Sensemaking in Clinical Qualitative Research
by
Ronald J. Chenail
+ and Paul Maione*

The Qualitative Report, Volume 3, Number 1, March, 1997
(http://www.nova.edu/ssss/QR/QR3-1/sense.html)


Abstract

When therapists research clinical populations or situations from a qualitative research perspective, their task is different from when researchers conduct their own clinical qualitative studies. With researchers, the study at hand may be their first time "in the field." For researchers in this situation it is easier to use qualitative methods such as grounded theory (Glaser & Strauss, 1967) because there is a "tabula rasa" quality to this initial foray into the "unknown" as a theory from observations is constructed anew. In the case of the therapists-as-qualitative-researchers, clinicians already have made some sort of sense of "the other" by virtue of their previous experiences or exposures with the population or situation in question. Instead of constructing theories like their researcher colleagues, researching clinicians must face their previous constructions (i.e., sensemaking from experience), create methods which allow for deconstruction (i.e., sensemaking challenged), and then work towards building reconstructions (i.e., sensemaking remade) (Dervin, 1992; Duffy, 1995; Shields & Dervin, 1993; Weick, 1995). In this manner, the confidence that therapist-researchers have in their observations can be both rigorously challenged and bolstered. We present ways of undertaking this triadic approach to inquiry and sensemaking along with a conceptual tool from the presenters' work, "The Y of the How," will be offered as one way this approach to clinical research can be accomplished.

Introduction

Contemporary qualitative research is experiencing unprecedented growth and expansion (e.g., Denzin & Lincoln, 1994). Moving beyond its traditional strongholds of anthropology, sociology, and communication, qualitative research is making impressive inroads into a variety of applied fields such as computer science and information systems (Wixon & Ramey, 1996), library science (Glazier & Powell, 1992), health and mental health care (Morse & Fields, 1995; Sherman & Reid, 1994), and business and organizations (Gummesson, 1991; Schwartzman, 1993).

This move to the applied fields has brought with it another interesting trend in qualitative research, namely the practitioner-as-researcher. When these researching practitioners such as computer programmers, librarians, nurses, therapists, physicians, and managers study their computer applications, service delivery, care-giving, counseling, consulting, or leadership, they are faced with a challenge their non-practitioner researching colleagues can avoid. Whereas all researchers have to deal with questions of time, money, approval, and access, practitioners-as-researchers also have to come to grips with how they are going to manage their previously acquired knowledge in their soon-to-be area of research. With this all of this pre-inquiry familiarization with their subject manner, how will these researching practitioners conceptualize, conduct, and evaluate their qualitative research projects in light of their already knowing too much? In other words, how can practitioners-as-researchers build upon their practice knowledge without being totally overwhelmed by it?

In this paper, we will discuss this potentially problematic situation and demonstrate how researching practitioners can make sense of their practice knowledge, manage it, and utilize it as a resource in their qualitative inquiries. In our presentation we will focus on one applied field, psychotherapy, and share our development of a sensemaking approach to the conduct of clinical qualitative research.

Clinical Qualitative Research and Sensemaking

Clinical qualitative research (Brown & Kreps, 1993; Chenail, 1992; Crabtree & Miller, 1992; Kreps, 1989; Miller & Crabtree, 1994; Schein, 1987) is an approach to inquiry in which at least one of the following conditions exists:

1. The focus of the qualitative research is on a clinical practice, population, or situation (e.g., Chenail, 1992; Crabtree & Miller, 1992; Miller & Crabtree, 1994).
2. At least one of the qualitative researchers in the study is also a clinician (e.g., Chenail, 1992; Crabtree & Miller, 1992; Miller & Crabtree, 1994).
3. All or part of the qualitative research method employed in the study has been derived from a previously known and practiced clinical technique or procedure such as circular questions (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978), reflecting teams (Andersen, 1991), or interpersonal process recall (IPR) (Kagan & Kagan, 1990) (e.g., Chenail, 1992).
4. The focus of the qualitative inquiry is on evaluating processes in an organization and assisting stakeholders in creating change in their organization (e.g., Brown & Kreps, 1993; Kreps, 1989; Schein, 1987).

In this paper, we want to concentrate on the second of these three conditions--the therapist-as-researcher--and to discuss some of the challenges involved in clinical projects in which the therapist-researcher is already familiar with the phenomenon to be studied. As discussed above, this "knowing-before-hand" presents the researching therapist with both some interesting resources and some perplexing problems. For instance, how can researching therapists take advantage of the rich experiences already created from their experiences in the field? At the same time, how can these experience-rich therapist researchers challenge their pre-existing notions of the phenomenon to be studied and fairly use their research time as an opportunity re-search the other anew?

This process is especially challenging for clinicians who study phenomenon or situations with which they already have some familiarity. For example, clinicians who study their own or others' therapeutic work for research, model building, and/or supervision purposes. Instead of the ahistorical posture of grounded theory (Glaser & Strauss, 1967), where the researchers are new to the clinical territory to be studied, reflective practicing clinicians must begin with their own understandings which have been constructed through their previous exposures to the "field." This is both an advantage and a disadvantage for the therapist-as-researcher. On the advantage side, clinicians who study familiar territories have already gained valuable access to the field, which can be a major stumbling block to studies. They also have a good start on gaining a feel for the phenomenon. The disadvantages can be summed up by the saying, "A little knowledge can be a dangerous thing!" Because clinicians may have preconceived notions regarding the phenomenon to be studied, this may lead to a premature narrowing of focus or, worse yet, to a view of the phenomenon which is replete with blind spots from this already-in-place lens.

Many non-clinician researchers use qualitative methods like grounded theory (Glaser & Strauss, 1967) because there is a "tabula rasa" quality to this initial foray into the "unknown." Conversely, researching clinicians must face their previous constructions (i.e., sensemaking from experience), create methods which allow for deconstruction (i.e., sensemaking challenged), and then work towards building reconstructions (i.e., sensemaking remade) (Dervin, 1992; Duffy, 1995; Shields & Dervin, 1993; Weick, 1995). In this manner, that confidence therapist-researchers have in their observations can be both rigorously challenged and bolstered.

One way for researching therapists to make their assumptions more overt and potentially more useful is to reflect upon their sensemaking activities rigorous asking of questions to themselves. Just as therapists' questions to their clients help to shape the talk in clinical sessions, therapists' questioning of themselves as therapists-turned-researchers help to shape the method in of study. We call this part of the conceptualization process, "The Y of the How: Sensemaking in Qualitative Inquiry." When a "Y" is drawn, one can see that three different areas have been created--all connected, yet separate spaces. The three spaces created by drawing the "Y" represent the three foci of the researcher's sensemaking activities in a qualitative research project.

One area of focus is the therapists' own sense of the phenomenon in question. For clinicians this usually comes from reflection on their previous experiences with the phenomenon in their clinical education, practice, and training. The second area is the therapists' sense of the sensemaking attempts others have made regarding this and related phenomenon. This area consists of the writings and comments of other researchers, practitioners, and/or any other person who has had some involvement with the phenomenon to be studied. The third area of focus for the therapists' sensemaking process is the study itself. As researching therapists begin to make sense of the data which is generated from the study, they will then carefully juxtapose these new sensemakings of theirs with those sensemakings they had previously constructed of the phenomenon in the "self-reflexive" and the "reflections on the others" phases of the process.

By examining these sensemakings, each in context with the others, researching therapists will see the relationships between them. Questions such as, "Are the different notions you have had about the phenomenon beginning to cohere? Are they beginning to disagree with each other? Are you gaining confidence in any one of them? Are your thoughts from one area of sensemaking beginning to change based upon your sensemakings in another?" can all be asked in this "bringing to light" process of the sensemaking enterprise in clinical qualitative research.

The ways in which therapists-as-researchers go about making sense of their own sensemaking is so crucial to the eventual success, or lack thereof, of a particular project. Therapists must bring forth their own ideas, hunches, biases, blind spots, and questions, examine them closely, and challenge them at the same time.

Concurrently, therapists-as-researchers must explore the sensemakings of others who have also traveled this territory. In combination with their own experiences of the phenomenon, which have been heightened through a systematic, reflective process, researching therapists must weave the ideas of others to form a focus into the phenomenon in question. In turn, this concentration of their senses will lead therapist researchers to construct their own understanding of the phenomenon with which they have been researching. All the time in this unfolding of their sensemaking, researching therapists will have allowed themselves to challenge the constructions of which they can become all too fond.

The scientific folks call this "falsification," but we see it more along the lines of a construction-deconstruction-reconstruction process leading to confidence building on the part of the researcher. The study undertaken is the one in which the greatest amount of confidence is placed. Following from this, the sensemaking account which finds it way into the project's re-porting is the one with which the researcher is the most confident of "projecting" into the ongoing conversation of clinical researchers and practitioners.

And, from where does this confidence come? As with artists and performers, it comes from the repetition of rituals and the practice of performance. It also takes shape through the steady flow of reviewers' praise and criticism. For researchers this can come from others (e.g., researchers, practitioners, the participants in the study) including themselves when they don their critics' hats.

At the same time, this sensemaking process can lead to a shaking of the researching therapists' confidences in what they think they know. A new study in a researching therapists' area of focus which contradicts their findings, a new clinical session they experience which reveals new insights on the phenomenon, the juxtaposition of a new metaphor which allows them to see the data in a novel way are all possibilities which must be embraced by researching therapists in this mode of inquiry. Any and all of these can lead to a deconstruction of the therapist-researchers' understandings and a lowering of their confidence. Of course, each of these revelations must also be scrutinized and challenged in its own right, but their coming to light must be dealt with and woven into the sensemaking process. It is the responsibility of the researching therapist to clearly delineate these reckonings when recounting their study (Chenail, 1994; Constas, 1992). Relating these challenges to therapists-as-researchers' sensemaking helps give a sense of trustworthiness to their accounts of the research. An openness to the telling of the "bumpiness" inherent in this winding road to understanding will be both truthful and persuasive to yourself and to your readers. Such a narrative tells the way these things happen and the tale will be readily recognizable for anyone else who travels along this research trail.

With all of this confidence building and shaking, what the researching therapist can legitimately say is, "This is how I make sense of this phenomenon now." Once that is said, the process begins again as the therapists-researchers re-search and seek to build upon those theories and/or to deconstruct them. As Jack Horner, the eminent paleontologist, says, "If anyone refutes one of my theories, I would like for that person to be me!" We think we would have to agree with him. It takes courage to do such a thing, but it is also the essence of what we do as researchers.

Equally important in qualitative research, especially when conducting case studies, is a N of 1, or where there are limited cases to study, researching therapists have to maximize the number of observations or "O's" they make. Quantitative researchers gain confidence in their numbers (of cases). Qualitative researchers also gain confidence with their numbers (of observations). Of course, qualitative researchers also gain confidence by building qualitative differences too. They can take qualitatively different perspectives on the same case. They can reflect on one observation at one time and use that new sensemaking perspective to look for something qualitatively different in the phenomenon from what had been the focus of study before.

Another area to explore in these studies are the multiple sources of data from the one case. For example, researching therapists can collect and study documents (e.g., case notes, journals, court papers), generate field notes from participant observations while observing the case unfold, interview participants and study the tapes and transcripts, conduct discourse analyses from tapes of the actual mediation sessions, and so forth. In each of these data bases, therapists-as-researchers can conduct different analyses, involve different analysts, juxtapose different metaphors, and so forth. All of these acts come together with one purpose--to construct an answer to some question and to challenge that construction so that eventually, therapists-researchers come with a narrative they can accept with a certain level of confidence, for now.

Techniques like member checking, audit trails, and journal keeping can also be used as challenges to these sensemakings of the phenomenon at hand in that their use may produce contrary or variant interpretations or descriptions with which reflective researching therapists must contend. Conversely, the use of these techniques can also serve as a confidence builder in the sensemaking process if they present interpretations and descriptions which give support to or cohere with the previous renderings of the data.

In this way of thinking, computerized qualitative data analysis programs can also produce the same effect in a qualitative research study as the audit trails, member checks, and journal keeping (Weitzman & Miles, 1994). The packages which aid in hypothesis testing can be sources of confidence building or confidence shaking depending on their relationship with the previous sensemakings of the data. One can almost hear this phenomenon in the language of those researchers who use these programs in their work. When they say something along the lines of "The results of this analysis do not support my hypothesis regarding this phenomenon," one can pick up on how the researcher's confidence has been shaken. Conversely, a statement like "My theory was supported by the results of the computerized qualitative data analysis," is brimming with the confidence which can come from "third-party" validation.

Lastly, we feel it is important to not save this whole constructing/deconstructing process for the last phase of the research process. We know some folks who approach it that way. For example, researchers build these wonderful constructions of what the data are telling them. They have spent countless hours honing and crafting this wonderful edifice of descriptions and interpretations. Then, sometimes just before a deadline must be met, they bring this structure of descriptions and interpretations before "an other," be it a dissertation committee member or a co-participant in the project, and ask them what they think about this fine building. That takes a tremendous amount of courage on both parties' parts. For readers, they must be comfortable enough to disagree with the researcher, if that is the case. Researchers on the other hand, must be comfortable enough with the possibility of having to take apart the whole wonderful building if the other does not agree that its structure is sound.

Instead of this "wait til the very end" scenario, all researchers should build this stream of difference into their constructing process as an ongoing occurrence. In the case of therapist-researchers, they can do this by traveling around the "Y" in fairly regular intervals. In the making sense of others area, therapists-as-researchers can revisit the ideas of others via member checking, literature reviews, Internet forays into online discussion groups, and World Wide Web surfings. With the making sense of the study at hand space, researching therapists can revisit the "field" and review the data they have collected and/or generate new data for new viewings. And, in the making sense of their own understandings realm, they can revisit themselves by writing new journal entries and by re-reading old ones, They can also take stock in the deficiencies and exuberances in their interpretations and descriptions, by attempting to "see" their blind spots and to "hear" their deafness.

If sufficient time is spent at the "Y" and the accounts of this are carefully relayed in writings and presentations, both the researching therapists and their audiences will have greater confidence in the research "findings" and constructions. The therapists-as-researchers and their colleagues will also find the work to be more trustworthy because the researching therapists will have had the integrity to open up their private observations for public scrutiny. They will have taken every opportunity to present the data with the descriptions of that data and they will also have included evidence of the "backstage" work which went into the "final" production the colleagues are now seeing in the presentations and are now reading in papers.

Despite the complexity, therapists-as-researchers can create informative and trustworthy research projects where they can be confident, if they keep one simple question in mind, "What can I do in my research that will afford me another opportunity to build my confidence regarding my sensemaking of this phenomenon and will also present me with another chance to shake my confidence regarding my understanding of this same phenomenon?" In this fashion, qualitative research becomes an unfolding dialectic of building and shaking confidence until researchers reach a level of trust in their sensemaking of the phenomenon in question that they are able to produce a study. At that point, they and others will then set about the process all over again. It will also be at that moment that they will begin to realize why this process is called "re-search" and not just "search" after all.

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Author Note

+Ronald J. Chenail, Ph.D. is Dean of the School of Social and Systemic Studies and Associate Professor in the Department of Family Therapy at Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, Florida 33314 USA. His email address is ron@nsu.acast.nova.edu.

*Paul Maione, Ph.D. is the Clinical Director at the Center for Family and Relational Therapy in Fort Lauderdale, Florida and an adjunct faculty member in the School of Social and Systemic Studies at Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, Florida 33314 USA. His email address is paul@nsu.acast.nova.edu.

The authors would like to thank Estella Martinez for her help in creating the Y of the How graphic.

      Chenail, R. J., & Maione, P. (1997, March). Sensemaking in clinical qualitative research [28 paragraphs]. The Qualitative Report [On-line serial], 3(1). Available: http://www.nova.edu/ssss/QR/QR3-1/sense.html

Ronald J. Chenail and Paul Maione
4 May 1997 copyright


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