Cross-cultural adaptation of the Inventory of Countertransference Behavior (ICB) into Brazilian Portuguese

Abstracts

OBJETIVO: O artigo apresenta a adaptação transcultural do Inventory of Countertransference Behavior (ICB) para o português brasileiro. O ICB constitui-se numa escala de 21 itens que busca acessar o comportamento contratransferencial. Esta escala, que deve ser preenchida pelo supervisor após a sessão de supervisão, abrange a contratransferência em suas categorias positiva e negativa. MÉTODO: Foram realizadas as etapas de equivalência conceitual, equivalência de itens, equivalência semântica, equivalência operacional, equivalência funcional e aprovação da versão final pelo autor original do instrumento. RESULTADOS: Os critérios de equivalência foram satisfeitos, tendo a versão final sido aprovada pelo autor do instrumento original. CONCLUSÃO: A adaptação do ICB disponibiliza para uso um instrumento de utilização prática, que abrange as categorias de contratransferência positiva e negativa. Constitui, deste modo, uma ferramenta de grande utilidade para a clínica, a supervisão e a pesquisa em psicoterapia e psicanálise, onde a contratransferência tem se mostrado um importante recurso, especialmente no tratamento de patologias fundamentadas em estágios precoces do desenvolvimento, nos casos graves e nos traumas severos.

Contratransferência; Inventory of Countertransference Behavior; adaptação transcultural

ORIGINAL ARTICLE

Cross–cultural adaptation of the Inventory of Countertransference Behavior (ICB) into Brazilian Portuguese

Patrícia Rivoire Menelli Goldfeld^I; Daniela Wiethaeuper^II; Luciana Terra^III; Rosana Baumgardt^III; Martha Lauermann^III; Victor MardiniIV; Claudio Abuchaim^V; Anne Sordi^VI; Luciana Soares^VII; Lúcia Helena Freitas Ceitlin^VIII

^IPsychiatrist. MSc., Graduate Program in Medical Sciences: Psychiatry, Department of Psychiatry, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil

^IIPsychologist. PhD in Clinical Psychology. Associate professor, Universidade do Vale do Rio dos Sinos (UNISINOS), São Leopoldo, RS, Brazil

^IIIPsychologist

^IVPhysician

^VPsychiatrist. MSc. in Psychology

^VIMedical student, UFRGS, Porto Alegre, RS, Brazil

^VIIPsychology student, UNISINOS, São Leopoldo, RS, Brazil

^VIIIPsychiatrist. MpH, PhD in Medicine. Associate professor, Department of Psychiatry and Forensic Medicine, UFRGS, Porto Alegre, RS, Brazil

^{Correspondence}

ABSTRACT

OBJECTIVE: This article presents a cross–cultural adaptation of the Inventory of Countertransference Behavior into Brazilian Portuguese. The Inventory of Countertransference Behavior is a 21–item scale designed to assess countertransferential behavior. This scale, which should be completed by the supervisor after a supervised session, comprehends countertransference and its positive and negative categories.

METHOD: The following steps were performed: conceptual equivalence, item equivalence, semantic equivalence, operational equivalence, functional equivalence, and approval of the final version by the author of the original instrument.

RESULTS: The study reached the objectives of equivalence, and the final Brazilian Portuguese version was approved by the original author.

CONCLUSION: This adaptation provides a Brazilian Portuguese version of a practical instrument to assess positive and negative countertransference. It represents a valuable instrument for therapists, supervisors and researchers on psychotherapy and psychoanalysis, where countertransference has proved to be an important resource, especially to the treatment of diseases based on early stages of development, as well as to severe cases and severe trauma.

Keywords: Countertransference, Inventory of Countertransference Behavior, cross–cultural adaptation.

Introduction

Studies on countertransference (CT) have served psychoanalysts and psychotherapists in general as a useful instrument to research the patient's subconscious.^1–14 This resource is even more important in severe cases, in diseases based on early developmental stages and in cases of severe trauma, in which the ability of symbolism and verbalization of feelings is abolished or impaired.^15–29

The concept of CT was initially defined by Freud to refer to what he saw as pathological and problematic in the analyst, due to the potential irruption of unanalyzed impulses. Freud claimed that CT was a permanent problem for physicians, which needed to be understood and overcome (classical concept).^30–32 That statement concerns an essential concept in psychotherapy and psychoanalysis: the limitations that neuroses, blind spots and character traits of therapists or psychoanalysts impose to the ability of understanding and responding to other people's communications. Further developments expanded and changed the concept of CT, which started comprehending all the therapist's conscious and unconscious feelings and being used as a therapeutic instrument (totalistic concept).^7,8,13,14

Glover, in his "Lectures on technique in psycho–analysis" distinguished CT as positive (affections related to the loving line) and negative (affections related to the aggressive line).^33,34 This form of classifying CT is still much used nowadays, as one of the most simplified forms of classification.

In psychology and psychoanalysis, it is common to develop scales to measure variables, concepts or theoretical constructs that are not directly observable, and CT is among them.³⁵ The need of having standardized instruments in Brazil to assess CT has been considered, as a way to help therapists and psychoanalysts in clinic and research on psychotherapy and psychoanalysis. With that aim, the Inventory of Countertransference Behavior (ICB)³⁶ was selected in the scientific literature among the instruments that assess CT, since it is a well–developed instrument, relatively easy to use and does not require specific training to be used by specialists in this area.

ICB is an important instrument to be used by a psychotherapy or psychoanalysis supervisor, since it traditionally assesses CT. It provides access to conscious and latent aspects of CT, comprehending positive (feelings of the positive spectrum) and negative (feelings of the negative spectrum) CT categories.

ICB consists of a 21–item scale to be filled by the supervisor, after a supervision session, which aims at assessing countertransference behavior.

This study aims at presenting the process of cross–cultural adaptation of the ICB to Brazilian Portuguese with regard to conceptual, item, semantic, operational and functional equivalence, and approval of the final version by the author of the original instrument.

Inventory of countertransference behavior (ICB)

This scale was developed by Gelso & Friedman³⁶ to access the therapist's countertransference behavior, as it is perceived by the supervisor during supervision sessions. The scale was originally composed of 32 items, each with 5 response levels (1 = very little, up to 5 = very intense). It currently has 21 items with Likert–type responses, from 1 = little or any degree, to 5 = high degree, to be answered by the supervisor after a supervision session. The items consider CT in its classical sense, as an obstacle, separating the therapist's countertransference behaviors assessed by the supervisor in its positive and negative aspects. The scale score is obtained by adding positive and negative items independently. The author of the scale recommends not considering Likert responses = 1 or 2 and adding only those = 3 or more.

For ICB analysis, 11 specialists provided face validity for the items, indicating that each one was, to a certain extent, an expression of CT. The total scale and each subscale (positive and negative CT) revealed strong internal consistency. An exploratory factor analysis of measures by 126 supervisors of supervised sessions revealed, as expected, the evidence of two factors. These factors, more than reflecting the dimensions of overinvolvement and underinvolvement as hypotheses, were better categorized within the concepts of negative and positive CT.

Methods

The conceptual and methodological theoretical background proposed by Herdman et al.³⁷ was used, recommending the use of a universal approach to cross–cultural research. For them, such approach does not a priori assume that constructs are the same between different cultures, and that this implies the need of establishing whether the concept exists and is interpreted similarly in both cultures and, if so, to which degree it is similarly interpreted. The aim of the universal approach is to verify which aspects of the concept are genuinely universal between cultures and use only these aspects for the development of instruments to measure the concept in different cultures. The methodological contributions by Moraes, Hasselmann and Reichenheim³⁸ were also used. Next, we describe the methodological stages resulting from that influence.

First of all, the author gave his permission to translate and use the ICB. Conceptual and item equivalence of the original scale was performed by a discussion group, which included bilingual professionals specialized in the theme discussed in the scale (one psychiatrist; one psychiatrist and psychoanalyst and one psychologist). The group considered the construct, as well as scale items, which were seen as equally relevant in our culture. After that stage, the instrument was independently translated into Brazilian Portuguese by two bilingual translators: one specialist in English and one psychiatrist.

Both versions in Portuguese were unified by a psychiatrist and psychoanalyst, resulting in a third version.

At that moment, the scale was presented to a group of 5 independent professionals of the research group (2 psychoanalysts, 2 psychologists and one medical student), who discussed item understanding and adequacy. Suggested changes were recorded and the author was contacted to clear any doubts. The third version in Portuguese and the suggestions of the professional group were analyzed as to content validity by two specialists in the mental health area (one psychologist and one psychiatrist), creating a fourth version in Portuguese. This last version was back–translated by an independent, bilingual translator and psychiatrist (who was unaware of the scale).

Finally, the research group held a meeting to discuss the referential meaning of terms/words in the scale,³⁷ comparing the original and the back–translated version, using a visual analogical scale,³⁹ which allowed the pair equivalence to be continuously scored, from 0 to 100%. It also aimed at assessing the general meaning of each item, which transcends word literality, considering the cultural context of the target population (Brazilian psychotherapists and psychoanalysts), using a 4–level classification: unaltered, little altered, much altered or completely altered.

Operational equivalence was assessed, consisting of the possibility of using the scale in the same format, administration mode and measurement methods as the original instrument, and functional equivalence, which aims at assessing the ability of the instrument to measure, in our country, what it proposes to in the original culture. To do so, the scale was used to train three referees, and then the inter–referee intraclass correlation coefficient (ICCm) was measured. Functional equivalence was demonstrated in another study, carried out with a sample of 92 therapists, and that has been sent for publication. The back–translated scale was sent to the author of the original scale for analysis.

Results

The objective of developing scales is to make their measures as accurate as possible, besides measuring what they propose to.³⁵ By developing a cross–cultural adaptation of the ICB, this study also aimed at assessing the validity of the scale as to its content: content and face validity. Content validity basically deals with the systemic examination of the test content, developed by experts in the area, who evaluate the items to determine whether they cover a representative sample of the universe of the behavior to be measured and to determine whether choice of items is appropriate and relevant. The experts who evaluated the ICB considered that it presented content validity in relation to CT in its classical sense. The experts also found face validity, which refers not to what the test actually measures, but to what it apparently measures, which also relates to language and to how the content is being presented. Discussion with the group of experts about appraisal of conceptual and item equivalence has led to linguistic adjustments and terminological adaptations in 8 items. In question 1: "Colluded with the client in the session", the word colluded had no equivalent in Portuguese as a verb, choosing the following translation: "mostrou/estabeleceu conluio com o cliente na sessão [showed/established collusion with the client in the session]." Item 4 required a change: the translation of "Befriended the client in the session" was interpreted in the group as: "Ficou amigo do cliente na sessão [Made friends with the client in the session]," choosing an expression that is more commonly used in Portuguese for this situation: "Agiu como amigo do cliente na sessão [Acted as a friend of the client in the session]." Item 6 required a contact with the author because what he meant with the following expression was not clear: "Behaved as if she or he were 'somewhere else' during the session." The author explained that "somewhere else" meant absent, thinking about something else, other than the session. In item 9 the word "criticized" was modified to "was critical about" for better understanding. In items 12 and 13, the word "form" was altered to "manner." In item 18, "realizou excesso de auto–revelação [performed excess of self–revelation]" was modified to "engajou–se em comportamento de auto–revelação excessivo [engaged into a behavior of excessive self–revelation]." In item 21, "estruturou excessivamente a sessão [excessively structured the session]" was altered to "forneceu estrutura excessiva à sessão [provided excessive structure to the session]." These changes were performed so that the items could be better understood in Portuguese, as an attempt to obtain the real original meaning.

Assessment of semantic equivalence between the original scale and the back–translation showed good general equivalence. Only 1 out of 21 items in the back–translation had, according to the visual analogical scale, a degree of equivalence of referential meaning higher than 90% compared with the original (Table 1). Meaning was unaltered in 95.2% of the items. Item 4 was considered little altered: "Befriended the client in the session", to which the experts considered not having an exact expression in Portuguese, changing to "agiu como amigo do cliente na sessão [acted as a friend of the client in the session]."

Assessment of operational equivalence showed that the instrument can be used in the same format, mode of administration and measurement methods of the original instrument and cal also be used to train referees, for the purposes of research in psychotherapy and psychoanalysis. To do so, a group of referees was created, including two psychologists and one medical student. The referees were given a 15–hour training on the instrument, reaching a high intraclass correlation coefficient (ICCm = 0.72). The instrument presented functional equivalence, since it measures in the target culture what it proposes to measure in the original culture. Such fact was verified with a sample of 92 therapists, and is demonstrated in another article that has already been sent for publication.

The final version of the ICB is available in Brazil, but it can only be used with the author's permission.

Discussion

Herdman, Fox–Rushby and Badia³⁷ recommend using a universal approach to cross–cultural research, which intends to assess and respect cultural differences. This approach implies the need of establishing whether the concepts comprehended in a given instrument exist and are similarly interpreted in both cultures and, if so, to what degree they are similarly interpreted.

The discussion of the group of experts, for conceptual and item equivalence, considered that concepts and items related to positive and negative CT used in the development of the instrument were equally relevant in our culture. Moreover, items were generally considered appropriate for evaluation of the two dimensions being investigated: positive and negative CT.

It is still necessary to verify scale reliability (accuracy, exactness) and its validity (if the test is measuring what the researcher thinks it is measuring) in relation to criterion (concurrent and predictive validity) and construct (convergent, discriminant, predictive and factor validity). It is also necessary to assess to what extent these are similar to the original instrument.³⁵ However, this study carried out a judicious cross–cultural adaptation into Brazilian Portuguese, resulting in a complete and elaborated instrument to assess the CT construct in its classical sense.

Some limitations may be identified in our study. Firstly, the limited number of qualitative investigations involving individuals with bulimia and binge eating. Secondly, we identified that great part of the identified studies was conducted with some methodological limitations, such as sampling strategies and analysis techniques. Finally, attention was drawn to the reduced number of published studies and the scientific production concentrated in a few developed countries, which may generate a culturally–driven perception.

Due to the short scientific production in this area, further studies are needed to deepen the issues under investigation.

References

Received January 19, 2007

Accepted March 21, 2007.

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Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Received
  19 Jan 2007
• Accepted
  21 Mar 2007