In addressing possible juxtapositions of qualitative research and clinical practice in this essay, I will concentrate more on practical issues rather than with philosophical or epistemological concerns. This is not to deny the importance of these perspectives in conducting qualitative inquiry or therapy. My choice in narrowing my discussion to these "nuts and bolts" aspects is that the context for this paper, being this conference, explicitly suggests that other pertinent issues to qualitative research such as the legitimacy and praxis of alternative constructions of knowledge, place of language in our lives, ethics and politics of professional practice, and the importance of gender issues already will be written and discussed elsewhere.
In deciding to use a qualitative approach in your study of clinical inquiry, it is good that you have some sort of idea for what qualitative research is useful and practical. Like all research methodologies, qualitative research has its limitations; but, if you take advantage of the strengths of qualitative research, I think you will find a number of interesting and wide-ranging applications for researching your clinical world.
Foremost, qualitative research methodologies can help you re-search and articulate that about which you are curious in therapy. Discovery-oriented inquiry (Mahrer, 1988), as opposed to hypothesis-testing research, is a major hallmark of qualitative-oriented research. In this style of research, researchers hope to avoid the pitfalls of some pre-mature quantitative research efforts by taking a slower pace with their work. Rather than being concerned with making inferential statements with their research, qualitative researchers are more interested in creating evocative descriptions and interpretations of some local phenomenon.
In this way, qualitative approaches ask researchers to spend considerable amounts of time "getting to know" their data. I believe for the qualitative researcher that this "quality time," is best spent from a perspective of curiosity and open-mindedness. This means that you can direct your curiosity, as in knowing what you do not know, and then spend your time focusing on a particular area of your concern. It also implies that researchers may adopt a posture of "just generally being curious" in their inquisitiveness as researchers in a way of exploring from a not-knowing-what-you-do-not-know perspective. With either stance of curiosity, qualitative researchers must be prepared to discover that which was previously unknown to them from their prior investigations including those times when they were reflecting on their therapeutic practices as clinicians.
One way we can begin to attain this goal of curious inquiry is for us to learn and to adopt one or more of the many means or metaphors for descriptive and interpretive ends found in qualitative research. A certain research method might provide us with a perspective on our clinical work which provides enough of difference which makes a difference for us.
For me, method in qualitative research is synonymous with the rigorous application of metaphor. For instance, take the analysis of narrative. When you apply this metaphor to a client's talk during a clinical interview, you want to talk about the thisness of the client's talk in terms of the thatness of the metaphor, narrative (Burke, 1945/1969). One step in the process of rigorously applying a metaphor involves learning and developing the metaphor you want to use.
For example, what are the parts of an analysis of narrative approach? You could have voice, plot, theme, characterization, and\or symbolism. You first have to learn these aspects of a narrative metaphor in theory or in general, then be able to apply this lens to a transcript or a recording you have collected, and finally see if you can see these narrative things or hear if you can hear them in the talk. With practice, you should eventually be able to talk about the client's talk in narrative terms.
It is a matter of pointing to a chunk of the data and telling the reader what it is you are seeing. This descriptive process is all done by the researcher from perspective which has been clearly delineated by the researcher and shared with the reader. It is a way of saying: "Look at what I'm seeing, Here it is. This is what I think it is. What do you think of my thinking?"
At the same time, we have to remember that when we use methods, there will always be an "unsaid" along with the "said." Methods help us see certain circumstances while blinding us to other matters. To forget this is to become dangerous for ourselves an d for others. Mary Catherine Bateson (1989) once said that there was nothing more toxic than a bad metaphor. The same holds for our choices of method, too! Shop around before you settle on a method. Be a smart consumer of research methodologies, and when you do select a particular approach for conducting a particular research project, be a constant critic of your inquiry.
One way to do this is to keep an eye to the margins of a project; for it is often those areas which are just slightly outside of the focus of your research lens which provide some of the most interesting and informative patterns for us investigators. An other way to challenge our own research metaphors is for us to always include a curiosity for the exception in our work and a hesitancy to explain quickly that which might turn out to be unexplainable.
Another strength of qualitative research is that researchers are asked to reflect on their own involvement in the inquiry process. We are active participants in the construction of our clinical and research knowledge. From this perspective, the most important "instrument" in qualitative inquiry is ourselves as researchers (Eisner, 1991), and our most crucial task may be to prepare ourselves to conduct our research. This preparation may entail transcription practice, interview construction drills, and\or writing lessons. It may also involve our getting to know ourselves better such as a coming to know how our cultural, ethnic, racial, and gender biases help us both to see certain things and to blind ourselves to others.
Learning how to put it all together in a qualitative study is quite an undertaking. For would-be qualitative researchers, I think it is a helpful thing to find good templates of completed studies (Mishler, 1990). These works, if teased apart, can help you to see how one researcher made choices of theory, method, data, presentation, narrative, rhetoric, pragmatics, and aesthetics, and was able to write up a study. Of course, you will probably end up not doing your study just like the one in your chosen template; but, if you collect enough of these exemplars, you should be able to construct a method of particularity for yourself, that is a method that works for you with a particular study at a particular time.
For the most part, what I have been discussing as qualitative research is the public variety (Chenail & Morris, 1995). By public research I mean that systematic inquiry we do which is intended to be shared primarily in a textual form with our colleagues through our dissertations, journal papers, and conference presentations. I say textual because even when we present a paper orally the intent is to improve or develop ideas which we will hope to publish one day. Of course we too should "get something" out of this inquiry in that what we have learned should inform our thoughts and practice as a therapist, but still we are also very interested in reporting the results to our peers.
The turn-around time between conducting a study of public research and publishing the results is usually three years by the time the ideas see the light of day in a journal. Issues of reliability, validity, and generalizability are established in the paper itself by the author and the merit of the work is constructed through the blind review\jury process of the journal editorial board system. The rewards for conducting public research are notoriety among our colleagues in academia, tenure and promotion in our university departments, and research dollars from granting institutions.
In contrast to the public variety of qualitative research, there is another style of qualitative inquiry called private research (Chenail & Morris, 1995). By private research I am referring to the reflexive posture therapists take as they reflect up on their interaction both during a conversation with a client or after a session has been completed. The purpose of conducting such research is to share the results of the inquiry with ourselves and our clients. This research can be conducted in silence, but usually the therapist reports the findings orally to the client during a session or possibly in the form of a letter given to the client. Results also may be shared with other therapists, team members, supervisors, referral sources, etc. The results may be textual in nature as in the instance of case notes, but the purpose of these recordings is to inform the therapist for future therapeutic conversations with the client(s) and ourselves.
If qualitative research is to have a future in the clinical world, I believe we have to combine the best of both research worlds, the public and the private. From the public style, therapists can "private-ize" a whole range of methodologies and techniques which may help themselves better articulate that which may have been beyond their private lenses. In addition, therapists can learn how to make their private research results public by adapting some of the written reporting forms found in qualitative research. This translation of private findings through public reporting means should help these researchers from different worlds begin to communicate. This "public-ation" of private research findings by therapists should be a much-anticipated event by researchers. The making known by private researching therapists of their sense-making of their clinical worlds should help inform public researchers in their future studies.
In the privatization of a heretofore public qualitative research method in clinical practice, the research becomes part of the clinical practice, not a post-session or post-therapy inquiry, but an in-session, real-time integral part of the therapy, and sometimes the research itself can become therapeutic. In making public the therapist-as-researcher point-of-view, therapists ask their clients to join them in this in-session inquiry; if clients accept, they have taken an important step in de-constructing the therapist\client relationship and re-constructing it as a co-researching one. These co-researchers, therapist and client alike, have their own methods, their own ways of knowing in the world: They share the results of their observations with each other in dialogue, sharing double descriptions and differences which make a difference for themselves and the other in conversation.
The best way I feel that I can portray this affiliation of private and public qualitative research with clinical work is to present a series of possible and hopefully interesting studies based upon the clinical scenario supplied by the conference organizers. In presenting these "how to's" my hope is that you will begin to get a glimpse how one qualitative researcher goes about his work and to gain an appreciation how qualitative research might be used to help therapists in their construction of knowledge in their clinical pursuits.
Here is that narrative:
Leaders of the social security unit in a medium sized town in Norway are concerned about the increasing number of persons with what they consider psychosomatic problems on disability pensions. They want to do something about this, and they embark on a project engaging mental health workers to do therapeutic work with this group. A psychologist is part of this therapy group, and he is promised possibilities for research which could lead up to a doctorate.
There are an infinite number of qualitative studies that could be done with this scenario, but the ones I wish to discuss in this paper should give you a feel for the rich variety of these possible studies. Although these studies which I am suggesting are hypothetical, they are based on actual projects that either have been completed in our School of Social and Systemic Studies at Nova Southeastern University or are currently in progress there (i.e., Mackintosh, 1993; Shilts, Filippino, Chenail, & Rambo, 1995).
The first project I would suggest for the psychologists is a clinical process research study. In process research, the researcher concentrates on making in-session observations and collecting and analyzing this data. The purpose of such inquiry is that you want to know more about that which is happening in therapy. You can be totally naturalistic about this process and collect material from a session and begin to see what it is you can see. You can pick out moments of the session which pique your curiosity and you can decide to spend more time describing what it is you see occurring during that segment.
For instance, our psychologist may select those moments in therapy where he is most frustrated and "stuck" with his clients, or times when he is most exhilarated with therapy. He could also collect those times during sessions in which he hears the clients speak of their "psychosomatic condition" and compare central tendencies and ranges of those conversations, as in "How are these conversations alike and How are these talks different?" Maybe our psychologist friend might begin to see some interesting patterns to the talk that he had not noticed when he was first hearing them in the flow of all the other in-session talk.
He can also be literature-informed with his observations. For instance, he might feel that something he has read from the literature pertains to a session he has conducted or to a population with whom he is working in this project. The literature serves as a "tip" for him as a researcher and he can begin his search by following the suggestion from the literature.
For example, Minuchin (Minuchin, Rossman, & Baker, 1978) and his team reported that psychosomatic families had poor conflict resolution skills. By this they meant that when these families fought and argued, they "resolved" these argumentative sequences by withdrawing, changing the subject, or involving another member of the family heretofore uninvolved in the conflict. To Minuchin and his group, none of these dispute resolution skills seemed to end or decide the conflict. They went on to hypothesize that these unresolved conflicts lead family members to feeling "stressed out" and sometimes this stress lead to psychosomatic behavior of one or more of the family members.
Whether or not our psychologist accepts this complete scenario of psychosomatic families, he might be interested in taking a closer look at how his clients settle their disputes. Like the first process example, he can collect exemplars of conflict resolution sequences and chart the sequential interaction as he sees it and\or compare and contrast these moments across sessions or cases to see what patterns he can construct.
A third type of process research is called task analysis (Toukmanian & Rennie, 1992). In task analysis, the researcher is interested in theory-informed tasks that therapists hope to accomplish in therapy. These tasks can also be called goals. The research starts with the therapist articulating, as best he or she can, what it is he or she does in theory at particular points in a session. The researcher then looks for these moments in a session and details the therapist's actions. Sometimes this close scrutiny of a piece of in-session process leads to a new or better articulation of what it is the therapist says he or she does in their therapy. In this way the research shifts from theory-informed research to research-informed theory.
For our psychologist, it might be interesting if he concentrates on his theory of helping clients construct alternative means of settling their disputes and sets about discovering more about what he feels he needs to undertake and accomplish this task. He can start with describing what it is he thinks it is he is doing with his clients and then select sessions in which he is doing this practice. By concentrating on segments of these sessions, he can begin to detail important process moments that seem to be part of successful encounters with clients and those times when things do not turn out so well. At that point, he can begin to consider other options he might want to incorporate in his personal prescriptions for working with his clients on constructing alternative dispute resolution patterns.
The series of process studies I described above had a private research feel, but they were still public research, too, in that the analysis was done after the session or therapy was completed. Although the results of such inquiry could help the psychologist complete his dissertation if he were to write it up using a public research format and his findings could also theoretically help him change his work in his future cases, his research did not necessarily help those clients who had participated in the studies. One way to remedy this situation is for the psychologist to make his research therapeutic by making his private research public with his clients and encourage them to be co-investigators in a joint research project.
In such a study, the psychologist might want to be able to hear from the clients what it is they think of the therapy, the things that he and the team did and did not do, and just what it is, if anything, that they think is making a difference for them in their conversations with their therapist. To encourage this type of dialogue in the therapy, the psychologist could incorporate reflective conversations by family members within the therapy session itself. For example, at the end of each therapist-client conversational session, a therapist\researcher would enter the room and ask the family members to give the therapist feedback on their experiences during the session. Each of these conversations, along with the other parts of therapy, would be videotaped and would be used by the participants to evaluate and to modify their understandings of the shape of their therapeutic conversations and to decide whether or not to continue this conversation in therapy.
If the psychologist wanted to make this study more in the public research vein, he could study the clients' reflections from this project as I proposed in the process research project discussed above. He could investigate how the language practices of the therapists were heard and interpreted by clients, and in turn he could present how these conversations helped the therapists to re-construct their own understandings of self and the other. In turn, he could include these public findings in the next round of his private research with his clients now turned researchers. In such a way, his conversation and construction of knowing continues between himself as researcher and himself as therapist, between a therapist and his clients, and between multiple co-researchers.
I know at the beginning of this paper I said I was going to try to be practical in my discussion of the relevance of qualitative research, but I would be remiss if I did not attend to some "praxis-tical" considerations of conducting qualitative research, especially when it comes to potential attacks from other researchers along the lines of legitimacy of the approach. Any such critical rhetoric of qualitative research usually involves the issues of reliability, validity, and generalizability. It only makes sense that I discuss these issues and suggest some ways to depict their place in these approaches to research. The place to start is with openness.
The more I think about qualitative research the more I think openness is the most important part of the inquiry and the base for constructing a work's reliability, validity, and generalizability. Qualitative researchers should embrace a stance of openness in all phases of their work. A way to maintain this posture is to consider the other in the process at all times and make it a priority that you present as much of the "back stage" information of your research as possible. By back stage I mean that you communicate as clearly as you can what it was that you did to create your project, what were your choices along the way, what else did you consider doing in the project but chose not to do. Get clear with yourself what it is that you are doing at every point along the way of doing your project. Note it and present it to your readers. Even if what you were doing was intuitive guessing, let the reader in on it. A good "how to" for this approach to research is Constas' (1992) article on category construction.
In addition to these considerations there are still other ways to embrace openness in your work. Present as much of the data you collected as is physically possible in your papers and presentations. Store your data and make it available for others to view and re-view. Of course in doing this you will have to notify the other participants in your study that this is your intention and secure their permission. A good example of this trend in qualitative research is Waitzkin's (1991) recent work. Not only did he present lengthy excerpts in his book from the transcripts he collected and analyzed, but he also made the complete transcripts available to the reader by storing them with a national clearinghouse. In this way, anyone who wanted to study the complete transcripts could do so.
Openness also entails involving "the other" in your research. The other can be the participants in your study and they can also be your colleagues who comment on and who read your work. Starting with a stance of openness makes the tasks of constructing reliability, validity, and generalizability for the work a different process than is found with other styles of research.
Reliability starts by your telling the reader what it is that you are planning to do in your study and then ends with you doing it. Someone who is reliable is someone you can depend on in a certain situation. They are consistent: They do it the same way all of the time, and they let you know if they had to change their plans. The same would hold for reliability in qualitative research: Be open with what it is you are going to do, give the details of your design and process as best you can, and then follow the plan each and every time you collect data, or transcribe, or categorize, and so forth. If through the process you decide that it would make sense to adjust what it is you are doing, note the change, describe it in detail, and follow through with the new plan. Through out this process, you invite the reader and\or co-participants in the study to dialogue with you as to how you are doing with your description of what it is you are doing and the actual carrying out of the plan.
As for validity, the more scientific types in qualitative research have written extensively on this subject. This is especially so in American educational circles. They even have had what they call "paradigm wars" over issues such as the philosophy of knowledge, reliability, and validity (e.g., Guba, 1990). It is probably a good idea that you take a peek at this literature. You just might like the approach they take with these issues and feel that this line of argument will work best with your dissertation committee, academic department members, or journal review board; or it fits with the way you see the world, but there are also some alternative views on validity (e.g., Eisner, 1991; Kvale, 1989; Maxwell, 1992; Mishler, 1990; Wolcott, 1990).
For instance, Brent Atkinson, Tony Heath, and I (1991) wrote a paper detailing our view on this issue a couple of years ago. We discussed validity as an interactional process which unfolds between writer and reader in public research and between researcher and research participants or co-researchers in private research. From this point of view, the researcher does not establish what is knowledge in the text itself, rather the validity of a study is constructed in an on-going dialogue between the researcher and the other. And sometimes, the researcher becomes an other as she or he reflects privately on her or his own research, be it of the private or public variety.
It is also from this perspective of on-going dialogue that I think generalizability should be discussed. Eisner (1991) has said, that generalizability, like validity, is not something established textually in the research paper. It is something we create in relationship to that which we read and interpret. We generalize what we read and experience to our own lives. If it makes sense to us, then we carry it along with us. It doesn't matter if the author has "clearly established" the generalizability along certain sample\population correlational relationships. We take such report as a suggestion and not as a command.
I sometimes think that we could "measure" generalizability along these interactional lines. By this I mean, we can say to what degree the results or findings of a project are generalizable by whether or not the ideas have a life beyond the project. Do people talk about the results after the project? Is the study ever cited again? Did the report of the project excite other researchers to do new studies? Did the study become an exemplar for others seeking templates for their own research (Mishler, 1990)? Was the work inspirational? Do clinicians embrace the findings and act as if the results are "true" when they do what they do in therapy? Do the ideas live on for the researcher of a study in his or her future works, or are the ideas abandoned or discarded because they no longer fit or make sense for the researcher? And in the same vein, will the ideas like the ones presented in this paper be discussed by the participants after a conference like this one is over? That issue remains open for conversation.
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