1. Introduction

As quantitative research still dominates the field of clinical psychology, qualitative researchers strive hard to be taken seriously within the field. However, while actively choosing a different way of conducting research, the quantitative stance still puts its stamp on many qualitative studies. As qualitative inquiry still carries the burden of being seen as biased and little objective, many researchers put big efforts in disproving these ideas. This results in a big focus on bracketing theoretical background and personal assumptions as much as possible. However, this fear of being theoretically biased often leads, in my opinion, to rather superficial analyses. In this chapter, I will argue how making use of a theoretical framework improves rather than limits the quality of qualitative research. I will use my own research regarding the subjective experience of negative symptoms in psychosis as an example.

2. Qualitative Methods in Clinical Psychology

In contrast with many other disciplines in the social sciences and despite being given a place within the American Psychological Association (^{Gergen et al. 2015}), qualitative research is still struggling to be taken seriously within the field of clinical psychology. Indeed, the dominance of the quantitative paradigm poses difficulties for the qualitative approach to develop itself to its full potential. Two different, but highly related aspects play an important role herein: mirroring oneself on the principles of quantitative methods and unfamiliarity with qualitative epistemology. The following paragraphs give a further discussion about these aspects and their consequences.

A first struggle qualitative researchers are confronted with is that their methodology is often criticized for being biased and unscientific (^{Gergen et al., 2015}). As a result, many qualitative researchers are trying very hard to prove they are as objective as possible. However, this seems to have rather adverse effects. Indeed, one way by which they hope to show their objectivity is by strictly avoiding to bring any form of theoretical knowledge into their data-analysis. As a result, they tend to summarize their data instead of really interpreting them, leading to rather superficial enumerations of categories (instead of actual themes)¹ or a mere translation of the research or interview questions into themes (^{Timulak & Elliot, 2019}). In these cases, the added value of a qualitative study compared to, for example, a questionnaire-based study seems to lie solely in being more lively as it is illustrated by quotes. So, whereas these studies make use of qualitative methodology, they fail to live up to the full potential of it. In the meantime, they do not adhere to the stringent criteria of quantitative studies, with respect to sample size and representativeness for example, causing quantitatively oriented researcher to be-understandable-rather skeptical regarding this kind of research.

In order to tackle this skepticism, to raise the overall quality of qualitative studies and to enhance the publication possibilities for qualitative studies, the APA recently developed reporting guidelines for qualitative research (^{Levitt et al., 2018}). However, whereas important, good guidelines on how to conduct and evaluate qualitative studies alone are not enough. Above all, the field needs a shift in the overall way of looking at research. Indeed, along with a big focus on statistics in psychology education programs, a (post)positivistic stance with regard to research is passed on to students (^{Ponterotto, 2005}). Within such a framework, letting theory and interpretation enter your analyses is seen as suspicious and no good science². If we want better qualitative research, we thus not only need correct evaluation guidelines for this method, but we also need to become aware of our epistemological assumptions and their implications. Whereas several qualitative methods can be conducted from a positivist stance, most methods better fit with a post-positivist, constructivist or critical ideological epistemology-or something in between (^{Ponterotto, 2005}). Nonetheless, regardless of the position you prefer, epistemology is something to think through, to make clear when describing your methodology and something you should handle according to during the whole research process. Whereas this might seem self-evident for an experienced qualitative researcher, it is not the case for researchers trained in a quantitative paradigm where epistemology often remains implicit.

A specific consequence of our epistemological stance is how we approach our data: do we see them as the reflection of the truth-(post) positivism-or more as a possible version of the truth-constructivism (^{Ponterotto, 2005})? As many qualitative studies aim at giving a voice to participants, we could assume this entails a belief in different truths-why would giving a voice to participants otherwise be of added value? This interpretation of the reports of participants as a possible version of the truth is reflected in phrases as “participants reported, said, mentioned…,” in which it is shown that these reflect the viewpoint of the participants and not necessarily the viewpoint of the researcher or the only possible viewpoint. However, here again we see that many researchers have a rather naïve conception of what this epistemological position really entails. Indeed, giving voice to your participants’ experiences and respecting their viewpoints does not mean you have to accept everything they tell at face value (^{Charmaz, 2014}). Whereas what they tell is of course their version of the truth and thus deserves credit in its own right, a belief in multiple truths also opens up the question as to how these truths came into being. Therefore, paying attention to which elements are highlighted or omitted from a report, which are the underlying processes of how participants account for something and so on, make really interesting material to include in your analyses. However, many researchers seem afraid to take this step. Indeed, knowing your participants and knowing they can recognize themselves in what you write about them, can cause a reluctance to critically interpret their stories (^{Josselson, 2011}), which is not involved in anonymous quantitative studies.

However, this critical look at your data is what can make the difference between a mere summary of results and a meaningful analysis.

Next, despite a widespread skepticism towards qualitative research, an oppositional tendency can also be noticed within the field. Indeed, there seems to be some kind of hype around conducting qualitative research, which can be found, for example, in the mushrooming of mixed-method studies (^{Gergen et al., 2015}). However, it seems that in these cases qualitative methods are approached much in the same way as it were a new statistical analysis-technique to be implemented. As a result, we get a lot of researchers conducting qualitative studies, without having the proper training or mindset for doing so (^{Ponterotto, 2005}). Whereas they have mostly carefully read a manual about how to conduct a specific qualitative method, you can clearly see their way of thinking is still mostly inspired by the classical (i.e., quantitative) way of doing research in the field. An example of this can be found in a master’s dissertation I had to quote last year in which the student described his sample of eight persons in terms of percentages. Whereas such ‘faults’ are rather amusing, instead of really hampering the quality of the research, the unfamiliarity with this way of doing research also has important implications on the analysis process. Indeed, as ^{Smith et al. (2009}) point out, novice researchers are often too cautious when conducting qualitative studies, as such backing away from really interpreting their data, ending up with rather descriptive analyses.

Overall, we can say that many have good intentions when it comes to conducting qualitative research. However, it seems that different hurdles still need to be overcome to turn good intentions into good research. One of these hurdles, on which I will focus in the remainder of this chapter, is the fear of using theory when interpreting data or to interpret at all. Indeed, it seems that in mirroring oneself too much on the quantitative way of conducting research-be it in an attempt to be taken more seriously or because of a lack of familiarity with qualitative methods and its epistemology-the request for bracketing one’s own assumptions when conducting qualitative research (e.g. ^{Smith et al., 2009}) is taken too far. Whereas methods differ in the amount of theoretical influence they see as acceptable, even methods with a strong focus on bracketing like Interpretative Phenomenological Analysis (IPA) and Grounded Theory are not opposed to making use of a theoretical framework as long as your analysis remains faithful to the principles of the method (^{Charmaz, 2014}; ^{Smith et al., 2009}). Moreover, as ^{Timulak and Elliott (2019}) point out, what is often referred to as bracketing, might in reality imply that an interpretative framework is influencing data- analysis, without this being made specific (or the researcher being conscious about this), which might undermine the credibility of a study. Based on these concerns, I will, in the remainder of this chapter, explore the questions if and how the incorporation of a theoretical framework can enhance the quality of a qualitative study. Therefore, I will discuss how in our own recent study we at first avoided to take a theoretical stance, but later deliberately incorporated a theoretical lens and how this provided us with a deeper understanding of our data. In the following section, I will first shortly provide some background information regarding the study in question, whereafter I will discuss our research process.

3. Negative Symptoms and Qualitative Research

In my PhD-research, I study the first-person experience of negative symptoms in psychosis. Negative symptoms concern the capacities which get lost after a psychotic episode (^{Kirkpatrick et al., 2006}) and are often compared to a zombie-like state. DSM-5 (^{APA, 2013}) discerns five negative symptoms: diminished emotional expression, avolition, alogia, anhedonia and asociality. These are typically divided in two categories: primary negative symptoms, which are seen as the direct result of the illness, and secondary negative symptoms, which can be attributed to other factors, like for example medication side- effects, post-psychotic depression, stigma etc. (^{Kirschner et al., 2017}). Negative symptoms are in the mainstream literature typically approached in terms of a loss (^{Kirkpatrick et al., 2006}). However, phenomenological studies (e.g., ^{Sass, 2003}) and reports based on personal experiences (e.g., ^{Longden 2012}) contradict this assumption, pointing out that so- called negative symptoms are rather characterized by a shift in the normal way of being-in-the-world. Qualitative methods can play an important role in shedding light on this discrepancy and in getting better insight in the subjective experience of these symptoms.

While qualitative studies are a minority in clinical psychology research, qualitative studies regarding psychosis are more or less ‘rare birds’ (^{Leader, 2011}). Indeed, as people who experience(d) psychosis are considered lacking insight in their experiences, their stories are often considered as being of little relevance (^{Roe & Davidson, 2005})-so far for bracketing theoretical assumptions, right? When it comes to negative symptoms, qualitative studies are almost completely missing, with only twelve studies being published up until 2018, the majority of these only highlighting one of the negative symptoms instead of the whole syndrome (see our review study: ^{Moernaut & Vanheule, 2020}). As the qualitative understanding of subjective experiences of negative symptoms can be considered a rather unexplored domain, my research aims at filling this gap by interviewing people with psychosis about their personal experiences with regard to negative symptoms.

4. Methodology

The following parts of the chapter are based on my own recent work regarding the experience of negative symptoms. I will focus here on how we conducted the data-analysis, further details on the study can be found in ^{Moernaut et al. (2021}). For this study, I interviewed fourteen participants³, who were being treated in a Belgian hospital for psychosis, about their experiences of negative symptoms. The interviews had a semi- structured nature and were analyzed based on Interpretative Phenomenological Analysis- guidelines (IPA; ^{Smith et al., 2009}). Our research team consisted of five persons, with all of us having a theoretical background in psychoanalysis (four Lacanian, one psychodynamic) and three of us also being substantially acquainted with phenomenological literature. Apart from that, I, myself, have considerable knowledge regarding the common theories on negative symptoms. Our epistemological position can be situated on the rather constructivist side, as we see people as meaning-making agents. Three of us participated in the whole data-analysis process, the other two functioned rather as auditors. The final data-analysis was conducted primary by me, but in close discussion with the other members of the research team. According to IPA-guidelines, we started with making case-by-case conceptualizations. In this part of the research, we tried to bracket our theoretical assumptions as much as possible: whereas we discussed elements that drew our attention from a theoretical point of view during our data-sessions; we formulated our case conceptualizations as much as possible in the words of the participants. When passing to the stage of bringing the cases together in an overall analysis, we also brought in some theoretical insights which fostered our understanding and helped us to come to a more in-depth analysis. Details on this process are discussed below.

5. To Theorize or not to Theorize

Already rather soon during the research process, when we were still collecting data and had not started the analysis yet, we noticed how many of our participants, especially at the start of the interviews, actively denied to have experienced primary negative symptoms. Whereas they all knew what I meant by negative symptoms, they ascribed those to other patients they knew, who they described as “wandering ghosts.” However, they could not align such an image with the ideas they hold about themselves. Nonetheless, later on in the interviews, it became explicitly or implicitly clear that most participants did in fact (had) experience(d) negative symptoms. These negative symptoms seemed to be experienced as the sword of Damocles which should be avoided by any means, including when talking about their experiences. As such, we noticed that most participants only reported negative symptom experiences when they were not explicitly called that way. Most participants also talked mainly about what they saw as the causes for their feelings of emptiness and passivity, instead of about the experiences themselves. This observation intrigued us and, approached from our theoretical ideas on the matter, also made a lot of sense. Indeed, in Lacanian psychoanalytical terms, negative symptoms can be understood as the result of a confrontation with perplexing experiences, which cannot be accounted for by means of language. (^{Vanheule, 2018}). Due to this linguistic impossibility, people might feel disconnected from their own experiences and the world, which in turn might lead to disinterest and passivity. In this perspective, it is not surprising that most persons do not succeed well in describing their negative symptoms. The whole interview context can even be seen as a re-realization of the difficulty people are confronted with when experiencing negative symptoms. However, as we tried to keep our theoretical preconceptions out of our data-analysis, these ideas did not really reverberate in our first attempt to come to an overall conceptualization, except for a theme called “negative symptoms as the sword of Damocles.”

As the so-called secondary negative symptoms (for example, feeling empty and very tired due to medication) were most discussed by our participants, these tended to take a central place in our final analysis. However, a too big focus on these secondary elements felt as a too superficial finding of our research. Moreover, it would be of little added value to the field, as simply rehearsing the typical primary-secondary negative symptom distinction⁴. Despite feeling there was something amiss in such an approach-our analysis felt at that stage rather as a categorization instead of a real analysis-the prominence of all these different causes for negative symptoms made it hard to get our focus away from them. While pondering about this, I returned to one of the discussions we had over one of the interviews⁵, in which one of my coworkers had made a comment, which relevance only struck me in retrospect: “it seems like this person is the only one who is really telling the story of his negative symptoms, while the others are rather telling their recovery story.” Whilst we had been discussing how our participants presented themselves during the interviews before, we were not sure how to incorporate this in our analysis. However, my colleague’s reference to the concept of the story made everything fall into place. Indeed, interpreting our data in terms of narratives made it possible to make the bridge between our rather abstract theoretical concepts and the concrete data. Inspired by the psychoanalytical idea of negative symptoms as the failure of language, we could reconceptualize negative symptoms as the moment the story comes to a halt which was of course present in the avoidance of many participants to talk about the pure experience of their negative symptoms, but was even quite literally stated by our participants when they described they had no words for their experiences. This led eventually to the main theme “When the narrative fails,” which handles about the experiences of negative symptoms themselves and addresses how people felt disconnected from existing narratives, how they lacked the words for their experiences, how their usual narratives to understand the world seemed to make no longer sense and so on. In the meantime, participants did tell us a lot during the interviews, hereby, as mentioned before, focusing especially on what they thought caused their negative symptoms. Here again, our psychoanalytical theory helped us to make sense of this. Indeed, whereas most of our participants were able to tell us a rather coherent story about their experiences, they were only able to do so in retrospect, i.e., when they were no longer experiencing negative symptoms. So, whereas their grip of their experiences by means of language was lost when they were experiencing these symptoms, they could construct a narrative about these on a later moment (i.e., during the interview). This point was further highlighted by the rather chaotic discourse of the participants who were still suffering from negative symptoms at the moment of the interview. As such, our second main theme described the way people tried to make sense of their negative symptoms, by focusing on causes, but also by relying on metaphors, philosophical ideas and delusions and was designated as the construction of a meta- narrative regarding negative symptoms (For a further discussion of these themes see ^{Moernaut et al. (2021})). Approaching our data in terms of narratives was an enormous help to bring the depth we were missing before into the analysis. On the one hand, it helped us to finetune our descriptions of the primary negative symptoms, which were in an earlier version of the analysis assigned to a rather undifferentiated category of “estrangement.” On the other hand, it still gave us the opportunity to do right to all the different causes for negative symptoms discussed by our participants, without giving these a too dominant role in the final write-up. An illustration of how some of the original themes developed in the more theoretical inspired themes through the lens of a narrative-conceptualization can be found in Figure 1.

Figure 1: Visualization of the Analysis Process 

Despite my enthusiasm when I first started to approach the data in the light of narrativity, I also doubted whether I was not imposing too much on the data, whether all elements could be grasped along this way, whether it was not a too theoretical interpretation and so on. In other words, I was afraid whether what I was doing was actually allowed within the framework of an IPA-study. However, the idea did not let go of me. Three important elements helped me to let go of these doubts. Most importantly of course was the enthusiasm of my co-authors who affirmed that this conceptualization matched our data. In the meantime, discussing this with them also helped to be critical of this interpretation and to bring the necessary nuances. Especially the more phenomenological approach from one of my co-authors was of major help herein. Next, I remembered a remark I made myself in my first publication about how the use of a theoretical framework helps to come to a deeper understanding of the data (^{Moernaut et al., 2018}). Some advice I also always give to my own students and apparently now had to give to myself. At last, there was also my own frustration regarding many qualitative papers I read, but which did not feel as an added value to my understanding of psychosis due to their shallow analyses. Therefore, I was strongly motivated to do a better job myself. However, my first attempt for an overarching conceptualization (which was not yet inspired by theory) was not really succeeding in this attempt, as it rather felt like a categorization of the data, without being a real analysis. The conceptualization based on narratives, however, did. So, despite needing to overcome a certain initial reluctance to let theory enter our analysis, I could not deny how this approach served as a major improvement to the depth of our analyses.

6. An Alternative Way of Bringing Theory in Qualitative Research

In our study, we made use of an existing theoretical framework to come to an-in-depth understanding of our data. However, there is also the possibility of going a step further. Indeed, qualitative research might also inspire theory building or the adaptation of existing theories. Qualitative research has the benefit of not averaging out atypical cases and as such has the opportunity to expose elements which tend to be overlooked in statistical hypothesis testing studies (^{Stiles, 2007}). This unique view might thus lead to new insights within the field. The most common approach to theory building in qualitative research is of course Grounded Theory-albeit that many Grounded Theory studies do not go as far as to build theory (^{Charmaz, 2014}). However, other approaches to come to theory based on qualitative research are also possible, see for example Stiles (2007).

7. Conclusions

In this chapter, I discussed how qualitative studies in psychology suffer from a fear to really interpret their data and proposed the incorporation of a theoretical framework as a possible way to overcome this issue. I illustrated this by means of our own study regarding the experience of negative symptoms. At first we tried to stay as close as possible to the data and as such backed away from incorporating our theoretical understanding of the phenomenon in our analysis. This way we wanted to avoid imposing anything on our data. However, in doing so, we felt frustrated as our analysis rather remained a categorization and was not able to reflect the richness of our data.

While we did not have the deliberate intention of using a theoretical framework to guide our analyses when starting our study, a rather casual remark about the story participants told, made the link with our psychoanalytic background suddenly very obvious. As our participants seemed to avoid to talk directly about their negative symptoms, but rather circled around them, this fitted very well with the psychoanalytic idea of negative symptoms as a failure of language, as a hole in the so-called Symbolic register (i.e., the domain of language which helps us to structure and make sense of our world and mental life; ^{Vanheule, 2011}). Whereas we had avoided this theoretical interpretation in an earlier phase, as it felt as a too big leap from our data, the notion of failure and construction of narratives helped us to make the bridge between our theoretical knowledge and the actual data. Thanks to this approach, we could both account for the big focus participants put themselves on the causes of their negative symptoms-given the theoretically assumed difficulty to bring the experiences themselves into words, this focus seemed rather logical- as for the underlying processes. Indeed, this conceptualization gave us the opportunity to make a theme of something which was actually largely lacking, namely the true discussion of negative symptoms in the majority of interviews. So, by making use of a theoretical framework-in our case Lacanian psychoanalysis-we moved from an analysis which was rather a categorization and just mimicked the typical primary-secondary negative symptom division, to an in-depth analysis, which went farther than what was literally said by our participants.

To avoid misunderstandings, I would like to remark that Lacanian psychoanalytic theory does not hold specific assumptions regarding negative symptoms. In the meantime, it did provide us with a framework to understand psychosis and how language functions and might fall short in psychosis. So, our theoretical framework rather served as a lens through which to look at our data instead of imposing specific assumptions on them. In conclusion, whereas I promote the use of a theoretical framework as a lens to look at data, I would also like to warn for too specific theoretical assumptions as these might cause you to overlook those elements which are not in line with your assumptions. Therefore, a theoretical framework preferably offers you a way to look at the world, without holding too specific ideas about the topic under research-if you do hold specific assumptions you might question whether qualitative methods are the best approach.

Next, it is always interesting to have someone in your research team with a different theoretical background to prevent you from being blind for the elements which do not match your theoretical assumptions. Whereas all members of our team were trained in psychoanalysis, especially one of my co-authors is in the meantime really critical regarding psychoanalysis and tends to interpret things rather from a phenomenological background. His questioning of our ideas from a phenomenological point of view, helped us to further finetune them and prevented us from jumping to conclusions. Overall, dare to interpret when conducting qualitative research. Listen to your participants, but go further than what they literally say: what are the things they do not say? How do they say things? In short, listen between the lines.