by Jon Weil
Jon Weil is an independent scholar focusing on psychosocial aspects of genetic counseling and on international genetic counseling defined broadly and deeply. This post is based on a section in his chapter 6 of Grubs et al. The Oxford Handbook of Genetic Counseling, in an effort to disseminate the ideas more broadly and stimulate discussion. That section, in turn, is based on his chapter 7 in Leroy et al. Genetic Counseling Practice: Advanced Concepts and Skills as well as the work of many other clinicians and scholars.
Patient resistance in genetic counseling takes many forms. When overt it may manifest, for example, as questioning the genetic counselor’s training and competence or refusing to continue the consultation. When subtle it may involve behaviors such as denying aspects of family history or arriving slightly late for an appointment. Intermediate examples include repeatedly changing the subject to an apparently irrelevant topic or inappropriate humor. It almost always involves an element of self-protection and/or protection of others, and most such behaviors can also be thought of as psychological defenses.
Overt resistance is clearly problematic for the genetic counselor. It may evoke a variety of responses such as frustration, concern about one’s professional competence, and a loss or reduction of empathy. Intermediate or subtle resistance may or may not require an adjustment in the genetic counselor’s responses. But whatever the response, patient resistance is often perceived as an impediment to the flow of the session and to pursuing the genetic counselor’s mandated and desired agenda.
Patent resistance has a central role in psychodynamically-oriented psychotherapy. The iterative, often multi-session process of identifying, acknowledging, exploring and at least partially addressing the underlying issues that led to the resistance is a major path toward resolving emotional issues. This is not possible or appropriate in genetic counseling. However, as genetic counselors are well aware, listening carefully and responding effectively is appropriate and often necessary. Thus, I wish to propose a different way to think about patient resistance:
Patient resistance is critically important, often at least partially non-verbal communication that, if properly attended to, can be immensely helpful in achieving the goals of the genetic counseling session.
I suggest that the reader’s introspection, like my own, will make this clear. When my cardiologist says, “You need to start taking your cardio-walk four times a week instead of three”, my immediate, self-protective response is, “I can’t; that is too much”. However, it is not the details of this interaction that are important. It is the fact that, at that moment, this is the most important, actually the only, issue on my mind. That is why it is so productive to interpret patient resistance as communication!
What are the implications of this reframing?
First and foremost, it puts the genetic counselor in direct, often at least partially non-verbal, contact with the fear, anxiety, confusion, desire to protect self and family, or other emotion or cognition that is consuming the patient at that moment. The evolving response that is crafted can then help both genetic counselor and patient address this critical issue. For example:
“I have been telling you about how this test works and what the results might be. But I didn’t realize until now that your primary concern is how the result might affect the rest of your family.”
(This is in part non-verbal because, behind what is said is the implicit message: I hear what you have been trying to tell me.)
Second, it may allow a more empathic, deeply understood response to the patient that potentially deepens the conversation in the remainder of the session and beyond.
Third, it may influence countertransference that the genetic counselor is experiencing. It will not necessarily reduce it. More direct contact with the patient’s fear, anxiety or hopelessness may increase the genetic counselor’s own concerns about working with the patient or resonate with her prior experiences. However, as already indicated, it may also help convert more difficult feelings into empathy and understanding, thus easing the burden of the interaction. Whatever the circumstances, as I have previously argued in chapter 8 of Leroy et al. Genetic Counseling Practice: Advanced Concepts and Skills, aligning the genetic counselor’s countertransference to more accurately reflect the patient’s concerns should improve its value as a guide to further interventions.
To conclude, perceiving patient resistance as communication, whatever its form and intensity, provides a key to identifying and responding to the most salient issue of the moment, thus advancing the conversation productively.
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