Alternative approaches to research in physical therapy: positivism and phenomenology.

To capture the variety of dimensions that embody the essence of physical therapy practice, we believe that multiple approaches to research are required. The selection of which research approach to use to study one or more facets of physical therapy practice depends on what the research question is and from which philosophical perspective one chooses to study that question. In our view, there are basically two different philosophical perspectives or paradigms that guide research. These alternative philosophical perspectives are based on different assumptions about the world and how science should be conducted.[1] The purposes of this article are to present these two different philosophical perspectives (ie, positivism and phenomenology), to discuss how these philosophical perspectives result in the choice and use of very different approaches to research, and to give examples of how different and mutually enriching knowledge evolves from research that stems from the use of alternative philosophical perspectives.

Searching for Knowledge:

The Research Question

Research begins with questions. Research questions come from our personal clinical experiences; from questions posed in professional publications; and from commonly accepted, but often conflicting, notions and theories about the nature of health and human movement.

When first formulated, research questions tend to be broad in scope, representing a general area of inquiry about some phenomenon or caused-and-effect relationship. As researchers contemplate their questions, the questions become increasingly better defined, and the researchers become clearer about the type of information they need to gather to answer the questions.

A variety of sources of information are used to answer clinical questions.[2,3] Historically, many of our questions have been answered through inherited customs or tradition. We were taught to do lumbar traction with a patient for 20 minutes. Why 20 minutes and not 40 minutes? Another frequent source of information for our questions is authority. We do procedure "X" because that is the way it was presented at our most recent continuing education course. Yet another source of information grounded in our own experience is trial and error. We have tried techniques in the past with certain types of patients and found that technique "X" worked best.

Working out the solution to a clinical question may lead one through a systematic reasoning or logical thought pattern that is either deductive or inductive. For example, working with several individual patients who have adhesive capsulitis and respond well to a treatment that combines mobilization and exercise may lead a therapist to generalize that this treatment approach may work effectively for other patients with this diagnosis. This is an example of inductive thinking, in which one reasons from specific incidences to a general conclusion or a general principle.

Alternatively, an example of deductive thinking is application of a general principle to a specific case. For example, new knowledge about the concept of stretch weakness leads a therapist to apply the concept to patients with muscle imbalance problems. Physical therapists accrue their personal clinical knowledge base using both inductive and deductive reasoning. Physical therapists who want to go beyond the evidence of their personal clinical experience may set out to "prove" their clinical findings by applying a testing framework they have been taught is the scientific method.

When we think of the scientific method, there are several "gold standards" or critical characteristics that come to mind. These include characteristics such as (1) order and control (isolate potential bias and confounding factors by procedures such as random sampling and random assignment); (2) empiricism (evidence is found in objective reality, not the personal beliefs of the researcher); (3) reality is objective and exists independently of human observation; and (4) phenomena have precipitating causes, and research is often focused on determining this cause-and-effect relationship.[2,3] We believe these characteristics are all grounded in assumptions that are part of the underlying philosophy of one approach to research, which is known as positivism.[4]

Philosophical Perspectives

The origins of positivism indirectly stem from the work of Thomas Hobbes, a contemporary of Galileo. Hobbes argued that phenomena are observable facts or events and that everything occurring in nature can be predicted according to reproducible scientific laws. Later, Auguste Comte, the French philosopher, developed Comtean-type positivism, in which he applied the scientific method to human affairs. He argued for a focus on observable phenomena that are to be determined objectively, that is, studied separately and distinctly from the internal reality of the researcher.[4,5]

Today, the philosophical orientation of positivism is associated with empiricism. Polit and Hungler define positivism as

... the process whereby evidence

rooted in objective reality and gathered

directly or indirectly through the human

senses is used as a basis for generating

knowledge.[2] (p18)

Examples of empirical evidence are data such as heart rate, leg-length discrepancy, and stride length. If a researcher holds a philosophical perspective that is positivistic, he or she aims to discover a single, objective reality. This reality often can be answered by posing and testing one or more testable hypotheses that reflect anticipated answers to questions about cause-and-effect relationships. The researcher and the components of the problem under investigation are perceived as independent and separate. The activity of investigating is perceived not to influence what the researcher is investigating; that is, one is considered to be "objective."[2,3] This positivistic approach to research has been used extensively in the natural sciences and is used today as the predominant paradigm in biomedical research. Although many present-day philosophers have abandoned positivism and argue that we are in a postpositivist era, the positivistic perspective remains the dominant paradigm for the researcher today.[6-9]

For 19th-century researchers interested in studying human behavior, the use of research approaches guided and constrained by the laws of positivism caused considerable frustration. out of this frustration, a second philosophical orientation to research, phenomenology, arose in the mid-1800s in Germany. The phenomenologist is one who tries to understand social phenomena or human activity from the viewpoint of the person being studied. Later, the term hermeneutics was used to further define this perspective. The term "hermeneutics" was derived from the name of the Greek god Hermes, whose job was to interpret.[4,5,10] Thus, phenomenology represents an orientation to human phenomena based on observable experiences of how things appear from the perspective of the humans under study.

The assumptions underlying phenomenology are quite different from the assumptions of the positivist. Phenomenologists believe that individuals need to be understood in their entirety within a situational context, not separated from the environments in which they function. The human experience, therefore, needs to be studied as it occurs. Reality is believed to be socially constructed by the individual, and thus multiple realities exist, not a finite number of objective truths.[8] In defining multiple realities, Merriam suggests

The world is not an objective thing out

there but a function of personal interaction

and perception. It is a highly

subjective phenomenon in need of

interpreting rather than measuring.

Beliefs rather than facts form the basis

of perception.[11] (p17)

In attempting to study phenomena that include multiple realities, the investigator is often directly involved in both data gathering and interpretation. Although in the positivist tradition verification or testing of hypotheses is often done deductively, the phenomenologist is frequently more concerned with using inductive processes in generating a better understanding of the unknown phenomena.[8,12]

Some researchers in the behavioral science area believe there is a strong association between the philosophical perspective or paradigm and the research design and method type.[6-9,13] Other researchers hold a more instrumental or pragmatic view of research methods and argue that research methods are not as tightly linked to the philosophical perspective.[14] Although we agree that some research methods are widely used in all forms of research (eg, the collection of demographic data to describe the sample), we believe that the philosophic perspective that one holds strongly influences the choice of one research design over another.

Thus, in this article, we present our perspective on how different philosophical perspectives guide the choice and use of different research designs. The Figure provides a schematic comparison of differences among research designs, methods, and data characteristics that result from research questions emanating from the alternative vantage points of phenomenology and positivism. The reader will note that not all research designs fall neatly into one perspective or another. Depending on the focus and comprehensiveness, clinical case studies, historical studies, and some descriptive studies contain methodological elements that could be considered under either paradigm.

One related issue that we, as authors, have grappled with repeatedly is whether the predominant philosophical perspective held by the researcher guides the choice of the research question or whether the research question dictates the most useful philosophical perspective from which to answer the question. We believe that both instances occur. If the researcher thinks about the world in terms of complex human behaviors and multiple realities, he or she is more likely to ask questions that encompass the study of these multiple dimensions. Alternatively, if the researcher is interested in studying the organic or biomechanical properties of behavior, he or she is more likely to ask a very specific question that focuses on identifying the existence and usefulness of singular physical attributes.

If a researcher is familiar with both philosophical perspectives, a research question could be asked from either vantage point, and the researcher could subsequently study either the specific relationship among two or more variables under highly controlled conditions or the relationships among any number of unknown variables that may exist in a situation that the researcher hopes to understand. We argue that a more profound understanding of a phenomenon comes from the examination of that phenomenon both from the use of different research designs within a single philosophical perspective and from the use of designs typical of alternative philosophical perspectives.

One example of the increase in understanding engendered by the use of alternative perspectives is the study of functional movement patterns (eg, coming from a lying to a sitting position or from a sitting to a standing position). VanSant[5] has engaged in one type of study from the positivist perspective; that is, subjects are asked to perform the functional movement, and researchers carefully describe what movements are occurring in the upper extremities, lower extremities, and axial region. This approach to studying functional movements across age groups has brought us to the new realization that movement patterns are not "developed" at an early age but are developing across the life span. Schenkman and associates[16] have examined movement patterns from the vantage point of another type of positivistic design. Subjects are asked to perform the functional task under highly controlled conditions, and data are gathered on maximum joint angles, torques, and velocities. This information increases our understanding of the normal kinetics and kinematics of functional tasks. Information from both types of descriptive (positivistic) research provide us with useful and complementary frameworks for analyzing functional tasks of patients who have lost motor function.

The researcher could also study these movement patterns from a phenomenological perspective. That is, the researcher could describe functional tasks within a home or work setting. In addition to information on movement patterns used in a variety of activities, data would be gathered on, for example, the perceptions of subjects as well as family members or co-workers about the physical, psychological, social, and environmental precursors to the subjects' movement patterns. These data would be used to explain or interpret why the subjects used different movement patterns under different conditions.

We believe that physical therapy researchers should gain an understanding of designs within and between perspectives so they could have the flexibility to state a research question and choose a corresponding design that is most responsive to the problem they want to study. As research designs that fall under the phenomenological perspective may be less well known to physical therapists, we have included an annotated bibliography that may be helpful to the reader interested in more information (Appendix).

Research Purpose

The purpose of research will be different depending on the philosophical perspective from which the researcher asks the question. If the researcher comes from a positivistic tradition, he or she will set out to test or verify a cause-and-effect relationship or to describe or show an association between two or more preidentified variables. The physical therapy literature is replete with examples of research from the positivistic perspective (eg, "Exercise-Induced Muscle Soreness After Concentric and Eccentric Isokinetic Contractions[17] and "Stereotyping Between Physical Therapy Students and Occupational Therapy Students"[18]). For these types of studies, the researchers assume that the knowledge that is sought is an objective reality that can be identified, quantified, and reported as a verifiable fact. Table 1 presents the specific purposes of these positivistic studies, which are identified as A (reference 17) and B (reference 18).

Table 1. Research Purpose Related to Positivistic and
Phenomenological Paradigms
Positivism                        Phenomenology
A. "In the first experiment,      C. "The purposes of this
we wanted to                      investigation were
determine whether there           (1) to develop and test an
was a                             observational
contraction-type - dependent      instrument that could be
difference in                     used to
the amount of                     systematically observe
exercise-induced muscle           physical
soreness in subjects who          therapist-patient
exercised at                      interactions and (2) to
equal levels of power."           develop an initial conceptual
                                  framework that
                                  could be used to guide
"We therefore hypothesized        further studies of
that there                        the work of physician therapy
would be no difference in         clinicians."[19] (p315)
the magnitude
of quadriceps femoris muscle
soreness
after exercise in subjects        D. "The purposes of this
who performed                     study were (1) to
concentric and eccentric          investigate the values and
isokinetic                        experiences of a
contractions at equal power       small sample of female
levels."[17] (p506)               physical therapists
                                  in the course of their
B. "The purpose of this study     professional
was to                            development, as they relate to
examine stereotypes at the        key elements
college levele                    of the gender and
in the junior classes of          professional issues
OT [occupational]                 identified in the literature,
therapy] and PT                   and (2) to develop
[physical therapy]                an initial conceptual
students at the University of     framework, based on
Illinois at                       the literature and the data
Chicago (UIC)."                   obtained in this
                                  study, that can be used for
"We hypothesized (1) that         posing
junior PT                         questions about the
students would score more         traditional view of
positively on                     professionalism and for
the HTSS [Health Team             guiding future
Stereotyping Scale]               investigations."[20]
than junior OT students           (pp531-532)
when describing PTs and (2)
that junior OT
students would score more
positively on
the HTSS than junior PT
students when describing
OTs."[18] (p17)

If the researcher holds a phenomenological perspective, the research purpose is directed toward describing, explaining, or interpreting human behavior from the perspective of the persons being studied.[7-9] As each persons, including the researcher, perceives and interprets reality somewhat differently based on the context of his or her past experiences and present situation, the phenomenological approach focuses on multiple realities, looking for common themes or denominators that will help explain the human phenomenon under study.[5,8] Few physical therapy researchers pursue research questions from the phenomenological perspective. Two reports of such studies are "The Novice Versus the Experienced Clinician: Insight into the Work of the Physical Therapist"[19] and "Perspectives on Gender and Professional Issues Among Female Physical Therapists."[20] Table 1 shows the purposes of these phenomenological studies, which are identified as C (reference 19) and D (reference 20).

Research Design

The selection of the research design follows naturally from the philosophical perspective and the stated purpose of the study. With positivistic traditions, the choice of design is likely to be experimental, quasi-experimental, or descriptive. These designs are often built around a priori hypotheses that can be confirmed or rejected. Data are usually numerical (quantitative) or categorical, and data analysis is directed toward testing, verifying, or predicting specific identifiable human behaviors or physical phenomena.

Research designs emanating from phenomenological traditions include qualitative case studies, ethnographies, and grounded theory research.[11,12] These research designs do not begin with the identification of specific variables or a priori hypotheses. The intent is to gather a wide variety of data that can describe, explain, or interpret the human behaviors or physical phenomena under study. The data collected are predominantly qualitative (words). From the vast amounts of data compiled, the researcher attempts to extract themes and concepts that suggest confirmation, revision of the conceptual framework,[21] or creation of grounded theory.[22] Table 2 gives examples of the different research designs used by Fitzgerald et al[17] and Streed and Stoecker[18] (positivistic) as compared with the designs used by Jensen et al[19] and Raz et al[20] (phenomenological).

Table 2. Research Designs Related to Positivistic and
PHenomenological Paradigms
Positivism            Phenomenology
A. Experimental[17]   C. Qualitative case study[19]
B. Descriptive[18]    D. Qualitative case study[20]

Research Methods

Many common data-collection techniques are used by researchers, regardless of philosophical orientation. For example, using survey instruments, making detailed observations, and extracting data from medical or other types of written or pictorial records are data-collection methods used in a variety of research designs.

The researcher adopting a positivist research design will use methods that fit the operational rules of the design. Thus, the positivistic researcher may gather data for experiments from controlled interventions or from descriptive methods that utilize survey instruments. These research methods remain constant throughout the course of data gathering.[2,3]

Conversely, the researcher adopting a phenomenological perspective initially identifies methods for data gathering that will yield an extensive "thick" description of the phenomenon under study. Merriam[11] notes that "thick description" is a term used by anthropologists to refer to a comprehensive literal description of the phenomenon being studied. These methods include observation of behaviors in natural settings, interviews with key informants, and review of materials such as logs and diaries. As the research unfolds, however, the researcher may find that in order to gain a better understanding of the phenomenon being studied, additional data-collection techniques must be applied. Under the precepts of phenomenology, the researcher is free to engage in any supplementary data-gathering methods that will yield additional illuminating information.[6,11,22]

In the examples of research from the positivistic tradition,[17,18] the variation among subjects will be controlled by establishing clearly defined criteria for subject inclusion or exclusion in the study. If an experimental design is used, subjects will often be randomly assigned to specific test groups. The environment will be controlled or manipulated to minimize any unwarranted variation within the environment that may influence, in an unpredictable manner, the behavior of the subjects under study. Behaviors of subjects to be observed as well as researcher behavior during subject-researcher interaction are prescribed in detail prior to the actual data collection. Instrumentation may include mechanical apparatuses, scales, or standardized questionnaires (Tab. 3).

Table 3. Research methods Related to Positivistic and Phenomenological Paradigms
Positivism                                     Phenomenology
A. "The instrumentation was     C. "We collected
the same in                     data through nonparticipant
both experiments.               observation, recording
A Kin-Com[R]                    of field notes, and
dynamometer(a) was used to      audiotaping of each
measure the                     treatment session. Two
power produced during           researchers simultaneously
contractions and                collected data on
to provide resistance during    each patient at each
the exercise                    site."[19] (p316)
portion of the study."
                                D. "The interview was chosen
                                as the primary
"The experimental procedure     method of data collection in
in                              order to examine
experiments 1 and 2             the values, perceptions, and
consisted of five               experiences that
sessions. These sessions        influenced these female
were                            physical therapists'
conducted on five               professional
consecutive days. A             development."[20] (p532)
summary of the procedures used in each
session is outlined in Figure 2."[17] (507)
B. "The HTSS [Health Team
Stereotyping Scale) was given to the PT
[physical therapy] and OT [occupational
therapy] students by the investigators as
a self-administered survey questionnaire
in the students' respective classrooms
during regularly scheduled class
periods."[18] (pp17-18)
(a) Chattecx Corp, 101 Memorial Dr, PO Box 4287, Chattanooga,
TN 37405,

In the examples of research from the phenomenological tradition,[19,20] the persons being studied assume the role of active participants, rather than those of subjects. Subject behavior is studied in natural settings, and no attempt is made to manipulate the environment. In this context, variation among participants is desirable because that variability is believed to reflect the real world. The selection of subjects usually is based both on inclusion criteria and on the perceived usefulness of the information the subject may hold about the phenomenon under study. The determination of both the criteria and the informational usefulness of the subject is guided by the specific elements identified in the conceptual framework or theory under study.[12,21] The primary data-collection instrument in phenomenology is the researcher, who observes, interviews, listens, and records data on spontaneous behaviors.

Reliability and Validity

An underlying foundation for both the research design and method for the researcher who uses the positivist approach is upholding the concepts of replicability and internal and external validity. Campbell and Stanley[23] laid the groundwork for much of the current thinking and behavior regarding these concepts. Reliability, or the degree to which results obtained through tests and measurements are reproducible, is based on the assumption that there is a single reality and, if this reality is studied repeatedly, the same results will appear." For example, to ensure reliability of a measurement, operational definitions (what to do and what to look for) are established by the researcher and used as prescribed guidelines for researcher and subject behaviors.[11,24] Other sources refer to reliability as the degree to which findings are free from errors of measurement; that is, Is the measuring instrument accurate?[25]

The concept of internal validity refers to causal relationships. For example, in experimental studies, does the independent (experimental, intervention) variable make a difference in the study such that a cause-and-effect relationship can be inferred? Control of outside influences is important so the researcher can infer, if possible, this causal relationship.[23]

External validity is concerned with the generalizability of the study. For example, to what populations, settings, treatment variables, and measurement variables can the effect be generalized?[23] A study must be internally valid before it can be considered to have generalizability.[11,23] Usually, the ability to generalize to other settings is enhanced through a priori conditions (eg, assumptions about equivalency between the sample and population from which the sample was drawn and the use of probability sampling methods.)[11,23]

For the researcher using the phenomenologist approach, whether and how the tenets of reliability and of internal and external validity apply continue to be the subject of much debate. Anthropologists have long held to the insider (emic) approach. Pelto and Pelto[26] describe an emic approach as one that uses the method of interviewing subjects for the purpose of understanding how the subjects perceive and ascribe meaning to events in their lives. They contrast this with the etic approach, which uses the method of observation of subjects for the purpose of identifying patterns of behavior. To apply an emic approach, the researcher would engage in extended investigation time in the field for the purpose of systematic acquisition of the perspectives of as many participants as possible through observation, interview, and document analysis. Validity would be ensured by describing culture from the worldview, conceptual framework, and terminology of the subject being studied.[9,27]

Educational researchers have advocated other ways of addressing the tenets of reliability and validity.[7,8,12] At the heart of the reliability issue is replication of the study, but as we have previously discussed, qualitative research is heavily influenced by the researcher's individual assumptions and perspectives. One of the assumptions the phenomenologist holds is the presence of multiple realities, not a single reality. The goal of the qualitative researcher is not replication of results, but rather producing an illuminating description and perspective of a situation that is based on a consistent and detailed study of that situation.[6]

For the phenomenologist using qualitative research methods, internal validity can be addressed through implementing a technique called triangulation. Triangulation refers to the use of multiple investigators, multiple sources of data, or multiple methods of confirming or disconfirming emerging findings.[12,28] Other strategies to ensure internal validity include the use of long-term observation at the research site and peer or participant examination of the research findings. Specific techniques used for the data collection that enhance both the reliability and internal validity of the data include the use of low-inference descriptors such as verbatim accounts of interviews, direct quotations in field notes, and mechanical methods of collecting data.[11,12,19] Phenomenologists also address the concept of external validity or generalizability, but not as defined by the positivists. Frequently, in qualitative research, the aim of the research is understanding the particular individual or setting in depth.[11,12] Shulman[13] argues that generalizability can be addressed by considering an "inferential bridge"; that is, the reader can judge whether the findings reported for individuals studied could be considered applicable to groups of individuals the reader knows. Inherent in this argument is the requirement for careful documentation of the details of the setting and individuals being investigated, in other words, disciplined inquiry. Cronbach[29] suggests that generalizations are difficult to obtain in the social sciences and should be replaced by working hypotheses. He states

Instead of making generalization the

ruling consideration in our research, I

suggest that we reverse our priorities.

An observer collecting data in one

particular situation is in a position to

appraise a practice or proposition in

that setting, observing effects in context.

In trying to describe and account

for what happened, he will give attention

to whatever variables were controlled,

but he will give equal attention

to uncontrolled conditions, to personal

characteristics, and to events that occurred

during treatment and measurement.

As he goes from situation to

situation, his first task is to describe

and interpret the effect anew in each

locale, perhaps taking into account

factors unique to that locale or series

of events.... Generalization comes

late.... When we give proper weight

to local conditions, any generalization

is a working hypothesis, not a

conclusion.[29 (pp124-125)

Additional strategies for addressing external validity include the use of multisite studies or longitudinal studies.[7,11]

Research Data

The data gathered and analyzed from positivistic and phenomenological perspectives look different and are used for different purposes. As previously stated, in the positivist tradition, the data are typically quantitative, that is, either numerical data or nominal data in the form of single words or phrases. These data are usually subjected to descriptive or analytical statistics. Because there are many different types of analyses to choose from, the challenge for the researcher is to select a form of analysis that is most appropriate for both the type of data collected (nominal, ordinal, interval, ratio) and the projected relationships among the data as determined by a priori hypotheses. The outcomes of this data analysis are reported as numerical significance or lack of significance. If hypotheses are stated, they are accepted as being true or they are not accepted. If the purpose of the research is descriptive, the findings are conveyed by descriptive and correlational statistics.[2.3] Table 4 provides examples of data found in research studies that exemplify a positivistic tradition.

Table 4. Research Data Related to Positivistic and
Phenomenological Paradigms
Positivism                      Phenomenology
A. "The VAS [visual analogue    C. "Each audiotape was
scale] has                      transcribed by one
been shown to be reliable       of the researchers who had
and valid as a                  performed the
ratio-scaled measure of         data collection. The
of pain[9] Parametric           transcription included
statistical tests are           both the verbatim data from the
therefore appropriate           audiotape
for analyzing VAS               and the nonverbal and
data."[17](pp59-510)            environmental data
                                recorded in the researcher's
                                field notes. This
B. "Semantic differential       integrated transcription was
test, such as                   then coded by
the HTSS [Health Team           all three researchers,
Stereotyping                    the two researchers
Scale], provide ordinal         who had done the observation,
data. Because the               and the third
assumptions of parametric       researcher not present at the
analysis                        observation
cannot be met, a nonparametric  We applied a coding system as
statistic                       advocated
is the preferred method of      by Strauss."19(pp317-318)
data
analysis."[18](p18)
                                D. "The data were then coded
                                according to
                                the coding categories generated
                                by the
                                interviews, the review of the
                                literature, and
                                the initial conceptual
                                framework."
                                "The coded data were analyzed,
                                including
                                consideration of frequency and
                                negative
                                examples, and then consolidated
                                into three
                                major concepts of values and
                                experiences:
                                values, family role, and
                                sexism."20(p533)

In the qualitative tradition, data are predominantly in the form of phrases and sentences that provide information. This information is analyzed throughout the data-collection process, thus informing the researcher about what additional data need to be collected.[8,12] The phenomenological researcher has mounds of observational and narrative data and must find an efficient way to reduce this information. One of the primary methods of analysis is called the constant comparative method.[11,12,30] In this method, as with statistical analysis, the researcher classifies, compares, and correlates data from multiple sources. The conceptual framework and the emerging theory play a major role in guiding the analysis.[21] The researcher determines whether the themes and concepts that emerge from the data reinforce or suggest revision of the framework or theory. The outcomes of the analysis are often rich, in-depth written descriptions and interpretations that enable the reader (or listener) to have a sense of having participated in the study. Quantitative data also may be used to highlight examples or add another dimension to the validity of the findings. The focus of the data, however, is to present an accurate portrayal of the participants' reality. Examples of qualitative data are shown in Table 4.

Theory

In the Figure, theory appears at the entrance and exit of all research processes. Theory, although often unstated, is, in our view, what guides all clinical practice and all research endeavors. Shepard[31] defines theory as an abstract idea or collection of ideas used to explain physical or social phenomena. Theory comes from the research literature as well as from our own experiences and related "hunches" about why and how certain phenomena exist.

In the positivist tradition, theory is what guides the establishment of a priori hypotheses and establishes the conditions under which the hypotheses will be tested.[32] For example, in the article by Streed and Stoecker,[18] the theory behind the stated hypotheses looks like this: Stereotyping is used in everyday interactions to allow us to anticipate the behaviors of others with some degree of efficiency + stereotypes begin with little information about a group + professional programs provide strong socialization to that profession but not to other professions [arrow left] "We hypothesized ... that junior PT [physical therapy] students would score more positively on the HTSS [Health Team Stereotyping Scale) than junior OT [occupational therapy] students when describing PTS ..."[18](pl7)

Phenomenologists, seeking to understand a phenomenon within its natural context, create theoretical frameworks, that is, theoretical or conceptual models in which all the perceived relevant elements of the phenomenon are identified and the relationships between the elements explicated, As field data are collected and analyzed, new themes and patterns emerge from the data, which can then be used to reaffirm, revise, or expand the theoretical framework. Thus, Raz et al[20] began their work on exploring the professional development of female physical therapists by creating a model of professionalism that was based on the literature on the traditional professions such as medicine and law. After interviewing female physical therapists, the model of professionalism was expanded to include three additional concepts: values, such as caring and empowerment of patients; family roles, which included strategies on how to cope with the dual roles of a career and motherhood; and sexism, which incorporated elements of discrimination against women.

In both types of study, information gleaned from data analysis was used to reaffirm (Streed and Stoecker[18]) or revise (Raz et al[20]) the original theory. Thus, in our view, theory is absolutely essential to the development of all research programs. Without theory that is explicated, there is no way to build upon ideas, to determine the conditions under which the theory is true, or to invent new theories to explain dissimilar results.[32]

The Future of Alternative

Approaches

Our ultimate goal as researchers in physical therapy is to contribute to the body of knowledge in our field. We want to emphasize that the application of research methods from alternative philosophical perspectives is not a different way of achieving the same end, but rather a different way of answering different questions. We believe that each perspective and each method is useful for verification and generation of physical therapy's knowledge base.

As a health field that continues to develop as a profession with increased emphasis on research, we also should take heed of what is happening in other professions. As educational researchers have noted, the quantitative methods of experimental, correlational, quasi-experimental, and survey research had their roots in research done early in this century in agriculture, genetics, and studies of heredity. These methods worked well for investigating the state of natural science, but some experts argue that several decades of application of this type of research in classrooms did not provide the insight needed to fully understand what happens between teachers and students.[7,13] Some psychologists, too, have questioned the continual application of traditional research approaches in their investigations into health. These researchers argue that if their research is on human subjects, then they must gather data on how people perceive reality and the meanings they ascribe to events; that is, the researcher must actively engage the subject in the method of inquiry.[33]

Health is a concept that is socially constructed; that is, human perception, interpretation, and individual meaning are all part of health. Health can be defined as a state of physical, mental, and social well being, not just the absence of disease or symptoms. In health care, the nursing profession has readily endorsed research from a phenomenological perspective.[34-36] More recently, physicians have begun to see that the use of a research paradigm that uses qualitative techniques may fill in many gaps in understanding what health is and how to study it.[37,38]

As Dr Kurt Stange from the Department of Family Medicine at Case Western Reserve University states,

Possible advantages of adding the concurrent

or sequential use of qualitative

methods to quantitative studies include:

1) cross-validation of data from

multiple methods and sources; 2) the

development of valid and culturally

relevant measurement tools; 3) improved

understanding of the meaning

of quantitative results; 4) greater insights

into possible sources of bias;

5) increased ability to explain outliers

or unexpected results; 6) the generation

of new theories and hypotheses;

and 7) increased ability to apply study

results to other populations or to individuals,

because of insight into the

effects of culture, the unique characteristics

of the study sample, or the research

environment of the study. if the

only tool researchers have is a hammer,

they tend to see every problem as

a nail. An appreciation of both quantitative

and qualitative approaches can

enhance a researcher's ability to answer

complex questions in a manner

which is efficient, internally valid, and

generalizable.[38](p451)

We would advocate the use of both philosophical perspectives to guide research used to establish the knowledge base in physical therapy. The question of researchers combining methods that emanate from alternative perspectives in the same study is one of continual debate. For example, using qualitative and quantitative methods together may be too time consuming or too costly. Other obstacles are the philosophical beliefs of the researcher and her or his level of preparation to work with alternative research paradigms. One way to overcome these obstacles is to encourage researchers with different methodological preparation to work together on complex problems and share their perspectives, insights, and methodological expertise.[13] Application of qualitative methods is not merely gathering interview data, reviewing documents, or observing in the field. There is rigor to the method that requires substantial grounding in the philosophical assumptions as well as field experience and training in the various methods of analysis.[12,20,22]

Conclusion

We have much to learn about the efficacy of our clinical practice - what works on whom under what circumstances and why. We strongly believe that to measure successfully the outcomes of physical therapy interventions, the acquisition and analysis of both quantitative and qualitative data are imperative. It is our belief that the research data derived from the use of both phenomenological and positivistic paradigms will revolutionize physical therapy knowledge and research practices in the same way these data have revolutionized the professions of teaching and nursing.

References

[1] Kuhn TS. The Essential Tension: Selected Studies in Scientific Tradition and Change. Chicago, Ill: University of Chicago Press; 1970. [2] Polit DF, Hungler BP. Nursing Research: Principles and Methods. 4th ed. Philadelphia, Pa: JB Lippincott Co; 1991:15-27, 49-69. [3] Payton O. Research: The Validation of Clinical Practice. 2nd ed. Philadelphia, Pa: FA Davis Co; 1988:7-30. [4] Phillips DC. Philosophy, Science, and Social Inquiry. New York, NY: Pergamon Press Inc; 1987:48-102. [5] Cohen MZ. A historical overview of the phenomenologic movement. Image: Journal of Nursing Scholarsbip. 1987;19(1):31-34. [6] Firestone WA. Meaning in method: the rhetoric of quantitative and qualitative research. Educational Researcher. 1987;16(8):16-21. [7] Eisner EW, Peshkin A, eds. Qualitative Inquiry in Education: The Continuing Debate. New York, NY: Teachers College Press; 1990: 201-232. [8] Lincoln YS, Guba EG. Naturatistic Inquiry. Newbury Park, Calif: Sage Publications Inc; 1985:14-45. [9] Fetterman DM. Qualitative approaches to evaluating education. Educational Researcher 1988;17(8):17-22. [10] Landsheere G. Research perspectives. In: Keeves J, ed. Educational Research Methodology and Measurement. New York, NY: Pergamon Press Inc; 1988;9-16. [11] Merriam SB. Case Study Research in Education: A Qualitative Approach. San Francisco, Calif: Jossey-Bass Inc Publishers; 1988:5-21, 163-177. [12] Goetz J, LeCompte M. Ethnography and Qualitative Design in Educational Research. New York, NY: Academic Press Inc; 1984:33-39, 211-231. [13] Shulman LS. Disciplines of inquiry in education: an overview. In: Jaeger RM, ed. Complementary Methods for Research in Education. Washington, DC: American Educational Research Association; 1988:3-23. [14] Reichardt CS, Cook TD. Beyond qualitative versus quantitative methods. In: Cook TD, Reichardt CS, eds. Qualitative and Quantitative Methods in Evaluation Research. Beverly Hills, Calif: Sage Publications Inc; 1979:7-32. [15] VanSant AF. Life-span development in functional tasks. Phys Ther. 1990;70:788-798. [16] Schenkman ML, Berger RA, Riley PO, et al. Whole-body movements during rising to standing from sitting. Phys Ther. 1990;70:638-651. [17] Fitzgerald GK, Rothstein JM, Mayhew TP, Lamb RL. Exercise-induced muscle soreness after concentric and eccentric isokinetic contractions. Phys Ther. 1991;71:505-513. [18] Streed CP, Stoecker JL. Stereotyping between physical therapy students and occupational therapy students. Phys Ther. 1991;71:16-20. [19] Jensen GM, Shepard KF, Hack LM. The novice versus the experienced clinician: insights into the work of the physical therapist. Phys Ther. 1990;70:314-323. [20] Raz P, Jensen GM, Walter J, Drake LM. Perspectives on gender and professional issues among female physical therapists. Phys Ther. 1991;71:530-540. [21] Miles MB, Huberman AM. Qualitatite Data Analysis: A Sourcebook of New Methods. New-buty Park, Calif: Sage Publications Inc; 1984: 17-25 [22] Jensen GM. Qualitative methods in physical therapy research: a form of disciplined inquiry. Phys Ther. 1989;69:492-500. [23] Campbell DT, Stanley C. Experimental and Quasi-Experimental Designs for Research. Palo Alto, Calif: Houghton Mifflin Co; 1966. [24] Michels E. Evaluation and research in physical therapy. Phys Ther. 1982;62:828-834. [25] Standards for Educational and Psychological Testing. Washington, DC: American Psychological Association Inc; 1985:19-23. [26] Pelto JP, Pelto GH. Anthropological Research: The Structure of Inquiry. New York, NY: Cambridge University Press; 1978:54-66. [27] McGee-Brown M. Reconstruction of which reality? Qualitative data analysis. In: Goetz J, Allen J, eds. Qualitative Research in Education: Proceedings from the Qualitative Research Conference. Athens, Ga; University of Georgia Press; 1988:91-103. [28] Mathison S. Why triangulate? Educational Researcher. 1988;17(2):13-17. [29] Cronbach Lj. Beyond two disciplines of scientific psychology. Am Psychol 1975;30:116-127 [30] Strauss AL. Qualitatite Analysis for Social Scientists. New York, NY: Cambridge University Press; 1987:1-39. [31] Shepard KF. Theory: criteria, importance, and impact. In: Contemporary Management of Motor Control Problems: Proceedings of II Step Conference. Alexandria, Va: Foundation for Physical Therapy Inc; 1991: chap 3. [32] Tammivaara J, Shepard KF. Theory: the guide to clinical practice and research. Phys Ther. 1990;70:578-582. [33] Thoreson CE, Strategies for health enhancement: overview. In: Matarazzo E, ed. Behavioral Health: A Handbook of Health Enhancement and Disease Pretention. New York, NY: John Wiley & Sons Inc; 1984:297-307. [34] Morse JM. Qualitative Nursing Research: A Contemporary Dialogue. Rockville, Md: Aspen Publishers Inc; 1989:15-40. [35] Leininger MM, ed. Qualitative Research Methods in Nursing. Orlando. Fla: Grune & Stratton Inc; 1985:1-25. [36] Thorne SE. Methodological orthodoxy in qualitative nursing research: analysis of the issues. Qualitative Health Evaluation. 1991;1: 178-199. [37] Ford AB, Folmar SJ, Salmon RB, et al. Health and function in the old and verv old. J Am Geriatr Soc. 1988:36:187-197. [38] Stange KC, Zyzanski SJ. Integrating qualitative and quantitative research methods, Fam Med. 1989;21:448-451.

Appendix. Annotated Bibliography - Phenomenological Perspective

Eisner EW, Peshkin A, eds. Qualitative Inquiry in Education: The Continuing Debate. New York, NY: Teachers College Press; 1990.

An excellent book that contains a series of papers by recognized scholars in the field on topics central to the use of qualitative inquiry. These topics include the following: subjectivity and objectivity, validity, generalizability, and ethics.

Goetz J, LeCompte M. Ethnography and Qualitative Design in Educational Research. New York, NY: Academic Press Inc; 1984.

The authors provide a detailed account on all aspects of ethnographic research and qualitative design. The chapters on data analysis and on reliability and validity are particularly well done.

Guba EG, ed. The Paradigm Dialog, Newbury Park, Calif: Sage Publications Inc; 1990.

A book for the experienced researcher interested in further exploration of the philosophical underpinnings of social science research. Discussion includes the use of critical theory, postpositivism, and constructivism as the basis for new methodologies. Several well-established social science researchers have contributed chapters.

Jaeger RM, ed. Complementary Methods for Research in Education. Washington, DC: American Educational Research Association; 1988.

This book provides instructional material on a wide variety of approaches in educational research. Chapters include use of case study methods, ethnographic methods, philosophical inquiry methods, historical inquiry methods, and survey methods as well as experimental and quasi-experimental/correlational approaches to research. Each chapter contains substantive material on the specific methodology, research examples, study questions, and an annotated bibliography.

Leininger MM, ed. Qualitative Research Methods in Nursing. Orlando, Fla: Grune & Stratton Inc; 1985.

The first qualitative research book developed by and for nurse researchers. Chapters on philosophy, research designs, and research methods, many with patient examples. In chapter 12, Toni TrippReimer contributes an interesting example of how to combine qualitative and quantitative techniques in studying the health belief system among Greek immigrants.

Marshall C, Rossman G. Designing Qualitative Research. Newbury Park, Calif: Sage Publications inc; 1989,

The authors wrote this book as a practical guide for constructing research proposals. The book is an excellent guide for beginning researchers. The authors provide many ideas for different approaches tor framing research questions and then setting an appropriate design for answering the questions.

Miles MB, Huberman AM. Qualitative Data Analysis: A Sourcebook of New Methods. Newbury Park, Calif: Sage Publications Inc; 1984.

Miles and Huberman's text is an excellent resource for qualitative analysis techniques. The authors provide numerous examples of how to systematically reduce, analyze, and display qualitative data. They also give examples of how to design, implement, and revise a conceptual framework.

Morse JM, Johnson KL, eds. The Illness Experience: Dimensions of Suffering. Newbury Park, Calif: Sage Publications Inc; 1991.

A collection of research papers that present the use of grounded theory as a technique to investigate what illness is like from patients' perspectives. In the last chapter, the editors combine themes uncovered in the papers to present a four-stage process that describes how the sick person and his or her family lives through and copes with the illness experience. A fascinating look at how the use of a phenomenological approach to studying patients yields new and important information about how patients survive illness and recover their state of wellness.

Patton M. Qualitative Evaluation Methods, 2nd ed. Newbury Park, Calif: Sage Publications inc; 1990.

This is the second edition of Patton's classic text on the use of qualitative evaluation methods. This edition includes additional chapters on the theoretical foundations of qualitative inquiry and approaches to qualitative data analysis.

Phillips DC. Philosophy, Science, and Social Inquiry. New York, NY: Pergamon Press Inc; 1987

This book, written for advanced students or experienced researchers, examines contemporary methodological controversies in social science research. Phillips presents philosophical arguments that challenge many of the assumptions underlying different approaches to research, including an excellent chapter on the demise of positivism.

Sage Publications Series on Qualitative Research Methods. Newbury Park, Calif: Sage Publications Inc.

This series now includes more than 20 volumes, each a short paperback. The series covers topics such as ethics, reliability and validity, interviewing, and writing up qualitative research. These books are brief, yet contain both philosophical and practical information for the researcher.

Strauss AS, Corbin J. Basics of Qualitative Research. Newbury Park, Calif: Sage Publications Inc; 1990.

The authors present a very readable text that covers all the practical procedures and techniques for doing grounded theory studies, The material on coding procedures is well done.

Yin R. Case Study Research. Newbury Park, Calif: Sage Publications Inc; 1984.

The purpose of this excellent text is to guide researchers in the use of case studies. Yin advocates case study design as a rigorous method of research. The book covers everything from design to analysis and reporting of data. This book is a must for anyone doing case study research in the social sciences.

For additional resources see "Annotated Bibliography of Selected Qualitative Texts" in Jensen GM. Qualitative methods in physical therapy research: a form of disciplined inquiry. Phys Ther. 1989;69:499.

Commentary

Qualitative research methods have traditionally dominated history, anthropology, literary criticism, and some schools of sociology and psychology. Increasingly, these methods are finding a place in professional disciplines, from education to medicine, where once only quantitative paradigms reigned. In areas where qualitative research is still rare, qualitative researchers often must answer objections about the "science" of their practice, questions that historians, anthropologists, and literary theorists have often been able to avoid because such methods are common in their fields. Qualitative researchers in quantitatively driven disciplines characteristically find themselves turning to philosophy to defend their methods; most often they look to phenomenology and modern hermeneutics, which offer sustained arguments about the need for a different kind of science for the study of human activity, one designed to ferret out the personal, social, and cultural meanings persons attach to the actions they take.

The article by Shepard and colleagues represents an important effort to ground a discussion of qualitative methods within a philosophical framework. No single article can be expected to detail the subtle philosophical issues at stake in a comprehensive way. And perhaps not all qualitative researchers can be expected to develop competence in philosophy. After all, we would never ask that of our statisticians. But as this article does claim to "present ... two different philosophical perspectives," it seems important to note some misleading or confusing discussions. I will make no attempt to review the authors' depiction of positivism, but I will elaborate what I take to be key issues within the phenomenological paradigm.

Phenomenology does not represent a single coherent position. Certain research movements in phenomenology drawing from the work of the philosopher Husserl presume that through intuition, it is possible to have direct access to the experience of others.[1] A hermeneutically informed phenomenology, by contrast, is much more linguistically oriented. Hermeneutics treats understanding along the analogy of trying to read a strange text.[1-3] This hermeneutic phenomenology is suspicious of direct intuition or direct observation, arguing that this is still too reminiscent of an empiricist position in which one can somehow just look out and directly apprehend the world through an inductive process of immersion in a life world. From a hermeneutic perspective, research is treated as a kind of translation process between the cultural codes that inform the researcher's understanding and the foreign cultural codes of those studied. Hermeneutic researchers are especially attentive to the observer's historical and cultural position and how this influences what counts as data. Qualitative research has been carried out in both these traditions. Notions of "grounded theory"[4] are rather closer to the first phenomenological tradition, depicting a highly inductive approach to data gathering that tries to be free from bias. Notions of "thick description,"[3] discussed in more detail later, are much more hermeneutic, much more concerned with learning to "read" the cultural code or "language games" of those one studies. My own discussion of phenomenology offered below emerges primarily from this hermeneutic tradition.

Judging the usefulness of phenomenological paradigms inevitably means plunging into a philosophical consideration of some basic epistemological assumptions. Phenemonology arose, in part, as a protest against the notion that the physical sciences could provide a model for all knowledge, especially knowledge about human action. Therefore, turning to phenomenology means raising some very basic questions about the nature of knowledge itself and how one most reliably acquires it. What, one is forced to ask, does it mean to know something? What is the position of the knower vis-a-vis the object "out there" to be known? Is there some value-free space, some Archimedian spot, from which one can safely (that is, objectively) survey the scene and judge the truth of something? Or, is there some set of procedures that guarantees an objective gaze? And what ought "truth" look like if one were able to discover it? Should truth reveal itself in the form of general causal laws that establish (under given prescribed conditions) invariable cause-and-effect relationships?

All these questions and more are necessarily raised when one shifts from research methods based in the physical and natural sciences to phenomenological methods associated with what are variously called the "human sciences," the historical sciences," or the "interpretive sciences." Speaking as an anthropologist who has worked within occupational therapy for the past 6 years, I believe that phenomenological and hermeneutic methods have a great deal to offer the health professions, especially those addressing chronic illnesses and disabilities. The authors of this paper have undertaken an extremely difficult and important task in trying to make a clear and comparatively simple description of the phenomenological position. They have rightly emphasized what is probably the most essential feature common to all phenomenological traditions - a focus on understanding a world, a "life world" as phenomenologists would say, from the perspective of those who live in it. Or, as anthropologists used to say, good ethnography demands discovering the "native's point of view." In the health professions, we might say that we need to understand the client's perspective.

Phenomenology and the

Interpretation of Meaning

Phenomenologists argue that the human sciences differ from the physical sciences because the subject matter of the two differs. The former concern themselves with self-interpreting, meaning-making "objects" (humans), whereas the latter do not. The natural sciences create interpretations and explanations of a nonhuman world, but the human sciences create interpretations of an already interpreted human world. To offer an example from the absurd, we need not worry about how plants feel about chlorophyll or how a comet might describe the pull toward its sun. These objects are not busy interpreting the events that we are trying to explain. But our study of human activities and human artifacts necessarily involves assumptions about how those humans classify and make sense of their own actions. In the human world, when we care about motivated action, we cannot even properly classify or name our objects of study until we have some understanding of how these objects are classified by the "natives" whose behavior we want to explain.

A simple example, one now classic in anthropology, may suffice to illustrate this very basic point. This example comes from the philosopher Gilbert Ryle and has been made famous in anthropology by Clifford Geertz' seminal essay "Thick Description: Toward an Interpretive Theory of Culture."[3] Ryle speaks of the difference between twitches and winks. A twitch and a wink may look the same but of course are utterly different "objects." A twitch is not really an act at all, it is simply an involuntary muscle movement. It is a phenomenon that can be usefully explained within the natural sciences (though even here, I suppose, a psychoanalyst might beg to differ). A wink, however, is an intentional act, a communicative act. As such, it is a phenomenon much better addressed by the interpretive sciences, for even a simple classification of a wink depends on an interpretation of just what the winker is intending to communicate. Is this a friendly wink? A flirtatious wink? A conspiratorial wink? A sarcastic wink? If I want to study winking behavior, I must first be able to distinguish twitches from winks, and very likely I must distinguish among a variety of types of winks. I cannot simply count winks. But how do I know when I am seeing a twitch and when I am seeing a wink? If I decide I have witnessed a wink, how do I know which wink has just been winked? I must assess the motives of the winker, motives that I interpret or infer from what I know about this particular person and about the social context. I see a bit of behavior; I interpret this behavior as a particular human act (a friendly wink) based on an inference about the motive behind the behavior; and I am able to make an accurate inference based on my knowledge of the person, the immediate social context, and the cultural rules governing behavior among those individuals where the wink occurred. Thus, even the simplest classification of human action depends on my understanding of the social context in which the action took place and some understanding of the culture of the winker. "The winker," as Geertz says, "is communicating, and indeed communicating in a quite precise and special way: (1) deliberately, (2) to someone in particular, (3) to impart a particular message, (4) according to a socially established code, and (5) without cognizance of the rest of the company."[3(p6)] Deciphering what the winker means to convey may be simple if I belong to the same culture (hence share the same socially established codes) but becomes immensely difficult if I try to make such interpretations in a strange cultural setting. The most obvious acts, from smiles to winks to frowns to shouts, quickly become opaque in unfamiliar places. This example of twitches and winks illustrates two essential features of qualitative research. One, observation alone will not allow the researcher to classify behavior - to distinguish the twitch from the wink. Accurate classification depends on the observer's familiarity with the actor's cultural codes. Two, familiarity with cultural codes is not available just for the asking. You cannot simply request that a winker provide the rules that make it possible to distinguish twitches from winks in his or her particular culture. We "know more than we can tell," as Polanyi[5] has said. We cannot simply ask people what they mean or what the cultural rules are that govern what they are doing. A simple example of this tacitness is our knowledge of grammar. Speakers of a language are able to produce endless novel sentences that are perfectly grammatical. This is a skill acquired by young children in the first few years of life. Yet how many of us can enumerate the cultural rules that we are tacitly using to govern our speech acts?

Geertz designates the interpretive work I engage in to understand why someone has acted in a certain way (or even to classify what act I have witnessed) as the creation of "thick description."[3] The outcome of good qualitative research is the production of thick descriptions. Such descriptions connect particular behaviors with the cultural codes that give them particular meanings for particular cultural actors. The ability to observe outward behaviors and create thick descriptions that interpret the meaning of those behaviors - turn them from physiological descriptions to human actions - depends on deep cultural knowledge of the actors. Such knowledge is acquired, in most qualitative traditions, through a combination of semi-structured and very in-depth interviewing with a small sample of subjects and observation of people in their "natural" worlds of practice.

What Phenomenological

Methods Offer Therapeutic

Practices

Why should physical therapists worry about twitches and winks? That is, why do physical therapists need to pay attention to the perspectives of those they treat in any more detail than common sense provides? Many practices need not attend to their clients with any subtlety. If one is an airline pilot, for instance, one needs to know many things but not much about the experiences, goals, dreams, and fears of one's passengers. Competence as a pilot depends on safely carrying passengers from one predetermined destination to the next, not on guiding how they experience the flight. But therapeutic practices are rather different. Often it is not enough to fix the "body" of the patient. Therapists are also asking the client to become an active participant in therapy, to practice exercises at home, to "buy in" to the goals of therapy. They may even set goals collaboratively, trying to individualize treatment to meet the needs and lifestyles of their clients. Phenomenological approaches have much to offer health practices, especially those such as physical therapy, whenever it matters not only what a patient's physical dysfunctions are but how those dysfunctions affect the patient's life. Put differently, phenomenological research is essential whenever the health professional must address the patient's "illness experience." Medical anthropologists have made a very useful distinction between the biomedical category of disease and the meaning-centered (or phenomenological) category of illness experience.[6,7] An illness experience concerns the meaning a person makes of the physical condition he or she confronts. Two patients may have the same disease (eg, severe Parkinson's disease), but if one of them is a 53-year-old, Irish academician and the other a 72-year-old, Italian, retired construction worker, they will undoubtedly have different illness experiences.

Increased interest in qualitative methods in the health professions accompanies a growing recognition that good treatment often means taking illness experiences of clients seriously, recognizing that the diagnostic picture that focuses so exclusively on the physical body provides only part of the problem. When a person discovers he or she will not be able to walk again, this is more than a physical fact. In phenomenological terms, that person's very sense of identity is assaulted. But if treatment is "treating a life," so to speak, and not just a body, then it is important to do research that illuminates the phenomenological aspects of treatment, that investigates the meaning of disability and treatment from the perspectives of all the key actors: therapist, client, family members, professional colleagues, even institutional contexts. Many of these meaning-centered issues are best addressed through qualitative methods, however thorny the philosophical problems raised.

References

[1] Ricoeur P. From Text to Action: Essays in Hermeneutics, II. Evanston, Ill: Northwestern University Press; 1991. [2] Ricoeur P; Thompson J, trans-ed. Hermeneutics and the Social Sciences. Cambridge, England: Cambridge University Press; 1981. [3] Geertz P. The Interpretation of Cultures, New York, NY: Basic Books; 1973. [4] Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York, NY: Aldine Publishing Co; 1967. [5] Polanyi M. Personal Knowledge: Towards a Post-Critical Philosophy. 2nd ed. Chicago, Ill: University of Illinois Press; 1962. [6] Kjeinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York, NY: Basic Books; 1988. [7] Good B, DelVecchio-Good MJ. The meaning of symptoms: a cultural hermeneutic model of clinical practice. In: Eisenberg I, Kleinman A, eds. The Relevance of Social Science for Medicine. Norwell, Mass: D Reidel; 1980:165-196.