A measure of the fully functioning person
In the move to measuring outcome in routine counselling practice, there has been a tendency to lose sight of the client as a whole person, someone who (we hope) will experience growth through the process of being in counselling. Instead, we fall in line with the medical model, reducing the client’s experience to symptoms of distress such as depression or anxiety. Successful outcome in counselling becomes the elimination of these symptoms.
In contrast, the Strathclyde Inventory (SI) was designed to measure Rogers’ concept of the fully functioning person: “the [hypothetical] end-point of optimal psychotherapy… the kind of person who would emerge if counseling was maximal”. Originally created by Beth Freire, and named after her then institution, the University of Strathclyde, the development of the SI has been a slow burner – a “quiet revolutionary”, if you like – until now.
In this blog, I introduce the SI, describe what it measures (referring to a study published recently by Professor Robert Elliott and myself), and suggest how to make sense of your client’s scores in the context of your work together.
What does it measure?
According to Rogers, the main characteristics of the fully functioning person are openness to experience, trust in one’s organism, internal locus of evaluation, willingness to be a process, unconditional self-regard, and living in harmony with others. Beth extracted descriptions of the fully functioning person from Rogers’ writings and adapted them into statements (items) for inclusion in the SI.
The original version was composed of 51 items. Over time, using data collected first from trained and student counsellors, then from clients accessing counselling at the Strathclyde Counselling & Psychotherapy Research Clinic, a process of refinement has resulted in the current 12-item version (SI-12). Six items are positively worded, and six items are negatively worded (and reverse scored = R):
- I have been able to be spontaneous
- I have condemned myself for my attitudes or behaviour (R)
- I have tried to be what others think I should be (R)
- I have trusted my own reactions to situations
- I have found myself “on guard” when relating to others (R)
- I have listened sensitively to myself
- I have felt myself doing things that were out of my control (R)
- I have lived fully in each new moment
- I have been aware of my feelings
- I have hidden some elements of myself behind a “mask” (R)
- I have felt myself doing things that are out of character for me (R)
- I have felt it is all right to be the kind of person that I am
The client assesses each item according to their sense of how often it has been true for them in the past month, then scores it using a 5-point rating scale (0-4) with anchor words: never, only occasionally, sometimes, often, all or most of the time. Higher scores suggest more open, fluid functioning; in other words, better psychological health.
Beth chose to use the time frame of one month because she felt that this represented a suitable period for clients to notice developments in the kind of experiences that she was seeking to capture with the SI. Although this requires clients to reflect back over a longer period than typically used by other outcome measures such as the CORE-OM, GAD and PHQ, this does not appear to affect the SI’s sensitivity to change. In our study, we found evidence of equivalent sensitivity to change in the difference between pre- and post-therapy scores collected on the SI (reflecting on the previous month) and the CORE-OM (reflecting on the previous week).
While we have not tested the administration of the SI on a weekly basis, there is no reason to think that this would be an unsuitable way to use the instrument as part of your practice. Indeed, it is possible that clients will develop more awareness of the type of experiences measured by the SI if they are invited to reflect upon them on a session by session basis. We would be interested in your feedback on this!
When we analysed SI data collected from 385 clients at different stages of their counselling process, Robert and I found a consistent pattern in the scoring of items that suggested a “hierarchy of item difficulty”. In other words, clients appeared to find that some items (e.g., I have been aware of my feelings) were easier to score at a higher point on the rating scale than others (e.g, I have lived fully in each new moment).
The content and order of items within this pattern indicated a possible emergent process of becoming more fully functioning, which can be depicted in this way: as self-awareness grows, self-trust strengthens; as self-trust strengthens, self-acceptance deepens; as self-acceptance deepens, openness to self emerges; as openness to self emerges, openness to others becomes more possible.
This process seemed familiar as a movement from incongruence to congruence, leading to me adopting the term “congruent functioning” as a way of bringing together these two synonymous ideas in person-centred theory.
A model of congruent functioning (©Susan Stephen)
How to understand the numbers
Although he found it useful to unpack characteristics of the fully functioning person, Rogers maintained that these were facets of the same experiential process. We tested the SI data we had collected and confirmed that the instrument could be treated as unidimensional. This means that, when using the SI-12, you can simply add up your client’s score then divide by twelve (or as many items as your client completed). This gives you a single average score, a snapshot of how your client perceives their functioning in relation to these items at the present time.
You and your client may choose to explore this snapshot together, perhaps reflecting on the experiences in the last month that influenced their responses to the items. As with all attempts to measure human experience, responses are subjective: clients will interpret each item according to their own meaning, and score according to their own weighting of the rating scale.
It makes sense that if we ask clients to complete self-report instruments that we take time to understand how they are using them. These conversations also help us to make sense of changes in clients’ scores that occur over time, and to understand the context of an individual client’s score, especially when comparing them to normative (i.e., standardised) data.
You may want to evaluate the “clinical significance” of your client’s SI score or monitor the amount of change that your clients are recording when working with you. If so, then use the values that we calculated: a clinical cut-off point of 2.36 (a score higher than this value is in the non-clinical range); and minimum reliable change values of .97 (if you want to be 95% sure that the difference in scores is not measurement error, the typical standard when calculating the average change for all of your clients) or .64 (a more moderate 80% certainty, appropriate for monitoring change in scores for individual clients). If your client’s SI scores have increased by at least this amount, and moved above 2.36, then you can classify this as clinically significant change.
When we compared change in SI scores collected from 225 clients with the change they recorded in their CORE-OM scores, we found a strong association between the two sets of data. This makes sense. As Rogers proposed (and as we observe with our clients) inner tension reduces as we become more fully functioning.
Our findings also provide reassurance to those who are tempted to shift from the CORE-OM that (as mentioned earlier) the SI is equally sensitive to change. What the SI offers that is different is a focus on whole person functioning, an attitude and a message that is a better fit for growth-oriented counselling practice.
Where you can find it
Copyright of the SI is held by Elizabeth Freire, Robert Elliott, Susan Stephen and Brian Rodgers. The measure is free to use provided it is not changed in any way. A digital ‘tick’ version in Word can be downloaded here. A prototype e-version has been developed by the TMN team. The SI is also one of the outcome measures included in Pragmatic Tracker, the online case management system currently being piloted by BACP in its AdaPT project.
Accessing our study
Unfortunately our study is not available as an open access publication. If you do not have access to the full published article via the journal’s website, you can download the author approved version here.
Susan Stephen, Ph.D., is a lecturer in counselling at the University of Strathclyde, Glasgow. Her research interests include investigating the development of congruent functioning in person-centred therapy, exploring methodological innovations in measure development and case study research, and supporting practitioners to develop an informed approach to measurement in counselling.