Traditional Psychological Assessment during COVID-19: Ethical Violations and Problems in Practice

Traditional


Introduction
The COVID-19 pandemic has been affecting the whole world for over a year and has led to a breakdown of routine business plans in many sectors. The workload of healthcare providers has increased, routine surgeries have been interrupted, and different applications have been required for invasive and non-invasive diagnosis and treatment procedures in the health sector. For instance, protective physical barriers have been required between the patients and the personnel so as to reduce the infection risk of COVID-19 in the surgery rooms.
As it has been the case for all other health fields, COVID-19 also caused various problems in the process of psychiatry and clinical psychology fields [1]. Especially, traditional psychological assessment is the most influenced field. In a typical psychological assessment that we are used to (such as school assessments, intelligence assessments, neuropsychological assessments etc.) the psychologist carries out the process in an environment that requires face-to-face or close contact with the patient/counselee [2]. Besides, the use of the same material throughout the test and the fact that the assessments require long time are among the problems encountered during the psychological assessment in the COVID-19 era.
When conducted studies are checked, it is seen that some manuals have been published so as to avoid ethical problems related with the psychological assessment process in the CO-VID-19 era and to minimize the problems faced by the psychologists. However, when these manuals are examined it is seen they have been prepared according to "de facto" information and that no empirical studies have been conducted with psychologists working in this field.

Abstract
The problems experienced by the psychologists while conducting psychological assessment during the COVID-19 era and the individual solutions offered for those problems have been examined within this study by taking into consideration the ethical principles. 50 participants working actively during the COVID-19 era have been reached out within the scope of the study. Semi-structured interviews have been conducted with all participants through online platforms. Then, the contents of the recorded interviews have been analyzed. Upon evaluating the findings of the research, it has been found out that in the COVID-19 era participants mostly had problems regarding the application of the tests (such as ignoring the standard application instructions). Then, it has been found that the application malpractices resulted due to anxiety and the fear related to COVID-19 (such as trying to end the assessment soon and quickly). It is believed that this study can be a guideway for the challenges faced during the COVID-19 era by psychiatric care personnel conducting psychological assessment.

Journal of Psychiatry and Behavioral Sciences
The purpose of this study is to research which problems have been experienced or not experienced by the psychologists during the psychological assessment proves and to study empirically what kind of solutions have been put forward for the problems. Thereafter, the solutions put forward have been examined both in terms of ethical compliancy and in terms of their compliance to rules such as the test's standard instruction and application.

Participants
Fifty psychologists working actively in the field of clinical psychology and neuropsychology in the COVID-19 era have been included in this study. It was tried to reach the participants who wanted to participate in the research voluntarily, primarily through personal communication. Afterwards, the number of participants was increased through professional association, as there was not enough participation. All participants were required to have "at least one year of psychological evaluation" experience prior to the pandemic, regardless of the sub-field. The age average of the participants has been calculated as 34.23 ± 3.67, 64% of the participant are female (n= 32) and the rest is constituted of male. In terms of the participants education level, it is seen that 48% (n=24) has a bachelor's degree, 36% (n=18) has a master's degree in clinical psychology or neuropsychology and, 16% (n= 8) has a doctorate degree in clinical psychology or neuropsychology. In terms of professional experience, the average professional experience has been calculated as 4.12 (years) ± 2.88.

Socio-demographic information
The participants have been asked to provide information regarding their working times, the tests they apply, the special groups they work with and, their working routines before and during the COVID-19 in addition to their age, gender, and demographical information.

Interview
The interview has been used as the data collection method for the research. As the participants' workload and the working hours differ, individual interviews have been opted instead of focus groups. All interviews have been conducted via online platforms and a fixed platform has not been used. The interview started by gathering the participants' socio-demographical information and then the problems faced during the COVID-19 period have been discussed. So as to transform all the information obtained through the interviews into frequency tables, the interviews have been carried on in a semi-structured way.

Analysis
As the interview technique has been chosen as data collection tool, the contents of the interview records have been examined and the problems faced, and the solutions offered to these problems have been coded. The main headings of these codes have defined as follows: problems related with the application of the tests, problems related with the self-awareness of the psychologist, and problems related the working conditions. Afterwards, the solutions offered by the participants for the aforementioned problems have been analyzed.

Information regarding the participant's socio-demographics and working conditions
When the information related with the participants' working lives are examined, it is seen that most of the participants work in public hospitals. In terms of the test applied, all the participants have indicated having conducted an intelligence test at the institution they work. It is seen that Weschler Intelligence Scale for Children-IV (WISC-IV) has been the most applied test. But Weschler Intelligence Scale for Adults (WAIS) and Raven Standart Progressive Matrices Test (RSPM) are also among the commonly used other intelligence tests. When the participants undergoing neuropsychological assessment were examined, the participants have indicated that they do not apply a single test to the patient, but they evaluate different cognitive skills at the same time when they assess a patient. The most preferred tests are Wisconsin Card Sorting Test (WCST), London Tower, Öktem-Verbal Memory Process Test (Ö-VMPT). The detailed information regarding the participants' working lives has been presented in Table 1. Later, the participants have been asked questions regarding their working conditions and routines before and during the pandemic. According to this, the weekly average working time of the participants before the pandemic has been calculated as 40.56 ± 2.37, while the weekly average working time during the pandemic has been calculated as 38.40 ± 5.93. Paired-Samples T Test has been applied to understand if there is a statistical significance between the weekly working time before and during the pandemic. According to this, a statistical significance (t(49)= 2.727, p= 0.009) has been detected between both periods in terms of working times. When the difference between the number of psychological assessments conducted by the participants before and during the pandemic has been tested, a statistical significance (t(49)= 4.064, p=0.000) has been detected between Journal of Psychiatry and Behavioral Sciences both time periods in terms of the weekly numbers of psychological assessments. According to this, the weekly number of psychological assessments (32.56 ± 11.57) carried out by the participants Before the Pandemic (BP) is higher compared to the weekly number of psychological assessments (26.04 ± 9.05) carried out by the participants During the Pandemic (DP). Each psychological assessment conducted in BP and DP era has been tested in minutes to find out if there has been a change or not. According to the Paired Samples t test analysis, it has been revealed that the psychological assessment time, for both time periods, has statistically differed statistically (t(49)= 11.487, p=0.000. When the averages are checked, it is seen that the time of the assessments conducted BP (68.10 ± 21.76; in minutes) is higher compared to the ones conducted DP (36.80 ± 13.32).
The problems experienced during psychological assessment conducted in the COVID-19 era, the individual solutions offered for those problems, and the compliancy of these solutions in terms of ethics have been discussed in this study. The aforementioned problems have been listed in Table 2. Applying the test faster than it is required due to the will of terminating the test application sooner

Solutions Provided For the Problems about Physical Conditions
Keeping the door and the windows open during the interview to keep the room ventilated

Dilemmas and problems experienced by the psychologist
Use of Mask and Not being able to understand the given instruction due to that Frequent use of disinfectants during the interview Not to archive the registry records about the patient's performance due to the risk of infection Not being able to disinfect the material used (especially paper materials) after usage Challenges about the use of masks during the interviews conducted with mentally retarded individuals Challenges about the assessment of the risky groups such as patients from prisons, hospitalized ones, and the ones above 65 years old with chronical diseases Not to have interviews with the relatives of the patient unless extremely necessary and keeping the interviews brief

Discussion
Psychological assessment is an assessment carried out to transform the psychological structures of the individual, such as cognitive (attention, memory, intelligence) and personality, into objective, digitalized and comparable condition. This psychological assessment consists of several steps such as getting information about the patient's medical history, the application of the psychological tests and getting information about the patient/counselee from the patient/counselee's relatives [3]. Besides the fact that each process is providing information to the psychologist regarding the patient's current mental and psychological condition, the application of the psychological tests is extremely crucial to evaluate the patient's mental and psychological situation objectively". As it is known, there are detailed instruction manuals for several psychological scaling tools providing information about how, when, where and to who they shall be applied. It is vital that the psychologist abide by the instructions while carrying out the test for the interpretation of the test score obtained from the patient. A malpractice resulting from the application of the test can cause crucial differences on the interpretation of the score to be obtained from the test and on a decision to be made for the patient. If the psychologist goes beyond the rules during the application of objective tests, the patient's performance may be affected by this practice and consequently, a wrong decision can be made regarding the patient's test score.
First of all, as it is the case for many professional groups [4], it has been concluded that the fear and concerns faced regarding the COVID-19 process is also valid for psychologists. In addition to the concerns of the COVID-19 infection possibility from the patients being interviewed, the fact that psychologists are carrying out interviews with many people for long hours also increases the concerns regarding the possibility of the psychologist to spread COVID-19 to the patient. It has been found that this fear was reflected both on the number of patients interviewed by the psychologist and the length of the interviews conducted. It has been determined that the participants considerably reduced the weekly-assessed number of individuals and reduced the assessment duration in terms of minutes. Preferring shorter and no-contact requiring tests for the psychological assessment, trying to reach a conclusion about the patient with basic tests out of all applicable tests, the presentation of instructions by the psychologist, the hurrying during the process of applying the tests and going beyond the standard instructions can be listed among the reasons of the decrease in the assessment times.
When this situation is evaluated, the fact that particularly the participants are conducting only some of the sub-tests of the time requiring tests like WAIS, WISC-IV tests enabling the assessment of the individual's cognitive skills holistically and reaching out a decision with these scores is an ethical violation. As in the ethics code indicated by the American Psychological Association [5] and Turkish Psychologists Association [6], the application instructions and standards shall not be ignored. On the other hand, it has been detected that when participants conducted neuropsychological assessment, especially for elderly individuals or for individuals with neurologic disorders, they opted for the shorter test believed to scale the same cognitive skill and that the patient's performance was not tested with similar tests to find out if the performance is holistic or not, as it was practiced before the pandemic. Although this case does not constitute an obvious ethical violation as the ethical violations experienced in the intelligence tests, it prevents to have a holistic decision on the individual's executive functions, by evaluating single or little amount of test result. A neuropsychologist given the code K9 stated the followings regarding the selection of tests: "While conducting an assessment inclusive of several cognitive skills for a patient pre-diagnosed with Alzheimer before the pandemic, nowadays (implying the times of pandemic) we opt for tests. For instance, we used to assess the patient's memory with Öktem-Verbal Memory Process Test or Journal of Psychiatry and Behavioral Sciences Weschler Memory Test, whereas now, we assess with the Digit Span Test." K9 also noted the following during the interview regarding the holistic assessment: "Before now, information was obtained from the relatives about the patient directed for differential diagnosis whereas now we talk with the companions on the phone to avoid face to face interaction or do not meet as long as it is not compulsory since the beginning of the pandemic. All in all, we need to minimize the risk of infection both for the sake of the patients and ourselves." Medical history taking from the patient's relatives is crucial for making differential diagnosis especially in the assessments conducted with patients having cognitive destruction. When it is taken into consideration that the dementia patients cannot express their complaints due to the loss of insight and that, they confabulate [7], patient relatives provide important information about the patients. Not to consult the companions regarding the patient is daily like activities can cause problem in the decision making.
It has been seen that some participants gave more than one breaks in between the applications to complete the test. Interrupting the test instead of applying some other sub-test while implementing sub-tests related with an assessment, giving break for the psychological assessment after certain tests, and increasing the frequency of the breaks seem to be a more ethical and reliable solution; however, it should not be forgotten that the increase of break frequencies will extend the total assessment time, and there will be a loss in the attention and motivation level due to the increasing tiredness of the assessed person. Thus, the duration should be decided upon considering the patient's needs and the scientific information regarding the infection risk of COVID-19 in closed environments. Sometimes the patient may wish to leave the clinic as soon as possible. In that case, the necessity to have a break and airing the room and why it is required should be explained by the psychologist. Especially, patients not cooperating for the interview (for example, prisoners and patients forced for assessment), children may want to leave the hospital right away.
The participants have indicated that the physical features of the environment, where the psychological assessment is conducted, also influence the application. For instance, it is more accurate to place the table and the chairs so as to minimize the infection risk in a room having a good air conditioning system. Nevertheless, some psychologists informed that due to the lack of space in the rooms they work and inadequate clean airing, it is not always possible to perform ergonomic changes. Some noted that they keep the door and windows open during the interview and this leads to distraction for the assessed person.
The problems caused by the anxiety and the fear experienced by psychologists in the COVID-19 era and the solutions offered are remarkable. M31 told the followings regarding this: "At the first stages of the pandemic, it was not completely known how the disease spread, what it did, or was it fatal or not. Thus, I cancelled the assessments of the patients requiring psychological assessment for the differential diagnosis and treatment evaluation in the first times. However, since the 4th -5th months of the pandemic, I have realized that we cannot run away from this any longer and that we have been doing ethical violations by disrupting the patients' diagnosis and treatment procedures, and I have restarted the interviews. But still, I am aware that I do tell the instructions faster than before when I apply tests".
As it has been also noted by the participant, disrupting the patient's diagnosis and treatment processes is an ethical violation. These problems encountered during the early stage of the pandemic is not only valid for the psychologists, but it is also known that several surgical interventions selectively stopped [8].
Yet, it has been found out that 86% of the psychologists (n=43) frequently used disinfectants during the interview due to their own concerns and fear while 58% (n=29) changed their masks more than once during the interviews. It is essential to take in consideration that doing these practices in front of the assessed person can influence the patient's performance negatively and non-adaptive compulsive behaviors should be avoided.
It has been detected that due to the use of masks, 66% (n=33) of the participants experience dilemma whether the instructions given are understood or not, and whether to repeat the instructions or not. For instance, it has been indicated that the fact that the word cannot be understood due to the use of the mask causes a problem during reading the word set to the patient while applying a memory test. The participants confirmed that they know that the word should be read only once due to the test standards; however, they noted that if they repeated the word one more time in case it is not understood, then they would go beyond the test's standard. Such that, the word or number set is only read once when short-term memory is assessed, and the assessed person is asked to repeat what he has in his mind. Provided that it is not too many times within the same test, the word/number indicated as not understood can be repeated; consequently, the dilemma whether the patient's bad performance is due to cognitive destruction or due to inaudibility/ambiguity can be solved.
Not to archive the test materials and the register documents regarding the patients is another ethical violation. Ethical Principles of Psychologists and Code of Conduct [5] indicates that the patient documents have legal responsibility and that these documents should be regularly archived by the psychologists. Archiving the patient files are of evidence for any further negative or legal problem to be resolved in the future by the psychologist. However, some participants (n=8) noted that they did not archive the records during the pandemic.
Lastly, it has been seen that during COVID-19 tele-assessment [9,10] and the usage of computer-based tests became mostly preferable by psychologists. Particularly, the computerized versions of neuropsychological test are increasing; but it is revealed by studies that the computerized test versions cannot be assessed like the manual versions and that they are not equal to each other in terms of psychometric attributes [11,12]. For example, Wisconsin Card Sorting Test's manual and computerized version have been compared in a recent research, in terms of psychometric attributes in two different sampling, and it has been shown that both versions are not equal. The authors provide extended suggestions regarding the version, the sampling be used under certain conditions. Under these circumstances, while interpreting the score obtained from the test, the psychologists should take into consideration the restrictions put forward by the version.
Briefly, COVID-19 pandemic brought some compulsory practices to the regular working routines. The problems occurring and the individual solutions offered by the psychologists have been the basis theme of this study. No empirical study has been Journal of Psychiatry and Behavioral Sciences found regarding the challenges the psychologists faced during the psychological assessment during COVID-19 when the literacy was examined. When the findings of the research were obtained, the findings obtained from 50 participants and the individual solutions were prepared as info-pack and sent to participants. In most of the feedback received from the participants, it has been stated that they had never thought that others were also dealing with these kinds of problems. This result points out the importance of social support in crisis period when the work stress and working conditions get harsher. This study is believed to be a guideline offering awareness regarding the problems the psychologists carrying out clinic assessment in COVID-19 era may encounter.

Limitations
Individual interview has been preferred as the data collecting method in this research. Within that scope, it has been thought that it would be more advantageous compared to other research methods to explanatorily analyze the problems brought by COVID-19 process. On the other hand, it could have been more useful to discuss all together the problems and the solutions offered by gathering up with participants.
A relatively young psychologist sampling has been worked on when the age range of the participants are examined. In addition, the age range is narrow. The challenges experienced by psychologists having been present in the professional life for a longer period (for example, more than 15 years) during CO-VID-19 era and the approaches brought for the problem could not be examined. Likewise, examining the solutions provided and the ethical violations according to the experience year by digitizing can be important.