University of Michigan School of Public Health, Ann Arbor, Michigan, USA.
Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA.
J Genet Couns. 2022 Oct;31(5):1020-1031. doi: 10.1002/jgc4.1609. Epub 2022 Jul 30.
Genetic counselors (GCs) have traditionally been trained to adopt a position of equipoise or clinical neutrality. They provide information, answer questions, address barriers, and engage in shared decision-making, but generally, they do not prescribe a genetic test. Historically, GCs have generally been trained not to persuade the ambivalent or resistant patient. More recently, however, there has been discussion regarding when a greater degree of persuasion or directionality may be appropriate within genetic counseling (GC) and what role MI may play in this process. The role for "persuasive GC" is based on the premise that some genetic tests provide actionable information that would clearly benefit patients and families by impacting treatment or surveillance. For other tests, the benefits are less clear as they do not directly impact patient care or the benefits may be more subjective in nature, driven by patient values or psychological needs. For the former, we propose that GCs may adopt a more persuasive clinical approach while for the latter, a more traditional equipoise stance may be more appropriate. We suggest that motivational interviewing (MI) could serve as a unifying counseling model that allows GCs to handle both persuasive and equipoise encounters. For clearly beneficial tests, while directional, the MI encounter can still be non-directive, autonomy-supportive, and patient-centered. MI can also be adapted for equipoise situations, for example, placing less emphasis on eliciting and strengthening change talk as that is more a behavior change strategy than a shared decision-making strategy. The core principles and strategies of MI, such as autonomy support, evocation, open questions, reflective listening, and affirmation would apply to both persuasive and equipoise encounters. Key issues that merit discussion include how best to train GCs both during their initial and post-graduate education.
遗传咨询师（GCs）传统上接受的培训是采取平衡或临床中立的立场。他们提供信息、解答问题、解决障碍并参与共同决策，但通常不推荐进行基因检测。历史上，GCs 通常不被鼓励去说服犹豫不决或有抵触情绪的患者。然而，最近有人讨论了在遗传咨询（GC）中何时更适合采取更大程度的说服或引导方向，以及 MI 在这个过程中可能扮演什么角色。“有说服力的 GC”这一角色基于这样的前提，即某些基因检测提供了可操作的信息，如果通过影响治疗或监测来明显使患者及其家庭受益，那么这些信息将是有益的。对于其他测试，其益处不太明确，因为它们不会直接影响患者护理，或者受益可能更具主观性，由患者价值观或心理需求驱动。对于前者，我们提出 GC 可以采用更具说服力的临床方法，而对于后者，更传统的平衡立场可能更为合适。我们建议，动机性访谈（MI）可以作为一种统一的咨询模式，使 GC 能够处理有说服力和平衡的情况。对于明确有益的测试，虽然具有引导性，但 MI 访谈仍然可以是非指导性的、支持自主性的、以患者为中心的。MI 也可以适应平衡情况，例如，减少引出和加强改变谈话的重视，因为这更像是一种行为改变策略，而不是一种共同决策策略。MI 的核心原则和策略，如自主性支持、唤起、开放式问题、倾听和肯定，适用于有说服力和平衡的情况。值得讨论的关键问题包括如何在 GC 的初始和研究生教育中最好地培训他们。
