Mental Divide: The Psychology Test That’s Failing Minorities
WHY YOU SHOULD CARE
The odds are loaded against psychologists of color — starting with the professional licensing examination — even if they hold top degrees.
By Molly Fosco
Three months after getting her Ph.D. in psychology from Columbia University’s prestigious Teacher’s College, Karima Clayton was filled with shame.
The 36-year-old from Harlem, New York, had taken the esteemed EPPP — the Examination for Professional Practice in Psychology, which psychologists must pass to practice in America and most of Canada. She had spent hundreds of hours studying and nearly $700 on the exam fee. But she failed. To get her license, she would have to do it all again. “It almost reinforces these stereotypes that you’re ‘less than,’” says Clayton.
Overall, 90 percent of all candidates pass the EPPP on their first attempt. But as a Black psychologist, Clayton’s experience is far from unique.
An OZY investigation reveals that among U.S. psychologists, the odds of entering the profession are dramatically loaded against those from minority communities — even after they’ve earned top degrees, like Clayton.
Just 5 percent of U.S. psychologists are Black, 5 percent are Hispanic and 4 percent are Asian, while more than 80 percent are White, according to the American Community Survey — even though racial and ethnic minorities account for 38 percent of the U.S. population. In other professions, such discrepancies are often explained away by college completion rates that are more than 15 percentage points lower for Black and Hispanic Americans compared to Whites.
But with the EPPP, non-White test-takers are twice as likely to fail to qualify as psychologists despite holding doctoral degrees, according to a previously unreported 2018 survey by the American Psychological Association (APA). The divergence could be even worse, the APA concedes, because the survey was voluntary and some practicing psychologists might not have wanted to disclose their failures.
Through multiple interviews with practicing and aspiring psychologists of color, OZY uncovered the reasons behind this failure rate — including the subtle biases that discriminate against minority test-takers by ignoring their perspectives, starting with the prep materials.
And it isn’t just one survey. A comprehensive 16-year review of all EPPP test results in New York by clinical psychologist Brian Sharpless concluded that the failure rate for Black and Hispanic EPPP applicants in the state was 2.5 times the rate for White applicants in the period up to 2017. His research was published in the The Journal of Psychology.
After filing Freedom of Information Act requests with every state, OZY discovered that New York is the only state that tracks demographic details of test-takers. But experts say the differences in pass rates in New York are likely reflected nationwide — the APA survey did not find any meaningful difference between pass rates in New York and the rest of the country. Nationally, the representation of ethnic minority groups in the psychology profession is 23 percent lower than in the overall workforce.
In responses to OZY, the Association of State and Provincial Psychology Boards (ASPPB) — the organization that prepares the EPPP — denied any discrimination. But the crisis this high failure rate is spawning is real.
Ethnic minorities are more likely to experience risk factors such as poverty and poor health that ultimately spark mental health issues, yet only 1 in 3 African Americans who need mental health care receives it, according to a study in the journal Psychiatric Services.
Those barriers represent a ticking time bomb for mental health in America, according to experts. The country needs “a full range of competent therapists available to help the full range of individuals,” says Sharpless. With America projected to turn majority non-White by 2045, that need will only grow.
Graduate school was where Clayton, the daughter of Jamaican immigrants, learned the full extent of what her profession could offer, through classes that fostered self-awareness. They helped her understand “why I think about the material the way I do as a person of color.” But when she took the EPPP in fall 2016, none of the questions tested candidates on “working with specific populations, specifically cultural content” in the real world. “They’re testing you on things that do not matter in our day-to-day clinical work,” she says.
Carlton Everett Green, a licensed psychologist and the director of diversity training and education at the University of Maryland, agrees that’s a key reason Blacks and Hispanics fail the EPPP more than Whites. “As we study, one of the things we try to do is bring a critical lens,” says Green, who is African American. He passed the EPPP on his second try in 2015. “We’re unpacking or undoing some of the ways traditional psychology has harmed communities of color.”
For example, if a gay teen is not accepted by their family for religious or cultural reasons, mainstream psychology literature often suggests they separate from their family. But for many people of color, that’s not an option, says Green. “To say ‘just leave your family’ is like telling a person of color to give up a part of him or herself,” he says. “I’m never going to advocate [that].”
The EPPP expects test-takers to regurgitate accepted views, Green says. Many psychologists of color have been pushing for a more critical analysis of the field, “but the EPPP does not value that,” he adds. “You almost feel erased in the process of taking the test.”
The ASPPB, the organization that prepares the EPPP, isn’t blind to this criticism. “We have, indeed, received this feedback and take it very seriously,” says Matt Turner, senior director of examination services. The exam body creates the test specifications after surveying thousands of American and Canadian psychologists, asking what they think entry-level professionals need to know.
But candidates often face biases against minority perspectives right from when they’re preparing for the exam. While only applicants inside the exam room can view the actual EPPP, Kip Thompson, an African American clinical psychologist and assistant professor at Fordham University in New York, recently dug up old preparatory material he had used. Thompson passed the EPPP on his first attempt in 2017.
One ethics question presumes that the test-taker would be troubled by clients with a history of criminal offenses and asks what an “ethical psychologist” should do. The “correct” answer is that the psychologist should refer the client to another professional. “But you might come from a community where people have a lot of offenses, and that might not bother you,” Thompson says. “You’re automatically trained to think that any type of past offense is bad.”
Another question asks the test-taker what they would do if a client demonstrates suicidal tendencies. The “correct” answer? The psychologist should get the client to sign a “no suicide contract.” But Thompson wonders why another option — alerting the client’s family — is necessarily wrong, since therapists are allowed to break doctor-patient confidentiality when a life is on the line. In many minority communities, strong families represent vital support structures for individuals. In such cases, “reaching out to the family might be your first option,” he says.
Turner says the questions did not come from the exam body and were likely designed by an independent test-preparation company.
That may be, but to psychologists like Thompson, the prep material and the EPPP’s refusal to question traditional psychology reflect how the exam is trying to find out if you’re a successful test-taker — not whether you’d make a good psychologist. “And the successful test-taker is less likely to be someone from a racially underrepresented group.”
That’s partly because of deep-rooted economic disadvantages. There’s no limit on the number of times an applicant can take the test. But the EPPP costs $687.50 each time in most states, not including study materials. Thompson spent $450 on one month of an Academic Review online subscription and studied for close to 500 hours over nine months. At first, he was working full-time while also studying for the exam, but then he was laid off. Luckily, his family was able to support him financially.
That’s not something many minority families can do. At $40,000, the real median household income for African Americans is 40 percent lower than for Whites ($68,000), according to the U.S. Census Bureau. For Hispanics, that figure is $50,500. “People who have more financial resources can get the most up-to-date, sophisticated study resources,” says Thompson. “But if you’re not in that category … then you have to make do with what you have.”
Melody Coste Sibilia, 35, first studied psychology in her native Puerto Rico before moving to mainland America with the dream of providing therapy to native Spanish speakers. She got her doctorate and took the EPPP in Virginia in 2017 for the first time. She didn’t pass until her third attempt. “The questions are so confusing because English is my second language,” Sibilia says.
For psychologists like her who primarily work with underserved, Spanish-speaking clients — in her case, people from Puerto Rico — Sibilia believes it would make sense for psychology boards to offer the EPPP in that language. America has more than 40 million native Spanish speakers.
Yet while Canadians can take the EPPP in French — Canada’s second language, as Spanish is in the U.S. — test-takers can’t attempt the exam in Spanish anywhere in America. Turner concedes the exam body only offers the test in a language other than English where it’s mandatory. The EPPP was offered in Spanish in Puerto Rico until 2017, when the territory stopped requiring it.
Sure, most examinations in the U.S. are conducted in English alone. But few occupations need the level of trust between a client and the professional that therapy demands. Lawyers — irrespective of who their clients are — need to know English because that’s the language of the court. For psychologists, the language necessary for them to communicate effectively with their clients is what matters most, say therapists.
“Diverse psychologists … [help] provide access to adequate psychological services to non-English speaking patients,” says Maria Espinola, who teaches clinical psychiatry at the University of Cincinnati and is originally from Argentina. A 2007 study in the Journal of Psychotherapy Research found that patients who prefer a therapist of their ethnicity, and are matched accordingly, have a better treatment outcome.
Sibilia now works at a Veterans Administration hospital in Augusta, Georgia, and frequently encounters native Spanish-speaking veterans who are told they have personality disorders but who she thinks are misdiagnosed. “Sometimes therapists think it’s a disorder, but really it’s just a cultural or language barrier,” she says.
Adriana Zuno, a graduate student in psychology at Santa Clara University, struggled for years to find a Latina therapist when she was suffering from depression as a teenager. A White therapist she saw was qualified but “lacked cultural sensitivity” and was unable to communicate well with her parents, who didn’t speak good English, she says. Now seeing a Latina therapist, Zuno feels safer and more connected because they have a similar background.
But many experts have an even more fundamental concern about the EPPP: that it hasn’t been tested itself. The exam, administered by computer-based testing service Pearson VUE, is meant to assess “entry-level knowledge of domains ranging from ethics to research methods.” About 4,000 people take the test each year and need to answer 225 multiple-choice questions over 255 minutes.
Yet there are no published studies showing whether EPPP scores are correlated with how well applicants go on to perform as therapists. Other professions’ licensing exams, for social workers and for entry to the bar, for example, have undergone peer-reviewed studies that helped identify the need for changes.
In order to take the EPPP, you must have your doctorate. But “most people have to study 100 to 200 hours to pass,” says Sharpless. “Why is it so hard for people with doctorates to pass an exam assessing ‘foundational’ knowledge?”
Barbara Prempeh is the first person in her family to go to college. She earned a doctoral degree in psychology from Kean University in New Jersey. But she’s becoming increasingly frustrated with her career. Prempeh has taken the EPPP twice and failed both times.
A mental health clinician at Metro Regional Diagnostic and Treatment Center in Newark, New Jersey, she often works with victims of trauma and abuse. Her current role doesn’t need her to be licensed. But because she hasn’t cleared the test, “there’s a limit to the responsibilities I can have,” Prempeh says.
Yet taking the test again isn’t an easy decision. The disadvantages that hobble the prospects of minority test-takers only multiply when they need to take the exam repeatedly. Sibilia, for instance, has spent nearly $4,500 on applications, test fees and study materials.
Turner says the ASPPB has recently begun collecting data on candidates’ racial and ethnic backgrounds to see how they “perform on individual items” in the test. It recruits test-question writers from diverse cultural backgrounds, geographical regions, industry settings and areas of practice and trains them to recognize implicit bias. Those are vital first steps, suggests Jessica Gurley, a clinical psychologist. “There shouldn’t be group differences if the exam is unbiased,” she says.
But the ASPPB can do much more to regain the trust of minority psychologists, say industry professionals. First, the test needs scientific validation, says Gurley. Turner contests the need for external validity studies, but Sharpless says they could be conducted quite easily. Doctoral students are continually assessed on comprehensive exams and by individual supervisors, and he points out that these data sources could be compared with EPPP scores. That’s particularly important, say psychologists, because of sharp differences in fail rates across schools. The pass rate at schools such as the University of Alabama and Arizona State University was 100 percent in 2016 but was less than 40 percent at Alliant International University in Fresno, California.
Better financial support for minority test-takers would also help. The ASPPB board of directors is considering reduced exam fees for low-income candidates, says Turner.
In the meantime, however, earning a psychologist’s license could soon get even tougher. In January 2020, the ASPPB will launch a second examination called “EPPP, Part 2: Skills” that aspirants will need to pass. A more practical exam of this sort is what Sharpless, Clayton, Sibilia and others are demanding — but not in addition to the existing, controversial test, unless it undergoes scientific validation.
The licensed psychologists the EPPP approves need to reflect the range of backgrounds that constitute America, says Clayton. “They should come from diverse backgrounds, [because] we work with diverse populations.”
Until that happens, perhaps it’s not would-be psychologists of color who are failing so much as it is the test.
Black Women OWN the Conversation, a unique TV show produced by OZY and the Oprah Winfrey Network, this fall featured an episode on “mind, body and soul,” looking at the mental health concerns of African American women. Read more here.