The November 2004 "Ethics Rounds" column commented upon ethical Standard 9.01, Bases for Assessments. In response, a reader has asked whether it is acceptable for psychologists to diagnose an individual solely on the basis of a record review, without an examination. Heartened to know I have a reader, I devote this entire column in reply.
A good starting point is to reflect upon our values as psychologists and to consider the significance of rendering a diagnosis. The Preamble to the Ethical Principles of Psychologists and Code of Conduct--our Ethics Code--states that the code has as a goal "the welfare and protection of the individuals and groups with whom psychologists work." Principle A, Beneficence and Nonmaleficence, exhorts psychologists "to benefit those with whom they work and take care to do no harm." Promoting welfare and safeguarding from harm are thus values central to our profession. Rendering a diagnosis has direct relevance to each.
The word "diagnosis" comes from the Greek word "to know." A diagnosis reveals something about an individual that a psychologist has special expertise in knowing. In few areas of practice does a psychologist exercise greater authority and influence than to render a diagnosis, for in so doing the psychologist comes to know and convey information that may profoundly affect that individual's life.
A diagnosis has clinical, personal and social significance. In the clinical context, a diagnosis reveals the nature of an illness. A correct diagnosis provides a basis for effective treatment. An incorrect diagnosis may delay or impede effective treatment or even exacerbate a situation by inviting inappropriate treatment. A diagnosis has personal significance insofar as it can become central to how a person experiences him- or herself. While a correct diagnosis of a severe disorder can be enormously difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling. A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placements. A diagnosis asserts itself on multiple levels of experience.
Rendering a diagnosis can be a complex process. Consider, for example, that psychotic experiences are part of multiple diagnoses. The treatment for an affective disorder with psychotic features, a schizophrenic disorder, a post-traumatic stress reaction, a severe personality disorder and a substance abuse disorder can vary dramatically; yet, psychotic processes may be present in each. Making the correct diagnosis will depend on the psychologist engaging in a thoughtful and competent process and often requires having sufficient time and opportunity to interact with an individual in order to differentiate among various possibilities.
Record reviews and the code
In the new APA Ethics Code, Section 9, Assessments, begins with standard 9.01, Bases for Assessments, which speaks directly to the foundation for diagnostic statements:
Consider three points about diagnostic statements made solely on the basis of a record review. First, a good record will almost certainly contain considerable information directly relevant to diagnosis. Psychologists may review the record and offer statements such as "This record is consistent with the diagnosis" or "Aspects of the record do not support this diagnosis." Given that psychologists render diagnoses on the basis of multiple sources of data, using the record as one data source is highly appropriate.
Second, in using multiple sources of data to render a diagnosis, psychologists inevitably make judgments concerning the quality of their data. In certain settings, psychologists can assess the reliability of the data source, for example, when the source is a supervisee or other members of a treatment team. In these instances, the psychologist can interact with other mental health professionals and, by extension, with the individual being diagnosed. Rendering a diagnosis thus becomes an interactive process, whereby the psychologist is able to assess directly the extent to which information relevant to the diagnosis can be relied upon and gather additional information if necessary.
Using a record as the sole basis for a diagnosis is a more static process. There may be limited ability to assess the quality of the data in the record and no opportunity to explore aspects of the record that are ambiguous or incomplete. If psychological testing is part of the record, there may be little evidence concerning whether the testing was done under standardized conditions and can be relied upon in making the diagnosis. A diagnostic process based solely on a record review thus potentially presents significant limitations.
While each clause in Standard 9.01 offers concrete guidance to psychologists making diagnoses from whatever source, clause (b), which addresses situations "in which an examination is not practical," speaks directly to the limitations inherent in record reviews. Under clause (b), psychologists clarify the probable impact of their limited information and appropriately limit their conclusions. Psychologists rendering diagnostic opinions solely on the basis of a record review therefore think through and make explicit how the absence of an examination affects their conclusions--and limit their diagnostic statements accordingly. Note how, through its limiting language, clause (b) emphasizes the centrality of an examination in the diagnostic process.
Under clause (c), psychologists make a preliminary determination that an examination is not warranted or necessary. In the case of a record review, it is helpful to read this phrase in clause (c) in conjunction with clause (a), which says that psychologists base their opinions on "information and techniques sufficient to substantiate their findings." Thus, to make a diagnostic statement solely on the basis of a record review, psychologists must first determine that the information they have, and the techniques used to gather that information, are adequate to support their findings. Only when this determination has been made could the psychologist conclude that an examination is not warranted or necessary for the opinion.
The Ethics Code exhorts psychologists to use their influence to do good and to avoid harm. Standard 9.01, Bases for Assessments, gives specific guidance for psychologists rendering diagnostic opinions, an area of practice where our profession's influence is most keenly felt. Offering a diagnosis based solely on a record review raises special considerations and unique challenges with great ethical significance. The spirit of the Code, embodied in the language of Standard 9.01, focuses on the quality of the data and processes we use to render judgments that affect the lives of others.