Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
Qualitative Research as a Methodological Framework
Through its strong focus on a casuistic study of the subjective logic in a patient’s functioning this kind of diagnosis is by itself a vulnerable method: vulnerable, that is, to becoming too strongly influenced by the style of a diagnostician, and by errors of thinking or preconceptions in her functioning. That is why we link our plea for function-oriented diagnosis by means of case formulation to the need to also systematize clearly this form of clinical diagnosis. Good function-oriented case formulation entails a method for quality monitoring that helps diagnosticians to optimize the validity and reliability of their decision-making.
To articulate principles for quality control, literature about the methodology of qualitative research is most useful. Obviously, clinical case formulation cannot just be considered as a form of qualitative research. Clinical casuistry aims at formulating a good and usable characterization of problems and strengths in someone’s functioning, and is often constructed while working with an individual: through clinical meetings (discussions, observations, testing) material is collected, and while doing so ideas are constructed concerning the organization of someone’s (dys)functioning. The time spent in building a case formulation is usually considerably less than the time spent on the actual clinical contact. Qualitative research on the other hand often has a more generalizing focus and aims at building controlled knowledge that carries much further than the personal situation of the participants. In order to achieve this type of knowledge one works with time-intensive forms of data analysis, which usually take much more time than the data collection.
Furthermore, in the context of psychiatric diagnosis questions and knowledge have another status. Typically, qualitative research starts with a question of the researcher: something in the outside world intrigues her and starting from this question she aims to build an explanation. The researcher hopes to construct knowledge to help others understand how an aspect of reality is organized. An example of such a qualitative study is found in the work of Nicole Highet and colleagues (2014). In collaboration with colleagues she examined how post-natal depression and post-natal anxiety are embedded into the world of women who are struggling with such experiences. On the basis of 28 interviews she discerns that experiences of loss and frustration appear to be at the basis of these forms of anxiety and depression. Herewith she points to the role of pregnancy-related changes (such as the change of one’s body shape) and disappointments that go hand in hand with pregnancy and maternity (such as complications with childbirth or conflicts around parenting with the partner). Such studies construct knowledge that is to be generalized beyond the specific situation of the women from the research sample. The researchers try to formulate insights that sharpen our general understanding about a specific aspect of psychological functioning. In clinical diagnostic situations, by contrast, the person who consults the psy-profes- sional asks the question. The patient suffers from how she functions and at that point would like help from a professional, with the hope that eventually the disturbing component will be resolved. The knowledge that the diagnostician builds aims at clarifying the problem and the experience, such that relevant interventions may be organized. The knowledge of the diagnostician does not involve the construction of generalizable knowledge. It is a practically oriented form of knowing that aims to clarify the structure or dynamic of one’s actions. For example, suppose that a young woman consults because of lethargy after the birth of a second child. General knowledge of post-natal mood problems, as found in the study of Highet et al. (2014), may be useful in this context as a background, but it is not enough to know what is going on. Only by learning in great detail about the mental and relational world of the woman in question can we see how the problem is embedded in her life and in her speech. The knowledge that a diagnostician constructs along this way has a strong singular component that is usually filtered out in scientific research: specificities that apply to this one individual stand to the fore.
What the work with clinical case formulations and qualitative research clearly have in common is a focus on language and speaking on the one hand, and an explicit emphasis on constructing well-reasoned assumptions about someone’s functioning on the other hand. Methodological guidelines concerning qualitative research can never simply be imposed on clinical diagnostic work, but can help to improve the quality of work with case formulations. It is in this way that I propose using them. Since case formulation primarily focuses on the nature and underlying structure of someone’s experience, we can place it in the field of the qualitative inquiry.
In the heyday of positivistic approaches in psychology (during the second half of the twentieth century) qualitative research was marginalized. Starting from the idea that only numerical data could form the basis of science, the value of narratives and non-quantitative observation data was disregarded for a long time.
However, qualitative research has a long history and had a place in psychology from the beginning. For example, Wilhelm Wundt (1897), one of the founders of experimental psychology, claimed that we must distinguish two research approaches. On the one hand Wundt distinguishes experimental psychology, which deals with the study of specific psychological functions, such as perception, memory, or cognition, and starts from laboratory studies following the model of the natural sciences. Within this paradigm the human psyche is seen as an object that one tries to access with exact measuring instruments. The subjective experience of the individual is ignored in such an approach. On the other hand, Wundt also discerns a branch of research that focuses on the study of so-called higher mental processes, such as the way in which a person interprets and experiences the world. Wundt indicates that such an approach to mental processes should make up the actual focus of psychology, and starts from interpretative research strategies that tally with what we now call qualitative methods.
For a long time, the systematic study of subjective experience was barely part of psychological research. Many years empirical and rationalist approaches dominated the question of how humans function, and as a result there was little room for the question of how subjective experience is organized (Bruner 1990, 1991; Lacan 1959; Merleau-Ponty 1945). For years psychologists mainly thought mechanically about the human experience, as if humans were a complex machine or a computer in which the hardware and the software could be studied in detail. Whereas in the eighteenth century the French philosopher Julien Offray de la Mettrie (1747) was ostracized because in his essay “L’homme machine” he dared to say that the human mind as well as the human body functions according to mechanistic natural laws, in the twentieth century it suddenly appeared pseudoscientific not to look at the human being as an ingenious machine. Qualitative research, as we know it now, was shaped out of a dissatisfaction with such mechanistic thinking and focuses on the study of subjectivity in particular (Madill and Gough 2008). Conversely, for a long time many academics and practitioners from the clinical field plainly neglected the question of the scientificity of their work. Wundt’s suggestion to develop appropriate methods for the systematic study of subjectivity remained unheard and did not reach the clinic. Scientific evaluation was only too happily left to the discretion of the laboratory psychologist working at a safe distance. Yet in the past decades attitudes have changed. In the nerve center of psychology, space for qualitative approaches was made, which aimed to study subjectivity following stringent methodological guidelines.
Jerome Bruner was one of the leading figures that very clearly made a plea for qualitative approaches in psychology. Bruner was partly at the origin of the so-called cognitive revolution. Out of dissatisfaction with the black-box approach of the behaviorist movement, which did not want to be involved with the study of internal psychological processes, he appealed to colleagues for an approach to human beings as generators of meaning. However, fairly early on he observed that within the cognitive movement all attention was being given to the way people process information, while the question as to how they make sense of themselves and the world disappeared into the background. Going against this tendency, Bruner (1990, 1991) argued that human beings should be considered as cultural creatures that produce narrative truths. Through language, humans structure the world:
We organize our experience and our memory of human happenings mainly in the form of narrative—stories, excuses, myths, reasons for doing and not doing, and so on. Narrative is a conventional form, transmitted culturally and constrained by each individual’s level of mastery and by his conglomerate of prosthetic devices, colleagues, and mentors. Unlike the constructions generated by logical and scientific procedures that can be weeded out by falsification, narrative constructions can only achieve “verisimilitude.”
Narratives, then, are a version of reality whose acceptability is governed by convention and “narrative necessity” rather than by empirical verification and logical requiredness. (Bruner 1991, p. 4)
The research that Bruner initiated was not clinically oriented, but his narrative approach connects closely with the work of the diagnostician who builds on case formulation. Indeed, the diagnostician also works with stories. These stories are not only listened to but also explored and synthesized, with the aim of grasping how the patient’s account is organized and embedded in broader contexts.
According to Bruner (1990), the psychological study of stories should bring the perspective of the narrator to the fore. Stories never speak for themselves, and always entail a major interpretation component that we have to take into account. To get hold of what a narrative means, Bruner (1991) examines the background from which the narrator speaks.
Applied to case formulation this implies that complaints and problems always need to be studied from the perspective of the person articulating them. Rather than generalize, neutralize, or anonymize complaints by means of diagnostic jargon, a narratively oriented qualitative approach requires us to clearly bring into account their person-specific status and to see how they are socially and culturally embedded (Parker 2005).
One point that stands out in both Bruner’s and Wundt’s work, and around which qualitative researchers unite more generally, is that the subjectivity of the participant should be central: “The heart of qualitative inquiry is its epistemological stance: its commitment to interrogating subjectivity, intentional action, and experiences embedded in real-life contexts” (Marecek 2003, p. 55). Qualitative psychologists do not want to make universal claims about the way phenomena are organized, but map the diversity and complexity of the human experience: “they are not searching for fundamentals of psychic life that exist apart from social context and they do not seek to make universalized claims about psychic life. Instead they set their sights on the ways in which human action and social identities are locally constituted and contingent on their time and place” (Marecek 2003, pp. 56-57). Furthermore, qualitative researchers consider language as the best way to get in touch with human subjectivity. Rather than rely on a variety of measurement instruments, qualitative researchers study the psychological reality of human beings through natural language use (Polkinghorne 1990). It is precisely by paying attention to subjective experience, diversity, and language use that there is a strong similarity between the focus of the qualitative researcher and that of the diagnostician who works with case formulations.
However, the points of commonality between various qualitative researchers have not given rise to the development of a generally accepted qualitative method, but to a variety of approaches that operate next to each other. Several methods of qualitative inquiry co-exist and often also have different aims (Madill and Gough 2008). For example, a phenomenological researcher who wants to gain insight into the nature and meaning of mental experiences has a very different approach compared to a scholar who (via discourse analysis) aims to grasp how language use reproduces power relationships. This methodological multiplicity offers a variety of perspectives for researchers, but does not foreground one single method of analyzing interview and observation data.
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