Cross-cultural adaptation of the Mental States Rating System to Brazilian Portuguese

Abstracts

INTRODUÇÃO: O artigo apresenta a adaptação transcultural do Mental States Rating System, uma escala de análise de conteúdo do discurso, seja ele falado, descrito ou filmado, que abrange de modo amplo tipos de contratransferência. 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 Mental States Rating System disponibiliza para uso um instrumento que não só abrange todas as categorias de contratransferência descritas na literatura, mas as amplia, através da Teoria dos Estados Mentais. Constitui, desse modo, uma ferramenta de grande utilidade para pesquisa em psicoterapia e psicanálise, onde a contratransferência tem se mostrado um importante recurso, tornando-se ainda mais crucial nas patologias fundamentadas em estágios precoces do desenvolvimento, nos casos graves e nos traumas severos.

Contratransferência; Sistema de Avaliação dos Estados Mentais; adaptação transcultural

ORIGINAL ARTICLE

Cross-cultural adaptation of the Mental States Rating System for Brazilian Portuguese

Patrícia Rivoire Menelli Goldfeld^I; Daniela Wiethaeuper^II; Marc-Andrè Bouchard^III; Luciana Terra^IV; Rosana Baumgardt^IV; Martha Lauermann^IV; Victor Mardini^V; Claudio Abuchaim^VI; Anne Sordi^VII; Luciana Soares^VIII; Lúcia Helena Freitas Ceitlin^IX

^IPsychiatry, MSc. in Psychiatry

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

^IIIPsychologist, PhD in Clinical Psychology. Full professor, Université de Montréal, Montréal, Québec, Canada

^IVPsychologist

^VPhysician

^VIPsychiatrist, MSc. in Psychology

^VIIMedical Student, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^VIIIPsychology student, UNISINOS

^IXPsychiatrist, MpH, PhD in Medicine. Associate professor, Department of Psychiatry and Forensic Medicine, UFRGS

Correspondence

ABSTRACT

INTRODUCTION: This article presents a cross-cultural adaptation of the Mental States Rating System, a content analysis scale applied to spoken, written or taped material, which covers a wide range of countertransference 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 has reached the objectives of equivalence, and the final Brazilian Portuguese version has been approved by the original author.

CONCLUSION: The study provides a Brazilian Portuguese version of an instrument that not only covers all the range of categories encompassed by countertransference described in the literature, but also expands it through the Mental States Theory. This represents a valuable tool for research on psychotherapy and psychoanalysis, where countertransference has proved to be an important resource, especially for the treatment of diseases based on early stages of development, for severe mental diseases and severe trauma.

Keywords: Countertransference, Mental States Rating System, cross-cultural adaptation.

Introduction

Multiple factors converge to the need of having instruments to assess countertransference (CT) in Brazilian Portuguese. CT needs to be understood and studied to help therapists, since it is an essential and crucial tool in the understanding of unconscious aspects in the patient/therapist pair.^1-34 It is even more important in severe psychopathologies or in those based on early development stages, in which there is impairment or abolition of the individual's symbolization ability.^35-43 In addition, in situations of severe trauma, as has been well described in the literature,^44-59 the individual's ability to symbolize may also be lost or blunted, and its place is taken by a "symbolic equation."^57,60 In this case, the word loses meanings, carrying the impact of the event "per se." In cases or situations such as that, CT feelings allow therapists to connect with the patient's unconscious elements, which are understood to be later treated in the sense of producing relief from suffering.

The term countertransference was used for the first time by Freud in 1909, in a letter addressed to Jung,⁶¹ and then in 1910, in "Future perspectives of psychoanalytic therapy,"⁶² to name the therapist's feelings that acted as obstacles against the treatment and should be recognized and overcome.⁶³ This is the classical concept of CT. Further developments in theory and technique expanded the concept of CT to serve as a therapeutic instrument and comprehend all the therapist's conscious and unconscious feelings, which is called totalistic concept.^14,15,25,26

Among the instruments for CT assessment found in the literature, the Mental States Rating System (MSRS) was selected because it is the most comprehensive instrument. It aims at assessing CT using the totalistic concept, including all categories described in the literature about the construct and evaluating it in its conscious and latent aspects. To do so, the MSRS uses trained raters with a high agreement rate.

This study aims at presenting the process of cross-cultural adaptation of the MSRS 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.

Mental states rating system

Based on the Countertransference Rating System^64-66, Bouchard developed the MSRS (Bouchard MA, Picard C, Audet C, Brisson SH, Carrier M. Differentiating mental states: therapists, patients, human subjects. Montreal: Université de Montréal; 1998. Scoring manual, unpublished manuscript), which not only focuses on CT concept, but also expands it using the Theory of Mental States. This refers to the modalities or categories of the individual's intrapsychic activity. In its more specific context, this scale refers to the activities by analytic or psychoanalytic therapists. Thus, within the therapeutic context, many forms of psychic activities arise, and some have the objective of perception and elaboration of conflicts in the internal world. The therapeutic context also presupposes ability of recognizing mental states that could be influenced by drives and affections, transformed into representable and symbolic forms, i.e., mentalization (Lecours & Bouchard, 1997).⁶⁷

It is an instrument of speech content analysis containing categories that are previously described in detail. It is applied on written or taped material of therapists' feelings or thoughts soon after sessions or reading of clinical vignettes. The instrument serves for the training of raters and requires 30 hours, in which examples of speech are individually rated and discussed as a group, until an interrater consensus calculated by Cohen's kappa index (Pestana & Gageiro)⁶⁸ reaches a minimum of 0.70, which is considered excellent as a reliability index (Shrout et al.).⁶⁹ Afterward, raters assess the research material individually, only gathering to discuss disagreeing cases, so that a consensus can be reached and prevails as final result.

The MSRS is composed of three main categories: objective-rational, reactive and reflexive mental states, as well as some subcategories (Table 1). Each category has rating criteria described in the manual, besides rating examples from other studies. In researches using this instrument, some mental states have proven to be repetitively antagonists, such as the reflexive and reactive (-0.70 correlation), whereas the objective-rational state does not seem to be related to any other category.^64,70 Interrater agreement for MSRS rating ranged between 67-79%, with kappa indexes ranging from 0.63 to 0.87, indicating an excellent agreement considering the effect of chance.^64,70

Table 1 - Click to enlarge

Method

The theoretical background proposed by Herdman et al.⁷² for the cross-cultural adaptation of instruments assessing quality of life was used, along with methodological suggestions proposed by Moraes et al.⁷³ in the adaptation of the instrument Revised Conflict Tactics Scales in our country.

The author gave his permission to translate and use the MSRS. A research group was created, formed by two psychiatrists and one psychologist experienced in clinical practice and research. Initially, the group discussed the CT construct and mental states, trying to understand the concepts included in the instrument and in all items. The group considered that there was equivalence of instrument concepts and items with the cultural concepts regarding mental states in our country.

Next, the instrument was independently translated by two bilingual translators, a psychiatrist and a specialist in English. Both versions in Portuguese were unified by a psychoanalyst researcher, resulting in a third version.

That version was presented to a group of five independent mental health practitioners, who discussed understanding and adequacy of each item. The author was contacted to clear any doubts whenever necessary. The third version in Portuguese and the suggestions by this group of professionals were analyzed as to content validity by two researchers, including an expert in the instrument. A fourth version was then developed by consensus. This last version was back-translated by an independent bilingual translator psychiatrist, who was unaware of the scale.

In the following stage, the research group analyzed the referential meaning of terms/words in the scale,⁷¹ comparing the original and the back-translated version, using a visual analogical scale,⁷³ 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, using a four-level classification: unaltered, little altered, much altered, and completely altered.

Operational equivalence was also assessed, consisting of the possibility of using the scale in the same format, administration mode and measurement methods as the original instrument, as well as functional equivalence, which aims at assessing the ability of the instrument to measure, in our country, what it proposes to in the original culture. The scale was used to train three raters, and then the interrater agreement kappa index was measured. A sample of 92 therapists was used to evaluate functional equivalence.⁷⁴ Finally, the back-translated scale was sent to the original author for analysis.

Results

The final version of the MSRS is available in Brazil, but it can only be used with the author's permission. Discussion with the group of experts about appraisal of conceptual and item equivalence has led to linguistic adjustments and terminological adaptations in 14 items: item 2, as to the objective-rational category; introduction and items 1, 3, 4 and 6, as to the concrete category at a non-psychotic level; introduction and item 1, as to the concrete category at a psychotic level; item 1, as to the reflexive category; items 1 and 3, as to the forms of reflexive category; items 2 and 3, as to the advance defensive category; items 2, 3, and 5, as to the intermediate-level defensive category; items 2 and 3, as to the primitive defensive category.

Assessment of semantic equivalence (Table 2) between the original scale and the back-translation showed good general equivalence. Only four out of 56 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. The research group chose not to change these items, since it considered that such differences had no influence on their understanding. As to general meaning, it was unaltered in 91.3% of the items and, therefore, was considered good.

Table 2 - Click to enlarge

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. To do so, three raters were given a training to use the instrument: one psychologist and two psychiatrists. The raters were given a 30-hour training, performed by an expert in the instrument, reaching a kappa index of agreement = 0.81 (p < 0.001), which is considered high. The instrument presented functional equivalence, since it measures in the target culture what it proposes to measure in the original culture, a fact that was found in a sample of 92 therapists.⁷⁴

The back-translated scale was sent to the author of the original scale for analysis. The author sent a few comments about some expressions used to describe some mental states in English, indicating their verification in the Portuguese version. These comments were studied by the researchers along with the translators, and then the final adjustments were performed in the Portuguese version. The author authorized the use of the final version in Portuguese.

Discussion

Herdman et al.⁷² support the use of a universalist approach to cross-cultural research, which aims at assessing and respecting cultural differences, implying the need of establishing whether the concepts understood in a given instrument exist and are interpreted similarly in both cultures; if so, to what extent they are similarly interpreted.

The discussion of the group of experts, for conceptual and item equivalence, considered that concepts and items related to the mental states construct used in the development of the instrument were equally relevant in our culture. Moreover, items were generally considered appropriate for evaluation of the three dimensions being investigated: reflexive, defensive or objective-rational thought.

This study carried out a judicious cross-cultural adaptation into Brazilian Portuguese, resulting in a complete and elaborated instrument to assess mental states. The instrument still needs to be validated. It is also necessary to measure its psychometric properties - reliability, responsiveness, and construct validity (including discriminating, appreciative and predictive properties) - and evaluate how similar they are to the original instrument. Part of this validation process has been performed, and its results will be soon presented to the scientific community.⁷⁴

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Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008

History

• Received
  19 Jan 2007
• Accepted
  05 June 2007