. This cutoff score is lower than the commonly used .30 standard, but with the relatively modest sample size for the factor analysis (n = 125), we wanted to be slightly less conservative for the sake of future exploration of these factors.

Table 3 Thematic analysis of countertransference experiences
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Factor 1 was labeled Control. This factor includes 10 items reflecting counselor reactions motivated by a desire to exert undue influence over ambiguity, affect (patient’s emotions or one’s own emotions), and/or the genetic counseling process. Factor 2 was termed Conflict Avoidance and includes 8 items pertaining to counselor actions motivated by a desire to prevent conflict due to emotions that might be triggered in patients (e.g., anger) and/or in the counselor (e.g., insecurity). Endorsement of items in Factor 2 suggests the genetic counselor may avoid being direct, respond defensively to perceived criticism, omit certain topics, skip over certain topics, and/or minimize certain topics. Factor 3 was termed Directiveness and consists of 4 items pertaining to actions motivated by a counselor’s desire to “push” patients regarding how quickly to decide or what to decide, and to either press them to decide on their own or to step in and do some of the decisional work for them. Factor 4 was labeled Self-Regulation and includes 4 items reflecting counselor actions motivated by a desire to manage CT through intentional self-reflection/awareness of one’s CT and through setting boundaries.

Thematic Analysis of Personal Experiences with Countertransference

Fifty-seven participants (40%) provided an example of a personal experience with CT. The results of the thematic analysis and illustrative examples are summarized in Table 3. Of note, while every example included a description of what triggered CT, explicit mention of manifestations, effects, and management were less consistent.

Triggers

Five themes reflect triggers of CT: general similarity, medical/genetic similarity, angry patients, patient behaves differently from genetic counselor expectations, and disclosing bad news. General similarity includes similar demographics between the genetic counselor and patient (e.g., age, socioeconomic status, personality characteristic), or the patient resembled someone with whom the genetic counselor was close emotionally. Medical/genetic similarity refers to patients who have the same or a similar medical condition as the genetic counselor or a family member. Patients who became angry also elicited CT reactions. Patient behaves differently from genetic counselor expectations includes situations in which the genetic counselor had anticipated the patient to act a certain way, and the patient did not do so. These situations include instances when patients made decisions with which the genetic counselor disagreed. Disclosing bad news triggered CT for some genetic counselors. For example, two respondents reported the difficulty of disclosing bad news around Christmas.

Manifestations

Five themes were extracted for manifestations of CT: genetic counselor becomes self-focused, projection, atypically intense emotional reaction, disengagement, and physical reaction. Genetic counselor becomes self-focused involves shifting the focus from the patient to one’s own internal processes (e.g., memories and emotions). Projection refers to instances where the genetic counselor over-identified with the patient or inaccurately assumed a better understanding of the patient; this type of manifestation is most similar to Kessler’s (1992) projective CT. Atypically intense emotional reaction includes counselor reports of experiencing more extreme feelings, or an “emotional pull.” Respondents variously described feelings of anger, fear, desire to be friends with the patient, or pressure to feed into the patient’s family dynamics. Disengagement refer to times when the genetic counselor felt less invested in the patient outcome or truncated the interaction by not asking certain questions or by wishing to avoid the patient during subsequent clinic visits. Physical reaction pertains to counselor physiological behaviors (e.g., talking more quickly than normal, speaking more casually, sweating, and increased heart rate).

Effects

Five themes reflect the type of effects respondents described in their examples: disruption in rapport building, repaired empathy, over-identification, conversation does not reach fullest potential, and genetic counselor is emotionally drained. Disruption in rapport building refers to instances where the genetic counselor had difficulty empathizing with the patient’s experience which interfered with rapport building and connection with the patient. Repaired empathy pertains to a perceived beneficial outcome of CT, that is, a better relationship developed between the genetic counselor and patient (e.g., the patient could relate to the genetic counselor, and the patient appeared to become more engaged in the session). Over-identification involves situations in which similarity of experience and/or “excessive emotional involvement” (Neumann et al. 2009) resulted in the genetic counselor either self-disclosing personal information or being tempted to do so. Conversation does not reach fullest potential refers to instances where genetic counselors believed CT interfered with their ability to conduct the session because they did not provide adequate information to the patients or failed to delve as far into the patients’ psychosocial issues as they might have done otherwise. Genetic counselor is emotionally drained refers to descriptions of how counselors felt after the session.

Management

Three themes encompass descriptions of how genetic counselors managed their CT: recognize countertransference as it occurs, self-reflection, and consultation. The most prevalent type of management was recognize countertransference as it occurs in the session. Respondents reported realizing they were having an atypical reaction during the session process. Self-reflection is a management strategy that occurred after the genetic counseling session. Counselors reviewed the session and their physical and emotional responses in order to identify their CT reactions. Consultation involves speaking with colleagues or supervisors about one’s experience in order to gain further perspective and insight.

Examples of Participants’ CT Experiences

The following section contains six examples illustrating themes generated from analysis of participants’ personal accounts of CT:

I think countertransference can be productive if a person is aware of it occurring in the moment. I often have patients whose situations cause me strong emotions, and the strong emotions often come from a place of extreme relatability to the patient. Recently, I had a patient who is my age and we discovered that her fetus had lethal anomalies. This is a huge fear of mine (I think working in genetics will do that to you), and I had a hard time with discussing the nature of the anomalies and the potential etiology. I’ll find that I don’t want to ask certain questions because I can feel the pain that they will cause or dredge up...[I do not] allow the conversation to reach its fullest depth. I’ll replay the conversation in my head dozens of times afterwards and realize there were openings that I could have utilized or times when I should have kept my mouth shut. But realizing that countertransference is present can actually lead to a really productive conversation even though it can be extremely uncomfortable…

The trigger in this account is general similarity where the genetic counselor identified with the patient due to a similar age. The manifestations of the CT can be described as disengaged. This genetic counselor reports not wanting to ask “certain questions.” The comment “I sometimes struggle with really allowing a conversation to reach its fullest depth” aligns with the effect categorized as conversation did not reach fullest potential. The genetic counselor in this example managed the CT with self-reflection. Importantly, this individual had the insightful realization that although uncomfortable, recognizing CT as it occurs can lead to a more productive conversation and allow the counselor to develop more rapport with patients.

Another illustrative personal story is also from prenatal genetic counseling:

[I] counseled a young woman who had a miscarriage [and] a karyotype on the products of conception…revealed a…MATERNAL balanced translocation that would, 100% of the time, result in an early pregnancy loss. I saw this woman to provide counseling about the translocation and essentially to tell her she would never be able to carry a child to term using her own genetic information. This situation hit close to home for me as I am a balanced translocation carrier who was told…I would never be able to conceive…While I am now a mother through other ways…and I was able to share these alternate options of getting to motherhood with this young woman, it was extremely difficult for me to counsel her as I saw myself in her...it’s like I was hearing this information all over again which impacted my life significantly and I knew I was impacting hers greatly in that very moment. All of the emotions I’ve dealt with over the years came flooding back. I did my best to be supportive and in the end, even shared with her my story which seemed right at the moment. I think in the future, I would defer this type of counseling session to another GC…because I am not sure how much my personal experience clouded my ability to counsel her appropriately. Others have told me I was probably the best person to counsel her given my experience, but after much reflection, it just hit too close to home...

The medical/genetic similarity between the genetic counselor and the patient triggers the CT in this personal account. The manifestation of CT is genetic counselor shifts focus from patient to self. The genetic counselor mentions questioning whether her “personal experience clouded [her] ability to counsel…appropriately” and is coded as over-identification. As in the previous example, the genetic counselor managed her CT with self-reflection and made the decision to defer future cases to another genetic counselor.

The following example is from cancer genetic counseling:

I met with a [young] man who was referred for the finding of a single large colonic polyp, as the referring physician was questioning Lynch syndrome. The plan was to offer IHC and MSI testing on the polyp. I anticipated it would be awkward to talk to this young man about colonoscopies, especially because I am a [young] female. I found myself rushing through the information and had to consciously stop myself and take a breath a few times. I also did not review a colonoscopy report with him in detail because there were pictures of his colon on it and I thought it would be too awkward. In retrospect, he was very straightforward and mature about the situation, and my anxiety was more about my own feelings and how I anticipated he would act. I wish I had taken more time to review the report with him and taken more time in the session to think about what I had to say… I think this was countertransference because I had pre-judged how he was going to act and when he did not act in that way, I wasn’t sure how to handle the situation.

In this cancer scenario, CT was triggered, in part, by the nature of the discussion (i.e., colonoscopies) and when the patient behaved differently from genetic counselor expectations. The manifestation of the CT occurred when the genetic counselor “found [herself] rushing through the information and had to consciously stop [herself] and take a breath.” This was categorized as a physical reaction to the patient’s trigger and genetic counselor projects feelings onto the patient. As with the previous account, the effects of CT were described as conversation did not reach fullest potential in that the genetic counselor did not provide as much information as she might have otherwise, such as insurance discrimination. Management can be inferred as self-reflection in that the genetic counselor realized her mistake.

Another cancer genetic counselor shared a personal story of CT:

I had a patient that was 85 yrs. old and she reminded me so much of my grandmother (looks, the way she spoke) that it was difficult to not treat her as I would my own grandmother. I spoke to my supervisor who is older than me to talk about issues that may be unique to that population that I have not experienced. Sometimes I think my own grandmother would not “understand genetics issues” and I was worried the patient would also not understand. This is what I would change, treating her differently because she reminded me of someone who doesn’t speak medical jargon.

Across respondent examples, the most commonly reported trigger of CT was when the patient has general similarities to the genetic counselor or a family member. In this case, the patient reminded the genetic counselor of her grandmother. Although this example does not mention any effects of CT, the counselor felt a need to seek consultation to manage her CT.

A common trigger of CT was patient anger, represented in the following example:

I have a patient who I saw in a previous pregnancy, which was affected with [a genetic condition]. The current pregnancy is now found to be at increased risk of [another genetic condition]…When reviewing the most recent test results, the patient’s husband made many remarks to me that are understandable, but he was sarcastic and demeaning. I look very young and in speaking to me, he would treat me as though I was a child and was unable to comprehend what he was saying. He would interrupt me frequently to make rude remarks about me or about our clinic. He also told me that he hated having to see my face again and that my office felt like a morgue…My patient (his wife) chuckled at his behavior throughout the session and I felt that she was condoning the way he was talking to me/egging him on. In the moment, I was sort of in shock and got very quiet. I only made the rude comments that I wanted to retaliate with after the session was over and to my coworker; however, I immediately hated both my patient and her husband. I started out the session with so much compassion for them and I felt that I had a history with them, but my empathy quickly disappeared and I know that this was evident in my nonverbal behavior during the session. I did not address the couple’s behavior directly, but I tried to wrap things up as quickly as possible so that I could get them out of my office. I felt anger toward them for not only treating me this way, but for seeming to forget how much I had invested in caring for them through…different pregnancies. At all subsequent ultrasound appointments in our clinic, I have avoided interacting with them as much as possible…In retrospect, I am glad that I was able to maintain control of my disgust toward them and to not “lash out” with remarks that were also hurtful; however, if I could do it all over again, I would stand a little more firm and I would directly address the couple’s behavior/coping mechanisms with them. I would try to not be as defensive…

This case represents a disruption of rapport building which was triggered by rude remarks and condescending behavior from the patient’s husband. The disruption was managed when the genetic counselor recognized CT as it was occurring after realizing her intense emotional reaction in the form of anger towards the couple and wanting to avoid them. The counselor indicated she was able to contain her negative emotional reactions during the session but also recognized the disrupted rapport with the couple.

Finally, CT may be beneficial when it results in repaired empathy:

I have “been there” many times...Most often it has been with patients having babies diagnosed with chromosome abnormalities or multiple anomalies, and I have shed tears with many of my patients. I truly feel for them and am there with them. After fertility problems and adopting my…[child] I have a lot of empathy for my patients and want them to be treated as I would like to be treated. I do feel close to many of these patients and they sometimes are like old friends when I see them back in another pregnancy. I do not believe I could do this job as effectively without having this compassion.

Although many of the participants reported negative experiences with CT, this example points to its potential benefits vis a vis repairing the empathic connection with patients. As the genetic counselor writes, “I truly feel for them and am there with them.” The counselor believes CT that is recognized and appropriately managed can be a valuable tool: “I do not believe I could do this job as effectively without having this compassion.” This participant did not mention a specific case, but noted that CT can be triggered when disclosing bad news such as chromosome anomalies and congenital malformations.

Discussion

This is the first empirical study focused solely on genetic counselor CT experiences and their management strategies. One-hundred twenty-seven clinical genetic counselors completed an anonymous survey examining the extent to which they perceive themselves as inclined to experience CT, gathered examples of CT they have encountered in clinical situations, and assessed their CT management strategies. Findings are discussed according to the major research questions, followed by study limitations, practice implications, research recommendations and conclusion.

Nature of Genetic Counselor Countertransference

Weil’s (2010) definition of CT was provided to survey respondents and a vast majority indicated they generally agreed with this description of the phenomenon. The results provide evidence of the validity of his conceptualization of genetic counselor CT as “conscious and unconscious emotions, fantasies, behaviors, perceptions, and psychological defenses that the genetic counselor experiences as a response to any aspect of the genetic counseling situation” (p. 176). These findings support a more moderate view of CT as opposed to a totalistic view (i.e., CT refers to all counselor reactions).

Every respondent reported that one or more of the individual CT items were at least somewhat characteristic of them. These findings support theoretical views of CT as an inevitable experience for genetic counselors (e.g., Djurdjinovic 1998; McCarthy et al. 2003; Weil 2010).

Factor analysis tentatively suggests four CT factors, Control, Conflict Avoidance, Directiveness, and Self-Regulation. Items loading on the Control factor concern difficulty tolerating ambiguity and discomfort with patients’ feelings. Given the inherent ambiguity and uncertainty involved in genetic counseling and the strong feelings evoked in many patients, it seems essential for genetic counselors to recognize their CT reactions so they can manage them in ways that promote patient goals as opposed to alleviating their own anxiety. Statements related to the factor Conflict Avoidance involve themes of discomfort with disagreements and strong patient affect such as anger. Genetic counselors who experience this type of CT may avoid appropriately confronting patients or respond defensively. As patient anger, including anger at the genetic counselor, is a prevalent dynamic in genetic counseling (Schema et al. 2015), it would behoove genetic counselors to recognize any propensity towards conflict avoidance. The third factor, Directiveness, involves items concerning involvement in patient decisions. Directiveness CT may manifest as “pushing” patients to make decisions that align with the genetic counselor’s views and/or according to the genetic counselor’s timeframe and/or decision-making style. Recognizing these behaviors is necessary to uphold a basic genetic counseling tenet of patient autonomy (cf. McCarthy Veach et al. 2007). The fourth factor, Self-regulation, involves items pertaining to behaviors for managing CT.

Considered together, these factors might be helpful in identifying CT tendencies in one’s self and in one’s supervisees and in managing CT reactions when they occur. These four factors, however, account for only 39% of the variance in participants’ responses. While this is a substantial amount of variance for this type of research, another 61% of the variance is due to other factors. Thus, more research is needed to more fully understand variables affecting genetic counselor CT. Factors 3 and 4 also had very low internal consistency reliability, though they each had only four items. This suggests the items contained in these factors may not represent a single construct.

Fifty-seven participants (45%) provided an example of a personal CT experience. Their examples support views that CT can occur even in the most “routine” cases as well as in emotionally complex situations. Thematic analysis of CT triggers, manifestations, effects, and management strategies yielded a number of findings. Prevalent triggers included general similarity to the patient, medical/genetic similarity, angry patients, patient behaves differently from genetic counselor expectations, and disclosing bad news. Prevalent manifestations included the genetic counselor shifts focus from patient to self, projects feelings onto the patient, experiences more intense emotional reaction to patient than normal, disengages, and has a physical reaction. Common effects of CT were disruption in rapport building, repaired empathy, over-identification, conversation does not reach fullest potential, and genetic counselor feels emotionally drained. Common management strategies included recognizing CT as it occurs, self-reflection, and consultation.

Generally, these findings support theoretical discussions of CT in the literature. Prior literature mentions general similarities between the genetic counselor and patient, angry patients, and disclosing bad news as possible triggers of CT (Mathiesen 2012; McCarthy et al. 2003; Kessler 1992; Weil 2010); all of these factors were confirmed in the present study. Schema et al. (2015) studied genetic counselors’ experiences of patient anger directed at them. The vast majority of their sample (96%) reported having experienced patient anger, especially when disclosing bad news. Genetic counselors generally report difficulties with delivering bad news (cf. Benoit et al. 2007; Udipi et al. 2008), including recognition that having to share unfortunate testing results is difficult for patients, often resulting in anger, and also is challenging for the counselors themselves. Practitioners who anticipate and/or experience one or more of these triggers in future sessions can be watchful for potential CT and attempt to manage it in order to prevent detrimental effects on the genetic counselor-patient relationship.

Empirical evidence of the manifestations of associative and projective CT, initially described by Kessler (1992), was also obtained in this study. Many respondents reported shifting focus from the patient to themselves, which aligns with associative CT. Many also reported projecting feelings onto the patient which can be described as projective CT. Research has not previously identified these types of reactions to patients, but some personal accounts provide examples of associative and projective CT. Hyatt (2012) reflects on her experience of associative CT when meeting with a patient who had a similar medical condition. She describes shifting her focus to her own internal experience rather than listening to the patient. Woo (2002) similarly talks about associative CT with grieving patients after experience a personal loss. She reports ultimately being able to use her past experience with loss to repair the empathic connection with patients. Anonymous (2008) shares her experience of ending a pregnancy for medical indications. Similar to Woo, Anonymous reports using her experience in an attempt to empathize with patients, but eventually she is compelled to leave her prenatal genetic counseling position due to chronic projective CT. She wonders, “It started to feel like I was carrying their grief on top of my own. Maybe I was projecting my own grief onto my patient, or maybe I had simply become more emotionally attuned to their situations...” (p. 416).

Several respondents mentioned effects of CT that have been investigated in genetic counseling research. The effects include over-identification, with many respondents stating they had self-disclosed because of associative CT. These results support prior speculations that self-disclosure may at times be prompted by CT (Redlinger-Grosse et al. 2013; Thomas et al. 2006). The present respondents also reported having intense emotional responses, which is a demonstrated risk factor for compassion fatigue (e.g., Benoit et al. 2007; Udipi et al. 2008).

Although many respondents reported negative effects of CT experiences, such as disruption in rapport, a number reported the development of a better connection/relationship with patients. The findings of positive effects are similar to genetic counselors’ personal accounts such as Woo (2002) who drew upon her personal experience with grief to “better anticipate some of [the patient’s] hardships that may follow (p. 297).” They also are consistent with Peters et al.’s (2004) findings that genetic counselors’ receipt of genetic counseling services may increase their connection with patients. Thus, it is important to note the potential for positive outcomes when genetic counselors recognize and appropriately manage their CT.

The present results regarding respondents’ management techniques are congruent with those discussed in theoretical literature. Recognition of CT as it occurs, self-reflection, and consultation are management techniques suggested in both the psychotherapy (e.g., Hayes et al. 2011) and genetic counseling literature (e.g., Djurdjinovic 1998; McCarthy et al. 2003; Weil 2000, 2010). Many respondents noted the benefits of peer and supervisor consultation. Prior research supports the effectiveness of peer group supervision for improving self-awareness and self-reflective practice (Zahm et al. 2008). Interestingly, none of the respondents reported seeking psychological services. In her personal account, Hyatt (2012) mentions the benefits of therapy for managing CT. Perhaps the present sample’s experiences of CT were less challenging, they were able to manage without such assistance, and/or their responses are due to an ascertainment bias.

Study Limitations

The present results are preliminary and require further investigation, particularly given the low estimated response rate. It cannot be determined whether and how those who responded differ significantly from those who did not, but an ascertainment bias could be present, especially given the sensitive nature of the topic. For example, the sample may be skewed towards counselors who are more prone to recognize CT. The factor analysis yielded low reliability for Factors 3 (Directiveness) and 4 (Self-Regulation), possibly due to the small number of items loading onto those factors. The study is also limited by its self-report design, as participants may lack full awareness of their CT tendencies. Indeed, one of the challenging aspects of conducting research on CT is that the phenomenon, by definition, involves unconscious reactions. Given these limitations, caution in interpreting the findings is warranted.

Practice and Training Implications

Despite study limitations, the present findings offer some suggestions for genetic counselors in various practice and academic settings. The findings provide evidence suggesting CT may be prevalent among genetic counselors and, as such, they help to normalize the phenomenon. Practitioners, supervisors, and instructors might review the CT-propensity items to help in assessment of CT tendencies, noting whether the items reflect Control, Conflict Avoidance, Directiveness, and/or Self-Regulation, or some other aspect of CT not assessed by these four tentative factors. Assessment of CT propensities may assist with recognizing and managing CT dynamics when they arise. They can also use the present results to anticipate possible common triggers and manifestations (e.g., it may be beneficial to know that perceived similarities between one’s self and patients, patient anger, and disclosing bad news may be common triggers for CT).

Genetic counselors could be encouraged to employ the management strategies identified in this study, particularly using intentional skills of self-reflection to recognize CT as it occurs. Three key questions genetic counselors could ask themselves in order to recognize and reflect upon their CT are: What is (was) my reaction (feelings, thoughts, actions)? Why am I reacting (did I react) that way? and Where did my reaction come from? Genetic counselors would be expected to benefit from on-going peer supervision and/or consultation. These strategies may help them to better utilize their CT to positively affect genetic counselor-patient interactions.

Both psychology and genetic counseling literatures unequivocally state that the key to managing CT is to recognize it as it occurs (cf. Cartwright et al. 2014; Hayes et al. 2011; Kessler 1992; McCarthy et al. 2003). McCarthy et al. (2003) recommend accepting that CT is inevitable. By adopting an accepting, non-defensive attitude, genetic counselors will be better able to locate the source of countertransferential feelings and better understand the origin of their reactions. Self-reflection is essential, as CT is often not detected until it occurs, largely in part because of its unconscious nature. Genetic counselors could attend to emotions before, during, and after patient interactions, particularly in sessions where CT is likely to occur (Weil 2000). As mentioned previously, supervision may also be beneficial in analyzing how CT manifests during a session (McCarthy et al. 2003; Weil 2000, 2010), and personal counseling or psychotherapy may be beneficial for some cases of CT (Hyatt 2012; McCarthy et al. 2003; Weil 2000, 2010).

The present findings suggest practitioners should consider whether a possible motivation for engaging in self-disclosure in some situations is associative CT. Prior research suggests self-disclosure about one’s personal experiences may be beneficial if used to build the patient-counselor relationship and promote decision-making, but it may compromise counselor non-directiveness and jeopardize boundaries with patients if used for other reasons (Peters et al. 2004; Redlinger-Grosse et al. 2013).

Research Recommendations

Further investigation into genetic counselor experiences with CT is recommended. Individual interviews with genetic counselors could be conducted to elicit richer, nuanced accounts of their personal experiences with CT. Additional studies could be performed to understand the origins of CT in genetic counseling, as this component of the Gelso and Hayes (2007) CT framework was not investigated in the present research. Factor analysis of the items on the CT measure used in this study could be repeated with a larger number of participants to determine their validity. Development of additional CT items to more fully capture the phenomenon among genetic counselors may be beneficial. Finally, studies with larger samples might yield insights regarding additional factors that contribute to CT [e.g., genetic counseling practice specialty, genetic counselor personal life circumstances (their own genetic risks, history of loss), compassion fatigue and burnout risk, and participation in peer supervision].

Conclusion

Both patients and genetic counselors bring their past experiences together in a way that affects their ability to understand and interact with each other. Genetic counselor CT involves conscious and unconscious emotions, fantasies, behaviors, perceptions, and psychological defenses genetic counselors experience in response to any aspect of genetic counseling situations (Weil 2010). The findings of this study tentatively suggest CT involves issues of control, conflict avoidance, directiveness, and self-regulation. Prevalent triggers include general similarity to the patient, medical/genetic similarity, angry patients, patient behaves differently from counselor expectations, and disclosing bad news. Effective management in the form of recognizing CT as it occurs, self-reflection, and seeking consultation and supervision may help genetic counselors manage their reactions. As the phenomenon of CT in genetic counseling is better understood, genetic counselors may be able to recognize and anticipate their own CT reactions and use this information in ways that are beneficial to genetic counseling processes and outcomes.