Dokter Blog: from the desk of Rahajeng Tunjungputri

Medicine et cetera by @ajengmd

Genetic Counselor and Ideas from Psychotherapy

I rarely post about genetic counseling, but to answer the basic questions, this is a clear explanation of what a genetic counselor is (ABGC, 2010):

A genetic counselor is a health care professional who is academically and clinically prepared to provide genetic counseling services to individuals and families seeking information about the occurrence, or risk of occurrence, of a genetic condition or birth defect.

The genetic counseling process involves the collection and interpretation of family, genetic, medical and psychosocial history information. Analysis of this information, together with an understanding of genetic principles and the knowledge of current technologies, provides clients and their families with information about risk, prognosis, medical management, and diagnostic and prevention options. Information is discussed in a client-centered manner while respecting the broad spectrum of beliefs and value systems that exist in our society. The genetic counseling process ultimately facilitates informed decision-making and promotes behaviors that reduce the risk of disease.


A very interesting book on genetic counseling provides a very useful insight. Below is my summary of the fourth chapter of the book, “Genetic Counselor and Ideas from Psychotherapy” (Evans, 2006):

Chapter 4: The role and skills of the counsellor and ideas from psychotherapy

(From Genetic Counselling by Christine Evans, page  61-82)

The role of the counsellor

There are different opinions on the role of counsellor. Some of these opinions are genetic counsellor as information provider or facilitator of decision-making. Another opinion stated that genetic counsellor play a role in assisting decision-making and helping to prepare clients for the result and to facilitate the client in accepting the meaning of a test result.

In practice, there change between the role of information provider and facilitator is a dynamic process. When a patient gives emotional response after information is given, then the role of the counsellor is more as a facilitator than information provider. The elements of genetic counselling are review of the family history, present and past relationships and attitudes, self-reflection, decision-making and coping. There is also a need to process emotions and contain anxiety. Skills repertoire of genetic counsellor may be expanded with additional ideas taken from general theory of psychotherapy.

Principles from psychotherapy

Winnicott (1971) and Bion (1959) emphasise the attitude and skill needed in professional relationship. There is also a need to understand the link between emotion and thinking in genetic counselling.

The structure of the interview

The interview takes place within a physical space, a time space and a psychological

space.

The physical space

The physical space of genetic counselling may be anywhere as long as the purpose is clear and there’s an agreed agenda for both patient and genetic counsellors. The space is more of an interactional space of discussion between the counsellor and patients or also with the family. The genetic counsellor is responsible for the time, focus, and approach.

The time space

A consultation may be similar to a music piece with a beginning that then builds up in the middle and ends with a conclusion. Within a time space patients can bring what is relevant about their condition to the genetic counselling process. Ending the meeting session may be difficult for the genetic counsellors or the patient, and the counsellor has to be able to let go and allow the patient to find their own way or manage their situation with the support of friends or family or alone.

The psychological space

The professional relationship between patients and genetic counsellors is also a psychological space where there is a potential for sharing feelings, developing thinking and decision-making. During the consultation, the counsellor needs to be aware and consider of how the patient is registering the experience.

The elements of a therapeutic professional relationship

The ‘facilitating environment’ and ‘potential space’

Winnicott (1971) and Bion (1959) developed understanding of the conditions needed for building a therapeutic encounter. Winnicott’s stated that genetic counsellors must have particular qualities – an attitude of being emotionally available, supportive, aware and understanding of the patients’ vulnerability. That relationship could then facilitate emotional growth and development in professional consultation. Bion (1959) stated that in the professional relationship there needs to be an ability of the counsellor to tolerate negative emotions, to be able to internally process them and transform them into positive feelings of empathy, concern and compassion. The counsellor is not disturbed by the patient’s high anxiety, but understands the fear, is able to tolerate it and gently and compassionately conveys that sentiment. In a more contractual language the counsellor and patient have to set up a working alliance.

The working alliance

This term refers to the necessity for the counsellor and patient to work together to complete the agreed tasks.

Bordin (1982) considers that there are three components to the working alliance: a consensus between the counsellor and patient on the goals of the encounter; an agreement on the topics and number of meetings to address how the goal is achieved; and, most importantly, the development of a strong affective bond between the professional and patient.

The co-construction of purpose of an interview with the definition of roles

A natural corollary to the working alliance is the idea of the co-construction of the purpose of the interview where the counsellor and patient jointly agree on the purpose of the interview. The counsellor must allow considerable space for the patient to tell their story, but also to keep the focus of the discussion. Sometimes, it may be difficult to interrupt a patient who is telling a personally significant and painful story but with skill and experience the counsellor will be able to balance listening to the story and focusing on the genetic task.

Empathy

Empathy is a ‘feeling state’ of being able to understand someone else’s subjective experience and is the essential skill in human interaction. It is the ingredient the counsellor needs to establish the secure base of relationship with patients. To achieve this special form of communication, the counsellor has to suspend personal ideas and views to be receptive, linked and attuned to the patient in order to understand the other person’s mindset.

Facilitating thinking

Genetic counsellors must aid decision-making and facilitate patients to process the effects of a result. The patient then must be able to self-reflect, which means not only experiencing, but also thinking about the experience. The ability to self-reflect results in thinking aloud, reflecting, integrating and also assessing one’s present position and comparing it to one’s former self. This self-reflection gives an overview and a deeper understanding.

Communicative competence and listening skills of integrating meaning

The counsellor should identify key words used by the patient and follows the train of thought, joins with the thinking process. The counsellor must also read the non-verbal behaviour and consider the level of intelligence. For example, the counsellor revealed a more complete understanding by pausing and summarising the story of the patient.

The use of metaphor

Metaphor language can facilitate an understanding where logical thought, clarification or explanation has failed. The use of metaphor allow the patient and counsellor away from the direct problem to look at it in another way, which is not personal but capture the similar problem of the patient.

Summary points

  • The genetic counselling process involve creating a physical and psychological space which facilitates the patient.
  • Anxiety of the patient may be contained when the genetic counsellor is empathetic and understand the patient’s experience.
  • Metaphors, listening and communication skills of the counsellor may facilitate the patient better.
  • Further on, the genetic counsellor must develop the patient’s ability to self-reflect, make decisions, and deal with the emotions and frustrations.

Further reading:

American Board of Genetic Counseling (ABGC), 2010. Genetic Counseling As A Career. [Online] American Board of Genetic Counseling. Available at http://www.abgc.net/english/View.asp?x=1484 [Accessed 26 June 2010].

Evans C., Biesecker B., 2006. Genetic Counselling, A Psychological Conversation. Cambridge: Cambridge University Press.

***

26 June 2010. Rahajeng. https://dokterblog.wordpress.com

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The Tobacco Epidemic: Problems, Conflicts, Solutions

Dear all,

I mentioned before that I was asked to speak about tobacco for a group of medical students few weeks ago. I wrote a more comprehensive review of the tobacco epidemic in Indonesia into my blog in doc2doc, “The Cure of The Tobacco Epidemic”.

At the event I brought up the issue of the tobacco epidemic; the problems, conflicts and solutions. This presentation is aimed to highlight the importance of consumer perception, the tobacco and anti-tobacco campaign “wars”, the socio-economic context of the tobacco epidemic in Indonesia and how physicians can contribute in curing this epidemic.

I have uploaded the presentation from that event to Slideshare.

For further reading, please do check the last slide with a list of great reference sites.

Regards,

Rahajeng

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Blog safely ^^

I’m in academics, so in the spirit of critical thinking and freedom of speech, I’d like to introduce you to this very useful site that give information about how to blog safely.

This is a very useful website which explains everything about how to blog safely. Being critical is exciting and inevitable, especially when you actually do have a critical mind. So this is a preliminary warning of the possible adverse consequences and how to avoid them.

Dr. Isis, a famous science blogger once wrote

“I consider blogging to be no different than buying advertising space on a billboard – thousands of people or more are going to see it and (unless you use password-protected entries) you have no control over who is reading it.  You also have no control over how people will use your information.”

And for me this has been my rule-of-thumb, that yes, indeed blogging is similar to having a huge personal billboard with whatever we have expressed on that given (very) public space. So please remember that. I have found that the best strategy is to keep in mind that everybody reads what you’re writing, whether you’re on facebook, twitter, or blogs.

Finally, my take home message is: You have the right to blog, and you have a right to blog safely.

Rahajeng

Filed under: miscelaneous,

Identification PPT for Parasitology Students

For students,

The following is now available on slideshare:

http://www.slideshare.net/rntunjung/identification-june-2010

And a very informative video on Schistosomiasis, this is the last of 3 videos:

Wish you all the best for your exams!

-Rahajeng

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Latest post on doc2doc.bmj.com

If smoking is bad, why do people still smoke? What does it take to successfully overcome the tobacco epidemic in Indonesia? Indonesia has been in the spotlight for not signing The World Health Organization Framework Convention on Tobacco Control (FCTC), but is it really just a matter of not having a political commitment and a failure of implementing health policy on tobacco?

Read more about “The Cure of Tobacco Epidemic” on my latest writing at http://doc2doc.bmj.com (or click here)

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Trematodes presentation

The short version of the powerpoint presentation of trematodes we use for response discussion was just uploaded. This only consists selected (and most important) slides.

You can click the pic below (or click here) to see the presentation on slideshare.

There is an interesting case report on trematode infection on NEJM:

Do Hyun Park, M.D., Ph.D.
Hyun-Young Son, M.D.
University of Ulsan College of Medicine
138-736, Seoul, South Korea
dhpark@amc.seoul.kr

A 62-year-old man reported having had fatigue, fever, and cramping abdominal pain for 7 days. He also reported that he had recently eaten raw pond smelt (Hypomesus olidus). The results of liver-function tests were abnormal, showing elevated levels of aspartate aminotransferase (350 IU per liter), alanine aminotransferase (352 IU per liter), alkaline phosphatase (204 IU per liter), {gamma}-glutamyltransferase (434 IU per liter), total bilirubin (6.4 mg per deciliter [109 µmol per liter]), and conjugated bilirubin (3.9 mg per deciliter [67 µmol per liter]). The white-cell count was also elevated (13,000 per cubic millimeter), and there was eosinophilia (27%). A computed tomographic scan of the abdomen showed dilatation of the common bile duct without definite filling defects. Given our concern that the patient might have acute cholangitis, a duodenoscopy was performed, and a prominent major papilla was discovered. After cannulation of the common bile duct, numerous leaf-shaped worms popped out (see video) and were subsequently identified as Clonorchis sinensis (also called Opisthorchis sinensis). The patient was given praziquantel and had a quick and uneventful recovery. The clinical manifestations of clonorchiasis tend to reflect the worm burden and the duration of infection. Clonorchis may persist in the biliary tree for decades, and prolonged infestation is associated with the development of cholangiocarcinoma. Acute cholangitis and pancreatitis are rare but important complications of C. sinensis infestation.

Good luck for your exams!
-Rahajeng-
*
Images used in the presentations are not mine, no copyright infringement intended.

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Disclaimer

Medicine is a growing field, and information presented here is reflective of the time of posting. Please refer to your physician for direct medical consultation. My views do not reflect those of my employers. --
Regards, Rahajeng

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