Luteijn (2019). Ethical aspects and the reporting of diagnostics

The Dutch association of psychologists has made ethical guidelines based on responsibility (1), integrity (2), respect (3) and expertise (4). There are several important points of the guidelines for use of tests (AST):

1. The initiator relationship
   The psychologist needs to determine who initiated the request for psychodiagnostic examination. The psychologist initially carries out the examination for the benefit of the initiator. The psychologist attempts to ask the questions of the initiator or if that is not possible, seeks contact with the initiator to rephrase the questions.
2. The psychologist’s expertise
   A client has the right to a psychologist’s expertise. The psychologist’s expertise must be up-to-date and maintained. It also means that the psychologist knows his own boundaries and limitations. Expertise also refers to the fact that the psychologist must make sure that the quality of the assessment is high.
3. Confidentiality
   The things a client say must be handled in a confidential way and the client’s dossier also needs to be confidential. The retention period of a dossier is one year or as long as necessary for the purpose it was created for or as long as required by law. The content can be used for a longer period of time in scientific research if the data has been anonymized.
4. Voluntary participation and information provision
   Participation in an psychological examination is always voluntary. A client is entitled to information during each phase of the psychological examination. The client also has the right to correct, supplement or omit any data from the report for which he can convincingly argue that the data are incorrect, incomplete or irrelevant. This does not apply to test results and conclusions. The client also has the right to stop the psychologist from reporting to an external initiator, unless the external initiator is a court order.

External initiators refer to initiators that do not have direct contact with the client in a personal manner (e.g. insurance companies, court). Non-external initiators refer to initiators who have direct contact with the client in a personal manner (e.g. client himself). Expertise refers to the psychologist’s theoretical and practical knowledge and skills.

If there is little psychological information about a client, the following steps will follow:

1. The psychologist will begin a comprehensive anamnestic and biographical interview or begin treatment if possible.
2. The psychologist will plan the examination.
3. The psychologist carries out the examination.
4. The testing assistant will score (and potentially interpret) the tests.
5. The psychologist will interpret all of the information and examine which insights and hypotheses can be supported or rejected by the results.

The reporting of diagnostics involves written and oral reports. The purpose of the reports is to communicate the findings and results of the psychological examination as well as suggestions and recommendations on which these are based.

A written report is mandatory in all cases except for communication with the client. The form and the content of the report will depend on the questions and hypotheses that are being examined (1), the person for whom the report is primarily intended (2), the diagnostic methods that are used (3), the psychologist’s frame of reference (4), the style and writing skills of the person writing the report (5) and reporting practices of the institution where the psychologist is employed (6).

There are three ways in which a report can be structured:

1. Around the diagnostic methods that have been used
   The results of the psychological examination are explained consecutively for each of the methods that have been used. The advantage is all of the available information is in the report. A disadvantage is that information that is included can be contradictory (i.e. between methods) (1) and is not always relevant for the hypotheses (2).
2. Around the hypotheses that have been examined
   The pertinent results for each of the hypothesis are explained. This is a goal-oriented method of reporting. The advantage is that it is shorter than other reports. The disadvantage is that the range of available information which does not directly relate to the hypotheses is not included.
3. Around the client
   The report is based around the overall picture of the client that is gained from the psychological examination. This is often strongly based on one theory.

A comprehensive psychological examination should be comprised of the following sections:

1. Client data
   This consists of name, address, date of birth, gender, educational level, occupation, date of examination and other relevant information.
2. Information on the psychologist and other persons involved in the PE
   This consists of psychologist’s name, psychologist’s department and the testing assistant’s name.
3. Initiator and initiator question
4. Client consultation
5. Definitive hypotheses
6. Diagnostic methods used
   This consists of a summary of the methods and tests that have been used.
7. Interview details
8. Observational data
9. Explanation of test results
10. Summary of main results
11. Conclusions of hypotheses
12. Period of validity for the report and test data

All of the results for the psychological examination must first be present before an oral report can be presented. The oral debriefing of the psychological examination must first be conducted with the client, even in cases which include external initiators. There are several important points of an oral report:

1. Avoid using difficult words
2. Match the client’s use of language
3. The debriefing should not be a monologue
4. The psychologist should be honest and open and discuss everything
5. A short account of the debriefing should be included in the written report