Qualitative analysis. Its use in psychopathological research

Qualitative analysis is a phenomenologically oriented framework for psychopathological research. Its aim is a wide-range understanding of the patient’s morbid subjectivity, not constrained in a priori fixed schemata such as specific rating scales. It is useful in exploratory studies, as well as in the assessment of real-world, first-personal experiences of sub-personal impairments. The qualitative approach to anomalous experience is concerned with bringing forth the typical feature(s) of personal experiences in a given individual to establish objective, trans-personal constructs. A three-step procedure is necessary to move from the assessment of subjective experiences, through personal narratives, to trans-personal constructs. The assessment of first-personal experiences requires attention to the manifold layers of subjectivity. Experiences convey an information content, e.g. a person thinks that he is depressed. In addition, they have a certain personal feel, e.g. what-it-is-like (1) to that person to be depressed. Each experience is also accompanied by a personal value and meaning that the person attributes to it, e.g. being depressed may be valued either as the comprehensible and thus non-pathological outcome of an experience of loss, or as the effect of a disease; in the former case, it may have passively suffered thus leading to apathetic behaviour, in the latter it may be valued as an undeserved burden and thus kindle a ‘fight’ reaction leading to dysphoric feelings and behaviours. The position-taking (meaning- and value-attribution) of each person towards his experiences contributes to shape distinct clinical pictures (2). A major issue in assessing subjective experiences is language, as all knowledge, including self-knowledge, is constructed through language. Shared meanings between interviewer and interviewee must not be assumed, but investigated. Most coding of subjective experiences requires an enquiry, e.g. with the very same word ‘depression’ different patients may designate different subjective experiences (e.g. ‘I feel sad,’‘I have no feelings’, ‘I am lacking an inner nucleus’) and attach to them different personal meanings (e.g. ‘I am in mourning’, ‘I am not humane and I have no soul’). During the course of the phenomenological interview, persons are encouraged to posit their experiences in a meaningful context, i.e. a narrative format. Narratives are the ordinary forms through which people attempt to order the meanings of their experiences and beliefs. Narrative reasoning is the ability to use structure above the level of the sentence, hence above the level of single experiences; they establish a form of organization in autobiographical memory providing temporal and goal structure, combining personal experiences into a coherent story related to the self. Narratives are personal meaningful reconstructions of one’s experiences and beliefs which are also based on general (i.e. impersonal), culturally shared or – in the case of severe mental illness – peculiar (although recurrent) patterns of meanings. Internal coherence is a basic requisite of narratives; it includes logical connections, richness of historical detail and plausibility (3). Persons are encouraged to organize their stories so that they fulfil the constraints of socio-culturally determined patterns of actions, themes and values, well-known social-frames. The degree each narrative is grounded in socio-cultural constraints is called external coherence. Constructs are based on a holistic approach, advocating the importance of the global grasping of a phenomenon as an organizing and meaningful Gestalt over a particularistic focus of attention. Trans-personal constructs, to be useful for psychopathological research, must be central exemplars of a wide range of personal narratives. They are prototypes– the best exemplars of a class, embodying a network of analogies between the manifold individual members of that class (4). Trans-personal constructs have to fulfil some formal criteria: sensibility (ability to depict different intensities of a phenomenon), reliability (they must consent consistent findings) and discriminant validity for patients with different psychopathological features. Constructs may be the starting point to elicit operational criteria to accurately describe a psychopathological phenomenon or to define single items to build up specific-rating scales. In the past few decades, the objectifying trend taking place in psychopathology has been criticized by many authors. It has been asserted that mental states ‘have unique features’ and that our knowledge and understanding of them cannot be achieved by the objectifying measures of the natural sciences alone (5), like structured interviews. Structured interviews inappropriately assume a priori systems of meanings that can overwrite personally structured meanings and narratives. Interviewing may turn out into a tautological enterprise avoiding the assessment of those phenomena which are not included in predefined diagnostic schemas, impeding the evolution of psychopathological knowledge. Psychopathological research only based on quantitative methods and structured interviews is at risk of the loss of relevant information, as it is the case in stepwise regressions looking for variables reduction, ‘tunnel vision’ (6) and ‘procrustean errors’ when researchers focus only on a priori fixed variables and ‘stretch’ the patients symptomatology to fit criteria (7). It also has the tendency to privileging reliability over validity. Qualitative analysis may be useful to integrate these shortcomings being effective in: (a) hypotheses formulation (8) and exploratory studies where standardized assessment are not yet developed, e.g. Which are the characteristics of self-disorders in schizophrenia (9)?; What is the value-system of people with schizophrenia (10)?; (b) controlling real-world relevance of a particular psychopathological issue usually investigated in laboratory tasks, e.g. Do persons with schizophrenia display in a clinical setting impaired Theory of Mind skills (11)?; (c) assessing real-world, first-personal experiences of sub-personal impairments, e.g. How do disorders of basic-cognition express themselves in everyday life of persons with schizophrenia (12)?; (d) studying from a new perspective clinical phenomena otherwise categorized through standardized rating scale, e.g. Which are the relevant features of prodromal syndrome in schizophrenia (13)?; (e) ascertaining if supervening variables contribute to the course of phenomena in areas where standardized research has provided inconsistent findings, e.g. What is the self-perception of quality of life measures in people with schizophrenia (14)? Qualitative analysis entails systematic but flexible interrogation of initially unstructured phenomena selected for their close relationship to the problem under investigation; it requires maximum elasticity in generating new categories from the phenomena; it promotes dense conceptual development and dialectical process between phenomena and the clinician’s conceptualizations. It usually implies cross-sectional empirical design and requires clear-cut defined hypotheses. Usually, anecdotal findings promote a systematic enquiry of a relevant psychopathological issue in a class of defined patients. The phenomena under investigation may be gathered from interview transcripts, diaries or personal notes provided from patients or their relatives. Sentences reported by patients as they were made explicit during therapeutic interviews are good exemplifications of their experience about themes under investigation. A major advantage of qualitative analysis is that it promotes therapeutic (especially if long-term oriented) settings as a source of relevant data for research and of a circumstantiated comprehension of them. In the course of interviews, patients are encouraged to narrate, conceptualize and elaborate on these themes. In subsequent interviews, each patient is asked to reflect upon the narratives he had previously articulated and about narratives of other patients. This cycle of interpretations is set in a context of dialogical reciprocity that widens rather than restricting the range of meanings; the setting of epistemological asymmetry that usually characterizes the clinical interview should be avoided. Elaborations of these materials and co-creation of meaningful narratives and constructs are seen as part of the treatment as well as of the inquiry. Phenomena are subsequently tentatively grouped together according to constant comparison and active theoretical sampling (15), aiming at trans-personal constructs. Constant comparison is a task of separating and comparing the elements gathered during interviews according to their similarities to generate the basic theoretical property of a given group of phenomena. Theoretical sampling is the active sampling of new relevant cases as the analysis proceeds. The aim is to deepen the interviewer’s emergent understanding, and not only to generalize hypotheses. Hypothesis formulation has to be conducted prudently, avoiding enthusiastic appreciation of isolated findings, but collecting data to maintain adherence to clinical evidence, considering all divergent findings and hypotheses. Researchers have to be of preference long psychopathologically trained. Findings have to be summarized in clearly defined constructs to promote improvement of operational criteria and standardized assessment instruments.