Genetic counselors' response types to prenatal patient deferring or attributing religious/spiritual statements: An exploratory study of US genetic counselors

Abstract Research shows religiosity and spirituality (R/S) influence genetic counseling patients' and families' risk perception, decision‐making, and coping. No published studies have examined how genetic counselors respond to patient‐initiated R/S statements. This exploratory study examined genetic counselors' response types and reasons for their responses to two prenatal patient's R/S statements. Genetic counselors (n = 225) recruited through a National Society of Genetic Counselors eblast completed a survey containing two hypothetical scenarios regarding a prenatal patient's receipt of a trisomy 18 diagnosis. Scenarios were identical except for the last patient statement: “God makes everything possible…we leave things in his hands” (a deferring statement) or “I feel like God is punishing me for something I did” (an attributing statement). Imagining they were the counselor, participants wrote a response to each scenario and provided reasons for their response. Responses were analyzed using the Helping Skills Verbal Response System. MANOVA and chi‐square tests, examining differences in response type based on patient statement (deferring or attributing), participant comfort with R/S, and years of experience, yielded a significant multivariate effect for scenario (p < 0.001). Responses to the deferring statement scenario contained a greater proportion of content statements (p < 0.001), closed questions (p < 0.001), and information‐giving (p < 0.001). Responses to the attributing statement scenario contained a greater proportion of open questions (p = 0.05), influencing statements (p < 0.001), and affective statements (p = 0.006). Neither comfort with R/S nor genetic counseling experience significantly affected response type. Thematic analysis of reasons for responses yielded nine themes. Most prevalent were exploration (of the patient's statement), validation, correction (of patient's beliefs), and reassurance. The findings reflect stylistic differences in how and why genetic counselors respond to patients.


| INTRODUC TI ON
Religiosity and spirituality (R/S) are key aspects of life for a substantial portion of the U.S. population. An estimated 50% report religion as personally very important, and a 2016 Gallup poll indicates 89% of Americans believe in God or a universal spirit ("Religion Gallup Historical Trends," 2017). R/S seem to be particularly important to people when dealing with stressful life events (Bjorck & Thurman, 2007). Healthcare studies have found religion and spirituality play a key role for some patients with respect to decision-making, coping, emotional well-being, recovery, and treatment compliance (Ehman et al., 1999;Grossoehme et al., 2010;Hodge, 2011;Medved Kendrick, 2017;Schwartz et al., 2000). Puchalski et al. (2014) speak to the importance of incorporating spirituality in healthcare to support and improve health outcomes and honor "the dignity of each person" (p. 642). Therefore, patientcentered approaches warrant the incorporation of religious and spiritual beliefs into some patients' care plans.
The relevance of R/S may intensify in genetic counseling situations, as patients often encounter uncertain genetic risk and information and/or face difficult decisions (e.g., Quillin et al., 2006;White, 2009). While patients with religious and spiritual inclinations may draw upon their faith in the face of genetic risks or diagnoses, little is known about how genetic counselors address patients' beliefs during a counseling session. The purpose of this study is to explore genetic counselors' responses to two different ways a hypothetical prenatal patient brings up her R/S in relation to a genetic condition.

| Definitions of religiosity and spirituality
Religiosity is often defined as adherence to a particular set of beliefs, participation in prayers or worship, upholding religious traditions, and/or affiliation with a specific religious community (Knapp et al., 2010). Historically, spirituality was considered a process that unfolds within a religious context (Steinhauser et al., 2017). While contemporary definitions of spirituality vary, they generally include an emphasis on a sense of purpose derived from a relationship with a higher power and reliance on personal moral and ethical standards (Knapp et al., 2010;Puchalski et al., 2009). R/S overlap in that religious individuals are often spiritual, and spirituality is commonly, though not always, expressed through religious practices and traditions (Knapp et al., 2010;Puchalski et al., 2009;Steinhauser et al., 2017).

| Effects of R/S on patients and families at genetic risk
Several studies have examined the influence of R/S on patients' risk perception, decision-making, and coping in relation to their own or their family members' genetic risks, diagnoses, and testing (e.g., Cotton et al., 2012;Ehman et al., 1999;Quillin et al., 2006;Sagaser et al., 2016;Seth et al., 2011;Schwartz et al., 2000). For instance, patients in prenatal and preconception genetic counseling have reported using their R/S to make decisions in their pregnancy and to deal with stressors (Sagaser et al., 2016). Seth et al. (2011) examined the role of R/S in decision-making for amniocentesis in pregnancy.
They found that although most of the participants' decisions about amniocentesis were heavily influenced by procedural-related risks for complications, they did rely on their faith and beliefs for comfort after making a decision. Themes in responses from all participants included "faith in the existence of God" and using their hope and faith as "pillars of support" (p. 665). Women with different obstetric risks have been found to use spiritual coping to deal with the various stresses of their pregnancies (Breen et al., 2006;Hamilton & Lobel, 2008).

| Patient perceptions of R/S exploration by healthcare providers
Research indicates that patients with and without religious beliefs generally welcome physicians' inquiry about their R/S beliefs (Daalemann & Nease, 1994;Ehman et al., 1999). Two genetic counseling studies demonstrated that patients generally are comfortable sharing their beliefs in sessions and would welcome the genetic counselor incorporating R/S into the discussion (Sagaser et al., 2016;Thompson et al., 2016). Sagaser et al. (2016) also found that genetic counselors were significantly more likely to identify R/S as important to a patient when the patient used religious/spiritual language (faith, belief, blessing, sin, trust, God's will, God's hands, etc.). In contrast, in the absence of such language, genetic counselors were usually uncertain about the importance of R/S to the patient.
Although research suggests some patients are comfortable with R/S discussions in genetic counseling session, one study found only about 60% genetic counselors reported performing a spiritual assessment in the previous year, and only about 8% of those counselors conducted the assessments in greater than half of their sessions (Reis et al., 2007). The most commonly reported reasons for

What is known about this topic
Studies have explored the use of religion/spirituality (R/S) by patients, but none have directly examined genetic counselors' response types to R/S statements.

What this paper adds to the topic
Findings illustrate the wide variety of genetic counselor response types to patient deferring and attributing patient statements and suggest variables warranting further research.
such assessment were because the patient initiated the topic, and the session involved termination and end-of-life issues. Frequently reported reasons for lack of assessment were low perceived relevance of spiritual assessment to genetic counseling and counselor discomfort.

| Purpose of the study
Prior research supports the importance of R/S to many individuals in the U.S. and R/S and coping may be particularly prevalent in This exploratory study begins to address a gap in the literature by identifying genetic counselor response types to a hypothetical prenatal patient bringing up her R/S in relation to a genetic condition.

| Participants
Upon receipt of approval from the University of Minnesota Institutional Review Board (STUDY00004207), genetic counselors were recruited through a National Society of Genetic Counselors (NSGC) eblast (~n = 3876). An invitation described the study as an investigation of how genetic counselors respond to patients' religious or spiritual statements with the goal of describing current practices and informing recommendations for current and future professionals. The invitation contained a link to an anonymous online survey. The initial study invitation was sent in October 2018, and a reminder email was sent 5 weeks later.

| Instrumentation and procedures
We developed an online survey (See supplemental appendix) comprising three sections. The first section reviewed the purpose of the study, consent information, and survey expectations. The second section contained two hypothetical prenatal genetic counseling scenarios in which Non-Invasive Prenatal Test and level 2 ultrasound findings for the patient are consistent with trisomy 18.
The genetic counselor is discussing with patient whether she wishes to pursue amniocentesis.
The scenarios and genetic counselor-patient dialogue were identical with the exception of the final patient statement which was either a deferring R/S statement or an attributing R/S statement. We created these statements based on our clinical experience that they are prevalent among prenatal patients who express R/S beliefs, as well as studies that have found a belief in God's will are a common theme among Hispanic patients, with R/S beliefs that accept or decline prenatal testing options ( Browner et al., 1999). God's will has been cited as referencing both acceptance of a health outcome, as well as a belief that God will assist them regardless of the outcome and/or God's power in a child's wellbeing (Rehm, 1999). As stated by Seth et al. (2011), "families not only believed in God's help, but felt that the outcome was also influenced by their own contributions to the child's health care needs" (p. 662). Thus, the scenarios and R/S statements in the present study are based on an amalgamation of anecdotal and empirical information. For clarity, we herein reference each patient statement/scenario as "deferring" or "attributing." The deferring R/S statement indicates the patient's reliance on an external entity. The attributing R/S statement expresses the patient's perception that she is the possible cause of the genetic condition.
Deferring "implies a voluntary yielding or submitting out of respect or reverence and affection toward another"; attributing is the interpretive process of making judgments about cause and includes "an inferring or conjecturing of cause" (Merriam-Webster, n.d.). Both responses were standardized with respect to word length, 20 and 21 words, respectively. Participants were asked to imagine themselves as the patient's genetic counselor and to compose a response to the R/S statement in each scenario as if they were speaking directly to her. After responding to the patient, they were asked to explain the rationale for their response. Presentation of the two scenarios was randomized and balanced to control for potential order effects.
The third section of the survey contained demographic questions (e.g., age, gender, ethnicity, genetic counseling experience, specialty area, whether they see patients, and if so, average number seen per week, and average hours worked per week). In addition to basic demographic information, participants were asked how often patients do/did bring up R/S issues (Scale: 1 = Rarely/Never, 2 = Sometimes, 3 = Often, 4 = Very Often) and their comfort level with R/S in sessions (Scale: 1 = Little or not at all comfortable, 2 = Somewhat comfortable, 3 = Comfortable, 4 = Very Comfortable).

| Quantitative analyses
Descriptive statistics were calculated for responses to the demographic questions. Participants' responses in each scenario were analyzed using the Helping Skills Verbal Response System (HSVRS; Danish et al., 1980;Dotson, 1984). The HSVRS assesses the types of helping responses (rather than response quality) individuals use in one-to-one interactions. The HSVRS has demonstrated reliability and validity in studies of the helping responses of diverse groups, including paraprofessional helpers and untrained individuals (McCarthy et al., 1979); crisis interveners, psychotherapists, and nursing students (McCarthy & Knapp, 1984;Ryden et al., 1991); informal helpers (D'Augelli & Vallance, 2006); clinical supervisors (McCarthy et al., 1994); job recruiters (DeBell et al., 1998); and peers who reply to messages posted on grief websites (Swartwood et al., 2011). P.MV. is a criterion-trained rater in the HSVRS system, and she analyzed the participants' responses to each scenario. First, she divided each response into thought units (independent clauses that comprise a subject and a verb). Next, she classified each thought unit into one of nine types of responses, described in Table 1. A one-way multivariate analysis of variance (MANOVA) was conducted to check for potential order effects for any of the dependent variables. A 2x2 mixed MANOVA examined differences in total number of thought units and in proportionate use of the nine response types as a function of genetic counseling scenario, controlling for order effects. Proportions were used to control for differences in participant verbosity. They were obtained by dividing the frequency of each type of response by the total number of thought units. A 2x2 mixed MANCOVA was conducted to see whether controlling for genetic counselor experience level or self-reported comfort discussing R/S issues affected the proportionate use of the nine response types.
A.S. reviewed all participant responses to the hypothetical patient and noted whether they mentioned R/S language (e.g., God, faith, religion, chaplain) based on R/S language denoted by Sagaser et al. (2016). A chi-square test examined whether there was a significant difference in the percentage of participants who mentioned R/S language in their response for the Deferring scenario versus the Attributing scenario. Chi-square tests were also done to examine whether mentioning R/S in either scenario was related to selfreported comfort level discussing R/S issues or level of experience.
Given the exploratory nature of this study, it is important to balance protections for Type I errors (false positives) and Type II errors (false negatives), as falsely declaring no effect could be just as damaging to future research efforts as falsely declaring an effect.
To this end, we assessed the two MANOVAs and the MANCOVA at α = 0.017 (Bonferroni correction for 3 tests) and the chi-square analyses at α = 0.01 (Bonferroni correction for 5 tests) as a compromise between a strict Type I error correction strategy and maximizing power to identify promising areas for future research. Further Type I error corrections for post hoc tests (e.g., univariate ANOVAs for significant factors in the MANOVA or MANCOVA) were not conducted, as such measures are overly conservative given the significant preliminary test (e.g., Howell, 2010).

| Qualitative analysis
The participants' reasons for their responses to each scenario were analyzed using an inductive approach that looks for patterns, themes, and common categories without imposing a preexisting framework on the data (Silverman, 2000). A.S. and K.R.G. served as data analysts. Together, they coded the first 20 participant rationales from each scenario to extract themes for subsequent coding of all rationales. Then, A.S. coded the remaining rationales while continually reviewing thematic groupings. Following this step, K.R.G. audited her coding. They discussed any discrepancies to reach agreement.

| Participant demographics
The recruitment process yielded 470 returned surveys (conservative response rate, assuming all members read the eblast = 12.1%). Of these, 225 participants responded to at least one scenario and were therefore included in the data analyses. Descriptive statistics for all study variables are shown in Tables 2 and 3. Participants were primarily female (90.7%) and White (87.6%), which is consistent with data from the 2018 NSGC Professional Status Survey (PSS; 95% female and 92% White; NSGC, 2018a). The 2018 PSS was used because it reflects NSGC membership at the time of data collection. Participants ranged in age from 24 to 72 years (M = 35.3, SD = 11.37) and had a mean of 7.58 years of experience (SD = 8.59). Work settings and practice specialties varied. The most prevalent work setting was a university medical center (33.3), and the most prevalent practice specialty was prenatal (34.7%). The most prevalent work setting on the 2018 PSS (NSGC, 2018b) was also university medical center (30%), though the most prevalent practice specialty was cancer (46%).
The sample varied widely regarding R/S affiliation. The most prevalent responses were agnostic (24.4%) and atheist (14.2%). The remaining participants reported a variety of R/S affiliations. Slightly more than half of the sample (53.8%) reported currently practicing their religion. When asked how often their patients have brought up R/S, the most prevalent response was "sometimes" (60%). When asked about their comfort in discussing R/S with patients, the sample was evenly divided, with 44.8% reporting either Little or not at all comfortable or Somewhat comfortable, and 48.9% reporting either Comfortable or Very comfortable.

| Genetic counselor response type to prenatal patient's R/S statements
There were 434 responses for the two prenatal scenarios (218 for the Deferring scenario, and 216 for the Attributing scenario). Seven participants did not provide a response to the Deferring scenario, and 9 participants did not provide a response to the Attributing scenario. Each of the nine HSVRS response types occurred in both scenarios (see Table 1 for illustrative examples). Table 3

| Do response types differ as a function of the content of the patient's R/S statements?
The first MANOVA found a significant multivariate effect for presenta-

Response type Definition
Deferring scenario example (participant number)

Content
Reflect patient statements It sounds like your faith is really important to you and that you would prefer to wait and see how things progress (2).
This was not something you had expected to have to deal with. (55) Affect Reflect feelings patient has not directly labeled It sounds like your faith is bringing you a sense of comfort and peace at this time (172).
You are overwhelmed because you do not know why this has happened to you. (22) Open Question Require an extended answer Could you tell me more about what you mean by "God makes everything possible?" (1) What is it that you think God is punishing you for? (2) Closed Question Require 1-or 2-word answer Do you feel that believing to leave everything in God's hands helps you during the pregnancy? (41) Do you feel like God punishes people in this way? (14) Influence Attempt to alter patient views; provide GC's opinion; encouragement Doing the amnio allows for more information so that you have all the facts to make decisions. (119) I want to let you know that there is nothing that you did that would have caused these test results. (1) Advice Suggest alternative behaviors If that were the case, you may want to be sure to deliver in a hospital that can provide the appropriate level of care.
The hospital also has a chaplain who would be happy to talk with you. (20) Information Provide facts or resources Diagnostic testing, and knowing that trisomy 18 is present, would provide you with information on what to expect going forward in pregnancy. (50) Our current understanding is that the risk of this happening increases as women get older. (7) Self-disclosure Factual information based on GC's work experience; personal info about GC Some of my patients have the amniocentesis, so that they have the answer and can prepare going forward -one way or another. (98) I do not know very much about religion, but I feel like God loves people and would never want to punish them. (14) Self-Involving Personal reactions to patient (usually GC feelings) I am glad to hear that your spirituality is a source of strength, because I know this news can be difficult. (112) I am so sorry that this news is so difficult.

| Are there differences in response types due to counselor comfort level discussing R/S issues?
The

| Are there differences in response types as a function of genetic counselor experience?
The MANCOVA analysis also showed that controlling for experience did not affect any of the nine response types [Wilks' λ = 0.904,F(10,191), p = 0.03, 2 p = 0.10]. There also was no significant association between having greater than or less than 5 years of experience (based on definition of novice genetic counselors; Zahm et al., 2015) and mentioning R/S language in responses to either scenario
Every theme was evident in both scenarios, with the exception of Reassurance, which was only seen in the Attributing scenario. The most frequent rationale for each scenario was Exploration and the least frequent rationale, mentioned by only a few participants, was Discomfort. Table 4

| DISCUSS ION
This study examined genetic counselors' response types and reasons for their responses to two prenatal patient-initiated R/S statements.
Two hundred twenty-five genetic counselors responded to two hypothetical scenarios involving a deferring (leave it in God's hands)

TA B L E 2 (Continued)
and attributing (God may be punishing me) R/S statement. Although prior research has investigated patients' R/S beliefs and their effects on genetic counseling processes and outcomes, this is the first investigation of how genetic counselors respond to patient deferring and attributing R/S statements. As the field strives for more culturally inclusive practices, this study provides an initial step in exploring genetic counselors' response types when R/S beliefs arise in sessions.

| Genetic counselors' response types to patient's R/S statements
Participants differed in their use of the nine helping skills response types for each patient statement. Content response types, which were prevalent in replies to the deferring R/S statement, encourage patient elaboration/exploration and are considered a form of empathy (Danish et al., 1980;McCarthy Veach et al., 2018). In the present study, self-reported comfort discussing R/S issues varied, although there were no significant differences in the response types given in each scenario or use of R/S language due to the genetic counselors' comfort ratings. These results differ from Reis et al. (2007) who found counselor discomfort was a perceived barrier to conducting spiritual assessments with genetic counseling patients. In the present study however, participants were directed to respond to patient's R/S statements, and it appears that they were able to "set aside" their own comfort/ discomfort to do so.
The genetic counselors' use of R/S language differed significantly between the two scenarios. Twice as many genetic counselors used R/S language for the patient's deferring R/S statement than for the attributing statement. One possible explanation is the higher prevalence of content responses to the deferring R/S statement. As content responses essentially reflect the patient's statements, they are more likely to mirror the patient's R/S language. Another possible explanation is the counselors were more comfortable using R/S language in response to the deferring statement because they perceived her statement that "God makes everything possible" to be a positive coping strategy, as opposed to the attributing statement "God is punishing me" which they may have viewed as a negative strategy and/or as scientifically incorrect.
There were no significant differences in the type of genetic counselor responses or in the mention of R/S as a function of their genetic counseling experience. These results are consistent with Reis et al.'s (2007) findings that experience did not influence genetic counselors' spiritual assessment practices in sessions. Further studies should explore possible associations between genetic counselor experience and their response types to patients' R/S statements.
It is worth noting that this study examined genetic counselor response type via the HSVRS. A thematic analysis of responses was I want to know if this means that they do not need more information because what will happen will happen… or do they mean that they think their baby will be healed. (9) Validation Acknowledgement and support the patient's statement, beliefs, thoughts, and/or feelings 94 I have heard many patients express similar feelings about a strong faith in God. For some people with this faith, an amniocentesis is not important because they believe that God has control. For others with a strong faith, an amniocentesis is important to know whether the baby has trisomy 18, either so the family can prepare or make pregnancy management decisions. What do you think about when you hear me say this?
I want to validate the patient's faith, but also acknowledge that some people with strong faith still undergo an amnio. Even though many people who are religious would not consider termination, I would still want to provide all of the information because I do not know her personal views. (4)

Correction
Challenges the patient's misunderstandings or misconceptions.

32
I have a strong faith, too. And I believe that what is God's will will happen and often we do not understand why. There is a chance your baby will be healthy and well. There is also a real chance that your baby will have trisomy 18. Either way I am here to support you along this journey. The amniocentesis will give you more information that may help to prepare you emotionally, and help your doctors to prepare for the delivery. However, the choice is yours -there is no right or wrong answer.
I try not to bring up my faith during genetic counseling sessions unless the patient does. If they bring up their faith, I would like to share this with them and make them aware that we can relate to one another on this spiritual level. Where I work now, many patients have a strong faith and often think genetic counselors are terrible because we even bring up certain topics. I want patients to know that we are here to support them and not to confront them with difficult decisions or options they see as immoral. (152)

Management
Clarify or direct the conversation to medical planning.

25
God may already know what will happen but an amniocentesis will give us a chance to discuss options that will help you and your family plan and prepare for a child that will need additional and special care early on and throughout his/her life. It sounds like your faith is very important to you and many families that I work with express the same thoughts that you just did.
I am trying to normalize that the decision to not pursue an amnio is okay. (2)

Discomfort
Communicates that participants were not comfortable addressing R/S or that it is out of their scope 8 Because I am required to give you all options, my job is to let you know that termination is an option in this state up to 21 weeks and 6 days.
I have no opinion about the right path for you but if you would like more information about termination I can give you that information. Ariana, this is not because of anything you did or did not do. There's always a chance with any pregnancy of a genetic change that leads to birth defects. It's unfair and senseless, but there's nothing you did wrong. There are unfortunately a lot of women who go through similar situations, but it can be very helpful to meet with them for support. If you are interested, I'm happy to find a group or an individual to talk to.
I wanted to help assure her that this is not her fault, but I wanted to at the same time steer a bit clear of getting too much into the science and biology of trisomies in case she thought I was dismissing the role God had in her situation. She also seems quite distressed (without having any body language to go off of) so I wanted to offer some support in the form of a support group or one-on-one meeting. (52)

Normalization
Communicate that the patient's experiences and/or statements are not uncommon 24 It is normal to wonder why this is happening or to feel like we are to blame. It is important to remember that Trisomy 18 occurs by chance, it is not something that anyone chooses.
It is sometimes hard to know the underlying reason for these comments but often it seems as though the person is feeling guilty or to blame. So that is why I would start by normalizing her feeling of questioning. It provides the genetic counselor a good opportunity to discuss those feelings of guilt or blame. (28)

Example rationale
Explaining Prioritize information to help the patient with decision-making, including making referrals.

23
Unfortunately, we do not have an explanation as to why this is happening specifically to you, and I know that this is a hard situation that you are in. Our current understanding is that the risk of this happening increases as women get older, but we cannot tell why it happens to one woman rather than another.
I am not a therapist and cannot help her to unpack why she feels that God is punishing her. I can only give her scientific facts to help her understand her situation. (7) Personalization Description of participants' own R/S affiliation (or lack thereof) and/or something personal about themselves to justify what they did/did not say to the patient 14 If this result is true and the baby does have Trisomy 18, I can assure you that this is not a result of anything that you did or did not do. When I hear responses like this, I find it is oftentimes a reaction of trying to make sense of the occurrence of a very difficult, unexpected, and random event. Unfortunately, parents have a tendency to blame themselves in these situations, which can mean drawing lines between unrelated events.
Clearly, she sees this event as a negative occurrence and punishment. Whether you want to call it karma, or God, or some other force, clearly she feels like there must be a reason for this event to have happened to her. In her case, the only explanation is that this is a punishment for something that happened in her past. You do not necessarily need to address God to let them know that this is not their fault. I find that telling people what God did or did not intend usually does not go over well, especially coming from someone who is not religious. (25)

Discomfort
Communicates that participants were not comfortable addressing R/S or that it is out of their scope 5 I know that this can be a lot of information to take in all at once. It sounds like you may be feeling a little overwhelmed? Trisomy 18 is something that occurs purely by chance in the developing embryo. Do you think it would help to speak with your [religious leader] or other members of your [religious institution] about all that's been going on? I feel confident that they would assure you that God is not punishing you for something you did.
As a non-religious person, this was SUPER hard to come up with a response to! I wanted to say that trisomy 18 is just a chance occurrence -even if to her it is "by God's hand." I do not feel that it's within my abilities or scope to speak about any religion's ideas about sin, punishment, or why bad things happen, so that's why I recommended she consider speaking with people more equip to answer her questions. I know it may not be true 100% of the time, but from what I know of religion, I do not feel like the religious institution's stance would be that she did something bad and now is going to have a baby with trisomy 18. (98)

Management
Clarify or direct the conversation to medical planning.

4
There is nothing you did to cause this and nothing you could have done to prevent this. These types of conditions truly happen by chance. Now that we have this information we can focus on what is best for you and your baby.
While I would not directly "correct" or "challenge" her statement, because I cannot begin to determine her interpretation of her religion, I want to make sure she hears that this is not her fault. I would then try and focus on the positive of the situation, which is having this knowledge now so we can plan and prepare appropriately. (146) Note: Participant numbers presented in parentheses after each quote. Rationales were coded into multiple themes when appropriate; thus, column totals will not be equal to total number of participants. When rationales contained multiple themes, the italicized portion of the rationale is what was representative of the theme.

TA B L E 4 (Continued)
not performed given the brief nature of genetic counselor responses that precluded this deeper analysis. While the purpose of this study was not to examine response quality or motivations, it is interesting to consider how genetic counselor's responses to R/S statements may be intentionally brief in nature. This could reflect a number of factors: the lack of comfort that influenced a more truncated discussion; the conflict between the teaching and counseling model of genetic counseling practice; and/or the lack of time that logistically prevents genetic counselors from more deeply addressing psychosocial topics. Another possible explanation is that participants were asked to provide a single response; thus, it is unknown whether they would have further discussed R/S in an actual session. There are potentially endless hypotheses, and yet, it may be that the cursory responses collected in this study accurately reflect the various ways in which genetic counselors navigate R/S when it arises in sessions.
Overall, the wide variation in response types found in this study indicates that there is no prescribed way to respond to patient's deferring or attributing statements in the context of R/S discussions.
Practicing genetic counselors, as well as trainees, may find freedom in their ability to respond in a patient-centered and tailored way to patient's discussion of their R/S beliefs. Training and education should similarly underscore the variety of ways in which genetic counselors might respond and identify possible advantages and disadvantages of different approaches for different patients. For instance, content and affective statements are "continuing responses" intended to promote elaboration of thoughts, feelings, and experiences of concern to the patient (Danish et al., 1980;McCarthy Veach et al., 2018). Questions, influencing responses, advice, and information statements, are "leading responses," that are intended to guide the conversation in directions of concern to the genetic counselor.
Self-disclosure and self-involving statements are "self-referential" responses intended to respectively share personal information and here-and-now reactions of the counselor. Consideration of concrete examples of these different response types to a patient's R/S statement can be used as a helpful starting framework, especially for trainees and novice genetic counselors.

| Genetic counselors' explanations of their responses
Participants provided a variety of reasons for their responses with exploration being most prevalent in both scenarios. Exploration is consistent with the use of content and affective responses, as well as with open-and closed-ended questions (Danish et al., 1980;McCarthy Veach et al., 2018), which were highly prevalent in the participants' response types. This reason is also congruent with studies showing the significant role R/S plays in terms of coping, risk perception, and decision-making by patients and families (Grossoehme et al., 2010;Quillin et al., 2006;Seth et al., 2011). Exploring patients' R/S statements allows the counselor to assess and better understand the patient's underlying thoughts, feelings, and beliefs which, in turn, may positively affect genetic counseling processes and outcomes. Studies have found that medical patients who had R/S discussion rated overall experience and satisfaction higher, and some patients want their genetic counselors to explore their R/S beliefs and values in the context of their healthcare (Sagaser et al., 2016;Williams et al., 2011). These findings reflect the ten- issues (Meiser et al., 2008;Paul et al., 2015). Finally, although participants' ratings of their comfort with discussion of R/S were not a significant factor in the current study, it is interesting to highlight that some genetic counselors identified their discomfort as a reason for their response in one or both scenarios.
They variously noted their discomfort originated from a lack of an R/S affiliation, lack of training regarding how to address patient's R/S, belief that R/S discussions were outside the scope of genetic counseling practice, and their disagreement with the patient's R/S sentiments. Reis et al. (2007) also reported these reasons as barriers to R/S assessment. Given cultural competency is one of the cornerstones of genetic counseling, R/S discussions arguably are within the scope of practice (Wang, 1994;Warren, 2011a;Warren, 2011b;Weil, 2001).
Almost 40% of the present sample (38.6%) identified themselves as agnostic or atheist, which is consistent with a recent study of genetic counseling students (37.9%, Stoddard et al., 2020). Further studies could investigate genetic counselors' reactions and responses when their R/S views are opposed to those of their patients.
Education regarding the role of religion and spirituality in patient care and ways to address it in sessions may increase genetic counselor comfort with such discussions in their practice (Murray et al., 2020) and reinforce that R/S discussions are within the scope of genetic counseling practice. Education also reinforces the importance of culturally inclusive care in healthcare. Practice opportunities such as role plays for students to specifically engage in R/S discussions in a deliberative may assist in increasing comfort (Murray et al., 2020).
It should also be considered that participants' reported discomfort could have stemmed from a countertransferential reaction to the patient statement(s) such as feeling they are not qualified to discuss R/S beliefs, concern they might unduly influence the patient, or feeling unable to connect empathically with them. The importance of self-reflection in promoting awareness and management of countertransferential reactions that may arise in discussions of R/S beliefs is warranted. Self-reflection has been shown to be a valuable tool in genetic counseling practice (e.g., Runyon et al., 2010), and as such, this practice can begin during training. Training programs can provide opportunities for introspection to enhance awareness of their own motivations, understand reactions generated by interactions with patients, and enhance the way they respond to R/S statements (Christensen et al., 2018;Ernecoff et al., 2015). Continued reflection opportunities through peer support/consultation may be one effective vehicle to promote self-reflection for practicing genetic counselors (e.g., Lewis et al., 2016;Zahm et al., 2007).
Again, overall, the participant's varied explanations of their responses even within these two scenarios indicate the unique intentions and perspectives of genetic counselors on R/S discussions.
Genetic counselors see their role and responsibility in responding to R/S statements quite differently -from empathic, to corrective, to discomfort. Regardless, the intentionality of how and why they address patient's R/S statements remains critical.

| Training and practice implications
As discussed above, the present findings suggest several training and practice implications. For trainees and practicing genetic counselors, the wide variety of response types obtained in this study illustrate different ways genetic counselors respond to the same patient's R/S statement. Awareness of this variability can liberate genetic counselors from the notion that there is a "correct" type of response to patient's R/S statements. The importance of deliberative and self-reflective practice in responding to R/S statements is another important takeaway from the study findings. This intentionality can be fostered within training programs as discussion of cultural factors such as R/S that inform patient's thoughts, beliefs, and reactions to genetic information. Role plays and peer consultation are suggested opportunities to foster comfort, versatility, and deliberateness in addressing R/S statements.
Finally, training can continue to stress the importance of fostering relationships with hospital chaplaincy, as well as other ancillary healthcare members, as a place to continue to build cultural humility in working with individuals and families where R/S plays a major role in their experience of genetic counseling (Puchalski et al., 2014).

| Research recommendations
This study is an initial step toward understanding how genetic counselors respond to patient's R/S statements in prenatal genetic counseling sessions. As discussed throughout, the present findings suggest several avenues for future research. While this study found that counselors respond to patient's R/S statements

| CON CLUS ION
Research shows R/S influence risk perception, decision-making, and coping by patients and families. This exploratory study explored the type of genetic counselor responses to a prenatal patient's deferring and attributing R/S statements in two hypothetical genetic counseling scenarios and the reasons for their responses. Results indicate a wide range of genetic counselors' response types that differed based on the content of the R/S statements, as well as varied reasons given for the responses. Responses did not differ significantly as a function of genetic counselor comfort with R/S discussions or years of experience. The findings reflect genetic counselor stylistic differences in how and why they respond to patients. Given patients also differ, genetic counselors continue tailor their counseling in a person-centered manner and emphasize the centrality of the patient-counselor relationship . Genetic counseling cannot be manualized. We need to find ways to address and incorporate our patients' beliefs into our counseling that are respectful and supportive. As genetic counselors continue in their efforts to address the diverse needs of our patients in a culturally inclusive manner, continued examination through training and research on responses to R/S will ultimately enhance genetic counseling processes and outcomes. All of the authors gave final approval of this version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

AUTH O R CO NTR I B UTI O N S
All authors reviewed and approved the revised and resubmitted manuscript.

ACK N OWLED G M ENTS
This study was completed in partial fulfillment of the requirements of the first author's Master of Science degree from the University of Minnesota, Twin Cities. We would like to thank the genetic counselors who participated in this study.

Alina Sitaula, Patricia McCarthy Veach, Ian M. MacFarlane, Whiwon
Lee, and Krista Redlinger-Grosse declare they have no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data for this study are available upon request from the corresponding author. All data obtained during this study that are relevant to the research questions are reported in the published article, tables, and supplemental material.

H U M A N S TU D I E S A N D I N FO R M E D CO N S E NT
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all participants for being included in the study.