The Controversy Over Racial Bias in Mental Health Clinical Exams

March 28, 2023

An illustration of a head with a tangle of thoughts inside it as the person learns about the bias in mental health clinical licensing exams.

Clinical exams are used as a licensing requirement for all U.S.-based behavioral health practitioners. However, these mental health clinical exams have recently come under scrutiny due to reports which showed major racial disparities in exam results.

In this article I’ll discuss the data analyzing the clinical exam pass rates by race. Additionally, I’ll explore how the exams are created and what several mental health groups’ opinions are on the exams.

Finally, for practitioners who may be wondering how to express their opinions on this issue, I’ll share steps you can take to make your voices heard.

Read on for an examination of the controversy over racial bias in mental health clinical exams.

Background on Mental Health Licensure Exams

All practitioners in the major psychotherapy professions in the U.S. must pass a clinical exam prior to achieving licensure and being allowed to practice independently.

Psychologists must take the Examination for Professional Practice in Psychology (EPPP), and soon will also be required to take the EPPP Part 2.

Clinical social workers must take the Association of Social Work Boards (ASWB) Clinical Exam.

Counselors must take either the National Counselor Examination NCE or the National Clinical Mental Health Counseling Examination NCMHCE.

And, finally, family therapists must take the Association of Marital and Family Therapy Regulatory Boards’ (AMFTRB) National Marital and Family Therapy (MFT) Exam, or in California, the California MFT Clinical Exam.

How Are Clinical Exams Created?

These exams are all developed in similar ways.

First, a survey is done of licensed mental health practitioners to understand what they are doing during their typical work in the field.

Next, data from that survey is used to determine the tasks and knowledge considered necessary for competent practice.

Then, exam questions are written to assess new therapists’ knowledge, and, at least in theory, to determine whether they have enough knowledge to competently carry out the required tasks of the profession.

Most exams use case vignettes in a four-option multiple-choice format.

Over the years, licensing boards and exam developers have increasingly hedged their language when it comes to what the exams are supposed to do.

On the ASPPB website, for example, the exams are now described as just “one of several methods used to determine readiness for autonomous practice” to assess whether a practitioner has adequate knowledge to practice competently in the behavioral health field without endangering the public.

According to the ASWB official exam handbook, every exam question undergoes “statistical analysis and sensitivity review by a group of expert social work professionals.” The ASWB exam handbook also says, “if such analysis demonstrates the potential for any race or gender bias, the item is deleted.”

Evidence of Racial Bias in Licensing Exams

Historically, exam developers have refused to provide exam performance data broken down by race or other factors.

Some exam developers haven’t gathered demographic information on those taking the exam so that they would be able to evaluate potential bias on their own exams.

Despite this, researchers have sometimes been able to gather this data from state licensing boards through public record requests.

The EPPP in particular has been repeatedly shown to produce disparate outcomes on the basis of race.

In 2022 the ASWB released a pass rate analysis report on its exams for social work licensure at all levels (bachelor’s, master’s, and clinical). The report showed substantial performance disparities between candidates of different racial and ethnic groups.

For instance, fewer than half of the Black candidates passed the ASWB Clinical Exam on their first attempt, while more than four out of five white candidates passed the exam on their first try.

This information contradicted earlier statements from the ASWB, including a statement in the official exam handbook, that claims “results over several years have shown that ASWB exams are statistically free from race and gender bias.”

At the same time, a group of researchers led by Diane Gehart (Disclosure: She’s my boss at California State University Northridge, where she directs the MFT program, and I serve as adjunct faculty) and Kevin Lyness have been looking into similar issues with the California and National MFT Exams.

They are finding significant racial and ethnic disparities in candidates’ performance on MFT clinical exams.

The relationship between candidates’ race and ethnicity and exam outcomes has not been revealed for the NCMHCE or NCE, as the developer of those exams (NBCC) has not made any related data public.

Additional Concerns About Clinical Licensing Exams

Critics of the exams (Disclosure: I’m among them) have argued that these racial and ethnic disparities, combined with the lack of ability to demonstrate mental health clinical exams’ predictive validity in ensuring safety or effectiveness in independent practice, mean the exams are decreasing access to mental health care rather than serving to enhance it.

The primary purpose of licensing boards and examination processes is, after all, to protect the public.

That said, as a National Council for Mental Wellbeing October 2021 report points out, the demand for mental health care has increased, the behavioral health workforce has reached a tipping point, and access to care is now a critical public safety concern.

When considering the data from ASWB’s 2022 exam pass rate analysis, it appears that clinical exams are reducing public access to care through effectively reducing the number of licensed practitioners of particular racial and ethnic backgrounds, including Black therapists.

Furthermore, there is currently no evidence these exams improve the quality of mental health care that is available.

In light of these concerns, the ongoing use of clinical exams arguably violates the mission and purpose of the licensing boards to ensure increased availability of licensed mental health practitioners, rather than advancing that mission.

Potential Conflicts of Interest

Most of these clinical mental health exams (with the exception of counseling exams, which are developed by an independent group) are developed by state licensing boards acting as a group.

In Psychology, the Association of State and Provincial Psychology Boards (ASPPB) develops the EPPP and EPPP-2.

In social work, it’s the Association of Social Work Boards (ASWB).

In MFT, it’s the Association of Marital and Family Therapy Regulatory Boards,(AMFTRB), whereas the California Board of Behavioral Sciences develops the California MFT Clinical Exam.

This puts individual state boards in the awkward position of being both the buyer of an exam (as a board choosing to use the exam) and the seller of that exam (through their role in the associations), which is a clear conflict of interest.

This means these boards have economic and other incentives to continue to blindly accept the validity and usefulness of these exams, because they had a direct role in supporting the exams’ development.

These associations of boards, as private organizations, are not bound to the open-meeting and public records laws that govern individual boards, shielding them from public accountability.

Even if individual boards want to use alternate processes for licensure, in many states they can’t. State statutes often mandate that mental health professionals pass a clinical exam for licensure.

In many cases, the licensing exam offered by the association of boards is the only one available—this is the very definition of a monopoly.

With no concerns over market competition, exam developers have little incentive to research or improve their exams nor to allow external researchers or the public access to exam data.

The Exam Developers’ Response

In attempting to reassure state licensing boards that their exams are appropriate and defensible, exam developers have raised a number of arguments.

On the issue of racial disparities in exam outcomes, the ASWB points out that they have a committee dedicated to identifying racial bias in exam content.

Additionally, they point out that they use statistical processes to identify items that appear to perform differently on the basis of race.

However, since at least 2009, there has been discussion that bias review committees don’t work in general.

And, some critics have said the ASWB’s specific statistical process for assessing bias was so poorly designed that it was sure to miss racial bias even where it was plainly occurring.

The ASWB has also placed responsibility for disparate outcomes on “upstream factors.”

Essentially, the ASWB argues that disparities in exam results by race accurately reflect differences in preparedness for the exam among different groups of exam candidates.

Furthermore, while the ASWB is funding research exploring these upstream factors, the group is not providing external funding for any independent investigation or research into the exams themselves.

In responding to concerns about clinical exams’ lack of predictive validity, ASWB has argued that predictive validity is not relevant for licensing exams.

The ASWB suggests that content validity—that the content of the exam sufficiently appears to reflect current practice—is sufficient.

The Professional Organizations’ Response

National professional organizations in psychology, counseling, and marital and family therapy have largely chosen to stay out of the discussion about racial bias in clinical exams.

Some smaller psychologists’ organizations, such as the Association for Behavioral and Cognitive Therapies (ABCT), have opposed the planned EPPP-2 implementation, citing concerns about its cost, necessity, validity, and equity.

Grassroots opposition to the EPPP-2 has also emerged, and some state boards have voiced reluctance to adopt the new test. ASPPB responded in October 2022 by making EPPP Part 2 a requirement.

Meanwhile, the 2022 pass rate analysis report on the ASWB exams galvanized social work organizations to take sides.

For example, the National Association of Social Workers (NASW) now opposes the continued use of ASWB exams at all licensure levels.

Additionally, the Council on Social Work Education (CSWE), the accrediting body for social work programs, wrote to state licensing boards calling for them to at least temporarily pause use of ASWB exams. CSWE also stopped using exam pass rates as a measure of program quality.

State Board Actions

Some state boards may be caught in a difficult position.

While some state boards may agree that the exams are problematic, they may not have other options available for licensure of mental health professionals.

Many states’ laws mandate that mental health professionals pass a clinical exam before they are issued a license.

The clinical licensing exams in use today are the only viable options that most state boards have under these laws.

Either a new organization would need to develop a competing exam from the ground up, or the state would need to change its laws to no longer require a clinical exam.

That can be a tough sell to lawmakers, who value the appearance of the high professional standard that exams promise—even if that appearance isn’t supported by data.

Even so, at least six states have responded to the ASWB report by introducing legislation that would allow social workers at various levels to achieve licensure without passing an ASWB exam.

Connecticut, Illinois, Maryland, Massachusetts, New York, and Utah have proposed alternative paths to licensure, with other jurisdictions likely to follow.

How to Get Involved and Ensure Your Voice Is Heard

Given the seriousness of the ASWB clinical exam pass rate analysis data, the ongoing discussions and new mandate around the EPPP Part 2, and similar conversations in marital and family therapy and counseling, it’s likely that the topic of clinical exams will be on the agenda for your licensing board to discuss sometime this spring or summer.

Wherever you land on the role of clinical exams in mental health licensure, the most direct way to influence those conversations is to be a part of them. Go to the meeting, and add your voice.

Social workers and allies who are interested in organizing against the ASWB exams can request to be added to the #StopASWB Discord server.

And many local and state-level social work and psychology groups are organizing to address concerns about equity in the mental health practitioner licensing process.