American Journal of Medical Genetics 72:164–171 (1997)

Psychological Aspects of Genetic Counseling. XI.

Nondirectiveness Revisited
Seymour Kessler*
Department of Pediatrics, University of California, San Francisco

Directiveness and nondirectiveness are con- them, respectively, with the giving and withholding of
sidered here as psychological phenomena advice. In contrasting the methods of psychiatry and
and separated from the issue of giving or genetic counseling, he stated, ‘‘. . . [T]he geneticist can-
withholding advice. The former is a form of not indulge in directives . . .’’ [Reed, 1964]. During this
persuasive communication involving vari- period, others addressed the same issue without using
ous combinations of deception, coercion, the term nondirective. Lynch [1969], for example,
and threat, whereas the latter describes wrote:
procedures that promote and enhance the
The counselor must never make decisions for the
autonomy and self-directedness of clients.
[client] regarding marriage, children, and other
Examples are given showing that profes-
important personal issues. These decisions are the
sionals have considerable difficulty dealing
[client’s] responsibility and only [the client] should
with relatively simple, common issues aris-
exercise this right.
ing in genetic counseling. It is suggested
that many, if not most, problems involving By the mid-1970s, these terms were firmly en-
the issue of nondirectiveness arise because trenched in the genetic counseling literature, although
of inadequacies in applying basic counsel- some medical geneticists had their doubts about pur-
ing skills. Several examples are given of suing a nondirective course. Porter [1979], for example,
nondirective counseling in situations in- in the halcyon period before HMOs, managed care, and
volving direct questions and the proffering the contemporary erosion of physician authority,
of ‘‘advice.’’ The need to raise standards in wrote:
counseling training is underscored if the
[T]he neutrality of the counselor . . . is unusual in
field of genetic counseling is to remain non-
medical practice, and is a difficult attitude for
directive. Am. J. Med. Genet. 72:164–171,
many physicians to adopt. . . . With prolonged ex-
1997. © 1997 Wiley-Liss, Inc.
perience and with more physicians providing ge-
netic counseling, we may expect a change to the
KEY WORDS: genetic counseling; counsel- more traditional doctor-patient relationship.
ing techniques; nondirective-
ness Nonetheless, the 1970s saw a gathering momentum
among geneticists toward a nondirective approach. By
the mid-1980s, surveys of medical geneticists around
the world showed an overwhelming endorsement of ND
INTRODUCTION in genetic counseling [Wertz and Fletcher, 1988]. More
It is unclear who first introduced the term nondirec- recently, a nondirective approach was strongly en-
tiveness (ND) into the genetic counseling literature. It dorsed by Baumiller et al. [1996] in their code of ethical
is likely that Sheldon Reed, who had earlier coined the principles for professionals in genetic services.
term genetic counseling [Reed, 1949], may have been Besides the anti-eugenics conviction of many geneti-
instrumental in this regard. By the early 1960s, Reed cists [Ludmerer, 1972; Porter, 1979; Fine, 1993] and
[1964, 1974] borrowed the concepts directiveness and the already changing nature of medical practice, the
ND from the field of psychotherapy and associated shift in thinking toward ND was influenced by the
growing consumerism movement. There was an in-
creased awareness among geneticists that they often
dealt with life problems and decisions about which they
This article is based on a lecture given at the National Society
of Genetic Counseling Annual Educational Conference, San Fran- had no greater expertise than anyone else. Last, but
cisco, CA, on October 27, 1996, and is dedicated to the memory of not least, there was the growing number of nonphysi-
Dr. Beverley R. Rollnick. cian professional women entering the field of genetic
*Correspondence to: Seymour Kessler, Ph.D., P.O. Box 7702, counseling. Women, more than men, are likely to be
Berkeley, CA 94707. nondirective [Wertz, 1994].
Received 12 January 1997; Accepted 7 April 1997 Like most concepts transposed from one field to an-
© 1997 Wiley-Liss, Inc.
 Nondirectiveness 165

other, something often gets lost in translation. Thus, graphic videotapes of fetuses being torn apart or sup-
the focus or emphasis on whether or not advice was posedly writhing in pain in utero, efforts all designed to
given tended to lead to a neglect of other important convince them to continue the pregnancy; if I tell them
aspects of what was involved in directiveness and ND. that what they have in mind is evil and sinful, that
For example, almost totally neglected were the coun- they will be punished for their actions; if physically, I
seling techniques associated with ND, which provided won’t let them leave until they promise to reconsider or
the means by which the ideal of ND could be achieved. change their decision. I have employed deception and I
It is not surprising then to read frequent complaints in have used threatening and coercive procedures to
the genetic counseling literature about the difficulty— change the women’s attitudes and behavior.
some say impossibility—of achieving ND. The how of One is also being directive when a salient option is
ND was misplaced in transposing this concept to ge- purposely withheld from clients in order to shape (or
netic counseling. coerce) their decision in a specific direction. If a profes-
In this paper, I would like to examine the psychologi- sional deliberately spends considerable time discussing
cal meaning of ND and show how a fuller understand- the negative aspects of trisomy 21 and gives very little
ing of it might be applied to the practice of genetic time to any positive ones, directiveness is clearly in-
counseling. First, let us examine directiveness to see volved. However, sometimes out of inattention, care-
what light might be shed on ND. lessness, thoughtlessness, or inadequate teaching or
counseling skills, professionals may unwittingly omit
Directiveness or overemphasize one option over another. Clients
might interpret such professional behavior as an im-
Attempts to influence us are ubiquitous. All the so- perative to act in a given direction, a mind set no dif-
cial institutions to which we are exposed (e.g., the fam- ferent from that induced by deliberate coercion.1 I tend
ily, churches and other religious institutions, school, to see these situations as ‘‘phenocopies’’ of directive-
political and professional groups, advertisers, and mer- ness arising as the result of inadequacies in the pro-
chants) all try to influence our attitudes and behavior fessional’s training and ability to apply counseling pro-
and we expect them to. In all of these attempts, the cedures.
element of individual choice or autonomy is not com- In the genetic counseling literature, ND is often for-
promised, especially as we approach and enter adult- mulated as the absence of directiveness as if the two
hood. We can choose which language to study to fulfill concepts were mutually exclusive. This I believe is a
our requirements in school, which automobile to buy, mistake. There is a vast grey area between directive-
which political party to vote for, which brand of tooth- ness, with its techniques of coercion [Milunsky, 1975;
paste to purchase, and which social causes to support. Antley, 1979], and ND. Much of what occurs in genetic
In this regard, our autonomy and our ability to accept counseling falls into this grey zone. By themselves dis-
or reject suggestions and other attempts to influence parate behaviors, such as giving directions, conveying
our behavior remain relatively intact. information, making health-promoting suggestions,
However, there is a form of persuasive communica- giving ‘‘bad’’ news, giving advice, and expressing one’s
tion in which our ability to choose and our individuality biases, are neither directive nor directive. With the in-
and autonomy are suppressed. In such situations, the troduction of deception and coercive techniques, these
individual is unaware that the other party has a hid- activities become directive.
den agenda and that that agenda is to systematically Ignoring coercion as the defining issue in directive-
and deliberately gain control over our attitudes and ness leads to a position in which almost any action or
behavior. utterance in genetic counseling could be interpreted as
By limiting access to information and contact with directiveness. The result is an unrealistic lumping to-
others with differing viewpoints, and by creating a gether of all forms of advice, directions, suggestions
sense of powerlessness and fear, our usual behavior and recommendations, helpful or not, coercive and non-
can be changed and new behavior substituted so that coercive, into a single, undifferentiated hodgepodge. A
we act in ways we would not otherwise have chosen. No recent study [Michie et al., 1997] illustrates this point.
one is immune to this process. Psychologists call this Not one of the examples they give as being directive
persuasive coercion, or as it is more commonly known, show any evidence of coercion, threat, or deception. In
mind control or brain washing. Our knowledge of such fact, depending on the counseling context, some of their
techniques comes from several sources, but most re- examples might just as easily be considered as nondi-
cently from the study of the way cults actively recruit rective or just neutral.
and incorporate new members and keep them in the Giving advice requires comment because it often
fold [Singer, 1995]. serves, mistakenly in my opinion, as the focal point in
Directiveness in genetic counseling needs to be the genetic counseling literature to differentiate direc-
thought of as a form of persuasive coercion. Like all tiveness and ND. First, there are ways to provide ad-
such techniques, one or more of the following elements vice in a nondirective way (see below). Second, advice
exist: 1) deception; 2) threat; 3) coercion. can be given in a noncoercive way which does not com-
I am being directive if I advertise in the telephone promise clients’ ability to choose or does not undermine
yellow pages that I am a provider of abortion services
(as some pro-life groups have done), and recruit unsus-
pecting women seeking to terminate a pregnancy; if I
subject them to intense efforts, such as showing 1
I thank Dr. Dorothy Wertz for bringing this to my attention.
166 Kessler

their autonomy. Third, noncoercive professional advice science and work it out with your wife.
does not seem to carry the weight or authority or in- [More discussion ensues]
fluence it once did in the past. Many clients resist, dis- W: What would you do if you had the trisomy
tort, or ignore advice that does not match their precon- child?
ceived ideas of risks and precounseling decisions [see P: Well, one can never say what they actually
Kessler, 1989, for a review of the literature]. would do in a situation. But I think I would be
willing to take advantage of these means and be
Nondirectiveness sure I don’t have a recurrence.
ND owes its origin to psychoanalysis and psychody- The professional here is dealing with a couple who
namic therapy. The original concept described a proce- seem to disagree about whether or not to have an am-
dure in which the analyst or therapist deliberately held niocentesis (see too a comparable analysis of this same
back from interfering with the verbal production of the excerpt by Wolff and Jung [1995]). Unfortunately, he
patient in order to encourage free association. In the neither acknowledges the disagreement nor explores
1930s and early 1940s, Carl Rogers [1942] appropri- what is at stake here, two very basic counseling strat-
ated the term ND to describe his personal approach to egies. For example, it is unclear whether or not M ob-
psychotherapy, which, similar to the psychodynamic jects to having the amniocentesis. Is his focus only on
tradition, gave clients the leeway to set the agenda, abortion? The limits of his objection are not made ex-
pace, and direction of their therapy. In the 1950s, for plicit. Is he willing to go along with W if she insists?
political reasons more than anything else, he renamed Would he leave the relationship if she went ahead with
his system, ‘‘client-centered therapy’’ [Rogers, 1951], in the amniocentesis or with an abortion? These implica-
order to emphasize the fact that he was rejecting the tions are not made known at this point, and may have
medical model of treating psychological problems. an impact on the subsequent course of the session.
Placing the full control of the agenda, pacing, and After M asks for advice a second time, the profes-
direction of treatment in the hands of the client is, I sional distances himself and rebuffs him (‘‘Well it’s not
believe, applicable only to psychotherapy and not ge- my problem. I am not you.’’). Of course, we do not have
netic counseling. Because of the relatively short dura- information about the inner state of the professional at
tion of professional/client contact and other factors this point. His statements could easily be interpreted
[Kessler, 1997a], such procedures are really not a vi- by M as a form of rejection and as an expression of
able option. Thus, in this regard, genetic counseling is annoyance for being placed in the position of ‘‘having’’
neither Rogerian nor client centered. By and large, at- to give advice. Finally, the professional relents. With
tempts to apply these terms to genetic counseling are, some qualification, he takes sides with W against M
in my view, misguided. and gives advice without establishing the context for it
On the other hand, since the beginning, there has or the possible fall-out of taking sides.
been a second aspect of nondirective methods that Fraser [1979] believes that this is directive counsel-
practitioners recognized, namely their ability to pro- ing. However, there is no effort to coerce the couple and
mote the autonomous functioning of the client. This there is certainly no deception involved. Thus, I see no
aspect of ND is clearly applicable to genetic counseling evidence of directiveness. However, several details
and I offer it as a definition: ND describes procedures stand out. An obvious one is the professional’s initial
aimed at promoting the autonomy and self-directedness ambivalence about giving advice, which seems to give
of the client. way as he becomes caught up in the clients’ conflict(s).
Note that much more than withholding or not giving His strategy to disengage from the conflict is to take
advice is involved. It is possible to withhold advice and sides, which is not the best counseling procedure. As
yet not be nondirective, just as it is possible to give the professional seems to experience and report the
advice and remain nondirective. The secret in the lat- exchange with W and M, he is pressured into being
ter case is how the advice is given. directive, thus implying that it was the clients’ respon-
Let us examine two apparently contrasting excerpts sibility that advice had to be given.2 Also, although
(in both instances the professional [P] is a male medical many details of the actual session are not available, the
geneticist; W 4 woman; M 4 man). professional seems uncomfortable in the counseling
Example 1 role and has difficulty sustaining a nondirective course.

In the first excerpt, a couple has had a previous preg- Example 2

nancy in which a trisomy was found [based on Fraser, In the second example, a woman who has had a pre-
1979]: vious child (deceased) with a neural tube defect is
P: [Explains the low recurrence risk and the pos- speaking:
sibility of amniocentesis.] W: Do most people go ahead and have this [amnio]
W: I want it. in our situation?
M: I don’t believe in abortion. Well, what are we
going to do?
[Further discussion ensues] 2
This very argument is advanced by the President’s Commis-
M: Well, what do we do? sion [1983], which essentially places the onus of directiveness on
P: Well it’s not my problem. I am not you. You’ll the clients for what in reality may be inadequacies in counseling
have to come to some resolution with your con- skills among professionals.
 Nondirectiveness 167

P: Do most people? I can’t answer. What do you skills or no confidence in the skills they do have. Also,
mean by ‘‘most’’? By far the largest group of it is a prediction of failure with self-fulfilling conse-
couples who come for amniocentesis are women of quences.
age 35 or above. [He goes on to distinguish between How would an experienced counselor with a nondi-
most women and most women referred to the rective bent go about dealing with the clients in the
clinic]. above examples? Let us begin with the first couple (Ex-
W: Do these things happen just because, I mean, ample 1).
for no reason?
P: [sarcastically] There’s nothing that has no rea- Example 3
son . . . [Explains genetic mechanisms again]. An experienced counselor would probably have dealt
W: But, would you advise . . . to have it? with the disagreement between the couple as follows:
P: I, that’s not my decision to make. All I can tell
you what the procedure is and what the risks W: I want it [the amnio].
are . . . M: I don’t believe in abortion.
W: [interrupts] Yeah, but if it were your sister sit- P: Correct me if I’m wrong but [to W] you seem to
ting there, and she, I mean, if, I don’t . . . want the amnio procedure. I’m not sure how you
P: [interrupts] I wouldn’t be able to advise my sis- [to M] feel about it?
ter on what to do. The strategy here would have been to try to separate
the issue of having an amniocentesis from that of hav-
Here the professional sidesteps the client’s questions ing an abortion, thus parceling out the problem into
and withholds advice. Is he being nondirective? I think more manageable chunks. Later in the session when M
not. Notice how he deals with the client. He shows dif- asks again:
ficulties in relatively simple counseling procedures
(some of which parallel those the professional in the M: Well, what are we going to do?
previous example had). First, he shows no evidence P: I’m not sure I know what you mean when you
that he understands what is on the client’s mind. Sec- say you don’t believe in abortion?
ond, he does not explore the dilemma(s) the client may The strategy at this point would have been to obtain
have which impedes her decision-making. In fact, he clarification of the clients’ belief system(s) (i.e., no abor-
shows little interest at all in the client’s thinking. tion ever; abortion sometimes, etc.). It would also be
Third, he shows or expresses absolutely no empathy important to establish how flexible or rigid M’s belief
toward her. He seems to miss the fact that she is des- system is (i.e., would he leave his wife if she decided to
perate to hear that she was not responsible for her have an abortion?). An alternative strategy would have
previous child’s problems and she needs his reassur- been:
ance in this regard. Fourth, he says things which are
patently unbelievable, particularly about how he might M: Well, what are we going to do?
deal with his hypothetical sister. Fifth, he is not helpful P: When you ask me, ‘‘What are we to do’’?, what
to the client. He gives no assistance on possible alter- do you see as the problem?
native ways of thinking about her problems or deci- That question might have elicited important infor-
sions. Lastly, he distances himself from and finally be- mation for the professional. M might have said that he
comes demeaning and nasty toward her. In short, he wants the latter to be the judge as to who had the
does not promote the autonomy and self-directedness of ‘‘correct’’ position. The professional might then have
the client. Thus, he is not being nondirective even had an opportunity to tell the clients that he was not a
though he has not given advice. judge, only a counselor, and that whatever advice he
What we have here is a professional who may be could give would require that he take sides and since it
extremely competent in everything else he does. He was more important that he retain the confidence of
may be a very good diagnostician and a competent both of them, that was not what he wanted to do. He
medical geneticist. However, he does not know the ba- might then have turned to them and asked how they
sic rudiments of counseling techniques. In short, this is resolve differences of opinion in other circumstances.
an example of unskillful, incompetent counseling. In He might then have used that as a model of how they
my mind, this is the kernel of the so-called problem might resolve the present problem.
many genetic counselors seem to have with ND. In sum, there were multiple, simple means the pro-
I suggest that one cannot achieve ND without a mini- fessional might have used to remain neutral and help
mum of basic counseling skills. I do not mean the kind the couple reach a satisfactory decision without resort-
of skills one might need to help clients in their decision- ing to advice-giving.
making or to change their personalities; I am referring
to basic counseling 101 skills. The persisting problems Example 4
of ND arise largely from inadequacies in applying
In Example 2, the following might have been said:
simple, basic counseling procedures.
As I read the genetic counseling literature I cannot W: Do these things happen just because, I mean,
help but be struck by the frequency with which the for no reason?
statement is made that ND is unachievable. What I P: Yes, those things happen right at conception,
hear in this perpetual repetition is a public confession right from the beginning and we don’t know or un-
that counselors have either inadequate counseling derstand why. But, one thing’s for sure, you defi-
168 Kessler

nitely didn’t make it happen in your last preg- discuss it with my mate and find out how he(she)
nancy. feels about this situation and see if we’re on the
same wavelength or not. If we are, that’s fine. If
The professional here attempts to relieve the client’s not, I would try to find some compromise or com-
sense of responsibility for having caused the initial mon ground and if necessary get outside help.
problem. The approach shows respect for her question Somewhere inside of me I know what’s best for me
and for her unstated concerns. just like somewhere inside of you, you know what’s
W: What would you advise your sister? best for you. Let’s see if I can help you find that
P: I suppose if my sister had turned to me for ad- place in yourself so that you can do what feels right
vice I would ask her the same questions I would for you. What do you think?
ask you. How would she feel if she didn’t have the Contrast the above approach to what the profes-
amnio and then had a child with a genetic prob- sional said to his clients in Example 1. In the approach
lem? Would she be able to live with it and with here, the professional identifies with the clients’ hu-
herself, or would she berate herself for the rest of manity and with their dilemma. There is a profound
her life? Also, I would ask her what she might do if psychological impact when clients feel that the profes-
she had the amnio and we found that the fetus had sional with whom they are dealing can identify with
a genetic problem? What would she do then? How and understand their feelings and confusions, respect
do you feel about these issues? them despite their possibly perceived failings, and help
Here the professional provides a framework by which them by giving them a way of thinking about their
the client might think through the problem facing her problem.
and arrive at her own decision. By treating the client in Example 7
the same way the professional might treat his sister,
notice how the emotional distance between profes- The following is a nondirective approach to the ques-
sional and client is narrowed as if to give the message tion, ‘‘What do most people do in our situation’’?:
that we are both human beings struggling together to
Most people go through the same kind of process
find some solutions. Contrast this with the first excerpt
you’re going through. They have to face the same
(Example 1) in which the professional says things
dilemmas and choices you do and each person,
which promote a psychological chasm between himself
each couple, has to make a decision that feels right
and the clients.
for them, a decision they can live with. I wish that
Here are some further examples of how experienced
decisions like this were easier to make, but usually
counselors go about being nondirective:
for most couples they’re not. Some people decide to
Example 5 go one way and some decide just the opposite. In
the end you have to make a decision that fits your
This is a reply to the question, ‘‘What would you do in personal needs and goals and feels best for you.
my place?’’ Any way I can help you make that decision I’ll sure
I really don’t know what I’d do in your place, but I try. What are your thoughts?
can tell you how I might think about it. There’s The professional here expresses empathy for the cli-
part of me that would be saying I want another ents’ dilemma and tells them that they are part of the
child and I want it to be healthy and another part normative population in their efforts to find a satisfac-
that’s afraid that if I did have a child I would have tory solution. Again, he offers to help them in their
one with a problem and that’s not what I want. So struggle, but no advice is given.
I guess I would have to ask myself am I ready and
willing to take the risk to have a child knowing Advice-Giving
that there are no guarantees in life. What are your Earlier on it was suggested that one might give ad-
thoughts about that? vice and remain nondirective. The following examples
As in the previous example, the professional here (8–11) address that point:
provides a suggested framework the clients might use Example 8
to think through their problem or dilemma so that they
might arrive at their own solution. The underlying Would you mind if I made a suggestion to you?
message is also one in which the professional strongly [The professional waits for permission to con-
implies that he has confidence in the clients’ ability to tinue.] I might be misreading the situation, but it
reach their own decision. seems to me that you’ve been through a lot and
maybe now’s not the time to have a baby. What do
Example 6 you think?
The following is an alternative approach to the same Example 9
question, ‘‘What would you do in my place’’?:
Joan, I’ve known you for quite a while now and I
Look, I’m just another human being like you and I think I have a good idea of what you’re thinking. Of
have the same concerns and anxieties you might course, I could be wrong, but it seems to me that
have. It wouldn’t be any easier for me to make the when you’re ready you might consider the possibil-
decision you’re facing than it is for you. I would ity of another child. What are your thoughts?
 Nondirectiveness 169

Example 10 esteem and leave them with greater control over their
lives and decisions. Genetic counseling based on the
I might be off base, and remember I don’t know you provision of information [Hsia, 1979; President’s Com-
as well as you know yourselves, but it seems to me mission, 1983] is limited in achieving these goals. In-
that there may be advantages in taking this test. formation-giving may provide facts, but does not nec-
[Outline one or two advantages.] What are your essarily give clients a way of thinking about the infor-
thoughts? mation they receive. It also tends to emphasize the
Example 11 professional’s authority and knowledge, factors which
tend to foster psychological passivity in clients. Such
Here’s a suggestion. Take it for what it’s worth, passivity, in turn, interferes with their evaluative pro-
reject all or part of it if you want, because I could be cesses and self-directiveness and tends to increase
way off base, you know the situation far better their dependency on professional advice [Kessler,
than I do, but I think perhaps . . . etc. etc. What do 1997a].
you think? When clients come into contact with professionals,
What makes the examples above nondirective is two they place themselves in a disadvantaged position and,
things. First, the counselor presents the advice as a for some, the context is stacked against them [Clarke,
suggestion as if it were a possibility of action rather 1991]. Professionals have authority and knowledge
than a certainty in his mind. Notice too how the sug- that clients lack, and thus are in a relatively superior
gestions are worded, especially the words in italics, so position. In addition, clients sometimes have unrealis-
as to deliberately emphasize the seeming tentativeness tic expectations of professionals and believe that the
rather than the certainty of each situation and of the latter are always unbiased and have no self-interest.
professional’s thinking. This is a common nondirective Directive professionals take advantage of such naı̈veté
strategy used to de-emphasize the professional’s image and inexperience to promote their own agendas. Non-
as one based on authority [Kessler, 1997b]. directive professionals actively adopt a strategy which,
Second, the professional gives the client permission, from the onset of the session, aims to restore the power
either implicitly or explicitly, to reject all or part of the balance between themselves and clients.
advice being proffered. Such strategies protect and pro- Thus, ND is an active strategy requiring quality
mote the clients’ self-directedness and ability to make counseling skills. ND does not happen by default or by
their own choice. Notice also how experienced counsel- not directing the client toward a particular decision or
ors invariably turn back to the client for feedback im- course of action. Just as professionals with a directive
mediately after giving the suggestion. This allows for agenda actively direct or guide clients to a particular
timely corrections, modification, and/or additional in- decision and course of action, so do nondirective pro-
put and underscores that the professional and client fessionals [Kessler, 1992]. The difference is that the
are working together toward a common goal. latter strive to guide clients to their own decision, not
Although nondirective counselors occasionally give the one the professional might make or believe the cli-
advice, they do so judiciously and rarely because with ent should make. ND is a way of thinking about the
experience they learn that there are major pitfalls in professional-client relationship in which at each step of
doing so. Often we do not always know what advice to the way the professional attempts to evoke the client’s
give. Also, we cannot live other people’s lives for them. competence and ability for self-direction.
When professionals give advice which is subsequently The difficulties genetic counselors seem to have in
rejected by clients, they risk jeopardizing the confi- dealing with direct questions, handling commonplace
dence the latter may have in them. Furthermore, un- counseling issues, providing empathy and a way of
less advice concurs with the clients’ thinking, it may thinking about problems (rather than giving advice), in
make their decision-making more difficult. Also, there combination with other problems, to be discussed be-
is no strong evidence that clients follow the advice3 low, all suggest the presence of major inadequacies in
they receive. Last, but by no means least, giving advice counseling training and skill. These deficiencies clearly
tends to gratify the ego needs of professionals more need to be corrected if the field is to adhere to a non-
than those of clients. Psychologically, advice-giving directive philosophy.
helps one feel less helpless or more powerful in their Why genetic counselors seem to have trouble dealing
professional role. with direct questions is puzzling and perhaps a way of
thinking about the problem would be in order. When
clients ask us for our advice, what do they want?4 A
DISCUSSION
nondirective approach would assume, among other
I have attempted to demonstrate here how the goal of things, that most clients have the ability to make their
ND is closely linked to counseling procedures. ND is own decisions. Thus, nondirective professionals would
more than withholding advice. It is a way of interacting infer that something beyond the literal was intended
and working with clients that aims to raise their self- by the question. They might think to themselves, ‘‘Af-

3 4
In some sociopolitical circumstances in which directive genetic Milunsky [1975] is close to the truth when he writes that such
counseling was the norm, as for example Communist-dominated questions ‘‘. . . may signal failure in counseling . . . [and that cli-
Hungary, nearly 40% of counselees ignored the professional’s ad- ents] are not interested in what the [professional] would do in like
vice [Czeizel et al., 1981]. circumstances . . .’’
170 Kessler

ter all, not all statements or all questions are meant to are in various stages of mastering certain skills. These
be understood literally. For example, when I ask cli- include keeping their personal feelings, thoughts, and
ents, ‘What brought you to the clinic?,’ I do not want opinions to themselves and sufficiently under control
them to understand me literally and reply, ‘I came by so that they do not intrude into their work. To the
bus.’ I want them to outline the problem about which extent that it is humanly possible, they stay focused on
they are concerned. In fact, when a client does answer the thoughts, feelings, and needs of their clients, not on
seriously in such a concrete manner, I would begin to their own.
suspect the presence of neurological organicity. So, Also, they have learned to identify and control their
what lies behind the question?’’ feelings of aggression (see Example 2 above) and com-
The professional might then entertain some plau- petitiveness as well as their tendencies to be emotion-
sible possibilities among which are: ally distant and self-absorbed which often accompany
1. It might be a way of asking for clarification of such feelings. An example of how genetic counselors
previously given information. compete with clients occurs when the former say, ‘‘I
2. It carries a psychological message suggesting that will support any decision you make.’’ This is often a
clients experience the professional as being too de- subtle form of competition for the moral high ground or
tached and emotionally unconnected to them. Thus, for power in which the professional gives the client a
their question may be an attempt to elicit a greater subtle reminder that the professional still holds the
involvement of the professional’s human side, as if to greater power. This is a strategy I would strongly dis-
say, ‘‘Please, put yourself in my place and feel what I’m courage. It may be sufficient to tell clients that you
feeling—understand me.’’ Rather than give advice, this understand how they feel.
realization might lead to a change in how they relate to How does one acquire nondirective counseling skills?
clients. There are four traditional steps. First, is self-
Nondirective strategies require professionals to pay knowledge. Here we invariably need outside help since
more attention to the strengths, accomplishments, and we generally are blind to our faults and failings and
competencies that clients bring with them to genetic generally distort our perceived strengths and limita-
counseling. These need to be verbally acknowledged tions. I would strongly recommend a course of personal
and bolstered throughout the session so that clients psychotherapy with a cognitive-behavioral slant as a
feel that the professional has confidence in their ability way of identifying and/or changing the beliefs about
to make their own decisions. Most clients are already self and others that impede our ability to be empathic
experienced decision-makers, and professionals need to and helpful as counselors.
draw on the intelligence, life experiences, and know- Second, is practical course work in counseling proce-
how they have used in the past to deal with current dures in which we receive feedback and constructive
issues [Parsons and Atkinson, 1993]. criticism and are helped to acquire and practice basic
Clients also need to be encouraged to talk more in the skills.
counseling session since this gives them a sense that Third, is ongoing, regular postgraduate supervision
they have greater control over the situation. This is and consultation. There are a number of ‘‘old-timers’’ in
almost impossible if the professional uses up the avail- the field of genetic counseling who would be invaluable
able ‘‘air time’’ giving information. In general, clients assets in this regard and could provide the needed sup-
receive far more information in genetic counseling than port to working with genetic counselors.
they can possibly absorb and integrate. Some of these Fourth, is continuing education. A counselor is never
difficulties might be alleviated if professionals utilized a ‘‘finished’’ professional. I would strongly recommend
alternative means of providing information, such as that professional organizations sponsor workshops us-
written formats and interactive technology, and then ing resources from within the field itself in which pro-
used the time together with clients more effectively as fessionals have an opportunity to hone their skills and
counselors. learn new ways to approach old problems.
Professionals need to learn how and when to reward As far as ND is concerned, the message needs to be:
clients and reinforce any effort toward autonomy and It is attainable; all you need is a few basic skills, con-
self-direction. This may mean that their need to be siderable good will, and kindness.
seen as authorities may have to be restrained in order
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