“What would you do if you were me?” I often hear this question as a genetic counselor practising in Oman, and I am sure many colleagues in the Middle East and beyond do as well. In such cases, I am often torn between my training in nondirective counseling and the patient’s clear request for guidance. Although I aim to stay neutral to support autonomous decision-making, my clients often seek more than just information. They are clearly looking for guidance. This recurring experience has made me question whether nondirectiveness as we know it truly addresses clients’ needs in my cultural context.

Nondirectiveness is an important principle in genetic counseling influenced by the work of Carl Rogers and client-centred care. Its purpose is to protect autonomy and avoid coercion by presenting information in a neutral way, allowing individuals to make their own decisions. However, as genetic counseling expands across different cultures, it is important to reconsider how this principle is understood and applied in practice.

Although nondirectiveness is frequently portrayed as a universally appropriate approach, it is more relevant to particular cultural ideas about autonomy, decision-making and the role of health care providers. In many Western settings, autonomy is understood as an individual’s right and responsibility to make independent decisions. In contrast, in some Eastern settings, decisions are often shared and influenced by family, trust in clinicians, culture and religious values. In such contexts, guidance is not seen as a threat but rather as an expected and valued part of care. A strictly nondirective approach can sometimes feel less like empowerment and more like a lack of support. This makes me wonder if our current approach truly supports our clients, or if we are not showing up for them as they make difficult decisions.

I came to realize that the expectation of guidance is not only cultural but also somehow rooted in religious understanding. In a discussion about decision-making with a group of friends, one mentioned that she would always consult a knowledgeable expert when faced with uncertainty, referencing the Qur’anic verse: “فاسألوا أهل الذكر إن كنتم لا تعلمون ” (“Ask those of knowledge if you do not know”). To her, asking for guidance is not about giving up autonomy, but about using it to seek help from someone who knows more when things feel complex or unclear. 

This becomes even more apparent in contexts such as prenatal diagnosis and decisions around termination of pregnancy. In many Middle Eastern contexts, where Islam is the main religion, these decisions are not based on personal preference alone but are guided by Islamic bioethical principles. You often see patients and families not only seeking medical information but also seeking clarity from religious authorities on what is religiously acceptable. In such situations, the decision is not based on a neutral presentation of possible options but is instead defined by a religious framework. If we strictly use a nondirective approach, it will not fully explore the ethical and religious considerations that are important to the decision-making process.

Nondirectiveness has been challenged for years, as it is argued that counselors can influence clients through framing, tone, and emotional responses (Kessler, 1980). More recently, this topic has been explored closer to home by professionals in the Middle East, with Almarri et al. (2025) describing how genetic counseling is influenced by sociocultural and religious factors, with practitioners often using a semi-directive approach. Decades apart, these articles show that the role of nondirectiveness remains a relevant topic for discussing how we can best support clients in making complex genetic decisions.

Rather than choosing between directive and nondirective counselling, a guided nondirective approach could allow us to respect autonomy while recognizing that it is expressed differently across different cultural and religious contexts. In practice, this might involve actively exploring their preferences regarding guidance, examining the values that shape their decisions and adjusting the level of support accordingly. For some, this could mean providing space for independent decisions. For others, it might involve offering more structured guidance or sharing a professional perspective when invited. 

What is important is that the guidance given will be based on the client’s values and priorities, not the counselor’s perspective. Decision-making becomes a collaborative process that respects autonomy while recognizing the cultural and ethical contexts in which decisions are made. The aim of guidance is not to tell clients what to do but to help them consider what matters most to them. 

Going back to the question “what would you do if you were me?”, the real challenge is not whether we answer it but how we interpret it. In many cases, it is not giving up autonomy, but instead it shows a need for support, reassurance and guidance within particular cultural settings. 

As genetic counselling continues to expand globally, there is a valuable opportunity to revisit how core principles like non-directiveness are applied across different settings. There is a clear need for further research into how culturally and religiously informed approaches can be meaningfully integrated into practice. I welcome discussions and collaboration in this area to develop models of care that reflect the realities of the communities we serve.

References

Almarri, H. J., Koodakkadavath, S., Rahma, A. T., & Al Saffar, M. (2025). Voices in practice: Exploring genetic counseling ethical, cultural, social, and religious dynamics in the UAE. Journal of Genetic Counseling, 34(6), e70139. https://doi.org/10.1002/jgc4.70139

Kessler, S. (1980). The psychological paradigm shift in genetic counseling. Social Biology, 27(3), 167-185.

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