“It's fundamental to the work that we do”: Genetic counselors' perceptions of their role in clients' mental well‐being

The role of a genetic counselor is to assist individuals and their families to comprehend and adapt to genetic information. However, a genetic counselor's role in clients' mental well‐being is unclear. Mental well‐being is an important component of overall health and it can be affected during the adaptation to genetic information. It is, therefore, essential to consider how mental well‐being is viewed in genetic counseling practice. Our research aimed to investigate genetic counselors' perceptions of their role in clients' mental well‐being. Our objectives were to (1) understand what genetic counselors perceived their role to be in clients' mental well‐being and (2) investigate what factors influence genetic counselors' perceptions of practice. We recruited participants via advertisements in the Human Genetics Society of Australasia and the Australasian Society of Genetic Counselors newsletters, and through the Genetic Support Network of Victoria social media. We completed semi‐structured in‐depth interviews with 12 Australian genetic counselors and analyzed the interviews using inductive thematic analysis. We found that genetic counselors viewed clients' mental well‐being as an important and crucial part of their practice. Three key themes were identified, first, all the participants' views of clients' mental well‐being were shaped by personal and professional beliefs. Second, all participants noted that there were factors external to them, such as workplace and professional guidelines, which shaped their role in clients' mental well‐being. Third, all those interviewed noted the boundaries of their professional role in clients' mental well‐being. From these three themes, we determined that genetic counselors see clients' mental well‐being as an integral part of their practice. Our findings add to the extant literature and can shape future practice in this field. Furthermore, we identified how future research priorities could further our knowledge in this area.


| INTRODUC TI ON
Genetic counseling encompasses both physical and psychological aspects of health; in our study, we define it as assisting individuals to comprehend and adapt to both genetic information and the medical, psychosocial, and familial implications of genetic disease (Resta et al., 2006).The role of genetic counselors (GCs) is to support individuals and their families throughout the process of adaptation to genetic information (Resta et al., 2006;Skirton et al., 2015).
In Australia, genetic counseling is mainly accessed through the public healthcare system and genetic services generally sit within large hospitals (Battista et al., 2012;Ormond et al., 2018).Genetic counseling aims to be a patient-centered practice, taking into consideration the physical, mental, and social well-being of the client (Macnamara et al., 2019).Mental well-being, as a component of overall well-being, has been defined variably in the literature (Fusar-Poli et al., 2019;Galderisi et al., 2015;Manderscheid et al., 2010).In our study, we aimed to understand the relationship between clients' mental well-being and genetic counseling, focusing on how GCs perceive their role in supporting the mental well-being of their clients and what factors contribute to their understanding of this.As such, we adopted the World Health Organization's (WHO) (2020) definition of mental well-being as a "state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community."This definition recognizes that mental well-being is dynamic and can fluctuate depending on influences on day-to-day life.
Previous studies have investigated mental well-being in genetic counseling (Macnamara et al., 2019, Meiser et al., 2005& Zurynski et al., 2017).There is a consensus that individuals who perceived their diagnosis negatively were more likely to experience adverse mental well-being affects than those who perceived their diagnosis positively.This potentially impacts the patient's psychological state and could provoke feelings of sadness, anger, and hopelessness.
Similarly, studies by Zurynski et al. (2008) and Meiser et al. (2005) found that the uncertainty of a molecular diagnosis can cause stress and anxiety about the unknown.This in turn could negatively impact an individual's mental well-being.Cunningham et al. (2018) investigated how genetic counseling clients are referred to mental healthcare services, finding that referrals could improve mental stability and positive thinking.Attention to date has been placed on mental well-being outcomes of specific conditions, for example, studies have investigated the psychosocial impact of breast cancers (Butow et al., 2003;Meiser et al., 2002;Randall et al., 2001), hereditary cancers (Walpole et al., 1995;Willis et al., 2017), and rare diseases (Anderson et al., 2013).
Previous research supports our premise that mental wellbeing can be impacted by a client's diagnostic odyssey.Studies by Helm (2015) and McAllister and Dearing (2014)

| Theoretical framework
The study applied a constructivist approach to the research, recognizing the contribution that societal factors and interactions between individuals and communities make to research findings (Sahhar et al., 2013;Tracy, 2010;Wainstein et al., 2022).The study was exploratory in nature, utilizing qualitative research to investigate perceptions of GCs as little is known about this area.

| Context
The Australian healthcare system is divided into the public and private sectors ( Dixit & Sambasivan, 2018).The public sector provides services for free or at a lower cost through Medicare, which is funded by the Australian Government and taxpayers (Calder et al., 2019).The

What is known about this topic
Mental well-being is an understudied area in the field of genetic counseling research.To our knowledge, no published studies have specifically investigated what genetic counselors believe their role to be in supporting clients' mental well-being.

What this paper adds to the topic
Our study found that genetic counselors believe that supporting the mental well-being of their clients is crucial; personal, workplace, environmental, and professional boundaries all influence their practice.majority of GCs practice in the public system, and there are only a small number of GCs who work in private practice or for private healthcare providers in Australia (Battista et al., 2012;Ormond et al., 2018).
To become a genetic counselor in Australia, individuals are required to complete a 2-year Human Genetics Society of Australasia

| Study design
The study was reported according to the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007;Appendix S2).Ethics approval was granted by the Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC 60538).The perceived role of genetic counselors in the mental well-being of clients is a relatively underresearched field Given this, we utilized a cross-sectional, exploratory, qualitative design, using semi-structured interviews.This study design allowed us to undertake an in-depth exploration of GCs' understanding of their role in clients' mental well-being, and understand what factors underlie their views.

| Participants
Given that country-specific factors can influence genetic counseling practice (Abacan et al., 2019;Kenen, 1986), we focused on recruit of Australian-based participants, to understand the experiences of working in Australia.Importantly, we also wanted to understand the impact of the Australian healthcare system and governing bodies on the practice of Australian-based GCs, as this could potentially influence the practice of the participants (Battista et al., 2012;Ormond et al., 2018).Potential participants were excluded if they did not fulfill the inclusion criteria.

| Recruitment
Advertisements about the study were distributed through online newsletters by the Human Genetics Society of Australasia (HGSA), the Australasian Society of Genetic Counselors (ASGC), and the Genetic Support Network of Victoria (GSNV) social media accounts.
The advertisements in the HGSA newsletter and GNSW social media included information about the study, describing that it was a Master of Genomics and Health (The University of Melbourne) student project and to be completed as part of the course.Interested individuals were invited to contact the researcher (MH) to participate.In total, 12 individuals responded to the recruitment advertisements, and all participated in an interview.

| Data collection
We undertook semi-structured telephone interviews between Semi-structured interviews allowed flexibility within the study and gave participants the ability to express themselves freely (Braun & Clarke, 2006;Braun & Clarke, 2014a;Braun & Clarke, 2014b;Kallio et al., 2016;Pope et al., 2000).MH introduced herself at the start of the interview as a Master of Genomics and Health second-year student and included that she was based in Melbourne, Australia.
Due to the COVID-19 pandemic, all interviews occurred remotely over the telephone and from MH's home address.No one else was present at the time of interview and no repeat participant interviews occurred.Positively, this approach to data collection meant that the reach of potential interview participants was maximized as there were no geographical boundaries for interviewees.Interviews were recorded, with participant consent, using a digital audio-recorder.
Notes were taken at the time of interview.Postinterview, conversations were transcribed verbatim and de-identified to maintain participant confidentiality.Transcripts were not returned to participants for comment.All interviews were between approximately 30 and 90 min in length.
Demographic information was collected at the start of the participant interviews.Interview questions included ascertaining years of experience, qualifications, previous work experience, and gender.
Ethnicity was not included as part of the data collection.Participant identifiers were stored separately from the data collected.A deidentified study participant code was assigned based on years of experience (denoted as y), for example, GC3 (5-10 y).Interview transcripts were managed using the NVivo 12 software program (QSR International, 2019).

| Data analysis
There are estimated to be approximately 300 registered Australian and New Zealand GCs (Abacan et al., 2019).Before recruitment commenced, the study team discussed recruitment targets and decided to aim to recruit a minimum of 10 participants to give a representative spread of the views of the Australian genetic counseling population (Francis et al., 2010).We estimated this provisional sample size would provide a complex range of participant experiences to reach data density (Braun & Clarke, 2014b).By the tenth interview, we appeared to be reaching data density as similar themes were identifiable.We continued with the last two interviews to confirm this.
We utilized inductive thematic analysis to identify GCs' perceptions of their role in clients' mental well-being and identify influences that impacted practice.Inductive analysis can be used to generate theories or ideas surrounding new areas of research (Patton, 2005;Thomas, 2006).We chose to use inductive thematic analysis as there was little previous research in this field and inductive analysis allowed us greater freedom to explore the topic (Braun & Clarke, 2006).Coding was completed by one researcher (MH) with regular discussion with the research team.Three transcripts were coded independently by all members of the research team, and discrepancies in coding were resolved.Some transcripts were coded individually.The research team met together regularly during the coding process to discuss difficult points and challenges.Mind maps were developed to present the themes that emerged.Themes were first developed by the researcher MH, then discussed and further developed with the other researchers.

| Recruitment and demographics
Participant demographic information is presented in Table 1, including information on participants' geographic location, level of experience, primary specialization, previous career, GC certification status, and gender.There were participants from all the states of Australia, who had a range of experience although most (n = 7) were very experienced with over 10 years in practice.Previous careers were varied, though more than half (N = 8) had laboratory-based research backgrounds.Most participants interviewed were female (N = 11), this is reflective of the genetic counseling population in Australia, which is a female-dominated industry.

| Inductive thematic analysis: Role of GCs in clients' mental well-being
Based on our participant interviews, we identified three overarching themes which described how GCs understood and experienced their role in clients' mental well-being.The first theme identified was: Internal Influences on Genetic Counseling.We defined this as personal factors that influence GCs' own understanding of their role in clients' mental well-being.This includes GCs' past life experience, view of mental well-being and its significance, and genetic counseling philosophy and training.The second theme identified was External Influences on Genetic Counseling.This theme described factors external to GCs that contribute to how they practice.This encompasses workplace influences including the perceived importance of mental well-being at a service, available workplace resources, and professional development relevant to clients' mental well-being.The theme also explored how the greater Australian healthcare system contributes to GCs' ability to individually support their client's mental well-being.The last theme determined was GC boundaries.This theme encompassed factors that limit the role of GCs in clients' mental well-being, this included the constraints of the role; GCs are not mental well-being healthcare professionals, and mental well-being is always in the context of the genetics of a condition.

Significance of mental well-being in genetic counseling
Through our interviews with participants, we found that the importance GCs placed on mental well-being contributed to how they practised.One participant, GC6 (5-10 y) explained "I strive to factor it [client mental wellbeing] in and make it a big part of the consultation."All GCs who participated in our study believed that clients' mental well-being should be incorporated as an important part of their practice.This is further illustrated by another

Personal view of mental well-being
GCs interviewed were united in their belief that their own personal view of mental well-being contributed to how they supported their clients' mental well-being in their genetic counseling practice.GC1 (20 + y) explained "my background philosophy is that everyone should have a psychologist."Many participants felt the more at ease they were with the concept of mental well-being, the easier it was to support the mental well-being of others.We have used the terminology "certified" and "associate" as this is commonly used among Australian genetic counselors. b We would like to acknowledge that genetic counseling is still a very female-dominated industry.c We note that gender was asked, and participants responded with male or female.
personal mental well-being experiences and their accumulation of counseling skills.
It would be hard for me to tease out whether it's having worked as a genetic counselor or whether it's having gained experience in terms of my own mental health or what my experience is in that sense.

(GC8 [20 + y])
Interaction within the wider healthcare system Additionally, many participants highlighted the broader Australian healthcare system and the mental well-being supports available to the population.This environment and facilities influenced their ability to support the mental well-being of clients.GC3 (5-10 y) made a comparison to the greater healthcare system "we are just one cog in a very complicated machine."Another participant explained their thoughts about the healthcare system: The mental healthcare system in Australia is pretty bad, so it's not my department, it's not the hospital, it's on a bigger level than that which is if you want to get mental healthcare it is really difficult to access and it's expensive as well unless you just go to any public psychiatrist or psychologist.And then it takes forever to go on the wait list, it is really poorly underresourced.It's really hard to say to a patient 'oh, go to your GP and get a mental healthcare plan' and that's all you can do when you know that even then they're probably going to have to pay for things or be out of pocket for things, it's just ridiculous.
(GC10 [10-15 y]) One participant highlighted the struggle between being able to identify mental well-being support services that are available for clients and the ability of their clients to access these services.
With some clients it is difficult to access appropriate support and sometimes that's to do with the health system, and things being difficult to access but then for some clients whatever you do you're never going to meet their needs.So sometimes there can be particular obstructions for the client that're very real, and as a genetic counselor we can't solve that sadly.
They're often systems problems, on the other hand sometimes there are clients that aren't in the space or frame of mind to actually seek the support that they can actually access.

Constraints of genetic counseling role in mental well-being
Many participants reported being aware of the boundaries of their role as a GC.As explained by GC3 (5-10 y) "I'm acutely aware that our skillset lies mostly in the context of the genetic condition."Along with the external and internal influences that shape GCs' perception of their role in clients' mental well-being, participants identified there were boundaries in their responsibility to support clients' mental well-being.
I think it's a very important role, more so in terms of directing them (clients) to access the right support group, the appropriate support group, rather than providing on-going counseling or consultation.I suppose that's probably the big difference between the genetic counseling role and the mental health wellbeing professional; although counseling is part of our profession but the way that's structured, we don't have that ongoing contact with the patient…I think the key goal is to identify that and to point them in the right direction to where they can access it, and then to support them in accessing that.
(GC12 [5-10 y]) I'm not resourced to provide chronic mental health counseling and then in an ongoing fashion, but it's not just because some could argue that's it's a bit of a cop out, the healthcare professional should be doing that but no we're actually not trained for it, there are limitations to the training to the psychology and the counseling and we're not equipped, and I am aware that I am not equipped to do long-term counseling just like I'm not required to be a child psychologist.
(GC11 [5-10 y]) Many GCs noted that supporting ongoing clients' mental wellbeing is not part of their role and that it is instead the responsibility of other healthcare professionals, including mental well-being professionals and general practitioners.
Our role is to assess where our client's mental wellbeing is at when we're counseling and support them during the decision-making process, and if there is a need for follow up to direct them to the appropriate care mental health workers or a GP to get a mental health plan.
(GC10 [10-15 y]) I think it's the role is to be very attuned with what's going on with the clients and being guided by that, because some clients are not interested in enquiring about the emotionality of the test they're having or the results they've been given, but it is your responsibility to assess their mental wellbeing and to take further steps if you feel that intervention is going to be helpful but I do think that some clients just want to get in and get out and you need to respect that as well.Our responsibility to assess and support however you feel that the client is wanting that.Then refer on when necessary, so linking them in with a GP if you know a referral to a psychologist or counselor that the client's open to.

| DISCUSS ION
Our study explored GCs' perceptions of their role in clients' mental well-being and what influenced their practice.All participants believed that clients' mental well-being was an important consideration for the profession though not necessarily the primary focus.Three key themes were identified by our research: (1) internal influencespersonal factors that impacted how GCs practice, with their understanding of the importance of mental well-being influencing their service delivery; (2) external influences-factors outside of the GC including workplace setting and resources which shape the ability to provide appropriate support of mental well-being; and (3) GC boundaries-limitations of the GC role regarding clients' mental well-being as understood by the participants.All of these influences contribute to GCs' role in mental well-being.
As a client's diagnostic odyssey can impact their mental wellbeing (Helm, 2015;McAllister & Dearing, 2014;Vos et al., 2008), it is important for GCs to be aware when additional support is required by clients and to be alert to signals that may indicate that clients have unaddressed mental health needs (Cunningham et al., 2018;Macnamara et al., 2019;Meiser et al., 2005).The participants in our study believed that being aware of mental well-being and mental health issues can lead to better counseling outcomes for clients.This includes building a strong relationship with patients to improve patients' understanding of health information and a better ability to adapt to this information which aligns with seminal genetic counseling training and literature (Arnold, 2014;Coulehan et al., 2001;McCarthy Veach et al., 2007;Myers, 2000;Rogers, 1975).
There were inconsistencies across Australian genetic health services' provision of genetic counseling professional development and resource availability.To us, this suggests that a uniform approach to mental well-being support including GC training and professional development could assist GCs to feel confident in supporting their clients in this area.It could be beneficial for continuing professional development and skills-based training in this area to be regularly and accessibly offered by the peak professional body for GCs thus providing consistent education opportunities to all GCs.Participants raised that their ongoing experiences with mental well-being, including their personal and professional experiences, improved their ability to support clients.We posit that further GC workplace professional development including seminars, lectures, and training sessions from mental well-being professionals alongside reflective supervision could support GCs to further develop their skills in this area.This training could also encourage GCs to draw on their personal mental well-being experiences to bring to their practice, as this emerged from interviews with participants as a valuable addition to GCs' ability to support the mental well-being of their clients.
Fostering reflective supervision emphasizing exploration of issues around clients' mental well-being would further support professional development.
The Australian study by Monohan et al. (2022) describes the use of a psychosocial screening tool, the Genetic Psychosocial Risk Instrument (GPRI), to improve patient outcomes and aid genetic counseling practice.The GPRI was found to be highly acceptable by patients and clinicians.Other studies have also implemented the GPRI tool, including the Canadian study by Esplen et al. (2013) and the Portuguese study by Gomes et al. (2022).Similar tools could be used to add genetic counseling practice going forward in clients' mental well-being.
Previous work experience (Table 1) impacted our participants' current practice and how they supported their clients' mental wellbeing.Promoting diversity in educational and employment backgrounds when selecting candidates for GC training, could enrich the skillset of the profession and deepen competency in supporting clients through the genetic health journey.At the time of this study, we could not identify any previous research that supported this finding; however it has been established that other diversity factors can enhance the genetic counseling workforce (Badman, 2022;Barlow-Stewart et al., 2015;Mittman & Sullivan, 2011).The US study by Mittman and Sullivan (2011), established that there is an underrepresentation of ethnic and racial minorities in the American GC cohort, there is no Australian study published on this topic but it was found in the review of the NSW genetic counseling workforce by Barlow-Stewart et al. (2015), that the Australasian Society of Genetic Counselors (ASGC) survey suggests that there is a similar underrepresentation of ethnic minority groups in the Australian genetic counseling workforce.Another factor that impacts diversity is gender, approximately 95% of the Australian genetic counseling workforce is female (Badman, 2022;Barlow-Stewart et al., 2015).We suggest that previous educational and employment backgrounds would also increase diversity which could enrich the way the GCs could support their clients.Additionally, participants reflected on the ways their own personal mental well-being experiences influenced their practice.They noted that their practice evolved with their life experience and accumulation of counseling skills as they progressed in their GC career.Through our research, it emerged that GCs see their role in supporting their clients' mental well-being to be key to person-centered care and that there are many factors that contribute to providing support in a confident and competent manner.
Participants in our study reflected on the factors external to themselves that impacted how they perceived their role in clients' mental well-being.This included the workplace environment and the workplace's view of mental well-being, resourcing, and the wider Australian healthcare system.The culture of the workplace and the opportunity for mental healthcare access in the wider healthcare system contributed to how well-supported the GCs who participated in this study felt in addressing the mental well-being needs of their clients.Previous research has found that positive mental well-being outcomes, such as decreased anxiety and depression rates, can be improved for clients if their diagnosis is framed in a positive way by genetic counselors (Helm, 2015;McAllister & Dearing, 2014).Further, positive framing of mental well-being by training and professional bodies promotes the consideration of patient mental well-being (Helm, 2015;McAllister & Dearing, 2014).
In the Australian landscape, most genetics services are located within a public hospital setting (Battista et al., 2012;Ormond et al., 2018), and participants noted that their access to funding and resources was dependent on systemic factors.Study participants expressed that some areas of the broader Australian healthcare system were poorly resourced, making it difficult for individuals to access appropriate support.Thus, improved resourcing of the Australian mental health system, and established links between genetic health professionals and mental healthcare professionals could improve GCs' ability to support their clients' mental well-being.
Many study participants reflected on the boundaries around their role in supporting their clients' mental well-being.Participants recognized the specificity of their roles in promoting understanding and adaptation to genetic health information (Resta et al., 2006;Skirton et al., 2015) but that long-term mental health counseling was best provided by referring to mental well-being professionals including counselors, psychologists, psychiatrists, general practitioners, and support groups.Recognizing the limits of one's role and knowing when to refer to appropriate support was a key proficiency in the GCs' practices.We, therefore, feel that it is important to foster links between GCs and mental well-being professionals to maximize access to appropriate support for the clients of genetic health services.

| Study limitations
A limitation of the study was that the sample was self-nominated, it could be possible that individuals who chose to participate had a particular interest in clients' mental well-being, thus potentially creating a cohort bias.Our participants may be more likely to stress the importance of supporting clients' mental well-being than others in the genetic counseling profession, possibly leading to an overrepresentation of its importance in our study.Another limitation of the sample cohort was that all participants worked in the public healthcare setting, only a single participant worked part-time in private practice, meaning it is not known if GCs working in the public sector hold differing views to those within private healthcare.However, given that the majority of Australian GCs work in the public sector (Abacan et al., 2019;Barlow-Stewart et al., 2015;Hoskins et al., 2021) we were able to capture a representative sample of the greater GC population.Another limitation may have been the participants' understanding of the term 'mental well-being' as no formal definition was provided to the participants interviewed, participants' interpretation may have resulted in a differing understanding of the topic.

| Practice implications
Our findings confirm that GCs see their role in their clients' mental well-being to be of importance, and they believe that it is part of their role to support the mental well-being of their clients.We believe that this knowledge can influence future priorities in GC education, with follow-on effects on practice, thereby improving GCs' ability to support their clients' mental well-being.Another practice implication is the importance of self-reflection and reflective supervision for GCs when supporting their clients' mental well-being.Future research with a larger GC cohort could confirm the transferability of our findings about the importance of clients' mental well-being.
We suggest future research focuses on identifying the barriers and enablers which influence GCs when supporting clients' mental wellbeing.This future research could strengthen and solidify the findings from our paper and build on what we know.

| CON CLUS ION
Through our study, we established that GCs place importance in supporting their clients' mental well-being as part of their genetic counseling practice.We identified three key themes contributing to participants' perception of their role in clients' mental well-being: (1) internal influences, (2) external influences, and (3) GC boundaries.
Our study establishes an understanding of clients' mental well-being and genetic counseling.With future research, we hope our findings can inform GC practice, training, policy-making, and research to improve future genetic counseling practice in Australia.

AUTH O R CO NTR I B UTI O N S
MH drafted the manuscript.SB, MdS, and KF revised and made edits to the manuscript.MH, SB, MdS, and KF approved the final version for publication.All authors were involved in the study conceptualization, study design, data collection, and analysis.MH confirms that she had full access to all the data in the study, and all authors take responsibility for the integrity of the data and the accuracy of the data analysis.All 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.

ACK N O WLE D G E M ENTS
This research was completed in partial fulfilment of the requirements for MH's Master of Genomics and Health from the University of Melbourne.The authors thank all interviewees for their participation in the research.

CO N FLI C T O F I NTER E S T S TATEM ENT
Ms Madeleine Harris, Associate Professor Stephanie Best, Dr Michelle de Silva, and Ms Keri Finlay declare that they have no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Additional data to support the findings of this study can be found in the Appendices S1 and S2.Consent was not received to share data more widely.

O RCI D
have shown that balanced framing of a genetic diagnosis by GCs can assist in better adaptation to changes associated with their condition, resulting in higher levels of resilience.Vos et al. (2008) found that during genetic counseling sessions, an individual's own risk perception can affect their experience of genetic counseling.Likewise, McAllister and Dearing (2014) found that clients were more likely to experience positive mental well-being outcomes if they had an awareness of the genetics of their diagnosis, and the implications for them and their families.To our knowledge, no previous studies in the published literature have investigated how GCs see their role in clients' mental well-being and what factors influence their perceptions.As such our research aims to investigate genetic counselors' perceptions of their role in clients' mental well-being.Our objectives were to 1. understand what genetic counselors perceive their role to be in clients' mental well-being 2. investigate the factors that influence genetic counselors' perception of practice in supporting clients' mental well-being.

(
HGSA) accredited Master of Genetic Counseling course.Once completed, individuals can practice as Associate Genetic Counselors (HGSA, 2023; NSW Health, 2021).To become a Certified Genetic Counselor (often referred to simply as a "Genetic Counselor"), individuals are required to complete further training and accreditation administered by the HGSA Board of Censors for Genetic Counseling which is governed by the HGSA Code of Ethics and the Scope of Practice for Genetic Counselors (HGSA, 2023).The accreditation assesses the knowledge, skills, and competency of the individual in a clinical role.
time of recruitment, individuals must have practiced clinically within the last 3 years* to ensure genetic counseling relevancy.*As study recruitment occurred in 2020, this timeframe was between 2017 and 2020.
March and June 2020.Interview guides were developed based on the literature and discussed with the research team genetic counseling experts (KF, MdS) to ensure we responded to the project aims.The interview guide was developed during multiple rounds of discussion by all authors after initial drafting by MH.It was designed to provide a framework for the participant interview without being prescriptive.The interview guide first aimed to understand each interviewee's genetic counseling role, including the length of time as a clinician, their clinical role, and the services at which they were based, and gather demographic information.The next section of the guide addressed the strategies and resources available to genetic counselors if they believed it was their role to support their clients' mental well-being.This included a discussion of strategies available and prompts of what individuals did in past situations.The last major section refers to barriers and enablers that GCs encountered when supporting the well-being of their clients.Prompting questions included positives and negatives, and helpful or useful strategies.The interview schedule is included as Appendix S1 in the supporting information documentation.The interview schedule was pilot tested by MH with MdS acting as a participant.
participant: I believe it's one of the critical roles of genetic counselors to support the mental wellbeing of clients, it's fundamental to the work that we do…I think you should enter every consultation with the belief that you are supporting clients' mental wellbeing… if you walk into the room and don't think that you're doing that, then you're not doing your job.(GC1 [20 + y]) Many participants stated that by understanding their client's mental well-being they were better able to support the needs of their clients.GC9 (5-10 y) explains "I'm always on the lookout for anything that I think might be going on for them mentally and emotionally."Many GCs further stressed the importance of being aware of their client's mental well-being, It is so important to understand and to talk to them [clients] about their mental health history.It helps you to understand what their needs are going to be.(GC2 [20 + y])

I
absolutely think that how comfortable you are with your own mental wellbeing and how comfortable you are with talking about it and all those sorts of personal factors are huge in determining how you respond to others … to provide support in the area of mental wellbeing, you have to be open to the idea of support for mental wellbeing to start with.(GC5 [5-10 y]) Some participants were also able to reflect on how their view of mental well-being may impact their everyday practice, even if this was not positive.I'm challenging myself now as we speak about whether I have come in with some preconceived ideas from my experience growing up in a regional setting where you didn't talk about it [mental wellbeing] …, and whether or not those expectations of how a typical person would behave is what I've brought into it [genetic counseling].(GC7 [15-20 y]) Other GCs reflected on how the way they viewed their role in supporting their clients' mental well-being was influenced by their TA B L E 1 Participant demographic information.

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External influences on genetic counseling Workplace environment and available resources Alongside internal influences, GCs noted the external influences which contributed to how they perceived their role in clients' mental well-being.Many participants discussed how their ability to support their clients' mental well-being was impacted by their workplace and the resources available to them.It's about what's expected at work, what a genetic counselor at my workplace is expected to provide to families and … I guess the support that we're given in order to do that.(GC5 [5-10 y]) Some participants noted that the availability of resources at their workplace impacted their ability to support the mental well-being of their clients.I'm sure there's a lot of clients that we don't assist that we could because of a lack of resources to keep in contact with them, or to offer ongoing support.
TE A M MH (female) is a research project assistant with a Master of Genomics and Health degree.SB (female) is an associate professor and Senior Implementation Research Lead with a PhD.MdS (female) is an Australian Associate Genetic Counselor and Senior Program Manager with a PhD.KF (female) has trained as an Australian Genetic Gounselor and her role is research project officer.SB, MdS, and KF have qualitative research experience.SB and MdS are members of the HGSA and ASGC although MH and KF are not.MH did not know any of the participants before the study although SB, KF, and MdS knew some participants.E TH I C S S TATEM ENTHuman Studies and Informed Consent: Approval to conduct this human subject research was obtained by the Royal Children's Hospital Ethics Board (HREC 60538).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.Informed consent was obtained from all participants for being included in the study.