Clinical Licensing Exams in Mental Health Care: A Critical Review

  • Executive Summary: Lack of Evidence and Harmful Impacts of Clinical Exams in Mental Health

    • Clinical exams for mental health licensure in the US, used for over 5050 years, lack any evidence of improving the quality or safety of mental health care.
    • Despite this absence of evidence, reliance on these exams persists, built on an undeserved trust from professionals, policymakers, and the public.
    • This trust is unwarranted due to: ample evidence of racial disparities in exam performance, long-standing and unaddressed criticisms, and potential conflicts of interest where boards act as both exam buyers and sellers.
    • The report focuses on exams for psychology, clinical social work, counseling, and marriage and family therapy.
    • These exams, despite good intentions, have never demonstrated predictive validity or correlation with professional knowledge, safety, or effectiveness.
    • Developers have consistently failed to address criticisms regarding necessity, value, validation, content, and structure.
    • Exams pose significant costs to professions and the public.
    • They repeatedly produce disparate outcomes based on race and ethnicity, adding a unique layer of structural racism to licensure.
    • Exams limit the mental health workforce supply and diversity without proven benefit.
    • Therefore, clinical exams in their current form are not supportable; alternative processes are reviewed to ensure public safety while minimizing costs.

  • Introduction and Background

    • Clinical exams have been a condition of licensure in the US for over 5050 years, starting with the EPPP in psychology in 19651965.
    • Exams are generally national, with common development processes and similar formats.
    • The stated intention is to ensure public safety via assessing general professional knowledge, which is a worthwhile goal.
    • However, numerous criticisms have not been adequately addressed.

  • Exam Development and Structure

    • Mentions clinical exams for psychology, counseling, clinical social work, and marriage and family therapy.
    • Specific Exams Discussed:
    • ASWB Clinical Level Exam (social work)
    • California MFT Clinical Exam (marriage and family therapy, CCE)
    • Examination for Professional Practice in Psychology (EPPP, psychology)
    • National Clinical Mental Health Counselor Exam (NCMHCE, counseling)
    • National Counselor Exam (NCE, counseling)
    • National MFT Exam (marriage and family therapy)
    • All listed exams are computer-administered and consist exclusively of 44-option multiple-choice questions with a single correct answer.

  • ASWB Clinical Exam

    • Used for clinical social worker licensure across the US and Canada.
    • Developed by the Association of Social Work Boards (ASWB), an association of licensing board representatives.
    • ASWB began offering exams in 19831983 and now offers exams for 44 levels of social work practice.
    • ASWB has historically been reluctant to release psychometric data; Minnesota licensing board consultants were unable to obtain data in 20082008.
    • Due to lack of public data, the ASWB clinical exam has rarely been studied academically.
    • In 20222022, ASWB published a report on examinee performance across its exams, allowing review by jurisdiction, gender, race, ethnicity, primary language (English vs. non-English), and attempt (first-time vs. overall).
    • The California BBS publishes quarterly performance data for California ASWB clinical examinees, disaggregated by attempt and graduate program, but not demographic factors.

  • California MFT Clinical Exam (CCE)

    • Used exclusively in California for MFT licensure.
    • Developed by the Board of Behavioral Sciences (BBS) in partnership with the state's Office of Professional Examination Services.
    • BBS publishes quarterly exam pass rate data by attempt and graduate program, but not by examinee demographics (state law prohibits mandating demographic data collection).

  • EPPP Part 1

    • Used in all US jurisdictions and multiple Canadian provinces for psychologist licensure.
    • Owned and developed by the Association of State and Provincial Psychology Boards (ASPPB).
    • In 20202020, it was split into EPPP Part 1 (knowledge) and EPPP Part 2 (skills).
    • Most jurisdictions use only EPPP Part 1; ASPPB encourages adoption of EPPP Part 2.
    • EPPP Part 2 is only available to those who passed Part 1.
    • Individual licensing boards have expressed reluctance to adopt EPPP Part 2 due to costs, necessity, and validity concerns.
    • ASPPB has published graduate program-level pass rates but not data disaggregated by examinee race, gender, or other characteristics.

  • National MFT Exam

    • Used for MFT licensure in all US jurisdictions except California.
    • Developed by the Association of MFT Regulatory Boards (AMFTRB).
    • AMFTRB does not publish pass rates in any form.

  • National Counselor Exam (NCE) and National Clinical Mental Health Counselor Exam (NCMHCE)

    • NCMHCE is used for clinical/mental health counselor licensure in many jurisdictions.
    • Some jurisdictions use the NCE for a broader