Interpretive description in psychiatry: a research note

Defining and placing interpretive description in the clinical context

One of the goals of qualitative research is to produce an in-depth understanding of people’s experiences, perspectives and histories in their personal contexts (Lincoln and Guba, 1985; Spencer et al., 2003). The ultimate aim of the analysis may be description, explanation or theory (Ritchie et al., 2014). Thematic analysis involves identifying, interpreting and reporting patterns of meaning within the data (Braun and Clarke, 2006). There is some overlap of analytical frameworks due to the close relationship between inquiry, description and interpretation (Sandelowski, 2000). In some cases, an excellent description may suffice. However, interpretive description may advance description one step further as a meaning-making activity that clinicians can directly understand and apply (Thorne, 2008). Interpretive description lends considerable flexibility to research. In each step of the process, there is a logical progression from aligning the research question with a clinical application that extends understanding of the phenomenon.

Interpretive description originated in the discipline of nursing. It may be viewed as a pragmatic approach to qualitative research (Thorne, 2008) underpinning practical knowledge held and tested by health professionals in their everyday encounters with patients (Thorne et al., 1997). Experiential, tacit and patterned aspects of their human experience in these encounters spark research questions in the quest for new empirical knowledge. Hence, the feedback loop of interpretive description is the application of research evidence to the lives of ‘real human beings’ (Thorne, 2008: 23). Interpretive description draws on theoretical elements of the research to find solutions to clinical problems and ultimately links the research to decision-making in the context of the practitioner–patient relationship. This process frames inquiry and dialogue between theory and practice, often referred to as a dialectic, that explicitly identifies theoretical assumptions about a clinical phenomenon and influences decision-making in the research process (Thorne et al., 1997). The dialectic between research and practice became evident in my research as I both conducted and researched serious incident inquiries following mental health-related homicide. This introduced a tension between my roles as clinician and researcher in the research process, from both clinical and research perspectives.

Interpretive description, therefore, is a way to name and reference logic derived from a clinical discipline. It has been described as a conceptual manoeuvre in qualitative research that rests on three ideas: gathering up available empirical evidence from all sources; having an actual practice goal; and, engaging with data in a way that acknowledges the clinical context. The element of description itemise or document the characteristics of a phenomenon. The element of interpretation aims to explain and render understanding of description, through the subjective lens of the inquirer. Health professionals may use interpretive description to relate practice to evidence that is grounded in a clinical phenomenon (Teucher, 2011). Thus, theory can contribute to solving ‘complex and difficult human health problems’ (Thorne, 2008: 23). The complexity of clinical practice is evident in psychiatry, which values clinical acumen in formulating a case, based on a deep understanding of long-term patterns of behaviour and relationships (Selzer and Ellen, 2014). Clinicians use a process of ‘formulation’ to encapsulate their understanding of patients, to explain their illness and decide how best to treat them (Sperry, 1989). In this eclectic process, clinicians attempt to combine their experience with different paradigms – biological, cognitive, psychodynamic and biopsychosocial – to deliver useful recommendations for treatment (Weerasekera, 1996).

To analyse data using interpretive description is to comprehend the data, synthesise and reflect on meanings, theorise relationships and recontextualise data into findings (Morse, 1994). The essential element of the analytic process, illustrated in both psychiatric case formulation and interpretive description, is the inquirer. Both clinician and researcher conceptualise and structure their findings and ultimately determine what data rise to relevance, for whom and the vehicle for dissemination (Thorne et al., 2004). The dialogue in clinical work is the situated application of evidence to practice, cognisant that interpretive description requires a dialectic between theory and practice. The clinical context has specific disciplinary requirements for knowledge and clinician-researchers should expect their epistemological claims to be challenged and scrutinised. This interrogation need not induce a schism between the two positions, each of which needs to engage in dialectic about using a theoretically driven approach to develop knowledge that accommodates specific contexts. As I discovered when researching serious incident inquiries into mental health–related homicide, adopting a dual position as clinician and researcher was not straightforward. Using interpretive description was far from neat because it offset the idea of going in blind as a researcher to a health field (May, 1991). Holding dual positionality required deep reflection on working inside this field while researching from outside the health system. It required me to consider my pre-existing knowledge in entering the research arena: working through potential conflicts of interest, such as approaching research participants who were harmed by my patients and were sometimes my colleagues and carefully tread around the boundaries of clinical practice and research. Responding to these needs equipped me to engage in dialectic with participants, colleagues and supervisors about how clinical experience and wisdom interact with research and its implications for clinical practice.

While training as a forensic psychiatrist I turned my attention to researching inquiries following serious mental health incidents. As a trainee, I observed clinical staff excluded from learning from mental health inquiries into systemic care of the service user. In response I posed a question, ‘what makes a good inquiry?’ that draws on my disciplinary orientation (Ng, 2016) to align clinical knowledge and clinical practice. I analysed data collected from inquiry reports and interviews with three groups of participants: families of victims of homicide, frontline clinicians involved with the cases of homicide and members of inquiry panels reviewing the cases. As I grappled with the task of abstracting relevant themes from the individual pieces of data I was aware of being accountable to my colleagues, some of whom were participants in the study. They reminded me of the ‘earthbound concrete realities’ that Thorne et al. (1997) describe in clinical practice. For example:

Early in your career you have very high expectations of how things should be done and then after a while you realise the world isn’t quite that perfect [member of inquiry panel, psychiatrist].

The output of an interpretive description is to describe coherently and capture thematic patterns of the phenomenon of interest with a practical imperative to produce sound and usable knowledge (Thorne et al., 2004). Clinician-researchers undertake the analysis with an intent to aggregate themes while retaining contextual features of individual cases. Methods of rigour in research are variable. In the course of my analysis, I employed a psychologist-researcher as a peer reviewer and ‘expert checker’ (Liamputtong, 2013). As she reviewed the documents, transcripts, and memorandums, and discussed with me the development of salient themes, she reflected on the impact of the research on her clinical work at a community mental health clinic, where similar inquiries of serious incidents had been conducted. She found herself questioning the lack of discussion about serious incidents within her team and the absence of systems to enable her to learn from inquiries. This illustrates the additional threshold that interpretive description reaches through the ‘thoughtful clinician test’ (Thorne, 2008). My colleague acted as a ‘collateral data source’ in ‘harvesting shared and patterned experiential knowledge’ (Thorne, 2008: 84). At various forums (hospital grand rounds, psychiatry interest forums, continuing medical education sessions and conferences), I returned to the context of practice my findings to colleagues providing direct care to patients. Sharing my results left me with mixed feelings: I felt excited that the findings had impact, but also conflicted in being required to defend the sensitive nature of my research and discomfort when colleagues challenged findings from my dual positionality as ‘too academic’. In defending my use of interpretive description, I recalled Thorne’s (2008) professional imperative to ask questions that are relevant to practice, align these questions with an appropriate methodological tool and defend new knowledge that is meaningful in both the fields of practice and research.

Interpretive description from a clinician-researcher perspective

Clinician-researchers need to try to suspend judgement based on established clinical knowledge and stepping beyond their clinical role to learn about a phenomenon. Clinician-researchers enter the participant’s world to learn and not necessarily bring their expertise into shaping the conversation as it unfolds. During interviews with my research participants, I became aware of using my clinical skills to establish trust and build rapport. I began considering how to portray myself in engaging with participants. Before interviewing family members of victims of homicide about their experiences of inquiries I fully disclosed my role as a forensic psychiatrist working in the public health system, as a court report writer and as a clinician involved with the clinical care of mentally ill offenders, some of whom were linked with their deceased family member. I accepted that I was sometimes seen as a representative of the hospital. For example:

You’re the first person that’s actually acknowledged [my brother’s] death, you know, from a district hospital board level [family member of homicide victim].

Holding a dual role, primarily as a researcher but also as a clinician, led to unexpected interactions. During one research interview, a family member of a victim asked me questions about my role as a clinician. I answered these questions as myself rather than on the behalf of the organisation I worked for. For example:

This type of interaction exemplifies the potential for clinician-researchers to influence research findings. It may not be possible to study a phenomenon without some degree of risk in influencing the process. This risk reflects what and who we are, our influence on what is revealed and how we choose to construct our accounts of the study. I was mindful of constraining my influence in the research process and that participants may have identified my role as more clinician than researcher. For example:

It’s hard for me when I look at psychiatric reports presented and I don’t mean any offence [family member of homicide victim].

There was also the shaping of participant narratives in response to my clinical role. For example, I felt a need to apologise for my profession to palliate a participant’s distress:

It makes me angry. You have to be responsible for your decisions; we all are as adults. Medical professionals aren’t; it’s my experience because medical professionals hide behind [certain legislation] so everything is covered. The mental health act also means that the health board just won’t tell you anything, they just say, ‘Nah, he’s got a right to privacy’. [family member of homicide victim]

Engaging with colleagues as participants was sometimes difficult ground to navigate. In order to interview clinicians, I attempted to suspend ideas of prior understanding as some participants prefaced their comments with assumption of knowledge. For example:

The first thing I’d say, you’ve probably heard this or you’re probably aware of this. . . [member of inquiry panel, psychiatrist]

I learnt to signal that I did not necessarily have prior knowledge that participants might have expected. I learnt to control my intuition to validate responses, avoiding using non-verbal cues such as nodding or minimal verbal encouragers that might have indicated understanding. I also became aware that clinicians who participated in the research were reflecting on their experiences to process their own understanding of the phenomenon. For example:

It’s interesting each time you have a discussion your ideas evolve or crystallise a little bit more. Even talking today that’s been the case so clearly a good exercise for me. [member of inquiry panel, psychiatrist]

As an ‘insider’ working in the health system, I had collegial relationships with some participants, including direct contact with staff who granted access to the serious incident reports, were known to the research group and authorised my research at the hospital locality. This situation introduced potential conflicts, particularly around the sensitive topic of homicide. To work through these challenges, I acquired a supervisor, a private psychiatrist external to my research and academic institution as a further source of triangulation. As another ‘thoughtful clinician’ his insights increased my appreciation of patterned knowledge garnered from experience, validated the analysis and increased my confidence in returning findings to my field of practice.

Conclusion

Interpretive description is well placed as a valid methodology within health research to study contradictions that arise between knowledge and practice to answer real and meaningful questions in the field of psychiatry. It is a flexible and coherent methodological tool to formulate complex phenomena in clinical contexts and confers a distinct advantage to clinicians by delivering research findings to the clinical context for practical scrutiny and application.