Genetic Counselors' Experiences with Paternal Involvement in Prenatal Genetic Counseling Sessions: An Exploratory Investigation.

P1: IZO Journal of Genetic Counseling [jgc]

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Style file version Nov 28th, 2002

C 2003) Journal of Genetic Counseling, Vol. 12, No. 3, June 2003 (°

Genetic Counselors’ Experiences with Paternal Involvement in Prenatal Genetic Counseling Sessions: An Exploratory Investigation Richard S. Lafans,1 Patricia McCarthy Veach,2,4 and Bonnie S. LeRoy3

Limited research exists concerning male partners’ participation in prenatal genetic counseling (R. Kenen, A. C. M. Smith, C. Watkins, & C. Zuber-Pitore, J. Genet Corns 9, 33–45, 2000). To further understand paternal participation, we interviewed 17 experienced prenatal genetic counselors to assess their perspectives on this issue. We investigated 6 research questions: 1) How do genetic counselors define paternal involvement, 2) how do they determine and address problematic involvement, 3) what factors influence involvement, 4) was paternal involvement addressed in training, 5) how might training be improved, and 6) how do participant strategies for addressing involvement compare to those of marriage/family therapists? Qualitative analysis revealed that 1) participants regard paternal involvement as important; 2) most address problematic involvement with strategies similar to those of marital/family therapists; 3) influential factors include male partner’s characteristics, the couple’s relationship (including cultural practices), and pregnancy factors; and 4) participants received little or no training on paternal involvement and recommended didactic and experiential activities. Implications and research recommendations are presented. KEY WORDS: paternal involvement; prenatal genetic counseling; prenatal testing.

I guess I just never thought about it until I started doing this, that the dad’s involvement would be any kind of an issue. —Study participant 1 Park

Nicollet Medical Center, Minneapolis, Minnesota. of Educational Psychology, University of Minnesota, Minneapolis, Minnesota. of Genetics, Cell Biology, and Development, Institute of Human Genetics, University of Minnesota, Minneapolis, Minnesota. 4 Correspondence should be directed to Dr Patricia McCarthy Veach, Department of Educational Psychology, University of Minnesota, 139 Burton Hall, 178 Pillsbury Drive, S.E., Minneapolis, Minnesota 55455; e-mail: [email protected]. 2 Department 3 Department

219 C 2003 National Society of Genetic Counselors, Inc. 1059-7700/03/0600-0219/1 °


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Although prenatal genetic counseling is a prevalent type of genetic counseling service, very little research has been conducted on the male partner relative to the female partner (Kenen et al., 2000). In the literature at least, fathers appear to be marginalized because their level of participation in prenatal genetic counseling sessions is not well-defined. For instance, only two published studies have examined the male partner’s perspective on decisions regarding prenatal testing (Browne & Preloran, 1999; Kenen et al., 2000). One study suggests that fathers are more likely to speak up about prenatal decision making when interviewed separately from their partners, and they may vary in their decision-making style, preferring either to defer to their partner or to be actively involved (Kenen et al., 2000). The other study indicates that, contrary to the researchers’ expectations, Latino women are more likely to make decisions concerning amniocentesis than are their male partners (Browne & Preloran, 1999). Several factors potentially contribute to the level of paternal involvement in prenatal genetic counseling. For instance, fathers may move through developmental phases of involvement that, for a time, keep them at a distance (Connor & Denison, 1990; May, 1978, 1980, 1982). Conflict may play a role, such that some couples may come to prenatal genetic counseling with significant disagreements, including the reason they are there (Sorenson & Wertz, 1986). Fathers may experience a threat to their parental role when there is a risk of discovering a problem with the fetus and the possibility of pregnancy termination (McConkie-Rosell & DeVellis, 2000). Resistance may play a role and can occur for reasons such as fear, resentment, misunderstanding, and/or failure to connect with the genetic counselor (McCarthy Veach et al., in press). Finally, adolescents and low socioeconomic (SES) fathers may be particularly difficult to engage in any type of counseling services (Fagot et al., 1998). Because facilitation of client decision making is a major genetic counseling goal (Walker, 1998), the involvement of both partners in prenatal sessions likely is optimal. Genetic counselors, therefore, need to accurately assess paternal involvement and decide whether and how to encourage greater involvement or to discourage overinvolvement. We conducted a qualitative investigation of paternal involvement in prenatal genetic counseling from the perspective of experienced genetic counselors. Seventeen prenatal genetic counselors participated in semistructured interviews in which they described their perceptions of paternal involvement, techniques they employ in managing the fathers’ involvement in sessions, and their suggestions for training on this issue. We investigated six broad research questions. 1) How do genetic counselors define involvement as it relates to fathers’ behavior in prenatal sessions? 2) What paternal behaviors, or lack of behaviors, indicate that fathers are involved, uninvolved, or overinvolved in sessions? 3) How do genetic counselors respond to problematic paternal involvement, and what strategies have they used that successfully and unsuccessfully address the level of paternal involvement? 4) What factors are believed by genetic counselors to be related to the father’s level of involvement


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in sessions? 5) Was paternal involvement in prenatal sessions addressed in the participants’ training, and if so, how was it addressed? How could it be improved in this regard? 6) How do genetic counselors’ strategies to regulate the level of paternal involvement compare to those used by marriage and family therapists? METHODS Participants Upon receipt of approval from a University of Minnesota institutional review board, we contacted 158 of the 181 members of the prenatal counseling/ultrasound anomalies Special Interest Group (SIG) of the National Society of Genetic Counselors (NSGC) for whom we could obtain valid e-mail addresses. We invited members with at least 5 years of experience in prenatal genetic counseling to participate in a study exploring genetic counselors’ perceptions of paternal involvement in prenatal genetic counseling sessions. Seventeen genetic counselors, all female, agreed to participate. To include male counselors, we extended the same e-mail invitation to all NSGC members who were identifiable as males by their first names and for whom we had valid e-mail addresses (n = 45). Four male prenatal genetic counselors agreed to participate. The final pool consisted of 17 females and 4 males; of these, all of the males and 13 of the females were interviewed. Because no new themes were apparent from the last three interviews conducted with females, saturation (redundancy) of the data was obtained (cf. Hill et al., 1997), and we discontinued interviewing female recruits. Instrumentation We developed a series of interview questions on the basis of our professional experience that includes mental health practice and genetic counseling practice. Nine questions request demographic information (gender, age, ethnicity, degree, years of experience, primary focus and work setting, number of prenatal patients seen weekly, and frequency of fathers’ attendance at the prenatal sessions). Eleven questions (see Appendix) ask participants to define and discuss paternal involvement, under-, and overinvolvement, and to describe their preparation regarding this issue R.L. piloted the questions with two genetic counselors (one female, one male) who have experience providing prenatal counseling. On the basis of their feedback, the final questions about training were added to the protocol. Data Collection R.L. conducted 17 semistructured, audiotaped telephone interviews within a 5-week interval from August to September, 2001. He adhered to the interview


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protocol, but also asked follow-up questions (e.g., “Can you tell me anything more about what you did?”) to draw out participant responses. The interviews lasted from 18 to 45 min (mean = 33 min). The audiotapes were transcribed by an experienced transcriber. Data Analysis R.L. analyzed the content of the transcribed interviews, using an inductive cross-case analysis method (Patton, 1990). In this inductive method, indigenous concepts (themes) are extracted without a preconceived framework being imposed on the data. In cross-case analysis, answers to each interview question are compared across participants. In other words the participants themselves are not the objects of study, rather the themes that emerge across participant responses are of interest. Once R.L. identified themes, an auditor, P.M.V., read the transcripts and discussed the themes with him until consensus was reached. The auditor had no access to the taped interviews, nor did she have access to any means of identifying participants. RESULTS Sample Characteristics All participants identified themselves as Caucasian. Fourteen currently practiced as prenatal genetic counselors; 3 had practiced within the previous 5 years. Their mean experience was 12.3 years (R = 5–25 years). Their primary practice focus was prenatal genetic counseling in a private agency (n = 6), private hospital (n = 6), or university setting (n = 5). They saw an average of 11.6 prenatal patients per week (R = 2.5–30). Estimated average attendance of male partners at prenatal sessions ranged from 25 to 90%, with 15 participants reporting that male partners were present at 50–75% of the sessions. What Is Paternal Involvement? All participants regarded the father’s involvement in sessions as an issue they had to deal with; however, estimates of the frequency of problematic paternal involvement ranged from occasionally to very often. The participants generally defined paternal involvement as attentiveness, interest in, and receptivity to one’s partner and to the genetic counselor, as well as a willingness to participate in the decision-making process. They emphasized the quality of paternal involvement more than quantity, especially because, as some stated, mothers typically do more of the talking. As shown in Table I, they identified 7 nonverbal and 10 verbal


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Genetic Counselors’ Experiences with Paternal Involvement in Prenatal Sessions Table I.

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Behaviors Indicating Paternal Involvement in Prenatal Sessions

Nonverbal communication Attends appointment Appears to be attentivea Gives eye contact to the counselora Sits close to partner, touches her, and/or holds her hand Leans forward to observe visual aids Faces the counselor Nods at the counselor Verbal Communication Asks questionsa : • For clarification • That indicate he has a stake in the pregnancy • Asks more than two questions during the session Expresses his own viewsa Interacts with partnera : • Asks about her thoughts or feelings • Refers to prior discussions about the pregnancy Answers questions willingly Answers questions with more than one word Requests prenatal genetic testing Participates in decision making a Indicates

behaviors identified by at least 6 participants.

behaviors indicative of paternal involvement in prenatal sessions. Most frequently mentioned were as follows: appearing to be attentive, giving eye contact to the counselor, asking questions, and expressing one’s opinions. What Is Paternal Underinvolvement? As shown in Table II, the participants identified six nonverbal and six verbal behaviors that indicate a lack of the father’s involvement in prenatal sessions. These behaviors suggest that the father is disengaged from the counseling interaction. He may be uncooperative, defensive, passive, distracted, and/or closed, and he may regard decision making as his partner’s responsibility. How Does Paternal Lack of Involvement Impact Genetic Counselor Behavior? To investigate typical impact, we asked the participants to recall a recent prenatal session in which the father’s lack of involvement was problematic. Nine participants recalled one or more specific sessions; the other 8 responded in generalities. Twelve participants indicated either that they had addressed the father’s lack of involvement or that they generally would do so, 2 did not specifically answer this question, and 3 indicated that they did not address it. Of these 3, one counselor generally does not address this issue, another did not address the situation because


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Lafans, McCarthy Veach, and LeRoy Table II. Behaviors Indicating a Lack of Paternal Involvement in Prenatal Sessions Behaviors

Participant quotes

Nonverbal behaviors Looks away/stares into spacea Appears passive/disinterested/yawnsa Engages in other activities (reads magazine/ newspaper; uses cell phone/computer)a Does not attend appointment Slumps/slouches/leans back in chair Falls asleep during the session Verbal Behaviors Says it’s his partner’s body and decisiona The husband wouldn’t give his opinion about whether they should have an amnio, and the woman was very upset, scared, anxious and kept looking to him for “What should we do?” . . . and I think she clearly wanted an amnio, but also clearly wasn’t able to make that decision without him, and he kept saying “Well, it’s your decision.” Does not participate in conversation It’s kind of like a red flag to me when a father doesn’t say anything . . . Gives short or no answers to questions When I ask them an open-ended question, I get a closed answer. Does not ask questions . . . if they asked two or more question during the course of the 45 minute counseling session, I considered that good. The vast majority of the time they came, they listened, they left. Is reluctant to express opinion [regarding testing decision] There are people who say, “I’d leave it up to you,” and then there are other people who say, “I don’t care”—kind of a disinterested comment. Responds defensively a Indicates

behaviors identified by at least 6 participants.

the mother appeared to be comfortable with her partner’s lack of involvement, and the third counselor described herself as not confrontational. As shown in Table III, the participants who indicated that they respond to lack of involvement generally do so by asking the father questions, using confrontation, and compelling him to participate.

What Types of Paternal Underinvolvement Are Particularly Challenging? The participants identified several particularly challenging types of paternal underinvolvement. Their descriptions included extreme versions of the behaviors listed in Table II (e.g., father refuses to express an opinion), plus three additional


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Table III. Participant Responses to Paternal Underinvolvement Responses Ask the father questions concerning • His understanding of reason for genetic counseling • What he would do if it were his decision to make • His history • Information only he would know • Reason for his disinterest/reluctance to be involved Confrontation • Respond to nonverbals

• Via humor • Via education

Enlist mother to confront him

Participant quotes . . . ask what has he been told by his wife or for genetic counseling partner. I’ll try to find out what he knows. . . Say, “Now, what would you do? . . . I want his decision to make your answer without her decision—realizing you’ll make a joint decision later . . .”

. . . your wife is crying and you’re not really . . . looking at her. What’s going on with you? . . . some just want to read the newspaper; I’ll address that—I’d like you to be part of this. . . . say to them, “You realize you’re talking to a counselor. I’m not going to let you get away with not talking about your feelings.” “This is a couple decision . . . whatever happens with the amnio has ramifications for both of you” . . . he says, “Well, she’s the one who gets the needle in her belly.” I said, “Well, that’s true, but it’s a minimal part of the amnio experience” . . . Did he feel he could support her if she chose to have it? . . . I intentionally said something I knew would be of interest to him, and he missed it. I looked at the wife, and at him, and she said, “Hon, if you’d put the newspaper down maybe you’d have heard it the first time.”

Speak to father until he responds a Most

participants gave only one example.

behaviors: father misses the first session but attends a second session; he has a hidden agenda; and he refuses to hear risk information. They also identified situations as challenging: very young fathers who are scared and ill-prepared for parenthood, couples from cultures that differ from the counselor’s cultures, hostile fathers, and situations where paternal lack of involvement seems to be related to either his female partner’s abusive behavior or nonpaternity. Failure to attend the session can be particularly problematic when the father calls later to say that he is refusing to allow any testing or when he misses the first session and attends a second one (. . . the 2nd or 3rd session when it’s bad news, and he’s almost antagonistic because . . . he doesn’t have a relationship with you . . . those are probably the hardest to involve the partner, yet respect the original relationship you have).


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One participant noted situations when the father seemed to have an agenda but would not express it (. . . you feel the husband clearly has an agenda and a decision, but he won’t share it, and the difficulty for me is that I know he will share it at some point . . . one of the things I often tell people is that if you have thoughts, they’re going to come out at some point. The question is, when? Is it going to come out now, or is it going to come out after your wife has made a decision? Is it going to come out a year from now? . . . If we don’t verbalize it, and it’s something we’re really uncomfortable with, we’ll lash out at them later. They’ll forget to tighten the bottle top on the ketchup, and you’ll say “You know, you were really awful when you made that decision”). What Is Paternal Overinvolvement? As shown in Table IV, participants identified 11 types of verbal behaviors suggesting that overinvolved fathers actively try to direct/control the counseling Table IV. Behaviors Indicating Paternal Overinvolvement in Prenatal Sessions Behaviors Speaks for the mothera

Nonnative English speaker selectively translates for mother Does most or all of the talking

Controls session flow to pursue his own agenda Makes decision for mother Questions all possibilities despite mother’s distress Asks irrelevant questions Asks most or all of the questions Demands that the counselor direct all questions to him Interrupts counselor Allows his hopefulness to sway mother to choose what he wants a This

Participant quotes . . . guys who speak for their wives. I find I’m having one conversation with him, and this eye contact conversation with her which is very different. . . . you get this idea she’s pleading “Please, find out what’s really going on in here with me.” . . . he was translating to her . . . basically I’d say a sentence, and he’d say two words. So, they either had an extremely efficient language, or he was just making all of the decisions, and she just followed. . . . there was an abnormal finding on the ultrasound . . . late in the pregnancy . . ..The wife basically cried and had trouble making one complete sentence . . . he couldn’t stop talking and saying what his opinion was strongly over and over and over and over . . . . . . men that say . . . “I don’t think we should have that test,” and the woman’s obviously very anxious and wanting to find out if there’s a problem . . . [he’ll] just say “You don’t even need to talk about that . . .” . . . some dads are definitely the voice in the family . . . used to having people do what he says and also being able to fix things . . . . . . he kept asking these extreme questions that made the wife uncomfortable and more scared . . .

behavior was identified by all of the participants.


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process (e.g., determining the questions that are discussed) and/or counseling outcome (e.g., making the decisions). One behavior mentioned by all participants was speaking for the mother. Additionally, several stated that some mothers collude with the father by saying that whatever he decides is fine, refusing to answer, and/or deferring to him. How Does Paternal Overinvolvement Impact Genetic Counselor Behaviors? Nine participants recalled a recent session in which the father’s overinvolvement was a concern, and 8 gave general examples without citing a specific session. Fourteen indicated that they chose to address paternal overinvolvement, 2 said they did not consider paternal overinvolvement to be an issue for them, and 1 did not indicate whether or not it was problematic. As shown in Table V, the 14 participants who addressed paternal overinvolvement described eight different responses that direct the interaction: comments to draw in the mother; an insistence on informed consent for the mother; inclusion of an interpreter other than the father; education to correct misperceptions; speaking to the mother alone; primary empathy (restatement, clarification); advanced empathy (interpretation); and confrontation (to get the father to acknowledge/own his behavior). What Types of Paternal Overinvolvement Are Particularly Challenging? Participant descriptions of challenging types of paternal overinvolvement concerned attempts by a father to control the session, the counselor, and/or his partner, and involved extreme versions of behaviors listed in Table IV. Participants speculated about the fathers’ motivations: Some fathers were overly protective of their partners and antagonistic towards the counselor (e.g., . . . the spouse feels like he has to be his wife’s protector. Sometimes people come into a session and feel like they’re being forced into something or like the genetic counseling is a way for us to sell them on amnio or talk them into going through with something . . . ). Some fathers seem to want to fix the problem instead of coping with it (e.g., . . . he sees his role as fixing the problem so that his wife isn’t having to be upset or deal with something wrong in the pregnancy . . . his prime thing is not “This is something we need to get through,” but “I need to totally fix this situation”). Disagreement between partners, whether spoken or unspoken, can result in the father dominating sessions in challenging ways (e.g., . . . cases where a woman’s biggest fear is that she would have to have an abortion, and she wants to control that fear by not having that testing . . . but the husband really has a need to know . . . you have a planner or an organizer, and you have a “whatever happens, happens,


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Lafans, McCarthy Veach, and LeRoy Table V. Participant Responses to Paternal Overinvolvement Responses

Comments to draw in mother Insists on informed consent for mother

Includes interpreter other than father Speaks to mother alone

Primary empathy Advanced empathy (interpretation)

Confrontation

Participant quotes Directs Interactiona . . . turn to the woman and say . . . “And how do you feel about this?” Try to get her to speak for herself. . . . try to explain . . . that my role is making sure everyone is informed and I want to respect their culture in the way that they make decisions in their family, but I also need to know from a medical standpoint that everyone is from a consensus . . . [if] they try to insist they can interpret the session I say “No” and I still get a phone interpreter . . . since it is the woman who is having the testing . . . she should have every right to know what’s going on . . . . . . instances when I’ve waited for him to leave and then try to pull her in privately to . . . double check that she’s doing what she wants to do . . . And I say, “Oh wait, you know, you can go into the waiting room. I just want to ask her something.” . . . summarize what I think his view is, and then I’ll turn to her and ask what she thinks . . . . . . tried to make him know I’d heard what he was saying . . . “Alright, you’re saying if your wife has this amnio and the baby has Down Syndrome, there’s no way that you’re going to raise a baby with Down Syndrome, and that you’ll leave her. Is that what you’re saying?” . . . once he got a chance to talk about his strong feelings . . . I could turn to her and say “Ok, I hear what your husband’s saying, and he’s very clear, but I get the feeling you feel very differently.” . . . bring it back to the wife and say, “Do you have strong feelings about that? . . . How do you think it affects your relationship as a couple?” . . .

Corrects misperceptions a This

type of response was identified by all of the participants.

and I’ll deal with it.” And they’re both very strong in that direction, and how do you come to a compromise that meets both their needs? . . . particularly if it’s the difficult ones around termination or whatever, if they don’t make a couple decision, they probably won’t stay a couple . . .). Participants mentioned that when the couple have cultural practices and values that differ from their own and/or there is a language barrier, the father’s behavior can convey overinvolvement, and these are among the most challenging situations. Two participants mentioned agendas concerning sex selection (e.g., I did have a woman who didn’t want to terminate a pregnancy . . . She was over 35 years old and therefore we had to do an amnio on her, but it was obvious this was a sex selection issue, and it was obvious that he was making the decision . . . she has to live with him, and yet she’s being essentially coerced into ending a pregnancy that she doesn’t want to end).


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Fathers with a scientific background and those who ask numerous questions were difficult for some participants (e.g., . . . [he is] going to come in with [his] list of questions, maybe to test me, to see how much I know, or to prove . . . that he knows something . . . he may be just truly interested, but I’ve had cases where he goes off on a tangent . . .). One participant finds it difficult to deal with a father’s overinvolvement that elicits countertransference due to her own family of origin issues (. . . hardest for me are the really domineering—“I’m going to tell the little wife what she should do”—because that kind of is the setting I grew up in, and it’s kind of hard to deal with—to get him to back down a little bit . . . My tendency is to just say, “Would you just shut up a minute!” and, obviously, we can’t do that). What Counseling Strategies Have Been Effective for Addressing Paternal Involvement? Eleven participants reported 42 techniques they have used to effectively address the father’s involvement in prenatal genetic counseling sessions. These techniques were categorized into seven general categories shown in Table VI. Nonverbal techniques included making eye contact with the fathers, arranging the furniture to facilitate involvement, and affording couples the opportunity to speak to each other privately. One category of verbal strategies is intended to increase the likelihood of the father’s attendance at the session and includes the following: communicating to referring physicians that they should instruct mothers to bring their partners to the genetic counseling session, asking the mother to invite him, inviting the father in the waiting room to attend the session, and telling the mother to have the father call with questions or to return with her for a subsequent session. Another category, establishing rapport, is accomplished by asking about family relationships, calling the father by name (especially when discussing sensitive material), asking questions about the father, and using humor. Another category involves orienting fathers and couples to the genetic counseling session, explaining the reason for the session and clarifying the roles and expectations of the counselor, mother, and father. A fourth category involves facilitating the counseling process by drawing in fathers early in the session or, as some participants said, it “won’t happen at all.” One technique to elicit early involvement is beginning with the father when obtaining the family pedigree. Another involves reviewing information already shared with the mother. Questioning techniques include asking the father how he feels about the pregnancy and testing, asking open ended questions (e.g., how he would feel about having a child with a birth defect, whether his agenda differs from his partner’s), and asking if he has any questions for the counselor. Several participants indicated that they monitor and validate the father’s apparent affect


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Table VI. Effective Strategies for Managing Paternal Involvement Nonverbal strategiesa Verbal strategies Encourage attendance

Establish rapporta Orient to Genetic Counselinga

Facilitate counseling process

Promote couple’s relationship

Confrontation

a Indicates

I always make a point . . . to make eye contact with both . . . make a point of calling them by name. I’d get lots of phone calls [asking], “Should I bring my husband?” . . . I say, “Well either I can go over everything, or you can go home and do it, and that means you’re going to have to remember . . . and understand . . . . . . asking personal questions and being interested in something he might say . . . . . . I usually start with defining what I am, and the process. Part of the contracting is to say, ‘I’m not here to tell you what to do . . . Usually the woman is the spokesperson, and she . . . has an agenda; she kind of tells him what it is, and he usually sits there and so, I turn to him and say “Okay, so your wife says she wants to talk about this, this, and this. What about you? Do you have the same agenda, or is yours a little bit different?” . . . . . . I was always taught you . . . get her entire family history, and then you go to the guy . . . I never take my pedigrees that way anymore because I feel like why would I encourage the woman’s monopoly of the conversation by focusing first on her side? Say, “I know these tests are really [scary]” . . . sometimes dad’s just aren’t allowed to say “I’m scared” . . . and yet they’re there, worried. They’re scared, and [I don’t] back away from it. . . . try to pay equal attention to both partners . . . direct about half your questions to each. I tell them I think it’s very important for a couple to talk over with each other what their feelings might be if the baby was to have such and such a problem . . . encourage them to get the big issues out. The father wants her to have the amnio, she doesn’t, and [I] go through some what if’s, “What if you had the amnio and had complications because of it, and she didn’t really want to do this to begin with? How do you see that affecting your marriage? What do you think would happen in that situation?” Say, “You seem withdrawn, uncomfortable, or confused about how to make this decision . . . to allow him to say either, ‘I don’t care,’ or ‘I don’t want an amnio, and that’s why I’m doing this.’ . . . ” Say, “I don’t think you’re hearing what she’s saying . . . paraphrase what she said and ask her . . . Is that what you’re saying?; then to him, ‘Is that what you’re hearing?” Say . . . “What would you do if you were making the decision all by yourself ” . . . that will get just about any male to state an opinion, and then . . . you can start discussion in coming to a compromise.

strategies identified by at least 6 participants.


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whether or not he expresses it. One participant apologizes if she senses the father does not want to talk about how he feels and is threatened by the expectation that he do so. Another category involves protecting/promoting the couple’s relationship. Some participants ask couples whether they have discussed impending issues or decisions prior to coming to genetic counseling. Some try to get a feel for the relationship. One participant makes it a goal to help preserve the couple’s relationship by ensuring that the father is involved. Some participants stress the importance of discussion between partners and use questions to encourage discussion either during or after the session. A final category is confrontation, mentioned by several participants for managing both over- and underinvolved behaviors. For example, 1 participant gives underinvolved fathers feedback about their apparent lack of affect. Some participants label overinvolvement and point out its inappropriateness. Several said they use confrontation with fathers who take the position that “It’s her body; it’s her decision.” One participant has explicitly asked fathers what they would do if it were their decision to make. Although not a counseling strategy per se, 1 participant reported bringing in a male physician to back her up in a situation in which she felt that cultural influences were undermining her efforts. Another pointed out the importance of not taking it personally when a father is overly involved and negative. What Counseling Strategies Ineffectively Address Paternal Involvement? Eleven participants stated that techniques for addressing paternal involvement sometimes are effective and at other times are ineffective. Two participants said they had stopped doing what did not work for them and, of these 2, one said that she had dispensed with ineffective strategies so long ago that she could not remember them. Despite these disclaimers, the participants identified 11 techniques that generally are ineffective: ignoring the father; avoiding the issue; humor (especially with young fathers); confrontation; asking direct questions that make some fathers go off on tangents; leaning towards the father and catching his eye; becoming defensive or angry; trying to force the father to participate; not addressing cultural issues; allowing fathers to dominate; not pushing them to participate; and interviewing the couple separately. What Factors Contribute to Problematic Paternal Involvement? The participants cited 39 factors that they believe contribute to problematic involvement. These were categorized into eight themes, shown in Table VII. It


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Lafans, McCarthy Veach, and LeRoy Table VII. Factors Contributing to Level of Paternal Involvement in Prenatal Sessions Themes

Relationship with partnera

Relationship with counselor Culturala

Gender of counselora Paternal attributesa

Discomfort in settinga

Pregnancy factorsa

Other Factorsc

a Indicates factors identified by at least b Factor leads to under-involvement. c Factor leads to overinvolvement.

Factors No longer a coupleb Relationship not strongb Unmarriedb Blended familyb Forced to attend sessionb Couple is close or not closeb Too much respect for mother’s autonomyb Older mom/younger dadb Age discrepancy between counselor and fatherb Education discrepancy between counselor & fatherb Father makes decisions for familyc Father is the spokespersonc Father translatesc Mother comfortable with father decidingc Religionc Female counselorc Female with patients of paternalistic culturec Female counselor with older fatherc Passive personalityb Affect (fear, guilt, or shame)b Does not want to be domineeringb Educational Level (low levelb ; high levelc ;) Father’s age (young fatherb ; older fatherc ) Frustrationc Apparent or expressed attitudesb,c Family of origin issuesb,c Uncomfortable with medical issuesb “Female” setting of clinicb Lack of socialization to roleb Unplanned, unwanted pregnancyb Couple have several other childrenb Planned and wanted pregnancyc First pregnancyc Previous genetic/chromosomal problemsc Fertility issuesc Does not understand purpose of genetic counselingb Does not regard self as “patient”b Socioeconomic status (lowb ; highc ) Feelings about counseling in generalb,c Physician recommended father attendb,c 7 participants.

should be noted that participants frequently discussed factors without specifically indicating how they are associated with paternal involvement. If a factor was specifically associated with over- or underinvolvement by participants, this is indicated in Table VII.


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The most commonly mentioned factors are the father’s personal characteristics, the couple’s relationship, and pregnancy factors. The father’s characteristics include personality traits, apparent or expressed affect and attitudes, and educational level (e.g., . . . that’s where you really have to be careful with assessing how you can bring that person in. You know, are they an abrasive person, and are they an adversarial person? And that has to go into part of shaping the strategy that you use to get them connected). It is noteworthy that most participants mentioned personality as an important factor whereas very few identified specific personality traits. Some participants described fathers whose demeanor suggested that they felt coerced to attend (e.g., . . . I think with the female partner, sometimes that’s a way of punishing them—either for being pregnant or for some other behavior; so . . . they have to come, and they sit there and don’t get involved ). Paternal affect was viewed by some as an influential factor and includes fear and anxiety; guilt, shame, and self-blame; anger; feelings of inadequacy and insecurity; and discomfort (with the setting, the risks involved, and the responsibility associated with the decision-making process); and frustration due to infertility. Fear and anxiety were the most frequently mentioned. However, 1 participant pointed out that care must be taken in interpreting lack of involvement as fear (You can have a husband who is stepping back because he is chickening out, and I think that’s where you kind of have to . . . push. But you also have to respect that . . . he may not be chickening out. This may be one of those things that he thinks, truly, he doesn’t want to put a burden on her either way). Of those who expressed an opinion, most thought that their gender plays a role in the father’s level of involvement, although some had difficulty articulating how/why it was influential. Some expressed a belief that male partners would be more appropriately involved with a male counselor, and some reported that gender is important when the couple is from a cultural background different from the counselor’s. Several participants noted that the couple’s relationship may not be strong or their dynamics may affect paternal involvement (e.g., . . . How they’ve operated in the past and how the relationship has been defined in the past probably—from what I’ve seen—is how they tend to go through the counseling). The couple’s cultural background was regarded as an important factor influencing the father’s level of involvement. Without exception, cultural background was viewed as being related to paternal overinvolvement. Some participants stated that if the pregnancy was either unplanned or unwanted, the father was less likely to attend the session or to be involved. One participant indicated that she always asks whether the pregnancy was planned because the response influences how she approaches the remainder of the session. Several participants pointed out that genetic counseling generally takes place in a medical setting and usually in a female-dominated setting. Some fathers were noted to be uncomfortable with medical issues (e.g., . . . It’s a relatively [new] occurrence that dads become involved in . . . the prenatal process, so they don’t know


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how it is they’re supposed to act, and then what happens when they get into the counseling session . . . If they don’t do anything, they . . . become non-involved. If they do something or say something, they become overly-involved and protective . . . so it’s a lose–lose situation for these guys . . .). Was Paternal Involvement Addressed in Training? How Could Training Be Improved? Eight participants reported that paternal involvement was addressed in their training, but not extensively; 8 stated that it was not addressed; and 1 participant did not receive genetic counseling training and have exposure to this topic. Those who received training described both classroom and clinical experiences. Didactic training recommendations include lectures and discussions on paternal involvement; techniques to manage difficult clients and patients’ in-session affect, particularly anger; course work in couples counseling; methods to facilitate couple communication and decision making; exploration of how men are typically involved in the pregnancy; information about if/how men and women cope differently with grief; and information about specific cultures and gender roles. Clinical experience recommendations include role playing, videotaping sessions for later supervision and feedback, conducting some individual sessions with fathers, and observing different genetic counselors to gain exposure to a variety of styles. DISCUSSION This study investigated paternal involvement in prenatal genetic counseling from the perspective of experienced genetic counselors. Findings are discussed according to the major research questions. Descriptions of Paternal Involvement in Prenatal Genetic Counseling Sessions The participants’ definitions and descriptions of paternal involvement were very consistent. Many reported that a father’s mere presence at the prenatal session was indicative of some degree of involvement. However, attendance varies, and some speculated that lack of attendance could be due to reasons other than paternal involvement. For instance, Berg and Rosenblum (1977) found that the most frequently stated reason for a father’s absence from family therapy was conflict with his work schedule (a possibility voiced by some of the present participants). The participants noted several verbal and nonverbal behaviors that suggest paternal involvement. These behaviors indicate that the father is attentive to his partner’s feelings and expressive of his own thoughts and feelings, participates


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in the genetic counseling process, and is actively involved in decision making. Participants regarded quality of the father’s involvement as more important than quantity. All reported that paternal involvement is an issue they have to contend with at least some of the time. The present sample’s descriptions of paternal involvement in prenatal genetic counseling generally are similar to those in the family therapy literature. However, in that literature, paternal involvement is identified as essential to successful therapy outcome (e.g., Berg & Rosenblum, 1977; Duhig et al., 2002). In contrast, responses by some participants suggest that they have fairly low expectations of paternal involvement (e.g., showing up for the appointment, giving more than oneword answers to questions, being willing to answer questions at all, and talking to one’s partner). A few participants indicated that they regard the mother as the primary patient and, while valuing paternal involvement, view it as less essential to genetic counseling outcome. Several participants noted that the couple’s cultural background affects a father’s involvement. For instance, in some cultures it is expected that the father is in charge either to protect his spouse and family or because he is the spokesman. Definitions of paternal involvement should accommodate cultural variation. Descriptions of under-involvement include both non-verbal and verbal behaviors that suggest the father is disengaged, distracted, uncooperative, and/or defensive. Underinvolvement is troublesome for most participants even when the behaviors seem acceptable to the mother. The most challenging types involve refusal to participate, to hear risk information, to help with decision making, and to express an opinion. Overinvolved fathers were described as exhibiting behaviors that control the content and flow of sessions, ignore their partner’s needs or feelings, and/or promote their own agenda. Challenging types of overinvolvement include the following: cultural issues, such as selective translating by the father and cultural practices that require the father to make all of the decisions; fathers who assume a protective role, as either a fixer or an antagonist; partner disagreement; and fathers who have made up their minds about testing prior to the session. Dominating fathers may elicit countertransference feelings. Similar to under-involvement, overinvolvement is troublesome for most participants even if the mother seems accepting of it. Most participants expressed concern that the mother be able to express her thoughts and feelings and to participate fully and equally in testing decisions. They also were concerned about obtaining maternal informed consent, particularly when the mother does not speak English. Participants’ responses suggest that they value the father’s involvement in the session. This value appears to be based, at least in part, on a belief that couples have a shared responsibility in decision making, and it is the couple who must live with the decision and its ramifications. For participants who espouse a couple as patient perspective, over- and underinvolvement appear to be equally problematic.


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Effective and Ineffective Strategies for Addressing Problematic Paternal Involvement The participants reported using a variety of nonverbal and verbal techniques to address problematic involvement. To manage underinvolvement, they invite fathers to attend sessions, to express their feelings and thoughts, and to participate in decision making. They address overinvolvement primarily via confrontation and advanced empathy (interpretation). They proactively direct the process by clearly stating their expectations about both paternal and maternal involvement and by attempting to draw in fathers early. Several participants had difficulty remembering ineffective techniques. Research with novice genetic counselors might yield a more detailed picture. Several approaches were mentioned as effective in some situations and ineffective in others. This may be partially explained by the mental health construct of response specificity (Teyber, 2000) in which unique client characteristics and/or life experiences mean that not all clients will respond in the same way to the same intervention. Generally ineffective techniques include humor, confrontation, and asking direct questions; being forceful, defensive, or angry; and interviewing partners separately. The majority of the sample considered avoiding or ignoring involvement issues to be ineffective. There appears to be a practice standard such that when paternal involvement is problematic, the genetic counselor should intervene. Factors Related to Problematic Paternal Involvement The participants generated numerous factors believed to contribute to paternal involvement in prenatal genetic counseling sessions. One of the most frequently mentioned concerns the nature of the couple’s relationship—its quality, dynamics of power and control, the extent to which the couple agrees about decisions, and who makes family decisions. Some participants noted that when a mother is secretly comfortable with her partner’s level of involvement, the mother may collude with him. The term collusion implies deception and, as such, has a negative connotation. An important question is whether this behavior constitutes collusion or an effective coping style. This likely is extremely difficult to discern in a time-limited prenatal session. Additionally, some participants stated that they did not have the time to influence these couples’ dynamics nor did they consider it their role to do so, and some expressed an attitude of “If it works for the couple, why interfere with it?” Future research is needed to determine how genetic counselors should respond to couple dynamics. When is acceptance of a couple’s style a respectful, appropriate counselor response, and when is it collusion with the couple? Cultural influences on couple dynamics were particularly salient for many participants. Some fathers may selectively edit/interpret the counselor’s statements,


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and traditional gender roles may exist such that the father is expected to speak for the family and to make important decisions. These cultural practices raise questions about the extent to which the genetic counselor has or can obtain informed consent from the mother. Indeed, Mittman et al. (1998) point out that not all cultures have an autonomous client concept. They further report that using an aide from the same culture as the client helps to ensure that informed consent is obtained. Several participants stated that the father’s personal characteristics affect his involvement. For instance, dominant personalities dominate, whereas passive ones may sit on the sidelines. Session content may elicit intense affect, and the father’s family of origin issues may be triggered by session process or content. Some fathers may be uncomfortable in medical settings, particularly a female setting such as an Ob/Gyn clinic. They may feel unwelcome or out of place and may need to be invited into the session and the discussion. Fathers who have not been socialized to their role in this setting may not understand their role and the prenatal genetic counseling process. Differences in counselor–father demographics may play a role. The counselor’s age and gender were salient for some participants, although several (all female) reported that gender did not matter. Other participants felt that having a male counselor facilitated the father’s involvement. Obvious educational differences may lead to problematic involvement. More educated fathers with a scientific background may tend to dominate, whereas those with less education than the counselors’ may be less involved, perhaps feeling intimidated by, or resentful of, the counselor. None of the participants explicitly mentioned the father’s decision-making styles, although some of the factors they identified might be subsumed by this construct (e.g., father as the protector, decision maker, take-charge person). Previous research suggests that decision-making style is an important factor (Kenen et al., 2000). Additionally, some literature suggests that problematic involvement may be exacerbated for fathers who are in the moratorium phase identified by May (1982). Such fathers are ambivalent about the pregnancy and engage in distancing behaviors to cope with their ambivalence. Training Regarding Paternal Involvement Most participants reported receiving little or no training regarding paternal involvement. Kessler (1997) argues that genetic counselors should be able to impart knowledge that a couple needs to make decisions and also be responsive to the complexity of human interactions in this context. Therefore, defining paternal involvement as an important process variable and addressing it via literature, discussion, skills practice, and supervised counseling as a component of training and continuing education would help counselors to develop skills in this area.


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Comparison of Genetic Counselor Strategies to Marital/Family Therapists’ Approaches Family/marital therapy is concerned primarily with improving overall family/ marital relationships and functioning, and multiple sessions usually are necessary for therapeutic success. In contrast, prenatal genetic counseling goals are to assist a couple in understanding their genetic risk and to facilitate decision making regarding testing and test results, usually within a single session. Nevertheless, in both types of counseling, the issues dealt with potentially are of great importance to the couple and their family. The father’s involvement in family therapy has been shown to be an important determinant of successful family therapy (Berg & Rosenblum, 1977). Although the present sample regarded paternal involvement as important, it is not known empirically how essential the father’s role is in prenatal genetic counseling. Nevertheless, both the present sample and the family therapy literature (e.g., Carr, 1998; Heker, 1991) indicate that it is ineffective to ignore problematic paternal involvement. There was considerable overlap in the techniques cited by the present participants and those reportedly used by family/marital therapists. At the front end are techniques for maximizing the likelihood that the father will attend. The family therapy literature suggests using a videotaped introduction to family therapy (Pimpernell & Treacher, 1990). Perhaps an orientation tape would help encourage fathers to attend and participate in genetic counseling by setting expectations and educating them about their role and those of their partner and the genetic counselor. Interestingly, although the present participants mentioned non-verbal techniques such as arranging the physical setting to facilitate involvement, these techniques are not apparent in the family therapy literature. Verbal techniques were enumerated in great detail by both the present sample and in the family therapy literature. These approaches are intended to establish rapport with the father, to join or align with him. One suggestion from family therapy is to normalize the father’s reluctance to be involved, or to reframe it positively (e.g., Allgood et al., 1992). The present sample reported using primary and advanced empathy with male partners for similar purposes.

CONCLUSIONS Nearly all of the participants try in some fashion to encourage fathers to express their feelings and thoughts, to show concern and respect for their partners, and to participate equitably in decision making. When the fathers are uninvolved, they try to engage them. When they are overinvolved, the participants try to tone down the father’s involvement or to ensure that the mother is not overshadowed.


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They attempt to treat partners as equals. However, when this equal treatment approach fails, some take the perspective that the mother is the ultimate decision maker. An important question, raised by several participants, is—“Who is the primary patient?”—a major ethical/professional challenge for genetic counselors (McCarthy Veach et al., 2001). Whose needs, preferences, and decisions take precedence, and/or from whom must informed consent be obtained, particularly when family members disagree? Participants in the present study varied in the extent to which they viewed either the mother or the couple/family as the “primary patient.” One could make the case that either the mother or the couple/family is the patient in all genetic counseling situations. However, a one size fits all view likely is ineffective. For instance, answers to this ethical question will necessarily be culture-bound and therefore value-influenced. The notion of informed consent, legally required from the mother, depends on the assumption of client autonomy, which does not exist as a concept in all cultures. Even when cultural differences are not apparent, diversity exists. Indeed, several participants noted that some mothers seem to accept their partner’s under- or overinvolvement, and they tried to read the mother in deciding what to do about the father’s involvement. Research is needed to determine whether this constitutes collusion or validation of a couple’s process. The participants indicated that several factors influence the father’s involvement in prenatal genetic counseling. Relationship, cultural, and personality factors were cited as important determinants. Although there was disagreement in this sample, the genetic counselor’s gender was not noted as a salient factor by most participants. More research is needed to clarify the importance of this genetic counselor characteristic. Finally, there appears to be considerable overlap in the techniques employed by marital/family therapists and those reported by the present participants. However, there seem to be enough differences to indicate that the genetic counseling field should develop and empirically validate its own model and methods for addressing paternal involvement. Study Limitations Qualitative methods yield information-rich data sets, but they do not permit the kind of generalization afforded by quantitative methods. The present results may be limited to prenatal genetic counseling and may reflect the perceptions and experiences of prenatal genetic counselors who are willing to participate in research, and/or individuals for whom the topic is particularly salient. Additionally, participants may have given socially desirable responses and/or provided responses that are inconsistent with their actual behavior, for instance, underreporting their failures while overreporting success.


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Implications for Training/Practice These findings suggest that programs should maintain curricula on involvement of the male partner. Students should be afforded the opportunity to engage in supervised practice dealing with paternal involvement issues. Continuing education on couples counseling, cultural influences, and paternal involvement should be offered. Finally, the genetic counseling field needs to sustain a conversation about “who is the patient” in prenatal genetic counseling. One speculation is that the bias towards the mother, while justifiable legally (i.e., she is the potential recipient of invasive procedures), reflects a bias that occurs because the vast majority of genetic counselors are women. Studies are needed to determine the extent to which female counselors define the patient differently from male counselors. Additionally, studies of whether/how to equalize participation by both mothers and fathers should be conducted. Suggestions for Future Research In future research, prenatal genetic counseling sessions could be videotaped and/or other behavioral measures could be employed to investigate the behavior of all parties with respect to paternal involvement. Both fathers’ and mothers’ perspectives on paternal involvement should be more fully explored, and problematic maternal involvement also should be studied. This is particularly important because one person’s problematic involvement may be another person’s business as usual. Some of the fathers’ behaviors described in this study (e.g., reading a newspaper during the session, selectively translating for the mother) likely would be viewed as problematic by most individuals. However, other behaviors may be differentially perceived and, more importantly, may have different explanations. For example, when is a father’s behavior under-involvement due to disinterest? When is it overinvolvement prompted by a hidden agenda? To what extent can a father’s behavior be explained by his relegation by society to a minor role in pregnancy? How much may be accounted for by gender differences in expectations of health care providers? Finally, to what extent is behavior perceived as problematic because of counselor countertransference (e.g., novice counselors may inaccurately perceive that assertive fathers who stress facts and figures are challenging their competency)? The present sample (particularly of male counselors) was too small to investigate gender differences. Future studies should investigate male versus female counselor experiences and approaches as well as whether/how counselor gender interacts with client characteristics. Research on paternal involvement should be expanded to include prenatal sessions in which positive test results are discussed and pediatric genetic counseling sessions. Finally, further investigations of the factors contributing to paternal involvement and effective counselor responses would allow genetic counselors to anticipate involvement issues with certain types of clients and to respond appropriately.


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APPENDIX: INTERVIEW QUESTIONS ABOUT PATERNAL INVOLVEMENT • How would you define the term “involvement” as it applies to a father’s behavior during prenatal genetic counseling? Is this an issue you as a genetic counselor have to deal with? • What behaviors of fathers indicate to you that they are involved during the prenatal genetic counseling session? • What behaviors of fathers indicate to you a lack of their involvement during genetic counseling? • Can you tell me about the most recent prenatal genetic counseling session in which you felt that the father’s lack of involvement negatively effected the session? What did he say/do? Not say/do? Did you choose to address his lack of involvement? If not, why? • Have you ever had a time when you felt the father was too involved and that had a negative effect on the session? What did he say/do? Not say/do? How did you address his involvement? What are the most challenging types of paternal overinvolvement you have encountered? • Generally, what types of counseling strategies have worked for you in addressing the father’s involvement during prenatal genetic sessions? • Generally, what types of counseling strategies have not worked for you in addressing the father’s involvement during prenatal genetic sessions? • What factors do you believe contribute to the father’s level of involvement, either too little or too much? • Was the father’s involvement in sessions addressed as an issue in your training? If so, how? Are there any ways you can think of that your training could have been improved in this regard? • Before we end the interview, is there anything else you would like to add? • Do you have any questions? ACKNOWLEDGMENTS This study was completed in partial fulfillment of the requirements for the first author’s doctoral degree from the University of Minnesota.

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