Motivational interviewing for genetic counseling: A unified framework for persuasive and equipoise conversations.

Genetic counselors (GCs) have traditionally been trained to adopt a position of equipoise or clinical neutrality. They provide information, answer questions, address barriers, and engage in shared decision-making, but generally, they do not prescribe a genetic test. Historically, GCs have generally been trained not to persuade the ambivalent or resistant patient. More recently, however, there has been discussion regarding when a greater degree of persuasion or directionality may be appropriate within genetic counseling (GC) and what role MI may play in this process. The role for “persuasive GC” is based on the premise that some genetic tests provide actionable information that would clearly benefit patients and families by impacting treatment or surveillance. For other tests, the benefits are less clear as they do not directly impact patient care or the benefits may be more subjective in nature, driven by patient values or psychological needs. For the former, we propose that GCs may adopt a more persuasive clinical approach while for the latter, a more traditional equipoise stance may be more appropriate. We suggest that motivational interviewing (MI) could serve as a unifying counseling model that allows GCs to handle both persuasive and equipoise encounters. For clearly beneficial tests, while directional, the MI encounter can still be non-directive, autonomy-supportive, and patient-centered. MI can also be adapted for equipoise situations, for example, placing less emphasis on eliciting and strengthening change talk as that is more a behavior change strategy than a shared decision-making strategy. The core principles and strategies of MI, such as autonomy support, evocation, open questions, reflective listening, and affirmation would apply to both persuasive and equipoise encounters. Key issues that merit discussion include how best to train GCs both during their initial and post-graduate education.http://deepblue.lib.umich.edu/bitstream/2027.42/175846/2/Motivational interviewing for genetic counseling A unified framework for persuasive and equipoise conversations.pdfPublished versio

Associations, active citizenship, and the quality of democracy in Brazil and Mexico

In many Third Wave democracies large classes of people experience diminished forms of citizenship. The systematic exclusion from mandated public goods and services significantly injures the citizenship and life chances of entire social groups. In democratic theory civil associations have a fundamental role to play in reversing this reality. One strand of theory, known as civic engagement, suggests that associations empower their members to engage in public politics, hold state officials to account, claim public services, and thereby improve the quality of democracy. Empirical demonstration of the argument is surprisingly rare, however, and limited to affluent democracies. In this article, we use original survey data for two large cities in Third Wave democracies-So Paulo and Mexico City-to explore this argument in a novel way. We focus on the extent to which participation in associations (or associationalism) increases "active citizenship"aEuro"the effort to negotiate directly with state agents access to goods and services legally mandated for public provision, such as healthcare, sanitation, and security-rather than civic engagement, which encompasses any voluntary and public spirited activity. We examine separately associationalism's impact on the quality of citizenship, a dimension that varies independently from the level of active citizenship, by assessing differences in the types of citizenship practices individuals use to obtain access to vital goods and services. To interpret the findings, and identify possible causal pathways, the paper moves back-and-forth between two major research traditions that are rarely brought into dialogue: civic engagement and comparative historical studies of democratization