Of all the respondents, only two counselors described strong
countertransference reactions that stemmed from their own unresolved personal cultural issues. Counselor 4, who is 27 years old and identifies with a minority ethnic background, had experienced being stereotyped while growing up. She always attempted to defy stereotypes she felt were held towards herself. She described the countertransference she experienced when working with patients of a different ethnic
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minority background, who exhibited stereotypes that had been applied to her by others:
...now for myself internally though, why else would I feel any kind of feeling toward these families or toward these situations? I don’t know if a part of it is coming from a background where I’m a minority and I didn’t go through these things and I didn’t have these issues and I’m like, well why are you doing this? Why are you making the stereotype more concrete and solidifying it? ...I mean it’s different for [my ethnicity]... But they’re stereotypes non-the less and I think part of my frustration might actually be from that. That I’m thinking, 'you know what? all you’re doing is firming up my stereotypes as they are, why are you letting me do that?'
As the interview progressed, Counselor 4 was able to come to a self-realization that her issues stemmed from her own life experiences. Counselor 6, who is 35 years old and identifies with a marginalized group, also described how her own life experience growing up with a dual identity has led to strong countertransference when working with minority patients:
I think, honestly, I think it’s kind of a reflection of my own identity issues and I’m, my struggle to really figure out where they lie, in terms of my ethnic background. And so, the best identity that I’ve come up with is “other”. And so I encounter somebody else who's in an “other” situation, I immediately feel like I relate to her but she doesn’t necessarily relate to me because she has no idea that that’s where I’m coming from...sometimes [I feel] an overwhelming amount of empathy. Like it’s just exhausting, because I just suddenly worry about everything for her. I just feel like I’m in a snowstorm of thought. Like, oh my God, she’s in a foreign culture and she doesn’t speak the language, and I’ve so been there like so many times. She needs a best friend, she needs a mom, and she needs somebody to do her grocery shopping. Or is she literate here or not? I don’t know because I’ve been illiterate in a country before and it’s scary. Does she have family support? Does she have a job? What’s going on here? So it’s not just genetics then suddenly, it’s like wow; this is
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DISCUSSION
The genetic counselors who participated in this study had an interest in increasing cultural competency in the field of genetic counseling. Through open discussion, it was evident that all genetic counselors had an appreciation for diversity, and many described personal experiences of having felt like a minority, either
growing up or later in life. Several described experiences of feeling different, or like an "outsider," because of ethnicity, religion, socioeconomic status, education, or personal experience. Others grew up in diverse communities and were shocked when first exposed to prejudice and racist attitudes. Counselors expressed both implicity and explicity that these experiences influenced worldviews, leading to increased appreciation of diversity and increased sensitivity to the need for cultural
competency. Regardless of sensitivity to cultural differences, the genetic counselors in this study described several challenges when working cross culturally.
In comparison to the current literature, the findings of this study overlapped with several others. Language barriers and working with interpreters is a challenge described by Bower, Veach, Bartels, and LeRoy (2002) as well as Kai et al. (2011). The results of these studies as well as the current one discussed how language barriers and working with interpreters can impede the communication process. The study by Kai et al. especially focused on the challenge of working with interpreters who were family members, a challenge briefly expressed by only one genetic counselor in this study.
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Differing values and beliefs is another challenge common to the results of several studies. Bower et al. (2002) reported how genetic counselors experience challenges with male dominated culture, including both paternalistic attitudes towards information sharing and preference for a male child. Similarly, Kai et al. (2011) also described the challenge of differing values experienced by different healthcare professionals, but focused on the need to focus more attention on the meaning of patient autonomy in a cultural setting, expressing that patient autonomy may not be universal in all cultures. The counselors in this study expressed the same challenges as both these studies.
While a few emergent themes of this study overlap with those found in the literature, this study attempted to explore professional challenges specific to cross- cultural genetic counseling and through its qualitative nature, attempted to gain a better understanding of the complexities of each challenge and how and why it may affect genetic counseling practice. In addition to language barriers and differing values and beliefs, other challenges emerged, including lack of experience,
stereotyping, and minority countertransference. Each challenge is discussed in more depth below.
Lack of Experience
While most counselors had past experience that made them more open to diversity, many counselors still expressed that lack of experience with certain cultures made working across cultures somewhat challenging. No one expressed that medical
care was directly affected, but challenges with regards to building rapport or helping patients psychosocially were discussed. One counselor expressed fear of being culturally inappropriate and another described not having a frame of reference from which to provide counseling. Another counselor specifically described how it can be challenging to discern the degree to which the psychosocial aspect should be
addressed. While counselors want to ensure they help facilitate decision-making, especially when patients may have underlying emotions associated with their
decisions, questioning decisions that may have a cultural basis may be disrespectful. It is often challenging to recognize which tactic is more appropriate in a cross-cultural encounter. Knowing how to address such situations can be challenging for genetic counselors, and it is quite possible for counselors to work from past experience, or stereotypes, in this situation, especially if they have a lack of experience with the specific culture of their patient.
Stereotypes
The professional challenge most described by genetic counselors was that of stereotypes. Multiple facets of stereotypes were described, showing the complexity of the topic. Stereotypes are rigid preconceptions held about all people who are
members of a particular group, whether it is defined along racial, religious, sexual, or other lines (Sue & Sue, 1990). Stereotypes have been described before as a potential challenge for genetic counselors when working cross-culturally (Middleton et al., 2007) and several papers regarding multicultural counseling describe the essential
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need to address stereotypes (Wang, 1994; Weil, 2001). When discussing stereotypes, counselors noticed trends in working with certain populations, and would thus naturally create stereotypes in order to help them in working with patients in which they otherwise would not have had any knowledge or experience. While counselors expressed the helpfulness of stereotypes, they felt it was unjust to categorize people. They felt that using stereotypes was ethically wrong because stereotypes have the potential to take away the personal spirit of the individual. However, many genetic counselors struggled with being open to other perspectives when patients' actions and beliefs fulfilled certain stereotypes. Intracultural variability was discussed, and it was stressed that while deviations from the stereotype occurred only rarely in the
participants’ experience, the fact that they do occur was enough to argue that
generalizations are not always correct. One counselor expressed that the danger with stereotypes is that they pigeonhole individuals into rigid preconceptions, implying that counselors may miss opportunities for fulfilling patients' needs if focus is spent on counselors' perceptions rather than on the true thoughts and feelings of the patient. It was evident that stereotyping the patient affected clinical practice, having the potential to inhibit care. One counselor used the example of being inclined to not provide certain options, such as termination, to a Hispanic mother because of the stereotype that most Hispanics don’t terminate due to religious beliefs. Another described the inclination of not wanting to discuss details of information when communication is challenging, for example, when language barriers are present. In order to prevent stereotypes from affecting clinical practice, several counselors
expressed the need to be aware of their inclination to stereotype in order to refrain from giving sub-par care.
Counselors themselves are not free from being stereotyped, and a few of the interviewees expressed resistance from patients, discussing feelings of being
stereotyped themselves. Counselors described distrust of the medical system by minority groups, which is a common challenge previously described with regards to the general medical field (Armstrong, 2007), including genetic counseling (Graves, 2011). With a history of oppression, discrimination, and racism, it is no surprise that certain groups possess vigilant and distrusting attitudes. According to the American Medical Association, minority patients may also develop mistrust because of fear of being treated differently or because of feelings of discrimination when they disclose that they have health beliefs that are not based on Western medicine. This may stem from stereotypes and beliefs that all healthcare providers are not as tolerant of
cultures differing from the majority culture. One counselor described the resistance as a barrier to understanding one another, thus making counseling the patient
challenging. Additionally, gaining patient trust was also a challenging task. While this was the case, one counselor expressed that a technique, like self-disclosure, helped to bridge differences, showing the patient she was not a threat.
Forming and using stereotypes can be bidirectional in a genetic counseling interaction. The overall challenge for genetic counselors with regards to stereotypes is preventing stereotypes from counterproductively affecting their practice, while at the same time understanding that patients may stereotype them due to historical and
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social influences. It is unrealistic to expect counselors or patients to not form stereotypes, as it is described as a natural human phenomenon. But realizing the impact that stereotypes can have on individuals as well as the impact it can have on clinical practice may help genetic counselors to appreciate the challenge. Genetic counselors can reflect on the challenges of being stereotyped as a counselor in order to better understand the similar emotions and challenges patients may face when they are being stereotyped.
Differing values and beliefs
Several genetic counselors described how working with patients with differing cultural values can be very challenging. As the genetic counseling profession
continues to advance and strives to equally serve a growing diversity of people, it is important to recognize that values that are central to the genetic counseling profession may not be held to the same degree of importance in other cultures. Likewise, values considered important in Western society may not be viewed similarly by patients with roots in non-Western culture. Because reactions to value and belief differences can be autonomic, cognitively understanding differences in values is only part of the
challenge. While value neutrality has been stressed in the people-centered approach to counseling, learning to be comfortable with differing values poses an even greater challenge for genetic counselors.
One example of a value in which patient and counselor may disagree is that of non-directive counseling. Non-directive counseling protects patient autonomy
because it is believed that patients have the autonomy to make the decisions that are in line with their own beliefs and values. Kessler claims that, “Non-directiveness describes procedures aimed at promoting the autonomy and self-directedness of the client." Non-directive counseling has been the central ethos of the field of genetic counseling for several decades (Weil, 2003). As a guiding principle in the profession, it not only protects patient autonomy, but it also protects individualism, a value highly regarded in Western culture. While one interviewee believed that her struggles with differing ethical values stemmed from disagreements with the genetic counseling culture, these values can span both genetic counseling and Western culture, and can be challenging for both reasons. No matter the reason, it is important to recognize that non-directive counseling or individual autonomy may not be appreciated as highly by other cultures. From a patient perspective, it is noteworthy that individual decision- making may present more burdens than benefits (Rapp, 1993) and that patient autonomy may be better accepted by individuals who have already acculturated to Western society (Awwad, 2007).
Another differing value is that of male favoritism, which can be seen to conflict with the value of equality, another highly regarded value in Western society. For cultures that value male favoritism, "the cultural basis for son preference may include the necessity or utility of male offspring for manual labor, war, elder care, property inheritance, continuation of the family name or blood line, and/or avoidance of the expense of dowries" (Puri et al., 2011, p. 1169). Male favoritism has a direct influence on sex selection, an ethical challenge many genetic counselors may face,
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especially in prenatal and reproductive specialties. When describing sex selection for a male fetus, one counselor in this study described the challenge of suppressing subconscious reactions when disagreeing with patient beliefs regarding the topic. This exemplifies the struggle with differing ethical values, even when counselors may be cognizant of the differences.
Lastly, the challenge of differing values and beliefs also encompasses challenges when working with patients who have differing religious beliefs.
Counselors expressed knowing that patients may possess different religious beliefs, but counselors struggled when it harbored patient guilt or prevented medical
intervention. Because genetic counselors strive for quality care, it is challenging when they feel that differing patient beliefs inhibits their ability to provide the appropriate care to their patients.
Language Barriers
Language barriers have previously been described as a professional challenge for genetic counselors (Bower et al., 2002; Forman, 2009). Counselors in this study expressed the same challenge, but elaborated on why they struggled with language barriers. Communicating across culture can be challenging when the meanings of phrases or words are lost in translation because cultural context can effect how words or phrases are interpreted. The challenge most described by counselors in this study with regard to language barriers was the difficulty in not only the communication process, but in how this lack of communication inhibited the genetic counselor's ability to provide psychosocial support. Counselors described feelings of worry and
confusion with regards to not being able to discern emotions or level of
understanding. Fulfilling genetic counseling duties can thus be hard to accomplish with such challenges.
Minority countertransference
Two counselors described very personal challenges when working with patients of different backgrounds. While not a prevalent professional challenge, the personal nature of the challenge made it noteworthy to discuss in this study. This was the theme of countertransference of the minority counselor. Countertransference is a psychoanalytical theory first coined by Sigmund Freud in 1910. His classical
definition focused on the clinician's unconscious and pathological reactions to a patient's transference. Kernberg (1965) considers countertransference a result of unresolved conflict. While countertransference has been extensively studied in the psychoanalytic literature, countertransference is a phenomenon in any counseling interaction, including genetic counseling (LeRoy, Veach, Bartels, 2010). Weil (2010, p. 176) describes countertransference as the "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." Using case examples, Middleton et al. (2007) examined transference and
countertransference during transcultural genetic counseling sessions. One of the case studies was from the perspective of the minority counselor, who described his countertransference when counseling patients of his same ethnic background. He
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expressed feelings of anxiety that were engendered by both his closeness to the culture as well as his feelings of empathy. Additionally, he expressed feeling pressure to be directive, which was the preferred counseling style of the culture.
In the present study, two counselors described how their own personal experience as a minority engendered countertransference reactions when working with other minority groups, making interactions with other minority clients a challenging endeavor. Because the majority of genetic counselors are of Caucasian descent, minority counselors have previously described "pressure from classmates, instructors, and colleagues to be diversity experts regarding all cultural/ethnic groups and to figure out how to increase diversity within the field" (Schoonveld, Veach, and LeRoy, 2007, p. 64). While counselors of certain ethnocultural backgrounds may have more cultural knowledge, they may face their own struggles when working with other minorities. This exemplifies how cultural competency can be seen as a goal for all genetic counselors, regardless of ethnocultural background.
Value of Professional Experience
The most salient lesson learned by genetic counselors was realizing the value of experience when working with patients of different backgrounds. Many described the value of experience, expressing that cultural competency is not easily taught in the classroom. It is through experience that one can be in tune with his or her own
cultural biases as well as gain better understanding of how one would handle
it was expressed that the best way to learn was through trial-and-error and human experience. While considered the most effective way to learn, experiential learning can be a difficult or painful process. One counselor described how she felt "really dumb" when she allowed stereotypes to affect her practice. Another counselor
described how her patient's prejudice attitudes were hurtful when the patient preferred a provider of a different ethnic background. Perhaps experiencing these painful processes is what engenders awareness with regards to both the perception of others as well as one's own biases.
Practice and Training Recommendations
The profession of genetic counseling is unique in that while genetic counselors are health professionals and medical providers, part of their role is to facilitate decision-making and provide psychosocial support. Cultural issues can make fulfilling these job responsibilities challenging. Being cognizant of one's own biases and, more importantly, the biases of the profession, may help counselors understand the role of genetic counseling in a cultural context. Tervalon and Garcia (1996) present the idea of cultural humility, stressing the importance of humility in developing and maintaining mutually respectful and dynamic partnerships when working cross-culturally. They stress the lifelong commitment to self-evaluation and self-critique as lifelong learners and reflective practitioners.
Additionally, while certain values and beliefs may be central and important to the profession, it is helpful to understand that these values and beliefs may not be
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central to other cultures. Providing quality care should continue to be the goal in working with different patients, but it is also important to realize that patient needs