THE IMPORT OF EUROPEAN NATIONALIST REFERENCES [6.3]

With Franco in power, the margins of the Spanish radical extreme right often opted for a type of nationalism that differentiated it from the autarkic national-Catholicism of the regime. To exist, the extreme radical right continued to look to Europe and transnational relations. The prestigious Spanish philosopher José Ortega y Gasset already was able to express his Europeanism in The Young Europe, a journal the Third Reich published in 1942 to promote "European liberation" through the participation of European intellectuals and collaborators such as the Italian Julius Evola or the French Marcel Déat. 1 However, neo-paganism and esotericism were weaker in Spain as compared to many other European countries; even the most radicals often retained an attachment to the Roman Catholic Church, which partly explains the profound difficulties the New Right experienced in establishing itself in the country. In 1951, Spaniards participating in the Malmö meeting gave rise to the European Social Movement (MSE). However, the two essential experiences to comprehend the structuring of the Spanish New Right were those of Young Europe (YE) and the Círculo Español de Amigos de Europa (Spanish Circle of the Friends of Europe-CEDADE). It was on this dual basis of the "national communalism" of YE and the European nationalism derived from CEDADE that neo-Eurasianism made its contributions in the 1990s.

 The camp mixed sports activities with debates and organized a wreath-laying ceremony at the tomb of José Antonio Primo de Rivera, the founder of Falange Española. Songs of the Falange, Afrika Korps, French resistance, and Italian partisans were sung around the campfires. 4

DRAFT

Chapter Six

Arriba Eurasia?

The Difficult Establishment of Neo-Eurasianism in Spain As a movement, neo-Eurasianism is far removed from the nationalist traditions of Spanish politics. It was imported as part of the long quest for new ideas and doctrinal references that followed the dictatorship of General Francisco Franco, who ruled from 1939 to 1975. Neo-Eurasianism is one of the ideological products patched together in the hope of resolving a political impasse-the far right has been limited to around 1 percent of the vote since the return to representative democracy in 1977. In addition to electoral impotence, the Spanish extreme right is characterized by exceptional fragmentation and powerful heteronomy compared with its European counterparts, especially in France and Italy.

[6.1] Alexander Dugin conducts regular conferences in Spain. He has always been hosted by the same small group led by Juan Antonio Llopart, through its various iterations (Alternativa Europa in Barcelona in 1994, the Movimiento Social Republicano in Madrid in 2013). This group grafted elements of Dugin's theories to preexisting European nationalist contributions, while also following an electoral strategy modeled on Marine Le Pen's National Front in France. This made for a heterogeneous mix, the coherence of which existed within the Spanish radical extreme right, but probably little for the masses. Understanding this gap requires comprehending the upheavals of the Hispanic nationalist space within the European context. Within this substratum, neo-Eurasianist theses were imported as part of a global reorganization of the European radical right. Hence the Movimiento Social Republicano (Republican Social Movement-MSR) arose to take a fragile place in the country's political landscape.

[6.5] However, Young Europe quickly fell into trouble in Spain. In March 1967, the authorities banned its nine-country conference in Madrid at the last minute. Thiriart saw in this move signs of U.S. influence on the Francoist state. 5 Ernesto Milá suggested more prosaically that, despite Young Europe's good contacts in the Franco regime, Thiriart had no way of understanding Spain's pro-U.S. geopolitical position and that YE Spain would have to awkwardly address the European group's fiery anti-American discourse with the Spanish authorities. [START_REF] Milá | La Nation européenne, el ultimo proyecto de Jean Thiriart[END_REF] Thiriart thus exited Hispanic nationalist political culture until the French New Resistance rediscovered him in 1991. Meanwhile, only Ernesto Milá tried to carry on this legacy, but he insisted that Spain should play an interfacing role in the new Europe because of its role in Latin America.

[6.6]

By working with Spaniard José Cudadrado Costa, Thiriart came around to the idea that only Russia could build a greater Europe. In 1984, in the journal of the National European Communitarian Party (PCN), Cuadrado Costa introduced references to the Russian Eurasianist movement of the 1920s. He believed the Soviet Union would be well advised to embrace these ideas. Citing Ortega y Gasset, the Falangist Ramiro Ledesma Ramos, Stalin, and Thiriart, he stuck to the idea of a pan-European space that was closed to China and India, among others, a view corresponding to that of a Europe "from Dublin to Vladivostok." 7

[6.7]

CEDADE was founded in 1962 by members of the Young Europe group in Madrid and was registered as a "cultural association" in Barcelona in 1966. [START_REF] Jabardo | Démobilisation de l'extrême droite en Es[END_REF] For CEDADE, the fundamental flaw of Thiriart was his materialism. [START_REF] Cedade | la Cultura de la Otra Europa[END_REF] The movement experienced a rapid ideological evolution, leading to a neo-Nazi position in 1969, demonstrating an unprecedented degree of racialism and anti-Semitism in the Spanish extreme right (only 0.05 percent of the population is Jewish; however, hostility to Israel is common). [START_REF] Perednik | Naïve Spanish Judeophobia[END_REF] It thus maintained relationships with the New European Order (NEO), founded in 1951 when the ex-communist, ex-Trotskyite, and ex-Waffen SS Frenchman René Binet split from the MSE (from its beginning, NEO defended decolonization and advocated the return of migrants to Africa in order to preserve each continent from biological and cultural mixing). NEO held its congresses in Barcelona in 1969Barcelona in , 1979Barcelona in , and 1981. 11 . 11 In particular, CEDADE was linked to the French neo-Nazis of the National and European Action Federation (FANE).

[6.8]

Among the groups linked to CEDADE were the National Socialist Party of Spain (Partido Nacional Socialista Español-PENS), with its bulletins Nuevo Orden and Joven Europa, and smaller groups such as Youth Association Jaime I (Asociación Juvenil Jaime I) for young people, the National Revolutionary Movement (Movimiento Nacional Revolucionario), and the Spanish Social Movement (Movimiento Social Español). External references are apparent in these names, and PENS maintained ties with Stefano della Chiae, who led the Avanguardia Nazionale (National Vanguard), which was deeply involved in terrorism in Italy. CEDADE formed its own party in 1979, the European National Party (Partido Revolucionario Nacional Europeo), but primarily dedicated itself to publishing anti-Semitic and revisionist texts. 12 This status of relative importance allowed for the translation of Imperium by the American Francis Parker Yockey, the CEDADE's racial-Europeanist reference. [START_REF] Bouchet | Yockey, le précurseur[END_REF] Fragmentation and ideological ferment were very present since the Spanish extreme right did not have the militant training or electoral power to make itself an influential group. Multiple factions claimed to be the authentic Falange, and the New Force (Fuerza Nueva) party founded by Blas Pinar failed to win despite its participation on the Euro-right list in the 1979 European elections. 14 [6.9] The "revolutionary traditionalism" of Franco Freda (improperly called "Nazi-Maoism" by the Italian press) also resonated in Spain. The French People's Fight Organization announced, after a similar statement by the Italian Lotta di Popolo, that with their arrival on the peninsula, the European Revolutionary Liaison Committee should see the "underground" birth of a Lucha del Pueblo section, built by members of PENS and Movimiento Social Español. 15 The operation collapsed, as the Spaniards preferred to work with the Avanguardia Nazionale militants. [START_REF] Selon | leader of the French OLP)[END_REF] Finally, the Spanish nationalist-revolutionary movement emerged through two distinct dynamics, which together formed the basis of the whole history of the Spanish New Right movement. The first is the founding in 1976 of the Authentic Assemblies of National-Syndicalist Offensive (Falange Española de las Juntas de Auténtica Ofensiva Nacional Sindicalista), inspired by the original fascist movement. The second came from a CEDADE split, which in 1978 gave way to the National Revolutionary Youth (Juventud Revolucionaria Nacional).

[6.10]

In 1983, some of its members founded Autonomous Bases (Las Bases Autonomas-BA), not a group in itself but a grassroots network like those in Germany and France. Although mainly located in Madrid's universities, BA became the Spanish Nationalist-Revolutionary reference. They played on ideological oscillation by claiming the mythical figure of the Spanish anarchist Durruti, an antifascist fighter in the Spanish Civil War, therefore foreshadowing the dialectology that Troy Southgate developed fifteen years later. Their international contacts should not be underestimated. On April 3, 1987, the BA and the Phalanx of Assemblies of National-Syndicalist Offensive (Falange de las JONS) attended a meeting in Paris convened by the French group Third Way, along with the Belgian New Forces Party and the Portuguese Movimiento de Accao Nacional. The ideological charter that they put together was the work of the French Third Way group, which published its "Manifesto of the European Nation" in 1986, to be approved organizationby-organization (starting with the Falange Española). After this meeting, the Italians of Terza Posizione and the Swiss Third Way joined the network. Thiriart aptly described the loose form of contacts among the organizations, dubbed the "March 12 Group," as "the International of mailboxes." 17

[6.11]

This French influence gave rise to the Spanish Third Way, which integrated the March 12 Group. It was led by Alberto Torresano and published the newsletter Revolucion europea, the title of which was taken from the French Third Way newspaper. 18 In 1989, it joined with the Coordinadora Alternativa Solidarista (founded in 1988 by a host of small groups) to create the Solidarist Third Way (Tercera Via Solidarista). At the helm of the organization were Secretary-General Juan Antonio Llopart (from the Juventudes del Frente Nacional of Barcelona) and President Alberto Torresano. In 1992, the Solidarist Third Way merged with the Vanguardia group, whose youth section took the name Joven Europa. Vanguardia was clearly neofascist, as evidenced by their use of the double ax of the Italian Ordien Nuovo. Denouncing Vanguardia's "right turn," Llopart and his allies kept their newspaper, Tribuna de Europa, and, following a European meeting, were the first group to invite Alexander Dugin to Spain. [START_REF] Collectivo | [END_REF]

[6.12]

THE NATIONAL-BOLSHEVIK ERA [6.13] Many extreme-right Spanish movements have sought to copy Le Pen in France, particularly in their anti-immigration sentiment-a tough bet in a country with 300,000 Roma, but where only 0.9 percent of the population were immigrants, of whom only 0.4 percent came from outside the European Union. [START_REF] Feliu | La Herencia desgraciada: racismo y heterofobia en Europa[END_REF] Tribuna de Europa simply recognized the impossibility of transforming neo-Francoism in quasi-Le Penism.

[6.14]

The evolution of the Spanish Nationalist-Revolutionary passed through France. In 1989, Third Way Secretary-General Christian Bouchet said his organization had two choices: either form a movement within the National Front (FN) or break with it and try to work within other groups dealing with ecological or regional issues, and with Islamic movements. [START_REF] Bouchet | Troisième voie-Année zéro[END_REF] His central idea was to challenge the FN from the left, imposing on Jean-Marie Le Pen a Nationalist-Revolutionary movement that only existed inside the party in 1974-1978, but the FN president rejected this faction. Led by Bouchet and André-Yves Beck, the rest of the Third Way was forced to hide their defeat. In 1991, they founded New Resistance, an organization dedicated to rejecting the FN, operating in the style of Ernst Niekisch's National-Bolshevism, and the union of the periphery against the center. [START_REF] Bouchet | The former has now joined the FN, the [6n22] latter is the head of the cabinet of[END_REF] Their promotion of a united antisystem front clearly influenced Alain de Benoist, the leader of GRECE, the main organization of the New Right. 23

[6.15]

European members of the New Right were interacting constantly, and the invitation to Dugin for the November 24, 1991, GRECE colloquium showed that this space was searching for post-Soviet ideological reconstruction. In order to make itself credible to Malliarakis, who stayed with Third Way, New Resistance contacted the March 12 organizations to propose a new international, the European Liberation Front-ELF, the name being taken from Parker Yockey. It was implemented much faster than had been expected, since the New Resistance founding congress gave itself the objective of creating a "representative European secretariat" in two years. The organization stipulated that all groups linked to Third Way would choose it. 24

[6.16]

Organizational icons also united the diverse nationalities in the ELF: all the cadres were influenced by the examples of Thiriart's Young Europe, Otto Strasser's European Popular Movement, and Yockey's Front, and fascinated by the example of the Fourth Unified International Secretariat. [START_REF] Bouchet | Les Nouveaux nationalistes[END_REF] Taken together, the diverse national publications also demonstrate Evola's strong influence (as could those of "Nazi-Maoist" Claudio Mutti in the ELF), but the ideological attitude was postmodern. The groups did their work with Evola or Thiriart, borrowing from them along the way as needed. This nondogmatic Evolism was palpable in the ELF and likely contributed to the adaptation of Dugin's theses, which also were influenced, but not determined, by Evola. Moreover, when Dugin sponsored a conference in Madrid in 2013, he opened it with a long summary of Il Fascismo visto dalla Destra and voiced a radical antimodernism more than a conservative-revolutionary critique. [START_REF] See | Is Alexander Dugin a Traditionalist? 'Neo-Eurasianism' and Perennial Philosophy[END_REF] The "new convergences" he advocated led to the import into Western Europe of the Russian red-brown label. But they did not correspond to a real alliance between "communists" and "nationalists." Within the ELF, as within the groups that composed the red-brown alliance, it was actually an alliance of the "right" wing (völkisch cultural European nationalism) and "left" wing (the New Right) of the radical extreme-right. Thus the Tribuna de Europa published articles by Ramón Bau, the former CEDADE secretarygeneral who led Mundo NS (National-Socialist Earth). 27 [6.17] While not blocked by a powerful national-populist party, Vangardia also was experiencing the difficulties of groupuscules. Its participation in the ELF led it to adapt to its intellectual ancestors. This included the denunciation of the "System," which the French extreme right itself had used since the 1950s, having borrowed it from the German Conservative Revolution of the 1920s. The National-Bolshevik eagle, which the New Resistance took back from Niekisch's Widerstand, was presented as the emblem of the French Nationalist-Revolutionaries. 28 After, the eagle and the appellation "National-Bolshevism" are adopted together Vangardia translated and distributed a French sticker against the globalization of McDonald's. The ELF also seemed to implement common strategies: in a coordinated move the groups tried to infiltrate environmentalist parties in Spain and France, as well as in Germany, Poland, Great Britain, and Italy. [START_REF]L'Europe combattante Note d'orientation no. 3 du secrétariat général de Nouvelle Résistance[END_REF] The connection with Russia was becoming increasingly comfortable before the Western European radicals took a trip to Moscow in the summer of 1992. [START_REF] Battarra | There was as much space for the New Right as the NR: de Benoist[END_REF] In France, Eduard Limonov contributed to L'idiot international, an anti-American periodical that supported rapprochement between the French Communist Party and the National Front, as well as the Choc du mois, a journal that interfaced between the FN and the radical extreme right. 31

[6.18]

In Spain, the European nationalist circles first noticed Dugin's work. In 1992, even before it was published in Russia, Rusia, El Misterio de Eurasia was released in Madrid by the publisher Grupo Libro 88, whose director was a former member of CEDADE, which explains the neo-Nazi reference to 88. When it voluntarily dissolved the following year, CEDADE orphaned the organization's militants, but hybridized politics and esotericism. However, the ethnic obsession led them to participate more in an Islamophobic, populist, and Spanish group, Democracia Nacional, than to rally to neo-Eurasianist perspectives. 32

[6.19]

The reconfiguration of the European radical extreme right continued in 1993. While the Franco-Belgian New Right was full of tension and the Spanish New Right had just produced Hespérides, the Community Activities Federation in Europe, a nonexistent structure that served to dress up a European neo-rightist university, organized a "summer university" in Lourmarin in southwestern France and brought together people in conflict with Alain de Benoist. Two members of GRECE set it up: Thierry Mudry, who associated New Right and neo-rightist circles in France with völkisch leanings (European Partisan, Nationalism and Republic, the Provence Forum, and the New Resistance) and his wife Christiane Pignacé (also a member of the Scientific Council of the FN). At the European level, the confluence ended in 1994, when Belgian Robert Steuckers managed the separation from GRECE by launching Synergies européennes. [START_REF] Steuckers | [END_REF] Synergies promoted a differentiated neo-Eurasianism by devising a Paris-Berlin-Moscow axis. This Russian angle first was promoted in France by the People's Fight Organization, in particular Jean Parvulesco, 34 a member of Synergies européennes and significantly inspired by Dugin's thinking. [START_REF] Dugin | La Grande guerre des continents[END_REF]

[6.20]

At the same time, another Franco-Belgian crisis appeared, which resulted in the transformation of the ELF. In October 1993, the ELF excluded the PCN for being "reactionary." This included contacts with the Vlaams Blok and the Belgian National Front, and the proposed adoption of an Islamophobic campaign (under the slogan, "Europe will not be an Islamic republic") while the ELF wished to move forward in conjunction with radical Muslim groups. European Synergies and the PCN collaborated and, without knowing it, PCN members applied to French authorities to receive official status for the ELF. 36 The PCN launched a new journal in which it claimed to be the European partner of the Russian National Salvation Front (while Dugin still was participating in the ELF) and opting for a line affirming that Islamism was a tool of the American order and that Europe and Islam were irreconcilable. 37 In the aftermath of the wars in the former Yugoslavia, the PCN introduced, via Yves Bataille, the Serbian argument. [START_REF] Bougarel | Travailler sur l'islam dans la Bosnie en guerre[END_REF] According to it, Serbs were defending Europe from the menace posed by the creation of an Islamic state in Europe, which would benefit U.S. objectives that sought to destabilize the continent. [START_REF] Bataille | Yves Bataille became a resident of Yugoslavia, where his wife was colleague of Radovan Karadzic, the leader of the Bosnian Serbs. See, for example[END_REF] The break between the ELF and European Synergies was less severe. In an internal note, the secretary-general of the ELF and New Resistance stated that although the structure was excellent in Spain and Por-DRAFT tugal, "in France and Belgium it is a small extreme right group on the margins of the FN." 40 [6.21] On the Spanish side, upon return to Lourmarin, Juan Antonio Llopart and his allies launched Alternativa Europea (AE), which was fully consistent with the orientations of the ELF. As its logo the organization adopted the five-pointed star commonly used by the New Resistance, which claimed that it was the symbol of "diverse anti-Yankee guerilla movements." [START_REF]The text takes its title and some of its ideas from the 1974 German "Nazi-Maoist" manifesto[END_REF] In reality it is the emblem of the Tupamaros (a left-wing movement in Uruguay), which the Red Brigade had introduced to Europe. [START_REF] Curcio | A Visage découvert[END_REF] The ideological hybridization was accomplished in the fourth issue of Tribuna de Europa, with the publication of an interview with Dugin. 43 On the summer solstice, Barcelona was one of the destinations of the Russian theoretician, while the ELF invited him to tour Western Europe (Grenoble, Milan, and Paris) from June 16 to July 1, 1994. Alternativa Europea deemed it a successful "full house," even though published photographs show more modest crowds. [START_REF]Tribuna de Europa[END_REF] The following spring, Tribuna de Europa clearly marked a new inclination by publishing the entire transcript of a Dugin presentation on Evola and a dossier on Eurasianism translated in Vouloir, the journal of European Synergies. 45 Alternativa Europea also held a seminar on the opportunity to transform itself into the Partido Nacional Republicano. 46 To do so, it borrowed wording from the French on the concept of "identity." [START_REF]Postwar radicals used it to circumvent the [6n47[END_REF] It is true that Alternativa Europea was growing and did not have any enemies on the right. It was discussed favorably in Éléments, de Benoist's review, and worked with Mundo NS. Highlighting an international affiliation allowed Alternativa Europea to extract itself from the infighting that had overtaken the Falangist space. It also moved from being a Barcelona bastion to opening sections in Madrid, Valencia, La Coruna, Vigo, Zaragoz, León, and Almeria. 48

[6.22]

The idea of the organization was to bring together all radical extremeright movements under its Partido Nacional Republicano, along the ideological lines of the ELF. However, discussions with other groups brought with them the byzantine quarrels of which the extreme Spanish right was fond, leading Alternativa Europea to quit the PNR project. The Spaniards, French, and Germans of the ELF then held a joint meeting in Paris. They decided to:

(1) draft an ideological manifesto that each group had to accept in order to be members of the ELF; (2) launch a coordinated agitprop campaign against NATO; and (3) work patiently to found a European party. 49 [6.23] Nevertheless, the Spanish projects were affected by Franco-Belgian enmity. New Resistance was shaken by turbulence following the reconciliation of part of its leadership with the FN, especially by the fact that André-Yves Beck joined the FN mayor of Orange. Certain members did not like the signals given to the former National and European Action Federation neo-Nazi Michel Caignet, organizer of the review Gaie France. Soon after Caignet was arrested for organizing a pedophilia network. This apparent combi-nation of juvenile pederasty and the New Right was controversial. Faced with attacks, Christian Bouchet resigned and announced that he would manage affairs until a congress could be convened on November 30, 1996. [START_REF] Bouchet | Lettre ouverte aux cadres de Nouvelle Résistance[END_REF] The PCN took the opportunity to go on the offensive and created the status of New Resistance. [START_REF]Statuts de l'Association Nouvelle Résistance[END_REF] It announced that the militants of New Resistance would be excluded from management for their "collaboration with the Le Penist reaction" and with Satanist-pedophile militants and then voted to merge with PCN structures, putting the ELF under a Black-Red-Green front. [START_REF]A propos du Front Européen de Libération et du PCN[END_REF] Alternativa Europa and ELF groups unanimously rejected this organization and maintained their relationship with the remnants of the former organization, which renamed itself Resistance Circles. 53

[6.24]

The New Resistance congress carried on. Their constitution was decided on the margins of the FN, along the lines of that of the New Right and based on publicity committees of the Voice of the People (the new name of the Struggle of the People), calling for unity among nationalists above all else. The ideological line was synthesized in the following terms: "In short, 'Less leftism, more fascism!'" The internal bulletin informed its subscribers that all ELF groups had renewed their confidence in the leadership team and conveyed the difficulty of managing an international New Right. Thus the result of the congress was rightward shift, from which a logical conclusion could be drawn: it is necessary to break with foreign groups aligned with the "left." 54

[6.25]

In Great Britain, the ELF was displaced, with the general-secretary post passing to Troy Southgate. The primacy in the community of references to ideological coherence was evidenced in the title of the European journal, which at the time the second ELF thought to produce in four or five languages, for a total of about one thousand copies: Young Europe. [START_REF]L'Europe combattante[END_REF] However, for Alternativa Europea, the French path could not be replicated in Spain, since no party there had absolute hegemony over the liberal-conservative right. [START_REF]Tribuna de Europa[END_REF] Alternativa Europea held its own congress in July 1997, opened with a message from Dugin, and featured presentations from the Frenchmen Christian Bouchet and Gregory Ombruck (Napalm Rock 57 ). The movement decided to found a Nationalist-Revolutionary party, a subversive matter of reputation since in this country with a Christian, Atlanticist, centrist, and monarchist right, the party was named Alternativa Europa-Liga Social Republicana (AE-LSR) and promoted federalism as much in "the Spains" as in the rest of Europe. This would be a Europe that included Russia, more than a Eurasia, along with many other Western ELF groups. Although the notion of empire was cultivated, ethno-nationalist worries prevented the full adoption of neo-Eurasianist theses. 58

[6.26]

At the end of 1997, the ELF merged with the Committee for a Nationalist-Revolutionary League, which was based in England. There it came into constant contact with the Liaison Committee of the Nationalist-Revolutionaries, the structure of which comprised of movements situated in the United States, Canada, and New Zealand. It was a clear departure from European thinking and a move toward white affirmation, but the ideological shift seems to have occurred easily. The September 19, 1998, meeting that established the new ELF was part of the annual festival of the FN, hitherto the supposed sworn enemy. [START_REF]La Lettre du Réseau[END_REF] Tribuna de Europa published the list of member groups of the new ELF, which included Dugin's National-Bolshevik party. 60 In 1999, Southgate published a manifesto for the organization, [START_REF] Southgate | Manifesto of the European Liberation Front[END_REF] centered around the idea of defending the white race against a Zionist plot that supposedly sought to bastardize the white race in order to assure global control (along the lines of a classic theme, but notable for its diffusion of the American acronym ZOG-Zionist Occupation Government--in Europe at the end of the decade, under the influence of the U.S. magazine Resistance. [START_REF] Durham | From Imperium To Internet: The National Alliance and the American[END_REF] ) Alternativa Europea expresses interest in anti-Semitism but has never exhibited much of it. The group did not publicize this text, and the second ELF slowly collapsed.

[6.27] BETWEEN RADICALISM AND POPULISM [6.28]

The most important issues to AE-LSR were support for the extension of autonomy, violent rejection of the monarchy, socialist references (extending to references to the Confederación Nacional del Trabajo and German councilism [START_REF][END_REF] ), and European claims. This stood in sharp contrast to mainstream Spanish political life, which long had been dominated by José María Aznar (Partido Popular), head of government from 1996 to 2004, who aligned Madrid's policies with those of Washington.

[6.29]

By transforming itself in 1999 into the Movimiento Social Republicano (MSR), AE-LSR mimicked the metamorphosis of New Resistance into Radical Unity, a so far near-perfect imitation of its skinhead magazine to a youth audience. This work to reach young skinheads appears to have produced results starting in 2010, when eighteen members of Blood and Honor were arrested for acts of violence, and seventeen of them ran on the MSR ticket in elections. [START_REF] Büttner | Right-Wing Extremism in Spain: Between Parliamentary Insignifi[END_REF] Militants from the two sides of the Pyrenees met regularly and, in 2001, jointly produced an anti-Zionist bumper sticker in the Catalan language. 65 The group also tried to move beyond the interior Spanish enclave. For the 2000 general elections, the MSR joined with three other nationalist movements to form the España 2000 platform. Despite support from Jean-Marie Le Pen, the platform obtained only 0.04 percent of the vote.

[6.30]

The ELF disintegrated in 2002, with the departure of Radical Unity's Christian Bouchet, followed by the dissolution of this movement by the French public authorities. This led to the establishment in France of the Social European Movement Identity Bloc in tandem with the MSR. According to Philippe Vardon, one of the Identity leaders, the titular reference is to the MSR, not the MSE. The Bloc identitaire, MSR, and Nation of Belgians moved closer together, but the Bloc abandoned all fascist references, converting radical anti-Zionism to Islamophobia, leaving aside the Greater Europe of regions project in favor of the articulation of French-European regions, leading to the separation. In retrospect, Vardon thought that the socialist and European references fell under a national-revolutionary label. Young Catalans pushed the MSR to conform to the French line, but it was in vain. [START_REF] Vardon | [END_REF] The MSR and Nation of Belgians only began to represent a new international partnership when the Italian group Movimento Sociale Europeo joined them in 2011.

[6.31]

In addition, the MSR maintained ties with the American Front, which had participated in the second ELF (and was renamed Open Revolt). [START_REF]The site Open Revolt offers texts written (and translated) by Alexander Dugin[END_REF] Although anti-Zionism remained a part of the MSR, Islamophobia was not totally ignored. [START_REF]SOS Racismo, Informe anual[END_REF] However, its adoption was difficult, given the pro-Arab tradition in the Spanish radical extreme right; [START_REF] Casals | El fascismo, entre el legado de Franco y la modernidad de Le Pen[END_REF] Islamophobia was present mostly in groups with völkisch identities. Still the 2002 summer solstice was celebrated with the French Land and People, a völkisch and Islamophobic movement defending a "Eurosiberia" to specify its racialist discrepancy with the neo-Eurasianist project. In a sign that Islamophobia was not well-established, the MSR initially reacted to the March 11, 2004, Islamist attack in Madrid (191 dead and 1,400 injured) by essentially blaming it on Prime Minister Aznar's opposition to Euskadi Ta Askatasuna (ETA), the Basque terrorist organization. [START_REF]El Movimiento Scial Republicano (MSR) exige medidas excepcionales y responsabilidades políticas tras el genocidio cometido en Madrid[END_REF] Nevertheless, in 2009, the MSR made a common European election list with the identity movement Partit per Catalunya (obtaining 0.04 percent of votes). At the same time it signed stillborn agreements with other small groups of various ideological persuasions.

[6.33]

Its participation in European elections allowed it to make contact with small groups. The MSR was part of the foundation of the European Alliance of National Movements (AEMN), chaired by the vice president of the FN, Bruno Gollnisch. In addition to the FN and the MSR, the group brought together Jobbik, the Movimento Sociale Italiano-Fiamma Tricolore (Italy), British National Party, National Front (Belgium), and National Demokraterna (Sweden). Various associative statuses then joined, including Svoboda (Ukraine), the Partido Nacional Renovador (Portugal), Bălgarksa Nacional-na-Patriotična Partija (Bulgaria), and Vlaams Belang (the Flemish nationalist party in Belgium). Hence, the AEMN has no ideological or programmatic coherence, given that it encompassed movements with totally divergent conceptions on both the nationality issue and on European projects. However, its members recognized their differences in worldview. The MSR was able to participate in the AEMN through social ties with the Briton Nick Griffin, but his electoral weakness and inability to unite the Spanish factions led the parties represented in the European Parliament to no longer want to fund him. According to Ernesto Milá, Bruno Gollnisch was annoyed by the incapacity of his Spanish partners to unite. Early in 2013, Marine Le Pen decided to end all ties with Spanish organizations, as they could not fall in line. [START_REF] Milá | DOSSIER |La extrema-derecha ante las elecciones europeas. Lectura crítica (i)[END_REF] Some months later, in order to avoid being accused of cooperating with neo-Nazis, the FN removed itself from the AEMN. In the European 2014 elections, the MSR won only 0.05 percent of votes (the five-party Spanish extreme-right list shared a total of 0.38 percent of votes).

[6.34]

Yet the shadow of the FN still hangs over the MSR. Although the MSR symbol is the flame of the Movimento Sociale Italiano, it was made popular by the FN. Its emblem changes as the French model changes, but remains in the black-red-white color scheme that is dear to the National-Revolutionary and to Falangism. It also gave a place of pride to the red and gold Spanish flag stripped of its coat of arms, which does not fit with the classic symbols of Spanish republicans (the purple, yellow, and red flag), but rather those of the nationalists of 1936. Some flags with chaospheres (spiked globes) were used during Dugin's 2013 conference. Although the symbol is customary in the International Eurasianist Movement, most observers likely associate it with pop culture, not politics. [START_REF] François | Un Occultisme postmoderne: la magie du Chaos[END_REF] One of the satellites of the MSR, the Study Circle La Emboscadura (Círculo de Estudios La Emboscadura-CELE), officially organized this conference. The CELE planned the annual "days of dissidence" that brought together the elite of the European radical extreme right, [START_REF]He supported Marine Le Pen over Bruno Gollnisch[END_REF] during which anti-Semitic speakers and Holocaust deniers have the spotlight. Dugin took part in it in 2007, the Frenchman Alain Soral was in attendance, and in 2013 it was the German Ernst Zündel. Dugin has not been the only member of the International Eurasianist Movement to be present, as Alexander Kuznetsov represented the organization in 2008. This judgment was overturned in 2011 by the Supreme Tribunal, which found that while anti-Semitic and Holocaust-denying materials were disseminated, they included no direct appeal to perpetrate massacres.

[6.36]

All of these difficulties led the MSR to have a tense congress in 2014. Fifty delegates were supposed to represent the three hundred militants who officially comprise the party. [START_REF] Rius | Mapa incompleto de la extrema derecha (3) MSR, Juan Antonio Llopart[END_REF] The number seems excessive, twice what was represented by movements such as New Resistance and Radical Unity, despite the smaller population of Spain and the balkanization of its nationalist scene. Tensions were strong enough to cause a confusing split. Llopart and his allies founded a new faction, Soberanía y Libertad, inspired by the Identity Bloc and using as its symbol the Greek lambda, which also represents its youth movement, Generation Identity.

  Having mounted the Radical Network in France, Bouchet launched with the Italian Sinistra Nazionale (publishers of the daily Rinascita) a Eurasian Geopolitics Network that attempted to follow the ELF and published the Eurasian Nation review. Nation, the Radical Network, and the Italians of the Democratici Egalitari d'Azione participated in a meeting in Barcelona on February 15, 2003, which the MSR convened in opposition to the war in Iraq. However, the MSR did not participate in the "voluntary human shields for Iraq" operation that Nation, Rinascita, the Radical Network, and the Party of French Muslims were undertaking.[START_REF][END_REF]

[6. 35 ]

 35 Other satellite structures exist, such as the Workers' National Union (Unión Sindical de Trabajadores), the Students' National Union (Unión Sindical de Estudiantes), and Alternativa Joven, for young people who are not students. Infiltration into environmental groups varied, with work in animal rights and anti-speciesism circles and the creation of dedicated structures such as Spanish Patriots Against Animal Torture (Patriotas Españoles Contra la Tortura Animal) and Green Spain (Hispania Verde). Circle Athena (Circulo Atenea) was founded in 2013, inspiring the French Antigones, who are "anti-FEMEN." Nueva República editions spread the ideological materi-al. This led the Barcelona provincial court to sentence Juan Antonio Llopart in 2009 to two-and-a-half years in prison for the diffusion of ideas that support genocide (whereas Ramón Bau, who in 1997 founded a Circle of Indo-European Studies to succeed CEDADE, was sentenced to three years).

  The extreme Spanish right has been in disarray since the end of Francoism. The importation of nationalist-European, and neo-Eurasianist references has not succeeded in resuscitating it. It remains crushed by the power of the Partido Popular, which has recycled old Francoists while adopting essential basics from the liberal-conservative right and maintaining a pro-U.S. foreign policy stance. Worse still, the neo-Eurasianism overhaul attempts labeled the MSR as a neo-Nazi movement in the mainstream media and among most of the right. Alexander Dugin's presence at various times in Spain thus highlights the particular impossibility of finding individuals with social and political pull. In twenty years of contact, he has passed from circles concerned with the breakdown of neo-Nazism to the hodgepodge of neofascism. Even the high tension that Catalan separatism created among the state's repressive sectors has not provided any dynamism. In addition, during his 2013 Madrid conference, Dugin mentioned neither these separatist tensions nor the economic crisis that has devastated the country (the unemployment rate among young people reached 53.8 percent in 2014). Instead, his ideas concentrated on the agitation France experienced during the seemingly endless protests against opening marriage to same-sex couples. His discourse seemed to be much more geared toward Paris than Madrid. The absence of a mass electoral party is clearly detrimental to the development of a pro-Eurasianist influence in Spain.


Keywords: Second Delphi round……………………………………………………………………, 25 Backward translation……………………………………………………………………27 47 Bibliography……………………………………………………………………………………, 48 Appendices………………………………………………………………………………………, 50

Matériels et Méthode

Une traduction aller-retour par méthode de consensus Delphi fut réalisée. Un groupe de travail initial composé de 2 généralistes, un linguiste et un psychiatre a réalisé une première traduction. Cette traduction fut évaluée et corrigée par un groupe d'experts composé de médecins généralistes en suivant la méthode Delphi. Une traduction retour fut ensuite réalisée par 2 linguistes et comparée à la version Anglaise originale pour contrôler la présence d'erreurs. Résultats 15 médecins généralistes ont participé à la procédure Delphi. Il n'y a pas eu de perdus de vue. La traduction fut validée en totalité en 2 tours. Une seule correction fut faite après la traduction retour.

Conclusion

Une traduction française de la WAI-SR par une méthode de consensus rigoureuse est maintenant disponible. Elle permettra dans le futur des études additionnelles et sera un outil utile en pratique clinique et en pédagogie.

A Laura, pour son amour et son insondable gentillesse, malgré que tu m'aies fait l'offense de ne me citer qu'à la quatrième page de tes propres remerciements ! A Bernard et Elizabeth, pour leur accueil dans leurs montagnes et les victuailles qu'ils ne manquent jamais de nous ramener de là-bas.

Aux copains de médecine : à Pierre-Yves l'exilé, à Thomas ma caution dans la flemme, à Thibaud toujours présent pour une pinte ou un bon concert, à Jean Baptiste pour m'avoir cassé la main au ski, à Matthieu pour la Mirabelle et ces parties de Left for Dead avec son chat Zombi, à Aurélien notre sitcom ambulante, à toute la bande de joyeux lurons de l'internat de Quimper, à Soline malgré son rire strident et sa bestiole bizarre, à Laurianne qui n'est pas si grignou que ça, au Marteau à qui je ne manquerai pas d'adresser tous mes fibromyalgiques, à Camille qui me rassure en finissant aussi à la bourre, à Sophie et Damien qui restent plutôt sympa pour une parisienne et un psychiatre, à Laetitia pour ne pas (encore ?) avoir fait sauter la gendarmerie Au BAMHE, car j'aime me battre A Valentin le Chevalier Cubis, à Tanguy le chevalier à la Physique irréprochable, à Adeline ainsi qu'à tous les autres A Cthulhu A Benjamin pour ses beuglements caverneux, à Angela pour ses rituels bizarres et sa collection de tentacules, à Jerry Tennessee pour ses coups critiques toujours opportuns, à Rupert le compas moral (vacillant) du groupe

Abstract Introduction

Therapeutic alliance is an important factor in the process of care, positively influencing outcome as well as patient adherence and motivation. The Tool Assessment for Therapeutic Alliance Study (TATA) aimed to select on a European level the most appropriate scale to evaluate the therapeutic alliance and to translate it in various European languages. The WAI-SR has been selected by a RAND/UCLA Appropriateness Method in 2016. The objective of this study was to translate the WAI-SR in French via a rigorous consensus method.

Materials and Methods

A forward and backward translation with a Delphi consensus procedure was completed. An initial translation group of 2 general practitioners, 1 linguist and 1 psychiatrist wrote a first translation. This translation was evaluated and corrected by an expert panel comprised of general practitioners following the Delphi technique. A backward translation was then done by 2 linguists and compared to the original scale to check for errors.

Results

15 general practitioners participated to the Delphi consensus procedure. There was no loss to follow up. The translation was validated in its entirety after 2 rounds. One correction was made after the backward translation.

Conclusion

A French translation of the WAI-SR by a valid consensus method is now available. It will allow further collaborative research and be a useful tool in clinical practice and pedagogy.

Résumé Introduction

L'alliance thérapeutique est un facteur important de la démarche de soin, qui influence positivement les résultats ainsi que la motivation du patient et son observance. L'étude TATA (Tool Assessment for Therapeutic Alliance) avait pour objectif de sélectionner à l'échelle européenne l'échelle la plus appropriée pour évaluer l'alliance thérapeutique puis de la traduire dans de multiples langues européennes. La WAI-SR a été sélectionnée par méthode de consensus RAND/UCLA en 2016. L'objectif de cette étude était de traduire la WAI-SR en Français par une procédure de consensus rigoureuse.

Introduction

The therapeutic alliance between a patient and his doctor has long been considered a key factor in the process of care. It can be defined as the mutual collaboration, the partnership, between the patient and the therapist with the aim of achieving fixed objectives [START_REF] Bioy | L'alliance thérapeutique : historique, recherches et perspectives cliniques[END_REF]. The concept takes its roots in the field of psychoanalysis and the work of Sigmund Freud, and since then has been studied by numerous authors (Rogers, Anderson, Orlinsky and Howard,…) [START_REF] Elvins | The conceptualization and measurement of therapeutic alliance: an empirical review[END_REF]. The modern definition of Therapeutic Alliance owes much to the work of Bordin, who isolated 3 main axes for its development in the course of care: agreement on therapeutic goals, agreement on therapeutic tasks, and the quality of the relational bond between the patient and therapist [START_REF] Doran | The working alliance: Where have we been, where are we going?[END_REF].

The influence of therapeutic alliance in the practice of medicine has since been frequently studied and it was demonstrated that it positively affects patient adherence, motivation and satisfaction with treatment (4). It has also been shown to positively influence outcome [START_REF] Sturgiss | Therapeutic alliance and obesity management in primary care -a cross-sectional pilot using the Working Alliance Inventory[END_REF][START_REF] Cook | The role of the working alliance in treatment for alcohol problems[END_REF][START_REF] Falkenström | Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement[END_REF][START_REF] Rosti-Otajärvi | Predictors and impact of the working alliance in the neuropsychological rehabilitation of patients with multiple sclerosis[END_REF]. This positive influence was found in psychiatry [START_REF] Cook | The role of the working alliance in treatment for alcohol problems[END_REF][START_REF] Falkenström | Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement[END_REF][START_REF] Klein | Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics[END_REF] and also in somatic fields like for example nutrition [START_REF] Sturgiss | Therapeutic alliance and obesity management in primary care -a cross-sectional pilot using the Working Alliance Inventory[END_REF], neurology [START_REF] Rosti-Otajärvi | Predictors and impact of the working alliance in the neuropsychological rehabilitation of patients with multiple sclerosis[END_REF], rheumatology [START_REF] Fuertes | The physician-patient working alliance and patient psychological attachment, adherence, outcome expectations, and satisfaction in a sample of rheumatology patients[END_REF]. Its effect has also been shown in group therapy [START_REF] Vîslă | The relation between outcome expectation, therapeutic alliance, and outcome among depressed patients in group cognitivebehavioral therapy[END_REF][START_REF] Robak | The working alliance in group counseling: an exploratory study[END_REF]. Its effect was present regardless of the setting, with a study demonstrating its influence in outpatient and inpatient setting [START_REF] Munder | Working Alliance Inventory-Short Revised (WAI-SR): psychometric properties in outpatients and inpatients[END_REF]. The positive effects were still demonstrated even after controlling for prior improvement and 8 prognostically relevant patient characteristics [START_REF] Falkenström | Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement[END_REF][START_REF] Klein | Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics[END_REF][START_REF] Xu | Reciprocal influence model of working alliance and therapeutic outcome over individual therapy course[END_REF].

Therapeutic alliance is also a frequent preoccupation in the field of French medicine. It is often studied and discussed in psychiatry [START_REF] Bioy | L'alliance thérapeutique : historique, recherches et perspectives cliniques[END_REF][START_REF] Charpentier | L'alliance thérapeutique, un enjeu dans la schizophrénie[END_REF][START_REF] Rodgers | L'alliance thérapeutique en psychothérapie : apports de la recherche empirique[END_REF][START_REF] Laconi | Relationship between defense mechanism and therapeutic alliance[END_REF]. It is also a subject of interest in somatic medicine, whether in general practice [START_REF] Sturgiss | Therapeutic alliance and obesity management in primary care -a cross-sectional pilot using the Working Alliance Inventory[END_REF][START_REF] Frémont | L'alliance thérapeutique au début d'une prise en charge pour dépression par le généraliste[END_REF] or for specialist practitioners [START_REF] Baudrant-Boga | Penser autrement l'observance médicamenteuse : d'une posture injonctive à une alliance thérapeutique entre le patient et le soignant -Concepts et déterminants[END_REF][START_REF] Chastaing | Adherence to treatment in chronic skin disorders[END_REF].

There is still a need for research in the subject of therapeutic alliance [START_REF] Bioy | L'alliance thérapeutique : historique, recherches et perspectives cliniques[END_REF][START_REF] Elvins | The conceptualization and measurement of therapeutic alliance: an empirical review[END_REF][START_REF] Doran | The working alliance: Where have we been, where are we going?[END_REF][START_REF] Rodgers | L'alliance thérapeutique en psychothérapie : apports de la recherche empirique[END_REF]. The effect on outcome needs further study. The influence of confounding factors on the effects of therapeutic alliance is still a matter of debate. New notions are emerging, which will probably drive new research. The handling of ruptures and conflict is suspected to be an important factor in the working alliance, and its influence will need to be studied. The variability of the alliance over time is another question that has been recently raised.

The access to a reliable tool to evaluate the therapeutic alliance is important, both in research and day to day practice. Numerous scales aiming to measure and characterize the working alliance have been created since the early 1960s. Among these scales, the most widely used are the Working Alliance inventory (WAI), the California Psychotherapy Alliance Scales (CALPAS), the Helping Alliance Questionnaire (HAq) and the Vanderbilt Therapeutic Alliance Scales (VTAS) [START_REF] Elvins | The conceptualization and measurement of therapeutic alliance: an empirical review[END_REF].

The WAI was created in 1989 by Horvath and Greenberg, and evaluates the Therapeutic Alliance by studying the 3 main axes formulated by Bordin (Goal, Task and Bond). It is a well triangulated measure, which has shown good validity [START_REF] Elvins | The conceptualization and measurement of therapeutic alliance: an empirical review[END_REF][START_REF] Horvath | Development and Validation of the Working Alliance Inventory[END_REF]. A short version of this scale, the Working Alliance Inventory Short (WAI-S), was also created at this date. The Working Alliance Inventory Short Revised (WAI-SR) was later created from these two previous tools in 2005 by Hatcher and Gillaspy.

The WAI-SR aimed to better differentiate Goal, Task, and Bond alliance dimensions. It correlated well with other alliance measures (CALPAS and HAq) [START_REF] Hatcher | Development and validation of a revised short version of the working alliance inventory[END_REF] and has shown good validity since [START_REF] Munder | Working Alliance Inventory-Short Revised (WAI-SR): psychometric properties in outpatients and inpatients[END_REF].

This study was part of the Tool Assessment for Therapeutic Alliance Study (TATA), by the European General Practice Research Network (EGPRN). Its aim was to find all the tool available to evaluate therapeutic alliance, to select the one most adapted to European general medicine practice, and to translate it for each country involved. In accordance to the protocol, six scales were first selected in 2013 by a systematic literature review [START_REF] Noël | Revue systématique de la littérature sur les moyens d'évaluation de l'alliance thérapeutique par des outils de mesure fiables et reproductibles[END_REF]. Among these scales, the WAI-SR was then selected as the one better suited for use in Europe by a RAND/UCLA Appropriateness Method in 2016 [START_REF] Letissier | Sélectionner un outil de mesure de l'alliance thérapeutique fiable et reproductible chez l'adulte, méthode de consensus par[END_REF][START_REF] Borgne | Selection of a reproducible and reliable tool assessment for therapeutic alliance in general practice, by a RAND/UCLA consensus method[END_REF].

As the next step in TATA, this study aimed to translate the WAI-SR in the French language, by using a Delphi consensus procedure with Forward/Backward translation.

Materials and methods

The aim of this study was to translate in French the previously chosen tool to evaluate therapeutic alliance in primary care, the WAI-SR. The method used was a forward backward translation with an inserted Delphi consensus method. The Delphi method is frequently used in studies to establish consensus for a variety of issues. It is widely regarded as an efficient and reliable way to search for consensus [START_REF] Villiers | The Delphi technique in health sciences education research[END_REF][START_REF] Tomasik | Reliability and validity of the Delphi method in guideline development for family physicians[END_REF][START_REF] Waggoner | Is There a Consensus on Consensus Methodology? Descriptions and Recommendations for Future Consensus Research[END_REF]. The Delphi technique is also considered a valid process in French medicine [START_REF] Letrilliart | A la recherche du consensus : quelle méthode utiliser ?[END_REF].

The WAI-SR was first translated from the original English to the French language by an initial working group of 4 persons. This group was formed with 2 general practitioners, 1 psychiatrist and 1 professional translator.

A second group of experts were then recruited to evaluate and modify this preliminary translation by using a Delphi consensus, following the method of the TATA study (Tool Assessment for Therapeutic Alliance). 15 general practitioners were recruited, all of them being native French speakers who also spoke English. They had to be currently in activity, and be fluent in English.

Sampling data was collected for each participant, the criteria chosen being: age, sex, total years of practice, setting type (rural, semi-rural, urban), practice type (solo, group, other), teaching activity, research activity, number of publications (French and English), level of fluency in English.

The preliminary translation was sent by email to each participant individually, without them having any knowledge of each other and their responses. The use of a mailing list was forbidden by the initial protocol to avoid experts to be influenced by a dominant opinion [START_REF] Waggoner | Is There a Consensus on Consensus Methodology? Descriptions and Recommendations for Future Consensus Research[END_REF].

The translation of the WAI-SR was split in 39 items. For each item, it was asked of each expert to rank the quality of the translation from 1 (=very bad) to 9 (=very good). For every rating below 7, it was asked of the expert to write a commentary to explain his disagreement and/or to write an alternate translation. An item was validated according to the consensus method if at least 70% of the ratings were 7 or above. The items that were not validated the first round were modified by the initial working group according to the commentaries of the experts. These items were then submitted again to the consensus group in another round of evaluation with the same method. This consensus protocol was repeated until all items were validated.

Once all the items were validated by the consensus group, a backwards translation was undertaken by 2 translators, from the new translation in French to English. This backward translation was then compared to the original English to check for any significant difference. The last step was a cultural check, to verify the validity of the translation according to French cultural differences.

This study was accepted in October 2014 by the Ethics comity of the Université de Bretagne Occidentale in Brest. Consent forms were signed and collected for each participant after the necessary information about the study was provided. average number of publications per participant of 6.87. 12 of them had already published in other languages, with an average number of publications per participant of 9.47. 12 of them estimated their level of English as good, 2 of them as intermediate, one of them as basic. Legend for Tables 3a, 3b and 3c: CODE: number referring to the participant, INSTRUCT: ratings for the "Instructions" part of the WAI-SR, IMPORT: ratings for the "Important!" part of the WAI-SR, ANSWER: ratings for the "Answers" part of the WAI-SR, Qx: ratings for the item number x, <7: number of ratings inferior to 7, >=7: number of ratings superior or equal to 7, CHECK: number of total ratings, TOTAL: percentage of ratings above or equal to seven

Results

Sampling data for the initial translation group

First Delphi round

After the first Delphi round, 9 items out of 15 were validated for the WAI-SR Patient. 8 out of 13 items were validated for the WAI-SR Family Physician. 10 items out of 11 were validated for the WAI-SR scoring sheet.

The remaining items were reformulated by following the remarks and propositions made by the expert panel:

_"Therapy" was initially translated by "suivi", which was replaced by "prise en charge" _"Underlined space" was initially translated by "espace", which was replaced by "espace souligné" _"Your own experience" was initially translated by "votre propre vécu", which was replaced by "votre vécu personnel" _"Please take your time" was initially translated by "Prenez s'il vous plait du temps", which was replaced by "Prenez le temps nécessaire" by "je pourrais être capable de changer"

_"towards mutually agreed upon goals" was initially translated by "vers des objectifs communs", which was replaced by "sur des objectifs convenus ensemble" _"I feel that" was initially translated by "je ressens que", which was replaced by "j'ai le sentiment que"

_"Accomplish" was initially translated by "atteindre", which was replaced by "accomplir".

_in the introduction of the therapist version "people" was initially translated by "soignants", which was replaced by "professionnels"

_"Confident about" was initially translated by "confiants dans", which was replaced by "convaincus de" _in addition, some minor syntax changes were made Legend for Tables 4a, 4b and 4c: CODE: number referring to the participant, INSTRUCT: ratings for the "Instructions" part of the WAI-SR, IMPORT: ratings for the "Important!" part of the WAI-SR, Qx: ratings for the item number x, <7: number of ratings inferior to 7, >=7: number of ratings superior or equal to 7, CHECK: number of total ratings, TOTAL: percentage of ratings above or equal to seven

Second Delphi Round

The entirety of the remaining items was validated in the second Delphi round.

Backward translation

The validated French translation was backward translated by two linguists and compared to the original English version to check for errors. 4 significant differences were identified, and prompted some new discussion with the 2 linguists:

_in the Item 1 of the WAI-SR patient: "comment je pourrais être capable de changer" was translated by "how I might be able to make changes to my lifestyle". The addition of "to my lifestyle" was unexpected. The original English is "how I might be able to change".

After discussion with the linguists, it was concluded that the change simply originated from a difference in writing style and that the French translation was therefore an accurate translation of the original English version.

_in the Item 7 of the WAI-SR patient: "m'estime" was translated by "respects me". The original english is "appreciates me".

After discussion with the linguist, it was concluded that the difference was due to cultural differences and that the French translation was therefore an accurate translation of the original English version.

_in the Item 10 of the WAI-SR patient: "les choses que je fais au cours de cette prise en charge" was translated by "the things I do as a result of these consultations". The original English is "the things I do in therapy", and seems to refer to actions happening during the care and not as a result of it.

After discussion with the linguist, it was concluded that the French translation did not accurately reflect the original English version and "les choses que je fais au cours de cette prise en charge" was changed to "les choses que je fais pendant les consultations".

_in the WAI-SR Scoring sheet: "lien" was translated by "doctor-patient relationship", which seemed to us a lot different. The original English is "Bond".

After revision, it was concluded that the difference emerge from a lack of clarity in the original English and maybe from differences between US and UK English. The final opinion of the linguists was that the French translation had chosen the most suitable word in French.

WAI SR Patient

1.

A la suite de ces consultations je vois plus clairement comment je pourrais être capable de changer 1. As a result of my consultations, I see more clearly how I might be able to make changes to my lifestyle.

1.

A

J'estime ___ en tant qu'individu

I respect ____ as an individual

J'estime ___ en tant qu'individu

English Original

Version

French Version Backward

Translation Final Version 6.We have established a good understanding of the kind of changes that would be good for .

6.

Nous nous sommes mis d'accord sur le type de changement qui serait bon pour ____ 6. We are agreed on the type of change which would be good for _____

English Original

Version

French Version Backward

Translation Final Version

To derive a scale or total score, simply sum and take the mean of the items.

Pour obtenir une échelle ou une note totale, additionnez simplement et prenez la moyenne des propositions:

To obtain a scale or a total score, simply add up and average the scores -Note de la version patient:

-Note de la version médecin généraliste:

-Type d'échelle:

Discussion

Main Result:

The main result of the study was a translated version of the WAI-SR from the original English to the French language. A backward translation was used to verify the homogeneity of the translation.

Strengths and limitations of the study:

There was no information bias in this study, as the information was transmitted and collected by the exact same way with all the participants (by email messages). The members of the expert panel had no communication with each other, to avoid the influence of a dominant opinion. There was no confusion bias but the possibility of a misunderstanding of the English by some of the experts with an intermediate or basic level. This bias was limited by the backward translation. A selection bias may be present, as suggested by the analysis of the sampling data: the majority of the participants were male (73%) and were working in a group practice (86.67%). All of them also had teaching and research activity. The diversity of their working environment was real (53.33% worked in an urban setting, the others in a rural or semi-rural setting).

The use of the Delphi technique is widely recognized as valid to obtain consensus in health sciences.

It enhances individual judgment by combining multiples opinions and experiences in an independent

way [START_REF] Villiers | The Delphi technique in health sciences education research[END_REF]. The French medical professionals also recognize it as a valid technique to reach consensus [START_REF] Letrilliart | A la recherche du consensus : quelle méthode utiliser ?[END_REF].

This study followed the recommendations of proper methodology for the Delphi technique according to the literature [START_REF] Waggoner | Is There a Consensus on Consensus Methodology? Descriptions and Recommendations for Future Consensus Research[END_REF]. The panel size was appropriate with 15 participants. There was no loss to follow up. The translation was validated in its entirety in 2 rounds, which is viewed as the optimal number of rounds.

Implications for practice, medical training and future research:

This translation of the WAI-SR in the French language will be useful for future research in the subject of the therapeutic alliance. Both French [START_REF] Bioy | L'alliance thérapeutique : historique, recherches et perspectives cliniques[END_REF][START_REF] Rodgers | L'alliance thérapeutique en psychothérapie : apports de la recherche empirique[END_REF] and English authors (3) remark a lack of research about the way the working alliance vary over time during the process of care. They argue that we should move away for a linear representation of the therapeutic alliance, and that that it is not sufficient to know the strength of the alliance at a static point in time, but that information about the trajectory of the alliance is critical to best predict treatment outcome. The WAI-SR, being a short and easy to use scale, could be used for repeated measures over time to better grasp the fluctuation of the therapeutic alliance. This is particularly relevant because data suggest that patient outcome vary depending on the pattern followed by the alliance for chronic care (3).

The influence of rupture in the alliance is another theme where research is needed, both in the English

(3) and French-speaking world [START_REF] Rodgers | L'alliance thérapeutique en psychothérapie : apports de la recherche empirique[END_REF]. French authors also note a lack of research about the effect of the therapeutic alliance in the somatic fields [START_REF] Bioy | L'alliance thérapeutique : historique, recherches et perspectives cliniques[END_REF]. French psychiatrist recently explored the relation between the therapeutic alliance and the different psychological defense mechanisms [START_REF] Laconi | Relationship between defense mechanism and therapeutic alliance[END_REF]. A valid and easy to use scale could be of use to explore these themes.

This study is part of the larger TATA study, which is currently translating the WAI-SR in multiples European languages. A cultural check will follow, to verify that these translations are harmonized and have no major differences. This will allow for the study of therapeutic alliance on a European scale.

This translation of the WAI-SR in the French language could also be useful in the day-to-day clinical activities of French professionals. For example, a study [START_REF] Frémont | L'alliance thérapeutique au début d'une prise en charge pour dépression par le généraliste[END_REF] about the treatment of depression by general practitioners in France showed that 95% of them considered that the quality of the Doctor/Patient relationship is a significant factor in the success of treatment. This study also showed that 60% of patients think of their care as a partnership with their Doctor, where they work together towards a positive outcome. The use of the WAI-SR could be in this context beneficial to both Doctor and Patient to verify the quality of their partnership.

French pharmacists conducted a systematic revue of the literature on the multiples factors that influence treatment adhesion [START_REF] Baudrant-Boga | Penser autrement l'observance médicamenteuse : d'une posture injonctive à une alliance thérapeutique entre le patient et le soignant -Concepts et déterminants[END_REF]. The effects of poor patient compliance with the prescribed treatment has a major impact, both medically and economically. They list the therapeutic alliance as one of the important factors that positively influence adhesion. They argue for the need to move from a paternalistic and authoritative model of Doctor/Patient relationship to a model structured around negotiation and collaboration. This points to the WAI-SR as a useful tool to improve treatment adhesion.

In their review of therapeutic alliance in Schizophrenia [START_REF] Charpentier | L'alliance thérapeutique, un enjeu dans la schizophrénie[END_REF], French psychiatrist noted that poor adherence to medication is a frequent problem in this pathology. In two thirds of cases, rehospitalisation was the result of complete or partial non-compliance. One year after first hospitalisation, 40% of relapse results from non-adherence to medication. They argued that the amelioration of the working alliance was one of the main way to obtain a better treatment compliance.

They proposed the use of the motivational interview technique and added that information and tools must be proposed to practitioners. This translation of the WAI-SR could help them in this approach.

A review by French dermatologists likewise highlighted the importance of a good therapeutic alliance in the treatment of chronic skin diseases [START_REF] Chastaing | Adherence to treatment in chronic skin disorders[END_REF], and the need to measure and consolidate it in the process of care.

Lastly this translation of the WAI-SR could be useful in the training of medical students in France.

A study evaluating ethical medical competencies during training found that the Patient/Doctor relationship was one of the foremost preoccupation of medical student in France [START_REF] Barrier | Comparaison des compétences médicales éthiques des étudiants de 3e et de 6e année en stage hospitalier en médecine interne[END_REF]. Finding valid ways to teach this partnership between Doctor and Patient was of interest to French medical universities [START_REF] Even | Enseigner la relation médecin-malade : Présentation d'une expérience pédagogique développée à la faculté de médecine de Créteil[END_REF]. A reliable tool to evaluate and follow the therapeutic alliance during the years of training of medical students would be useful on a pedagogical level.

Conclusion

Therapeutic alliance is a key factor of the process of care, and it plays a constant part in the day-today activities of Physicians and other health practitioners. It influences patient adherence to treatment, his satisfaction and motivation regarding his care. It helps to achieve better outcomes, across numerous specialties and pathology.

This French translation of the WAI-SR can now be used in a clinical setting, as well as in the training of medical students. It will also be used, alongside equivalent translations in various other languages, to further study Therapeutic Alliance on a European scale.

Annex A WAI SR (Original English version) WAI-SR -Patient

Instructions: Below is a list of statements and questions about experiences people might have with their therapy or therapist. Some items refer directly to your therapist with an underlined space --as you read the sentences, mentally insert the name of your therapist in place of ______ in the text. Think about your experience in therapy, and decide which category best describes your own experience.

IMPORTANT!!! Please take your time to consider each question carefully.

1. As a result of these sessions I am clearer as to how I might be able to change.

     Seldom Sometimes
    

Seldom Sometimes Fairly Often Very Often Always

WAI-SR -Therapist

Instructions: Below is a list of statements about experiences people might have with their client. Some items refer directly to your client with an underlined space --as you read the sentences, mentally insert the name of your client in place of ___ in the text.

IMPORTANT!!! Please take your time to consider each question carefully.

1. ___ and I agree about the steps to be taken to improve his/her situation.

     Seldom Sometimes

Annex C: WAI-SR (Backward English translation) WAI-SR -Patient

Instructions: You will find below a list of statements and questions about the experience patients may have regarding their GP or about their care. Some proposals refer directly to your GP (indicated by an underlined space______). As you read these proposals, the name of your GP would go in the underlined space ______in the text. Think about the care you have received and decide which category best describes your own personal experience.

IMPORTANT: Take your time to consider each question carefully.

A

  Monsieur le Professeur Le Reste Qui m'a guidé lors de ce travail et qui me fait l'honneur de présider mon jury A Monsieur le Professeur Le Floch Merci de me faire l'honneur d'être présent ce jour A Monsieur le Docteur Nabbe Merci de me faire l'honneur d'être présent ce jour A Monsieur le Docteur Odorico Merci de me faire l'honneur d'être présent ce jour A Alex et Richard Gillman, ainsi qu'au Docteur Morgane Guillou Pour m'avoir aidé à réaliser cette traduction Aux membres du groupe d'expert Pour avoir accepté de participer à ce travail Au Docteur Anne Poinot, mon tuteur lors de ce troisième cycle Pour sa patience A tous les autres membres du groupe de thèse pour notre entraide, et plus spécialement Adrien, MVP incontesté Aux équipes des services d'Urgences Adultes et Pédiatriques de l'hôpital de Brest, des services de Gériatrie et d'Endocrinologie de l'hôpital de Quimper Au Docteur Jeffredo, à l'équipe du Point H et de SOS Médecins, au Docteur Binard Aux Docteurs Balouet, Furet, Nerriec et Barraine Pour leur enseignement au cours de cet internat, ainsi que pour les bons moments A mes parents Patrick et Annie, pour leur soutien de toujours A Mamie Yvonne, pour toutes ces belles vacances dans la campagne Bretonne, ainsi qu'à Mamie Annie et Papi Charly qui me manquent A Simon et Allison, le Japon nous attend! A mes innombrables oncles, tantes, cousins et cousines, à Suzie tout spécialement pour son exemple de courage

-

  Item de la WAI SR:

2 . 6 . 9 . 10 .

 26910 -Version Médecin -Traduction françaiseConsignes : Ci-dessous vous trouverez une liste d'affirmations concernant le vécu que les professionnels peuvent avoir vis-à-vis de leur patient. Certaines propositions font directement référence à votre patient (sous la forme d'un espace souligné _____). En lisant ces propositions, remplacez le nom de votre patient à la place de l'espace souligné ______ dans le texte.IMPORTANT : Prenez le temps nécessaire pour considérer attentivement chaque question 1. ___ et moi sommes d'accord sur les étapes à suivre pour améliorer sa situation  Je suis sincèrement concerné par le bien-être de ___  et moi sommes tous les deux convaincus de l'utilité de ce que nous faisons actuellement au cours de cette prise en charge  Nous nous sommes mis d'accord sur le type de changement qui serait bon pour ____ et moi avons une perception commune de ses objectifs  Je respecte ___ même quand il/elle fait des choses que je n'approuve pas  Nous sommes d'accord sur ce qui est important pour ___ de travailler 

2 . 6 . 9 . 10 .

 26910 -Version Médecin -Traduction françaiseConsignes : Ci-dessous vous trouverez une liste d'affirmations concernant le vécu que les professionnels peuvent avoir vis-à-vis de leur patient. Certaines propositions font directement référence à votre patient (sous la forme d'un espace souligné _____). En lisant ces propositions, remplacez le nom de votre patient à la place de l'espace souligné ______ dans le texte.IMPORTANT : Prenez le temps nécessaire pour considérer attentivement chaque question 1. ___ et moi sommes d'accord sur les étapes à suivre pour améliorer sa situation  Je suis sincèrement concerné par le bien-être de ___  et moi sommes tous les deux convaincus de l'utilité de ce que nous faisons actuellement au cours de cette prise en charge  Nous nous sommes mis d'accord sur le type de changement qui serait bon pour ____ et moi avons une perception commune de ses objectifs  Je respecte ___ même quand il/elle fait des choses que je n'approuve pas  Nous sommes d'accord sur ce qui est important pour ___ de travailler  thérapeutique est un facteur important de la démarche de soin, qui influence positivement les résultats ainsi que la motivation du patient et son observance. L

Sampling data for the expert panel

		Table 1a: Sampling data -Initial translation group
	FORMATION	SEX	AGE	FLUENCY IN ENGLISH
				READING	WRITING SPEAKING
	GENERAL	Male	52	Good	Good	Good
	PRACTITIONER 1
	GENERAL	Male	30	Good	Good	Good
	PRACTITIONER 2
	LINGUIST	Female	64	Good	Good	Good
	PSYCHIATRIST	Female	40	Good	Good	Good
	Table 1b: Additional sampling data -Initial translation group
	FORMATION		NUMBER OF PUBLICATIONS
		FRENCH		ENGLISH
	GENERAL	20		22
	PRACTITIONER 1
	GENERAL	0		0
	PRACTITIONER 2
	LINGUIST	N/A		N/A
	PSYCHIATRIST	0		0
	The initial translation group included 4 persons. There were 2 general practitioners, 1 linguist and Legend for tables 2a and 2b: CODE: number referring to the participant, SOLO: experts working alone, GROUP:
	experts working in a group practice, OTHER: experts working in another type of practice, CONSENT: consent form 1 psychiatrist. The average age was 46.5 years. They all had a good level in English. Only one of sent to the researchers
	them had published studies before. Two of them had teaching activities in addition to their clinical
	activities. The two general practitioners worked in semi-rural environments, in group practices. The 15 experts were recruited for the study. They were all general practitioners. The average age was
	psychiatrist worked in a hospital in an urban environment. 40 years old. 73% of them were male and 27% of them female. The average number of years of
	practice was 11. Almost all of them worked in a group practice (86.67%). 53.33% of them worked
	in an urban environment, 33.33% in a semi-rural environment, 13.33% in a rural environment. All
	of them had teaching and research activities. 10 of them had already published in English, with an

TABLE 2a :

 2a Sampling data of the expert panel

	List of participants	CODE	BIRTHDAY AGE	GENDER	YEARS OF PRACTICE PRACTICE TYPE
				(years)	MALE	FEMALE		SOLO	GROUP	OTHER
	Participant 1	1 21/05/1982	35	1	0	7	0	1
	Participant 2	2 18/04/1982	35	1	0	8	0	1
	Participant 3	3 07/01/1961	56	0	1	30	0	1
	Participant 4	4 20/01/1980	37	0	1	2	0	1
	Participant 5	5 07/01/1986	31	1	0	2	0	1
	Participant 6	6 03/02/1963	54	1	0	20	0	1
	Participant 7	7 20/04/1979	38	1	0	9	0	1
	Participant 8	8 30/06/1979	38	1	0	8	1	0
	Participant 9	9 22/03/1982	35	0	1	8	0	1
	Participant 10	10 10/03/1983	34	1	0	5	0	1
	Participant 11	11 20/01/1984	33	1	0	1	0	1
	Participant 12	12 15/05/1986	31	1	0	3	0	1
	Participant 13	13 13/01/1980	37	0	1	9	0	1
	Participant 14	14 02/07/1956	61	1	0	30	0	1
	Participant 15	15 23/08/1964	53	1	0	23	0	0
	NUMBER OF PARTICIPANT	15		608	11	4	165	1	13
	INCOMPLETE ANSWER	0				15
	ANALYSIS	15		40,53	73,33%	26,67%	11,00	6,67%	86,67%	6,67%
						100,00%				100,00%
				AVERAGE %MALE	%FEMALE AVERAGE YEARS	%SOLO	%GROUP %OTHER
	CHECKING DATA			AGE		PRACTICE
	ANALYSIS Each yellow case should be equal to this one	If not error in data	percentage Each case in purple should equal 100% missing data/to precise		to correct

TABLE 2b

 2b

		: additional sampling data
	CODE	SETTING	TYPE			TEACHING		RESEARCH		NUMBER	PUBLICATIONS	LEVEL	ENGLISH	CONSENT
		RURAL	SEMI	RURAL	URBAN	YES	NO	YES	NO	ENGLISH	OTHER		BASIC	INTERMED	FLUENT
	1		0	1	0	1	0	1	0		2	7		0	0	1
	2		0	0	1	1	0	1	0	20	20		0	0	1
	3		0	0	1	1	0	1	0	13	16		0	0	1
	4		0	1	0	1	0	1	0		0	2		1	0	0
	5		1	0	0	1	0	1	0		0	0		0	0	1
	6		0	1	0	1	0	1	0	13	7		0	0	1
	7		0	0	1	1	0	1	0	10	21		0	0	1
	8		0	0	1	1	0	1	0		0	4		0	0	1
	9		0	0	1	1	0	1	0		3	5		0	0	1
	10		0	0	1	1	0	1	0		2	5		0	0	1
	11		0	0	1	1	0	1	0		0	0		0	1	0
	12		1	0	0	1	0	1	0		0	0		0	1	0
	13		0	0	1	1	0	1	0		6	10		0	0	1
	14		0	1	0	1	0	1	0	10	15		0	0	1
	15		0	1	0	1	0	1	0	24	30		0	0	1
	15		2	5	8	15	0	15	0	103	142		1	2	12
					15		15		15					15
		13,33%	33,33%	53,33%	100,00%	0,00%	100,00%	0,00%	6,87	9,47	6,67%	13,33%	80,00%
					100,00%		100,00%		100,00%					100,00%	100,00%

TABLE 3b :

 3b

	CODE	INSTR	IMPORT	ANSWER	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10
	1	9	9	9	9	5	5	8	8	7	9	6	9	9
	2	7	7	7	7	8	8	5	7	7	3	5	7	7
	3	8	6	8	8	8	6	8	8	8	8	6	8	6
	4	8	6	9	8	7	7	8	8	8	6	6	7	8
	5	7	7	7	8	9	5	5	6	8	8	8	9	9
	6	6	9	9	9	9	9	9	9	9	9	9	9	9
	7	4	4	5	9	9	5	6	9	5	9	5	9	9
	8	7	6	8	8	8	8	8	8	7	8	9	8	8
	9	9	9	9	9	7	7	9	8	7	9	7	9	9
	10	4	5	9	8	1	6	4	9	4	5	2	9	8
	11	5	9	5	9	5	7	7	7	7	5	9	7	9
	12	9	9	9	9	9	5	9	9	9	9	9	9	9
	13	6	5	9	9	8	4	4	6	8	9	5	9	7
	14	8	9	9	9	7	7	7	9	8	9	9	8	6
	15	9	8	9	9	9	9	9	9	9	9	9	9	9
	15
	< 7	5	6	2	0	3	7	5	2	2	4	7	0	2
	>= 7	10	9	13	15	12	8	10	13	13	11	8	15	13
	CHECK	15	15	15	15	15	15	15	15	15	15	15	15	15
	TOTAL	66,67%	60,00%	86,67%	100,00%	80,00%	53,33%	66,67%	86,67%	86,67%	73,33%	53,33%	100,00%	86,67%

ROUND 1 RESULTS ---WAI-SR FAMILY PHYSICIAN VERSION

TABLE 3c :

 3c ROUND 1 RESULTS ---SCORING SHEET

	CODE	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11
	1	8	8	8	9	9	9	8	8	8	8	9
	2	8	8	8	8	8	8	8	8	8	8	8
	3	8	8	8	8	8	8	8	8	8	8	5
	4	8	9	9	9	9	9	9	6	8	8	9
	5	9	9	9	9	9	7	8	6	8	8	7
	6	9	9	9	9	9	9	9	9	9	9	3
	7	9	9	9	9	9	5	9	9	4	4	7
	8	8	9	9	9	9	8	8	8	9	9	8
	9	8	9	9	9	9	8	9	8	9	9	7
	10	8	7	7	9	9	9	9	4	7	7	2
	11	9	8	9	9	9
									4	4	4	5
	14	7	7	7	9	9	7	7	5	7	8	7
	15	9	9	9	9	9	7	9	9	9	9	9
	15
	<7	0	0	0	0	0	3	0	5	2	2	4
	>=7	15	15	15	15	15	12	15	10	13	13	11
	CHECK	15	15	15	15	15	15	15	15	15	15	15
	TOTAL	100,00%	100,00%	100,00%	100,00%	100,00%	80,00%	100,00%	66,67%	86,67%	86,67%	73,33%

TABLE 4a

 4a

		: ROUND 2 RESULTS
	WAI-SR PATIENT VERSION
	CODE	INSTRUCT IMPORT	Q1	Q4	Q6	Q10
	1	9	9	8	9		9
	2	9	9	9	9		9
	3	6	6	8	7		8
	4	8	7	7	7		8
	5	8	8	8	8		8
	6	9	9	9	9		3
	7	8	9	9	8		8
	8	8	7	9	8		8
	9	9	9	9	9		9
	10	6	9	9	9		9
	11	8	9	9	8		7
	12	9	9	9	9		9
	13	6	9	8	8		9
	14	8	2	5	9		8
	15	9	9	9	9		9
	15
	< 7	3	2	1	0		1
	>=7	12	13	14	15		14
	CHECK	15	15	15	15		15
	TOTAL	80,00%	86,67%	93,33%	100,00%	93,33%	93,33%

TABLE 4b

 4b

		: ROUND 2 RESULTS
	WAI-SR FAMILY PHYSICIAN VERSION
	CODE	INSTR	IMPORT	Q3	Q4	Q8
	1	9	9	9	6	9
	2	9	9	9	9	9
	3	6	6	8	5	7
	4	9	7	8	7	8
	5	8	8	7	8	8
	6	9	9	9	9	9
	7	9	9	9	8	9
	8	8	7	8	8	9
	9	8	9	9	8	9
	10	6	9	9	9	9
	11	7	9	9	9	9
	12	9	9	9	9	9
	13	5	6	9	9	9
	14	9	4	9	9	8
	15	9	9	9	9	9
	15
	>7	3	3	0	2	0
	>= 7	12	12	15	13	15
	CHECK	15	15	15	15	15
	TOTAL	80,00%	80,00%	100,00%	86,67%	100,00%

TABLE 4c

 4c

		: ROUND 2 RESULTS
	SCORING SHEET
	CODE	Q8
	1	9
	2	8
	3	9
	4	8
	5	8
	6	8
	7	9
	8	8
	9	9
	10	9
	11	8
	12	9
	13	9
	14	9
	15	9
	15
	<7	0
	>=7	15
	CHECK	15
	TOTAL	100,00%

  Fairly Often Very Often Always 2. What I am doing in therapy gives me new ways of looking at my problem.

	5. ___and I respect each other. 11. _____ and I have established a good understanding of the kind of changes that would be good
	 for me.					
	Always 	Very Often Fairly Often Sometimes   	Seldom 
	6. ___and I are working towards mutually agreed upon goals. Always Very Often Fairly Often Sometimes	Seldom
	 12. I believe the way we are working with my problem is correct.   	
	Always	Very Often Fairly Often Sometimes	Seldom
	7. I feel that___appreciates me.
						
	Seldom	Sometimes Fairly Often Very Often	Always
	8. _____ and I agree on what is important for me to work on.
						
						
	Always	Very Often Fairly Often Sometimes	Seldom
	Always	Very Often Fairly Often Sometimes	Seldom
	9. I feel _____ cares about me even when I do things that he/she does not approve of.
	3. I believe___likes me.
						
						
	Seldom	Sometimes Fairly Often Very Often	Always
	Seldom	Sometimes Fairly Often Very Often	Always
	4. ___and I collaborate on setting goals for my therapy.
	10. I feel that the things I do in therapy will help me to accomplish the changes that I want.
						
	Seldom 	Sometimes Fairly Often Very Often   	Always 
	Always	Very Often Fairly Often Sometimes	Seldom
						51 52

WAI SR (French version validated by the Delphi procedure) WAI SR -Version patient -Traduction Française Consignes

  ___ and I both feel confident about the usefulness of our current activity in therapy. : Ci-dessous vous trouverez une liste d'affirmations et de questions sur le vécu que les patients peuvent avoir vis-à-vis de leur généraliste ou de leur prise en charge. Certaines propositions font directement référence à votre généraliste (sous la forme d'un espace souligné ______). En lisant ces propositions, remplacez le nom de votre généraliste à la place de l'espace souligné ______ dans le texte. Pensez au vécu de votre prise en charge, et décidez quelle catégorie décrit le mieux votre vécu personnel.

	4.  Seldom 5. I appreciate ___ as a person.  Sometimes Fairly Often Very Often       Always Very Often Fairly Often Sometimes 10. We agree on what is important for ___ to work on.     Always Very Often Fairly Often Sometimes 5. _____ et moi nous respectons l'un l'autre     Toujours Très souvent Assez souvent Parfois 6. _____ et moi travaillons sur des objectifs convenus ensemble  Always  Seldom  Seldom  Rarement      Toujours Très souvent Assez souvent Parfois Rarement 11. _____ et moi nous sommes mis d'accord sur le type de changement qui serait bon pour moi      Toujours Très souvent Assez souvent Parfois Rarement Annex B: IMPORTANT : Prenez le temps nécessaire pour considérer attentivement chaque question 12. Je crois que la façon dont nous travaillons sur mon problème est appropriée
	6. We have established a good understanding of the kind of changes that would be
	good for ___. 7. J'ai le sentiment que _____ m'estime 1. A la suite de ces consultations je vois plus clairement comment je pourrais être capable de changer     
	  Rarement	  Parfois	  Assez	  Très	  Toujours
			souvent	souvent
	Always Rarement	Very Often Fairly Often Sometimes Parfois Assez Très	Seldom Toujours
			souvent	souvent
	7. ___ and I respect each other. 8. ______ et moi sommes d'accord sur ce qui est important pour moi de travailler
	2. Ce que je fais au cours de ce suivi me donne de nouvelles façons d'envisager mon problème     
	  Toujours	  Très	  Assez	  Parfois	  Rarement
	Seldom Toujours	Sometimes Fairly Often Very Often souvent souvent Très Assez Parfois souvent souvent	Always Rarement
	Fairly Often Very Often 9. J'ai le sentiment que ____ prend soin de moi même quand je fais des choses qu'il/elle Always 8. ___ and I have a common perception of his/her goals.      n'approuve pas 3. Je crois que ______ m'apprécie          
	2. I am genuinely concerned for ___'s welfare. Always Very Often Fairly Often Sometimes Rarement Parfois Assez souvent Très souvent souvent souvent Rarement Parfois Assez Très	Seldom Toujours Toujours
					
	9. I respect ___ even when he/she does things that I do not approve of.
	Always  10. J'ai le sentiment que les choses que je fais au cours de cette prise en charge vont m'aider à Very Often Fairly Often Sometimes Seldom     4. _____ et moi collaborons pour établir les objectifs de ma prise en charge     accomplir les changements que je souhaite       3. We are working towards mutually agreed upon goals.      Seldom Sometimes Fairly Often Very Often Always Rarement Parfois Assez souvent Très souvent souvent souvent Toujours Toujours Très Assez Parfois Rarement
	Seldom	Sometimes Fairly Often Very Often	Always
					53 54 57 58

WAI SR (Final French version) WAI SR -Version patient -Traduction Française Consignes

  1. As a result of my consultations, I see more clearly how I might be able to make changes to my lifestyle. _____ and I are agreed on the kind of changes that would be good for me. You will find below a list of statements regarding the experience that professionals may have with their patients. Some proposals refer directly to your patient (indicated by an underlined space______). As you read these proposals, the name of your patient would go in the underlined space _______ in the text. : Ci-dessous vous trouverez une liste d'affirmations et de questions sur le vécu que les patients peuvent avoir vis-à-vis de leur généraliste ou de leur prise en charge. Certaines propositions font directement référence à votre généraliste (sous la forme d'un espace souligné ______). En lisant ces propositions, remplacez le nom de votre généraliste à la place de l'espace souligné ______ dans le texte. Pensez au vécu de votre prise en charge, et décidez quelle catégorie décrit le mieux votre vécu personnel.

	5. _____ and I respect each other.   Always Very Often Quite Often Sometimes   6. _____ and I work together on agreed goals.     Always Very Often Quite Often Sometimes 11.     Always Very Often Quite Often Sometimes 12. I believe that the way we are working on my problem is appropriate.  Rarely  Rarely  Rarely      Rarely Sometimes Quite Often Very Often Always 4. ______ and I are both convinced that what we are currently doing during this period of care is useful.      Rarely Sometimes Quite Often Very Often Always 5. I respect ____ as an individual.      10. We agree on what is important for ______ to work on.      Always Very Often Quite Often Sometimes Rarely 5. _____ et moi nous respectons l'un l'autre      Toujours Très souvent Assez souvent Parfois Rarement      Toujours Très souvent Assez souvent Parfois Rarement 11. _____ et moi nous sommes mis d'accord sur le type de changement qui serait bon pour moi      Toujours Très souvent Assez souvent Parfois Rarement Annex D: IMPORTANT : Prenez le temps nécessaire pour considérer attentivement chaque question 6. _____ et moi travaillons sur des objectifs convenus ensemble 12. Je crois que la façon dont nous travaillons sur mon problème est appropriée
	7. I feel that ______ respects me. Always Very Often Quite Often Sometimes	Rarely
	 Rarely 2. These follow-up meetings give me new ways of thinking about my problem.     Sometimes Quite Often Very Often Always      Always Very Often Quite Often Sometimes Rarely      Rarely Sometimes Quite Often Very Often Always 8. ______ and I agree about what is important for me to work on.      Always Very Often Quite Often Sometimes Rarely 9. I feel that ____ cares about me even when I do things that he / she does not approve of. WAI-SR -Therapist 6. We are agreed on the type of change which would be good for _____      Always Very Often Quite Often Sometimes Rarely 7. _____ and I respect each other. 7. J'ai le sentiment que _____ m'estime 1. A la suite de ces consultations je vois plus clairement comment je pourrais être capable      de changer      Rarement Parfois Assez souvent Très souvent Toujours 2. Ce que je fais au cours de ce suivi me donne de nouvelles façons d'envisager mon Rarement Parfois Assez souvent Très souvent Toujours 8. ______ et moi sommes d'accord sur ce qui est important pour moi de travailler      Instructions:     Rarely Sometimes Quite Often Very Often Toujours Très Assez Parfois Rarement Always       problème     souvent souvent  Toujours Très Assez Parfois Rarement
	3. I think that _______ likes me.   Rarely Sometimes Quite Often Very Often   souvent souvent 9. J'ai le sentiment que ____ prend soin de moi même quand je fais des choses qu'il/elle  Always 8. ____ and I share a common perception of his/her goals. n'approuve pas
	 Rarely 4. _____ and I work together to establish goals for my care.    Sometimes Quite Often Very Often Rarely Sometimes Quite Often Very Often Always Very Often Quite Often Sometimes souvent souvent 10. I feel that the things I do as a result of these consultations will help me accomplish the changes  Always Always Rarely 2. I am sincerely concerned about _____'s well-being.     Always Very Often Quite Often Sometimes Rarely Rarement Parfois Assez Très Toujours souvent souvent           3. Je crois que ______ m'apprécie       Rarement Parfois Assez Très Toujours
	 I want to achieve. 9. I respect ___ even when he/she does things that I don't approve of.    10. J'ai le sentiment que les choses que je fais pendant les consultations vont m'aider à  Rarely Sometimes Quite Often Very Often      3. We are working together on agreed goals.      accomplir les changements que je souhaite 4. _____ et moi collaborons pour établir les objectifs de ma prise en charge           Always Always Very Often Quite Often Sometimes Rarely      Rarely Sometimes Quite Often Very Often Always Rarely Sometimes Quite Often Very Often Always Rarement Parfois Assez souvent Très souvent souvent souvent Toujours Toujours Très Assez Parfois Rarement
		62 63 64 65
		68 69

IMPORTANT: Take your time to consider each question carefully 1. ___ and I agree on the steps to be taken to improve his/her situation.

  'étude TATA (Tool Assessment for Therapeutic Alliance) avait pour objectif de sélectionner à l'échelle européenne l'échelle la plus appropriée pour évaluer l'alliance thérapeutique puis de la traduire dans de multiples langues européennes. La WAI-SR a été sélectionnée par méthode de consensus RAND/UCLA en 2016. L'objectif de cette étude était de traduire la WAI-SR en Français par une procédure de consensus rigoureuse.Matériels et MéthodeUne traduction aller-retour par méthode de consensus Delphi fut réalisée. Un groupe de travail initial composé de 2 généralistes, un linguiste et un psychiatre réalisé une première traduction. Cette traduction fut évaluée et corrigée par un groupe d'experts composé de médecins généralistes en suivant la méthode Delphi. Une traduction retour fut ensuite réalisée par 2 linguistes et comparée à la version Anglaise originale pour contrôler la présence d'erreurs. Résultats 15 médecins généralistes ont participé à la procédure Delphi. Il n'y a pas eu de perdus de vue. La traduction fut validée en totalité en 2 tours. Une correction fut faite après la traduction retour.ConclusionUne traduction française de la WAI-SR par une méthode de consensus rigoureuse est maintenant disponible. Elle permettra dans le futur des études additionnelles et sera un outil utile en pratique clinique et en pédagogie.IntroductionTherapeutic alliance is an important factor in the process of care, positively influencing outcome as well as patient adherence and motivation. The Tool Assessment for Therapeutic Alliance Study (TATA) aimed to select on a European level the most appropriate scale to evaluate the therapeutic alliance and to translate it in various European languages. The WAI-SR has been selected by a RAND/UCLA Appropriateness Method in 2016. The objective of this study was to translate the WAI-SR in French via a rigorous consensus method.Materials and MethodsA forward and backward translation with a Delphi consensus procedure was completed. An initial translation group of 2 general practitioners, 1 linguist and 1 psychiatrist wrote a first translation. This translation was evaluated and corrected by an expert panel comprised of general practitioners following the Delphi technique. A backward translation was then done by 2 linguists and compared to the original scale to check for errors. Results 15 general practitioners participated to the Delphi consensus procedure. There was no loss to follow up. The translation was validated in its entirety after 2 rounds. One correction was made after the backward translation.ConclusionA French translation of the WAI-SR by a valid consensus method is now available. It will allow further collaborative research and be a useful tool in clinical practice and pedagogy.

	MOTS CLES : MOTS CLES :
	ALLIANCE THERAPEUTIQUE ; MEDECINE GENERALE ; WAI-SR ; PROCEDURE DELPHI THERAPEUTIC ALLIANCE ; FAMILY MEDICINE ; WORKING ALLIANCE ; WAI-SR ; DELPHI
	TECHNIQUE
	JURY : Président : Monsieur le Professeur JY Le Reste JURY : Président : Monsieur le Professeur JY Le Reste
	Membres : Monsieur le Professeur B Le Floch Membres : Monsieur le Professeur B Le Floch
	Monsieur le Docteur P Nabbe Monsieur le Docteur P Nabbe
	Monsieur le Docteur M Odorico Monsieur le Docteur M Odorico
	DATE DE SOUTENANCE : DATE DE SOUTENANCE :
	30 novembre 2017
	ADRESSE DE L'AUTEUR :

Remerciements

ADRESSE DE L'AUTEUR : BOTTEMINE (Thomas) -Translation of the Working Alliance Inventory Short Version (WAI SR) in French by a Delphi process with Forward/Backward translation Th. : Méd. : Brest 2017 ABSTRACT:

WAI SR SCORING SHEET SCORING KEY FOR THE HATCHER GILLASPY SHORT FORM OF THE WAI