According to the Model of Organization of Personality [1], personality refers to the behavioral patterns that result from a dynamic integration of factors, including temperament, cognitive abilities, character and internalized value systems. Behavioral patterns can be organized into four psychological structures, or deep structures [1], namely the Normal/Healthy Organization (HO), the Neurotic Organization (NO), the Borderline Organization (BO) and the Psychotic Organization (PO) [1,2]. Individuals are classified according to the severity of their psychological impairment, with those in the highest level of organization being the most healthy and well-adapted [3]. At the highest level, we find the HO, which consists of individuals healthy, adaptable and able to properly manage their relationships. At the next level is the NO, which is composed by individuals with obsessive-compulsive, depressive and hysterical personality disorders. Next, we find the BO, which includes individuals with severe personality disorders and can be further divided into Higher Level Borderline Organization (HBO) and Lower Level Borderline Organization (LBO). Whereas the HBO includes individuals diagnosed with avoidant, dependent, histrionic or narcissistic personality disorders, the LBO is considered more severe and refers to individuals who have paranoid, schizoid, borderline, antisocial and schizotypal personality disorders. At the lowest level is the PO, which includes cases that have atypical psychosis diagnoses and do not fall into the abovementioned types of personality disorders. These four levels of organization have been used to distinguish between diagnoses [1-6].

The assessment of psychological structures is based on three ego functions: ego identity (integrated versus diffuse), defense mechanisms (higher versus primitive) and reality testing ability (present versus impaired versus absent) [1-3]. Although both HO and NO tend to involve integrated identities, defense mechanisms focused on repression and normal reality testing abilities, they differ in the degree of flexibility and adaptiveness. Specifically, whereas NO individuals are psychologically less flexible and adaptive, HO individuals tend to have a greater egoic flexibility, which enables a greater adaptiveness. For BO and PO, identity tends to be diffuse, and defense mechanisms tend to be primitive with reality testing ability present but impaired at the BO level and absent at the PO level [1-6].

The Structural Interview was the first method developed to evaluate the three ego functions (i.e., identity diffusion, defense mechanisms and reality testing) within the framework of the Model of Personality Organization [3]. This interview evaluates the ego functions by inducing the activation of latent dynamisms. The interview consists of three phases: 1) clarification, cognitive exploring of the patient’s consciousness; 2) confrontation, enabling the patient to become aware of conflicts and inconsistencies; and 3) interpretation, resolving the conflicts and inconsistencies [3]. Next to be developed was the Inventory of Personality Organization (IPO) [7] self-report instrument used to evaluate the ego functions. This instrument consists of 83 items, each rated on a 5-point Likert-type scale (1 “never true” to 5 “always true”), that correspond to five subscales [8]. The first three, or the “Primary Clinical Scales”, are used to assess one’s primitive defenses, identity diffusion, and reality testing. These scales enable the clinical evaluation of the psychodynamics of personality structures and the related changes. The two other subscales, or the “Additional Scales”, are used to assess one’s aggressiveness and moral values , both being dimensions that tend to be highly varied in personality disorders. Ongoing work by the same research team is under way to develop a new instrument, called the Structured Interview for Personality Organization (STIPO), for evaluating ego functions [9].

The IPO has been found to have good psychometric qualities [10]. Importantly, the IPO has been adapted and validated for use across different languages and cultures, including Japanese [11], Dutch [12], Canadian French [13] Belgian [14], Italian [15] and Spanish [Argentinian [16], Colombian [17] and Mexican [18], among others]. The goal of our study was to translate and adapt the IPO for use in the Brazilian language and culture. Additionally, via this article, we aim to show in detail the steps of instrument adaptation to provide a guideline for other researchers.

The procedures previously described in the literature [19-22] were adapted to meet the specific needs of this study. The process was divided into two phases. In the first phase, the original inventory in American English [8] and the approved version in Argentinian Spanish [23] were translated into Brazilian Portuguese. The Argentinian version was used to inform possible structural rearrangements of the items to enable better fit with the Brazilian context. In the second phase, we focused on adapting the items to the Brazilian linguistic and cultural context by modifying the items to represent colloquial Brazilian Portuguese. Figure 1 shows a schematic of the procedures employed in the translation and adaptation that resulted in the trial version of the Inventory of Personality Organization – Brazil (IPO-Br). (Figure 1)

Figure 1: Techniques used for IPO’s translation and linguistic-cultural adaptation to context Brazilian.

As shown in Figure 1, in the first phase, we performed a total of four translations into Brazilian Portuguese. Four independent translators were recruited for this purpose [19], with two of them responsible for translating from American English version and the other two responsible for translating from the Argentinian Spanish version. All translators were proficient in the language (English or Spanish) and had lived in countries in which Spanish or English was spoken as a native language. In addition, three out of the four translators also had expertise in psychological assessment and psychometrics. Each translator received a translation protocol containing information about the instrument and instructions for the translation procedure. A synthesized version was created based on the completed translations and taking into account the theoretical aspects that underpin each item.

The synthesized version was examined by a committee of three experts [19] (Figure 1 - Phase B) who had extensive clinical experience and expertise in psychological assessment, psychometrics and psychoanalytic theory. The experts received an evaluation protocol and had to indicate on a 3-point scale (1 = Poor / inadequate, 2 = Average / acceptable, 3 = Good / appropriate) the clarity, appropriateness and semantic equivalence to the Brazilian culture for each of the translated items. For each item that was scored as “poor” or “average” (1 or 2), the experts provided justification and offered comments and suggestions for improvement. As a result of these comments and suggestions, a new version was prepared by considering both the relevance of the experts’ suggestions and the theoretical underpinnings of the items.

The resulting version of the IPO was presented to a focus group [22]. The first part of Table 1 displays the profile of the four members of the focus group. The sample was a convenience sample that was intentionally selected such that all members had secondary education as their highest level of education. Participants were asked to read the items and decide on a 5-point scale (1 = Unable to understand, 2 = Confusing, 3 = In doubt, 4 = Able to understand, 5 = Understood) the extent to which each item was clear and understandable. Next, each participant read the instructions of the instrument and scored, based on the same 5-point scale, the extent to which the instructions were understandable. Examining the comprehensibility of the instructions after that of the items prevented the participants from responding to the scale by following the instructions of the instrument instead of evaluating the clarity and comprehensibility of the items themselves. Finally, the group was asked to discuss the items that were scored as 1, 2 or 3 on the comprehensibility scale. Based on the comments and suggestions from the focus group, the intermediate version of the IPO was developed (Table 1).

Table 1: Sociodemographic characteristics of the samples of procedures Focus Group (n = 4) and Pilot Testing (n = 10).

The intermediate version of the IPO that resulted from the focus group was administered to 10 participants (see participant profile in the lower half of Table 1). First, participants were asked to read the instructions, respond to the instrument and mark the items that they had difficulty answering [24]. Any comments and observations gathered during this procedure were used to guide the necessary changes.

Finally, back-translation was performed as a procedure of validation [20]. Two independent translators were hired: a native English speaker who resided in Brazil and a Brazilian who was fluent in American English and had experience translating Brazilian Portuguese into English. Both translated versions were evaluated. Translations that best fit the Brazilian Language and retained the meaning of the original version were kept. Some items in the synthesized version were the result of merging two translations of the same item. Finally, a synthesized and back-translated version was presented to one of the authors of the original instrument (i.e., JF Clarkin) for validation [20- 25] with any resulting observations considered in the development of the trial version of the Inventory of Personality Organization - Brazil (IPO-Br). This trial version is being tested in ongoing studies.

Region-specific expressions were avoided throughout the translation and adaptation process so that the instrument can be used throughout the Brazilian territory. The translators and experts were recruited in Porto Alegre – RS. The focus group and participants of the pilot application were recruited in Lavras – MG.

This study was approved by the Ethics Committee in Research (approval number 2010073) of the Institute of Psychology at the Federal University of Rio Grande do Sul (CEP-PSICO) in agreement with Resolution 196/96 of the Commission National Research Ethics (CONEP) and with Resolution 016/2000 of the Federal Council of Psychology (CFP). As advised, we sought and received permission from one of the authors of the original IPO (namely, John F. Clarkin) to work with the instrument [25].

The data were analyzed qualitatively. All notes and suggestions resulting from each procedure were evaluated by the authors of this study in light of their relevance to theory and practice. The procedures were performed between October 2010 and February 2011.

The results corresponding to each technique employed in the study are presented below.

Translation

The Argentinian Spanish IPO version, which had been validated by the authors of original IPO, was used to identify instances when the items on the Brazilian Portuguese version departed in meaning from the original items. However, it is important to mention that the process of compiling and formatting items to Brazilian Portuguese was based on the original version to keep the Brazilian version similar to the original model. Methodologically, the use of another established adaptation allows one to understand the possible means of item presentation.

In the preparation of the first Brazilian IPO, we evaluated each item by considering its respective underlying construct. To this end, a protocol was developed, resulting in six versions of IPO items, including American English (original), Argentinian Spanish, two translations from American English and two translations from Argentinian Spanish. To elaborate the first version, the items were prepared using the following methods: a) choosing one of four versions of an item; b) integrating two or more versions; and c) as was the case for few items, developing a new version (that did not resemble any of the four translated versions). This initial version of the whole scale was then evaluated by an expert committee.

Expert Committee (EC)

Three experts received an item assessment protocol that they followed to judge the items on their clarity (C), semantic equivalence (SE) to the American English version and adequacy with regards to the Brazilian context (BC). The experts were allowed to access information about the instrument, each subscale and their constructs.

Of the 83 items on the IPO, 60 (72.3%) received comments, and 48 (57.8%) had their presentation revised for improvement. In addition, we modified 5 items that did not receive comments. Table 2 shows (under the EC columns) the number of comments that each item received and the items that were modified (highlighted).

Evaluation by an expert committee tests the adequacy of the translated version with respect to the context in which it is intended for use. Furthermore, this process strengthens the equivalence between the original and adapted versions [24]. As shown in Table 2, among the 48 modified items, 37 (77.1%) did not undergo any changes in its presentation in other procedures, indicating that these items were appropriate both with respect to the original version and the Brazilian culture.

Table 2: Modifications of the items in the procedures of IPO’s linguistic-cultural adaptation.

Focus Group (FG)

Use of the instrument with a focus group proved to be useful for identifying potential problems in item comprehension. In addition, feedback from a focus group enabled us to adapt the items to the lifestyle of the population tested [22]. As seen in the first half of Table 1, focus group participants had all completed high school. In other words, the items were comprehensible to subjects with equivalent education levels. As shown in the columns FG of Table 2, this procedure resulted in the alteration of 12 (14.5%) items. Participants’ suggestions focused on alternative wording and sentence restructuring. Of the 12 modified items, 9 (75%) did not undergo further changes in other procedures, suggesting that they were comprehensible and appropriate at both theoretical and cultural levels.

Pilot Testing (PT)

This procedure aimed to identify the items that were confusing and misleading in connotation [24], As shown in Table 2 under the columns PT of Table 2, only 2 (2.4%) items were altered. Of the 83 items on the IPO, 14 (16.9%) were identified as being difficult to answer; however, only 2 were effectively modified. Among the items listed, some participants reported that they could not understand the meaning of the sentence. Others failed to understand individual words or pointed out other specific aspects. Finally, some participants understood a sentence but had difficulty providing a score because they could not apply the item to their lives. We analyzed the characteristics of reported difficulties and found 2 items that needed major adjustments. Both items remained unchanged in the next steps, which suggested that the adjustment was appropriate with respect to the study goals.

Back-translation (BT)

In the process of instrument adaptation, back-translation helps to ensure that the similarity and equivalence of the translated items with the original items [20]. The back-translated version comprised 42 items (50.6%) from the native English-speaking translator, 21 items (25.3%) from the Brazilian translator, 4 items (4.8%) that were identical across the two translators and 16 (19.3%) that were elaborated based on the overlap between the two translations. This version was presented to one of the authors of the original instrument (i.e., John F. Clarkin) for evaluation.

In the version presented for evaluation, item 70 was followed by an explanatory note. The word “hostile” from the original version was replaced by the expression “turn into a beast” in the Brazilian version. This change was based on expert suggestions (generated in the Expert Committee procedure) that Brazilians with low levels of education are unlikely to understand the meaning of the word “hostile”. In contrast, the expression “turn into a beast” is an expression of the colloquial Brazilian Portuguese and is thus comprehensible across social classes and levels of education.

In the evaluation, the author of the original instrument recommended the reformulation of 6 (7.2%) items (see column B of Table 2). Of these, 4 remained unchanged (items 1, 8, 12 and 24), as the author agreed after an explanation combined to another backtranslated version of these items. For example, for the item 12, the word “erratic” in the original version was translated to “unstable” in the Brazilian version. The author of the original instrument pointed out that the word “erratic” referred to behavior that was “rather irregular”, which in Brazilian Portuguese and in line with Brazilian culture could be understood as “unstable”. Nonetheless, items 17 and 79 were modified following the author instructions due to the original meaning not being captured by the Brazilian version. At the end of this process of evaluation and revision, the trial version of Inventory of Personality Organization - Brazil (IPO-Br) was produced.

Trial version of the Inventory of Personality Organization - Brazil (IPO-Br)

In the original IPO, items were organized in their respective subscales (see Table 3). In the Brazilian version, we chose to randomize the items to avoid that similar items be next to one another.(Table 3)

Table 3: Distribution of items in the IPO-Br and their correspondence to the original IPO.

In Table 3, the items on the IPO-Br are listed under the columns with the heading “Brazil”. Randomization of the items was conducted using the website http://www.random.org/. Specifically, the option “Random Sequence Generator” was selected, with 1 as the lowest value and 83 as the highest value. Table 3 shows the results of this procedure, and Appendix shows the items of both versions (original and Brazilian).

The process of translation and adaptation of tests must be conducted with rigor. This is because serious consequences might result from using an instrument across different languages and cultures without adequately preserving the essence of the original instrument or adapting the instrument to fit the new population [26]. As suggested in psychological research [26], cultural factors may interfere in the evaluation process. Thus, we designed a methodology to translate and adapt the IPO to the Brazilian culture.

In Brazil, there has been a lack of valid instruments for assessing different constructs [28-29], including personality disorders. The IPO has shown good psychometric qualities in different cultures [10- 15,17,18,23] and has proven adequate for evaluating patients with personality disorders [11,12,14]. Given that the proposed structural diagnosis based on the Model of Organization of Personality [2-7]) focused on the understanding of the patient, the development of treatment programs and the establishment of prognosis, it is believed that the IPO may be a useful tool in the Brazilian context.

In terms of methodology, the translation of items in two versions (original and Argentine) was a new strategy. The Argentine version was selected for two reasons. First, because the Argentinian Spanish resembles the Brazilian Portuguese, this version allows us to observe possible standards and suggest ways of presenting items already approved by the original authors. Second, given researchers’ intention to compare South American countries using the IPO, the availability of an Argentine version as a comparison standard may further strengthen this initiative. In addition, the Brazilian IPO was based mainly on original IPO items, which consist of psychopathological descriptions and complex scenarios. The Argentine version informed our decisions on the best ways to structure and present the items in the Brazilian version. The proper application of this procedure is essential for the development and success of the adaptation process [19-22, 24-27]

The use of experts is a well-established element of instrument adaptation [19-22]. In this study, expert input was essential for adapting the items to the Brazilian culture in light of the underlying theoretical construct. Due to logistical constraints, the experts in this study were unable to gather for a discussion of the items but made notes individually in the protocol he/she received. As a result, the task of judging, modifying and elaborating on the items in the synthesized version was left to the authors. Therefore, whereas the systematic collection of notes and observations from each expert represented a strong point of this study, the lack of debate on the items was a limitation.

Although the use of focus groups does not receive as much attention in the literature on instrument adaptation as in the literature on other techniques, focus groups proved to be important for identifying issues of item interpretation. Assessing the familiarity of items [22] was essential in helping to identify the items that have a more complex linguistic structure.

Pilot testing is an important procedure in the process of adaptation [26]. In this study, pilot testing led to the clarification of items that had been confusing or easily misinterpreted. Whereas the literature recommends recruiting approximately 30 to 40 people for pilot procedures, we observed that 10 people were sufficient to meet the demands of this instrument.

Despite the suggestion by some authors that back-translation should be performed immediately on the synthesized translation [24- 26], back-translation was performed at the end of this study to allow the original authors to assess the Brazilian items with all the cultural changes. Using a complex procedure that takes into consideration the Brazilian culture and the original IPO, we have developed a trial version of the Inventory of Personality Organization – Brazil (IPO-Br). Importantly, this trial version has been approved by one of original authors of the IPO. The approval of the original author indicated that the methodology employed was accurate [30].

We have noticed that several adaptation articles did not show their procedures in a detail way [31-32]. With this article, we tried to show our procedures in order to provide a guideline for other researchers. This means that this way is not the only one, and small changes are expected depending on the context or the instrument.

In this study, we translated and adapted the Inventory of Personality Organization to the Brazilian context, culminating in a trial version of the IPO-Br. The procedures used followed the recommendations in the literature with adaptations to meet the specific needs of this study. Ongoing work is being performed to examine the factorial and concurrent validity of the subscales in the IPO-Br. Future studies that involve the use of the IPO-Br with clinical populations are also in preparation.

The authors express their esteem to John F. Clarkin Ph.D. André Luiz Franco Sampaio Ph.D., Jefferson Silva Krug M.Sc., Rafael Stella Wellausen M.Sc., Luciane Maria Baddo Psy.S. and members of the research group GEAPAP for their collaboration. The authors express their thanks to CNPq for the finnacial support.