American Journal of Medical Genetics 72:172–179 (1997)
Nondirectiveness in Genetic Counseling: A Survey
of Practitioners
Dianne M. Bartels,1* Bonnie S. LeRoy,2 Patricia McCarthy,3 and Arthur L. Caplan4
1
Center for Bioethics, University of Minnesota, Minneapolis
2
Institute of Human Genetics, University of Minnesota, Minneapolis
3
Department of Educational Psychology, University of Minnesota, Minneapolis
4
Center for Bioethics, University of Pennsylvania, Philadelphia
The literature defines nondirectiveness as a
genetic counseling strategy that supports
autonomous decision-making by clients
[Fine, 1993]. This study surveyed 781 full
members of the National Society of Genetic
Counselors (NSGC) between April and June,
1993, to assess how they define nondirec-
tiveness, its importance to their practice,
and how and why they are ever directive.
Almost 96% of 383 respondents reported
viewing nondirectiveness as very impor-
tant, but 72% stated they are sometimes di-
rective. The most common reasons for direc-
tiveness include: difficulties ensuring that
verbal and nonverbal cues remain nondirec-
tive; to recommend testing; client is unable
to understand; a better choice is clear; to
recommend medical care or counseling; or
when a client has difficulty making a deci-
sion. Nonsignificant Chi-square analyses in-
dicated that counselor responses were inde-
pendent of counselor demographics. While
these findings suggest that nondirective-
ness is a goal in genetic counseling, it is not
the only goal. Recognition of the delicate
balance between directing the process and
defining the outcome of genetic counseling
can enhance clinicians’ ability to discern
the circumstances under which directive-
ness is and is not appropriate. Am. J. Med.
Genet. 72:172–179, 1997. © 1997 Wiley-Liss, Inc.
KEY WORDS: nondirective; genetic coun-
seling practice; NSGC
*Correspondence to: Dianne M. Bartels, Center for Bioethics,
University of Minnesota, Suite N504, 410 Church Street SE, Min-
neapolis, MN 55455.
Received 25 June 1996; Accepted 7 April 1997
© 1997 Wiley-Liss, Inc.
INTRODUCTION
The Human Genome Project is having a profound
impact on the practice of medicine by making available
genetic tests for common diseases like cancer and heart
disease. These developments create new challenges for
clinicians in primary practice and in academic health
centers. Scientific information will need to be transmit-
ted to clients in a meaningful way so that clients can
use it to make decisions. ‘‘Patients must not only un-
derstand the information provided concerning the na-
ture of genetic testing and the foreseeable conse-
quences of consenting to or refusing testing, but also
must have attention given to that information they
consider to be material to their decision to authorize
testing’’ [Geller and Holtzman, 1991, p. 322]. The man-
ner in which the communication process occurs will be
as important as the information itself in assisting cli-
ents in making decisions.
Receipt of genetic information and subsequent deci-
sions often have a major impact on the lives of indi-
viduals. Because genetic decisions are often linked
with reproduction, they fall within a zone of privacy
where American law and public policy have tradition-
ally placed great weight on individual autonomy. Be-
cause of these sensitivities, supporting client autonomy
by presenting information in a nondirective way is the
stated norm among U.S. geneticists [Wertz and
Fletcher, 1988] and genetic counselors [Fine, 1993].
But there are emerging challenges to the norm of
respect for client autonomy. Client demands for treat-
ment which clinicians regard as not medically indi-
cated, futile, or immoral may not be automatically en-
dorsed. For example, some clinicians do not offer pre-
natal testing to individuals who want test information
only to make a decision about whether to continue a
pregnancy based on gender of the fetus [Burke, 1992;
Evans et al., 1991]. Furthermore, many primary care
providers are not comfortable with a value-neutral
stance in their dealings with patients [Caplan, 1993].
What should be the guiding norm(s) for communicat-
ing genetic information in medical practice? We de-
cided to examine current genetic counseling practice
for baseline data about existing norms, as a first step
toward formulating what should happen in the future.

Genetic counseling is the process of communicating
genetic information to patients or clients who will use
it to make health care decisions. Initially conducted by
M.D. and Ph.D. geneticists, counseling today is often
provided by master’s-level genetic counselors. Nondi-
rectiveness is, and has long been, an explicit norm for
genetic counselors [Marks, 1993] and a strategy that
genetic counselors have adopted to promote autono-
mous decision making [Fine, 1993]. The Code of Ethics
for Genetic Counselors states:
The counselor-client relationship is based on val-
ues of care and respect for the client’s autonomy,
individuality, welfare, and freedom. The primary
concern of genetic counselors is the interests of
their clients. Counselors strive to . . . Enable their
clients to make informed independent decisions,
free of coercion, by providing or illuminating the
necessary facts and clarifying the alternatives and
anticipated consequences, . . . [or] refer clients to
other competent professionals who can, when they
are unable to support the clients [National Society
of Genetic Counselors, 1991].
When Wertz and Fletcher [1989] conducted a 19-
nation survey of M.D. and Ph.D. geneticists they found
a high level of endorsement for nondirectiveness. In 3
cases which focused on counseling approaches in a situ-
ation where the fetus was affected by a condition
viewed as ‘‘low burden,’’ there was 75% or greater con-
sensus in 75% of the nations that counseling should be
nondirective. In regard to a possible small neural tube
defect, 98% of respondents would disclose the informa-
tion and 87% would counsel nondirectively, while 5%
would advise carrying to term and 8% would advise
abortion.
Although nondirectiveness is the most universally
espoused norm in genetic counseling literature, some
data suggest that it is not always followed in actual
practice [Brunger and Lippman, 1995; Yarborough et
al., 1989]. For example, when genetic counselor re-
sponses were compared to those of geneticists using
scenarios similar to those used by Fletcher and Wertz,
their responses generally corresponded. But in some
instances which addressed disclosure of information,
counselors more consistently favored patient autonomy
and confidentiality [Pencarinha et al., 1992].
In a more recent survey of geneticists based on the
same case studies, Marteau et al. [1994] showed that in
the United Kingdom, Germany, and Portugal there is
broad agreement on the goals of genetic counseling
among geneticists, but not all consider nondirective
counseling appropriate in all situations. They found
that on a scale of nondirectiveness, German and Por-
tuguese geneticists were significantly more directive
than U.K. geneticists. In prenatal testing, German ge-
neticists were more likely to encourage continuing
pregnancies, while Portuguese geneticists were more
likely to encourage termination of affected pregnan-
cies. Responses to cases which described varying ge-
netic conditions indicated no strong agreement on the
proper approach to a specific condition [Marteau et al.,
1994].
It is noteworthy that nondirectiveness in these stud-
Nondirectiveness in Genetic Counseling 173
ies is addressed by cases which focus exclusively on
advice given in the prenatal situation. We cannot as-
sume responses would be the same if geneticists and
genetic counselors were presented with cases concern-
ing testing for genetic conditions in adults. It is impor-
tant to clarify the norms that actually guide practice,
as genetic counseling services continue to evolve.
Therefore, we asked genetic counselors about the im-
portance of nondirectiveness in their work.
METHODS
Survey
We surveyed genetic counselors between April and
June, 1993, to better understand how they view the
role of nondirectiveness in practice. Respondents were
asked to indicate the extent to which nondirectiveness
is important in their clinical practice, how they define
directiveness, and under what conditions they believe
they are directive. Additional survey questions solic-
ited information about respondent demographics; focus
and setting of practice; educational needs; and time
spent giving information, listening, and providing sup-
port during genetic counseling sessions. Responses to
survey questions are presented below.
Sample
A questionnaire was sent to 781 full members of the
National Society of Genetic Counselors. Two follow-up
postcards were sent as a reminder to return the survey.
Any identifiers were removed from the survey prior to
scoring for results. Three hundred eighty-three or
49.0% of practicing counselors returned completed sur-
veys. Sample demographics are reported in Table I. We
compared all demographic information in Table I with
that obtained by Boldt [1994] in a professional survey
of members of the National Society of Genetic Counsel-
ors. Although not representative of the general U.S.
population, the respondents were representative of the
membership of the NSGC.
Analyses
Two independent judges (one doctoral level psycholo-
gist and one medical doctor/lawyer) were trained in the
same system for coding the open-ended responses for
definitions of nondirectiveness and reasons for direc-
tiveness. Thirty response sets were randomly selected
to calculate interrater agreement using the kappa sta-
tistic as recommended by Tinsley and Weiss [1975] and
Hill [1985]. The kappa statistic for definition of nondi-
rectiveness was .82; while the kappa for reasons for
directiveness was .98. The relationship between each
category and respondent demographics was tested for
significance using a Chi-square analysis of contingency
tables.
RESULTS
Counselor Activities During Genetic
Counseling Sessions
Respondents were asked ‘‘What percent of the time
do you spend in each of the following activities during
a genetic counseling session: provide support, listen,
174 Bartels et al.

TABLE I. Sample Demographics

Variable n % Mean Range SD
Age 383 34.2 21–69
Gender
Female 357 93.2
Male 26 6.8
383 100.0
Ethnicity
Caucasian 365 95.8
Asian/Pacific Islander 7 1.8
African American 5 1.3
Hispanic 1 0.3
Biracial 1 0.3
Other 2 0.5
381 100.0
Highest degree
M.S./M.A. 354 92.4
Ph.D. 15 3.9
M.D. 4 1.0
Other 10 2.6
383 99.9*
Graduate of formal counseling
program
Yes 340 89.0
No 42 11.0
382 100.0
Board eligible/certified by the
American Board of Medical
Genetics
Yes 367 96.3
No 14 3.7
381 100.0
Credit hours of psychosocial
counseling coursework 354 9.7 0–142.5 13.4
Years of genetic counseling
experience 380 6.9 0–21 5.0
Average number of counseling
sessions per year 370 413.7 0–1,500 251.8
Currently providing genetic
counseling
Yes 359 93.7
No 24 6.3
383 100.0
Primary work setting
University medical center 184 50.3
Private hospital/facility 100 27.3
HMO 20 5.5
Private practice 19 5.2
Federal/state/county office 12 3.3
Outreach/satellite clinic 10 2.7
Diagnostic laboratory 7 1.9
Other 14 3.8
366 100.0
Primary focus of genetic
counseling
Prenatal 202 55.8
Prenatal and pediatric 77 21.3
Pediatric 40 11.0
Pediatric/specialty disease 13 3.6
Specialty disease 11 3.0
Public health/newborn 4 1.1
Adult and specialty disease 2 0.6
Screening 2 0.6
Adult 1 0.3
Molecular/cytogenic/bioch 1 0.3
Other 9 2.5
362 100.1*
*Does not equal 100% due to rounding.
 Nondirectiveness in Genetic Counseling 175

give information, and ‘other’?’’ As outlined in Table II, TABLE III. Directiveness vs. Nondirectiveness
counselors spend more than half of their time providing Importance of nondirectiveness in respondents’ genetic
information to clients, greater than 40% listening and counseling practice (n 4 371)
giving support, and only a small percentage of time
Not at all important Extremely important
engaged in ‘other’ activities.
When asked whether ‘‘counseling’’ is an appropriate 1 2 3 4 5
term for the services they provide, the majority of coun- 0% 0.8% 3.2% 38.5% 57.4%
selors answered affirmatively. Percent of counselors who are ever directive in their genetic
counseling (n 4 349)
Descriptions of Nondirectiveness Yes 72.2%
No 27.8%
Counselors were asked, ‘‘In your own words, please
describe ‘nondirective’ as concretely as you can.’’ The
majority of responses fell into three major categories.
Present both (all) sides. Almost 63% of the and nonverbal responses are nondirective. For ex-
sample indicated that nondirectiveness means giving ample, ‘‘I am never purposely directive. However, I am
adequate information about all options and supporting sure that at times a patient may not perceive me as
all options equally to avoid influencing the decision. such based on my posture, voice, etc. I am not sure
Allow client values to determine the outcome. anyone can really remain nondirective.’’
Forty seven percent of the respondents indicated that The next most frequent responses, each mentioned
they respect client values and many commented that by more than 5% of the respondents, included the fol-
they, ‘‘don’t let personal opinions/values influence the lowing: to recommend genetic testing (15.4%); client is
client’s decision.’’ They also indicated that counselor unable to understand (9.3%); if a better choice is clear
support should not be conditional in relation to client (8.6%); to recommend medical treatment (8.6%); and
decisions or values. client cannot decide (6.5%). Examples of illustrative
Be objective. To be objective was mentioned by respondent comments follow.
36.8% of the respondents and was defined as present-
ing information in an unbiased way, or letting the pa- To Recommend Testing
tient/couple decide.
‘‘I counsel women from high-risk cancer families–I
Examples of descriptors provided by respondents to
am not neutral about offering guidelines for screening.
define nondirectiveness include: client-centered, i.e.,
I feel this type of counseling is substantively different
meaning reflecting the client’s perspective; empathic;
from prenatal reproductive counseling.’’
and nonjudgmental. These responses very closely re-
‘‘In pediatric genetics, we must sometimes refer for
semble those included in Carl Roger’s [1951] nondirec-
testing that could identify further problems once a con-
tive, person-centered approach to counseling.
Directiveness Versus Nondirectiveness TABLE IV. Reasons Given by Sample of Genetic Counselors
for ‘‘Directiveness’’*
Respondents were asked to rank on a five-point
Likert scale (14not important at all; 54very impor- Frequency %
tant), ‘‘How important is nondirectiveness in your clini- Nonverbally/order of information/word
cal practice?’’ As shown in Table III, the majority of choice 65 23.3
respondents endorsed a rating of five or four where five To recommend testing/screening 43 15.4
indicated ‘‘extremely important.’’ None of the counsel- Client is unable to understand 26 9.3
ors endorsed ‘‘not important at all.’’ Even though non- If better choice is clear/patient choice is
not best one 24 8.6
directiveness appears to be very important, 72% stated To recommend medical care/counseling 24 8.6
that they are sometimes directive in their sessions. Client has difficulty deciding 18 6.5
Respondents were invited to ‘‘Please comment,’’ and Prompted by drug/alcohol/teratogen use 14 5.0
279 counselors wrote extensive comments about their To support/backup patient’s decision 14 5.0
directiveness, often in an apologetic tone. Their re- When asked what I would do/what I
sponses were categorized into reasons for directiveness think 13 4.7
To encourage patient/couple to take time
and are summarized in Table IV. The most frequently to decide 11 3.9
cited reason, which was indicated by 23.3% of respon- With low functioning clients (e.g.,
dents, focused on the difficulty of ensuring that verbal mentally retarded) 11 3.9
In extreme or critical cases/patient’s life
in danger 8 2.9
TABLE II. Counselor Activities During Genetic When it is culturally/ethnically
Counseling Sessions appropriate 6 2.2
When pressured or inappropriate referral
How time is spent during a genetic counseling session
by M.D. 6 2.2
(n 4 355)
With very young mothers 6 2.2
Providing support 16.8% Other 9 3.2
Listening 24.5% No comment given 104 27.2
Giving information 54.1%
Other 5.8% *Percentages add up to more than 100% due to multiple responses. n 4
279.
176 Bartels et al.
dition has been identified (e.g., renal scan to find
Wilms’ tumor in Beckwith-Wiedemann patients).’’
‘‘I am directive in reference to carrier screening. In
all counseling sessions, I am sure I am directive to a
degree in terms of the length of time I spend on a topic
and how I present information.’’
‘‘Prenatal clinic patients who are under 18 years of
age with abnormal ultrasound findings incompatible
with life . . . We encourage them to consider the option
of TOP seriously.’’
Client Is Unable to Understand
‘‘I try not to be, but in the cases in which patients are
very low functioning (i.e., mentally retarded) I find my-
self sometimes suggesting the option which I feel may
be most appropriate.’’
‘‘We deal with a lower socioeconomic class that might
not understand the consequences of their actions or
need some guidance in making decisions.’’
‘‘Sometimes it is very difficult to be nondirective
when a patient presents at 28 weeks and does not
speak English well. Patient does not seem to under-
stand information . . .’’
‘‘A patient couldn’t decide about a coagulation test
for hemophilia A. I told her to have the test because I
didn’t feel she understood the situation.’’
‘‘Rarely–in situations where client immaturity, cul-
tural practice, educational background, or comprehen-
sion renders decision-making seemingly impossible.’’
If a Better Choice Is Clear
‘‘Sometimes if a patient is choosing a procedure that
is clearly not the best choice (e.g., CVS in view of family
history of NTD or CVS in view of history of infertility
and bleeding in pregnancy), I will try to steer [the]
patient toward a better option.’’
‘‘Occasionally I will be directive through reassur-
ance. When I perceive a risk to be very small and a
patient doesn’t seem to be keeping it in perspective.’’
‘‘When counseling couples regarding issues that may
potentially have a large impact on other family mem-
bers, such as familial translocations or familial disor-
ders such as Fragile X Syndrome, I strongly encourage
persons to discuss the information with at-risk family
members or to have those persons contact our office. I
do inform them that it is their decision.’’
To Recommend Medical Treatment
‘‘One patient’s life was endangered by her medical
situation, complicated by a dying fetus with a lethal
condition. I agreed with her M.D. that the pregnancy
should be terminated now, rather than let nature take
its course.’’
‘‘If a client is continuing an abnormal pregnancy I
may pressure them to return for their follow-up care to
monitor the pregnancy/baby.’’
‘‘. . . Only if, in my professional opinion, a child’s
health would be jeopardized otherwise . . . referring to
counseling parents of a child with a metabolic condi-
tion, for instance, that requires a specific diet that the
parents may not want to follow.’’
‘‘The only situation where I feel that I would inten-
tionally be directive is if a child was not getting the
appropriate care or treatment due to parental denial
and all else failed.’’
Client Cannot Decide
‘‘Occasionally I am directive with clients unable to
make choices for various reasons (e.g., being paralyzed
by indecision) when they clearly indicate a preferred
choice.’’
‘‘I talk to people from many different ethnic groups
and as much as I try to let them make their own deci-
sions, some expect me to tell them what to do.’’
‘‘There are times when clients have difficulty making
choices due to language/cultural barriers (e.g., husband
making decisions for a wife without considering her
feelings).’’
‘‘Sometimes a gentle push is necessary for clients
who are paralyzed by fear–rational or irrational–and
stuck, unable to come to any decision whatsoever. The
‘push’ is used not to force them into decision making,
but to enable a new focus putting fear into perspective.’’
Although several counselors mentioned that refer-
ring physicians were sometimes unhappy with their
nondirective stance, they indicated that they are tena-
cious in their attempts to be nondirective.
Relationships between counselor demographics and
their responses to ‘‘are you ever directive’’ and ‘‘impor-
tance of nondirectiveness’’ were examined by Chi-
square analyses. None of these analyses indicated a
significant relationship between counselor responses
and age, gender, ethnicity, education, hours of psycho-
social counseling coursework, years of genetic counsel-
ing experience, number of counseling sessions con-
ducted per year, whether the counselor is currently
practicing, or work setting or primary focus of counsel-
or practice. This differs from the findings of Pencarinha
et al. [1992] who found that genetic counselors who had
more counseling education and who spent more time
with patients have stronger opinions about patient au-
tonomy and right to choose.
DISCUSSION
The results of this study suggest that nondirective-
ness is a valued goal of genetic counselors. Almost 96%
of the sample rated nondirectiveness as very important
to their clinical practice. This percentage is higher than
that obtained by Wertz and Fletcher [1989] who re-
ported that 75% of their international sample of medi-
cal geneticists were committed to a nondirective prin-
ciple. Perhaps nondirectiveness is more widely en-
dorsed ‘‘as a paradigm for counseling’’ (p. 429) in the
United States, and/or by individuals who are educated
to provide genetic counseling. In addition, support for
nondirectiveness did not vary by gender in the present
study as it did for geneticists in the Wertz and Fletcher
[1989] study where men were found to favor ‘‘. . . more
directive approaches’’ (p. 36) to counseling.
The present results also indicate that respondents
adhere to a relatively uniform conception of nondirec-
tiveness. Their written definitions included these
themes: presenting both (all) sides, allowing client val-
ues to determine the outcome of decisions made after

receiving genetic information, and being objective.
Terms used by respondents to describe nondirective-
ness include client-centered, empathic, and nonjudg-
mental. These descriptors reflect a Rogerian orienta-
tion [Rogers, 1951] to counseling consistent with those
described by Marks [1993] and incorporated into the
Genetic Counselors Code of Ethics [National Society of
Genetic Counselors, 1991].
Although nondirectiveness was endorsed as a pri-
mary goal of genetic counseling practice, 72% of the
respondents indicated that they are sometimes direc-
tive with their clients. Their responses support Wolff
and Jung’s [1995] argument that genetic counseling is
an influence process and that counselors need to ac-
knowledge and reflect upon their influence. The re-
spondents wrote extensive comments explaining the
circumstances in which directiveness occurs. The tone
of their comments was frequently apologetic as they
described veering from the morally right course of non-
directiveness. Similar to the findings of Brunger and
Lippman [1995], many of the genetic counselors in the
present sample experience conflict between the ideal of
nondirectiveness and the reality that they are some-
times directive.
The respondents provided some compelling reasons
for intentionally moving toward more directive re-
sponses. Many noted that it is impossible to be totally
nondirective in one’s choice of what information to in-
clude and exclude from a counseling session. These
comments support Brunger and Lippman’s [1995] con-
clusion that genetic counseling is not a ‘‘one-size-fits-
all’’ endeavor; rather, information must be tailored to
specific clients and their circumstances. Many respon-
dents also commented that it is impossible to control
nonverbal behaviors and acknowledged that they
might be communicating their opinions to clients
through their nonverbal responses. A number of re-
spondents indicated that they were directive when they
recommended genetic or medical testing. This type of
directiveness is consistent with informed consent, a
principle that may supersede the nondirective stan-
dard. Informed consent requires that professionals
share relevant information with their patients/families
in comprehensible terms so that they can make health
care decisions. Genetic counselors are expected to pro-
vide this type of information.
Several respondents reported that they were direc-
tive in recommending medical treatment when it was
available and relevant to the health of their clients or
their clients’ children. It was evident from the ex-
amples they provided that these recommendations
were intended to prevent harm, which is one of the
most basic moral tenets of the medical and genetic
counseling professions. Indeed, in instances where sub-
stantial harm might result from nontreatment and/or
lack of information, it is the counselor’s duty to make
strong recommendations to promote health and/or to
prevent serious consequences [Beauchamp and Chil-
dress, 1994].
One respondent differentiated directiveness in pro-
cess versus directiveness in outcome: ‘‘When clients are
having a hard time making a decision . . . I will be very
Nondirectiveness in Genetic Counseling 177
directive in telling people how to go about resolving
conflict/making decisions, but will not be directive
about what the decision should be.’’ This process-
outcome distinction is important. Genetic counselors
are experts both in genetic information transmission
and in conducting counseling sessions. As such, they
are responsible for directing the flow of the session in
order to convey sufficient information to prepare cli-
ents to make informed decisions. However, once clients
have had an opportunity to receive and understand the
available information, then the final decision ought to
reflect their values, and not counselor values.
Does this imply that counselors should always re-
frain from disclosing personal biases and values to
their clients? The majority of genetic counseling texts
indicate that what a counselor might decide to do is
irrelevant to the client’s decision since the circum-
stances and values of each person can be quite unique.
However, Wachbroit and Wasserman [1995] have a dif-
ferent perspective. They argue that it is possible for a
counselor to express values, ‘‘so long as she carefully
disclaims any special expertise in matters of value,’’ (p.
3) and clarifies that the views expressed do not have
the authority of science behind them. Furthermore, the
counselor should be very clear about the necessity for
clients to examine their own values and to take respon-
sibility for subsequent decisions. Similarly, Brunger
and Lippman [1995] suggest that it is no less directive
to withhold one’s opinion than to give it, and that dis-
closing one’s perspective can help the counseling pro-
cess be ‘‘. . . more open, honest, and less stressful for
counselors’’ (p. 165). We would add the caveat that
counselors must work to ensure that their opinions do
not lead to premature closure of the client’s decision-
making process and do not unduly influence decision
outcomes.
In addition to the reasons for directiveness described
above, a few infrequently reported reasons merit care-
ful consideration. Some respondents stated that they
were directive when they determined that clients ei-
ther could not understand or were unable to make a
decision. Specific comments indicate that these in-
cluded situations where the counselors believed that
the clients could not understand due to cognitive im-
pairment, the clients could not ‘‘make up their minds,’’
or the clients expected on the basis of their cultural
backgrounds to be told what to do. In these cases the
counselors were directive about decision outcomes, as
opposed to directing the decision-making process.
It is our opinion that intellectual functioning, inde-
cision, and cultural differences should not automati-
cally lead genetic counselors to make decisions for their
clients, especially without considering viable alterna-
tives. For example, counselors could recommend other
resources to assist with the decision. A parent or
guardian, spouse, and/or community leader may be in a
better position than the counselor to assist the client in
decision-making that is consistent with the client’s val-
ues and the cultural context in which she or he lives.
Genetic counselor medical expertise is not synonymous
with either moral or cultural expertise.
178 Bartels et al.
Nondirectiveness Reconsidered
Seventy-two percent of the respondents indicated
that it may not be possible to be nondirective in all
situations, yet they believed they ought to be. A goal of
complete nondirectiveness is neither feasible nor desir-
able. However, it is important to be as intentional as
possible in one’s directive behaviors in order to provide
effective services to clients. An important distinction
concerns directiveness about the decision-making pro-
cess, and directiveness about decision outcomes. Coun-
selors should assume responsibility for directing the
session, e.g., explaining the nature of genetic counsel-
ing [McCarthy et al., 1996], clarifying client expecta-
tions and questions, sharing genetic information, and
facilitating client understanding and communication.
Counselors can also offer additional information, sug-
gest more decision options, and provide referrals to ap-
propriate resources to further assist clients in their de-
cision-making. These activities are consistent with the
genetic counselor roles of expert informant and facili-
tator.
Counselor directiveness regarding decision outcomes
is a more controversial issue. Experts in the field differ
in their endorsement of this type of directiveness. In
our view, it may be appropriate in some situations for
counselors to share personal biases, but this must be
done only after careful assessment of client expecta-
tions and needs, and after a careful judgment of the
likely impact of such disclosure on the client’s decision-
making. When possible, counselors should help clients
to examine their own values and/or to find other re-
sources to assist with decision outcomes.
The present findings suggest that nondirectiveness,
although generally rated as important to practice, is
not the only principle guiding counselor behavior. The
respondents also reported attempts to maximize client
understanding and to minimize potential harms. Main-
taining the presumption of nondirectiveness related to
outcomes can continue to sensitize counselors’ aware-
ness of when and why they choose to be directive. Stra-
tegically directing the process in counseling sessions
can enhance patient understanding and allow discus-
sions of values clients bring to their decisions.
Limitations of Study and Future Research
Recommendations
The present sample consisted of about one half of the
members of the National Society of Genetic Counselors,
and their demographics were representative of the so-
ciety’s entire membership. Nevertheless, it is not
known to what extent their responses to questions
about nondirectiveness are representative of nonre-
spondents. Thus, generalizability of the findings may
be restricted.
Further restrictions may have resulted from our in-
tentional choice to exclude from participation non-
members who are likely to be M.D. and Ph.D. geneti-
cists, and medical subspecialists who utilize genetic
testing in diagnosis. The norm of nondirectiveness has
been endorsed more explicitly in genetic counselor edu-
cation and literature than in most other professions.
Although support of patient autonomy is a major value
in medicine, prescription is not only allowed, but ex-
pected [Caplan, 1993]. Therefore, it is possible that
non-society members would have responded quite dif-
ferently to the questionnaire items. Future studies
should include these professionals.
The number of males in this study is representative
of their numbers among the U.S. genetic counselor
population. However, the sample size is still relatively
small. Therefore, conclusions about the lack of gender
differences concerning nondirectiveness should be
made cautiously. More research is needed using larger
numbers of male participants in order to determine
whether counselor gender is a significant factor.
In this study the type of clinic or setting did not in-
fluence the counselors’ expectation for directiveness.
However, both clients and counselors may revise their
expectations as genetic testing moves increasingly into
primary practice arenas where preventive health be-
haviors could influence health outcomes. Studies of cli-
ent perceptions of genetic counseling address under-
standing and retention of information, expectations,
and goals, but do not discuss nondirectiveness per se
[Sorenson et al., 1981].
Another limitation of the present study is that de-
scriptions of counselor behavior are based exclusively
on counselor self-report. Although this is typical of
studies of genetic counselor practices [e.g., Brunger
and Lippman, 1995; Sorenson et al., 1981], observa-
tions of actual counseling sessions are needed. Such
studies should examine differences in counselor nondi-
rectiveness and directiveness as a function of client ex-
pectations, counselor and client gender, cultural back-
grounds, client presenting conditions, and counselor
experience. This type of research is imperative in order
to establish current norms for counseling practice es-
pecially since genetic information is rapidly becoming
an integral part of medical practice.
ACKNOWLEDGMENTS
The authors thank Robin Reese-McLeod, Ph.D., for
her assistance with coding and statistical analyses for
this project, and Wayne M. Hartley for his editorial
assistance.
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