Whenever I get into conversations about the licensing process, a number of the same questions keep coming up. Many of these questions revolve around the value of having a license exam. It’s perhaps the most pesky, the-answer-should-be-obvious-but-isn’t question: Do licensure examinations make for better therapists?
The complaints, heard often, are that (1) licensure exams bear no resemblance to actual therapy, and reward good test-taking skills more than they reward the ability to, say, formulate a working hypothesis about a case; and (2) exams may unfairly disadvantage those for whom English is a second language, which is especially unfortunate given the need for culturally competent mental health services seen across the country.
The first point is relatively easy to refute. Of course licensing examinations do not look like actual therapy — they are not supposed to. They are designed to establish a floor for minimally competent practice, but they do not do this in a vacuum. The many hours of supervised experience one receives prior to licensure are a much better avenue for guiding, and ultimately ensuring, competent practice in the therapy room. Licensing exams focus on conceptualization: are you aware of state law, do you know crisis procedures, etc. Yes, these things could be tested in an in vivo process, but doing so is complicated, expensive, and extremely difficult to do objectively. So a multiple-choice exam, with all its imperfections, has a necessary and important role. Of course, test-taking skills will be rewarded; lots of events in a therapist’s practice will be tests of various sorts, so I have no problem rewarding those who perform well in a structured and stressful environment.
The second point is more complex. The troubling effect an examination process can have on minority applicants is certainly seen in other professions:
[S]tate-mandated teacher testing is associated with increases in teacher wages, though we find no evidence of a corresponding increase in quality. Consistent with the fact that Hispanics have marked lower licensure scores than non-Hispanic Whites or Blacks, testing appears to reduce the fraction of new teachers who are Hispanic (Angrist & Guryan, 2008, p. 483)
Identification of factors associated with National Council Licensure Examination-Registered Nurse (NCLEX-RN) success is critical at public colleges of nursing with diverse student populations. … Significant correlations were found between success in the NCLEX-RN and cumulative undergraduate nursing program grade point average, English as the primary language spoken at home, lack of family responsibilities or demands, lack of emotional distress, and sense of competency in critical thinking (Arathuzik & Aber, 1998, p. 119).
The easiest solution to this problem, at least as far as the exam process goes, is to offer licensing exams in multiple languages. However, there are major political and practical roadblocks to doing so. Politically, public preference for English and opposition to other languages in state programs seems to go in waves, but is unpredictable. As a practical limitation, some family therapy terms simply do not translate well to all languages, and any new version of a licensing exam would need to be re-normed and validated for each new language group. Looking beyond the test process itself, in some locations, the reporting responsibilities of psychotherapists (to report child abuse, for example) must be carried out in English, so language proficiency becomes a necessary and reasonable qualification for the license.
Ultimately, it can safely be said that the testing process (including the lengthy preparation for it that many go through) leads therapists to be more aware of the theories that guide their work and the laws that govern it. It is an objective way of establishing that the therapist’s prior education and experience have provided them with at least a minimal level of competency in the profession. There is little to no scientific evidence, however, that the testing process, in and of itself, makes therapists more clinically effective.
Originally posted December 2008; updated August 2014.References
Angrist, J. D., & Guryan, J. (2008). Does teacher testing raise teacher quality? Evidence from state certification requirements. Economics of Education Review, 27(5), 483-503.
Arathuzik, D. & Aber, C. (1998). Factors associated with national council licensure examination-registered nurse success. Journal of Professional Nursing, 14(2), 119-126.