Ethical aspects and the reporting of diagnostics - Luteijn - 2019 - Article

What are the ethical rules for diagnostics?

Ethical rules are very important when performing diagnostics. The Dutch Association of Psychologists (NIP) has developed a professional code for psychologists. They have drawn up four guidelines based on certain principles: responsibility, integrity, respect, and expertise. These guidelines are elaborated in the Guidelines for the Use of Tests Use of the NIP. There are several important points that will be elaborated on in this article, such as the client relationship, expertise, confidentiality, voluntary participation, and information provision.

The initiator relationship

Before a psychologist starts a psychodiagnostic examination (PE), he must first determine who initiated the request. A distinction can be made here between external and non-external initiators. External initiators are, for example, a court of law or an insurance company. 

Once a psychologist has determined who the initiator is, he must check whether the goal of the examination is clear enough. If this is not clear, he must try to clarify this.

The psychologist’s expertise

A client has the right to the psychologist’s expertise. This implies three things: first, a psychologist must have sufficient theoretical knowledge and sufficient training. To guarantee this expertise, there are registrations such as registration as a health care psychologist, registration as a clinical psychologist and registration as a neuropsychologist. When a psychologist has a registration and therefore had sufficient training, it is important that he continues to keep his theoretical knowledge up to date through courses or literature.

Another form of expertise is that a psychologist is aware of his own limitations. If he is dealing with a client who could be helped better by his colleague, the psychologist must refer this client to this colleague.

Expertise also relates to specific practicalities:

The choice of methods used is made on the basis of the COTAN criteria. The COTAN Documentation is intended for test users to assist in making an objective and responsible choice for a suitable (psychodiagnostic) instrument.

COTAN assesses the quality of tests on the following seven criteria:

• Principles of the Test Construction
• Quality of the Test Material
• Quality of the Manual
• Standards
• Reliability
• Concept validity
• Criterion validity

If tests on one of these seven criteria are assessed as unsatisfactory, this test should preferably not be used.

The administration, scoring, and interpretation of tests should be as described in that test manual.

The oral and written reporting of a psychodiagnostic examination must be done in an effective and understandable manner.

Confidentiality

A client is also entitled to confidentiality and confidential treatment of all information known to the psychologist. The client and the psychologist must have made agreements with each other before the psychodiagnostic examination. The client must give his / her own permission to pass on information about him or her to third parties. This is often done using a standard form.

Confidentiality also has to do with a client's file. A file contains information from the psychodiagnostic study, such as completed test forms, raw and standardized scores, qualitative data from indirect methods and anamnestic and biographical data. The file does not contain personal notes from the psychologist. A file is kept for one year or longer (based on the purpose of the investigation or as described in law). If the data in a file is anonymized, the file can be kept for much longer.

Voluntary participation and provision of information

Participation in a psychodiagnostic study is always voluntary. A client can refuse to participate. Even if a court is a principal for an investigation, the client may refuse. A client may also stop during an investigation.

The client is also entitled to information at any stage of the investigation. Before an investigation commences, the purpose, content, method of investigation, manner of reporting to the client, and any other clients and the costs of the psychodiagnostic investigation must, therefore, be known.

The client is also entitled to information during the study, for example, if he wants to know why a specific test was used.

After a study has ended, the client is the very first person entitled to the information. This transfer of information can be oral or written. An oral report means that the psychologist himself tells the client the information. 

Finally, the client has the right to block the reporting of his data to third parties. This is only not possible if an external client such as the court can legally demand this information.

What are the practical issues during a psychodiagnostic examination?

During psychodiagnostics, a distinction can be made between Situation A and Situation B.

Situation A means that little information is available about a client in advance, Situation B means that a lot of psychological information is available about the client in advance.

Situation A

For this client, a psychodiagnostic examination always starts with an anamnestic examination and a biographical interview. The purpose of this is to get ideas or hypotheses about what is going on (recognition), how this can be explained (explanation), and what could be done (indication). Sometimes everything is immediately clear and treatment can be started:

• After this, the psychologist plans the examination, determines the tests and methods that will be applied and consults with the person who carries out the examination; this is often the test assistant;
• Then the investigation is carried out. Sometimes it may be desirable to perform the examination in one day because some clients do not have the time to visit more often;
• After the examination, the tests are scored, norm scores are sought, scores are interpreted and an observation report is made;
• Then the psychologist interprets everything and examines which ideas or hypotheses are supported or rejected. Then, he formulates answers to the initiator’s questions and writes a draft report. The client will then see this report and can make additions if necessary.

Situation B

If a lot of information about a client is already available prior to a psychodiagnostic examination, it is often possible to immediately start conducting the research.

How does reporting take place?

Written reports

Preferably, results are reported in writing to the client. If there is an external referrer, a written report is even mandatory. There is no standard way of writing a psychological report. The content and form of a report depend on the hypotheses for whom the report is intended, the diagnostic methods used, the theoretical frame of reference, and who makes the report (style and writing skills). Psychiatric terms must be explained to a client.

The diagnostic methods used

The results of a psychodiagnostic study are described on the basis of which methods were used. For example, if a conversation first took place, then was observed and the last tests were taken, for example, conversation data can be reported first, then observation data and then test results. In this way, all relevant information is included in the report. A disadvantage is that there is sometimes information, but that it does not answer the hypotheses. This information is then not reported, although it could be important.

The questions / hypotheses

 For each hypothesis, only the results that answer it are described. So this is a targeted way of reporting. A drawback with this way of reporting has already been described in 'the diagnostic methods used'.

Around the client

Sometimes a psychologist writes a report based on the overall picture he or she has of a client. It is then often strongly based on one theory. Nowadays this is not done much anymore.

What are the report-writing recommendations?

There are several recommendations for when a report is drawn up, these are:

• Vary in the style of writing and in the use of language;
• Let the conclusions depend on the validity of the method. Therefore, if a test is insufficiently assessed on one of the criteria of the COTAN, it is important to make light statements in this area;
• Do not make Barnum statements. Barnum statements are statements that apply to many people and therefore do not provide as much information about the client (so do not say: “the client sometimes feels gloomy);
• Avoid difficult words or explain what it means;
• Indicate sources and the standard groups used. Only mention scores with a confidence interval, although it is even better not to mention scores at all.

What is an example of a written report?

An example of a written report is of a 47-year-old married man with two children. He has been referred by his doctor to the Psychiatric Department of a General Hospital with fatigue complaints, depressive complaints, and problems at work. These complaints started four years ago and have worsened since then.

This client has been referred to a psychiatrist. The questions are: does this client have a mood disorder, what are the causes of the disorder, and what is the advice regarding the treatment of this client?

Psychological report

This report presents the demographic data of the client first. Then the questions that were asked are mentioned. Then there is conversation data: so, what does the client say? How does he feel during his work? How is the relationship between him and his colleagues? Based on this discussion, additional questions can be asked, which can be formulated as hypotheses. Then, tests are taken and the client is observed. The test results are analyzed and summarized. Finally, conclusions are formed.

What is an oral report?

Before an oral report can take place, all the results of the psychodiagnostic examination must be known. If tests have been used, they must be scored and interpreted. The psychologist must clearly know in advance what he will report to the client.

Also, for the oral report, it is important that this takes place with the client himself. When having an oral report, it is important that:

• Difficult words are avoided. The client must know clearly what is being told to him or her;
• A discussion should not become a monologue, the client should be asked whether he understands everything and whether he thinks the results fit his image of himself;
• The psychologist talks honestly and openly;
• A short report of this discussion is included in the written report.

What are the conclusions?

In the conclusion, the authors describe that the main principles in psychodiagnostics are: the client relationship, the psychologist's expertise, confidentiality, the client's voluntary participation and the guidelines for providing information about the client.