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ORIGINAL PAPER
Contemporary Family Therapy
https://doi.org/10.1007/s10591-024-09729-5
there were specic factors that were related to passing and
failing this exam.
Currently, there are two clinical exams used for licensing
marriage and family therapists: the “National Exam,” over-
seen by the American Association of Marriage and Family
Therapy Regulatory Boards (AMFTRB), and the Califor-
nia Clinical Exam, administered by California’s Board of
Behavioral Sciences (BBS). All states use the National
Exam except California (AMFTRB, 2024; BBS, 2024).
Many states add a supplemental part to cover their spe-
cic legal matters (AMFTRB, 2024; Caldwell et al., 2011).
Both exams use a multiple-choice format, with four options
(i.e., A, B, C, D) and rely heavily on vignette-based ques-
tions that require the exam candidate to apply professional
knowledge. The national MFT exam has 180 questions, and
California’s Clinical exam has 170 questions.
This article describes the ndings of a study that explored
prominent factors that inuence the pass rate for those tak-
ing the MFT licensing exams. Given limited research on
the topic, this exploratory study aimed to identify possible
connections between a wide range of factors, including
demographics, university and eldwork experiences, test
anxiety, stress levels, coping strategies, and trauma history.
Based on these ndings, the discussion section includes
Standardized examinations are a common step towards state
licensure within the mental health professions: marriage and
family therapy (MFT), clinical mental health counseling.
(CMHC), clinical social work (CSW), and psychology.
Despite the signicance of such tests in the profession, little
has been explored around specic factors that contribute to
one’s likelihood of passing or failing (Caldwell & Rous-
maniere, 2022). As educators and trainers in the eld of fam-
ily therapy for decades, we have heard about our students’
experiences of struggle with the exam and were curious if
Kevin Lyness
klyness@antioch.edu
Diane Gehart
dgehart@mac.com
Brian Hannigan
bhannigan@antioch.edu
Barrie Birge
bbirge@antioch.edu
Sheiketha Ross
sross7@antioch.edu
1 Antioch University New England, Keene, USA
2 California State University, Northridge, Northridge, USA
Abstract
This article describes the ndings of a study that explored potential factors that inuence the pass rate for those taking
marriage and family therapy (MFT) licensing exams, both the national and California exams. An online, national survey
was conducted to determine factors associated with passing the MFT licensing exams. The survey included measures of
test anxiety, coping strategies, perceived stress, and experience of discrimination. The demographic results included pat-
terns of racial and age disparities similar to those reported by the Association of Social Work Boards (2022), especially
for Black respondents. Specic and readily implemented recommendations for making the current exams more equitable
include (a) changing the phrasing of questions, (b) clarifying and reducing the scope of the content, (c) reducing the
number of questions during the 4-hour period, and (d) ensuring adequate accommodations for disabilities.
Keywords Licensing exams · Marriage and family therapy · Pass rates · Racial disparities · Age disparities
Accepted: 20 December 2024
© The Author(s) 2024
Licensing Exam Pass Rate Disparities in Marriage and Family Therapy:
Using an Analysis of Predictive Factors to Inform a More Equitable
Licensing Exam Process
KevinLyness1· DianeGehart2· BrianHannigan1· BarrieBirge1· SheikethaRoss1
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Contemporary Family Therapy
recommendations for exam improvement, including bridg-
ing age and racial pass rate disparities.
Current State of Research on Licensure
Examinations
Research regarding factors that inuence passing the MFT,
CMHC, CSW, and psychologist examinations is limited,
with much of the related literature being oriented towards
other elds of health, law, and teaching professions (ABA,
2022; Allen & O’Dell, 2007; ASWB, 2022; Caldwell &
Rousmaniere, 2022; Nettles et al., 2011). Below is a sum-
mary of relevant literature.
Family Therapy
Family therapy has minimal published research on its licens-
ing exam. In 2011, Caldwell and colleagues conducted a
study that examined whether students from schools accred-
ited by the Commission on Accreditation for Marriage and
Family Therapy Education (COAMFTE) had higher exam
pass rates than those from regionally accredited schools on
the California licensing exams. They found that students
who graduated from COAMFTE programs had signicantly
higher pass rates on the California exams than those who
came from non-accredited programs. A potential dierence
may be that students with stronger traditional academic
skills are accepted into the COAMFTE program (Caldwell
et al., 2011).
One other article has looked specically at the MFT
licensure exam, though it is quite old at this point, using
data from 1994 to 1996 (Lee, 1998). In that study, the
author was able to examine actual total exam scores on the
national exam in relation to questionnaire data gathered at
the time the participant took the exam for over 1000 test
takers over a three-year period. In that study, gender and
age both aected scores, with women and younger respon-
dents scoring signicantly higher (Lee, 1998). The sample
was over 90% White, with only 1.9% reported as Black.
Lee reported that there was overall signicant variability in
scores by race, but the cell sizes were too small for mean-
ingful group comparisons. Lee also found that 86% of this
sample was taking the exam for the rst time, with 10% tak-
ing it the second time, and 4% taking it for the third or more
time, and that those who were taking the exam the rst time
scored signicantly higher. In addition, test takers who had
graduated more recently relative to taking the exam did bet-
ter, and participants who used multiple preparation methods
also scored signicantly higher. Lee did not report pass rates
for the exam, just total scores on the exam. One advantage
of Lee’s study is that the exam scores came from the testing
service and the questionnaire was administered to those tak-
ing the exam directly, reducing response bias potential.
Counseling and Social Work
Regarding the exam for CMHC, one dissertation (Carr,
2016) was found that began to explore the presence of
test-anxiety in students taking the National Clinical Men-
tal Health Counseling Examination (NCMHCE). The
CSW exam—governed by the Association of Social Work
Boards (ASWB)—is more prominently written about, with
Allen and O’Dell (2007) describing corollary, yet statisti-
cally insignicant relationships between passing the ASWB
exam and being involved with a preparation course. More
historically, Borenzweig (1977) concluded that neither age,
sex, ethnicity, graduate school orientation, eldwork, or
supervisor credentials had any statistical bearing on passing
the social work exam in California in 1977. Interestingly,
the only statistically signicant conclusion for Borenzweig
was that people who passed were more likely to be in their
own personal therapy than those who had failed.
Most recently, the ASWB (2022) published an in-depth
analysis of pass rate data for their licensing exams. Their
analysis included ndings from test-takers from 2011 to
2021 on all ve of their exams, with their clinical exam
closest to licensing exams in family therapy, counseling,
and psychology. They compared the “eventual pass rate”
(p. 4) over the four-year period of 2018–2021 for all can-
didates taking the clinical exam based on gender, age, eth-
nicity/race, and primary language. Their analysis identied
signicant disparities based on age, ethnicity/race, and lan-
guage but not gender. The eventual pass rate over a four-
year period was 82.7% for women and 80.1% for men. In
terms of age, they found that rates dropped signicantly
for older candidates. Over the four-year period of 2018–
2021, pass rates varied by age as follows: 18–29 = 91.0%,
30–39 = 86.1%, 40–49 = 75.5%, 50 and over = 64.8%. A
similar disparity in pass rates was found related to race/
ethnicity: Black = 57.0%, Native American/Indigenous peo-
ples = 73.5%, Hispanic/Latino/a = 76.6%, Asian = 79.7%,
Multiracial = 86.6%, White = 90.7% (ASWB, 2022). The
ASWB (2022) also found that candidates whose rst lan-
guage was English had an 83.4% pass rate, whereas 70% of
candidates who spoke English as a second language passed.
In their discussion of age disparities, the ASWB (2022)
identied factors such as increased family, nancial, and
professional responsibilities as a possible reason that older
exam candidates may nd it hard to prioritize exam prepara-
tion. Similarly, regarding racial disparities, they suggested
that lower household income and wealth, educational
inequities, and lower rates of health coverage as possible
explanations. Additionally, they posited that stereotype
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Contemporary Family Therapy
threat—an individual’s fear that their test performance may
conrm negative stereotypes—could also be a factor.
Psychology
The Examination for Professional Practice in Psychol-
ogy (EPPP; Association of State and Provincial Psychol-
ogy Boards, 2024) is the exam required for licensure as a
psychologist. Sharpless (2019, 2021; Sharpless & Barber,
2013) has published several recent articles exploring factors
that inuence pass rates for the EPPP, including demograph-
ics and program characteristics. Sharpless has consistently
found that minority racial status (especially being Black) is
related to poorer pass rates on the EPPP.
Regarding program characteristics, Sharpless and Barber
(2013) found that GRE scores, percentage of minorities in
the program, and internship match rates were all predictive
of pass rates for graduates, and they also found that those
with PhDs passed the exam at higher rates than those with
PsyDs. Chaparro (2020) also explored the eects of numer-
ous variables (i.e., GRE scores, gender, program type, years
to completion, etc.) on EPPP pass rates and found only
admission rates of one’s college/university to be statisti-
cally related to pass rates. As admittance rates decreased,
pass rates increased (Chaparro, 2020). All other variables
within Chaparro’s work were unpredictive of passing the
EPPP. In another study, Macura and Ameen (2021) spoke to
pass rates for the EPPP and identied statistically signicant
relationships between passing the test and race (White psy-
chologists had higher rst-time pass rates), degree type, and
institution accreditation status. Macura and Ameen (2021)
also highlight anecdotal accounts of study material usage,
study time, personal life factors (i.e., unexpected life events
at time of exam), and challenges with test accessibility.
Racial Disparities
In their 2022 report, the ASWB (2022) concluded that sys-
temic issues are likely related to ethnoracial dierences in
pass rates. They noted that historically marginalized groups
often experience higher rates of socioeconomic hardship,
higher poverty rates, inequities in educational resources, as
well as lower rates of health coverage, wealth, and home
ownership. These factors may aect exam candidates’ access
to preparation resources and time to study. Another possible
contributing factor to pass rate disparities the ASWB identi-
ed was stereotype threat, dened as an individual’s fear
that their performance may reinforce preexisting negative
stereotypes.
McWhorter (2022), a Black linguist at Columbia Uni-
versity, oered another explanation for ethnoracial dis-
parities in exam pass rates. McWhorter believes that these
disparities have an added dimension of social class, a fac-
tor identied as contributing to pass rates in this study.
McWhorter cites a classic study in linguistics in which the
language socialization of working-class Black families was
compared to middle-class white families. In working class
Black families, the conversations between parents and their
children focused on practical problems: addressing prob-
lems in the real world with less reliant on book knowledge.
In contrast, middle-class suburban parents engaged their
children in conversations that involved “disembodied infor-
mation-seeking,” (para. 9) discussing facts for facts’ sake
with no direct real-world value. These linguistic dierences
have been observed across ethnoracial groups, meaning that
White working-class families have patterns more similar to
Black working-class families.
There have been several race-based critiques of licensure
exams that are relevant here. Caldwell and Rousmaniere
(2022) state:
After more than 50 years of use, there remains no
evidence that clinical exams in mental health care
improve the quality or safety of that care. Absent
such evidence, our reliance on these exams is built on
trust, from professionals, policymakers, and the pub-
lic…With ample evidence of racial disparity in exam
performance, credible and longstanding criticisms
that have not been adequately addressed, and poten-
tial conicts of interest among boards serving as both
exam buyers and sellers, that trust is not deserved.
(Caldwell & Rousmaniere, 2022, p. 3)
Similarly, Kendi has said this:
[T]oday, many Americans still imagine an achieve-
ment gap rather than an opportunity gap. We still
think there’s something wrong with the kids rather
than recognizing the[re is] something wrong with the
tests. Standardized tests have become the most eec-
tive racist weapon ever devised to objectively degrade
Black and Brown minds and legally exclude their bod-
ies from prestigious schools. (2020, para. 12)
The National Education Association subtitled their report
on racism in standardized testing “From grade school to
college, students of color have suered from the eects of
biased testing” (Rosales & Walker, 2021, p. 1). In discuss-
ing bias in teacher preparation programs Petchauer (2014)
says: “Because African American test takers are roughly
half as likely to pass basic skills exams on their rst attempt
compared to White test takers, this portion of the licensure
exam is a key gatekeeper to the eld and directly shapes the
racial diversity of the profession.” (p. 1).
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Contemporary Family Therapy
choice, with a single correct answer; often based on a very
brief case vignette) is an inappropriate vehicle for perform-
ing and assessing ‘knowledge’ relevant to professional clin-
ical practice” and recommends suspending licensing exams
until the exams are able to meet the industry standards (p.
15; emphasis in the original).
Factors Influencing Examination Anxiety
A critical consideration when exploring exam pass rates is
test anxiety. The consequences associated with test anxiety
are far reaching and well documented, resulting in lower
motivation (Elliot & McGregor, 1999), diminished cogni-
tive ability, and reduced immune system function, which all
lead to lower test scores, grades, and opportunity (Eysenk
& Calvo, 1992, Sarason, 1988; Zatz & Chassin, 1983). Test
anxiety has been found to aect females more than males
(El-Zahhar & Hocevar, 1991; Speilberger, 1980; Zeidner
& Nevo, 1993). Females may perceive test taking as more
threatening, experiencing emotions such as fear, worry, and
anger. Males may experience test taking as more of a “per-
sonal challenge” (Peleg-Popko, 2004, p. 649), using anxiety
in a more productive way.
Research about specic factors aecting individuals
taking the MFT licensing examination is sparse. However,
becoming a licensed MFT takes an enormous commit-
ment of time, energy, and resources. Although states have
the nal say in what is required to be a licensed practicing
MFT (Lyness, 2020), the amount of work to become a clini-
cian is signicant. The overall stress of completing: eleven
required courses, a specic amount of supervised client clin-
ical hours, at least 1000 h of postgraduate clinical work and
200 h of postgraduate supervision, and a passed licensing
exam is anxiety provoking (West et al., 2010). Test anxiety,
a multidimensional issue, includes worrying about exams,
lack of condence in test performance, thinking about fail-
ure and the consequences. The emotional part of test anxiety
includes feelings of “tension, apprehension, and nervous-
ness towards [an] exam” with congruent somatic feelings
experienced, such as “nausea, sweating and increased heart
rate” (Sansgiry et al., 2005, p. 122). Also contributing to test
anxiety is a student’s perception of how dicult the study
material is. Research to identify specic stressors that aect
Doctor of Pharmacy students was done at two diverse uni-
versities, Howard University and the University of Hous-
ton (Sansgiry et al., 2005). Test anxiety has been negatively
attributed to academic performance, academic competence,
test competence, and time management (Sansgiry et al.,
2005). An empirical study of test anxiety revealed that aca-
demic competence and test competence predictors were
the most signicant predictors of test anxiety (Sansgiry
et al., 2005). At the University of Houston, students were
Caldwell and Rousmaniere (2022) summarize the issue
of race in licensure exams well:
Clinical exams have been repeatedly shown to pro-
duce disparate outcomes on the basis of race and eth-
nicity. Rather than being passive recipients of existing
disparities, evidence suggests that clinical exams add
a unique layer of structural racism to the process of
mental health licensure. Clinical exams also limit the
mental health workforce by constraining licensure–a
function that would make sense if there was evidence
of their benet, but without such evidence, only serves
to reduce the supply and diversity of mental health
care professionals available to serve the public. (p. 4)
There is a clear ongoing critique in the literature around race
and racial bias in these exams, and our data contributes to
that critique.
Psychological Testing Standards
Caldwell (2023) analyzed the current mental health licens-
ing exams in terms of their adherence to industry standards
for testing, specically Standards for Educational and Psy-
chological Testing established by the American Educational
Research Association (AERA). Caldwell notes that mental
health licensing exams fail to meet many of the required
standards for fair and equitable testing. First, the exams do
not meet the standards for construct clarity, which would
require a clear description of what exactly is being tested. In
stark contrast to testing norms, licensing exam test develop-
ers provide vague lists of general topics rather than clearly
identifying the specic knowledge covered on the exam.
Second, the author notes that these exams also fail to meet
the standards of construct validity–evidence that the test
accurately measures what it says it measures–and criterion
validity—the standard by which the scores are interpreted
and used to make decisions. None of the licensing exam
developers in mental health have taken reasonable eorts to
assess whether these exams meaningfully assess a person’s
ability to be an eective, independent practitioner despite
the use of these exams for decades to determine such readi-
ness. The AERA standards also require that test developers
ensure that their tests are fair to all test-takers, which most
licensing exam test developers have ignored until recently.
Finally, testing standards also require rigorous statistical
analysis to ensure that individual exam items as well as
the exam itself are not biased toward groups of test takers.
However, developers of mental health licensing tests either
ignore or downplay the importance of using statistical anal-
ysis to reduce test bias. Caldwell concludes that “the over-
all structure of these exams (primarily four-option multiple
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Contemporary Family Therapy
stress; study habits, past experiences, health aspects, course
content, test situation, motivation, self-concept, the expecta-
tion of student and parental pressure may impact examina-
tion anxiety.
There is some research that specically looks at the role
of coping with stress and test anxiety in professional exami-
nations (see Amate-Romera & de la Fuente, 2021). We were
interested in exploring whether specic coping strategies
would be related to passing the LMFT exam, including
exploring emotion-focused and problem-focused coping
(Amate-Romera & de la Fuente, 2021; Tobin et al., 1989).
Context for Current Study
Minimal research exists on predictive factors related to
exam pass rates on MFT exams specically and mental
health licensing exams more broadly. Both prior studies on
MFT pass rates are well over a decade old, with one report-
ing on data from the mid 1990s (Caldwell et al., 2011; Lee,
1998). These studies identied the following factors related
to passing the MFT exam: age, gender, COAMFTE-status
of graduate program, number of exam attempts, and timing
of exam relative to graduation. Signicant variability was
identied in scores by race, but the cell sizes were too small
in the study for meaningful comparisons (Lee, 1998). More
recently, the ASWB (2022) released a report indicating age
and race disparities in their exam pass rates. Additionally,
in a recent analysis, Caldwell (2023) determined that the
current mental health licensing exams fail to meet industry
standards for fair and equitable testing. Other research has
indicated that text anxiety is a signicant factor aecting
general exam pass rates, aecting women more than men.
In addition, coping factors in dealing with stress have been
linked to test anxiety in professional examinations. Anec-
dotal information and the stories told to us as educators
suggest that there may also be other signicant barriers to
passing the licensure exam and so in this exploratory study
we sought to examine all of these factors and how they con-
tribute to passing the licensure exam. Additional variables
of interest from these more informal sources included over-
all levels of perceived life stress, experiences of discrimi-
nation, as well as several specic barriers, including those
related to logistics around the examination process, ade-
quacy of disability accommodations, and factors related to
the Covid-19 epidemic. Our overall research question was
to explore which of these factors was signicant in predict-
ing whether participants reported passing the LMFT licen-
sure exam. While we had some directional hypotheses (e.g.,
that test anxiety would be negatively related to passing the
exam) we approached the analysis in an exploratory fashion
trying to identify signicant factors reported by participants
related to their reported passing of the exam.
comfortable with their pharmacology classes. However, the
study material given to the students for the exam and the
amount of preparation time necessary may have increased
test-taking anxiety (Sansgiry et al., 2005). This research is
cited, along with earlier noted research on test anxiety in the
counseling exam (Carr, 2016), to show that there may be
a link between this anxiety and performance on important
professional examinations like the licensure exams in MFT.
Carr’s study is the only study we could nd that directly
examined the link between test taking anxiety and profes-
sional licensure exams, but we felt this was an important
variable to explore for the LMFT exams.
Stress, in general, is part of most academic and licensure
testing. However, when stress becomes extreme, it leads to
anxiety and ultimately impacts academic achievement. Stu-
dent stress seems to be universal. A review of the study done
by Kumari and Jain (2014) in India showed signs of stress
that impact exam achievement is: insucient or irregular
sleep, feeling tired, isolated or sad, experiencing somatic
conditions; upset stomach, restlessness, which all led to the
inability to recall what the students have studied (Kumari &
Jain, 2014). Addressing stressors: lifestyle (rest, nutrition,
and time management), preparation of information before
the test (date of exam, location of exam, content covered,
paperwork required), while reducing catastrophic thinking
(“there is no way I am going to pass this”) and irrational
thoughts (“I will hate myself if I fail”) (Kumari & Jain,
2014) are all critical to reducing examination stress.
Another study researched undergraduate nursing stu-
dents and the factors that inuenced their examination anxi-
ety. Once again, the researchers determined too much stress
confuses, exhausts, and overwhelms students’ test-taking
ability. Three hundred and forty undergraduate nursing stu-
dents (90.3% female) with a majority of 61% experienc-
ing average amounts or no test anxiety, 25% with mild test
anxiety, and 2% experiencing severe test anxiety were the
sample (Vaz et al., 2018). The study looked at four factors
impacting test anxiety: “learning process” (study habits,
preparedness, course content, sleep pattern, motivation),
“perceptions related to examinations” (condence level,
expectations, experience, test situation, health aspects, and
recall), “learning patterns” (how students deal with chal-
lenging subjects, time management, revision), and “over
expectations related to learning outcomes” (expectations of
parents and student) (Vaz et al., 2018). The research showed
that all four factors had a positive correlation (0.05) to
examination stress. Perceptions related to examination and
learning patterns had a moderate correlation (r =.655 and
r =.368), and the least correlated factor was over expecta-
tions related to learning outcomes factor and had the weak-
est correlation (r =.017 and r =.132) (Vaz et al., 2018).
Results from the study point to elements that contribute to
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Contemporary Family Therapy
Social Support, Problem Avoidance, Wishful Thinking,
Self-Criticism, and Social Withdrawal). These can be com-
bined into four secondary factors (Problem Engagement,
Emotion Engagement, Problem Disengagement and Emo-
tion Disengagement) and two tertiary factors (Engagement
and Disengagement) (Tobin et al., 1989). We utilized the
primary factors in our analyses.
Perceived Stress Scale
The Perceived Stress Scale (PSS; Cohen et al., 1983) is a
short 10-item measure of respondents’ perceptions of the
amount of stress experienced in the past month. The items
are measured using a 5-point Likert-type scale (0 – never to
4 – very often). Four of the items are reverse-scored, and the
overall score is a total of the items, ranging from 0 to 40. In
addition to perceived stress, we asked a few questions about
history of trauma.
Everyday Discrimination Scale
The Everyday Discrimination Scale (EDS; Williams et al.,
1997) is a short measure of 10 questions that get at experi-
ences of discrimination as well as the attributed reason for
that discrimination (including a wide range of possible rea-
sons). The rst nine items are measured on a 6-point fre-
quency scale (1 – never to 6 – almost everyday) while the
nal item asks what the respondent believes is the main rea-
son for experiences, with response items include ancestry or
national origin, gender, race, age, religion, and so forth. The
overall score is a sum of the rst nine items.
Additional Measures
Our primary measure of exam success was the question
“Have you passed the LMFT licensure exam?” (yes or no).
We also asked how many times the respondent had taken the
exam, with those answering “one” having passed the exam
on the rst try. With this information, we were able to know
whether someone passed on the rst attempt, passed on a
subsequent attempt, or had not yet passed the exam, though
for many analyses we simply used pass/not passed as the
criterion variable. Respondents were also asked whether the
exam was the national exam, the California exam, or both.
We asked a series of demographic questions, about age,
ethnicity, gender, sexual orientation, marital status, income,
and employment status. In addition, we asked about highest
degree level, type of degree and subject area, and whether
the program was accredited by COAMFTE (yes/no/unsure),
as well as the location of the program (by state) and the
delivery model (face-to-face, online, hybrid).
Method
Sampling
Participants were recruited through convenience sampling
via emails to program directors in accredited marriage and
family therapy programs, via postings to social media, and
via emails to email lists accessible to the authors. A sec-
ond round of emails and postings was designed to recruit
additional participants who had not passed the exam as
our initial sample was overrepresentative of those who had
passed. Data collection took place over about two-and-a-
half months at the end of 2021 and start of 2022.
Procedure
We utilized SurveyMonkey (www.surveymonkey.com) as
our online survey platform, and our survey was only avail-
able in English. The survey started with an informed con-
sent document followed by demographics and measures.
The research was approved by the university Institutional
Review Board as an exempt study. It took respondents an
average of 29 min to complete the survey.
Measures
We utilized four already established measures for several
key constructs: test anxiety, coping strategies, perceived
stress, and experiences of discrimination. We then added
additional questions regarding other variables of interest
and demographics. Each of these is described further below.
Westside Test Anxiety Scale
The Westside Test Anxiety Scale (WTAS; Driscoll, 2007) is
a short 10-item measure of test anxiety that has been dem-
onstrated to be correlated with test performance and is a reli-
able indicator of impairment in test performance (Driscoll,
2007). The ten items are measured on a 5-point Likert-type
scale (1 – not at all or never true to 5 – extremely or always
true), and the overall score is an average of those scores
(ranging from 1 to 5). The WTAS was designed to identify
individuals who would benet from an anxiety-reduction
intervention to improve test performance.
Coping Strategies Inventory – Short Form
The Coping Strategies Inventory – Short Form (CSI; Tobin
et al.,1989) is a 32-item measure of coping to manage stress.
There are several ways to interpret the measure. The rst is
to look at 8 primary subscales or primary factors (Problem
Solving, Cognitive Restructuring, Emotional Expression,
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Contemporary Family Therapy
The sample was relatively middle class, with only 15%
reporting incomes less than $50k/year, and almost 22%
reporting family income over $150k/yr. Nearly 75% were
employed full-time, with fewer than 6% not working.
Income was related to pass rates (X2(12) = 57.85, p <.001),
with those with higher income more likely to have passed
on the rst attempt and less likely to have not passed. Simi-
larly, employment status was signicantly related to pass
rates (X2(4) = 11.47, p =.02), with those working part-time
more likely to have passed on the rst attempt and those not
working for pay more likely not to have passed yet.
Regarding marital status, the sample was 60.8% married,
19.3% single, 10.8% cohabiting, and 9.2% divorced. Marital
status was signicantly related to pass rates (X2(6) = 28.35,
p <.001), with married respondents being more likely to
have passed on the rst attempt than those reporting other
marital statuses.
The sample was fairly diverse regarding race; 59.5%
White (n = 187), 13.9% Black (n = 44), 12% Latino/a
(n = 38), 4.1% Asian American/Asian (n = 12), 2.5% other
race (n = 8), 7.9% multiracial (n = 24). Race was signi-
cantly related to passing the exam (X2(5) = 38.34, p <.001).
The pass rates for each group were as follows: White, 87%,
Black, 48%, Latino/a, 66%, Asian or Asian/American, 75%,
other race, 63%, multiracial, 87.5%.
Regarding education, 86.7% had a master’s degree,
with 10.8% having a PhD, and 2.5% a professional doctor-
ate. Regarding COAMFTE accreditation, 74.4% said yes,
17% said no, and 8.5% were unsure; 88.6% had degrees
in C/MFT. Those with PhDs and professional doctorates
were more likely than those with master’s degrees to have
passed on the rst attempt (X2(4) = 9.83, p =.04), but gradu-
ating from a COAMFTE-Accredited degree program was
unrelated (74.1% graduated from a COAMFTE program;
X2(4) = 8.37, p =.08). Program delivery model was strongly
related to pass rates, with students from online programs
(37% passed, group n = 31) being less likely to have passed
the exam, while those from face-to-face programs (82%
passed, group n = 244) and hybrid or low-residency pro-
grams (82% passed, group n = 49) were more likely to have
passed (X2(2) = 28.95, p <.001). Because the face-to-face
and hybrid programs had essentially the same pass rates, for
later comparisons online vs. not-online was used. Programs
were located in 38 states or territories and 4 other countries
(but not Canada), and 36% of respondents went to CA grad-
uate programs (next highest was KY and MN at 6% each).
Preliminary Analyses
We conducted a number of preliminary analyses explor-
ing variables of interest. Self-reported hours of studying
was signicantly related to pass rates—those who studied
Respondents were also asked questions about challenges
and barriers to successfully passing the exam. One question
asked about whether the respondent struggled with test anx-
iety, with knowledge of the content of the exam, and/or with
knowing the correct test-taking strategy for the exam, while
another question about barriers to taking the exam (such as
logistics, inadequate disability supports, language barriers,
etc.). These were in the form of checklists where respondent
checked o barriers or struggles that they had experienced.
For some analyses, we looked at a count of the number of
barriers reported. Finally, we asked some questions about
exam preparation materials used and strategies and time put
in to studying for the exam.
Results
Of the 340 people who started the survey, 317 submitted
it. On average it took about 29 min to complete the survey.
After accounting for missing data, we had 270 complete
surveys. IBM SPSS Statistics (Version 26) was used to ana-
lyze the data.
General Exam Outcomes for Respondents
Overall, 78% had passed the exam (passed 1st attempt,
n = 197, passed on 2nd or subsequent attempt, n = 47, not
passed, n = 69). Nearly 70% of respondents had taken the
exam once while nearly 7% had taken the exam 4 or more
times (the highest was 12 times). Regarding which exam
was taken, 64.2% took the National exam, 31.9% took
the CA exam, 3.8% took both. Pass rates were similar for
those taking the national exam (n = 198; 75.8% passed), the
CA exam (n = 99; 80.8% passed), or both (n = 12; 91.7%
passed) (X2(4) = 3.02, p =.56).
Demographics
The mean age was 43.46 (SD = 12.2). Those who passed
on the rst attempt were signicantly younger (M = 41.86)
than those who had not passed (M = 46.25) (overall
F(2,309) = 4.68, p =.01, Tukey HSD post-hoc test p =.03).
(The p value comparing passed on 1st vs. subsequent
attempts was 0.07, and mean age of that group was 46.13).
The sample was 88% female, 11.7% male, and 0.3%
gender queer. Gender identity was unrelated to pass rates
(X2(4) = 1.53, p =.82). The reported sexual orientation in the
sample was 86% straight, 5% bi, 3.5% lesbian, 2.5% queer,
2% something else, 0.6% gay, 0.6% preferred not to say.
Reported sexual orientation was also unrelated to pass rates
(X2(12) = 11.63, p =.476).
1 3
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Contemporary Family Therapy
We also explored the role of trauma, focusing on a ques-
tion that asked how much negative eect on current func-
tioning the participant reported (from 1 = a great deal to
5 = none). Those who had passed the exam reported sig-
nicantly lower eects from trauma than those who had
not passed (M = 3.07 vs. 3.78, t(285) = 3.96, p <.001). This
variable was also related to other study variables: WTA
r = −.224**, ED r = −.183**, PSS r = −.377**. There were
also signicant correlations with almost all of the coping
measures.
Primary Results
Logistic regression was chosen as the best analytic strategy
to explore what best predicts passing the exam. While we
also had a three-group classication (passed on 1st attempt,
passed on 2nd or subsequent attempt, not passed), the rela-
tionship of nearly all of the predictor variables with this
three-group classication was linear. While we could use
discriminant function analysis, it is less robust, especially to
unequal group sizes like we have here. Logistic regression
also provides easy-to-understand odds ratios and each pre-
dictor shows how strong the eect is while controlling for
all of the other variables and we felt it provides the best and
most parsimonious analysis of the data.
To that end, the rst step was to examine bivariate rela-
tionships, looking for signicant relationships with the
binary pass/not-pass variable. The everyday discrimination
variable was eliminated due to very low correlations with
study variables. We decided to include all of the coping
strategies in the rst regression analysis even though several
showed low correlations with the primary outcome variable
for theoretical reasons (variables that have theoretical simi-
larity are often retained in hierarchical regression models at
the rst step).
The second step was to create a stepwise logistic regres-
sion. The rst block included demographic variables (age,
being Black vs. non-Black, family income, being married
vs. non-married). Because the primary dierences in pre-
liminary analyses were between Black vs. non-Black and
married vs. non-married respondents, these simplied
dummy variables were used in the regression (in the second
block we similarly used online vs. other delivery models). A
second block included variables related to the testing (spe-
cic barriers related to logistics and disability accommoda-
tions, test anxiety, perceived stress, online delivery model,
trauma eects, struggles with test content and test strategy).
The third block included coping strategies.
The nal step in the regression process was to simplify
the model by eliminating variables with p values greater
than 0.25 (trauma eects, social contact, prob avoidance,
more were less likely to pass (probably because folks who
knew they might struggle studied more but still struggled).
There was also a small but signicant positive correlation
(r =.123, p =.032) between hours studying and number of
times taking the test.
We asked if the respondents’ programs had provided
exam preparation training as part of the program (nearly
70% of programs did not provide this), but this was unre-
lated to pass rates (X2 (4) = 7.13, p =.13). Nearly 93% of
respondents reported using formal test preparation materi-
als (and 20 of the 22 people who did not use formal test
prep materials passed the exam on the rst attempt, skewing
the results such that using test prep materials was related to
not passing the exam). Those who reported using test prep
materials reported signicantly more test anxiety than those
who did not, likely indicating that those who are more anx-
ious are more likely to use those materials (t(309) = 2.50,
p =.013). A more useful measure looked at how useful
respondents found the test prep materials, and unsurpris-
ingly those who had not passed the exam were less likely
to nd the materials helpful (scale of 1 – a great deal to
5 – not at all) (oneway ANOVA F(2, 287) = 18.43, p <.001;
M(passed 1st) = 1.56, M(passed 2+) = 1.48, M(not passed) = 2.30).
Kendall’s Tau b correlation was 0.228 (p <.01).
We explored barriers experienced that may have inter-
fered with taking the exam. We looked at this data a couple
of dierent ways. First, we created an index that was a count
of how many of the barriers were experienced (range 0 to
7, M = 1.25, SD = 1.34). This index was signicantly related
to pass rates, with those having not passed reporting signi-
cantly more barriers than those who has passed on the rst
or subsequent attempts (M(not passed) = 2.03, M(passed 1st) = 1.01
[p <.001], M(passed 2+) = 1.13 [p =.001]). We also used logis-
tic regression (looking at the binary variable passed or not
passed) to explore which of the barriers was most predic-
tive of not passing the exam and found that only two bar-
riers signicantly predicted not passing while controlling
for all the others. These were inadequate disability accom-
modations (OR = 4.71, p =.008) and diculty with logistics
(OR = 5.19, p <.001). One note is that African American
respondents were more likely to report having diculty
with logistics (X2(1) = 10.05, p =.002) and there was also a
signicant eect when looking at passing or not passing the
exam (X2(1) = 21.10, p <.001), where there was a signi-
cant dierence in percentage of those reporting no diculty
with logistics by race (but the lack of logistical diculties
was more salient for non-Black participants, with 85.4% of
non-Black participants who passed the exam reporting no
logistical diculties, but only 59.0% of Black respondents
who passed reported no logistical diculties—meaning that
not experiencing logistical diculties was more benecial
for non-Black respondents).
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Contemporary Family Therapy
Barriers: most did not show signicant dierences com-
paring Black to non-Black respondents. One exception
was Diculty with Logistics of the exam (X2(1) = 10.05,
p =.002). (Black respondents reported this diculty 22%
vs. non-Black 7.5%). However, follow-up analysis showed
that Diculty with Logistics was only signicantly related
to not passing exam for non-Black respondents, so even
though they reported this barrier more often, it was less
likely to aect their passing the exam. The pass rate for
Black respondents was virtually identical when looking at
the national exam (51% passed) vs. CA exam (50% passed).
For non-Black participants, it was 81% passed for national
and 84% passed for CA. So, the exam pass rates for Black
respondents cannot be explained by dierences in other
variables (like test anxiety, coping strategies, stress, barri-
ers, or diculties, each controlled for in the analysis and not
demonstrating any dierence between Black and non-Black
respondents). One key consideration, though, is program
delivery.
Discussion
Recently, the AAMFT Diversity, Equity, and Inclusiv-
ity Oversight Committee (2024) published results from a
membership survey with current demographics, though the
response rate was only 1.5%, and it was a survey on diver-
sity, so it is dicult to know how representative these results
are. Regarding race, our results were comparable though the
AAMFT sample was slightly more diverse (53% White,
11.5% African American, 6.4% Latinx/Hispanic, and 4.1%
Asian/Asian American). Our respondents were more likely
to be female (88% vs. 63.8% in the AAMFT sample). Our
sample was signicantly younger (58.2% of our sample was
under age 45, compared to only 30.6% of the AAMFT sam-
ple) though this makes sense given we were targeting those
who had recently taken the licensing exam. Our sample also
consisted of more respondents with just a master’s degree
(86.7% compared to 66%), though again this makes sense
given that the master’s degree is the qualifying degree for
licensure.
The data from this study closely parallel the ndings from
ASWB’s 2022 exam analysis related to gender, age, and eth-
noracial identity. Both studies (ours and the ASWB’s) found
no signicant dierence in terms of pass rate based on gen-
der. Similarly, our study did not nd dierences based on
sexual orientation. However, both studies found a signi-
cant dierence based on age, as did Lee (1998) (Table 2).
In terms of ethnoracial identity, both our study and the
ASWB data showed signicant disparities, which is simi-
lar to research results on licensing exams in teaching, nurs-
ing, law, pharmacy, and social work (ASWB, 2022). In both
and wishful thinking). Each step of the regression showed
signicant improvement in the model.
See table for nal model results Table. 1.
The predictor with the largest odds ratio is coming from
a program with an online delivery model (OR = 7.45), fol-
lowed by inadequate disability accommodations (OR = 4.90)
and being Black (OR = 3.30). Although struggling with test
content and strategy both had relatively large odds ratios,
they were not signicant predictors of passing when con-
trolling for these other variables.
One result of note is that one strong predictor of not
passing the exam is being Black (OR = 3.30). We did sev-
eral additional analyses to explore this result. There were
no signicant dierences by race on any predictors of pass
rates (e.g., text anxiety, number of barriers, perceived stress,
etc.) except for family income and program delivery model.
Black respondents had less income (t(312) = 3.80, p <.001),
and were more likely to have attended online programs
(X2(2) = 16.96, p <.001), and each of these are predictors
of lower pass rates. Further analysis of delivery model also
shows a racial eect. More Black students went to online
programs (24% of Black students vs. 6% for non-Black;
overall X2(2) = 16.96, p <.001) and Black students who
went to online programs were less likely to have passed the
exam than non-Black students at online programs (17.4% of
non-Black students in online programs had not passed com-
pared to 39.1% of Black students). In fact, if you remove
delivery model from the regression analysis, being Black
becomes the variable with the largest odds ratio predicting
not passing the exam.
Table 1 Hierarchical logistic regression examining passing or not
passing licensure exam
Predictor B SE B Odds
Ratio
Age 0.07** 0.02 1.07
Black 1.2* 0.58 3.30
Family Income -0.45** 0.16 0.64
Not Married 0.56 0.45 1.75
Westside Test Anxiety 0.79** 0.29 2.19
Perceived Stress Scale 0.10** 0.04 1.11
Barrier: Logistics 1.19 0.64 3.29
Barrier: Inadequate Disability
Accommodations
1.59* 0.74 4.90
Online Delivery Model (vs. F2F or
Hybrid)
2.01** 0.71 7.45
Struggled with test content 0.77 0.48 2.16
Struggled with test taking strategy 0.89 0.50 2.44
Expressing Emotions -0.55* 0.25 0.58
Self-Criticism 0.50* 0.22 1.66
Social Withdrawal -0.73* 0.29 0.48
Constant -6.65 2.15
Notes: Overall model X2(15 ) = 131 . 9 6 , p <.001. Outcome variable
coded 1 = Passed Exam, 2 = Not Passed
* p <.05, ** p <.01
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Contemporary Family Therapy
in expected directions (self-criticism positively predicts not
passing the exam while emotional expression is associated
with passing the exam). It was somewhat surprising that
problem-focused coping strategies were not predictive of
passing the exam, as might have been expected (see Amate-
Romera & de la Fuente, 2021). What was interesting is that
social withdrawal was associated with passing the exam
(the fourth Emotion-Focused strategy is Social Contact,
which was not a signicant predictor of passing the exam).
It may be that in this instance withdrawing from friends
and others may be an adaptive strategy—perhaps reducing
negative inuences. Interventions focused on coping strate-
gies may then focus on reducing self-criticism. These nd-
ings were signicant in the regression analysis denoting that
these coping strategies are signicant predictors of passing
the exam while controlling for the demographic and other
factors.
Recommendations for Short-Term
Adjustments to Licensing Exams
Licensing of family therapists is a complex ecosystem
with multiple interlocking bureaucratic systems, including
individual state licensing boards, state legislatures, exam
creators and administrators, hundreds of universities, sev-
eral professional organizations, and professional accredit-
ing bodies. None of these systems makes changes quickly
alone. Trying to make sweeping changes across multiple of
these systems is a daunting task that will require higher lev-
els of cooperation than we have typically seen in the past.
Nonetheless, strategic modications to existing exams and
exam practices should be the rst step in reducing dispari-
ties in exam outcomes. These modications include:
Changing the Phrasing of Questions
Given McWhorter’s (2022) explanation for racial dispari-
ties on mental health licensing exams that rely heavily on
disembodied information, the use of over one hundred
hypothetical scenarios to test a candidate’s clinical skill
appears to be contributing to ethnoracial disparities in pass
rates. The ability to analyze disembodied scenarios unfairly
favors those who have more experience with such linguistic
exercises and has been largely attributed to the social class
of one’s family of origin. Vignettes never capture the rich-
ness and complexity of real-life clinical situations, and exam
candidates tend to ll in the gaps of the vignette with their
own clinical and personal experience, often introducing
assumptions and issues that were not in the written vignette.
To reduce the bias, test-writers should write exam ques-
tions that clearly and objectively measure the candidate’s
this study and the ASWB study, Black identifying exam
candidates had signicantly lower pass rates compared
with white candidates, followed by “other” race, Native
American/indigenous, and Latino/a/x. Lee (1998) did not
have enough minority respondents to meaningfully analyze
group dierences.
The consistency and parallel ndings in the ASWB and
current study reveal a concerning pattern, especially when
licensing exams are considered within the broader context
of formal, standardized exams. In contrast to most stan-
dardized exams such as the Scholastic Aptitude Test (SAT)
in which Asian-American candidates often outperform all
other candidates (Reglin & Adams, 1990), in both our study
and the ASWB study, white candidates had an 11–12%
higher pass rate than Asian-Americans, indicating that a dif-
ferent testing dynamic may be at play with licensing exams
compared with traditional high-stakes college exams. At
this time, McWhorter’s (2022) explanation that points to
specic linguistic skills due to social class enabling white
children to develop more “disembodied, information seek-
ing” (McWhorter, 2022, para. 9) abilities is the leading the-
ory for why licensing exams have a distinct racial disparity
pattern (Table 3.
Coping Strategies
The CSI-SF secondary factors include Emotion-Focused
Engagement and Emotion-Focused Disengagement (as well
as Problem-Focused versions of both; Tobin et al., 1989).
Three of the four Emotion-Focused scales were signicant
predictors in the nal regression analysis, with two of those
Table 2 Comparison of this study’s age data and ASWEB 2022 data
Pass rate by Age Current study of MFTs ASWB
2022
(Clinical
exam)
18–29 88.5% 91.0%
30–39 81.6% 86.1%
40–49 77.8% 75.5%
50+70.7% 64.8%
Table 3 Comparison of this study’s Ethnoracial identity data and
ASWB 2022 clinical exam data
Pass rate by Ethnoracial
identity
Current Study of
MFTs
ASWB
2022 (Clini-
cal Exam)
Black 48% 57%
Other race 63% Not reported
Native American No responses 74%
Latino/a/x 66% 77%
Asian/Asian American 75% 80%
White 87% 91%
Multiracial 88% 87%
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Contemporary Family Therapy
1. The rst option involves continuing doing what he is
already doing, which is discussing the case with a col-
league. The problem with this response is twofold: (a)
he is not doing anything new or dierent now that the
client reveals he is in the same situation as the therapist,
and (b) arguably talking with a colleague is not “seek-
ing appropriate professional assistance.” A colleague is
likely to be a friend and biased and may or may not have
sucient clinical experience to be helpful. Professional
assistance would more commonly be dened as a super-
visor, personal therapist, or consultant.
2. The second answer involves providing limited self-dis-
closure to promote empathy, which some theories would
support. Some therapists considered this an appropriate
clinical response, but not all would agree. However, the
question asks about managing the ethical issues in the
case, and this response relates more to clinical issues.
3. In the third option, the therapist is going to great lengths
to ensure crystal clear boundaries and avoid harming
the client due to his personal issues. However, from the
vignette, it is not clear whether he is impaired to the
point of warranting a referral, which ultimately costs
clients money and lost time and typically creates emo-
tional distress.
4. The last option describes how the therapist manages the
situation by not bringing up their personal issues and
instead focusing on the presenting problem. Depending
on the situation, this may be an appropriate direction.
An exam candidate who is familiar with the standard reads
these four answers, there is no quickly identiable correct
answer that directly aligns with the standard. Instead, the
candidate must sift through several options that each has
some merit. To identify the correct answer, the candidate
must notice in the stem that the question asks about what the
therapist “should” do to manage ethical issues, which makes
B and D less desirable because they primarily address clini-
cal issues. This is the rst place where candidates have more
experience with “disembodied information” can catch the
subtle linguistic distinction in the question.
Then the candidate is left deciding between A and C, with
the former describing continuing to do what the therapist
was doing before, which is talking with a colleague but not a
typical form of “professional assistance,” and the later mov-
ing in a very cautious and conservative direction, which is
often the correct answer on licensing exams. The candidate
is left to decide whether to go with an option that is less
formal than the described in standard or a more conservative
option based on the vignette. This is another point where
experience and uency with “disembodied information”
benets the candidate in weighing the pros and cons. This is
knowledge of well-established principles without the use of
hypothetical scenarios that easily introduce bias and cultural
assumptions. It is interesting to note that the recent revision
of the National Clinical Mental Health Counselor Exam
takes the opposite approach: It oers much *longer* clini-
cal vignettes than other mental health exams do, utilizing
11 case examples (NBCC, 2024). This may serve the same
ends: It may reduce instances of examinees adding their
own assumptions and biases into exam questions, though
there is not yet evidence of this.
For example, California’s current clinical exam outline
includes the following sample question (BBS, 2024, p. 27):
A therapist is currently involved in a contentious
divorce and perceives his spouse as aggressive and
unreasonable. The therapist begins meeting weekly
with a colleague for consultation to prevent his feel-
ings from impacting therapy with his clients. Three
weeks later, a client who has been in ongoing therapy
for symptoms of depression begins describing rela-
tionship diculties that are similar to what the thera-
pist is experiencing. Which of the following actions
should the therapist take to manage the ethical issues
involved in this case?
a. Provide continued treatment to the client and discuss
the case with the colleague to monitor own feelings.
b. Utilize limited self-disclosure and reassure the client
of the therapist’s understanding to enhance therapeutic
empathy.
c. Explain the potential for bias on the part of the therapist
and refer the client to an alternate therapist to provide
ongoing treatment.
d. Contain the therapist’s own feelings and focus discus-
sions on the client’s depression to maintain consistency
with established treatment goals.
This question is attempting to assess the candidate’s knowl-
edge related to ethical practice, specically 3.3 of the
AAMFT (2015) Code of Ethics:
3.3 Seek Assistance. Marriage and family therapists
seek appropriate professional assistance for issues that may
impair work performance or clinical judgment.
None of the four answers clearly and unambiguously
align with the ethical standard. Instead, the candidate is
expected to apply the standard to the vignette and the four
answer options. However, many assumptions and leaps of
interpretation need to be made, which is the most likely
source of the current ethnoracial pass rate disparities. Con-
sider the process of answering this question:
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Contemporary Family Therapy
applicability over time and across contexts, these compe-
tencies do not name specics, such as essential theories or
areas of research. Similarly, the condensed version of these
competencies proposed by Northey and Gehart (2019) does
not list specic theories or areas of knowledge to increase
its applicability. Similarly, the MFT accreditation standards
(COAMFTE, 2023, Version 12.5) summarizes the required
curriculum in nine broad areas of knowledge that does not
dene specic theories, practices, research, or areas of
knowledge. Thus, the eld does not have any readily agreed
upon specic areas of knowledge for licensing boards to
build their exams around.
To add further confusion to the exam content, the ques-
tions are initially drafted by subject matter experts, which
the BBS simply denes as licensed MFTs in good stand-
ing and currently practicing, which is lower than typical
academic standards for an expert. When developing items
for the national exam, the AMFTRB has the questions writ-
ten by experts then reviewed and revised by a second com-
mittee appointed by the board, for which the standards are
again not clearly dened (AMFTRB, 2024; BBS, 2024). In
sum, the level of competence of the persons writing exam
questions is dicult to determine.
The BBS (2024) identies 356 areas of content knowl-
edge described over 25 pages of their exam handbook and
specically lists 19 dierent theories, several of which are
listed as “general family systems theories,” “general cog-
nitive behavioral theories,” “general postmodern theories,”
“general psychodynamic theories,” and “general humanis-
tic-existential theories” theories (p. 23–24). Similarly, the
AMFTRB (2024) lists 106 clinical tasks, such as “practice
therapy in a manner consistent with the philosophical per-
spectives found in systemic theory” (p. 17) as well as 70
general knowledge areas, such as “family studies and sci-
ence,” “models of marital, couple, and family therapy,” and
“individually based theory and therapy models” (p. 22).
Even with the long lists of possible content, the exact theo-
ries, research, and practice standards that need to be studied
is unclear. In sum, the scope of the MFT exams is arguably
innite, with the entirety of the knowledge foundation of
multiple disciplines listed as “what to study.”
The content of the MFT licensing exams could be clari-
ed and narrowed to focus on the core knowledge necessary
to protect the welfare of the public and render competent
care by focusing on:
1. Diagnosis: Know how to assess and diagnose all mental
health disorders in the DSM-5-TR that are within our
scope of practice; know when to refer out for those out-
side of our scope of practice.
2. Law and ethics: Know how to use the the AAMFT
code of ethics (CA and national exam) and CAMFT
also an example of how knowing the ethical standard does
not ensure answering the question correctly.
In contrast, shifting to a style of question that eliminates
ambiguity and directly measures knowledge of clearly iden-
tiable and agreed upon exam content would make it pos-
sible for all exam candidates to identify the correct answer.
Using the above question as an example, a less ambiguous
way to assess knowledge of the same ethical standard.
If a therapist is experiencing countertransference with a
client, the ethical standards include the following guidance:
1. The therapist is instructed to seek professional assis-
tance to help them address issues that may impair their
judgment or performance.
2. The therapist is encouraged to use transparency and
appropriate self-disclosure to communicate their empa-
thy with the client’s experience.
3. The therapist is required to immediately refer out all cli-
ents with whom they experience countertransference to
ensure clear boundaries and avoid any possible harm.
4. The therapist is directed to redirect the session to focus
on topics that are more comfortable for the therapist.
The correct answer (A) is much easier to identify when the
question is phrased with a focus on factual knowledge and
without applying the ethical standard to a hypothetical case.
Increasing Content Clarity of and Reducing the
Scope of Content
The age disparity in pass rates that begins with candidates
in their 30s in both the present study and the ASWB (2022)
study is best explained by older students who typically
have more family and work commitments and less time
to study rather than age-related cognitive decline. Having
more clearly dened and narrowly focused content to study
would likely help reduce the current age disparities. In the
course evaluations of an exam preparation program, can-
didates reported studying an average of 100 h, with many
spending up to 200 h, in order to pass their exam on the
rst attempt, which equates to adding a part-time job to their
regular workload: 10 h per week for 10 weeks or 5 h per
week for 20 weeks (XXXX, personal communication).
As noted in Caldwell (2023), the MFT licensing exams
fail to meet industry standards for construct clarity, which
may be due to the eld as a whole not having a clearly
dened scope of required knowledge. Arguably, the closest
approximation to a description of required knowledge for
MFT licensure are the MFT Core Competencies. Published
in 2004 by AAMFT, these competencies are a set of 128
statements about general areas of knowledge and skill to be
an independently practicing MFT. However, to ensure their
1 3
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Contemporary Family Therapy
do further investigation to determine how best to meet the
needs of test-takers with disabilities.
Research Limitations
There are several important limitations in this study. First,
and most importantly, this is self-report data from a con-
venience sample. There is no way to determine if there is
signicant response bias (perhaps participants in one racial
or ethnic group who had not passed were more likely to
respond that those from that group who had passed, skew-
ing the results). In addition, this is correlational data and
we cannot establish causality—we can only note that the
variables are related in this data set. However, given how
our data compares to other similar data, we feel that this is
an important start in exploring these issues on the LMFT
exams.
Conclusion
Like other mental health professions, the eld of marriage
and family therapy must critically examine its existing
approach to licensing exams. Data from multiple studies
indicate clear patterns of racial and age disparities that can-
not be ignored. Although a long-term solution may move
away from multiple choice exams altogether, all existing
evidence demands immediate action. One clear implication
is that we need data on the current exam. We believe that
the AMFTRB and BBS must produce and publish exam
performance data disaggregated by demographic factors,
just as ASWB did. The AMFTRB and BBS can produce
much higher quality data because they would not be reliant
on convenience sampling, and this data is vital in under-
standing the factors that inuence success on the exam.
In addition, the current exams can be rapidly improved by
(a) changing how questions are phrased, (b) clarifying and
reducing the scope of the content, (c) reducing the number
of items during the 4-hour period, and (d) ensuring adequate
accommodations for disabilities.
Acknowledgements We would like to thank Dr. Benjamin Caldwell
for comments on a draft of this manuscript.
Author Contributions KL wrote the main draft including tables and
gures, with BH, BB, and SR all contributing to the literature review
and DG contributing to the discussion. Data collection was conducted
by KL, BH, BB, and SR, with DG contributing research questions. All
authors reviewed the manuscript.
Data Availability The dataset cannot currently be shared in order to
protect the privacy of respondents.
code of ethics (CA) to protect clients and render profes-
sional care.
3. Core MFT theories: Know 8 of the foundational theo-
ries in the eld, upon which newer approaches are built.
Specifying the foundational theories rather than newer
theories signicantly reduces the costs of exam prepa-
ration. We recommend the following 8 theories due to
their enduring inuence in the eld and centrality in
most major theory textbooks in the eld (Gehart, 2024;
Gladding, 2018; Nichols & Davis, 2016):
●Strategic family therapy.
●Structural family therapy.
●Bowen intergenerational family therapy.
●Satir family therapy.
●Emotionally focused couple and family therapy.
●Cognitive-behavioral family therapy.
●Solution-focused therapy.
●Narrative therapy.
Reducing the Total Number of Questions
Anxiety was a signicant predictor of passing the exam in
this study, which is consistent with other studies on text
anxiety (Eysenk & Calvo, 1992; Sarason, 1988; Vaz et al.,
2018; Zatz & Chassin, 1983). One of the major sources
of anxiety for licensing exams is time pressure. On the
National MFT exam, candidates have 240 min to answer
180 questions, approximately 1.33 min per questions, while
on the California exam they answer 170 questions in 4 h,
approximately 1.3 min per question. Most questions require
reading vignettes that are 200 words or more. Test-takers
who have English as a second language, read slowly, experi-
ence stereotype threat, or become anxious for other reasons
are likely to score lower for reasons other than their mastery
of the content (ASWB, 2022).
Thus, another strategy for reducing racial and age dis-
parities is to reduce the number of questions by 50% (90 on
the national exam and 85 on the California) over the same
4-hour exam period. Reducing the time pressure will cre-
ate more equitable testing conditions for candidates from
diverse and working-class backgrounds, who speak English
as a second language, who experience more test anxiety,
and/or who may be older.
Accommodations
Inadequate disability accommodations were identied as
one of the most signicant predictors of passing the exam.
These ndings suggest that the exam testing sites may not be
providing adequate accommodations for those with disabili-
ties, which is concerning. The AMFTRB and BBS should
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Contemporary Family Therapy
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Declarations
Competing Interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons
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