Using Online Methods to Develop and Examine the Hong Kong Chinese Translation of the Dissociative Experiences Scale

ABSTRACT

Identifying dissociation is important for mental health services because it could fundamentally affect one’s diagnosis and treatment plan. The Dissociative Experiences Scale (DES) is a widely-used self-report scale for measuring dissociative experiences. It has been translated into many languages and used in many countries. However, there is no validated Hong Kong Chinese version of the DES available in the field, and there is no other validated Hong Kong Chinese instrument for assessing dissociative disorders. This pilot study used online methods to translate the DES to Hong Kong Chinese (HKC-DES). The results indicated that the HKC-DES has excellent internal consistency (α = .953) and very good test-retest reliability (r = .797). Bilingual participants’ responses to the DES and HKC-DES indicated high similarity, and were significantly correlated (r = .960). These results initially verified the reliability and cross-language equivalence of the scale. Implications for healthcare practice and research are discussed.

KEYWORDS:

• Mental health
• Dissociative Experiences Scale
• Chinese
• online methods

Dissociation is a psychological phenomenon covering a wide array of experiences in our daily life, such as daydreaming, trance-like feelings, absorption, and forgetfulness. The concept of “dissociation” has been operationalized in the literature for almost 30 years (Bernstein & Putnam, 1986; Ross, 1997) and it is regarded as one of the “big five” in the mental health field, the other four are depression, anxiety, substance abuse, and psychosis (Ross, 2007). Dissociation may be used pathologically or as a normal coping strategy. It is widely perceived that pathological dissociation is associated with psychological trauma, especially childhood trauma (Irwin, 1999; Putnam, 1985; Van der Hart, Nijenhuis, & Steele, 2006). Pathological dissociation can be found in patients with dissociative disorders (DD), post-traumatic stress disorder (PTSD), and some other mental health conditions (Van der Hart et al., 2006).

Identifying dissociation is important for mental health services because it could fundamentally affect one’s diagnosis and treatment plan. There are several reasons. First, high level of dissociation increases the chance of having an undiagnosed DD. Second, high level of dissociation may indicate the needs of trauma-informed and psychosocial services because dissociation is generally associated with adverse life experiences (e.g., trauma, neglect, parental dysfunction, chronic stress; Draijer & Langeland, 1999). Third, certain dissociative symptoms require specific interventions (e.g., dissociation-focused psychotherapy) and they would improve as long as they are specifically targeted (Brand & Webermann, 2015; International Society for the Study of Trauma and Dissociation, 2011; Jepsen, Langeland, Sexton, & Heir, 2014).

The Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986; Van IJzendoorn & Schuengel, 1996; Waller, Putnam, & Carlson, 1996; Waller & Ross, 1997), which has 28 items, is a widely-used self-report instrument with good reliability and validity. Each of the 28 items scored on an 11-point scale, asking the subject to choose a number to indicate what percentage of the time a particular experience happens to them (from 0 to 100%). The overall score is the mean of the 28 items. An overall score equal to or greater than 30% is generally perceived as a cutoff score to indicate potential DD (Carlson et al., 1993; Ross, 1997). In addition, the DES-Taxon (DES-T) is an eight-item measure drawn from the DES (items 3, 5, 7, 8, 12, 13, 22, and 27), which can be used to assess pathological dissociation (Waller et al., 1996; Waller & Ross, 1997). It has been found that the DES-T can diagnose complex DD with excellent agreement (Cohen’s kappa) with clinical interview and other structured instruments (Ross, Duffy, & Ellason, 2002).

Although the DES is not a diagnostic instrument, it is a very useful screening tool and had been used in more than 100 studies in the first 10 years of its existence (Van IJzendoorn & Schuengel, 1996). The DES has been translated into many languages and used in many countries (International Society for the Study of Trauma and Dissociation, 2011; Ross, 1997; Şar, 2011). However, to our knowledge, there is no validated Hong Kong Chinese version of the DES available in the field, and there is no other validated Hong Kong Chinese instrument for assessing DD. The lack of a validated Hong Kong Chinese version of the DES may hinder rigorous academic research and cross-cultural comparisons. This may, in turn, obscure our perception about the prevalence of DD among Hong Kong Chinese, and mislead the helping professionals to underestimate the prevalence of unrecognized DD cases (Fung, 2016a, 2016b). In addition, inappropriate treatments may create a vicious cycle that may be harmful to DD patients (International Society for the Study of Trauma and Dissociation, 2011; Steinberg & Siegel, 2008). As such, lacking a local DD assessment tool does not just affect our understanding of the situation, but it may do harm to DD patients.

A Hong Kong Chinese version of the DES is important for supporting the helping professionals in Hong Kong to accurately assess DD and related clinical conditions (e.g., dissociative subtype of PTSD) in the local context, and to research about relationships between dissociative experiences and other mental health issues. In the process of this cross-cultural instrument adaptation, the cultural and technological contexts of Hong Kong may have unique contributions.

First, the process of cross-cultural adaptation of scale involves translation, back-translation, and testing the bilingual version using bilingual subjects (Beaton, Bombardier, Guillemin, & Ferraz, 2000; Chan & Holosko, 2017; Sousa, Zauszniewski, Mendes, & Zanetti, 2005), local university students can serve as a convenient participant pool to help examine translated instruments. Hong Kong was a British colony before 1997, many citizens in Hong Kong actually can use English as a second language, and some were even raised bilingual. Although Chinese is the native tongue of most citizens, both English and Chinese are official languages in the local context, English is the official language in higher education settings, and most of the university-level programs used English as the medium of instruction and required certain English proficiency as an entrance requirement. As such, many university students in Hong Kong can read English pretty well, although much less of them can write and speak English equally well. If questionnaire items are presented in plain English, university students in Hong Kong are competent enough to understand them.

Second, previous studies indicated that the psychometric properties of “paper and pencil” based DES and web-based DES are equivalent, and suggested that the Internet could be an efficient means of data collection and research (Collins & Jones, 2004; Rutherford et al., 2016). The technological infrastructure of Hong Kong may further facilitate such online methods. Online methods have been commonly used in subject recruitment (Amon, Campbell, Hawke, & Steinbeck, 2014), data collection (Chan & Holosko, 2016), large-sample epidemiological surveys (Youn et al., 2013), respondent identity verification (Paolacci & Chandler, 2014), and scale development (Jelenchick et al., 2014). In this study, online methods were used in all these processes, as the technological infrastructure of Hong Kong is mature enough to support such methods. In 2015, there were more than 7.3 million people residing in Hong Kong, and 84.9% of those aged 10 and over reported that they were regular Internet service users (Census and Statistics Department of the HKSAR, 2016). There were 66% of the population in Hong Kong who had an account with some social media network, in which Facebook was the most popular platform, indicating a 50% penetration rate in the entire population (Statista, 2016). In February 2016, the residential fixed-line penetration rate was 94.83%, and the mobile subscriber penetration rate was 228.7%, meaning that each person, on average, has more than one mobile phone number (Office of the Communications Authority of the HJKSAR, 2016).

Taken together, this pilot study served a dual purpose: First, it aimed to translate the original DES to the Hong Kong Chinese version of the DES (HKC-DES), and initially examine its psychometric properties (Bullinger, 1995; Leplège, Ecosse, Verdier, & Perneger, 1998; Sousa & Rojjanasrirat, 2011). Second, it also aimed to open discussion of the use of online research methods in scale development, and help explore the potentials and limitations of such methods.

Method

The study made reference to a range of widely accepted protocols for scale translation (Beaton et al., 2000; Bracken & Barona, 1991; Cabrera-Nguyen, 2010; Sousa & Rojjanasrirat, 2011; Sousa et al., 2005) and guidelines for online research methods (British Psychological Society, 2007; Eysenbach, 2004), and finally adopted the following steps.

Collaborative translation facilitated by the Internet

Different experts in Hong Kong, Macau, Canada, and the United States were connected via the Internet. The scale was translated from English into Chinese and back-translated to English using a three-step process: (1) Translation: Two translators (the second and the third author of this article) respectively provided their Chinese versions of the Scale; (2) Back-translation: The two Chinese versions of the scale were back-translated into two English versions by a translator (a professional reporter who is extremely fluent in English and Chinese) who had not seen the instrument before; (3) Compare and synthesis: A panel reviewed and compared the two Chinese versions translated from the original English DES, compared their corresponding back-translations, and compared them with the scale in its original language. In this study, the panel members included Dr. Im Wai Lao (psychiatrist, Macau), Dr. David Yeung (retired psychiatrist, Canada), and Dr. Chitat Chan (first author of this article, assistant professor, registered social worker, Hong Kong). All of the panel members are fluent in English and Chinese. After discussion, selection, and refinement, the panel reached a consensus, and the HKC-DES was produced and used in the subsequent pilot test.

A preliminary psychometric testing

Recruiting bilingual local university students via social media

In this study, local university students served as a bilingual participant pool to examine the cross-language relevance of the HKC-DES. Bilingual herein refers to people who use both Chinese and English in their everyday lives, regardless of whether it is in bilingual families or in the context of immigration or study (Chan, Parker, Tully, & Eisenbruch, 2007; Thumboo et al., 2002). This study used social media to recruit college students, because it is part of daily life for most of the university students (ONS, 2014; PEW Research Center, 2014a, 2014b). We used a short article to make a pitch to invite university students to voluntarily help answer our questionnaire. The algorithm of social media helped associate like-minded people and largely facilitated our snowball sampling. We embedded a Google online form in our short article to invite potential participants to provide their official university student e-mail addresses. This online form was posted on various popular online platforms in Hong Kong, such as Facebook, Online Media for Human Services (a Hong Kong based group blog on Blogger), and Stand News (Hong Internet-based media). A snowball sampling method was used because a random sampling method would result in low reply rates when sensitive topics are involved (Hsaio et al., 2010). Registered participants from different universities were motivated students who voluntarily took part in the study and did not receive any monetary incentives. This helped ensure they had basic motivation to provide genuine responses.

Verifying student identity online

Verifying research participants’ identity is a key challenge in online research (Eysenbach, 2004), as the participants and researchers are not physically brought together during the research process. Therefore, researchers have employed a variety of mechanisms to authenticate participant identity, such as checks made by credit cards, using passwords, or registration of an e-mail (British Psychological Society, 2007). In this study, participants needed to fill in an online form to provide their official university student e-mail addresses. The actual online questionnaires were sent to these official student e-mail addresses via the MySurvey system of the Hong Kong Polytechnic University (PolyU). Participants’ access rights of their own official student e-mail accounts served as a proof to authenticate their student identity in local universities. Each registered participant received an e-mail indicating a unique hyperlink to access the online questionnaire. This unique hyperlink represented a unique participant identity code, therefore, the responses from individual participants could be identified by the system. This authentication process served to ensure participants’ identity and get their formal consents.

Collecting data via a secured online questionnaire system

Data were collected online via the MySurvey system of the PolyU. All study participants completed a questionnaire having both Chinese version and the English version of the scale. After they completed the Chinese version, they needed to complete the English version. The items were randomly assigned, so that the question sequences of both versions were not corresponding to each other. All fields were mandatory and submission was not allowed in case there was any field missing. Therefore, there was no missing data in a submitted response.

The retest was facilitated by the unique identity codes assigned by the system

Each participant who answered the questionnaire would have their unique participant identity code, in which the responses from individual participants could be traced and paired up with subsequent retests. A retest of the HKC-DES was conducted 1 month after the first test. Given that we aimed at examining the test-retest reliability of the HKC-DES, the retest did not include the DES. All individual participants who took part in the first test would receive a system generated e-mail showing a unique hyperlink to access the same questionnaire.

Analyzing the psychometric properties of the scale

The Statistical Package for the Social Sciences was used in the data analysis. Collaborators can access the software hosted by the PolyU web-based platform via VPN. Psychometric properties of both language versions of the instrument provide evidence of their equivalence. The reliability (the degree to which the HKC-DES is stable and reliable) and validity (the degree to which the HKC-DES is equivalent to the DES) of the scale were tested. Characteristics of the sample were depicted by computing frequencies for categorical variables and descriptive statistics. Reliability analyses involved examination of Cronbach’s alphas, inter-item correlations, and item-to-total scale correlations. Validity testing involved the use of similarity check, paired t-tests, and Pearson’s correlations between the English and Chinese item scores and total scale scores.

Results

Overall profile

We started the recruitment on May 4, 2016 and recruited more than 200 participants on a rolling basis within a month without paying any monetary incentives or advertising fees. After collecting participants’ registration information, we manually checked the submitted e-mail addresses, rectified obvious typos, and made sure that they were associated with local universities. Unqualified entries were out. We then rolled out the online survey batch by batch between May 5 and June 1, and collected 108 valid responses coming from more than nine institutes. Among the 108 responses, 20% were male, 80% were female, and the average age was 26.4 (Table 1). We started the retest on June 13 and collected more than 47 valid responses in a week (i.e., 44% return rate). The mean score of the DES is 20.2 (SD = 16.5), and the mean score of the HKC-DES is 22.9 (SD = 15.8).

Table 1. Demographic Information of the Participants.

	First Test		Retest
Demographic Information	Frequency	Percentage (%)	Frequency	Percentage (%)
Variable	Gender
Female	86	80	37	79
Male	22	20	10	21
Variable	Level of Education
Associate’s degree or equivalent	13	12	6	13
Bachelor’s degree	56	52	23	49
Master’s degree or above	38	35	17	36
Other	1	1	1	2
Variable	Subjects
Arts and humanities	10	9	4	9
Life sciences and biomedicine	6	6	3	6
Other	17	16	8	17
Physical sciences	2	2	1	2
Social sciences	72	67	31	66
Technology	1	1	0	0
Variable	Institutions
City University of Hong Kong	25	23	7	15
The Chinese University of Hong Kong	11	10	6	13
Hong Kong Baptist University	1	1	0	0
Hong Kong Institute of Education	13	12	8	17
The Open University of Hong Kong	8	7	6	13
The Hong Kong Polytechnic University	36	33	13	28
Hong Kong Shue Yan University	7	6	2	4
The University of Hong Kong	4	4	3	6
Lingnan University	2	2	1	2
Other	1	1	1	2

Reliability

Reliability was assessed by Cronbach’s alpha, the results of the DES was .964, and the HKC-DES was .953. These results were consistent with the results from a previous study, which reported .95 (Frischholz, Braun, Sachs, & Hopkins, 1990). The results indicate excellent reliability, as .8 is a widely accepted standard (Gliem & Gliem, 2003). Moreover, Cronbach’s alpha was not increased by deleting any items and all items showed good item-to-total correlations, indicating homogeneity across items and across different language versions. All items in both the DES and HKC-DES indicated significant correlation at 1% level, except item 17 in the HKC-DES which indicated significant correlation at 5% level (see Table 2). The means of inter-item correlations were .489 and .418 for the DES and HKC-DES, respectively. This indicated homogeneousness of items without losing uniqueness, as they were within the recommended range (Clark & Watson, 1995, from 0.15 to 0.50; Nunnally & Bernstein, 1994, from 0.30 to 0.70). Cronbach’s alpha and item-to-item correlation for both genders were also assessed separately and showed similar reliability as aggregated results.

Table 2. Item-to-total Correlation and Cronbach Alpha Statistics.

	HKC-DES		DES
Item	Corrected Item–Total Correlation^a	Cronbach’s Alpha if Item Deleted	Corrected Item–Total Correlation†	Cronbach’s Alpha if Item Deleted
1	.719	.948	.660	.961
2	.594	.949	.656	.961
3	.640	.949	.697	.960
4	.692	.948	.737	.960
5	.589	.949	.674	.961
6	.570	.949	.659	.961
7	.557	.949	.694	.960
8	.698	.948	.692	.960
9	.698	.948	.689	.960
10	.576	.949	.647	.961
11	.684	.948	.753	.960
12	.680	.948	.764	.960
13	.723	.947	.816	.959
14	.707	.948	.777	.960
15	.632	.948	.710	.960
16	.718	.948	.791	.960
17	.237*	.953	.472	.962
18	.731	.947	.735	.960
19	.653	.948	.575	.961
20	.752	.947	.709	.960
21	.443	.951	.564	.962
22	.674	.948	.685	.960
23	.434	.950	.518	.962
24	.573	.949	.670	.961
25	.651	.948	.707	.960
26	.664	.948	.729	.960
27	.656	.948	.658	.961
28	.708	.948	.753	.960

^aAll items’ correlations were significant at 1% level except item 17 of the HKC-DES.

*p < .05.

The HKC-DES showed good test-retest reliability. There were n = 47 subjects (44%) who responded to the retest invitation. The whole sample and the retest sample showed similar demographic information, except in the distribution of affiliated universities. The difference between the overall mean scores of the tests taken by the same participants at the two time points was insignificant. Differences between the scores of individual items at the two time points were also insignificant, except two items which reported a difference at 5% level of significance (see Table 3). The overall scores of the tests taken at the two time points were also highly correlated (r = .797, n = 47, p < .01). The test-retest reliability of the HKC-DES is lower than the test-retest reliability of the DES reported in a previous study which reported .93 (Frischholz et al., 1990), and yet both results are considered very good to excellent.

Table 3. Test-Retest Reliability of CDES.

Item	First Test		Re-test		t
	M	SD	M	SD
1	20.6	27.5	24.9	27.5	1.3
2	46.6	28.5	45.3	28.9	–0.4
3	9.8	18.6	16.2	24.5	2.6*
4	9.1	21.0	11.7	21.9	1.1
5	18.3	21.1	14.9	16.9	–1.1
6	13.0	20.8	17.0	23.8	1.5
7	11.9	18.7	16.2	23.2	1.5
8	14.3	23.8	13.4	22.6	–0.3
9	16.4	23.4	14.5	22.8	–0.6
10	22.8	24.2	18.3	20.3	–1.3
11	13.0	24.3	12.3	22.1	–0.2
12	19.1	26.4	22.8	29.4	1.4
13	18.3	26.5	17.9	27.1	–0.2
14	31.5	29.6	27.4	29.2	–1.5
15	34.0	28.6	33.6	30.8	–0.1
16	20.6	24.4	21.5	21.3	0.3
17	53.4	24.3	50.4	29.0	–0.9
18	27.4	26.2	26.6	27.0	–0.3
19	23.2	25.7	23.0	24.1	–0.1
20	34.7	30.6	31.5	26.1	–0.9
21	16.8	27.6	23.2	29.4	2.1*
22	28.3	30.5	25.7	27.0	–0.6
23	34.9	24.5	33.8	22.9	–0.3
24	26.2	24.8	25.3	27.1	–0.3
25	24.0	24.8	19.4	22.5	–1.4
26	19.8	22.3	22.6	24.0	1.0
27	26.4	29.1	22.8	28.4	–1.0
28	14.0	25.1	18.9	23.4	2.0
Total	23.2	18.2	23.3	19.4	0.0

*p < .05.

Validity

The similarity of the results of equivalent items in the DES and HKC-DES from the same participants was examined. There were 83% responses that were deemed similar. We considered two responses similar when their difference was not greater than one Likert scale point (i.e., 10%).

Pearson correlations between the DES items and HKC-DES items were used to examine the validity of the translated scale (Polit & Beck, 2004; Son, Zauszniewski, Wykle, & Picot, 2000; Zauszniewski & Harman, 1996). The overall scores of the DES and the HKC-DES were significantly correlated (r = .960, n = 108, p < .01). In addition, correlation between the DES and the HKC-DES is significant at 1% level for both genders (Male = .920; Female = .968).

Paired t-test was used to examine the significance of the mean difference between the results of same item in the DES and HKC-DES from the same participant (see Table 4). The findings showed that two thirds of the 28 items did not indicate significant mean differences, implying cross-language equivalence. Among the one third, which indicated significant mean differences, the scores from the HKC-DES were generally higher than that from the DES. The paired t-test is not shown for various subgroups (e.g., genders, institutions) of the sample because the sample size of subgroups are too small (n < 30) for conducting t-test.

Table 4. Paired t-Test Between the DES and the HKC-DES.

	HKC-DES		DES
Item	Mean	SD	Mean	SD	t
1	19.7	24.6	17.9	24.5	1.0
2	45.5	28.4	37.6	28.8	4.4**
3	9.7	17.8	10.8	18.6	–1.3
4	7.0	16.5	8.7	17.6	–2.7**
5	18.9	20.2	13.7	17.5	3.9**
6	12.8	19.0	12.7	19.3	0.1
7	13.0	21.1	12.4	20.6	0.5
8	11.6	19.1	10.6	18.3	0.9
9	14.7	22.5	14.9	22.5	–0.2
10	25.2	25.5	16.9	20.2	4.4**
11	10.8	18.9	11.3	19.2	–0.7
12	20.9	25.7	19.4	24.4	1.0
13	17.0	25.1	15.8	23.6	1.1
14	28.3	27.4	26.1	26.9	1.4
15	34.0	28.6	26.1	26.4	3.4**
16	21.7	25.0	20.6	23.8	0.6
17	53.1	26.7	42.0	27.6	5.6**
18	28.1	26.6	26.2	27.1	1.2
19	23.1	23.8	19.4	22.5	3.4**
20	31.5	28.8	30.9	26.8	0.4
21	17.1	27.2	18.6	28.0	–1.5
22	25.6	27.1	24.9	26.2	0.7
23	37.9	26.0	27.3	26.0	5.9**
24	28.1	25.9	25.3	24.6	1.8
25	23.3	21.1	21.8	21.7	1.1
26	20.6	20.8	16.9	20.3	3.0**
27	27.3	28.0	23.9	26.4	2.5*
28	14.9	23.7	13.8	21.5	0.9

*p <.05. **p < .01.

Discussion

The results indicated that the HKC-DES has excellent internal consistency (α = .953) and very good test-retest reliability (r = .797). Bilingual participants’ responses to the DES and HKC-DES indicated high similarity, and were significantly correlated (r = .960). These results initially verified the reliability and cross-language equivalence of the scale.

Yet, there were some limitations in this pilot study. First, we only used a small sample size of about 108 participants, though the variety of the study backgrounds may help offset some sampling bias. Second, as the study was conducted purely online, all the recruited participants might have some common Internet habits reflecting common personality traits. Third, although most of the online methods used in this study demonstrated good effectiveness and had largely facilitated the research process, we still needed to check manually the e-mail addresses submitted by the participants to ensure that they were university-based e-mail addresses, and we lost contact with some registered participants because of the typos in the e-mail addresses they submitted. Notwithstanding these limitations, the methods used in this study demonstrated high efficiency, and allowed for much more unique data to be collected from motivated and voluntary participants in a short period of time.

Some observations require further discussion. First, item 17 in the HKC-DES has indicated a low correlation with other items, as well as the entire scale. This item refers to the experience that: “Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them,” and participants were asked to indicate how frequent was that experience in their daily life. The average score of this item tended to be on the high side, regardless of the average scores the individuals or the sub-groupings of the sample. In fact, based on our daily observations in Hong Kong, the experience of immersing in television, movie, or any media products is a very common experience among Hong Kong people. This raises questions about whether item 17 is still a valid indicator assessing people living in a highly mediated city, although this may also mean that the results indeed revealed a prevailing type of dissociation experience in such environment. We suggest that researchers may need to review the clinical implications and the relevance of item 17.

Second, 17% responses in the English version were different from the Chinese version by more than one Likert point. It should be noted that, the DES is virtually an 11-point Likert scale (0 to 100%), which is different from a commonly used 5–7 point Likert scale in much psychological research. This means, in principle, the scale will result in a wider range of variance, and will pose greater challenges in giving the same responses. Inferences based on comparing differences or similarities may need to take this factor into consideration. Moreover, the time taken for the retest was too long (2 to 3 weeks) in this study. Result of retest may be affected by different factors, such as interventions provided for them (if any) or participants may have discussed the items among themselves. A week or less test-retest interval would be better.

Third, among the 28 items, nine consistently reported a slightly higher score in the HKC-DES than in the DES at 1% level of significance (see Table 4). These differences were found in various subgroups of the same sample set (e.g., different combinations of universities, subject areas, education levels). Nonetheless, rather than a sign of inequivalent translation, we see the tendency of having higher scores in the HKC-DES, a result related to the everyday language context of the bilingual subjects. It is possible that the English medium is not as effective as the Chinese medium in facilitating subjects living in a Chinese context to recall their daily experiences. Local university students are living in a Chinese context; even though they can master the two languages pretty well, they would recall more experiences in a language medium that they used more frequently, and therefore, the HKC-DES may possibly return slightly higher scores. Recent studies did consistently show that subjects’ autobiographical memory will be affected by their language medium (Marian & Fausey, 2006). An alternative explanation is that the English (as a second language) scale may, in fact, provide a “less biased” representation of one’s experience. Recent research indicated that when individuals interpret emotion-laden texts, they think and judge more rationally and objectively in a second language than in their native tongue (Costa et al., 2014; Gao, Zika, Rogers, & Thierry, 2015; Hsu, Jacobs, & Conrad, 2015; Keysar, Hayakawa, & An, 2012; Pavlenko, 2012).

These inferences, though very preliminary and inconclusive, raise questions about whether the Hong Kong Chinese population would recall their dissociative experiences equally “valid” when they use an English scale and in a Chinese scale. That is, it is worthwhile to further explore whether the results from a native language instrument are a “less biased” representation, a “less accurate” representation, or an equally valid representation in researching bilingual Hong Kong Chinese. As both English and Chinese are official languages endorsed by the Hong Kong Government, and citizens are used to have the options to choose their preferred language in working with official documents, this inevitably implies a practical question concerning which language should be used in psychological tests among educated Hong Kong Chinese. Further research using a larger sample size or using a different bilingual Chinese population in Hong Kong may help enrich the discussion.

Concluding remarks

To conclude, this pilot study used a cost-effective method to translate the DES from English to Chinese, and initially showed that the HKC-DES demonstrates acceptable reliability and validity. This has significant implications on local healthcare practice and research. At a practice level, the HKC-DES and HKC-DES-T can support the assessment of DD in Hong Kong. When doing psychiatric assessment, measuring dissociation is a recommended step (Fung, 2016b; Ross, 2007; Steinberg & Siegel, 2008; Welburn et al., 2003). We suggest that Chinese helping professionals, especially those who work with traumatized clients, can use the HKC-DES and HKC-DES-T in their actual practice. It can be used as a pretest-posttest instrument, and support outcome evaluations of local services for traumatized and dissociative clients. At a research level, HKC-DES may facilitate the development and validation of other Chinese trauma and dissociation instruments (e.g., the Dissociative Disorders Interview Schedule; Ross et al., 1989), and help further explore mental health issues among Chinese populations in different regions. Future studies can employ this HKC-DES to investigate dissociative experiences among various clinical and non-clinical populations in Hong Kong. This instrument may also facilitate cross-cultural comparison, for example, comparing the clinical features between DD patients from Hong Kong and those in the other countries.

Our online methods have largely facilitated the research process. It shows that using online methods to translate scales/instruments into Chinese is promising and cost-effective. However, we also see that there is still room for further improvement. As mentioned elsewhere, we lost contact with some of the registered participants because of the typos in some of the e-mail addresses they submitted. We suggest that the steps of registration, screening, sending invitations, and authentication can be further automated and streamlined. That is, in principle, once a potential participant has submitted their university-based e-mail address, the program should be able to verify whether it is a valid e-mail address belongs to a web domain registered in a list of targeted domains, and then the program should be able to automatically send an invitation e-mail embedded with a unique questionnaire hyperlink. Further technological adaptation and development will be required.

Finally, we recommend a more comprehensive psychometric testing of the HKC-DES in a larger Hong Kong Chinse sample and/or in Chinese populations in other Chinese contexts. The more complete the testing of the HKC-DES, the more we can know about its reliability and validity. Moreover, with a larger sample, exploratory factor analysis and confirmatory factor analysis can be applied. Further, we also see that scale translation is a dialectic complex. Both the cultural contexts and the scale have informed each other, and they may co-construct the reality of what is to be measured. The true potential of any well-crafted scales can only be fully actualized in the local context if the local research community can take a more proactive role in adapting and indigenizing the scales.

Appendix

Table A1. The Dissociative Experiences Scale in English and Hong Kong Chinese.

Item No.	DES	HKC-DES
1	Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don’t remember what has happened during all or part of the trip.	有些人在駕駛或乘搭汽車、巴士、地鐵等交通工具時，會突然意識到他們記不起行程中發生過的全部或部分事情。
2	Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said.	有些人有時在傾聽別人說話時，會突然意識到他們並沒有聽到別人說話的部分或全部內容。
3	Some people have the experience of finding themselves in a place and have no idea how they got there.	有些人突然發現自己身處一個地方，卻又不知道自己是怎樣來到這個地方。
4	Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on.	有些人會發現自己身上穿著某些衣物，卻記不起是自己穿上的。
5	Some people have the experience of finding new things among their belongings that they do not remember buying.	有的人會發現自己有一些新的東西但是卻不記得自己曾經買過那些東西。
6	Some people sometimes find that they are approached by people that they do not know, who call them by another name or insist that they have met them before.	有些人有時候會發現他們不認識的人會前來接近自己，這些人會以其他名字稱呼自己或堅持之前曾與自己見過面。
7	Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person.	有些人有時會有一種經歷，他們感覺好像站在自己的身邊，或從旁看著自己做事，他們看著自己就彷如正在看著另一個人似的。
8	Some people are told that they sometimes do not recognize friends of family members.	有些人會被告知，他們有時候不能辨認出自己的朋友或親人。
9	Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation).	有些人會發現，他們對於自己生命中某些重要的事件（例如：婚禮、畢業）毫無記憶。
10	Some people have the experience of being accused of lying when they do not think that they have lied.	有的人有這種經驗，他們會被人指責說謊，而自己卻不認為說過謊。
11	Some people have the experience of looking in a mirror and not recognizing themselves.	有些人有過這樣經歷，照著鏡子時認不出自己。
12	Some people have the experience of feeling that other people, objects, and the world around them are not real.	有些人有過這樣經歷，覺得身邊的人、物件和整個世界都不是真實的。
13	Some people have the experience of feeling that their body does not seem to belong to them.	有些人有過這樣經歷，覺得他們的身體似乎不屬於自己。
14	Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event.	有些人有過這樣經歷，有時候記起過去某些事情時，會逼真得令他們覺得自己好像正在重新經歷該事情一樣。
15	Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them.	有些人有過這樣經歷，他們無法肯定自己所記得的事情是真實發生過，抑或只是在夢境裡發生過。
16	Some people have the experience of being in a familiar place but finding it strange and unfamiliar.	有些人有過這樣經歷，發現自己身處一個熟悉的地方，卻又覺得這個地方陌生和不熟悉。
17	Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them.	有些人會發現，當他們正在看電視或電影時，會全神貫注於當中的情節，甚至沒覺察到自己四周正在發生的事情。
18	Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them.	有些人會發現，他們會深深沉浸在幻想或白日夢裡，覺得這好像是真實發生在自己身上。
19	Some people find that they sometimes are able to ignore pain.	有些人會發現，他們有時候能夠忽略疼痛的感覺。
20	Some people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time.	有些人會發現，他們有時候坐著發呆、什麽也沒想到，並且沒有意識到時間在流逝。
21	Some people sometimes find that when they are alone they talk out loud to themselves.	有些人有時候會發現，當他們獨自一人時會大聲地對自己說話。
22	Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people.	有些人會發現，他們在某情境中的行為舉止與另一個情境中的行為舉止相比，可以有很大分別，感覺彷如是兩個不同的人。
23	Some people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (for example, sports, work, social situations, etc.).	有些人有時候會發現，在某些情況下，他們能夠毫不費勁、自然地做到一些平時覺得很難做的事情（例如：運動、工作、社交場合等等）。
24	Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (for example, not knowing whether they have just mailed a letter or have just thought about mailing it).	有些人有時發覺，他們不能記起是否曾經做過某件事情，抑或只是曾經想過做該件事情（例如：不知道是否曾經寄過一封信，抑或只是曾經想過去寄該封信）。
25	Some people find evidence that they have done things that they do not remember doing.	有些人會發現他們做過某些事情的證據，卻記不起自己曾做過這些事情。
26	Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing.	有些人有時候，會在他們的財物之中發現肯定是自己做過的文稿、圖畫或筆記，卻無法記起自己曾做過這些東西。
27	Some people sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are doing.	有些人有時候會發覺，他們聽到頭腦內有一些聲音叫自己去做某些事，或評論自己正在做的事情。
28	Some people sometimes feel as if they are looking at the world through a fog, so that people and objects appear far away or unclear.	有些人有時候會發覺，他們好像隔著一層霧來看世界，以至人和物件都顯得很遙遠或模糊。