Characterizing psychosocial assessments across genetic counseling sessions through qualitative content analysis

Abstract

Although psychosocial support and assessment is a required competency of genetic counselors (GCs), how the psychosocial assessment is actualized in sessions is not well studied. We aimed to describe the landscape of psychosocial assessments in clinical genetic counseling sessions at a single institution through direct analysis of audio recordings. Clinical GCs at Stanford Medicine and their new English-speaking adult patients were eligible. After GCs and patients completed demographic surveys, we audio-recorded sessions for which the GCs and patients enrolled. Purposive sampling, prioritizing a breadth of GCs, specialties, indications, and patient demographics, was used to select audio recordings for transcription and analysis. We used a blended inductive and deductive approach to develop the codebook. Code frequency and memos were assessed for descriptive content analysis of psychosocial components of the sessions. We analyzed 23 audio recordings, representing nine GCs across cancer, cardiology, and prenatal. We identified three distinct psychosocial styles that GCs used: “Direct,” “Informational,” “Casual.” While all styles incorporated emotion-focused conversation to some degree, only the “Direct Psychosocial Style” included an explicit psychosocial assessment of patients. Psychosocial assessments consisted of direct feelings questions, emotion-focused responses, and advanced empathy. The “Informational Psychosocial Style” was characterized by GC responses to patient feelings and sympathy statements, without consistent exploration of patient feelings throughout the session. The “Casual Psychosocial Style” was characterized by an observable rapport between the GC and patient that carried throughout the session, allowing for psychosocial issues to be explored organically. GCs varied in their use of each style across patients, specialty, and indication. In conclusion, we observed three distinct psychosocial styles, of which only the Direct Psychosocial Style had an overt psychosocial assessment. Further research is needed to examine patient outcomes within each style.

1 |. INTRODUCTION

Patients and families enter genetic counseling sessions with a variety of emotional, support, and psychosocial needs, including emotional distress, family dynamics, and coping with their genetic risk (Ballatore et al., 2020; Eijzenga et al., 2015; Eijzenga, Hahn, et al., 2014; Ingles, 2020; Schoeffel et al., 2018). The term “psychosocial” refers to the “psychological and sociocultural factors impacting a patient at the time of the genetic counseling interaction” (Moscarello et al., 2024). When psychosocial support and resource needs are not met, patients and families may experience chronic psychological stress, indicating that tailored psychosocial support would benefit them (Nevin et al., 2022). Genetic counselors (GCs) are able to identify emotional and familial difficulties patients are experiencing but have been found to underestimate the severity (Brédart et al., 2022). As GCs increase their attention to the psychosocial needs of patients, better psychological and knowledge outcomes follow (Austin et al., 2014; Eijzenga, Bleiker, et al., 2014).

Patient-centered psychosocial support, including assessment, is a required GC competency (Accreditation Council for Genetic Counseling, 2023). Genetic counseling-specific models taught to GC students are often broadly descriptive and theoretical in nature without attention to specific strategies used or without a clear consensus on how to define “psychosocial assessment” (Hartmann et al., 2015; Moscarello et al., 2024; Redlinger-Grosse et al., 2017; Veach et al., 2007). One such genetic counseling model, the Reciprocal Engagement Model, is built on tenets and goals for practice, with two tenets centered around patient emotions and the relationship as integral to genetic counseling (Veach et al., 2007). Moving beyond theory, an interview-based study elicited summaries of skills and example phrases GCs use to recognize and respond to patient emotions (Zale et al., 2022). However, actual interactions with patients have not been recorded or analyzed, but this is underway (Fisher et al., 2024). Recent work proposed a definition for psychosocial assessment based on collective experiences of GCs: “The intentional, focused exploration of psychosocial factors impacting the patient, via either verbal dialog or administered questionnaires” (Moscarello et al., 2024).

Previous GC research on psychosocial assessment tools has focused on the use of questionnaires to assess psychosocial needs patients experience during genetic counseling sessions, but has not assessed the questions, themes, and flow of this content in real-time (Brédart et al., 2022; Eijzenga et al., 2015; Eijzenga, Hahn, et al., 2014; Esplen et al., 2013). Studies that include recordings of sessions involved simulated patients and aimed to compare the psychoeducational and clinical teaching models rather than describe how the psychosocial assessment was performed (Roter et al., 2006). Within clinical psychology, descriptions of how to perform a psychological assessment exist as the “mental status examination,” which uses direct questions (e.g., asking the patient to describe how they are feeling), observations, and active listening to assess the patient’s mood, affect, and thought content (Voss & Das, 2024).

Although psychosocial support is a central tenet of genetic counseling sessions, how the psychosocial assessment is performed verbally with patients in a clinical setting has yet to be addressed in literature specific to genetic counseling. We aimed to characterize how GCs perform the psychosocial assessment during real clinical sessions across diverse indications. We also aimed to describe the proportion of sessions that included a psychosocial assessment.

2 |. METHODS

This study was approved by the Stanford University Institutional Review Board. Writing and dissemination of this work followed the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014).

2.1 |. Eligibility and recruitment

We aimed to collect audio recordings of actual genetic counseling sessions, which required consent from both GCs and patients. To achieve this, we developed stepwise recruitment strategies and eligibility criteria for each group, as described below.

2.1.1 |. Genetic counselors (GCs)

GCs in direct patient care in cardiology, cancer, and neurology genetics clinics at an adult hospital (Stanford Health Care), and prenatal and medical genetics clinics at a children’s hospital (Stanford Medicine Children’s Health) were invited to participate in the study via email. There was no requirement for the number of years GCs practiced in order to be eligible for this study. We invited a total of 42 GCs to participate. Interested GCs clicked the REDCap link in the email and were presented with a fact sheet describing the time involvement, risks, benefits, payment, and participant rights (Appendix S2). If they consented, they selected “I DO agree” within REDCap. Consenting GCs agreed to audio record their sessions over a 1-month period. Patients scheduled within that month were invited to participate via email as well. Participating GCs were gifted a $50 Amazon gift card for their time and effort.

2.1.2 |. Patients

Patients were eligible if they were English-speaking adults, scheduled for their first genetic counseling session, either in person or via telemedicine, and scheduled with a participating GC in this study. The research team identified eligible patients through chart review and invited them to participate via email and/or phone. Interested patients clicked the REDCap link in the email and were presented with a fact sheet describing the time involvement, risks, benefits, and participant rights (Appendix S3). If they consented, they selected “I DO agree” within REDCap. The primary author conducted a follow up call to patients who had not responded and discussed the fact sheet with them. If the patient consented to participate, the primary author filled out the consent form and demographics survey with the patient while on the phone.

2.2 |. Data collection

GC and patient demographic data were collected using the secure, web-based platform REDCap (Research Electronic Data Capture) hosted by Stanford Medicine (Harris et al., 2009, 2019). GCs completed a survey that included age, gender, race/ethnicity, number of years of clinical practice, and primary specialty. Participating patients were contacted via telephone or sent an online survey that included age, gender, race/ethnicity, highest level of education completed, and annual household income range. GCs were notified if their patient had consented to audio recording prior to the beginning of the session. GCs audio recorded their sessions over a period of 1 month through Stanford Zoom, an encrypted hospital-approved mobile device, or an encrypted handheld audio recording device. Each file storage and recording device used was encrypted and compliant with HIPAA and PHI policies at the university and hospital (e.g., REDCap, Zoom, Box). The genetic counseling session proceeded as usual per standard clinical care. After the session was completed, participating GCs uploaded recordings to their private folder within the secure cloud content storage platform Box where the research team accessed the recordings. GCs were only able to access their own recordings within their private folder.

2.3 |. Sampling

We anticipated that a large number of recordings would be submitted, so we used purposive sampling to identify and select recordings for transcription and analysis that were relevant to our aim of psychosocial analysis and represented a breadth of GC and patient demographics (Palinkas et al., 2013). KR listened to all audio recordings, and those with major technical issues or interruptions were removed from the data set. Sampling prioritized stratification across GCs, specialty, patient indication, patient age, and patient race/ethnicity. The Santa Clara County 2022 census (U.S. Census Bureau QuickFacts: Santa Clara County, California, n.d.) was used to guide selection of audio recordings most representative of the local population (i.e., 49.7% white, 41.4% Asian, 24.7% Latine, 2.9% Black/African American, 1.2% American Indian/Alaska Native, and 0.5% Pacific Islander/Hawaiian). Given these factors and time constraints present due to this study being completed as part of graduate requirements, 23 recordings were found to be sufficient for analysis. Selecting additional recordings for analysis from the 25 unused recordings would have enriched our sample for certain GCs, indications, or GC and patient demographics already represented in our sample (Table S1). We aimed to broadly characterize across our data set, so including more recordings would have created an imbalance.

2.4 |. Analysis methods

Recordings were transcribed verbatim by Microsoft Word, reviewed for accuracy by KR, and manually de-identified by KR. Our study reflects a constructivist-interpretivist research paradigm as we analyzed GCs in their natural environments, or in real sessions with patients (Wainstein et al., 2022). Research team members used an inductive and deductive approach to codebook development for content analysis (Appendix S1; Elo & Kyngäs, 2008; Giacomini & Cook, 2000; Roberts et al., 2019). A combined inductive and deductive approach was selected because our coding schema was derived from the data set with attention to the authors’ experiences, and with attention to already established frameworks that enhanced and rationalized the derived coding schema (Coulston et al., 2025). Given this was a qualitative and exploratory study, descriptive content analysis was utilized to develop a nuanced and representative understanding of the data (Coulston et al., 2025).

Review of the transcripts for psychosocial content, including psychosocial questions, responses, and overall flow throughout each session, in the following stepwise process informed our inductive approach. K.R., A.N., and C.R. co-coded the first three transcripts, met to discuss code application, and refined the codebook until consensus was reached. K.R. and A.N. coded the remaining transcripts. To ensure consistent codebook application, K.R. coded four transcripts and co-coded the 5th transcript with A.N., repeating this pattern until all 23 transcripts were coded. Any adjustments made to the codebook throughout this process were applied to previously coded transcripts. Code frequency across transcripts was assessed and memos were used to compare transcript content. Descriptive content analysis was performed and discussed at research team meetings (Vaismoradi et al., 2013). Analysis included categorization of transcripts based on observed patterns, such as how frequently each code appeared within a transcript and the overall pattern of psychosocial content within each transcript.

Professional experiences of the authors and literature review of already established psychosocial frameworks such as the BATHE method (Lieberman & Stuart, 1999) informed our deductive approach. Our team of authors consists of GCs and qualitative researchers who have worked in direct patient care and as educators, supervisors, and students within GC programs. We all philosophically believe that attention to the psychosocial needs of patients within GC sessions is crucial. Several of us have educated students and GCs on the implementation of psychosocial tools within sessions and have reflected on our own clinical experiences to inform psychosocial practices. We have practiced and researched in a wide range of specialties and spaces, and all are based in the United States.

3 |. RESULTS

3.1 |. Audio recording sample characteristics

A total of 57 audio recordings were collected across four genetic counseling specialties: prenatal, cancer, cardiology, and medical genetics. Out of these, 48 were high-quality recordings. After purposive sampling, the final data set consisted of 23 audio recordings from telemedicine sessions across prenatal, cancer, and cardiovascular genetics. Demographic characteristics of participating GCs and patients are described in Table 1. The nine GCs were mostly women (67%), white (67%), and cancer GCs (56%), and were 36 years old on average. There was a wide range in years of clinical practice from less than 1 year to 19 years, with a mode of 5 to 9 years (45%). The 23 patients were most frequently women (74%), and white (48%), and on average were 44 years old (Table 1). Session indications included family history (35%), personal history (22%), both personal and family histories (35%), and pre-test prenatal options (13%).

TABLE 1.

Genetic counselor (GC) and patient demographic characteristics of 23 analyzed audio recordings.

Variable	GCs (years)	Patients (years)
Age range	25–49	20–65 and above
Age mean	36	44
Variable		GCs N (%)	Patients N (%)
Gender	Man	3 (33)	6 (26)
	Woman	6 (67)	17 (74)
Race/ethnicity	American Indian, Alaskan Native, or Indigenous Peoples of Canada	0 (0)	1 (4)
	East Asian	0 (0)	3 (13)
	Hispanic or Latine	1 (11)	5 (22)
	Middle Eastern or North African	0 (0)	2 (9)
	Native Hawaiian or Other Pacific Islander	0 (0)	1 (4)
	South Asian	1 (11)	3 (13)
	White	6 (67)	11 (48)
	Two or more	1 (11)	3 (13)
	Prefer to self describe	0 (0)	1 (4)
	Prefer not to answer	0 (0)	1 (4)
Specialty	Cancer	5 (56)	13 (57)
	Cardiology	3 (33)	7 (30)
	Prenatal	1 (11)	3 (13)
Years in clinical practice	<1	1 (11)	N/A
	1–4	1 (11)	N/A
	5–9	4 (45)	N/A
	10–14	1 (11)	N/A
	15–19	2 (22)	N/A
Indication	Family history	N/A	8 (35)
	Personal history	N/A	5 (22)
	Personal and family history	N/A	8 (35)
	Options (prenatal)a	N/A	3 (13)
Length of session (average, range)	48 min (23–80)

^a“Options (prenatal)” refers to initial prenatal genetic counseling sessions that include discussion of screening and diagnostic testing options.

3.2 |. Diverse psychosocial styles observed across genetic counseling sessions

Three distinct psychosocial styles emerged during our analysis, that we term “Direct,” “Informational,” and “Casual.”

The “Direct Psychosocial Style” was characterized by the GC overtly engaging with or eliciting patient emotions through direct feelings questions or responses (Table 2). The GC incorporated psychosocial statements and questions regularly throughout the session, such as during the information-gathering or family history portions of the session, to probe and explore patient feelings as they arose. These explicit questions and responses allowed for continuous and layered emotional conversations.

TABLE 2.

Psychosocial styles observed across diverse genetic counseling sessions.

Style	Definition	Illustrative excerpt	Sessions observed with style N (%)
Direct	Explicit and consistent exploration of patient feelings through psychosocial questions and statements throughout session GC creates opportunities for psychosocial discussion via open-ended questions, emotion-focused responses GC uses advanced empathy skills and complex reflections	GC: In general, how are you feeling about your heart? I know you’re excited to get that ablation. Hopefully that will take care of most of the symptoms for you. P: In general, it’s OK. I feel a lot better that my heart has gotten stronger. GC: And is there anything that particularly has worried you about your heart? P: I don’t want to be on blood thinners for the rest of my life. That’s the only thing that really worries me. GC: Do you feel like you have all those support and resources around the house, people to talk to, people to help you out as you recover from your procedure, things like that? (GC13_227) P: She passed away in 2022. GC: How are you and the family coping with the loss? How’s everyone doing? P: Yeah, getting better. My dad’s definitely struggling, but hardest for him for sure. You know she was a big part of the family. GC: Got it. OK. Well again, I’m sorry for the loss. I’ll just mention that genetic counseling and genetic testing can bring up unexpected feelings related to grief. So if anything like that is going on, you know, overtly or covertly, maybe you just notice yourself, kind of being a little more grumpy, you know that’s not at all unusual. A very common response to this sort of thing. And if you need to take a break through the session at any point, just speak up. OK? P: OK. (GC2_261)	7 (30)
Informational	Feelings questions are indirect and responses are information-driven rather than focused on exploring emotions GC does not regularly incorporate psychosocial statements/questions into the session or create opportunities to explore patient feelings Short sympathetic responses, no wider exploration of feelings	GC: How long ago did she pass? P: Seven months ago. GC: Oh gosh, so super recent. I’m so sorry. I am so sorry. I just, I can only imagine she’s so young. P: Yeah. GC: It seems like it was fairly rapid from diagnosis to her passing. P: Yup. GC: Yeah. Do you have - So I’m going to ask some questions that you may not know the answer to, but it’s worthwhile throwing the questions out there. Sounds very clearly that it was stomach cancer and not some other sort of organ in the abdomen. It was very clearly a cancer that started in the actual stomach. Is that correct? P: Yeah, that’s what her doctor confirmed. GC: OK. The one question you may not have the answer to. There’s a particular type of stomach cancer that has us thinking about a particular hereditary cancer predisposition and the stomach cancer type is typically called diffuse stomach cancer. Does that ring any sort of bells at all? (GC3_304) GC: OK, how many siblings does your mom have? P: A brother and a sister. GC: Are they both still living? P: No, her brother actually just passed away like a month ago. GC: Oh no, I’m sorry. P: He is a miracle. He had throat cancer, and was a lifelong smoker, but survived for almost 20 years. Pretty debilitating cancer, so somewhat of a miracle. GC: Yeah, cancer is a really nasty one. How old was he? P: Early 80s, like 82. GC: And prior to his passing, any known heart problems? P: I wouldn’t know. I mean the biggest thing for him was just the cancer battle. I don’t know if there were any known heart issues. GC: Yeah, OK. Did he have children? (GC11_252)	12 (52)
Casual	Exploration of feelings occurs as a result of organic and comfortable rapport that carries throughout session Exploration of feelings may be indirect rather than explicit or casually build throughout session GC and patient comfort within session demonstrated through laughs and banter	GC: Ugh. Do we happen to know what type of, like, where the cancer started? The type of cancer? P: Uh it was in his back in his lungs. GC: It’s just widely spread at time of diagnosis. P: And by the time they found it they don’t really know where it started. GC: I’m so sorry to hear that. P: Yes, that’s very sudden. Jeez very depressing conversation *laughs* GC: I know. I’m sorry. *laughs* Sometimes it ends up being that way where, you know, you kind of think of these individuals here and there. But when you kind of talk about them as a whole, it’s like, yeah. (GC3_334) GC and patient build rapport based on job experiences, families, etc. Laughs are dispersed throughout. This leads into discussion of family history: GC: Because she has one sister who has no cardiomyopathy, one brother who is living, and one brother who passed away suddenly? P: Yes. GC: At what age, do you know? P: Like 40 or 41. GC: OK gosh. P: Yeah, no known history of any cardiovascular problems. So it came as a shock to everyone in the family. GC: Gosh, I’m sorry. P: Yeah. I mean we are hypersensitive to [child’s name]. It was heart racing or something like that. … GC: And I’m going to assume that neither of your kids have kids of their own? P: Yeah no, none that we know of anyway. *laughs* GC: I have made assumptions in the past. *laughs* P: Yeah, you gotta, *laughs* You see everything right? GC: Oh my gosh, yeah. Speaking of [ancestry testing] I have heard some crazy stories. P: *laughs* I can imagine. Conversation surrounding patient and GC experiences with ancestry testing continues (GC11_231)	4 (18)

The “Informational Psychosocial Style” was observed when the GC asked the patient questions that were not explicitly about their feelings but may have indirectly prompted sharing of emotions. The GC often responded with sympathy rather than by exploring emotions further (Table 2). In this style, the GC did not depart from education and information-giving to explore patient feelings and instead returned to the family history or genetics education parts of the session within a few sentences.

The “Casual Psychosocial Style” was observed when the GC explored patient feelings as a result of contracting and strong rapport that carried throughout the entire session (Table 2). This strong rapport and apparent comfort between the patient and GC in the session was demonstrated through laughter, banter, and casual side conversation. The GC tended not to explicitly ask direct feelings questions (e.g., “How has this impacted you?”) or proceed with a line of questioning regarding feelings, but instead GCs tended to respond to and explore patient feelings as they came up spontaneously throughout the conversational session. GC exploration of the psychosocial topics that arose was limited, came to an end within a few sentences, and did not build into a layered emotional conversation.

Figure 1 summarizes how the content and skills observed in the transcripts differed and overlapped between styles.

FIGURE 1.

Content and skills observed across psychosocial styles. Distinct and overlapping questions and statements observed within each psychosocial style. EF, emotion-focused; IF, information-focused. E.g., EF Direct feelings questions: “How are you feeling about everything that is ahead of you?” Open-ended question: “How are you coping with all this change?” Closed-ended question: “Are you feeling sad or frustrated?” EF, Indirect feelings question: “How has your pregnancy been so far?” EF Sympathetic statement: “I’m so sorry that’s so frustrating.” EF Reflection statement: “I’m hearing you say that this has been difficult for you.” EF Affirmation: “Well it’s true it is a difficult cancer to treat.” EF Reframing: “I don’t think this is a completely hopeless situation, I think we are just at the beginning of this process.” EF Summarizing statement: “You have been through a lot these last couple months.” EF Advanced empathy: “That must have been really frustrating for you.” IF Reflection statement: “It sounds like it took a while to get here.” IF Affirmation: “Yup, sounds about right.” IF Summarizing statement: “You met with your oncologist previously.”

3.3 |. Variability among psychosocial styles

We observed that each GC did not necessarily use the same style with each patient, as reflected in Table 2 where GC3 and GC11 both used the Informational Psychosocial Style with one patient and the Casual Psychosocial Style with another patient. We explored if there were patterns in the session characteristics that shed light on when a GC used one style over another. The most common style used out of all GC sessions was Informational (52%), followed by Direct (30%), then Casual (18%) (Table 2). In sessions where the patient had both a personal and family history indication, we observed the Direct and Informational Psychosocial Styles most often. In sessions where the patient had solely a family history indication, the Informational Psychosocial Style was observed most often.

We noted that the Direct and Informational Psychosocial Styles occurred most often in sessions where the GC had been practicing clinically for 5–9years and that within these styles, the GC was most often of a different race/ethnicity from their patient. We observed that the Casual Psychosocial Style typically occurred in sessions where the GC had been practicing clinically for 15–19 years, and the GC was most often of the same race/ethnicity as their patient. Additionally, each GC did not adhere strictly to a single psychosocial style across all patient interactions. Rather, the styles employed and their execution varied widely across patients, their situation, and how much they chose to share verbally during the session.

3.4 |. Explicit psychosocial assessment occurs in the direct psychosocial style

Explicit assessments of emotions were not observed in every patient session, and these sessions were described as either Informational or Casual Psychosocial Styles. Given these observations, an explicit psychosocial assessment can be characterized as an overt exploration of patient emotions observed solely in the Direct Psychosocial Style (Figure 2).

FIGURE 2.

Explicit psychosocial assessment within the direct psychosocial style. GC, genetic counselor; P, patient. The flow diagram illustrates the three main psychosocial styles observed in our sample: Direct, Informational, and Casual. The explicit psychosocial assessment of patients was observed only within the Direct Psychosocial Style and was initiated by either GCs (black) or patients (gray).

The Direct Psychosocial Style contained a building exploration of emotions that could be initiated either by the patient as they shared feelings or the GC as they overtly probed about emotions (Figure 2). Regardless of who began this discussion, the GC performed the psychosocial assessment through use of direct feelings questions and emotion-focused responses to better understand how the patient and family were impacted by their situation and genetic information (Figure 3). GCs asked direct feelings questions most often throughout information gathering about personal or medical history. The feelings questions asked were most often open-ended and direct rather than closed-ended or indirect (Figure 1). For the most part, GCs engaged directly with negative patient feelings statements (e.g., “This has been hard.”) rather than positive (e.g., “I’m feeling hopeful.”) or neutral (e.g., “I’m okay.”) patient feelings statements. GCs were also observed responding to patient emotions using advanced empathy (naming unstated emotions; e.g., “This has been difficult for you.”), reframing statements, summarizing statements, and reflections (Figure 1).

FIGURE 3.

Annotation of an illustrative psychosocial assessment. GC, genetic counselor; P, patient. Example psychosocial assessment conducted during a cardiovascular genetic session. Arrows label GC statements and questions used to conduct the psychosocial assessment.

4 |. DISCUSSION

This study aimed to describe how the psychosocial assessment is actualized within genetic counseling sessions through analysis of verbal exchanges between real patients and GCs, a novel approach to this question. We found that psychosocial styles were the manner in which the GC interacted and engaged with psychosocial content elicited by the GC or introduced by the patient. We observed three distinct psychosocial styles where use depended on GC, patient, and situational factors: the Direct Psychosocial Style, the Informational Psychosocial Style, and the Casual Psychosocial Style. However, only the Direct Psychosocial Style involved an explicit psychosocial assessment. Since not every GC used this style in every session, an explicit psychosocial assessment was not performed in every session.

The psychosocial styles that GCs used to interact with patient emotions and psychosocial content were variable across sessions, specialties, and GCs. This could reflect a patient-centered approach that aligns with the central tenets of genetic counseling that emphasize personalized and informed decision making through therapeutic relationships and empathic understanding (Biesecker, 2020). There is a need for GCs to communicate with patients in a personalized, flexible, and adaptable manner to facilitate a common understanding of attitudes, knowledge, and beliefs, and establish trust and empathy (Cohen Kfir et al., 2021; Joseph et al., 2019). Exploration of GC styles in prior work has been limited to comparing the extent to which the teaching and counseling models are used in sessions (Ellington et al., 2006). In the psychology literature, however, the term “Personal Style of the Therapist (PST)” suggests personality is a contributing factor to how emotionally “expressive” practitioners are with clients (Casari et al., 2019).

Explicit psychosocial assessments only occurred in the Direct Psychosocial Style, and as a result occurred in the minority of cases (7 out of 23, 30%). This style showcases the result of an evolution in the genetic counseling practice model from one that was traditionally psychoeducational to one that is psychotherapeutic with an emphasis on relational counseling (Biesecker et al., 2019). The focus on patient emotions and the relationship within the Reciprocal Engagement Model are also reflected in this style (Veach et al. 2007). The psychosocial assessment mirrors the “mental status examination” in psychology that uses direct questions about patient feelings to evaluate patient affect and mood in the moment (Voss & Das, 2024). Empathetic and sympathetic responses were observed in this style and align with previous GC summaries of how they show empathy, provide sympathy, and create space for emotional processing (Zale et al., 2022). Advanced empathy skills have also been described as GCs naming and responding to implicit patient feelings and were present in the Direct Psychosocial Style in our study (Tomozawa et al., 2023).

The small number of sessions with an explicit psychosocial assessment observed in our study suggests that the aforementioned approach to psychosocial content may not always be feasible during a session. Provider comfort with an education-based session rather than a psychosocial-based session or differences in how counseling is taught and how it is practiced has been described as a barrier to psychotherapeutic integration (Austin et al., 2014). Additionally, a more established barrier to implementation of psychotherapeutic and emotion-based approaches to genetic counseling sessions is time. When time is limited, especially during initial sessions which were solely included in our sample, the session can be overrun by providing adequate information to the patient rather than exploring their emotions and reactions to the information (Hartmann et al., 2015). These factors may have contributed to the prominence of the Informational Psychosocial Style in our study.

The Informational Psychosocial Style was observed in sessions where education and information-gathering took up the majority of the content of the session. This study only included initial patient sessions where education and information-gathering were essential, especially in cancer genetics. This may also be due to the origins of genetic counseling that separated teaching and counseling approaches and goals (i.e., educated vs. autonomous counselee) with less psychosocial information, fewer psychosocial questions, less personalized information, and more closed-ended than open-ended questions in the teaching approach (Kessler, 1997; Roter et al., 2006). Scholars have recognized that the teaching model limits self-directed patient decision making, while the counseling model personalizes health information and results in better patient outcomes (Austin et al., 2014; Ellington et al., 2006; Kessler, 1997). However, the educational approach could be seen as necessary as the demand for cancer genetic counseling and testing has resulted in increased patient volumes (Boothe et al., 2021; Clark et al., 2023; Greenberg et al., 2020). An educational approach has also been shown to benefit patients within cancer genetics with reported increases in knowledge, perceived personal control, and positive health behaviors as well as decreased cancer-related distress, anxiety, and conflict (Madlensky et al., 2017; Rana et al., 2023).

We also considered scenarios where a psychosocial assessment may be deprioritized or inappropriate. As previously mentioned, there are time constraints and educational needs during sessions. Additionally, psychosocial assessments may be inappropriate in sessions where patient emotional trauma is pertinent. Patients who have experienced trauma may be harmed or feel unsafe as a result of focused emotional discussion that may include past traumas, especially without established therapeutic relationships with their GC (Tong et al., 2019). The family history portion of the genetic counseling session can reintroduce trauma to individuals and can be especially impactful if there is intergenerational trauma (Carrion et al., 2023). Borrowing from trauma-informed care strategies, GCs can implement thoughtful practices to mitigate psychological harm and create safe spaces for patients while performing a psychosocial assessment (Berring et al., 2024; Carrion et al., 2023; Edelman, 2023; Grossman et al., 2021; SAMHSA’s Trauma and Justice Strategic Initiative, 2014). GCs can create comfortable spaces for patients of all backgrounds and leverage rapport to understand patient emotional needs.

The Casual Psychosocial Style, where rapport and comfort arose organically between patient and GC, has several important, unique characteristics. The phenomena of warmth (friendliness, trustworthiness, empathy) and competence (intelligence, efficacy, skill) have been shown to contribute largely to a positive interaction between a physician and a patient, impacting whether the patient thinks the provider “gets it” and “gets [them]” (Howe et al., 2019). The Casual Psychosocial Style also aligns with the Reciprocal Engagement Model as the rapport necessary for this style builds upon the relationship between the patient and GC as well as the patient’s emotional state throughout the session (Veach et al., 2007). Additionally, it is possible that the organic and casual nature of this psychosocial style lends itself to more experienced GCs as the Casual Psychosocial Style was observed most often in sessions where the GC had been in clinical practice for at least 15years. This aligns with anecdotes from seasoned GCs (>15 years post degree experience) who indicated that they shifted from being “more information and agenda-driven to more emotion focused and patient-driven” over the course of their careers (Zahm et al., 2015). Several GCs stated that as their confidence increased, they were more comfortable addressing patient emotional and counseling needs as they emerged during sessions or “in the moment” (Zahm et al., 2015). This conversational approach is evident within the Casual Psychosocial Style where flexibility rather than structure guided the course of the session, and less explicit psychosocial assessments may have occurred during discussions of psychosocial content.

Our observation that not all genetic counseling sessions included a psychosocial assessment suggests that some emotional needs of patients may be unmet. Indeed, not all patients will openly volunteer emotional distress, and prompting by a clinician may be the difference in eliciting such concerns (Austin et al., 2014; Lieberman & Stuart, 1999; Moscarello et al., 2024; Weil, 2003). By not assessing, GCs may miss the opportunity to attend to psychosocial concerns and promote positive patient outcomes (Austin et al., 2014; Moscarello et al., 2024; Murray et al., 2021; Semaka & Austin, 2019). This also signals a potential area of improvement to better train and equip GCs with skills to confidently perform psychosocial assessments routinely. For most GCs in our sample who did perform an explicit psychosocial assessment, no consistent structure guided the manner in which they elicited or responded to patient emotions. While measures have been developed to better characterize the concrete communication skills GCs use to achieve session goals, there is generally a lack of standardized methods for verbal psychosocial assessments (Hehmeyer et al., 2023; Moscarello et al., 2024).

The explicit psychosocial assessment within the Direct Psychosocial Style could be supplemented by the BATHE method: a structured, verbal psychosocial assessment tool that has been shown to improve patient empowerment, patient satisfaction, and person-centered care, and has been described as a useful tool for GCs (Akturan et al., 2017: DeMaria et al., 2011; Lieberman & Stuart, 1999; Platt, 2020; Thomas et al., 2019). Trainees who are establishing their style can utilize the genetic counseling adaptation continuum model to contextualize patient psychosocial complexity, further their understanding of patient adaptation to a genetic condition, and cultivate advanced counseling skills (Shugar, 2017).

5 |. STUDY LIMITATIONS

We were limited to data collection at a single site and our sample did not include GCs or patients from other specialties. The sample was not spread evenly across specialties, and observations surrounding years of practice could be due to the nature of the composition of the sample. However, given that psychosocial styles varied across GCs within each specialty and between each session with the same GC, we can anticipate that these patterns will appear across other specialties, session types (i.e., follow up), and GCs not included in this study. Additionally, the psychosocial style that GCs applied during their sessions and the opportunity for psychosocial support, questions, and responses depended on the patien’s willingness to verbally share and interact with the GC. There may have been instances where having a patient who was more open to discussing personal issues would have resulted in more opportunities for the GC to ask direct feelings questions or assess the psychosocial status of the patient. Lastly, all genetic counseling sessions were coded using audio recording transcripts. These transcripts did not capture the tones, inflections, and nonverbal cues that contribute to the psychosocial interactions between GCs and their patients.

6 |. RESEARCH RECOMMENDATIONS

Future studies could explore the relationship between psychosocial styles, presence of psychosocial assessments, and patient outcomes. Future research could also verify if GCs identify with these psychosocial styles and their rationale behind their approach within sessions. GC and patient racial/ethnic, gender, and age concordance across psychosocial styles could be evaluated. Video analysis of genetic counseling sessions could also be used to capture the nonverbal cues utilized during sessions and the psychosocial assessment. Patient preferences for provider psychosocial style could be investigated. Future research could include more genetic counseling specialties, different types of sessions, and various institutions to more completely describe the landscape of the psychosocial assessment across genetic counseling sessions.

7 |. CONCLUSIONS

It is important that the field of genetic counseling defines how psychosocial assessments are conducted in order to assess patient-provider interactions, highlight aspects that work well or could be improved, and allow for more tailored implementation of these processes across specialties.

We described three distinct psychosocial styles (Direct, Informational, Casual) and observed explicit psychosocial assessments in a minority of analyzed sessions. Given the variability across sessions and GCs, a standardized psychosocial assessment framework could be a useful tool to facilitate comprehensive psychosocial assessment of patients. Further work is needed to assess efficacy of and explore patient outcomes within each psychosocial style and psychosocial assessment.

Supplementary Material

Additional supporting information can be found online in the Supporting Information section at the end of this article.

What is known about this topic

Psychosocial support and assessment are central to genetic counseling practice, allowing genetic counselors (GCs) to meet the complex emotional needs of their patients and families. Several broad and theoretical frameworks exist to facilitate this process, and the psychosocial content of simulated sessions has been analyzed in previous literature.

What this paper adds to this topic

We have expanded this line of inquiry from simulated to actual genetic counseling sessions as we characterize how GCs conduct psychosocial assessments through descriptive content analysis of genetic counseling session audio recordings. Three distinct psychosocial styles were observed as GCs interacted with psychosocial content (“Direct,” “Informational,” “Casual”), and an overt psychosocial assessment was observed in the “Direct Psychosocial Style” alone.

DATA AVAILABILITY STATEMENT

Data are available upon request with appropriate data sharing agreements.