Counseling Theories and Models

Genetic counselors draw on established counseling theories and models to guide patient interactions, facilitate adaptation, and support decision-making. Understanding these frameworks is essential for clinical practice and for recognizing how they apply across genetic counseling contexts.

• Reciprocal engagement model (REM): Developed by McCarthy Veach, LeRoy, and Bartels specifically for genetic counseling. It describes genetic counseling as a dynamic relationship with five tenets: (1) genetic information is key, (2) relationship is integral, (3) patient autonomy must be supported, (4) patients are resilient, and (5) patient emotions make a difference. REM emphasizes that the counselor-patient relationship itself is a therapeutic tool.
• Kubler-Ross model (Five Stages of Grief): Describes grief as progressing through denial, anger, bargaining, depression, and acceptance. Important caveats: stages are not linear, not universal, and not all patients experience every stage. Originally developed for terminal illness, not genetic diagnosis. Apply with caution.
• Dual-process model of coping (Stroebe and Schut): Proposes that bereaved individuals oscillate between loss-oriented coping (processing the loss itself) and restoration-oriented coping (attending to life changes, new roles, practical tasks). This oscillation is normal and adaptive. Particularly useful in genetic counseling because patients often must simultaneously grieve and make practical decisions (e.g., a parent grieving a child's diagnosis while also arranging therapies).
• Chronic sorrow (Olshansky): Describes periodic recurrence of grief over a lifetime, triggered by milestones or reminders of what was lost. Common in parents of children with genetic conditions: grief may resurface at school entry, when peers reach milestones, or at transition to adult care. Chronic sorrow is normal, not pathological.
• Health belief model: Predicts health behavior based on perceived susceptibility (do I think I'm at risk?), severity (how bad would it be?), benefits (will this action help?), barriers (what prevents me from acting?), cues to action (what triggers action?), and self-efficacy (can I do this?). Useful for understanding why patients do or do not pursue genetic testing or follow surveillance recommendations.
• Self-efficacy (Bandura): A person's belief in their ability to perform a specific behavior. In genetic counseling, high self-efficacy predicts better adherence to screening recommendations and more active coping. Counselors can bolster self-efficacy by providing clear, actionable steps and celebrating small successes.
• Brief solution-focused therapy (BSFT): Focuses on solutions rather than problems, emphasizes patient strengths and resources, and uses techniques like the miracle question ("If you woke up tomorrow and this problem was solved, what would be different?") and scaling questions ("On a scale of 1-10, how confident are you?"). Well-suited to the time-limited nature of most genetic counseling sessions.
• Motivational interviewing (MI): A collaborative, patient-centered approach that helps patients resolve ambivalence about behavior change. Uses techniques including open-ended questions, affirmations, reflective listening, and summarizing (OARS). Useful when patients are ambivalent about testing, surveillance, or lifestyle changes.

• A mother of a child with cystic fibrosis breaks down in tears at a routine clinic visit when she learns her child's classmates are going on a field trip her child cannot attend. This is a textbook example of chronic sorrow: the grief is not new, but resurfaces at developmental milestones.
• A patient at 50% risk for Lynch syndrome says, "I know I should get a colonoscopy, but I just keep putting it off." Using the health belief model, the counselor might explore perceived barriers (fear of the procedure, cost, time) and bolster perceived benefits and self-efficacy.
• A couple recently received a diagnosis of spinal muscular atrophy in their infant. The father is researching clinical trials (restoration-oriented coping) while the mother is crying and unable to focus on next steps (loss-oriented coping). The dual-process model explains that both responses are normal, and the couple may oscillate between these modes at different times.
• A genetic counselor has 30 minutes with a patient who is anxious about BRCA testing. Using BSFT, the counselor might ask a scaling question: "On a scale of 1-10, how ready do you feel to get this test?" and then explore what would move the patient one number higher.

• Kubler-Ross stages are not linear and patients do not need to progress through all five. This is a common misconception. The model is descriptive, not prescriptive.
• Know the difference between chronic sorrow and complicated grief. Chronic sorrow is a normal, recurring response to ongoing loss. Complicated grief (prolonged grief disorder) involves persistent, debilitating symptoms that impair functioning. This warrants referral.
• The reciprocal engagement model is the only model developed specifically for genetic counseling. When a framework unique to the field is needed, REM is the one.
• Recognize the model from the patient's behavior: oscillation between grief and practical planning = dual-process model; recurring sadness at milestones = chronic sorrow; belief that testing won't help = low perceived benefit (health belief model).