Assignment 4
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Ethics in Psychological Assessment
Dr. White was contacted by the general counsel of a manufacturing company to do a blind review of the test results of a woman who is making a disability claim against the company. He was provided with the results of her Minnesota Multiphasic Personality Inventory— 2 (MMPI–2) by the attorney, who pointed out that the “fake bad” scale was elevated and that the profile had a high score on the F scale and low score on the K scale. Such scores indicate signs of possible exaggeration, or faking, especially in the context of litigation. The attorney lacked information about how and why the test was administered, but she asked Dr. White to write a brief report stating that the woman is very likely exaggerating her disability. The attorney also indicated that Dr. White’s court testimony would not be necessary— only the report is needed.
Dr. White was experienced in forensic work. He was well aware of the attorney’s obvious attempts to persuade him to state that the woman was exaggerating her disability. However, he was concerned that making such statements in the absence of additional information about the woman and the circumstances of testing would be overreaching and knowingly doing something with the test results that would be deceptive to the court. He informed the attorney of his reservations and withdrew from the case.
http://dx.doi.org/10.1037/12345-009 Essential Ethics for Psychologists: A Primer for Understanding and Mastering Core Issues, by T. F. Nagy Copyright © 2011 American Psychological Association. All rights reserved.
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Introduction
Assessing human behavior with a variety of instruments has long been an important part of psychological work, with standards providing guidance in the very first edition of the American Psychological Association (APA) Ethics Code (APA, 1953a). That edition had three principles concerning assessment—Test Security, Test Interpretation, and Test Publication—and listed eight separate paragraphs, most of which can still be found in some form in the Assessment section of the Ethics Code today (APA, 2010).
Another publication, the Standards for Educational and Psychological Test- ing, a joint venture of the APA, the American Educational Research Asso- ciation (AERA), and the National Council on Measurement in Education (NCME), provides a comprehensive review of the pragmatics and ethics of assessment. It consists of a glossary, three sections (Test Construction, Fairness in Testing, and Testing Applications), and 264 standards (AERA, APA, & NCME, 1999). These standards are prescriptive only; there is no specific entity responsible for enforcement and no consequences for vio- lating them. They promote the highest standards in sound and ethical use of tests and provide optimal criteria for the evaluation of tests, testing prac- tices, and the effects of test use.
Psychological tests are commonly used for four different purposes: (a) diagnosis, as at the beginning treatment; (b) intervention planning and outcome evaluation, such as evaluating a child suspected of having attention-deficit/hyperactivity disorder and planning a course of treat- ment for the child; (c) legal and governmental decisions, such as eval- uating a suicidal patient who wishes to sign him- or herself out of the hospital against medical advice; and (d) personal awareness, growth, and action, helping clients to learn more about themselves. I now dis- cuss how these apply to a variety of patient populations and settings.
Instruments of Assessment and Their Application
Psychological assessment is carried out in a variety of settings with clients and patients of any age who find themselves in many different life situ- ations. These settings include outpatient clinics and private offices of psy- chologists (e.g., diagnostic testing, treatment evaluation), hospitals (e.g., mental health evaluation for organ transplantation, end of life decisional capacity), schools (e.g., assessing learning disabilities), industry (e.g., employment, performance appraisal), the courts (e.g., evaluating capac-
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ity to stand trial, child custody evaluations), and research (e.g., using a broad array of assessment instruments for the study under way, screen- ing out research participants with mental disorders or those inappropri- ate for the study).
The types of psychological tests commonly used by psychologists fall into five categories (AERA, APA, & NCME, 1999). These are (a) cognitive and neuropsychological testing; (b) social, adaptive, and problem behav- ior testing; (c) family and couples testing; (d) personality testing; and (e) vocational testing. I briefly examine each of these categories of tests.
Cognitive and neuropsychological testing is usually carried out by a psychologist who specializes in assessment and provides measures of the following abilities: cognitive ability; attention; motor functions, sensori- motor functions, and lateral preferences; perception and perceptual organization and integration; learning and memory; abstract reasoning and categorical thinking; executive functions; language; and academic achievement. This testing is useful in evaluating patients who have had head injuries, organic brain damage from some other cause, significant learning problems, or pervasive developmental disorders.
Testing for social, adaptive, and problem behavior provides mea- sures of the individual’s ability and motivation to provide self-care and have social relationships with others. This assessment is beneficial for those with mental retardation, dementia, or cognitive deficits that may significantly impair one’s ability to thrive independently.
Family and couples testing provides information about interpersonal relationships, compatibility, shared interests, and intimacy. It is used by couples and family therapists for assessing parents who wish to adopt a child, parents who have remarried and may have problems in their rela- tionships with the stepchildren, or even extended family members who may be living under the same roof.
Personality testing provides information about an individual’s for- mulation and expression of thoughts, attitudes, emotions, and behav- iors. It is commonly used in clinical settings to assist with treatment, in employment settings to assess suitability for work, and in forensic set- tings to assess competence to stand trial and custody issues. The formats of these instruments vary considerably and may consist of asking the test taker to respond to multiple-choice questions (e.g., self-report invento- ries) or placing the client in a novel and partly unstructured situation (e.g., responding to visual stimuli, telling stories, discussing pictures or other projective stimuli).
Vocational testing assesses clients’ interests, work needs, and val- ues and may be used with college students or young adults or with older clients undergoing career transitions. It uses interest inventories; work values inventories; and measures of career development, maturity, and indecision.
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Use of Computers in Testing
Computers have been used for psychological testing for nearly 50 years for the administration of tests, test scoring, and computer-generated interpretations of test results. In 1966, the APA published its first guide- lines for psychologists using computers: Automated Test Scoring and Inter- pretations Practices. By 1986, this document had developed into Guidelines for Computer-Based Tests and Interpretations and consisted of two sections: The User’s Responsibilities and The Developer’s Responsibilities (APA, 1986). These guidelines continued to evolve as psychologists relied more heavily on computers and eventually were absorbed in modified form in the 1999 publication mentioned previously, Standards for Educational and Psychological Testing (AERA, APA, & NCME, 1999).
Competence in the use and application of computers is of critical importance in each area of testing—development, administration, scor- ing, and interpretation. Comprehensive knowledge of the instrument being used and evidence-based clinical judgment about the patient being evaluated are both prerequisites for competently assessing a patient. Psychologists should only use computer-generated interpretive reports for explaining test results with clients when they have a good under- standing of the variables on which the interpretations were derived. Test users should not rely on computer-generated interpretations of test results unless they have the expertise to consider the appropriateness of these interpretations in individual cases. There is no substitute for sound clinical judgment, and test users must understand how to inter- pret conflicting data between test results and personal evaluation of the client being assessed.
Selection and Use of Assessment Techniques
Competent use of assessment techniques is spelled out in a general way by the Ethics Code; psychologists must consider the research and evi- dence of usefulness of a particular test for a particular situation. They must use the right test for the job. A neuropsychologist evaluating an adolescent boy who had a head injury from playing football 6 months previously would carefully select appropriate instruments to evaluate the presence of organic brain damage. If the young man was Latino and his understanding of English was limited, the evaluation should be con- ducted with the assistance of a Spanish-speaking interpreter who is
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familiar with psychological assessment, and a Spanish edition of any printed materials should be used, if possible.
The onus is always on psychologists to use assessment instruments with demonstrated validity and reliability for members of the popula- tion being tested. A newly released instrument for evaluating couples and families that was standardized on a population of Caucasian men and women in the United States may have diminished validity for use with a family who has recently emigrated from Japan.
Administering and scoring tests must also comply with established procedures, with no shortcuts or delegation of these tasks to unqualified persons (e.g., clerical workers or untrained graduate students). Psycho- logical tests are generally meant to be administered by the psychologist on the premises where the psychologist’s office is located in a reasonably quiet, well-lighted, and comfortable setting that is free from distractions. Giving a client a test to take home not only compromises test security but may also increase the likelihood of other factors that could affect performance, such as fatigue (e.g., taking the test late at night), distrac- tions (e.g., going online or talking to others while taking the test), or interruptions that could affect performance (e.g., telephone calls, eating, or drinking alcohol). It also erodes the integrity of the assessment process by allowing the possibility of an individual other than the patient to complete the test unbeknownst to the psychologist.
Informed Consent for Assessment
Before beginning any type of assessment, psychologists must obtain informed consent from the client, whether it is a paper-and-pencil test, structured clinical interview, projective test, behavioral observation, or any other form of personal evaluation. An excellent and concise state- ment from the Science Directorate of the APA reviewing the rights and responsibilities of test takers may be accessed online (http://www.apa. org/science/programs/testing/rights.aspx).
Informed consent normally consists of a discussion with the client in simple language disclosing and explaining the nature and purpose of the test, any fees that must be paid, the fact that feedback about the results will be provided, any involvement of third parties (e.g., using the services of a psychologist specializing in assessment or responding to a court order for psychological assessment), and limits to the usual expecta- tions of confidentiality concerning test results. The limits of confidential- ity change when a client is ordered by the court to undergo assessment, such as in cases of competency to stand trial or child custody evaluations.
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It must be explained to the client in these situations that the psychologist will generate a psychological report based on the assessment procedure and submit it to the court to be used in the ongoing judicial procedures. Clients and patients must also be allowed to ask questions about the anticipated testing and receive answers as a part of the informed con- sent process, and all authorization must be documented as well in the clinical record.
If the client is unable to authorize assessment, either for legal or psy- chological reasons, such as in the case of a child or psychotic patient, then the psychologist must obtain informed consent from a parent or legal guardian before proceeding. The psychologist must also inform those with a questionable capacity to consent about the nature and purpose of the proposed assessment, using nontechnical, reasonably understandable language.
There are situations in which full informed consent is not required, such as (a) when testing is mandated by a court order or governmental regulations (e.g., applying for a government position such as working as a police officer or in the Central Intelligence Agency); (b) when informed consent is implied, as in routine educational, institutional, or organiza- tional activity (e.g., a person voluntarily agreeing to assessment when applying for a job); and (c) when evaluating decisional capacity (e.g., with moribund patients contemplating a choice of medical interventions). However, even in situations described in the first exception, court orders and government regulations, psychologists must inform testees of the nature and purpose of the proposed assessment, although they are not required to provide full informed consent (e.g., disclosures about excep- tions to confidentiality, third-party involvement).
Mr. Hirting, a new client with chronic back pain who was beginning treatment both for pain management and relationship problems with his wife, was asked to undergo testing by his therapist early in treatment. It included the following: (a) The West Haven Yale Multidimensional Pain Inventory to assess the impact of pain on his life, (b) the Melzack Pain Questionnaire to assess the subjective severity and type of pain, (c) the Millon Clinical Inventory to assess psychopathology, (d) the Beck Depression Inventory to screen for the presence of depression, and (e) the Symptom Checklist-90 to evaluate the frequency and intensity of certain cognitions, emotions, behavior, and physical symptoms. The therapist then explained how using such instruments could help with diagnosing and treating Mr. Hirting, likely resulting in more efficient therapy and useful strategies in treatment. The therapist also explained the format of each test— whether it consisted of multiple-choice answers, a rating scale of frequency or intensity, diagrams to be filled in, or open-ended oral questions. Mr. Hirting was then told that the results of the testing would remain confidential, as are all clinical records, with the usual exceptions. He was also informed that the results of the
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assessment would be shared with him, and he was encouraged to ask questions in advance about any aspect of the testing.
If the situation were slightly different and the client not only had a history of chronic pain and marital difficulties but had actually initiated a legal separation from his wife, the confidential- ity disclosure might be different. If the couple should divorce and there was conflict about the terms of custody of the children, it is possible that the therapist’s records of assessing and treating Mr. Hirting could be subpoenaed in the course of resolving the dispute. It would be important to inform him of this possibility because it might affect his decision to proceed with the assess- ment. If he believed that psychological testing might reveal personal deficits that could weaken his role in custody litigation and reduce his chances of obtaining custody of his children, he might choose to delay the testing and only proceed with psycho- therapy at this time.
Basis for Assessments and Explaining Assessment Results
Psychologists are required to use current editions of tests and base their findings and recommendations on current test data of clients and patients. Psychologists generally must not rely on obsolete editions, outdated mea- sures, or evaluations of clients that may no longer be valid because so much time has past since the assessment was completed.
They also have an obligation to interpret and explain assessment results to their clients, whether they score and interpret the tests them- selves or use computer narrative printouts or other automated services. When doing so, they must take into account a variety of factors that could influence the results, including (a) the situation, (b) the milieu, and (c) personal attributes and the language of the client being tested. Situational factors include such things as the purpose for taking the test (such as a voluntary vocational test battery, a timed aptitude or intelli- gence test, a mandated personality assessment by a court, an optional evaluation at the outset of treatment, or employment screening for a new job). The testing milieu includes lighting, ambient noise, use of a computer for test administration, the physical presence of others (such as in group testing), or other distractions that could influence the out- come. Personal variables can also influence the validity of a test and should be addressed in advance and in providing interpretations later; these include physical disability, reading level, test-taking ability, lan- guage (English as a foreign language), and culture (using a personality test for a Vietnamese immigrant only if the test has been standardized for that culture).
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Psychologists’ opinions in formal recommendations, reports, diagnos- tic or evaluative statements, and forensic testimony must be based on suf- ficient information and assessment techniques. Psychologists must always disclose when the validity of the assessment might be diminished, as with the personal factors listed previously with the Vietnamese client.
Another example is the forensic psychologist who is testifying about the parenting ability of a lesbian woman based solely on the psychologist’s extensive review of the woman’s psychological tests performed by another psychologist but not including a personal evaluation of the woman by the psychologist him- or herself. In such a situation the psychologist would clarify the likely impact of limited information (e.g., failure to personally evaluate the woman) or situational factors that would affect the reliabil- ity and validity of his or her opinions, and the psychologist must also exer- cise caution about his or her formal conclusions and recommendations. Hunches and opinions not based on the assessment data must always be identified as such. A psychologist may harm patients by giving opinions that are not sufficiently based on well-established assessment techniques, such as testifying, drawing conclusions, and making recommendations on the basis of data from an unvalidated or obsolete test. This could impact major aspects of a client’s life, such as competency to stand trial or eligibil- ity for long-term disability compensation.
Dr. Palmer had recently stopped doing clinical work and was transitioning to doing fitness-to-work evaluations for employees of a company. He was offered a contract if he could do them at a cost that would include a 2-hour interview and administering the MMPI–2 and the Millon Multiaxial Clinical Inventory—III (MCMI–III). After he agreed, the employer indicated that a substance abuse evaluation also needed to be included and asked Dr. Palmer about his expertise in this area. Dr. Palmer stated that in past years he had done many substance abuse evaluations but recently he had been referring those evaluations to others. His employer said that would not be possible but noted that their last evaluator relied on the McAndrews scale on the MMPI–2 and the alcohol and drug dependency scales on the MCMI-III plus some interview questions to “get the job done.”
Dr. Palmer realized that he should “beef up” his experience in substance abuse assessment because some collateral interviews were really needed. It would not be sufficient to rely on the original protocol suggested by the employer to provide a valid assessment of the employee (G. Schoener, personal communication, August 13, 2009).
In this situation a psychologist evaluated himself as no longer being competent in a certain area of assessment, even though his employer was willing to cut him some slack and get the job done by simply throwing in a few interview questions and relying on the objective testing subscales. Dr. Palmer knew that he needed additional training to once again be competent in evaluating those with substance abuse as well as to conduct
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collateral interviews with family members and fellow employees who have observed the candidate’s behavior.
Release of Test Data
Since 2002, the Ethics Code has permitted clients and patients to have access to their own test data. These data include raw and scaled scores, their responses to test questions or stimuli, and psychologists’ notes and recordings concerning client statements and behavior during an exam- ination. However, psychologists may refuse client access to protect a client or others from significant harm, misuse, or misrepresentation of the data. A client with borderline personality disorder who has only been in treatment for 2 weeks may not be emotionally prepared to view her entire psychological report; she may feel demeaned, criticized, angry, and hopeless if permitted to read it in its entirety at such an early stage of treatment, before diagnosis has even been discussed. Also, in recent years in the legal arena there has been an increase in the use of psycho- logical data, such as in child custody litigation and criminal lawsuits. In these situations the court may order the plaintiff or defendant to have a psychological evaluation to determine his or her mental status, with the psychologist’s report then being entered into evidence (e.g., a “not guilty by reason of insanity” defense).
State and federal laws may also have a bearing on clients’ rights to their own test data and psychologists’ rights of refusal. The Health Insurance Portability and Accountability Act of 1996 privacy rules also address this topic and may preempt the ethical standards under certain conditions.1
Assessment by Unqualified Persons
Test publishers normally sell psychological tests only to licensed men- tal health providers, and psychologists are ethically bound to only pur- chase and use tests for which they have the competence and training to
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1According to the Health Insurance Portability and Accountability Act, a psychologist may only deny clients or patients access to their own test data if it is reasonably likely to endanger the life or physical safety of the individual or another person or cause equally substantial harm. Those denied access also have the right to have a denial reviewed by a designated licensed health care professional in hopes of reversing the denied access.
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administer, score, and interpret. A psychologist may be licensed to prac- tice but rusty in his or her training and current research on, for exam- ple, the Rorschach Test. Although technically qualified to administer and score this test, the psychologist would be more compliant with the spirit of the ethical rules concerning competence if the psychologist updated his or her skills and reviewed current research in this area.
Psychologists also have a responsibility to refrain from promoting the use of psychological assessment techniques by those who are not sufficiently trained or proficient. This includes delegating test adminis- tration or scoring responsibilities to a clerical helper or receptionist who is obviously not licensed or qualified to practice psychology. It might also include the gray area of predoctoral or postdoctoral psychological assistants whom the psychologist is supervising but who lack sufficient training or basic understanding of the assessment process. Examples are the psychologist who gives supervisees too much independent respon- sibility for the informed consent of clients at the outset, for administer- ing the test itself, or for scoring as well as the psychologist’s failure to properly review a psychological report written by a supervisee before it is filed. Of course, psychologists must limit their own use of assessment procedures, as well, if they lack competence. The following vignette includes issues of competence, multiple roles, and assessment.
Dr. Brown is a child psychologist in a county hospital who specializes in the diagnosis and treatment of Asperger’s syndrome. One day the chief of the psychiatry department, a friend of Dr. Brown’s who is involved in a custody battle for his children, mentioned to Dr. Brown that he was worried that his ex-wife is “poisoning” his daughters against him and asked if an evaluation might be able to provide evidence to that effect. Dr. Brown stated that this was possible, although he has never actually performed a custody evaluation before. The chief then asked Dr. Brown to interview the chief’s daughters in addition to carrying out psychological testing; the chief then informed Dr. Brown that he would not be able to interview the chief’s ex-wife because she was not being cooperative. Dr. Brown decided to perform the assessment to see what would be revealed, believing that he could ethically offer the disclaimer in his psychological report that his findings might have a limitation because only the girls and the father were assessed (but not the mother).
It is significant that although Dr. Brown had never performed a custody evaluation before, he held the misimpression that he could perform a valid assessment in this complicated situation and write an objective and valid report that might be used later by the chief’s attorney in pleading his case. It is also significant that Dr. Brown had entered into a multiple-role relationship by agreeing to assess someone with whom he already had several preexisting relationships (friendship and employee–employer
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relationship). By so doing, he exposed his psychological work to being challenged by his ex-wife’s attorney and possibly undermined the strength of his friend’s legal case as well. He would have been wiser just to say no to his friend and refer him to a psychologist experienced in these matters.
Test Security
Psychologists must be responsible stewards of the tests that they own and use. This means that they must protect test instruments, protocols, questions or stimuli, and manuals from unauthorized access and use. The reason for this is to protect future clients and patients from learn- ing the actual test questions and items, which would provide them with opportunities to prepare for psychological assessment so that they could influence the outcome, whether in school settings, litigation, employ- ment situations, or anywhere else.
Psychologists must comply with the instructions in the manual con- cerning test administration, even though they may be tempted at times to gratify a patient’s request on the basis of convenience or expediency. Giving an outpatient a copy of the MMPI to take home and complete whenever the patient feels like it not only permits him or her to consult with others while answering but also compromises test security, allow- ing the person to photocopy test items or even distribute them over the Internet. Discussing and revealing test items to a newspaper or television journalist in the course of a media interview about psychological assess- ment would also compromise security and could ultimately affect the usefulness of the test in the future.
There are situations in which test data and records may be subject to a subpoena or court order as a consequence of litigation concerning a patient’s mental health or competence. This includes such situations as guilt or innocence in a criminal proceeding, a patient’s lawsuit against a third party (e.g., a former employer), child custody litigation, a mal- practice action against the treating psychologist, or any legal action in which the patient’s mental status is at issue. A psychologist must release a copy of the client’s test data to him or her if requested to do so. This is consistent with the rights of clients and patients as articulated by federal law (the Health Insurance Portability and Accountability Act). However, the psychologist may usually protect the security of the copyrighted test materials by not releasing them, unless, of course, with certain tests the answer sheets or psychologist’s notes that are being requested are com- bined with the test questions themselves.
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Test Construction
Psychologists developing tests, structured clinical interviews, question- naires, or other assessment techniques that they intend to promote for clinical settings, educational settings, management consulting, forensic settings, or other professional settings are obliged to follow certain prin- ciples of test construction. These principles include a working knowl- edge of psychometric procedures and current scientific or professional knowledge for test design, standardization, validation, reduction or elim- ination of bias, as well as recommendations for use.
It would be unethical for a psychologist to develop and use his or her own inventory or personality questionnaire with his or her psychother- apy clients and patients and falsely promote it as a “standardized instru- ment” if the psychologist did so without regard for well-established principles of test construction. This might particularly be problematical if a psychologist were to publish his or her unvalidated test in a self-help book, release it to the media, or place it on his or her website for public access and use.
It is useful to consider the psychologist who creates a test to measure whether an individual or his or her spouse has repressed memories about childhood physical abuse but does not adhere to known principles of test construction. As mentioned previously, it is an ethical require- ment that any valid assessment instrument, including one purporting to uncover early childhood trauma, adhere to the standard principles of test construction and be administered in a standardized way, not online or in the media. The therapist developing such a test for self-diagnosis or spouse diagnosis exposes the public to the risk of false positives as indi- viduals “discover” that they supposedly have been traumatized in their childhood, when, in fact, this was not the case, and as they conclude that they therefore needed treatment. This area is fraught with misinforma- tion, clinical implications, and ethical and legal risk. For some, merely taking and scoring this test could result in clinical symptoms of anxiety or depression or exacerbate psychological symptoms already present.
From both a clinical and scientific point of view it would be irre- sponsible, at best, and harmful to the public, at worst, to develop such a test solely on the basis of the therapist’s experience treating survivors of childhood abuse. In either case, such a course of action would be con- trary to the standard concerning test construction, standards involving competence (requiring psychologists to base their work on established scientific and professional knowledge of the discipline), as well as Prin- ciple A: Beneficence and Nonmaleficence.
People who are assessed by psychologists fill a variety of roles— students, clients, patients, candidates for employment, defendants in legal
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situations, parents in custody evaluations, moribund inpatients for deci- sional capacity, and many others. It is the psychologist’s privilege and duty to honor the trust placed in them by creating and using tests in a fair and competent manner. Sound assessment practices set the stage for better interventions in business settings, schools, court rooms, and therapy offices. Chapter 10 focuses on the treatment setting and the ethical pitfalls and abuses that can spontaneously present themselves as a result of the power differential between therapists and their patients inherent in the setting.
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