Qualitative methods in aphasia research: ethnography

aphasiology, 1999, vol. 13, nos. 9±11, 681±687

Qualitative methods in aphasia research: ethnography NI N A S I MMONS -MA CKI E*‹ and J ACK S. D AMI C OŒ ‹ Department of Special Education and Communication Sciences and Disorders, Southeastern Louisiana University, Hammond, Louisiana, USA Œ Doris B. Hawthorne Professor of Special Education and Communicative Disorders, University of Southwestern Louisiana, Lafayette, Louisiana, USA

Qualitative methods in aphasia research: ethnography Ethnography is the study of the rich, complex matrix of social life and culture. It has been described as a ` particular tradition in social science that fundamentally depends on watching people in their own territory and interacting with them in their own language, on their own terms’ (Kirk and Miller 1986: 9). This methodologyis most widely identi®ed with anthropology,where it was developed as a means of studying alien culturesÐcultures about which information was insu¬cient to formulate speci®c hypotheses. Ethnography allowed the researcher to ` discover’ the cultural meanings of practices from the perspective of the participants. Modern ethnographershave adapted the method to understand social dynamics in modern society. Ethnography is useful for explicating the dynamics of social institutions and organizational practices, describing groups of people or understanding speci®c events or behaviours. Increasingly variations of ethnographic methodology are being used in communicative disorders to study behaviours as they naturally occur (e.g. Simmons 1993) and to understandthe perspectives of the people being investigated (e.g. Parr et al. 1997). The methodology holds promise for adding to the database that informs the study and practice of clinical aphasiology. Characteristics of ethnography Although the topic of ethnography is quite extensive, this paper will focus on several key characteristics of the methodologyand will refer to research examples to illustrate these characteristics. The research examples are extracted from a study of feedback in aphasia therapy (Simmons-Mackie, in press, Damico and Damico 1996). Broad beginnings An ethnographic study typically begins by loosely identifying an area of inquiry rather than stating a speci®c hypothesis or framing an explicit research question. The area of inquiry can be a behaviour, a person, an event, an institution or a * Author for correspondence: e-mail : nmackie!

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culture. For example, the authors were interested in studying traditional aphasia therapyÐan event. The wide-angle lens of ethnographywas adopted in an attempt to understand `what goes on’ in traditional aphasia therapy. The topic was approached broadly without a preconceived hypothesis or a priori categories of interest. Rather an open-ended question, typical of ethnography, was adoptedÐ`What happens in traditional aphasia therapy? ’ Naturalistic and holistic The naturalistic research philosophy of ethnography assumes that realities are wholes that cannot be understood in isolation from the natural context (Lincoln and Guba 1985). There is an assumption that understanding a behaviour or an event requires understanding the complex, interacting variables within the social system. In other words,the paradigm requires that authentic contexts and naturally occurring events serve as the sources for data collection. Therefore, the study of aphasia therapy required observation of actual therapy sessions,review of existing therapy charts and inquiries regarding experiences of practicing aphasia therapists. In other words the events studied would have happened whether the researchers were present or notÐthe events were naturally occurring in an authentic context. Multiple sources Ethnographic data collection consists of ®eldwork in which multiple data sources are accessed. One common data source involves participant observation in which the investigator directly observes the phenomenon of interest and documents the observationswith ®eld notes (Spradley 1980). Ethnographic interviews are another source of data ; these informant driven interviews follow speci®c guidelines in order to access the perspectives of informants and avoid bias (Spradley 1979, Westby 1990). Analysis of video and audiotapes is an appropriate source of data that is particularly useful in studies of communication. Additional information might be obtained by studying ` artifacts ’ or objects related to the phenomena of interest such as diaries, reports,notes or artwork. Review of data by sources other than the investigator for purposes of generating and verifying interpretations is often accomplished through focus groups or lamination interviews. Finally, introspection is a potential source of data ; that is, the researcher’s intuitions and experience provide one perspective. Several data sources were accessed in order to study aphasia therapy. The data sources included observations of therapy sessions, ethnographic interviews with participants, videotapes of therapy sessions, review of reports and therapy notes and lamination interviews with therapy participants and speech-language pathologists who had not participated in the sessions studied. The ®nal ethnography represented 15 diåerent therapy sessions including ®ve diåerent therapists and 11 diåerent clients in several diåerent settings (e.g. home, hospital and clinic). Emergent design The collection of data from all sources does not occur prior to data analysis as in experimental research. Rather, ethnographic research design is emergent. It unfoldsas data are collected and analyzed resulting in a cyclical and ¯exible process. Thus, the investigator collects, analyzes and veri®es data, identi®es phenomena of interest, then continues to collect and analyse data to progressively narrow the

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Figure 1. Example of analysis of aphasia therapy data.

investigation and hone in on phenomena of interest. Unusual, repeated or patterned events or behaviours often provide a focal point for the narrowing investigation. For example, in the study of aphasia therapy, initial observationswere collected and analyzed into broad descriptive categories using a semantic analysis method adapted from Spradley (1980). Broad categories, such as therapy setting, therapy routines, therapy goals and therapy materials, were further analysed into subcategories. Thus, the category of `therapy routines’ was broken down into ` openings’, `task introductions’, ` doing tasks’ and ` closings’. New data were collected to verify or refute categories and narrow the focus of investigation. Figure 1 represents a portion of the semantic analysis conducted to narrow the focus of investigation. During this process of analysis a particular phenomenon of interest emergedÐ inconsistency between the stated goals of therapists and their feedback to clients during therapy. For example, a therapist reported that her goal was ` to train gestures as a means of getting ideas across’ yet she rewarded a verbal rather than a gestural response during the task as in the following example : Clinician : Show me with your hands how you drive a car Client : Drive a car (verbal response) Clinician : Nice job

The investigators found this mismatch between stated goals and feedback to be interesting and unexpected ; therefore, the investigation narrowed to focus on aspects of this phenomenon. ` Feedback ’ in therapy became the new focus of the investigation and a new cycle of data collection was initiated. Discovery driven In other words, in ethnography the investigator seeks to discover whatever emerges as important to understandingthe phenomenon under study. Therefore, the ultimate focus of the study is often not predicted at the outset. This open-ended

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Figure 2.

Example of veri®cation process.

approach generally precludes a priori hypotheses,predetermined categories or predecided questionnaires, which might bias discovery procedures. The study of aphasia therapy could have taken any number of directions; there were multiple possible relevant outcomes. We became interested in feedback mismatches because the phenomenonwas unexpected and evoked a ` What’s going on here? ’ reaction. In discovery driven research unexpected events or observations often providea window into the phenomenonof interest, since the ` unusualevent’ tends to highlightwhat the investigator expects or considers` normal’ (Agar 1986). This contrast between expectations and observations is one means of discovering new insights and exposing researcher biases and beliefs. Veri®cation In the ever-narrowing cycle of data collection and analysis the most critical procedure is veri®cation. Veri®cation is accomplished through triangulation requiring multiple data sources, multiple instances of a phenomenon and multiple levels of analysis (e.g. Agar 1986, Kirk and Miller 1986). Such triangulation insures authenticity and representative perspectives. The process resembles ongoing testing of ` mini-hypotheses’. The investigator makes an observation or interpretation (mini-hypothesis), then reviews the data and collects data to con®rm or refute the observation or interpretation. These `mini-hypotheses’ become increasingly focused and increasingly interpretive as the study emerges. For example, the study of aphasia therapy began to focus on feedback that was inconsistent with stated goals. The observation of feedback mismatches was veri®ed as the primary investigator reviewed existing data and collected new data seeking additional instances of feedback mismatch across therapists and settings. Also the therapist participants and other speech-language pathology informants reviewed therapy samples, including some feedback mismatch examples and commented on what was going on. Their comments veri®ed the existence of feedback mismatches. An `auditing’ investigator looked at the data for veri®cation. Thus, the observation that some feedback did not match stated goals was con®rmed by repeated instances, in multiple settings and across multiple data sources. Figure 2 provides a graphic example of veri®cation of an observation. A


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Figure 3. Cyclical pattern of data collection, analysis and veri®cation.

similar process of veri®cation to support or contradict ®ndings is employed at every level of the investigation to verify observations and interpretations. The veri®ed observation that multiple therapists during multiple sessions provided feedback that was inconsistent with goals raised a question to the investigators. If the feedback did not supportthe stated goal of the activity, then what was going onÐWhat function was the feedback performing? This question led to a new round of data analysis focusing on potential functions of feedback in aphasia therapy. Figure 3 demonstrates this cyclical narrowing of focus with ongoing veri®cation and triangulation typical of ethnographic research. Thus, veri®cation is a continuous process in which the ethnographer looks for cases to contradict ®ndings as well as evidence to support®ndings.Results are not simply interesting observations; they are carefully veri®ed cumulative outcomes negotiated across multiple sources and perspectives. Immersion Another interesting characteristic of ethnographyis ` immersion’ of the researcher in the process. Rather than maintaining distance, the investigator maintains direct contact with the people under study. Through immersion the observations are grounded in personal experience. This allows for rich description and understanding through participation and introspection.In the aphasia therapy study the investigator’s experience as an aphasia clinician provided an ` insider’ perspective. In addition, availability of videotapes of the investigator engaged in aphasia therapy added another dimension to the interpretation. Disciplined subjectivity In spite of introspection and direct experience, the ethnographer must adopt a stance of neutrality. Disciplined subjectivity rather than objectivity is the goal (Agar 1986). The ethnographer strives to remain nonjudgmental by employing a variety of methodological strategies. Typical approaches to achieving ` informed’ subjectivity include triangulation, external reviews, investigator diaries to raise bias to a conscious level, notes to make decisions explicit, multiple data sources,

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debrie®ng and participant lamination or audit (Agar 1986, Hammersley 1992, Lincoln and Guba 1985, Strauss and Corbin 1990). In the aphasia therapy study, several strategies were employed to maintain the ` discipline ’ in disciplined subjectivity. These included: maintaining written notes on feelings, biases and reactions of investigators, scrutiny of one investigator’s analyses by a second investigator, multiple data sources, and triangulation via outside sources. However, although the researcher seeks neutrality, the researcher’s thoughts, intuitions and perspectives are ` part’ of the research and cannot be extricated ± the `subjectivity’ in ` disciplined subjectivity’.

Interpretation and Explanation The goals of ethnography are to interpret and to explain rather than to generalize or predict. The results providetentative applications, new insight, new models and sensitization to important issues (Hammersley and Atkinson, 1983). For example, the feedback study revealed a variety of functions of feedback in the sessions studied. Some of these functions were related directly to the stated aphasia therapy goals, while others ful®lled unstated social functions such as subtle projection of attitudes, maintaining roles of patient and therapist and upholding the power balance. The results of this study did not allow us to predict that other therapists will perform the speci®c feedback behaviours identi®ed. Rather, the study suggested that aphasia therapy is a very complicated social event that potentially can exert powerful in¯uences beyond simply changing linguistic skills. The theme of `therapy as a socialization context’ suggested the need for further research into the potential in¯uences of therapy interactions on characteristics such as independence, empowerment and con®dence.

Reporting Traditions The product of ethnographic research is `the ethnography’ ± a comprehensive, written narrative that describes and explicates the phenomenon studied. Ethnography employs speci®c reporting traditions. Description is used to weave a story ± a story that creates a theory of social organization or a narrative that explains some event or behaviour (Hammersley 1992). Because of the narrative quality of ethnography,it is often di¬cult to extract key concepts or condense ®ndings into a meaningful format for brief articles or presentations. The whole of the ethnography constitutes the product of the research. Ethnographic reports rely more on semiotic than statistical representation (Atkinson 1990, Hammersley 1992). Throughdescription the ethnographerstrives to provide the reader with a sense of what the ethnographer experienced. Representative examples are chosen to breathe life into the story and enrich the description. Although an example, in eåect, is ` one data point’, the example represents a carefully researched and veri®ed interpretation across multiple examples. The reader must accept that the narrative and the examples represent the events as seen through the eyes of the participants and accept that the purposeis to producesensitizing concepts and models that allow people to see these events in new ways (Atkinson 1990, Hammersley 1992).


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Criteria of acceptability The key criterion of ethnographic research is authenticity. That is, the data must represent multiple instances of naturally occurring phenomena, collected from various sources and analysed at multiple levels in order to insure that the perspectives and outcomes are representative. Since ethnographyseeks to represent the perspectives of participants and since the design is emergent with multiple potential outcomes, ` replicability ’ of research in the traditional sense is not a meaningful criteria. Rather, qualitative research should producea thick description that is plausible and credible based on the evidence presented (Strauss and Corbin 1990). In addition, interpretations must be clearly grounded in the data. The quality of the ethnography lies in the knowledge, skill, practice, sensitivity and integrity of the investigator. Conclusion Ethnography is a qualitative and interpretive research tradition that has ¯ourished in the social sciences. Although relatively new to communicative disorders, ethnography provides an interesting methodology for aphasiologists. Ethnographic research can describe the world from the point of view of people with aphasia and their loved ones (Parr et al. 1997). It can help us understand communication within natural contexts. It can reveal the meaning of behaviour rather than evaluate behaviour.For example, one might discover what a behaviour means to an individual or why the behaviour is manifested in certain situations as opposed to judging the behaviour relative to a norm. Ethnography can help explicate aberrations or unexpected ®ndings within quantitative studies. In the hands of a responsible, knowledgeable scientist, ethnography provides the potential to enhance our information base and expand our understanding of aphasia. References Agar, M. H. 1986, Speaking of Ethnography (London: Sage Ltd). Atkinson, P. 1990, Ethnographic Imagination : Textual Constructions of Reality (London: Routledge). Hammersley, M. 1992, What’s Wrong with Ethnography ? (London: Routledge). Hammersley, M. and Atkinson, P. 1983, Ethnography : Principles in Practice (London: Tavistock). Kirk, J. and Miller, M. 1986, Reliability and Validity in Qualitative Research (London: Sage Ltd). Lincoln, Y and Guba, E. 1985, Naturalistic Inquiry (London: Sage Ltd). Parr, S. Byng, S. Gilpin, S. and Ireland, C. 1997, Talking about Aphasia (Buckingham, UK : Open University Press). Simmons, N. 1993, An Ethnographic Investigation of Compensatory Strategies in Aphasia (Ann Arbor, Michigan : UMI Dissertation Services). Simmons-Mackie, N., Damico, J. and Damico, H. in press, A qualitative study of feedback in aphasia therapy. American Journal of Speech-Language Pathology. Simmons-Mackie, N., Damico, J. and Damico, H. 1996, The many faces of feedback in aphasia treatment. Poster presentation at the annual meeting of the American Speech Language Hearing Association, Seattle, WA. Spradley, J. 1979, The Ethnographic Interview (NY : Holt, Rinehart & Winston). Spradley, J. 1980, Participant Observation (NY : Holt, Rinehart & Winston). Strauss, A. and Corbin, J 1990, Basics of Qualitative Research (London: Sage Ltd). Westby, C. 1990, Ethnographic interviewing : Asking the right questions to the right people in the right ways. Journal of Childhood Communication Disorders, 13, 101±112.