Ethical Issues Relevant to Assessment by Kourtney J. Gorham
University of Regina
EPSY 829: Ethics and Professional Practice
The skillset and knowledgebase of psychologists is highly respected within our society, with psychological assessment often earning the highest regard (Koocher & Rey-Casserly, 2003; Turchik, Karpenko, Hammers, & McNamara, 2007). The testing business was estimated to be a 400 to 700 million dollar industry in the early 2000s and it continues to grow (Clarke, Madaus, Horn, & Ramos, 2001; Public Broadcasting Services (PBS), 2002). Psychological assessments are tools that help psychologists derive objective information about an individual’s abilities, weaknesses, interests, learning capacities, and potential diagnoses. Psychological assessments differ from informal tests and online measures because they include an in-depth assessment of the person through the referral question(s) asked and require specific procedures for how the test is managed and scored by a qualified professional (Naglieri et al., 2004). However, ethical issues can occur when the assessment is not used as intended. In these instances, the measure may overshadow the individual being assessed and/or fail to answer the referral questions (Adams & Luscher, 2003; Turchik et al., 2007). Psychologists need to use clinical judgement when deciding when and if to assess and determine if psychological assessment will lead to intervention and support rather than simply a number or score on a report.
Koocher and Rey-Casserly (2003) noted that psychological assessments can have both a negative and positive impact on people. Negative outcomes may include diagnostic labels, unanswered questions, legal trials, job loss, university admission challenges, and wait-times for assessment and services (Evans, 2011; Koocher & Rey-Casserly, 2003; Michaels, 2006). Furthermore, assessment can impact how the client views themselves and is viewed by others; stigmas and negative judgements may be formed (Michaels, 2006). Take, for instance, the misinterpretation of diagnostic labels, test scores, Intelligence Quotients (IQ), and personal descriptors that can find their way into conversations and formal documents, such as an Inclusive Intervention Plan in the school setting (Michaels, 2006). Unfortunately, both laypersons and professionals may misinterpret psychological assessment and this can negatively impact a person’s life course. It becomes easy to reduce someone to a score on a psychological report and forget the human and personal factors not accounted for in formal testing.
However, while there are negative aspects to psychological assessment, there are also many benefits. If a person is properly assessed this will increase their self-awareness about what is going on and thus, their ability to advocate for the services and supports they need. While a diagnosis can lead to a label, it also ensures that evidence-based resources, supports, and interventions are being used. Assessment also acts as a tool to determine and validate who gets certain supports in our school systems and other social programs (Dombrowski & Gischlar, 2014). It acts as a concrete way to determine funding and can connect individuals to much-needed outside agency supports.
Because psychological assessments
have both negative and positive impacts on individuals, we can view them as
being both ethical and unethical. Koocher & Rey-Casserly (2003) note the
importance of considering all ethical aspects before, during, and after
assessment. While this is no small feat, by using the ethical standards set
forth by the Canadian Psychological Association’s Canadian Code of Ethics for Psychologists (2017) and the Saskatchewan
College of Psychologists’ Professional
Practice Guidelines (2010), psychologists in Saskatchewan can ensure they
avoid ethical issues related to competency, informed consent, and
confidentiality when assessing clients.
Competency is the area of expertise that a psychologist has developed through their education and supervision, as well as their own professional development pursuits (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003). Standards II.6 and II.9 of the Canadian Code of Ethics for Psychologists (2017) highlight that a psychologist must work within their area of competency (CPA, 2017). Thus, when it comes to assessment, a psychologist must first assess their own capabilities before working with the client. Self-assessments of competency also must include up-to-date knowledge of testing psychometrics. A psychologist must be trained in assessment selection, procedures, scoring, and interpretation as per the standards set forth by the Canadian Psychological Association (2017) and the Saskatchewan College of Psychologists (2010) (CPA II.9; SK 14.2). In general, a knowledgebase in validity, reliability, norms, standardization, standard error of measurement, false positives and negatives, sensitivity, specificity, test specifications, and convergent validity of multiple assessments (Adams and Luscher, 2003; Evans, 2011) is required in the broad sense and specifically in regards to each specific assessment measure to be used. Psychologists must critically select tests by weighing the pros and cons and researching them beyond the publisher’s self-reports (Evans, 2011; Koocher & Rey-Casserly, 2003).
Psychologists need to assess their own bias when selecting tests, especially when working for agencies that may prefer one assessment over another due to financial or accessibility reasons (Koocher & Rey-Casserly, 2003). Turchik et al. (2007) note that tests are frequently updated and this may cause financial barriers. There is a cascade of costs if multiple kits, testing forms, and computer interpretation programs are required or the agency serves a wide variety of needs. Furthermore, one measure may not be sufficient (Adams & Luscher, 2003). The Professional Practice Guidelines (2010) highlight the need to use the most recent edition of assessments (SK 14.5).
Both Koocher and Rey-Casserly (2003) and Simner (1994) argue that if a psychologist is not trained in testing psychometrics than they cannot critically judge the test features and thus its applicability to the situation, referral question(s), and individual. The Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) note that test selection is done on a case-by-case basis, using methods that are valid to the population and questions sought (CPA II.13; CPA II.18; SK 14.3; SK 14.4). This requires careful consideration that the client’s language, race, educational level, culture, and age match the norm group, as well as the adequacy of the instrument to meet the identified need (Koocher & Rey-Casserly, 2003). It is important to note that, an assessment can be psychometrically sound but fail to meet the client’s needs and/or answer the referral question(s) (Adams & Luscher, 2003). In many cases, multicultural groups and those with disabilities have been left out of the norm groups. While adaptations can be made and reported on to accommodate this as per standard 14.3 (SKCP, 2010), these adaptations need to be reported and cannot impact the overall validity of the test (Koocher & Rey-Casserly, 2003). For instance, an interpreter or nonverbal measure may be used if a person speaks a different language but it is important to ensure comprehension of the questions asked, fidelity to the questions asked, and that the measure itself is being tested versus language (Evans, 2011; Koocher & Rey-Casserly, 2003). The Canadian Code of Ethics for Psychologists (2017) includes standards on respecting others regardless of these differences (CPA 1.1) and evaluating our own biases (CPA III.15). Ensuring our own competency and the applicability of an assessment measure is one way to ensure that these standards are met.
Informed consent is a shared decision-making process that starts from the outset and continues throughout the professional relationship (Barnett, Wise, Johnson-Greene, & Bucky, 2007). From a legal standpoint, the client must give consent voluntarily and they must comprehend and thus, have the capacity to do so (Barnett et al., 2007; Evans, 2011). This is represented in the Canadian Code of Ethics for Psychologists (2017): consent must be voluntarily given (CPA I.27), all the information that a reasonable person would need to make an informed decision must be shared and updated throughout the process (CPA I.23; CPA I.25), and the information must be presented at an attainable level for all involved (CPA I.24). From the outset, Simner (1994) recommends that the client(s) receive honest information about what the assessment process can reasonably uncover. Adams and Luscher (2003) stress the need for written and oral language that matches the client’s level of understanding. The informed consent piece is vital to ethical assessments from the outset because it allows reasonable expectations to be set, clarification of the referral questions and goals, and can be telling of the client’s desires and hopes of assessment.
Assessment of minors poses an additional challenge because minors are often referred by third-parties, such as school teams and caregivers (Koocher & Rey-Casserly, 2003). In these instances, it is the caregivers who provide consent (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003; Tan, Giovanni, Passerini, & Stewart, 2007). The Canadian Code of Ethics for Psychologists (2017) states that consent is granted from caregivers of children (CPA I.34), but active participation occurs from all involved (CPA I.19) and clarification of multiple relationships, such as third-parties (CPA I.26), is carefully established so that the psychologist knows who to serve. When it comes to assessing children, psychologists need to determine who the client is – for instance, the caregiver who pays the fees, the child who is being assessed, or the school who requires the assessment results for placement decisions – and if the goals of all parties involved align (Koocher & Rey-Casserly, 2003). Further challenges include determining if the child understands what they are consenting to (Adams & Luscher, 2003) and ensuring that they have not being coerced intentionally or unintentionally by the adult influences in their life. For psychological assessment to be ethically conducted on children, it is essential that the psychologist does not allow third-party desires to result in assessment bias (Koocher & Rey-Casserly, 2003). Adherence to the informed consent codes can help psychologists ethically conduct assessments of minors.
Confidentiality is the client’s right to privacy and autonomy. Michaels (2006) noted that assessment may uncover information that did not relate to the original purpose. There may be pressure to disclose additional information gathered to the school team (Bhola & Raguram, 2016) and pressure to change results when they are not favorable or as expected (Koocher & Rey-Casserly, 2003). In these instances, the psychologist must use clinical judgement to determine what to share and include in the report. The Professional Practice Guidelines (2010) indicate that the psychologist must work directly with the client and they are responsible for accurate interpretations based on up-to-date information, even when computer interpretation programs are used (SK 14.6; SK 14.7; SK 14.9). Koocher & Rey-Casserly (2003) also note the importance of ensuring tests were appropriately scored – especially when using computer-automated tools – and noting any limitations. Any modifications, such as errors, changes to the release of information, and omission of data that is unnecessary to share, should be noted and corrected (Koocher & Rey-Casserly, 2003). In any case, reporting should be clear and objective with a strengths-based style to ensure minimal harm to the client (Michaels, 2006). The results must be accurately reported, even when unfavorable. Tranel (1994) and Knauss (2001) recommend that when reporting results, assume anyone can read it, including the legal system, to avoid unprofessionalism and opinion-based reporting. The Canadian Code of Ethics for Psychologists (2017) is clear that the reports must be objective (CPA III.10), related only to the questions sought (CPA I.37), and regardless of the communication mode, information must be shared in a way that respects the client’s right to privacy (CPA I.41).
It is important to consider testing factors when interpreting and reporting on assessment results. Threats to internal validity must be considered, such as testing effect, maturation effect, or statistical regression effect (Neuman, 2011). External and internal factors, such as being tired, hungry, or bored, may impact a child’s performance. Furthermore, the relationship with the psychologist may not be adequate in the child’s opinion and they may not feel comfortable or able to do their best. They may perform poorly due to lack of exposure versus cognitive deficits. These factors can affect overall results and are harder to track with high-risk populations, such as children (Flanagan, Sotelo-Dynega, & Caltabiano, 2010; Russell, Norwich, & Gwernan-Jones, 2012). Tranel (1994) notes that, along with the test findings, applicable diagnoses, and relevant recommendations, a report should include background history and the setting and environmental factors noted during testing. Koocher & Rey-Casserly (2003) recommend noting any testing behaviors in the final report that may better explain the results. In fact, psychological assessment differs from other measures by how meaning is derived through accurate administration and interpretation of all relevant factors (Jacob-Timm, 1999; Knauss, 2001), including testing conditions.
Assessment reporting has both confidentiality and informed consent considerations. As per the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010), it is the psychologist’s job to ensure understanding, highlight opinions in an unbiased and professional manner, and explain the assessment in a variety of culturally-appropriate ways for all parties involved (CPA II.20; CPA II.32; SK 14.1; SK 14.8). Unfortunately, often when assessing children the information is more likely to be shared with the caregivers and school team without including the child. In addition, this information can be hard to understand. Tranel (1994) notes that scores, taken out of context, have no meaning. Furthermore, reports and technical terms are not always accessible to caregivers and educators even after explanations are given. This creates an ethical challenge because the caregivers and educators are the ones who will likely be implementing the strategies with the child and need to understand the results, including what the scores and percentile ranks mean (Flanagan et al., 2010; Lefaivre, Chambers, & Fernandez, 2007). Furthermore, it is of the highest ethical standard to ensure that recommendations are being followed. An ethical challenge occurs when caregivers do not follow-through with recommendations in reports, such as not attending a doctor appointment or attending family counselling, after the psychologist has made the referral.
Another area of consideration includes keeping the tests themselves confidential. If a client has been pre-exposed to testing materials, including from previous versions of the test, this causes an internal threat to validity through testing effect and diffusion of treatment (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Neuman, 2011). LoBello & Zachar (2007) found 82 psychological tests for sale on Ebay during a three month period; unfortunately, 48% had no restrictions on buyer credentials and many of the sales showed pictures of test materials that could be compromising. Similarly, Tranel (1994) found that test manuals that should only be available to licensed psychologists were accessible in bookstores and online sales. This can also become an ethical issue if tests are not disposed of appropriately (LoBello & Zachar, 2007) or if reports or tests are photocopied and/or left behind after a meeting. Adams and Luscher (2003) note that in order to protect assessment validity, clients should never take test materials home. Furthermore, assessments should be stored securely as per standard I.41 (CPA, 2017).
Psychologists may be pressured to release reports to third parties, such as schools, caregivers, insurance providers, and the legal system. This can be particularly challenging in regards to the legal system because the laws and ethics often clash and all information, scores, and notes can be subpoenaed (Koocher & Rey-Casserly, 2003; Tranel, 2003). When psychologists have client’s assessments subpoenaed these materials need to be sealed after the trial and may require publishers to fight copyright on their own behalf (Koocher & Rey-Casserly, 2003). Assessments should only be interpreted by a licensed psychologist to ensure minimum harm to the client due to copyright issues and proper interpretation of raw scores (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Michaels, 2006; Tranel, 1994). Both the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) are clear that we need to protect the physical tests and methods used (SK 14.10) and testing techniques and interpretations from being misused (CPA IV.11).
The Canadian Psychological Association’s principles – Respect and Dignity of the Person, Responsible Caring, Integrity and Relationships, and Responsibility to Society – need to be at the forefront of our assessment practices. Psychological assessment can be challenging to do ethically; Kirby et al. (2009) note that only 16% of individuals receive an accurate diagnosis and out of those with an accurate diagnosis, only 16% of adults and 10% of children receive adequate supports (as cited in Mash & Wolfe, 2019). However, there are both positive and negative outcomes of psychological assessment and thus, it is not a practice we can simply discontinue. Instead, we need to use the codes and standards to guide our practice before, during, and after assessment so that we can ensure minimal harm and maximum benefit to clients. Alternatives to assessment, such as barrier-free approaches are an option but they pose their own challenges. For instance, many of our Autism Resource Centers in Saskatchewan only require a brief initial observation or a brief screener to receive supports rather than a formal assessment and diagnosis. While this speeds up the process for some children who require the supports, others are overlooked due to the lack of scope and sequence in brief screeners and the crossover of many of the diagnostic categories. Furthermore, some children are supported when they may have other conditions, such as Attention Deficit Hyperactivity Disorder (ADHD) and would be better served by other empirically supported means. While the child may not have received the diagnostic label, caregivers and educators tend to adopt these once the child is accessing services, despite formal assessment to confirm these claims. In the end, although psychological assessment can be an ethical minefield, it continues to prove valuable. If we continue to find ways to conduct assessment in adherence with the ethical codes, the answers derived will ensure maximum benefit for the clients and society that we serve.
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