Robin Phillips, Ph.M.: Thank you so much for joining us here at AATBS to talk about your experience with the National Clinical Mental Health Counseling Exam (NCMHCE). Let’s start by having you introduce yourself to our readers.

Alyson M. Carr, Ph.D., LMHC: Thank you for having me, Robin – I’m really happy to be here with you today. My name is Alyson Carr and I’m a Counselor Educator – I specialize in NCMHCE Preparation. I’ve conducted research on the factors that stand in the way of test takers passing the NCMHCE and when I’m not facilitating NCMHCE Prep Workshops, the majority of my days are spent helping test takers prepare for the NCMHCE and working one on one with interns actively studying for the exam.

RP: Can you tell us about your own experience with the counseling exam and what you learned from that?

AC: Absolutely. My first exposure to the NCMHCE involved failing miserably and having to really examine who I was, what I was doing, and whether or not I even belonged in the profession. You’ve shared about that in a previous AATBS blog post here so I won’t go into a lot of detail now. Suffice to say, like many test takers who fail the NCMHCE, being knocked down was what allowed me to grow in the personal ways I truly needed to at that time. But failing the NCMHCE also helped me to grow in professional ways: my failing score on the exam is what motivated and inspired me to begin specializing in NCMHCE preparation. You know, Robin, if I hadn’t failed the NCMHCE I would have never conducted the research that ultimately informed my dissertation topic!

RP: Fascinating. And for the sake of our readers, if I may, I’d like to point out that you were recently interviewed by The Thoughtful Counselor Podcast about your article, “Why Failing the NCMHCE Felt So Good,” which was the most readCounseling Today article of 2016. Here’s a link to the podcast:

A License to Fail: How Personal and Professional Failure Make You a Better Counselor with Alyson Carr

But getting back to my questions. In your experience helping candidates prepare for the NCMHCE, what would you identify as the primary barriers that hold people back from success?

AC: Although every person’s experience with the NCMHCE is unique, there are a few factors I see consistently that are barriers to success. These include (1) not knowing how to prepare/what to study, (2) real world experience clouding judgment, and (3) struggling with test anxiety.

RP: Could you expand on each of these for our readers?

AC: Of course. Obviously, the variable of not knowing how to prepare or what to study can lead to an undesirable outcome on test day, right? How could anyone be successful on a test if they don’t know how to prepare? This issue of not knowing how to prepare or what to study can also be very frustrating for test takers as they anticipate their exam date. Unfortunately, this frustration can make studying aversive, which typically leads to the task being avoided all together, or endured with resistance, which results in the test taker being distracted and not fully grasping the material being studied.

When I say that real world experience can be a barrier to success, what I mean is that when test takers try to apply their real life knowledge on the exam sometimes it can actually steer them in the wrong direction. For example, perhaps an established protocol at an agency requires screening every client who comes through the doors for suicidal ideation – if a test taker applies this real life protocol and “conducts a suicide assessment” in a case with a 6-year-old client who is eating rocks and chalk and has no symptoms of depression or suicidal ideation, this selection would likely be irrelevant and therefore incorrect on the actual exam even though it might align with standards of practice in one’s work setting.

As far as test anxiety is concerned, this factor presents issues for many test takers in a variety of ways. For example, some test takers are test anxious in any/all testing situations whereas others have developed test anxiety in response to unsuccessful exam attempts. Some test takers I work with have no history of test anxiety and haven’t taken the exam before but instead experience debilitating anxiety related to the NCMHCE because of what failing might mean for their professional lives. A counselor’s current position at work and their ability to fulfill obligations made to colleagues often depend on a passing score, and when the stakes are so high this can cause test anxiety even for those who do not normally struggle with it.

Interestingly, of the hundreds of people I have talked to about their experiences with failing the NCMHCE, not one has said that they weren’t impacted by test anxiety….

RP: Let me just stop you there for a minute Alyson, to check that I heard you correctly. You’re telling me that of all the hundreds of people you’ve spoken to, not one single person felt that their performance wasn’t impacted by test-taking anxiety?

AC: That’s correct for the re-takers I have worked with, Robin. But, the bottom line is that whether an intern is a first time test taker or a re-taker, this process is emotionally and mentally challenging for everyone to some degree. With that said, it’s hard to envision what the picture would look like if the licensure process and this exam weren’t such a rigorous undertaking. Could you imagine a world where mental health practitioners who have such a huge responsibility to clients feel something like “Whew! My credentialing exam was so easy!” Take a second to think about a cardiac surgeon who is about to perform open heart surgery on your loved one thinking the same thing about his/her board exam and credentialing procedures…Oy vey!

RP: That’s a really important point, Alyson, because a lot of uninformed lay people have this idea that a counselor just has to be a good listener and then offer opinions on how someone can deal with their problems, but this is far from correct. Tell us about some of the things a counselor has to be trained in and which of these the counseling exam is designed to test.

AC: The view you describe is very far from an accurate understanding of the responsibilities of a mental health counselor. Although a licensed professional mental health counselor can provide a safe and supportive place to vent as well as offer healthy and sound guidance to those in need, they offer so much more. They don’t hope to answer questions for clients, instead, they hope to lead clients in the direction they need to answer the questions themselves. They focus on encouraging their clients to rely on themselves to navigate through challenges, which requires promoting the ethical principle of autonomy. Being a counselor also requires much more than a professional mindset and a desire to help others. Professional counselors are expected to treat clients using techniques that are informed by theory and research, administer appropriate assessments, accurately diagnose mental disorders, develop treatment plans, implement evidence-based practices, and evaluate outcomes of therapy. Counselors are also expected and often required to collaborate with other providers, which requires knowledge of legal and ethical guidelines related to confidentiality, informed consent, and releases. In addition, professional counselors must be trained in multicultural issues and emerging themes in the literature in order to appropriately treat clients from a variety of backgrounds. The NCMHCE assesses counselors on all of these areas as well as on their competency as supervisors, consultants, group facilitators, and family and marriage therapists.

RP: Why do so many people who do well in grad school struggle when it comes to passing the counseling exam?

AC: I’m so glad you brought this up Robin, because so often test takers describe their disappointment and confusion about earning all A’s in grad school, but being unable to pass the NCMHCE.

One explanation for this phenomenon relates to the pressure associated with a credentialing exam as compared to a course examination. The emotional pressure associated with high stakes exams can be so intense that it triggers test anxiety, which can compromise performance on the exam.

In addition, although NBCC implemented some changes in 2015 that now allow approved programs and eligible Master’s students to sit for the NCMHCE prior to graduation, many of the test takers I work with are no longer in school, have lost contact with their cohort, and feel very isolated during this process. Feeling isolated coupled with no longer being in “school mode” can certainly contribute to test takers performing differently on tests than they did when they had a built in support network of classmates and were in the mindset of studying and preparing to be assessed on a consistent basis.

Last, the format of the NCMHCE is quite different than the format of the exams administered during completion of the Master’s degree in counseling. The NCMHCE includes 10 simulated cases – these simulated cases have multiple sections with various questions and correct answer selections reveal information that is needed to answer future questions. So, if a test taker doesn’t make a correct answer selection early on in a case they may not get the information they need to make a selection in a future section. For example, perhaps a test taker doesn’t “explore Johnny’s eating habits” so they don’t learn that he is binging. This could present major problems when the test taker is then asked to select treatment goals because they would have no idea that “decreasing binging episodes” is relevant if they didn’t explore it when they should have earlier on in the simulated scenario.

RP: What’s the difference between the NCE and the NCMHCE?

AC: Depending on the state, a passing score on the NCE and/or the NCMHCE is required to become licensed to independently practice. To determine what the requirements are for licensure in your state, click on the state board directory through NBCC here.

The format of the NCE and the NCMHCE are very different. The NCE is administered in a multiple-choice format and the content on the exam is more “fact based” (for example, a question might be something like “who developed client centered therapy?”), whereas the NCMHCE requires the application of skills and knowledge beyond simply recalling memorized facts. As I mentioned earlier, the format of the NCMHCE differs in that it involves simulated cases with clients. I’m often asked if one exam is “easier” than the other. My opinion is that these are two very different examinations and they present different challenges, for different test takers, for different reasons.

RP: I know many people are overwhelmed by the DSM-5 and may feel that their education didn’t properly prepare them to be tested on this material. What advice do you have for people who find themselves in this position?

AC: You are so right, Robin. I get emails daily from interns asking, “Do I really need to know the DSM-5? How is this realistic!?” This task feels impossible to many test takers but it can be especially overwhelming to interns who studied the DSM-IV in grad school and/or to those who aren’t regularly exposed to the DSM-5 in their positions at work.

The truth is that there is no way to get around learning the DSM-5 if a test taker wants to be successful on the NCMHCE. Although we typically refer to the DSM-5 in actual practice for insight and verification of a mental disorder, licensed clinicians should be proficient in their ability to identity symptoms of mental illness without using the book. They should also be able to know which disorder(s) the symptoms correspond to and be able to apply evidence-based interventions accordingly.

For anyone who is wishing they could unread the sentence “there is no way of getting around learning the DSM-5,” recognize that learning the DSM-5 diagnostic criteria is no bigger of a task than learning any of the other material you need to know to be successful on the NCMHCE. It also isn’t a bigger task than learning all you did to earn your Master’s degree in the first place. My advice is that if you are a person who feels overwhelmed by the idea of learning the DSM-5, begin your studies with a tool or resource that helps to break down diagnostic criteria information. Then, once you’ve metaphorically gotten your feet wet, take a dive into the actual DSM-5 to expand and strengthen your knowledge. Opening the big book with some clarity and confidence under your belt already can go a really long way in terms of managing this task with a good attitude and a level head.

RP: On testing day, how important is it to be able to manage anxiety? Also, what kind of anxiety-management skills can candidates practice prior to testing day to ensure they are ready to perform at their optimum?

AC: Anxiety management is one of the most, if not THE most important practice to implement on test day. Earlier I mentioned that test anxiety can compromise test performance, but let me go into some more depth about the relationship between test anxiety and a failing score on the NCMHCE. According to the research, test anxiety contributes to something called information processing impairment. During a stressful situation, have you ever felt like your mind has gone blank? Or like you read a question totally differently than the way it was actually worded? If so, you may have been bitten by the test anxiety bug and it may have triggered an impairment in your ability to process information.

Information processing impairment is one of the most influential negative consequences associated with test anxiety. Think about it – you could have studied everything you were supposed to, you could be totally prepared to showcase all of your knowledge, and then find all this preparation sabotaged by test anxiety. When test anxiety increases to the extent that your ability to make correct choices is compromised, the opportunity to demonstrate all of your hard work is wasted essentially because your brain is playing tricks on you.

My suggestion is to practice anxiety management techniques as you are studying so you are fully prepared to implement your anxiety reducing strategies in the event your anxiety starts to increase during your exam. The anxiety management techniques that tend to be most useful to test takers involve deep breathing, meditation, and cognitive restructuring. Remember that your test anxiety will do nothing to help you on test day, it will only compromise your performance. Stay in control of your anxiety; don’t let your anxiety control you.

RP: Could you be more specific about some of these anxiety-management techniques?

AC: Deep breathing during the NCMHCE is useful for a number of reasons, including that the practice helps test takers pace themselves when they are being mindful of their body and breathing during the exam. Deep breathing also calms and slows down the mind, which reduces test anxiety. I suggest that test takers master their deep breathing and relaxation skills before test day by practicing every time they work through a simulation when studying. A good regimen would involve meditating for a few minutes before working through a case and then maintaining a centered and calm headspace by deep breathing throughout. Meditating could involve doing a mental body scan, progressive muscle relaxation, or silently chanting a mantra such as “I am calm, I am relaxed, I am still” or the sound om.

Test anxiety can contribute to distorted thoughts while studying and during the actual exam. During the study process, these distorted thoughts could sound like “I’m not going to pass this test.” On test day, when an incorrect answer selection is made, Wrong-Answer-Test-Anxiety can be triggered which activates thoughts such as “I am failing.” To manage anxiety while studying, rather than doubting yourself, mentally say “I’m doing everything I can to set myself up for success” and then channel your nervous energy in a way that is productive. On test day, rather than catastrophizing a wrong answer choice, tell yourself “I don’t have to get a perfect 100%. I’m going to get answers wrong, and still pass this exam.” 

RP: This has been hugely instructive being able to talk with you this morning. Before we end I wondered if you could just tell our readers a bit about your dissertation.

AC: For every doctoral candidate, the dissertation process is incredibly special and personal. For me, the research felt deeply meaningful because it involved relaying the stories of test takers I personally worked with who failed the NCMHCE. More specifically, I explored the impact test anxiety has on NCMHCE outcomes as well as variables that contribute to improving scores. The Cliff’s Notes are this:

  • Every re-taker included in my study reported suffering from test anxiety. (I know we addressed this earlier, but isn’t that interesting? Not a single re-taker said they weren’t test anxious?). As I mentioned before, it is possible that these individuals have always been test anxious, and it’s also possible they developed test anxiety as a result of failing the NCMHCE
  • Test anxiety triggers information processing problems
  • Interventions that incorporate both study skills training and CBT techniques tend to improve outcomes for those suffering from test anxiety

Based on this information, I developed and applied the Counseling Exam Test Anxiety Intervention to my work with NCMHCE re-takers, which resulted in reduced test anxiety and passing scores for the majority of the participants in my study. My research on evidence-based techniques that lead to passing scores on the NCMHCE inform all of the curriculum I develop and the work I do to prepare counselors for the exam.


Studying for the NCMHCE and don’t know where to begin? AATBS offers exam prep packages to cover the content and enough practice questions to have you feeling confident come exam day. Learn More >