Assessing Sleep Difficulty in University Counseling Centers: What Happens when Clients and Clinicians Disagree?

This blog is a summary of a sleep research article recently accepted for publication that used CCMH data.


Pottschmidt, N. R., Castonguay, L. G., Janis, R. A., Carney, D. M., Kilcullen, J. R., Davis, K. A., & Scofield, B. E. (in press) Client-therapist convergence on sleep difficulty and its impact on treatment outcomes. Psychotherapy Research.


Agreement between clients and their clinicians on the goals and direction for therapy is often seen as one component of the therapeutic alliance (goal consensus; Bordin, 1979). Congruence between clinician and client is especially important during the initial assessment of a client’s presenting concerns. Accurately evaluating a client’s presenting problems is crucial for case formulation and treatment planning. To date, little is known about the rate of agreement between client and therapist on presenting concerns, however, the research that has been completed demonstrates frequent disagreement about the presence and severity of clinical symptoms at outset of treatment (e.g., Holmqvist et al., 2016). It is unclear how agreement or disagreement between client and therapist impacts treatment outcomes.

Sleep, a transdiagnostic problem that occurs across many mental health disorders, may have more disagreement between clients and therapists. A recent review makes the convincing argument that while the average person knows the negative impact of recurring sleep difficulty, the current diagnostic system often considers sleep problems to be a symptom of another diagnosis, instead of an independent problem needing treatment (Freeman et al., 2020). When sleep problems co-occur with anxiety or depression, for example, they may be seen as less clinically relevant. However, there is evidence that sleep difficulties can predict and maintain many mental disorders, rather than just being a result of other psychological problems.

In university counseling centers (UCCs) specifically, sleep as a presenting concern is far less frequently identified by clinicians as a presenting concern than other problems. Data from the 2020 CCMH Annual Report indicate that clinicians report anxiety as a concern for 63.0% of clients and depression for 47.7%, whereas sleep is only reported as a concern for 12.6% of clients. In contrast, research on the general student body indicates that a majority of students (over 60%) self-report poor sleep (Becker et al., 2018). Taken together, there appears to be a discrepancy between sleep problems as reported by college students compared to those assessed by providers in UCCs.

Current Study

To investigate this apparent difference, Pottschmidt et al. (2021) used CCMH data from the 2017-2019 academic years to investigate the following:

  • Were there differences in the clients that clinicians identified as having a sleep concern vs. not?
  • How often did clients and clinician ratings agree on the presence of a baseline sleep problem?
  • Did baseline sleep problems reported by the client and/or clinician have an impact on therapy outcomes?

To accomplish this, clients’ ratings of their own sleep difficulty were assessed using a single item from the Counseling Center Assessment of Psychological Symptoms (CCAPS-34; “I have sleep difficulty”), which is a client self-report measure of psychological symptoms particularly relevant for college students. Additionally, the Clinician Index of Client Concerns (CLICC), a checklist of common concerns that clinicians complete after a client’s initial interview, was used to determine if clients had a clinician-identified presenting sleep concern. The CCAPS-34 was also used to measure clients’ change over the course of treatment on eight symptom subscales: Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Eating/Body Image Concerns, Hostility, Alcohol Use, Distress Index.

We found that clients whose clinicians identified a presenting Sleep Concern self-reported more distress at baseline on all subscales of the CCAPS-34, attended more appointments, were more likely to live alone, and were more likely to belong to a racial or ethnic minority group than to identify as White. While 49% of clients self-reported a high level of sleep difficulty (rating a 3 or 4 on the 0-4 scale for the CCAPS-34 sleep item), only 16% of clinicians identified a presenting sleep concern in their clients. However, when clinicians did identify a presenting sleep concern, those clients had higher self-reported sleep difficulty than clients without a clinician-identified sleep concern. These patterns suggest that clinicians use more than their clients’ self-report to determine presenting concerns to ensure that sleep is a clinically relevant concern for the client.

Using both client and clinician reports of sleep problems at baseline, we predicted client outcome scores on the single sleep difficulty item along with all subscales of the CCAPS-34. Overall, we found that in comparison to clients without clinician or self-reported baseline sleep problems, clients who had either were more likely to end treatment with poorer outcomes on not only sleep difficulty itself, but also several subscales of the CCAPS-34 (Generalized Anxiety, Depression, Social Anxiety, Academic Distress). Beyond the individual effects of client- and clinician-reported sleep difficulties, there was also an interaction effect between the two, representing the impact of divergent reports from client and clinician. Compared to clients and therapists who both agreed that there is no sleep problem, clients who rated their own baseline sleep difficulty as low (0-2 on the 0-4 scale) but whose clinicians identified a significant sleep concern ended treatment with worse outcomes on sleep difficulty, Depression, Generalized Anxiety, and the overall Distress Index.. In other words, when clinicians identified a sleep concern not reported by their clients at baseline, these clients reported more distress than expected at the end of treatment. This difference was slighter for clients who already rated their own sleep difficulty as high at the start of treatment; these clients ended treatment with similar outcomes on sleep problems regardless of the clinician report.

Clinical Implications

Findings from this study suggest that clinicians should pay close attention to the sleep health of their clients, especially those who live alone or hold a racial/ethnic minority identity. Interestingly, although we didn’t expect to find differences across racial/ethnic identities, this is in line with prior work reporting poorer sleep in Black/African American and Asian students living in dormitories, in comparison to White students (Jones et al., 2020). Furthermore, clients who report high distress at baseline across psychological symptom domains may be more likely to have clinically relevant sleep concerns. It should be noted that for this study, students responded to a single item, “I have sleep difficulty,” and clinicians indicated the presence of “sleep” as a client concern, which might have contributed to the level of disagreement between clients and therapists. While both items might indicate the presence of sleep problems, they are not necessarily endorsed at the same rate because one instrument is the client’s self-report of a symptom that may/may not be related to their reasons for seeking services, whereas the other measure is the clinician’s assessment of a “primary concern” that needs treatment. As such, clinicians might use students’ self-reported sleep difficulty to further evaluate if clinically significant sleep disturbances are present that commonly occur in college students. For instance, students with characteristics of insomnia may have difficulty falling or staying asleep when they have appropriate time available for sleep, while students with characteristics of a Circadian rhythm sleep phase disorder may be able to sleep well when they’re able to sleep at their preferred time but have difficulty when their internal sleep “clock” is misaligned with the time available for sleeping.

Additionally, clinician assessment of sleep concerns, although less frequent than client self-reported sleep difficulty, may represent a clinically distinct group of clients. We found that when clients did not indicate problematic sleep at baseline, but their clinician identified sleep as a presenting concern, these clients had poorer outcome ratings on the sleep difficulty item, along with the Depression, Generalized Anxiety, and Distress Index subscales. It’s possible that when clinicians identify a sleep concern, especially if clients did not previously recognize their sleep deficits, psychoeducation is delivered about the impacts of poor sleep on mood, concentration, and energy. This may lead to clients’ increasing awareness of these difficulties in their lives, reflected in higher CCAPS-34 ratings after treatment. Thus, sleep health may be especially important to assess for clients who report lower levels of sleep distress at baseline, as clinicians may recognize problematic patterns of sleep that clients do not.

Attending to sleep concerns is important even in the context of other presenting concerns at intake. For instance, cognitive-behavioral therapy for insomnia (CBT-I) has been shown to reduce not only symptoms of insomnia but also a wide range of comorbid psychiatric symptoms (Wu et al., 2015) and the risk of mood episode relapse (Harvey et al., 2015). Furthermore, CBT-I is an empirically supported treatment for college students, can be delivered in relatively few therapy sessions (i.e., a mode of 6), and there is evidence that relatively few modifications are required for CBT-I to be effective in the college campus setting (Kloss et al., 2011; Taylor et al., 2014) Within a short-term treatment model, as is frequently the case in UCCs, the appropriate selection of treatment targets is crucial; it may be broadly efficacious and efficient to address sleep concerns in college counseling.

This blog post was written by CCMH Business Team member, Natalie Pottschmidt, M.S. Natalie is a Doctoral Student in Clinical Psychology at PSU and a part of the Castonguay Lab. 

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