ConsGen_Curs4_ENGLEZA

8/19/2019 ConsGen_Curs4_ENGLEZA

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Introduction:

• Mapping the human genome - remarkable scientific achievement - anew template with which to consider the relationship betweenmolecular factors and human behavior and psychology.

• Modern genetic efforts continue to clarify our understanding ofthe human condition while challenging our medical, social, andethical preparedness to deal with the opportunities andimplications associated with these new discoveries.

• Anderson and Nickerson (2!" - emphasi#e that psychologists willbe best prepared to participate in the clinical$ research$ and policyissues emerging in this genetic era when they are knowledgeableof the tools and findings related to genetic developments.


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• Advances in genetic science over the past half century have spanned abroad spectrum of human conditions. %&. the etiological andhereditary mechanisms of numerous diseases have now beenidentified' forms of cancer$ kidney disease$ muscular dystrophies$ and

select neurological disorders.

• enetic science offers the ability to better identify and even predictcertain diseases - hopes for early intervention and treatment.

• )n addition$ genetic research - provides insights into the relationshipbetween genes and specific cognitive and developmental limitationssuch as *ragile-+$ ,urners$ linefelters$ /illiamss syndromes andeven 0owns syndrome.

• Moreover$ modern genetic research offers the hope of identifyingthe multiple genes$ and gene-environment interactions$ contributingto comple& psychological and behavioral dimensions involved inaddiction$ aggression$ learning and memory$ and numerousdevelopmental deficits (e.g.$ autism$ attention deficit disorder$reading disabilities$ and depression1 see lomin$ 3445".


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• ,his ever-growing accumulation of genetic 6 the postgenomics age (lomin 7 8rabbe$ 2"$ characteri#ed by a future now focused ondeveloping new methods$ techni9ues$ and strategies to helpresearchers and practitioners use genetic information to

diagnose, predict, and ultimately intervene in matters of humanhealth and behavior.

• )mportant' genetic information is no longer part of a knowledgedomain with applications limited only to medical researchers andpractitioners.

• 8ounseling psychologists may be instrumental in helping individualclients$ as well as the public$ understand the relevance of geneticinformation to psychological$ behavioral$ and lifespan developmentissues.

• Advances in genetic knowledge will clearly e&pand the issuespsychologists might consider when helping certain clients managethe social-emotional and behavioral challenges associated with thepresence (or prospect" of a particular disability or illness.


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• Concern about genetic conditions : a ma;or reason that clients seekcounseling services$ particularly when undergoing genetic-testingprocedures to identify the presence of genetic mutations associated withclinical disorders.

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• The first part of this review (i.e.$ ,he 8ounseling sychologist/ithin the enetic 8onte&t" : offers a =biopsycho-sociocultural>framework for conceptuali#ing the e&perience of clients withgenetic concerns$ summari#ing certain procedural or logistical

aspects of genetic testing and considering various issues inmedical genetics$ behavioral implications of genetic results$ andinterventions associated with genetic conditions.

• The second part (i.e.$ Assisting 8lients with enetic 8oncerns" -considers how the counseling psychologist can apply his or her

uni9ue training and skills to help clients move through a genetic-testing process and prepare for a future with geneticimplications.

• The final section (reparation for ?cientist-ractitioners/orking in enetic 8onte&ts" addresses the development of

skills$ competencies$ and professional perspective needed byscientist-practitioners to best meet the clinical$ research$ andlegal-ethical issues that counseling psychologists are likely toencounter in the genome era.


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TH C!"#$%I#& '$(CH!%!&I$T )ITHI# TH &#TICT$TI#& C!#T*T

• ,he developments stemming from the mapping of the human genome- a philosophical shift in medical perspective from a reactiveposition (i.e.$ treatment follows diagnosis" to a more predictiveendeavor (see @en#ong$ 23"$ whereby genetic markers for later-developing conditions can be identified prior to symptomdevelopment.

• ,he medical application of our increasingly advancing knowledge ofthe human genome is most evident in various genetic-testingprocedures$ which can': help identify a parent carrying an inherited recessive mutation (i.e.$

carrier testing": aid in confirming an e&isting condition (i.e.$ diagnostic testing": assess the risk to a fetus for certain defects (i.e.$ prenatal testing": or establish an ostensibly healthy adults risk for developing a disease

later in life (i.e.$ presymptomatic testing".


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TH C!"#$%I#& '$(CH!%!&I$T )ITHI# TH &#TICT$TI#& C!#T*T

• ,he importance of a truly multidisciplinary perspective ofdisease has intensified in the modern genetic era$ furthersuggesting that disease and disability in the 23st century willre9uire the application of both reductionistic and lifespandevelopment perspectives when considering the needs of thosedealing with genetic information.

• )n this conte&t$ the counseling psychologist may be in a mostuni+ue position to help where other professionals havesomewhat less to offer.

• )ndeed$ where biomedical options are limited$ or where difficultdecisions must be made concerning future issues$ counselingpsychologists possess the skills and training in assessment$therapy$ and perspectives on vocational planning and adustment that can help promote present and future adaptive behavior.


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ramework for Considering &enetic-/elated Concerns

• ealth and disease are best considered within conte0t.

8onte&tual variables typically reflect the richness and depth ofan individuals uni9ue life circumstances$ shaped not only by apersonal history but also by psychological$ social$ and culturalcharacteristics collectively influencing a future tra;ectory.

• %ngel (34BB" previously offered a biopsychosocial perspective ofhuman illness$ emphasi#ing the relationship among biomedical$psychological$ interpersonal$ and sociocultural dimensions of apersons life conte&t and e&perience with an illness.

• ,oday$ and in the years ahead$ the uni9ue life conte&t of each

individual might include genetic information$ thus offering anadditional perspective for thinking about client care across thelifespan (aut$ 221 earney 7 Mount$ 2".


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ramework for Considering &enetic-/elated Concerns

• ,he framework presented here (see *igure 3" is modeled in partfrom %ngels (34BB" earlier work and offmans (2" more recentefforts$ suggesting that a counseling psychologists appreciation of aclients genetic concern is enhanced through understanding relevantbiomedical issues (genetics$ biological structures$ and systems"$ theclients psychological characteristics and coping strategies$ and thebroader environmental dimensions impacting the clients life.

• ,he framework also incorporates elements of Cronfenbrennersecological perspective on lifespan development$ recogni#ing thatgenetically linked conditions affect behavior through an interactionamong various life compartments (e.g.$ self$ environment$ andculture" and time-dependent changes occurring as individualsanticipate future disease or progress through an actual illnesstra;ectory.

• ,his framework suggests opportunities for counseling psychologiststo intervene and provide support throughout all phases of a clientse0perience1before, during, and after a genetic-testing process.


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• enetic tests can be conducted at multiple points indevelopment and for various reasons'

: prenatal detection of certain disorders (e.g.$ 0owns syndrome and*ragile-+"

: identification of parental carrier status (e.g.$ cystic fibrosis and0uchenne muscular dystrophy"

: confirmation or diagnosis of a suspected medical condition (e.g.$kidney disease and neurofibromatosis"

: early detection of genes related to adultonset disorders (e.g.$breast and ovarian cancer and untingtons disease D0E".

• @egardless of the presenting concern or circumstance$ genetic

testing in its varied forms is fundamentally associated withthe need for information, guidance related to decisionmaking, and general social or emotional support.


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&enetic Testing

• ,o facilitate clientsmovement through a genetic-testing process$ )suggest a limited series of +uestions in Table 2 to promote counselingpsychologists consideration of the procedural or logistical elementsinvolved in genetic testing in addition to the identification of relevantgenetic issues$ bio-behavioral implications$ and potential intervention ortreatment alternatives associated with a genetic scenario.

• *or the counseling psychologist$ information gathering may be aprincipal ob;ective when working with clients in a genetic conte&t$

particularly with a limited background in basic and applied genetics.

• ,he counseling psychologist can obtain helpful and readily accessibleinformation from various online sources regarding basic genetic terminology associated with concepts (see the National uman enome@esearch )nstitute"$ in addition to coverage of specific conditions$

testing procedures$ and available testing locations (ene,ests$http'FFgenetests.org".

• )t is also helpful to be aware of local or regional genetic testingcenters and to consider the support available through relevant medicalor genetic testing personnel whenever necessary.


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'rocedural considerations:

• As noted in *igure 3$ genetic testing is a multidimensional process$ characteri#edby the influence of biological elements and psychosocial resources on adaptive

behavior over time.

• )n addition$ there are procedural$ financial$ and time-related aspects of theprocess itself that could impact a clients e&pectations$ attitudes$ and perceptionsof genetic testing (refer to ,able 2".

• 0epending on the nature of the condition in 9uestion and the type of testingre9uired$ a client might undergo a series of consultations with medicalprofessionals$ genetic counselors$ and psychologists as part of a formal genetic-testing process.

• ?uch a process may involve multiple visits to a genetic-testing center devoted todeveloping a client history$ discussing the clients e&perience with the condition in9uestion$ providing educational information$ becoming familiar with the testing

process$ and administering the test process itself.


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2rocedural considerations'

• )n the conte&t of a genetic concern$ a counseling psychologist may beinstrumental in providing information as part of an assessment process. Insome cases, a psychologist3s primary responsibility may be to providemedical and genetic-testing personnel with information regarding theclient3s psychological and emotional readiness to undergo the testingprogram.

• ?ome clients may have already established a relationship with a counselingpsychologist in advance of their decision to seek testing$ whereas others maybe referred to a psychologist as part of the testing process.

• )n either case$ the counseling psychologist should possess a level ofknowledge that appreciates the genetic condition in 9uestion$ providesinsight into the process the client will e&perience$ and raises awareness ofthe factors potentially influencing the clients decision to seek testing and

his or her ability to deal with an eventual result (see de/ert$ 3445".


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'rocedural considerations:

• Apart from understanding the procedural issues$ it is important torecogni#e the costs$ both financially and emotionally$ for the client.

• enetic testing can be somewhat costly depending on the type of analysis(e.g.$ C@8A3FC@8A2 cancer screening can range from G! to G2$H"$although the cost of 0NA testing and genetic counseling sessions(appro&imately G32Fhr" may be covered if the process is medicallyindicated.

• *inancial demands and obligations are naturally part of a clients overallgenetic-testing conte&t$ but there may also be privacy concerns regardingan insurance providers knowledge of genetic-testing procedures. ?uchissues should be clarified or further investigated with genetic-testingpersonnel where necessary.

• ,he counseling psychologist need not be an e&pert in the procedural orlogistical elements in the genetic-testing process$ but a basicunderstanding of this information (or at least an awareness of where toseek answers" can provide an important framework for understanding oranticipating a clients e&perience and for identifying possible 9uestionsregarding testing (see ,able 2".


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&enetic results and bio-behavioral implications .

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&enetic results and bio-behavioral implications .

• ,he decline in physical status associated with a condition like 0 is certainlynot representative of all genetic scenarios$ yet this e&ample underscores the

need for counseling psychologists to systematically approach a genetic concernby gaining familiarity with relevant genetic terminology$ identifying andunderstanding the biological systems involved$ and considering the eventualimpact on client health and wellness.

• A counseling psychologist might work with any one of a growing number ofgenetic concerns affecting individuals at various points across the lifespan

(refer to ,able 3"$ including families of children with 0uchenne musculardystrophy (+p23.2"$ adults dealing with hereditary cancers (e.g.$ ,!J$C@8A3FC@8A2"$ and individuals preparing for a future clouded by theuncertainty associated with a probability for Al#heimers dementia (?%N3".

• Although circumstances may be 9uite different$ each conte&t re9uires anawareness of how genetic information relates to disease probability$ physical

and behavioral e&pression$ and intervention strategies.


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• &enetic results and treatment implications .

• )n many of the previously mentioned conditions$ the tendency is

certainly to medicali#e the issue and approach intervention from ahighly reductionistic perspective.

• ,he medical model generally identifies the source of a problem andattacks it via pharmacological or other biomedical strategies. )n somegenetic scenarios$ which arguably represent the most reductionistic

of all medical issues$ treatment aimed at early detection or preventionmay be available$ whereas in others$ this may not be an option.

• ,he counseling psychologist$ when researching a particular condition$should appreciate the realistic range of available options and thelimitations of science and medicine in predicting and treating a givendisorder (see ,able 2".


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• *or e&ample$ a client with a family history of cancer might receive geneticconfirmation of a specific mutation (e.g.$ 3Bp3J.3$ the ,!J gene1 see ,able 3"indicating a predisposition to certain types of cancer (i.e.$ technically referred to asKi *raumeni syndrome1 see http'FFgenetests.org".

• ,he recommendation following this determination may be for early and continuedsurveillance$ including a yearly dermatological analysis$ colonoscopy (depending onfamily history"$ and ongoing attention to certain physical symptoms.

• ,he counseling psychologist who is aware of the clients genetic status and medicalrecommendations for surveillance and testing may be best prepared to help theclient think about future health care decisions and the need for compliance withassessment strategies and best practices in health care.

• 8lient vigilance regarding medical monitoring$ and attention to emerging or changingphysical symptoms$ may be essential for optimal adaptation to the knowledge ofones current or future disease risk. )n other situations$ specific pharmacological oreven surgical options may be discussed in addition to surveillance recommendations.

• ,his may be best illustrated in the case of individuals (generally women" testingpositive for the C@8A3FC@8A2 mutation associated with an increased risk of breastand ovarian cancer (see ,able 31 ,hull 7 Logel$ 2I". 8ancer screenings may berecommended for certain clients$ whereas the suggestion of chemopreventivetechni9ues (e.g.$ ,amo&ifen" or prophylactic mastectomy in women may also bediscussed (,hull 7 Logel$ 2I1 see also http'FFgenetests.org".


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• /hen considering the various factors that might influence aclients decision making and behavior following a genetic result(refer to *igure 3"$ it is helpful to understand the biomedicalissues specific to a given genetic concern.

• )n addition$ it may be important to consider how well a clientunderstands the potentially novel and comple& informationpresented in a genetic scenario (%vers-iebooms et al.$ 2".

•


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$$I$TI#& C%I#T$ )ITH &#TIC C!#C/#$

• 8onsidering the procedural$ genomic$ and functionalFtreatment implications of agenetic process helps establish an important framework for thinking about aclients genetic concern$ yet this does not specifically address the counseling

psychologists central role in the genetic conte&t' supporting a client dealing withthe often comple& social$ emotional$ and developmental issues surrounding agenetic test and result.

• 8ounseling psychologists professional training and uni9ue strengths may be mostapplicable when helping clients identify and manage emotional challenges$ makeinformed decisions$ and prepare for optimal adaptation in a future influenced by agenetic outcome.

• A counseling psychologist working in a genetic conte&t will likely find manysimilarities to situations involving other chronic health concerns (e.g.$ coronaryheart disease$ oncology$ and neurological deficits". %ssentially$ the emphasis is onhelping clients manage the various social$ emotional$ behavioral$ and even vocationalissues associated with a given health condition.

• As reflected in *igure 3$ counseling psychologists might need to think about aclients adaptive needs at different times throughout a given tra;ectory whilerecogni#ing that these needs change over time.

• ,herefore$ the psychologists role might vary depending on when he or shebecomes involved with a client dealing with a genetic issue.



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• At this ;uncture$ it is important to briefly emphasi#e the distinction betweengenetic counseling and counseling psychology within the genetic conte&t.

• enetic counselors$ having speciali#ed training and certification in medicalgenetics$ help clients make informed genetic-testing decisions byemphasi#ing client education and preparation for future management andad;ustment.

• Alternatively$ counseling psychologists can offer support concerning thesocial and emotional issues associated with testing and decision making whilehelping clients develop insights and strategies concerning current and futureadaptation.

• ,here may be some overlap between counseling psychologists and geneticcounselors in the types of 9uestions asked or issues discussed when workingwith clients.

• owever$ the counseling psychologist might be involved with clients atvarious pointsand for potentially longer periodsthroughout a giventra;ectory (refer again to *igure 3"$ underscoring the need to appreciate themultidimensional nature of genetic issues$ the genetic-testing process$ andthe potential multilevel impact of genetic information across the lifespan.


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• ,able J suggests a range of issues and potential+uestions intended primarily to help the counselingpsychologist think about various factors andcircumstances that might affect clients but also topromote discussions with clients in the geneticconte&t.

• )nitially formulated according to pre-testingcounseling practices with clients preparing for 0testing$ the issues represented here can providehelpful and informative themes for consideration whenworking with clients presenting a much broader rangeof genetic concerns at any time in their personale&periences.


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• ,he general domains and sample 9uestions included here might help acounseling psychologist better understand a clients current conte&tby'

• (a" considering the motivational factors influencing a decision toseek testing

• (b" identifying a clients level of information regarding the conditionin 9uestion

• (c" observing a clients cognitive and emotional level of preparationfor a test result

• (d" addressing the degree to which a client has anticipated futureimplications of a test outcome.


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• Client 4otivation and %evel of Information

• ,here will undoubtedly be many reasons that an individual or family is

engaged in the genetic-testing process. Accordingly$ for the counselingpsychologist$ it might be helpful to develop a basic understanding of aclients rationale or perceived purpose for testing (de/ert$ 3445".

• 0iscussing client motives (e.g.$ =/hat has motivated you to seektesting>" might help clarify some of the circumstances surrounding adecision to consider testing and might open a discussion regardingperceived benefits and concerns related to the testing process oroutcome (for helpful perspective regarding C@8A3 screening$ see@obertson et al.$ 231 concerning 0$ see 8odori 7 Crandt$ 344I".

• )n9uiring about a clients e&perience with a given condition might alsoreveal information about his or her motivation (or reluctance" to seek

testing.

• *amily history and concerns about future planning may be significantfactors for many clients$ but individual differences in intellectual andemotional reactions to the condition for which testing is being sought arelikely to influence these issues (see ,aylor$ 2I".


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Client 4otivation and %evel of Information

• ,herefore$ discussing a clients knowledge of the condition as it might

emerge (e.g.$ symptoms$ associated impairments$ personal-familial impact$and need for support" and the potential implications of testing might offerinsight into his or her emotional e&pectations and cognitive understandingof the issue.

• %thically$ clients should have ade9uate information concerning medical andgenetic aspects of testing but should also recogni#e the psychological$

social$ and familial issues inherent in discovering ones genetic status (fordiscussion$ see de/ert$ 3445".

• ,he counseling psychologist should recogni#e the limitations of his or herown level of knowledge regarding the condition in 9uestion yet attempt tounderstand the possible moral and ethical concerns associated withobtaining and disclosing ones genetic status (de/ert$ 34451 ,aylor$ 2I"and the behavioral and psychological implications of a given genetic outcome.

• )n this regard$ consulting with a genetic counselor may be appropriate toclarifying information (or seeking referral sources where necessary" whileidentifying important issues for further discussion and consideration tobest assist a clients personal ad;ustment.


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Client 4otivation and %evel of Information

• ,he counseling psychologist need not limit himself or herself to

discussions based solely on the domains or 9uestions in ,able J. )ndeed$ aclients uni9ue circumstances$ needs$ and personal characteristics mightre9uire ad;usting a line of in9uiry or altering discussions of informationspecific to a given condition.

• ?ome clients preparing for genetic testing may not be comfortablediscussing long-term implications$ whereas others may be more inclined todiscuss such matters.

• ?ensitivity to a clients position along a particular tra;ectory (i.e.$ prior totesting$ shortly after testing$ and in the presence of symptoms" and anawareness of his or her emotional disposition can help frame the relevantissues and guide the nature and direction of discussion.

• 0ialogue concerning some of the preliminary issues listed in ,able J (e.g.$motivation and information" not only provides background informationconcerning client knowledge$ intellectual style$ and emotional status butalso offers an opportunity to consider his or her preparation for a test result (or reaction to a previously learned outcome" and anticipation of

current and future needs related to a genetic finding.


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• Client 'reparation for a Test /esult

• )ndividuals preparing to go through a genetic-testing process must ultimately beprepared to receive the results and digest the information regardless of the outcome .A clients coping resources might be challenged at each of the processs three points'the test$ the wait (i.e.$ while genetic testing is being completed"$ and the delivery ofresults.

• )n addition$ it is obvious that coping skills and adaptive resources can be challengedwell into a clients future$ particularly if the specific genetic concern is not e&pectedto emerge until well after a result is obtained (e.g.$ presymptomatic testing andprenatal testing".

• One of the uni9ue aspects of some genetic-testing scenarios$ such as testing for 0or breast and ovarian cancer$ is the possibility of confirming future disease riskwell in advance of possible symptom development (%vers-iebooms et al.$ 2".

• Accordingly$ a counseling psychologist can help identify immediate and long-termcircumstances that might influence a clients behavior$ decision making$ and generaldevelopment (refer to *igure 3".


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• Client 'reparation for a Test/esult

• A counseling psychologist can facilitate an attitude of preparation by helping a client discuss (or at least consider" how he or she mightdeal with the various testing stages while considering possiblereactions to a test result (positive or negative".

• sychological distress concerning a genetic outcome might be a focalpoint for some clients. ,herefore$ a client might be encouraged todiscuss how she or he might respond to the stress of receiving acertain test result and to address any plans of coping at the momenta result is delivered and in the time after it is obtained (see ,able J$preparation".

• ?uccessful coping with a testing outcome is a function of multiplefactors$ including financial and other environmental resources$available social and psychological supports (including pretest andposttest counseling1 de/ert$ 3445"$ and a clients uni9uepsychological resources brought to bear on the emotional andinformation-processing demands of a genetic scenario.


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Client 'reparation for a Test/esult

• ,he personal characteristics and e&periences of a client$ coupledwith his or her emotional and intellectual response to the genetic-testing conte&t$ might suggest additional issues to consider whenevaluating level of preparedness .

• articularly$ when a client appears distressed$ a counselingpsychologist might discuss appropriate responses to the stress ofuncertainty$ anticipatory an&iety$ or depression that might occurduring or after the testing process.

• )mportantly$ the psychologists repertoire of stress-managementtechni9ues may be of particular benefit at any time in a clientstra;ectory and may include client education$ cognitive-behavioralinterventions (see arker$ 344!1 ?ilver$ 2J"$ pharmacologicalconsiderations$ and referrals to local group organi#ations or peer-

group counseling for those who have obtained a result.


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• )t should be noted that the first three domains in ,able J (motivation $information $ and preparation " underscore the counseling psychologistsrole as information gatherer $ educator $ and counselor . )n addition$ thecounseling psychologist may find himself or herself in an evaluativerole.

• 0epending on the genetic conte&t$ he or she may be called on toe&plicitly evaluate the preparedness of a client to receive a result (e.g.$ 0 testing" and communicate this information to genetic-testingpersonnel.

• )n other situations$ considering intellectual$ emotional$ and decision-making characteristics might simply provide conte&tual informationconcerning the psychological resources available to the client as he orshe moves through a genetic-testing process. )n any event$ a counselingpsychologist may need to address the clients educational (i.e.$information and condition-specific knowledge1 ?oldan et al.$ 2"$cognitive$ and emotional status.

• ,hese represent issues that might impact a clients level of preparationfor a testing process while influencing his or her ability to anticipateor manage the immediate or long-term circumstances that might arisein the genetic testing conte&t.


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nticipation of Immediate and %ong-Term #eeds

• ?ome clients may have already spent considerable time thinking about

the future$ especially in cases where they have witnessed others dealwith the condition (?oldan et al.$ 2" or have learned of the futureconse9uences through previous genetic counseling.

• %ven so$ it might be helpful for clients to openly discuss their plans ande&pectations regarding a potential genetic outcome and to articulatetheir perceived needs and resources.

• )mportantly$ a counseling psychologist can help a client develop acognitive framework for at least thinking about the issues pertinent tohis or her future development.

• *or e&ample$ it might be beneficial to help a client discuss the meaningof a specific genetic outcome in the conte&t of his or her life and howthis information might be incorporated into his or her sense of self. )npart$ this will likely involve some attention to how a genetic status mightinfluence decisions about the future$ which could include family planning$financial decision making$ educational or vocational choices$ and a generalree&amination of personal priorities.


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• nticipation of Immediate and %ong-Term #eeds

• ,he specific issues to consider will vary depending on the clientand the genetic circumstances.

• An adult seeking testing for the 0 mutation may be faced withdifferent future implications (e.g.$ lack of curative treatmentand progressive neurodegeneration" than would a woman learningof her cancer risk due to a C@8A3 genetic mutation. )n turn$

both of these scenarios might differ from the issuesconfronting an e&pectant mother learning of her fetuss 0ownssyndrome status or from parents obtaining informationregarding a *ragile-+ mutation in a child.

• @egardless of the condition$ each scenario represents a need forcounseling psychologists to help clients anticipate theirimmediate or long-term needs while raising awareness of theresources available to meet potential challenges.


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• nticipation of Immediate and %ong-Term #eeds

• An awareness of financial and other organi#ational resources (orlimitations" can be an important part of helping clients thinkabout the ability to deal with possible developmental$ educational$medical$ or even vocational issues associated with a geneticoutcome.

• 8lients may need information regarding various options and

agencies available for support but may also need increasedawareness of the potential issuesboth short and long termthat might re9uire attention throughout a given tra;ectory.

• *or the counseling psychologist$ this means being reasonablyfamiliar with a given condition$ thus permitting competent

discussion of issues a client will likely encounter. Ceingknowledgeable of the potential resources available to a client(e.g.$ personal$ familial$ and professional" and discussing relevantprinted or electronic materials can certainly help prepare clientsto better anticipate how medical personnel$ genetic specialists$and counseling psychologists can support clients changing needsand circumstances.


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• '/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#& I#&#TIC C!#T*T$

• 8ounseling psychologists are in a uni9ue position$ in terms of bothprofessional training and applied perspective$ to effectively support clientsdealing with the genetic-testing process and potential outcomes.

• As in other physical and mental health conte&ts$ 9uality support depends oncareful evaluation$ which involves insight into client characteristics (e.g.$personal history and sub;ective distress"$ the nature of the presentingproblem (e.g.$ pathophysiology and prognosis"$ sociocultural conte&t$ and

features of the relevant health care setting itselfincluding aconsideration of potential barriers to service delivery.

• As new developments emerge in genetic testing$ coupled with the likelihoodof greater predictive and diagnostic potential$ genetic concerns will beadded to the many other health issues confronting modern psychology.Therefore, counseling psychologists should be prepared to deal with

client concerns in diverse genetic scenarios.

• reparedness is a multidimensional endeavor and is viewed here as anongoing and developmental process. ,he process might begin at thegraduate training level but is consolidated over time in light of newinformation$ opportunities$ and frameworks for client assessment andintervention.


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'/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#&I# &#TIC C!#T*T$

• Awareness of the terminology inherent in genetic research$testing$ and related disorders is an important educationalob;ective but is best placed within the broader conte&t ofadaptive behavior.

• Modern perspectives of client care have done well to promote a

bio-psychosocial awareness of human health and behavior$ yetthese re9uire continual e&amination$ testing$ and modification.

• 8onceptual models help identify$ organi#e$ and integrate issuesbelieved to be important for effective client evaluation andintervention. owever$ as professional demands andopportunities change with emerging mental and physical healthcare issues$ counseling psychologists should continually e&aminethe utility of various frameworks for client care in the conte&tof their own practices and research.


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• '/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#& I# &#TICC!#T*T$

• ,he importance of a unified perspective on human health and behavior in the conte&tof future genetic discoveries cannot be overemphasi#ed.

• enetic scenarios can be 9uite comple&$ bringing together the backgrounds$assumptions$ and perspectives of both counselor and client$ thus re9uiring the carefulconsideration of many social$ cultural$ and environmental circumstances influencingimportant life decisions. )nasmuch as multicultural awareness is a core value ofcounseling psychology programs$ this value should also be e&amined within thebiomedical domain (e.g.$ Ota /ang$ 3445".

• ,he fundamental nature of 0NA does not differ among people groups$ but thebeliefs$ values$ and e&periences of different cultures (and families" create thepotential for marked differences in how the client perceives a genetic test or anoutcome.

• ,herefore$ preparing to work with clients with genetic concerns not only involvesfamiliarity with genetic terminology and broader biological concepts but also depends

on appreciating how individual and cultural differences might influence informationprocessing and decision making in genetic and medical conte&ts.

• Moreover$ the counseling psychologist should be aware of how his or her ownpersonal$ educational$ cultural$ and even spiritual beliefs might shape his or herattitudes concerning human genetics (and medical decision making" and how theseattitudes might influence discussions with clients and the decisions clients makebased on genetic information (see /eil$ 23".


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• A practitioner-oriented perspective of mental health in geneticcircumstances recogni#es the intersection between biological reductionismand more global intra-individual and sociocultural factors (see *igure 3"while providing a framework for identifying potential barriers andresources influencing client adaptation.

• )n addition$ it is helpful to incorporate perspectives offered by diverseareas of research and practice$ such as rehabilitation medicine$

neuropsychology$ geriatrics$ womens health$ and spirituality.

• )ndeed$ genetic results may foreshadow neurological involvement (e.g.$neurofibromatosis:,ype 2$ *ragile-+$ 0"$ age-associated cognitivedysfunction (e.g.$ Al#heimers disease"$ predisposition to cancers andfemale specific cancer concerns (e.g.$ breast and ovarian cancer and coloncancer"$ and various disorders with uni9ue diagnostic$ preventive$ and

intervention issues affecting persons across the lifespan (refer to ,able 3".

• Any one of these issues can be placed along the timeline represented in*igure 3$ and the decision-making process will likely differ depending onuni9ue characteristics such as client age$ gender$ racial and ethnic status$values (e.g.$ spiritual and moral"$ and availability of resources.

'/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#& I#&#TIC C!#T*T$


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&#TIC C!#T*T$

• ,he diversity of genetic concerns and life implications can be matched onlyby the level of eclecticism inherent in the field of counseling psychology.

• aving diverse areas of practice and research is a strength of the discipline$ yet continued research may be necessary to assist clients in managingongoing life activities while making plans for futures influenced by geneticconcerns. ?imilarities may be evident to working with clients with otherchronic health conditions (e.g.$ coronary heart disease$ cancer$ and )L-A)0?"$ yet the diversity of genetic-testing conte&ts may re9uire newperspectives on applying techni9ues for an&iety reduction$ stress

management$ cognitive reframing$ and decision making.

• 8ounseling psychologists must recogni#e the limits of their knowledge andseek additional information (e.g.$ from local hospitals$ physicians$ geneticcounselors$ and /ebbased resources"$ or make appropriate referrals$ when aclients presenting concern e&ceeds professional e&perience.

•


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• ,he processes of decision making$ personal and familial adaptation$ andgeneral planning following a genetic outcome may be among the moreimportant issues for counseling psychologists further consideration. 8lientsmay need support with decisions impacting their personal beliefs$ spiritualand moral values$ sense of meaning in life$ and plans for the future.

• ?uch decisions might include disclosure of genetic status$ educational andvocational considerations$ personal or familial financial planning$ reproductivepreferences$ and even pregnancy termination.

• ?uccessful mapping of the human genome holds great promise forunderstanding$ treating$ and potentially preventing various humanpathologies.

• owever$ some genetic developments will present dilemmas and pose9uestions that certain professions$ and society at large$ are unprepared toaddress.

• As such$ continued research and personal reflection concerning the ethicaland practical challenges present in the genetic conte&t should be emphasi#edin counseling psychologists training and professional development.

'/'/TI!# !/ $CI#TI$T '/CTITI!#/$ )!/5I#&


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• '/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#&I# &#TIC C!#T*T$

• 8ounseling psychologists are encouraged to read$ discuss$ andcontribute to research in the fields of behavioral genetics$genetic testing$ and other genome-related issues.

• )n addition$ they should actively engage in the dialogue and

research concerning genetic testing and associated implications.

• 8learly$ biomedical researchers$ medical professionals$ mentalhealth practitioners$ and society in general have only begun todeal with the e&citing yet difficult issues emerging in this geneticera.

'/'/TI!# !/ $CI#TI$T '/CTITI!#/$ )!/5I#&


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• '/'/TI!# !/ $CI#TI$T-'/CTITI!#/$ )!/5I#&I# &#TIC C!#T*T$

• As future developments surrounding the human genome and

genetic testing influence society$ counseling psychologists havean opportunity to influence the physical and mental health ofthose dealing with many genetic issues.

• ) offer the model here (*igure 3" as one perspective to helpconceptuali#e the multidimensional nature of modern geneticscenarios. owever$ the preceding overview is certainly not aprimer on genetic testing or intervention1 rather$ it is an effortto encourage dialogue on this important issue.

• iven the anticipated growing relationship between genetics and

mental health providers (see lomin$ 21 lomin 7 8rabbe$2"$ counseling psychologists have much to contribute ingenetic conte&ts$ and preparedness will be the key to futuresuccess.


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