Raised in a psychosocial model of genetic counseling, I have long believed that understanding and addressing our patients’ psychological needs are critical to our role as genetic counselors. As such, I was pleased to see Biesecker et al.(2016) article, “Theories for psychotherapeutic genetic counseling: Fuzzy trace theory and Cognitive Behavior Theory” and their presented framework for how to apply psychological theories to genetic counseling practice. I wholeheartedly agree that the use of a counseling approach to guide our interactions will enrich our work - for both patients and also for genetic counselors as professionals. Where I disagree, however, is Biesecker et al.‘s argument for the adoption of a practice descriptor or “moniker” of “psychotherapeutic genetic counseling.” Having practiced in both worlds, psychotherapy and genetic counseling, I struggle with their assertion and find myself wondering, are we looking at the same end goal, but from a different vantage point? In this commentary, I offer an alternative perspective in hopes of continuing the conversation of how to best meet our patients’ psychological needs.

First, let me describe my professional path and acknowledge my biases. After working for 10 years as a genetic counselor in prenatal and metabolic settings, I began to sense a desire – both personally and professionally – to more deeply address the complex emotional needs of genetic counseling patients. With much consideration, I chose to return to school to pursue a PhD in Counseling Psychology. My goal was never to trade in my genetic counseling “hat” for that of a psychologist; rather, I hoped to integrate these two professions through additional training that would foster the adoption of a psychological lens in which to view the needs of genetic counseling patients. I admit that my journey is still evolving. Yet, I do know, having practiced in both professional worlds, that genetic counseling and psychotherapy share fundamental distinctions which warrant acknowledgement.

First, however, it is important to recognize areas of professional overlap. Genetic counselors and psychotherapists1 both approach clients in a relational, person-centered manner. Psychoptherapists and genetic counselors build positive working alliances using complementary skill sets and strategies (e.g., basic and advanced counseling skills, building rapport, supporting patients/clients, etc.). At the center of the Reciprocal Engagement Model (REM) of genetic counseling practice is the tenet, “Relationship is Integral to Genetic Counseling,” surrounding it are tenets that support the importance of a patient’s resiliency and acknowledgement of their emotions (McCarthy Veach et al. 2007). As Biesecker et al. (2016) present in their paper, psychological theories offer genetic counselors a framework for assessment and interventions that allow us to better understand and support our patients. This can potentially lead to better patient outcomes. Austin et al. (2014) have similarly argued, “…meeting the emotional needs of clients is strongly associated with better psychological results, which in turn can support knowledge-based outcomes” (p. 905). Thus, I share and emphatically endorse a stance that acknowledges the professional connections between genetic counselors and psychologists, especially as it supports a psychological approach to genetic counseling.

1 Herein, I use the term psychotherapist to include doctoral level psychologists, as well as other mental health professionals trained and licensed to provide psychotherapy.

There are more distinctions between the professions, however, that make me hesitant to fully endorse the assertion that we are offering “psychotherapeutic genetic counseling.” While “psychotherapeutic” could be an adjective to describe genetic counseling processes and strategies, I believe Biesecker et al. may have gone too far in describing genetic counseling as a form of psychotherapy. The predominant educational component of genetic counseling is more extensive than even the most “psychoeducationally-focused” forms of psychotherapy, and the medical context of genetic counseling is not necessarily the framework for most psychotherapy. When Sheldon Reed coined the term “genetic counseling” (Resta et al. 2006), I believe he wanted to emphasize that the form of psychological support genetic counselors offer to patients is different from that of psychotherapy, especially with respect to varying processes, goals, and outcomes.

I have previously argued that psychosocial counseling for genetic counselors has a different process (e.g., brief, present focused), as well as a more specific outcome goal (e.g., decision-making, acceptance of genetic diagnosis, communication of genetic information) than interactions in psychotherapy (Redlinger-Grosse 2014). While psychotherapy is a process involving behavior change on a longer-term basis; genetic counseling is a process of behavior facilitation (e.g., decision-making). I return to Jon Weil’s discussion of “little and big psychosocial” (Personal communication, October 2, 2008) to highlight these differences. Weil coined these terms as a way to frame the psychological areas of expertise of genetic counselors versus psychologists. He proposes that genetic counselors work with their patients on “smaller, immediate, interactional aspects” (i.e., little psychosocial issues) of counseling; in contrast, the larger, longer-term big psychosocial issues such as “marital discord, significant anxiety or depression” are better addressed in long-term therapy with psychotherapists.

I have experienced these subtle, but important distinctions in how little and big psychosocial issues are addressed in genetic counseling, and more recently in my psychotherapy work in psychology. For example, in the context of psychotherapy, practitioners approach an issue such as anxiety through a comparatively long-term relationship, incorporating assessment of origin based on family and culture, broadly defined; assessing impact on functioning, including interpersonal relationships; and using interventions aimed at promoting lasting and sustainable change. Genetic counselors and the process of genetic counseling do not exclusively share these processes and goals. We do not look to address long-term management of the patient’s anxiety. Rather, genetic counselors are skilled at working with a patient’s anxiety within the context of a genetic diagnosis and/or decision. We are extremely adept at quick assessment and building of rapport. The patient’s anxiety is acknowledged and understood to impact their immediate reactions to genetic information. We draw upon the patient’s strengths and pre-existing coping skills to facilitate their ability to incorporate information and/or make informed decisions; this is a our primary goal (albeit one of many potential genetic counseling goals and outcomes). As illustrated, the pacing of practice is inherently different given the brief model of genetic counseling versus longer-term model of psychotherapy. Psychologists are careful to only address issues and concerns that are within the scope and time frame of what the client and setting has to offer. Similarly, genetic counselors need to practice within their ethical bounds of what time (and competencies) allow and should refer patients and families to a psychotherapist when their concerns warrant longer-term support.

The differences in education/training and supervision between genetic counselors and psychotherapists also warrant discussion. It is worth acknowledging that the training I received, in part from the first author of the paper on which I am commenting, was more extensively focused on counseling and supervision than is typical in other genetic counseling training programs, and for this I am grateful. In the past six years, however, the additional training and supervision in psychological theory and my clinical work have been rigorous and fostered a broader and deeper psychological lens that I use to approach patients/clients. With this training and psychotherapy experience, I have gained a comfort level and clarity that allows me to shift between the worlds of genetic counseling and psychotherapy and in doing so, recognize the unique differences. I question, however, the extent to which genetic counseling students and practicing genetic counselors are similarly willing and able to make these distinctions. In training genetic counseling graduate students, I (and others) have spoken about the ways in which the very notion of providing “psychosocial counseling” evokes hesitation and anxiety (cf. Borders et al. 2006; Yager 2014). Practicing genetic counselors have also expressed concerns that the goals of their practice, according to some of the proposed REM goals that address patient’s long-term psychological needs such as adaptation, coping, and empowerment, are beyond the scope of their practice (Hartmann et al. 2015). Additionally, proposing a moniker of “psychotherapeutic genetic counseling” only further muddies the waters with respect to several professional fields that claim to be providing psychotherapy (e.g., clinical psychologists, counseling psychologists, marriage and family therapists, psychiatric social workers, psychiatric nurses, etc.). I believe genetic counselors do not feel fully trained or proficient to align wholly within this professional group of psychotherapists. While I think we need to move through these reactions and demystify the way in which a psychological approach to genetic counseling is attainable, I wonder (and worry) if the term “psychotherapeutic genetic counseling” will further perpetuate these fears and resistance to addressing patients’ psychological needs.

Ultimately, I believe that Biesecker, Austin and Caleshu (2016) and I are arguing for the same end goal: the incorporation of psychological concepts and strategies in genetic counseling to meet the psychological needs of our patients. Our vantage points, however, are different. My experience and training in genetic counseling and psychology inform my belief that, while the “counseling” in genetic counseling is critical for our patients, we are not providing psychotherapy. I think we need additional dialogue – a call and response - within our field to more carefully establish appropriate language and terms to capture the unique ways in which genetic counselors use psychological concepts and strategies to impart genetic information and support patients. Further conversation will allow us to establish better education, training, and supervision strategies to address barriers towards adopting a practice model such as the REM that incorporates teaching and counseling goals. The fields of genetic counseling and psychology can then share a common vantage point that articulates the strengths within our similarities and distinctions.