Respond to the following in a minimum of 175 words:
Review this week’s course materials and learning activities, and reflect on your learning so far this week. Respond to one or more of the following prompts in one to two paragraphs:
- Provide citation and reference to the material(s) you discuss. Describe what you found interesting regarding this topic, and why.
- Describe how you will apply that learning in your daily life, including your work life.
- Describe what may be unclear to you, and what you would like to learn.
Case Study Seven Worksheet
Respond to the following questions in 1,250 to 1,500 words.
1. Why is this an ethical dilemma? Which APA Ethical Principles help frame the nature of the dilemma?
2. To what extent, if any, should Dr. Vaji consider Leo’s ethnicity in his deliberations? Would the dilemma be addressed differently if Leo self-identified as non-Hispanic White, Hispanic, on non-Hispanic Black?
3. How are APA Ethical Standards 1.08, 3.04, 3.05, 3.09, 7.04, 7.05, and 17.05 relevant to this case? Which other standards might apply?
4. What are Dr. Vaji’s ethical alternatives for resolving this dilemma? Which alternative best reflects the Ethics Code aspirational principle and enforceable standard, as well as legal standards and obligations to stakeholders?
5. What steps should Dr. Vaji take to ethically implement his decision and monitor its effects?
C. B. (2013). Decoding the ethics code: A practical guide for psychologists. Thousand Oaks, CA: Sage.
PART3-Develop an 2-slide Microsoft® PowerPoint® presentation with detailed speaker notes on the selection process of a culture-neutral assessment. Include examples of when culture-biased assessments have been problematic.
Use a minimum of 2 peer reviewed (scholarly journal articles) sources.
(I WILL ADD MORE DETAILS FOR PART 3 BY TUESDAY)
Chapter 12 Standards on Assessment 9. Assessment
9.01 Bases for Assessments
Psychological assessment serves the public good by providing information to guide decisions affecting the well-being of individuals, families, groups, organizations, and institutions. Psychologists who base their conclusions about information and techniques on the scientific and professional knowledge of the discipline are uniquely qualified to interpret the results of psychological assessments in ways that merit the public trust. However, the public and the profession are harmed when psychologists provide opinions unsubstantiated by information obtained or drawn from data gathered through improper assessment techniques (Principle A: Beneficence and Nonmaleficence; Principle B: Fidelity and Responsibility). Standard 9.01a of the APA Ethics Code (APA, 2010b) prohibits psychologists from providing written or oral opinions that cannot be sufficiently substantiated by the information obtained or the techniques employed.
The standard is broadly worded to apply to all written and oral professional opinions, irrespective of information recipient, setting, or type of assessment.
The standard prohibits unfounded professional opinions offered to, among others, (a) individual clients/patients or their representatives; (b) other professionals; (c) third-party payors; (d) administrative and professional staff at schools, hospitals, and other institutions; (e) businesses, agencies, and other organizations; (f) the courts; (g) the military or other governing legal authorities; and (h) callers to talk radio programs or those interacting with psychologists via the Internet or through other media.
Need to Know: Assessment in Child Protection Matters
Forensic examiners retained in response to an accusation of child abuse and neglect need to obtain competencies relevant to the intersecting interests of the child, the parents, and the state, including laws on parental termination and the role of kinship and policies favoring child placement with extended family members in favor of foster care (Standard 2.01f, Competence; APA, 2013b). The primary purpose of the assessment is to help government agencies and courts determine whether a child’s health and welfare may have been and/or may be harmed. Consequently, in addition to the broader parent–child “fit” considerations typical of custody evaluations, psychologists need to select assessment techniques sufficient to address the particular vulnerabilities and risks of maltreatment associated with specific child characteristics (e.g., children with developmental disabilities or other medical needs) and the need for and likelihood of success of clinical interventions for problems associated with abuse, maltreatment, or neglect. This may include familiarity with techniques for assessing the role of specific cultural patterns of parenting, impact of familial separation, and foster and kinship-based alternative care. In interpreting results, psychologists must also refrain from assuming a child advocacy role and gather information impartially based on reliable methods established in the field (Standard 2.04, Bases for Scientific and Professional Judgments).
Standard 9.01a applies to (a) diagnostic opinions offered orally in the office of a private practitioner; (b) written reports provided to clients/patients, other practitioners, or third-party payors through the mail, the Internet, or other forms of electronic transmission; (c) testimony provided in the courts; and (d) opinions about an individual’s mental health offered over the Internet, radio, television, or other electronic media.
Types of Assessment
The standard pertains to all unfounded opinions claiming to be based on any form of evaluation, including but not limited to (a) standardized psychological, educational, or neuropsychological tests; (b) diagnostic information gained through clinical interviews; (c) collateral data obtained through discussions with family members, teachers, employee supervisors, or other informants; (d) observational techniques; or (e) brief discussion or correspondence with an individual via radio, television, telephone, or the Internet.
Violations of this standard are often related to failure to comply with other standards, including Standards 2.04, Bases for Scientific and Professional Judgments; 9.01b, Bases for Assessments; and 9.02b, Use of Assessments. For example, psychologists should not use test scores as sole indicators for diagnostic or special program placement but instead use multiple sources of information and, when appropriate, provide alternative explanations for test performance (AERA, APA, & NCME, 2014). The following are examples of opinions based on insufficient information or techniques that would be considered violations under this standard:
Psychologists who knowingly provide unsubstantiated opinions in forensic, school, or insurance reports fail to live up to the ideals of Principle C: Integrity and may also find themselves in violation of Standard 5.01, Avoidance of False or Deceptive Statements (see Hot Topic “Avoiding False and Deceptive Statements in Scientific and Clinical Expert Testimony,” Chapter 8). However, psychologists should also be alert to personal and professional biases that may affect their choice and interpretation of instruments. For example, in a survey of forensic experts testifying in cases of child sexual abuse allegations, Everson and Sandoval (2011) found that evaluator disagreements could be explained, in part, by individual differences in three forensic decision-making attitudes: (1) emphasis on sensitivity, (2) emphasis on specificity, and (3) skepticism toward child reports of abuse.
Standard 9.01b specifically addresses the importance of in-person evaluations of individuals about whom psychologists will offer a professional opinion. Under this standard, with few exceptions, psychologists must conduct individual examinations sufficient to obtain personal verification of information on which to base their professional opinions and refrain from providing opinions about the psychological characteristics of an individual if they themselves have not conducted an examination of the individual adequate to support their statements or conclusions. As video conferencing and other electronically mediated sources of video communication become increasingly common, appropriately conducted assessments via these media may meet the requirements of this standard if the psychologist has had the appropriate preparatory training and the validity of the video methods of assessment has been scientifically and clinically established for use with members of the population tested (Standards 2.01e, Boundaries of Competence; 2.04, Bases for Scientific and Professional Judgment; 9.02, Use of Assessments).
Standard 9.01b also recognizes that in some cases, a personal examination may not be possible. For example, an individual involved in a child custody suit, a disability claim, or performance evaluation may refuse or, because of relocation or other reasons, be unavailable for a personal examination. The standard requires that psychologists make “reasonable efforts” to conduct a personal examination. Efforts that would not be considered reasonable in the prevailing professional judgment of psychologists engaged in similar activities would be considered a violation of this standard. Consider the following two examples of potential violations:
When, despite reasonable efforts, a personal interview is not feasible, under Standard 9.01b psychologists in their written or oral opinions must document and explain the results of their efforts, clarify the probable impact that the failure to personally examine an individual may have on the reliability and validity of their opinions, and appropriately limit their conclusions or recommendations to information they can personally verify. Psychologists may report relevant consistencies or inconsistencies of information found in documents they were asked to review (see Standard 9.01c below). However, they should avoid offering opinions regarding the personal credibility or truthfulness of individuals they have not examined or when basic facts contested have not been resolved through assessments (APA, 2013b).
This standard applies to those assessment-related activities for which an individual examination is not warranted or necessary for the psychological opinion. Such activities include record or file reviews where psychologists are called on to review preexisting records and reports to assist or evaluate decisions made by schools, courts, health insurance companies, organizations, or other psychologists they supervise or with whom they consult. Record reviews can be performed to (a) determine whether a previously conducted assessment was appropriate or sufficient; (b) evaluate the appropriateness of treatment, placement, employment, or continuation of benefits based on the previously gathered information and reports; (c) adjudicate a disability or professional liability claim based on existing records; or (d) resolve conflicts over the applicability of records to interpretations of federal and state laws in administrative law or due process hearings (Bartol & Bartol, 2014; Hadjistavropoulos & Bieling, 2001).
Reviewers provide a monitoring function for the court or a function of forensic quality control so the court will not be misled by expert testimony of evaluators that is based on flawed data collection and/or analysis (Austin, Kirkpatrick, & Flens, 2011). According to Standard 9.01c, psychologists who provide such services must clarify to the appropriate parties the source of the information on which the opinion is based and why an individual interview conducted by the psychologist is not necessary for the opinion.
Simply complying with this standard may not be sufficient for psychologists who are in supervisory roles that carry legal responsibility for the conduct of assessments by unlicensed supervisees or employees. In many of those instances, psychologists may be directly responsible for ensuring that individuals are qualified to conduct the assessments and do so competently (see Standard 2.05, Delegation of Work to Others).
- ☒ Testifying on the validity of a child abuse allegation based on the results of an idiosyncratic, improperly constructed parent checklist of child behaviors
- ☒ Diagnosing an adult with impaired decisional capacity as developmentally disabled without taking a developmental history
- ☒ Providing preemployment recommendations on the basis of a personality test with no proven relationship to job performance
- ☒ Submitting a diagnosis of neurological impairment to a health insurance company based solely on information derived during therapy sessions
- ☒ Informing parents that their preschooler is autistic on the basis of a single observational session
- ☒ Recommending a child for special education placement solely on the basis of scores on a standardized intelligence test
- ☒ Offering a diagnosis of PTSD based on a 5-minute discussion with a listener who calls in to a radio program hosted by the psychologist
- ☒ Offering a diagnosis of bipolar disorder based on an individual’s comments on the psychologist’s blog
- ☒ Submitting for health insurance reimbursement a diagnosis of dementia in an elderly patient complaining of memory lapses, without conducting a neuropsychological assessment
Digital Ethics: Use of Mobile Phones for Treatment Adherence Monitoring
For some mental health disorders such as anorexia nervosa, borderline personality disorder, and substance dependency, downloadable mobile phone applications (mHealth) for client/patient self-monitoring can be a valuable adjunct to in-person psychotherapy, as they can reduce vulnerabilities of memory and help clients/patients reflect critically on their thoughts and behaviors (Aardoom Dingemans, Spinhoven, & Van Furth, 2013; Ambwani, Cardi, & Treasure, 2014; Dimeff, Rizvi, Contreras, Skutch, & Carroll, 2011; Dombo et al., 2014). When deciding whether mHealth is clinically indicated for a specific client/patient, psychologists should consider (a) whether the client/patient can effectively use the technology without supervision, based on diagnostic assessment as well as conducting an in-office assessment of the client’s/patient’s ability to utilize the technology, and (b) the likelihood that clients/patients will become overdependent on the mobile technology in ways that jeopardize their ability to implement behavior management skills independent of the technology (Ambwani et al., 2014; Standards 2.04, Bases for Scientific and Professional Judgments, and 3.04, Avoiding Harm). To ensure appropriate confidentiality protections, psychologists should (a) assess risks to confidentiality that may be inherent in the client’s/patient’s home, work, and other treatment management–related environments; (b) utilize behavior management mobile applications and/or Internet sites with adequate security protections; and (c) provide clients/patients with instruction on how to protect their privacy and confidentiality (Standards 4.01, Maintaining Confidentiality; 4.02, Discussing the Limits of Confidentiality).
- ☒ A psychologist testified about a parent’s psychological fitness for visitation rights, drawing his opinion solely from comments made by the child and divorced spouse in the absence of an individual examination of the parent.
- ☒ A psychologist contracted by an insurance company to evaluate an individual’s mental health as part of a current disability claim provided an opinion based solely on job performance evaluations written by the insured’s immediate supervisors and diagnostic information collected by another psychologist prior to the incident cited in the claim.
- ☒ A psychologist working in a correctional facility who was asked to recommend whether a prison guard’s mental status was a risk to prisoner protections did not personally examine the guard but instead gave an opinion based on reports by facility administrators, staff, and prisoners.
- ☒ A psychologist was contracted by a prison to evaluate the job potential of guards hired for a probationary period. Without conducting an individual interview, the psychologist wrote a report concluding that emotional instability of one job candidate made him ineligible for full-time employment. The psychologist justified the lack of a personal examination on the fact that several coworkers had claimed the guard was too dangerous to interview.
- ☒ A psychologist hired by the attorney of a husband engaged in a custody suit provided court testimony on the wife’s parenting inadequacies without having interviewed her personally. The psychologist claimed that the wife had not responded to the psychologist’s letter requesting the interview. On cross-examination, it was revealed that the letter written by the psychologist included the following language seemingly designed to discourage agreement to be examined: “I have reason to believe from interviews with your spouse and an examination of your children that you are responsible for the children’s current mental health problems and would like to conduct an examination to confirm or dispute these assumptions.”
- ☑ A court-appointed psychologist attempted to contact the biological parent of a child currently in foster care to make recommendations regarding parental visitation. The parent was no longer at the last known residence and had not left a forwarding address. In testimony, the psychologist described the current mental health status of the child, the child’s statements regarding the biological parent, and the observed relationship between the child and foster parents. In referring to the biological parent, the psychologist informed the court of efforts to contact the parent, described how failure to interview the parent limited any conclusions that could be drawn regarding the parent’s psychological characteristics and parenting competence, and clarified that recommendations regarding visitation were based on the child’s attitudes, mental health, and foster care arrangements.
Review of Data From Surreptitious Investigative Recording
There are instances when forensic psychologists may be asked to evaluate past mental states from audio or video recordings of a defendant’s behavior at the time of the alleged offense or surreptitious recordings of a plaintiff’s behavior in a personal injury, insurance disability, or divorce case (Denney & Wynkoop, 2000). Before agreeing to review such recordings, psychologists should make sure that the surveillance information was obtained legally at the time it was recorded, that the party requesting the psychologist’s evaluation has the legal right to share such information, and that inadmissibility of such information will not compromise the psychologist’s findings. Psychologists should also take reasonable steps to ascertain that they have been provided with all legally available recordings and other available information relevant to the forensic opinion. The psychologist’s oral testimony or written report should clarify the source of the information and why an individual examination is not warranted or necessary for the type of evaluation requested.
9.02 Use of Assessments
The appropriate use of psychological assessments can benefit individuals, families, organizations, and society by providing information on which educational placements, mental health treatments, health insurance coverage, employee selection, job placement, workers’ compensation, program development, legal decisions, and government policies can be based. The inappropriate use of assessments can lead to harmful diagnostic, educational, institutional, legal, and social policy decisions based on inaccurate and misleading information.
Standard 9.02a is concerned with the proper selection, interpretation, scoring, and administration of assessments. It refers to the full range of assessment techniques used by psychologists, including interviews and standardized tests administered in person, through the Internet, or through other media. According to this standard, ethical justification for the use of assessments is determined by research on or evidence supporting the purpose for which the test is administered, the method of administration, and interpretation of scores (AERA, APA, & NCME, 2014). To comply with the standard, psychologists should be familiar with and be able to evaluate the data and other information provided in test manuals detailing (a) the theoretical and empirical support for test use for specific purposes and populations, (b) the test’s psychometric validity, (c) administration procedures, and (d) how test scores are to be calculated and interpreted. Psychologists should also keep themselves apprised of ongoing research or evidence of a test’s usefulness or obsolescence over time (see also Standards 2.03, Maintaining Competence; 2.04, Bases for Scientific and Professional Judgments; 9.08b, Obsolete Tests and Outdated Test Results). The standard also requires that psychologists adhere to standardized test administration protocols to ensure that test scores reflect the construct(s) being assessed and avoid undue influence of idiosyncrasies in the testing process (AERA, APA, & NCME, 2014).
Violations of Standard 9.02a occur when psychologists use assessments in a manner or for a purpose that is not supported by evidence in the field (see also this chapter’s Hot Topic “The Use of Assessments in Expert Testimony: Implications of Case Law and the Federal Rules of Evidence”).
Modifications for Individuals With Disabilities
Test administration for individuals with disabilities may require modifications and adaptations in testing administration to minimize the effect of test taker characteristics incidental to the purpose of the assessment. Standard 9.02a permits departure from a standard administration protocol if the method of test adaptation can be justified by research or other evidence. For example, converting a written test to Braille for an individual who is legally blind, physically assisting a client with cerebral palsy to circle items on a written test, or providing breaks for an individual with a disability associated with frequent fatigue is acceptable if the particular disability is not associated with the construct to be measured by the test and there are professional or scientific reasons to assume that such modifications will not affect the validity of the test (AERA, APA, & NCME, 2014). However, such accommodations are not appropriate if the disability is directly related to the abilities or characteristics that the test is designed to measure. Any modifications to testing and potential limitations in interpretation must be documented. Federal regulations relevant to the assessment of individuals with disabilities include IDEA (http://idea.ed.gov), Section 504 of the Rehabilitation Act of 1973, revised 2006 (http://www.hhs.gov/civil-rights/for-individuals/disability/index.html), and ADA (http://www.ada.gov).
Digital Ethics: Internet-Mediated Assessments
Psychologists administering assessments via the Internet need to remain up-to-date on research demonstrating the assessments’ validity or lack thereof for use in this medium (Montalto, 2014; Standard 2.03, Maintaining Competence). Verification of the examinee’s age, gender, and honesty of disclosures is important to the assessment’s validity and reliability (Alleman, 2002). Some assessments developed for in-person administration require verbal, auditory, or kinesthetic clues for accurate diagnosis (Barak & English, 2002). When assessments have not been validated for use via the Internet, psychologists should make every effort to conduct an in-person evaluation. When this is not possible, psychologists should select instruments that research or other evidence indicates are most appropriate for this medium, implement when possible information-gathering techniques that can best approximate in-person settings (e.g., video and auditory interactive technology), and acknowledge limitations of the assessment in interpretations of the data (Standard 9.06, Interpreting Assessment Results). Technology-based testing is also related to concerns regarding standardized administration and construct validation. Psychologists need to be aware of limitations in administration and interpretation for examinees who may not have access to or are unfamiliar with the use of new technologies or will be using older computers or devices with slower processing speed (AERA, APA, & NCME, 2014; Standard 3.01, Unfair Discrimination).
- ☒ A psychologist contracted to conduct employment testing for an organization administered a series of personality inventories with little or no validity evidence supporting the link between scores on the inventories and actual job performance.
- ☒ A counseling psychologist working with an isolated rural community administered a series of tests over the Internet without previously establishing whether the Internet-mediated scores measured the same construct as scores from the paper-and-pencil version (Buchanan, 2002).
- ☒ A school psychologist working under pressure to meet the school system’s quotas for weekly testing gave the same battery of tests to all students irrespective of their grade level or presenting problem.
- ☒ A neuropsychologist conducted a forensic examination of a prisoner in a room occupied by other prisoners, thereby compromising the validity of score interpretation based on norms established under standardized distraction-free testing environments.
Need to Know: Assessment of Dementia
The APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (APA, 2012d) stress the importance of using age-normed standardized psychological and neurological tests, being aware of the limitations of brief mental status examinations, and estimating premorbid abilities. The Guidelines also describe the following key elements that should be obtained to ensure accurate diagnosis of conditions associated with cognitive decline (p. 5):
- The onset and course of changes in cognitive functioning
- Preexisting disabilities
- Educational and cultural background that could affect testing variability
- General medical and psychiatric history
- Past neurological history, including prior head injuries or other central nervous system insults (strokes, tumors, infections, etc.)
- Current psychiatric symptoms and significant life stressors
- Current prescription and over-the-counter medication use
- Current and past use and abuse of alcohol and drugs
- Family history of dementia
Presence of Third Parties to Assessments
Standard 9.02a requires that psychologists administer tests in a manner consistent with procedures and testing contexts used in the development and validation of the instruments. Many psychological assessment instruments and procedures are validated under administration conditions limited to the presence of the psychologist and testee. In rare instances, psychologists may judge it necessary to include third parties to control the behavior of difficult examinees (e.g., parents of young children, hospital staff for psychiatric patients with a recent history of violence). In such situations, psychologists should select assessment instruments that are least likely to lend themselves to distortion based on the presence of a third party and include in their interpretations of test results the implications of such violations of standardized testing conditions.
Psychologists providing expert forensic consultations in relation to a criminal case, tort litigation, insurance benefits, or workers’ compensation claims may find that the assessment validity of tests is compromised when third parties are present as mandated by state law, institutional policy, or a judge’s ruling. For example, in neuropsychological assessments related to workers’ compensation cases, the presence of the plaintiff’s legal counsel, family members, or company representatives may distort the testing process or render test scores and interpretations invalid if the third party influences the test taker’s motivation or behavior or the psychologist–testee rapport (American Academy of Clinical Neuropsychology, 2001). The use of data from such assessments may be unfair to individuals if it leads to invalid test administration or misleading interpretations of the testee’s responses (Principle D: Justice and Standards 1.01, Misuse of Psychologists’ Work; 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority; and 9.06, Interpreting Assessment Results). When there is no legal flexibility to deny third-party presence during an assessment, psychologists should select those tests and procedures found to be least susceptible to distortion under such conditions and ensure that their written reports highlight the unique circumstances of the assessment and the limitations in interpretation.
Trainees and Interpreters as Third Parties
Third parties may observe evaluations for training purposes or serve as interpreters when translation is necessary to ensure accuracy and fairness of assessments (Standard 9.02c, Use of Assessments). In such instances, psychologists must select procedures that research or other evidence has demonstrated can be applied appropriately under these circumstances, ensure that trainees and interpreters are trained adequately to minimize threats to the proper test administration, and include in their reports any limitations on conclusions due to the presence of the third parties (Standards 2.05, Delegation of Work to Others; 9.06, Interpreting Assessment Results).
The central idea of fairness in psychological and educational testing is to identify and remove construct-irrelevant barriers to maximal performance and allow for comparable and valid interpretation of test scores for all examinees (AERA, APA, & NCME, 2014). The proper use of tests can further principles of fairness and justice by ensuring that all persons benefit from equal quality of assessment measures, procedures, and interpretation (Principle D: Justice; Standard 3.01, Unfair Discrimination). Fair applicability of test results rests on assumptions that the validity and reliability of a test are equivalent for different populations tested. Validity refers to the extent to which empirical evidence and psychological theory support the interpretation of test data, that is, whether the test measures the psychological construct it purports to measure. Reliability refers to the consistency of test scores when a test is repeated for an individual or for a given population (see AERA, APA, & NCME, 2014).
A test that is a valid and reliable measure of a psychological construct in one population may not adequately measure the same construct in members of a different population, especially if members of the population of interest were represented inadequately in the normative sample or if test validity has not been established specifically for that group. Standard 9.02b requires psychologists to select assessment instruments whose validity and reliability have been established for use with members of the population tested. This standard applies to psychological assessment of any population, including clients/patients, students, job candidates, legal defendants, and research participants.
To comply with this standard, psychologists, when selecting a test, must be familiar with the specific populations included in the standardization sample and the test’s validity and reliability estimates. At minimum, psychologists should determine the applicability of a test to an individual of a given age group, ethnicity/culture, language, and gender and, where applicable, disability or other population characteristic when scientific or professional evidence suggests that test scores may not be psychometrically, functionally, or theoretically comparable to scores for the reference groups on which the test was normed (Landwher & Llorente, 2012).
Psychologists should also be familiar with relevant federal laws on the selection and administration of nondiscriminatory assessment and evaluation procedures (e.g., IDEA, 34 CFR 300.30[c][i]).
The dynamic and evolving nature of this country’s cultural, political, and economic landscape creates situations in which population-valid and reliable tests of a psychological construct may not be available for the individual or group tested. Psychologists asked to evaluate individuals from such groups should select tests validated on other populations with caution because they may produce results that do not adequately assess the qualities or competencies intended to be measured (AERA, APA, & NCME, 2014). Recommendations based on these assessments in turn may lead to unfair denial of educational or employment opportunities, health coverage, legal rights, or necessary services (Principle D: Justice). According to Standard 9.02b, psychologists who use tests without established norms for the individual or population assessed must describe in their reports the strengths of using the specific test results as well as the limitations the use of such tests places on psychologists’ interpretations and recommendations.
Psychologists conducting evaluations with members of racial/ethnic minority or immigrant groups must be particularly sensitive to the lack of cultural consideration inherent in the most popularly used mental health diagnostic and classification tools: the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11). To avoid errors that may be associated with applying these tools, Johnson (2013) recommended that psychologists (a) apply culturally competent skills to understand attitudes toward mental health that may affect the client’s general response to testing; (b) establish an initial trusting relationship with clients; (c) consider including a measure of acculturation; (d) become familiar with cultural conditions that can impact the sharing of personal history information and the presentation of symptoms; and (e), when appropriate, draw on the appendices in the DSM-5 and ICD-11 to proactively use culture as a factor in the diagnostic process.
- ☒ A school psychologist was asked to evaluate a bilingual child whose family had recently moved to New York from Puerto Rico. The psychologist used the English version of a well-known intelligence test without considering whether the standardized Spanish version of the test was or was not more appropriate for the child.
- ☒ A psychologist working in a nursing home always used the Beck Depression Inventory (Beck, Steer, & Brown, 1996) to assess patient depression without considering the appropriateness of other measures specifically standardized on elderly populations or populations with chronic illnesses.
- ☒ A consulting psychologist was hired to evaluate the job performance of a factory supervisor who had a visual disability. The psychologist limited her assessment to oral administration of tests that were validated on individuals without vision impairment and neglected to assess unique ways in which the supervisor might successfully compensate for his disability.
- ☑ A forensic psychologist was asked to evaluate the competence to stand trial of a prisoner who had recently immigrated to the United States from Botswana. The prisoner’s English was poor, but there were no tests for competence standardized for individuals from the prisoner’s cultural or language group. The psychologist selected the best culturally sensitive techniques and assessments available and in written conclusions to the court explained the limitations of the tests used.
Selection of “Culture-Free” Tests
School psychologists and neuropsychologists conducting assessments of intellectual, educational, and cognitive abilities may attempt to be culturally sensitive by “stacking” their test batteries with nonverbal visuoperceptual and motor tests when assessing patients who speak languages in which more traditional language-based tests are not available. The use of such tests requires ethical caution since nonverbal tests of cognitive ability can be just as culturally biased as verbal tests (Wong, Strickland, Fletcher-Janzen, Ardila, & Reynolds, 2000).
Language differences are part of the cultural diversity, rich immigration history, and individual differences in hearing and other linguistically relevant disabilities that make up the demographic mosaic of the United States. The validity and applicability of assessment data can be severely compromised when testing is conducted in a language the testee is relatively unfamiliar with or uncomfortable using. Under Standard 9.02c, psychologists should select tests in the language that is most relevant and appropriate to the test purpose (AERA, APA, & NCME, 2014).
Whereas the inappropriateness of English-only-based psychological testing is obvious when testees speak little or no English, the hazards of English-only testing for bilingual persons or oral-language-only assessment of persons with hearing disabilities who can read lips and communicate in sign language are often overlooked. The linguistic competencies of individuals who are bilingual often vary with the mode of communication (e.g., oral vs. written language), language function (e.g., social, educational, or job related), and topical domain (e.g., science, mathematics, interpersonal relationships, self-evaluations). In addition, individuals’ language preferences do not always reflect their language competence. Individuals may be embarrassed to reveal that their English, hearing, or oral language is poor; believe non-English or nonhearing testing will negatively affect their evaluations; or misjudge their language proficiency. The following steps are recommended to help psychologists comply with Standard 9.02c (see also AERA, APA, & NCME, 2014):
- Psychologists can use language tests that assess multiple language domains to determine language dominance and proficiency relevant to different modes of assessment (e.g., written, oral) and topics (e.g., academic, interpersonal).
- Whenever possible, psychologists should use test translations that have been developed according to accepted methods of test construction (see Standard 9.05, Test Construction).
- When a test is translated or adapted, test developers and test users must describe the adequacy of theory, evidence, and methods used to establish the validity of test score interpretations for intended use (see Standard 2.04, Bases for Scientific and Professional Judgments).
- Additional testing or observation may be necessary to determine whether what appears to be eccentric behavior (e.g., short phrases or reticence in response to test questions) reflects differences in cultural communication styles or an individual characteristic.
- To the extent feasible, psychologists must ensure the language competence of the test administrator (see also Standards 2.05, Delegation of Work to Others; 9.03c, Informed Consent in Assessments).
- When interpreting assessment results, test norms for native speakers of English should not be used for individuals for whom English is a second language or should be understood in part as reflecting a level of English proficiency.
- ☒ A neuropsychologist was hired by an insurance company to assess a recent Nigerian immigrant who claimed he had suffered brain damage from falling on the premises of a store insured by the company. Because the man had such limited English skills and no test was available in his primary language, the neuropsychologist decided that the most culturally sensitive approach would be to assess the man’s cognitive capacity with an assessment battery composed entirely of visuospatial, perceptual, and motor tasks. The psychologist’s report did not describe the limitations of test results based on the absence of language-based assessments of reasoning and other cognitive abilities, nor did the report acknowledge the absence of preinjury cognitive tests necessary to determine whether behavioral and cognitive functioning had declined after the fall (adapted from Wong, 2000).
When English or Other Language Proficiency Is Essential
There are instances when proficiency in English or another language is essential to the goal of the assessment. For example, the ability to communicate with English-speaking employees may be a necessary qualification for a successful applicant for a personnel position. Evaluating a student’s English proficiency may be necessary to determine appropriate educational placement. The ability to read and speak English may be important to certain service positions responsible for protecting public health, safety, and welfare. Inclusion of the phrase unless the use of an alternative language is relevant to the assessment issues indicates that Standard 9.02c permits psychologists to use tests in a language in which the testee may not be proficient, if effective job performance, school placement, or another goal of assessment requires the ability to communicate in that language.
9.03 Informed Consent in Assessments
To comply with this standard, psychologists must obtain and document, with few exceptions, written or oral consent in the manner set forth in Standard 3.10, Informed Consent. Psychologists must provide individuals who will be assessed and, when appropriate, their legal representative a clear explanation of the nature and purpose of the assessment, fees, involvement of third parties, and limits of confidentiality. Psychologists should also be attuned to consent vulnerabilities related to transient disorders, such as depression (Ghormley, Basso, Candlis, & Combs, 2011) and develop appropriate measures to ensure consent comprehension.
Core Elements of Informed Consent in Assessment
Nature of the Assessment
The nature of an assessment refers to (a) the general category of the assessment (e.g., personality, psychopathology, competency, parenting skills, neuropsychological abilities and deficits, employment skills, developmental disabilities), (b) procedures and testing format (e.g., oral interviews, written self-report checklists, behavioral observation, skills assessment), and (c) duration of the assessment (e.g., hours or multiple assessments).
Purpose of the Assessment
The purpose of the assessment refers to its potential use, for example, in employment decisions, school placement, custody decisions, disability benefits, treatment decisions, and plans for or evaluation of rehabilitation of criminal offenders.
Discussion of fees must include the cost of the assessment and payment schedule and should be consistent with requirements of Standard 6.04, Fees and Financial Arrangements. When applicable and to the extent feasible, psychologists must also discuss with relevant parties the extent to which their services will be covered by the individual’s health plan, school district, employer, or others (see Standard 6.04a and 6.04d, Fees and Financial Arrangements).
Involvement of third parties refers to other individuals (e.g., legal guardians), HMOs, employers, organizations, or legal or other governing authorities that have requested the assessment and to whom the results of the assessments will be provided. Psychologists should be familiar with ethical standards, state law, and federal regulations relevant to the appropriate role of third parties and the release and documentation of release of such information to others (see Standard 4.05, Disclosures). Psychologists asked to evaluate a child by one parent should clarify custody issues to determine whether another parent must give permission.
Informed consent to assessments must provide a clear explanation of the extent and limits of confidentiality, including (a) when the psychologist must comply with reporting requirements such as mandated child abuse reporting or duty-to-warn laws and (b) in the case of assessments involving minors, guardian access to records (see discussion of parental access involving HIPAA, FERPA, and other regulations in Standards 3.10, Informed Consent; 4.01, Maintaining Confidentiality; and 4.02, Discussing the Limits of Confidentiality). Psychologists who administer assessments over the Internet must inform clients/patients, research participants, or others about the procedures that will be used to protect confidentiality and the threats to confidentiality unique to this form of electronic transmission of information (see also Standard 4.02c, Discussing the Limits of Confidentiality).
Implications of HIPAA for Confidentiality-Relevant Information
The HIPAA regulation most relevant to informed consent in assessments is the Notice of Privacy Practices. At the beginning of the professional relationship, covered entities must provide clients/patients a written document detailing routine uses and disclosures of PHI and the individual’s rights and the covered entities’ legal duties with respect to PHI. Psychologists conducting assessments should also be familiar with HIPAA-compliant authorization forms for use and release of PHI and HIPAA requirements for Accounting of Disclosures. These regulations are described in greater detail in the section “A Word About HIPAA” in the preface of this book and in discussions of Standard 3.10, Informed Consent, in Chapter 6; Standards 4.01, Maintaining Confidentiality, and 4.05, Disclosures, in Chapter 7; Standard 6.01, Documentation of Professional and Scientific Work and Maintenance of Records, in Chapter 9; and Standard 9.04, Release of Test Data, in this chapter.
Dispensing With Informed Consent
Under Standard 9.03a, informed consent may be waived when consent is implied because testing is conducted as (a) a routine educational activity, such as end-of-term reading or math achievement testing in elementary and high schools; (b) regular institutional activities, such as student and teaching evaluations in academic institutions or consumer satisfaction questionnaires in hospitals or social service agencies; or (c) organizational activity, such as when individuals voluntarily agree to preemployment testing when applying for a job.
Standard 9.03a also permits psychologists to dispense with informed consent in assessment when testing is mandated by law or other governing legal authority or when one purpose of testing is to determine the capacity of the individual to give consent. For example, during an initial consultation, neuropsychologists may also need to determine whether a client/patient with suspected dementia or brain injury has the capacity to independently consent to a full cognitive and neuropsychological assessment. Forensic psychologists conducting civil capacity assessments of older adults must select appropriate assessment techniques for determining whether clients/patients meet the legal standards of diminished capacity, testamentary capacity, and other abilities relevant to decisional capacity as defined by law (Moye, Marson, & Edelstein, 2013). Ethical steps that must be taken in these contexts are discussed next under Standard 9.03b.
Under Standards 3.10b, Informed Consent, and 9.03a, Informed Consent in Assessments, informed consent in assessment is not required when an individual has been determined to be legally incapable of giving informed consent, when testing is mandated by law or other governing legal authority, or when one purpose of testing is to determine consent capacity. These waivers reflect the fact that the term consent refers to a person’s legal status to make autonomous decisions based on age, mental capacity, or the legal decision under consideration. Consistent with the moral value of respect for the dignity and worth of all persons articulated in Principle E: Respect for People’s Rights and Dignity, under Standard 9.03c, psychologists must provide all individuals, irrespective of their legal status, appropriate explanations of the nature and purpose of the proposed assessment. Readers may also refer to the Hot Topic in Chapter 6, “Goodness-of-Fit Ethics for Informed Consent Involving Adults With Impaired Decisional Capacity.”
Standard 9.03a often applies in situations where assessment is requested by parents of children younger than age 18 years or family members of adults with suspected cognitive impairments. In some contexts, the affirmative agreement of the testee is not required. In these situations, the psychologist must provide information in a language and at a language level that is reasonably understandable to the child or adult being assessed. When both the permission of the guardian and the assent of the child or cognitively impaired adult are sought, psychologists working with populations for whom English is not a first language should be alert to situations in which prospective clients/patients and their legal guardians may have different language preferences and proficiencies.
Need to Know: Informed Consent for Forensic Assessments Requested by an Examinee’s Attorney
When testing is requested by an examinee’s attorney, informed consent should help the examinee understand the difference between forensic and other psychological services. To accomplish this Younggren, Bennett, and Harris (https://www.trustinsurance.com/resources/download-documents/) recommended that forensic informed consent contracts include the following:
- The evaluation is not being conducted for the purposes of counseling or treatment. The results may or may not be personally helpful to you but will provide your attorney with information on how you function psychologically.
- Your participation in the assessment is voluntary, and you have the right to stop the evaluation at any time. However, there may be legal consequences to stopping that should be discussed with your attorney.
- If you consent to the assessment, the report will be sent to the retaining party (e.g., the examinee’s attorney), who will have complete authority over the results.
- When the evaluation is completed, with permission from your attorney, I may be able to meet with you to explain the results.
- Although the forensic report is normally protected by attorney–client privilege, if used for legal proceedings, the report may be admissible into evidence, and the extent of other confidentiality protections will be determined by the rules of that legal system.
The term informed consent is applied when individuals are legally permitted to make their own decisions about undergoing a psychological assessment and whether and to whom the results of testing are disclosed. The term does not apply when testing is mandated through a court order or other governing authority. Psychologists conducting forensic, military, or other assessments that have been legally mandated should provide the examinee with a notification of purpose that explains the nature and purpose of the testing, who has requested the testing, and who will receive copies of the report. If the examinee is unwilling to proceed following a thorough explanation, the forensic practitioner may attempt to conduct the examination, postpone the examination, advise the examinee to contact his or her attorney, or notify the retaining attorney of the examinee’s unwillingness to proceed (APA, 2013a).
Defendants who are entering a plea of insanity may not be able to act on their Fifth Amendment right to silence and avoidance of self-incrimination. To avoid compromising the admissibility of a comprehensive forensic evaluation, Bush et al. (2006) suggested that psychologists first assess competency, then sanity, and separate the reports given to the court to provide the court the opportunity to first determine the competence question.
Informed Consent for the Assessment of Malingering
Malingering refers to the intentional production of false symptoms to attain an identifiable external benefit (Butcher, Hass, Greene, & Nelson, 2015; Iverson, 2006; National Academy of Neuropsychology Policy and Planning Committee, 2000). Tests of symptom validity, exaggeration, and malingering have become integral components of neuropsychological evaluations for traumatic brain injury and other suspected neurological disorders. Some have argued that assessment of malingering is the number one priority of forensic assessment, preceding any professional conclusions in forensic evaluations (Brodsky & Galloway, 2003; Kocsis, 2011). Malingering can be manifested through intentional under- or overperformance during psychological assessment. Accurate assessment of malingering is ethically important because errors in diagnosis can impede justice when undetected in forensic procedures or obscure adequate treatment for psychopathology (Principle A: Beneficence and Nonmaleficence; Kocsis, 2011).
Some have questioned whether describing the purposes of tests for malingering during informed consent compromises the validity of the assessment or whether failing to include such information during informed consent violates testees’ autonomy rights (Principle E: Respect for People’s Rights and Dignity; Standard 9.03, Informed Consent in Assessments). Current standards of practice support communicating to testees prior to and during informed consent or notification of purpose that measures will be used to assess the examinee’s honesty and efforts to do well, without describing the particularities of the tests that will be used to measure exaggeration or other elements of malingering (Carone, Bush, & Iverson, 2013). Individuals undergoing evaluation for Social Security Disability benefits or compensation for work-, sport-, or military-related injuries may be wary of practitioners and feel the need to prove that they are neurologically compromised. In such contexts, psychologists should take extra steps to develop rapport and a trusting relationship and to craft language and procedures that ensure testees understand that honesty and effort are required; in some cases, this may involve reading the informed consent material to clients/patients (Carone et al., 2013; Chafetz, 2010). Carone et al. (2013) also provided guidance for how to include the results of effort, exaggeration, and other tests during feedback sessions with clients/patients (Standard 9.10, Explaining Assessment Results).
Research on Coached Malingering
A practical concern in the forensic assessment of defendants or plaintiffs is whether existing tests of malingering can detect over- or underexaggeration of symptoms when the examinee has been coached by individuals familiar with the tests (Butcher et al., 2015; Jelicic, Cuenen, Peters, & Merckelbach, 2011). When researchers attempt to study the extent to which commonly used tests are vulnerable to coached faking, there is a risk that the information provided to research participants or disseminated through publication will be used to improve the success of coached malingerers (Berry, Lamb, Wetter, Baier, & Widiger, 1994). Ben-Porath (1994) suggested that to protect against these risks, investigators can (a) coach research participants on items similar but not identical to those on the test under investigation, (b) provide only a brief synopsis of coaching instructions in published articles, and (c) release information on verbatim instructions only to those bound by the APA Ethics Code to protect the integrity of tests (see also Standard 9.11, Maintaining Test Security).
Compliance with the consent requirements outlined in Standard 3.10 obligates psychologists to provide information in a language and at a language level that is reasonably understandable to the client/patient and, where applicable, his or her legally authorized representative. Psychologists may use the services of an interpreter when they do not possess the skills to obtain consent in the language in which the client/patient is proficient.
When delegating informed consent responsibilities to an interpreter, psychologists must ensure not only that the interpreter is competent in the consent-relevant language (see Standard 2.05, Delegation of Work to Others) but that the interpreter also understands and complies with procedures necessary to protect the confidentiality of test results and test security. An interpreter who revealed the identity of a client/patient or the nature of specific test items used during the assessment would place the psychologist who hired the interpreter in potential violation of this standard. Because test validity and reliability may be vulnerable to errors in interpretation, Standard 9.03c also requires that the involvement of the interpreter and any related limitations on the data obtained be clearly indicated and discussed in any assessment-based report, recommendation, diagnostic or evaluative statement, or forensic testimony.
9.04 Release of Test Data
Definition of Test Data
In Standard 9.04a, the term test data refers to the client’s/patient’s actual responses to test items, the raw or scaled scores such responses receive, and a psychologist’s written notes or recordings of the client’s/patient’s specific responses or behaviors during the testing. The term notes in this standard is limited to the assessment context and does not include psychotherapy (or process) notes documenting or analyzing the contents of conversation during a private counseling session.
Test Data and Test Materials
Recognizing that availability of test questions and scoring criteria may compromise the validity of a test for future use with a client/patient or other individuals exposed to the information, Standard 9.04a distinguishes test data, which under most circumstances must be provided upon a client/patient release, from test materials, which under most circumstances should not (see Standard 9.11, Maintaining Test Security). The definition of test data does not include test manuals, protocols for administering or scoring responses, or test items unless these materials include the client’s/patient’s responses or scores or the psychologist’s contemporaneous notes on the client’s/patient’s testing responses or behaviors. If testing protocols allow, it is good practice for psychologists to record client/patient responses on a form separated from the test items themselves to ensure that upon client/patient request, only the test data and not the test material itself need be released.
The Affirmative Duty to Provide Test Data to Clients/Patients and Others Identified in a Client’s/Patient’s Release
Release to Clients/Patients
Under Standard 9.04a, psychologists have an affirmative duty to provide test data as defined above to the client/patient or other persons identified in a client/patient release. The obligation set forth by Standard 9.04a to respect clients’/patients’ right to their test data is consistent with legal trends toward greater patient autonomy and the self-determination rights of clients/patients as set forth in Principle E: Respect for People’s Rights and Dignity. Although not explicitly stated in the standard, it is always good practice for psychologists to have a signed release or authorization from the client/patient even if the data are to be given directly to the client/patient. This standard does not preclude psychologists from discussing with a client/patient the potential for misuse of the information by individuals unqualified to interpret it.
Digital Ethics: Client/Patient Requests for Electronic Records
The 2013 HIPAA Omnibus Rule permits patients to receive a copy of their health record in an electronic form. Covered entities are permitted to charge for the costs of supplies if the client/patient requires data to be provided on a USB flash drive, compact disc, or other electronic media and for the costs of having to hire technically trained staff to recover PHI (see Standard 6.04, Fees and Financial Arrangements).
Release to Others
A fundamental tension exists between the desire of psychologists to respect clients’/patients’ right to determine who will have access to their assessment results and the desire to ensure that the data are not reviewed by unqualified individuals who might misinterpret or misuse the data or violate contractual agreements designed to protect a test publisher’s proprietary interests (Principle A: Beneficence and Nonmaleficence; Principle D: Justice; Principle E: Respect for People’s Rights and Dignity). The language of Standard 9.04 reflects this tension by providing exceptions to the release of test data under conditions in which the release might lead to substantial harm or misuse of the test.
There are several reasons why the standard supports release of test data to clients/patients and those whom they authorize to receive the data. First, whether a person designated by the client/patient is qualified to use test data is determined by the context of the proposed use. For example, restricting release of test data to individuals with advanced degrees or licensure in professional psychology would preclude other qualified health care professionals from using the information. Broadening but limiting the definition of qualified person to health professionals might jeopardize appropriate judicial scrutiny of psychological tests and a client’s/patient’s right to the discovery process to challenge their use in court. Second, even if a consensus around the definition of a “qualified” person could be achieved, requiring a psychologist to confirm the education, training, degrees, or certifications of other professionals would pose a burden that might not be feasible to meet. Third, as described below, with few exceptions, HIPAA regulations require that covered entities provide clients/patients and their personal representatives access to PHI.
Withholding Test Data
Standard 9.04a permits psychologists to withhold test data to protect the client/patient or another individual from substantial harm. The standard also permits withholding test data to protect misuse or misrepresentation of the data or the test. Before refusing to release test data under this clause, psychologists should carefully consider the proviso in the standard that such decisions may be regulated by law. For example, when refusing a client’s/patient’s request to release test data based on the psychologist’s judgment that the data will be misused, psychologists should document in each specific case their rationale for assuming that the data will be misused and refrain from behaviors that may be in violation of other standards (e.g., Standard 6.03, Withholding Records for Nonpayment).
Need to Know: Access to Forensic Records
According to the Specialty Guidelines for Forensic Psychology (APA, 2013e), forensic psychologists should provide attorneys and others who retain their services access to and explanation of all information in their records relevant to the legal matter at hand, consistent with relevant law and applicable professional standards, institutional rules, and regulations. Forensic examinees are not provided access to their assessment data or records unless the retaining party provides written consent for their release (see Standard 9.03b, Informed Consent in Assessment).
Implications of HIPAA
Requiring psychologists to release test data to the client/patient or others pursuant to a client/patient release reflects a sea change in the legal landscape from paternalistic to autonomy-based rules go