The construction of the Dynamic Occupational Therapy Method: a non-dichotomous production between knowledge and practice

Abstract

Introduction  Occupational Therapy arrived in Brazil under the logic of rehabilitation and distanced from the Brazilian reality. Therefore, occupational therapists embarked on the adventure of thinking about the profession and its theoretical-practical aspects based on their contexts. Jô Benetton is among these professionals. Formed in 1970, she began a research project that culminated in the construction of the Method Dynamic Occupational Therapy - DOTM. Recent literature reviews that focus on the theme of epistemological constructions, when using journal indexing mechanisms, only cite the author's work, without explaining her contributions to the field and her knowledge construction process.

Objective  To elucidate aspects of the DOTM construction process, to understand how the production of knowledge occurred based on practical situations placed as an object of study, which resulted in the proposition of a theoretical-methodological framework specific to and in Brazilian Occupational Therapy.

Method  Qualitative research, with data from two interviews with Jô Benetton and one with Sonia Ferrari, analyzed thematically.

Results  Three main themes were identified that express how the DOTM was constructed in the light of a pragmatist epistemology: 1) Concerns, searches and experiments; 2) Inventions; 3) Emergence of a way of thinking-doing in practice.

Conclusion  The construction of the DOTM occurred in a non-dichotomous way between the production of knowledge and care, allowing the establishment of new relationships between theory and practice.

Keywords:
Occupational Therapy; Occupational Therapy/History; Epistemology; Professional Practice; Philosophy

Resumo

Introdução  A terapia ocupacional chegou ao Brasil sob a lógica da reabilitação e distanciada da realidade brasileira. Por isso, terapeutas ocupacionais lançaram-se à aventura de pensar a profissão e seus aspectos teórico-práticos a partir de seus contextos. Jô Benetton figura entre essas profissionais. Formada em 1970, iniciou um projeto de investigação que culminou na construção do Método Terapia Ocupacional Dinâmica – MTOD. Revisões recentes da literatura que se debruçam sobre a temática das construções epistemológicas, ao se utilizarem de mecanismos de indexação de revistas, apenas citam a obra da autora, sem explicitar suas contribuições ao campo e seu processo de construção de conhecimento.

Objetivo  Elucidar aspectos do processo de construção do MTOD, de modo a compreender como foi ocorrendo a produção do saber a partir das situações práticas colocadas como objeto de estudo, que resultou na proposição de um referencial teórico-metodológico específico da e na terapia ocupacional brasileira.

Método  Pesquisa qualitativa, com dados provenientes de duas entrevistas com Jô Benetton e uma com Sonia Ferrari, analisadas tematicamente.

Resultados  Foram identificados três temas principais que expressam como o MTOD foi sendo construído à luz de uma epistemologia pragmatista: 1) Inquietações, buscas e experimentações; 2) Invenções; 3) Emergência de um modo de pensar-fazer na prática.

Conclusão  A construção do MTOD ocorreu de modo não-dicotômico entre produção de conhecimento e de cuidado, permitindo instaurar novas relações entre teoria e prática.

Palavras-chave:
Terapia Ocupacional; Terapia Ocupacional/História; Epistemologia; Prática Profissional; Filosofia

Introduction

The occupational therapy profession (OT)¹ began in the USA in the 20th century, immersed in an effervescent social and civilizing movement to expand the social participation of people who found themselves in situations of exclusion – migrants, people with mental disorders, people with disabilities (Morrison, 2014). Also present at the beginning of the profession, pragmatist thinking stands out for placing experience as the center of learning and possibilities for social transformation, from a non-dichotomous perspective. In this sense, aspects of everyday experience provide the empiricism to be taken for reflection, in the construction of solutions to social problems (De Wall, 2021). The first occupational therapists, notably Eleonor Slagle, built the foundations for the profession based on experiments with occupations considering the relevance of the action to human life. Thus, the belief that carrying out activities could promote health, development and social participation contributed to the construction of practices aimed at those who were excluded from this participation, with the greater aim of restoring and maintaining well-being (Creek & Allen, 2022; Lima, 2021.

Therefore, pragmatist epistemology was central to the development of occupational therapy at the beginning of the last century (Morrison, 2014). Particularly for Dewey (1985), a collaborator at Hull House, perplexity – or doubt, arising in a conflictual situation experienced by human beings, is an indeterminate situation. Knowledge, in turn, is the element of control, of determining this situation. Knowing, therefore, is an operation in which an indeterminate situation becomes determined, that is, it is under control due to the knowledge acquired (Teixeira, 1955). In this sense, Dewey recovers “the dignity of practice, without however subordinating thought and knowledge to it” (Mogilka, 2010, p. 127). Thought, then, represents a stage of action, as a capacity of the human organism to solve problems of its social existence, and not just through mere speculation or pleasure. In view of this, the philosopher ends up distancing himself from metaphysics, as well as rationalist philosophies that separate rationality from experience and practice from thought (Marcolino, 2022; Mogilka, 2010).

However, the profession began to expand around the world under another paradigmatic logic: that of rehabilitation and functional recovery (Benetton, 2005; Melo, 2015; Morrison, 2014). In this sense, Morrison (2014) reflects that the profession's relationships with its initial philosophical foundations are not always properly considered in professional training, although such epistemological foundations are essential and relevant for understanding the discipline. As a result, the emerging profession increasingly aligned itself with medicine, thus distancing itself from the social activism of its founders and founders.

In Brazil, occupational therapy began in the 1950s, with the implementation of courses resulting from the International Rehabilitation Movement, and therefore under the logic of rehabilitation. Since the 1970s, this conception has been heavily criticized, as it did not respond to Brazilian needs. The normative and biomedical logic of cause-effect/complaint-conduct did not answer the questions posed by the need to transform society, in a period of important restriction of rights due to the military dictatorship (Cardinalli, 2017; Mello, 2023). As a result, many occupational therapists, from the 1970s and 1980s, embarked on the adventure of thinking about occupational therapy and its theoretical-practical aspects based on the reality of their contexts (Mello, 2023).

Jô Benetton is among these professionals. Graduated in 1970, she was the first occupational therapist to take on a public OT position in the State of São Paulo, in the area of ​​Psychiatry. Dissatisfied with her initial training, a well-known passage in her history also marks her professional trajectory. Jô says that, as soon as she finished her degree, she came to her mother – a historian and museologist – in tears, saying that she had graduated in a profession that did not exist (Cardinalli, 2017). At the time, as recorded in Cardinalli's thesis (2017), her mother replied: “then, make it exist, be your character”. However, more recently, in the class on the topic “occupational therapist” of the clinical specialization course in the Dynamic Occupational Therapy Method (DOTM), on June 24, 2023, Jô confessed that she would have loved for her mother to have told her this. She, who usually tells us that she would have liked to have had an occupational therapist supervisor, now also tells us that she wishes she had had a mother who would have shown her the way. The new story told by her that day allows us to know that, after her mother told her: “every profession has a story”, it was she, Jô, who said: “I will be your character”.

Tassara (1993) and Benetton (1995) help us to think that the construction of knowledge in occupational therapy encompasses knowledge that is directed towards professional practice, with a view to solving problems arising from this. Thus, over just over 50 years of research, Jô's main contribution was and has been the construction of a specific method for thinking about and doing occupational therapy: the Dynamic Occupational Therapy Method (DOTM). Although she is one of the best-known authors in the history of Brazilian occupational therapy and has completed the entire academic career of training and consolidation in research (master's, doctorate and post-doctorate), the majority of Jô Benetton's professional career took place outside formal academic spaces (Cardinalli, 2017).

Jô Benetton taught the occupational therapy course at the University of São Paulo between 1996 and 2002, but her vast production goes beyond this short period at the university. Furthermore, a considerable part of his work can still be found in his doctoral thesis (not published in articles) and in works presented in the magazine published by CETO, which remained active from 1995 to 2012. This magazine did not join the indexing system of academic journals, thus making it difficult to circulate their production through search and rescue mechanisms for productions in a specific field.

In this direction, recent literature reviews, which focus on the theme of epistemological constructions in occupational therapy at a national level, when using such journal indexing mechanisms from the 1990s onwards (Galheigo et al., 2018), or when carrying out a thematic mapping of Brazilian productions throughout history (Cardinalli & Silva, 2019), they only cite Jô Benetton's work in a decontextualized way. This fact does not allow us to elucidate both her contributions to the field and the process of knowledge construction undertaken by her.

The Dynamic Occupational Therapy Method

The Dynamic Occupational Therapy Method (DOTM) is a theoretical-methodological framework aimed at practice that began to be built in Brazil in the 1970s, and is today the oldest research enterprise in the field of Brazilian occupational therapy. In 1972, Jô Benetton, interested in investigating the practice of occupational therapy and “in building an internal logic for occupational therapy procedures” (Benetton, 2006), began study cycles with other occupational therapists. In 1980, in partnership with occupational therapist Sonia Ferrari, Jô Benetton founded CETO² , a private teaching, research and assistance institution that offers clinical training at DOTM. Although the theoretical-conceptual and methodological construction of this method was authored by Jô Benetton, Sonia was her oldest collaborator, using her own practice as an empirical field for the development of the DOTM (Benetton et al., 2021). Sonia Ferrari, graduated from the University of São Paulo in 1975, was an intern for Jô Benetton in the area of ​​psychiatry, at Santa Casa de Misericórdia in São Paulo (Mello, 2023). Currently with 49 years of professional experience, she is the director of Instituto A Casa, a training teacher at the DOTM and has a vast bibliography on occupational therapy in the field of mental health, focusing on the practice supported by the DOTM (Ferrari, 2002, 2012, 2015; Ferrari et al., 2022).

In this sense, the DOTM was built with the aim of proposing a theoretical and methodological apparatus using a language capable of acting as a structure for occupational therapy practice, supporting professional thinking-doing and enabling teaching-learning (Benetton, 1994). The construction of the DOTM is based on the assumption that occupational therapy “often has empiricism as an element that hinders its transmission” (Benetton, 1994, p. i), and precisely for this reason, it is necessary for the practice itself to be an object of research (Benetton, 2010, 2012). Thus, the DOTM has been constantly constructed, reformulated and expanded through empirical investigation of practice, in a process called “technique theory” (Benetton, 1994; Benetton, 2010). The theory of technique consists of the observation and analysis of practice, to build generalizations with theoretical explanations that support a theoretical-methodological framework that turns back to practice (Benetton 1994, 2010; Benetton & Marcolino, 2013).

Currently, the DOTM already has its own consolidated conceptual framework, presented in multiple theoretical and theoretical-practical publications (Marcolino & Fantinatti, 2014; Benetton et al., 2021). To present it succinctly, we chose not to detail it conceptually, but rather to present the path it proposes for interventions in occupational therapy. Thus, it starts with situational diagnosis, a continuous descriptive and analytical process, to identify the needs and desires of the target subject. For its composition, aspects relating to the subject themselves, other people in their environment are taken into account, in addition to information from the perception of the occupational therapist, in a triadic relationship – occupational therapist, target subject and activities (Benetton et al., 2021).

The intervention is guided by the establishment and management of this triadic relationship. It is a dynamic process that is based on the action and reaction of the three elements of this same relationship, in a subjective-objective setting that supports it. Educational action plays a central role in the therapeutic function, supported by the positive transference of the occupational therapist, in the search for establishing the subject's affection and desire to learn and develop (Benetton et al., 2021). The evaluation of the intervention takes place in a process of dialogical construction of meanings supported by the existence of a space of historicity, which allows not only to evaluate, but also to tell the story of the events from a narrative and not a chronological perspective. It is a continuous process from which new meanings are constructed through the target subject's analysis of their situation, their activities/productions, as well as when making decisions about the therapeutic process and their life. In the Associative Trails technique, associations are raised through the analysis of the activities carried out, which are subsequently grouped by the target subject themselves, enabling dialogue and reflection to recognize themself in terms of their skills, capabilities and limitations (Benetton et al., 2021).

These processes make it possible to expand healthcare spaces. Based on experiments in the triadic relationship, the occupational therapist supports the subject's unique identification and qualification of what they consider healthy and a source of well-being. Carrying out activities considered healthy will be expanded into their daily lives, increasing their participation and social insertion. Although considered in their singularity, the target subject is understood in their situationality, which also involves other people who make up their social world. Interventions with these people, when necessary, seek to integrate them into the triadic relationship as new terms of this relationship – the fourth terms. This is not only to guide families, employers, teams or friends, but so that these people can participate in a new relational system that allows the subject to be recognized in their real strengths and limitations (Benetton, 1994; Marcolino et al., 2020; Benetton et al., 2021).

The process of building this theoretical-methodological framework can be seen in Marcolino & Fantinatti (2014). These authors present an epistemological mapping of the development of the DOTM and systematize the dynamics of its transformation over time, identifying three main phases. The first of them covers the period between 1984 and 1993, characterized by the use of activities based on psychoanalytic theory, the landmark of which is Jô Benetton's master's thesis, later published as the book “Trilhas Associativas”, in 1991. In this phase, activities come to be understood as part of the relational system of the triadic relationship, composed of the occupational therapist, patient and activities, and “expression, communication and mediation between the internal world and external world were the characteristics most associated with activities” in this period (Marcolino & Fantinatti, 2014, p. 144).

The second phase of development of the DOTM, from 1994 to 1999, is related to Benetton's doctoral thesis (1994), in which she dedicated herself to the systematization of knowledge arising from empirical processes, described in the thesis through clinical cases that she conducted or supervised, and conceptual elaboration through the theory of technique. The three terms of the triadic relationship were defined and conceptualized, and procedures for establishing and managing this relationship were outlined, as well as the main processes for practice, such as situational diagnosis and associative trails (Marcolino & Fantinatti, 2014). The third phase began in the 2000s, after carrying out her post-doctoral research in Health History, at the École des Hautes Etudes en Sciences Sociales, through which the DOTM acquired a more refined outline, paradigmatically located in the initial proposals of foundation of the profession, at the beginning of the 20th century, in the United States. At this stage, greater robustness of the foundations that support the DOTM in social practice is identified, in the search for the insertion of people in situations of social exclusion, whereby the concepts of health and daily life are better worked on (Marcolino & Fantinatti, 2014).

Although it advances in unveiling the DOTM construction process, the analysis by Marcolino & Fantinatti (2014) was based on static bibliographic products, through which it is not possible to grasp the living process of construction. Thus, this article seeks to elucidate aspects of this same process, to understand how the construction of knowledge occurred through the practical situations that were placed as an object of study, and the process that supported the solutions/inventions that culminated in the construction of a reference theoretical-methodological specific to and in Brazilian occupational therapy.

Methodology

This study was developed in the context of two doctoral research (Araújo, 2022; Mello, 2023) aimed at understanding the process of constructing the DOTM and the characteristics of the thinking-doing process in practice, the clinical reasoning of expert occupational therapists that underlie professional practice at MTOD. This is qualitative research, immersed in the perspective of seeking to understand, describe and explain phenomena through understanding how people construct the world around them, to access experiences, generally considering real cases to understand the study question (Barbour, 2009).

The data analyzed in this article comes from two interviews carried out with Jô Benetton and an interview with Sonia Ferrari, both audio-recorded, transcribed and validated. This data was organized and analyzed thematically in NVivo®, version 12.6.0, a virtual software created to organize and analyze qualitative data. For analysis, the data were coded using the NVivo® software, which allowed the identification of meaning cores about the DOTM construction process (Minayo, 2014).

Ethical aspects

Both doctoral studies were approved by the Human Research Ethics Committee at UFSCar, under favorable opinions n. 3,382,934 and n. 4,473,156, with explicit authorizations for the public use of the names of the participants, namely: Jô Benetton and Sonia Ferrari.

Results

Table 1 presents the composition of the themes and subthemes arising from the thematic analysis.

Table 1
Themes and subthemes about the DOTM construction process.

Themes	Subthemes
1. Concerns, searches and experiments	1. Search for theoretical materials
	2. Experiments in practice
2. Inventions	1. Observations from practice
	2. Reflections supporting the proposition of new concepts
3. Emergence of a way of thinking-doing in practice	1. Departure from what is psychodynamic, moral, protocol and pre-established
	2. A thinking-doing that is ethical-aesthetic, situational and singular

• Source: adapted from Araújo (2022).

Concerns, searches and experiments

Jô Benetton and Sonia Ferrari spoke about their dissatisfaction with the theoretical productions and practice in occupational therapy that prevailed in Brazil in the 1970s and 1980s, when they were newly graduated. Such productions proposed that the occupational therapist build her practice in normative and adaptive ways, in addition to not clearly indicating how to think and act in practice.

[...] the occupational therapy course, at the time when I took it, was supported by three books, three authors [...] it was what we had in college [...] it was a normative, adaptive occupational therapy. [...] work with symptoms, medical model, such an activity for such a pathology, such an indication, such a contraindication, that was it (Sonia Ferrari).

In normative occupational therapy, clinical reasoning is medical clinical reasoning. Fully glued to the medical model. In one of the books we had at college [...] he states: pathology - Schizophrenia; symptoms; activity indications; contraindication of activities. Fully glued to the medical model. A leaflet. [...] I mean, there is no subject. He has illness (Sonia Ferrari).

[...] I didn't have a profession, and I wanted one. I didn't know what to do (Jô Benetton).

These dissatisfactions mobilized Jô Benetton to actively seek out various theoretical materials, both specific to occupational therapy and related content, that would contribute to expanding his way of thinking and practicing occupational therapy. Jô Benetton and Sonia Ferrari came across psychodynamic theoretical materials, which went beyond a search for normativity and adaptation, also considering the internal contents (subjective, emotional and intrapsychic) ​​of the people served.

I looked for theories outside of occupational therapy, as a resource [...] (Jô Benetton).

[...] in the 80s [...] I studied Fidler, Winnicott, Wittkower, Ázima, who were people who spoke about Psychodynamic Occupational Therapy (Jô Benetton).

What came later [theoretical materials] was very much a search that Jô carried out. [...] traveling, she would go into bookstores, she would look at the books, she would bring the books, we would read them. Fidler came to us like this (Sonia Ferrari).

When we discovered psychodynamics it was wonderful. Because they proposed something else. It wasn't adapting anyone, it wasn't putting anyone to work within the hospital industries. It was: ‘this guy has an internal world, he is communicating through activity, he is saying things about himself’. This was a fantastic discovery. [...] it came largely due to Jô's merit, of looking for these things on trips and in bookstores. We devoured everything. I translated at home, studied, trying to decipher every word and finding another world. This passage through psychodynamics was important because it was a departure from super-normative occupational therapy [...] (Sonia Ferrari).

Involved in resolving her dissatisfactions and building a practice different from what was available at the time, Jô Benetton, based on her studies and observation of what happened in practice, began to expand her way of thinking and experiment with new ways of practicing.

[...] when I started working, I already had a lot of personal difficulty fitting into pre-established protocol programs. [...] in the hospital [where she worked] [...] it was forbidden [...] to give artistic activities to patients because [they said] this increased delirium. And I secretly went to do it. [...] watching this I saw how different people were [...] I'm very curious, I was already trying things out (Jô Benetton).

However, Jô Benetton says that she did not uncritically apply the theoretical contents she studied, but observed the events of the therapeutic processes she was following and questioning theoretical aspects that she believed did not respond to the demands she was facing. Jô Benetton and Sonia Ferrari were, therefore, studying, experimenting and seeking to identify what worked or not in their own situated practices.

[...] but I never applied those [theories] in the way they proposed (Jô Benetton).

You enter into a matter of trying something. If it worked, we continued. If it didn't work, we went back (Jô Benetton).

[...] I loved the Fidler triad [...] But they put object as an object relation. I decided 'let's try it', I spoke to Sonia, 'I want to try that this isn't an object, it's an activity. Patient, therapist and activity. Let’s see if there’s any momentum in this.’. In the 1980s. [...] I was researching, I was curious to know if I could say of a triadic relationship with the activity in fact, not with the object from a fantasy, unconscious, psychodynamic point of view. [...] I was also looking for this association. If these three terms could be worked associatively (Jô Benetton).

Inventions

Faced with his dissatisfactions and criticisms of the theoretical contents with which he had contact, Jô Benetton realized that it would be useful to remain open to observe what the target subject was doing in the therapeutic process, giving less emphasis to what they were saying and trying as much as possible not to interfere in your doing.

I simply tried to observe what was happening in my situation (Jô Benetton).

[...] I started looking at what the subject did, not what they said. [...] from 1985 [...] it became clear to me this question [...] that I had to ask (Jô Benetton).

When I noticed that it was possible... when he asked me for the work, I took the work silently, I didn't do anything. Only when he started to spread it out did I say 'let's put it all over the room and then everything will fit'. That's what I said, the rest was all his (Jô Benetton).

Observing what the target subject was doing, Jô Benetton was surprised and enchanted by the unusual phenomena that appeared in practice. She emphasized that she often did not think about the possibilities that emerged. The subjects themselves demonstrated the ability to find solutions – affirming their position as a therapist, of not rigidly imposing their ideas/interpretations or even the course of the therapeutic process. The proposal was to remain open and respond to the phenomena that occurred in the practical situation, learning from these events.

[...] it is a path that goes from childhood to old age. Patients [...] taught me a lot [...] they were surprising. They could do things I had never thought of doing. [...] I remember one case [...] the patient had all the difficulties you can imagine because of her age. [...] The woman could make biscuit boxes, wonderful! The woman was in no condition, looking from the outside [...] I never thought of giving her a box of biscuits. I didn't think. But the biscuit box happened and I stopped (Jô Benetton).

I have to see the other person as they are. [...] people are very different. [...] People surprise me with their things, their news, their things that happen. And they're always nice. For example, one of the cases that I think is super cool in my life. [...] the patient had improved. Schizophrenic. I asked if he wanted to clean up my farm [...] here he and his father come. The father says ‘he does his housework so well. He is taking care of... our house, our shack has not been robbed since he has been there, making food, cleaning, washing. So he lets me clean up his farm and he stays at home.'. Look what an incredible solution. People gave me this as a solution when I looked at all of them. [...] the subject takes care of themselves. These things have enchanted me my entire life (Jô Benetton).

Based on her careful observations of the events of the therapeutic process, and not simply trying to fit the phenomena experienced into the theories she studied, Jô Benetton reflected on the phenomena that were occurring in her practice, stating that it is empirical observation that leads to theory.

I like the word think, reflect. I was making an observation of something, of some phenomenon that was occurring in my relationship with a patient. From then on, I kept reflecting on, for example, why that happened, that phenomenon, and not another (Jô Benetton).

[...] it is observation that leads to theory. [...] Because otherwise you will already be stuck with a theory [...] (Jô Benetton).

These reflections on practice (at the time the practice was happening) and on practice (after the practice), added to her studies, allowed Jô Benetton to construct a new way of thinking and propose or “invent” new concepts. This conceptual construction was close to the demands she was experiencing in practice, such as triadic relationships, dynamics of triadic relationships, association and associative paths.

Wow, this is surprising! Based on this [the observations] I began a new way of seeing that phenomenon, which usually had to do with three terms: patient, therapist and activities. For many years I have been thinking about this triadic relationship, the dynamics of this relationship, between human and non-human (Jô Benetton).

Case G. [...] I think it was the most interesting thing for me to always think that there was a possibility of free association with patients [...] any patient [...]. Suddenly this guy [G.] gave me this thing, because he selected his works and started telling stories. [...] It's fantastic there! I don't believe that myself. [...] it was exactly because of his unusual [...] bringing together work, HE takes the work [...] when he separates it [...] that allowed me, for example, to work for the rest of my life with the [associative] trails (Jô Benetton).

[Case] ​​S. is a consequence of my discovery that it could be evaluated through activities, through the triadic relationship. What [he] felt about me, what he thought of the activities, what stories they told about the three of us. I think this is an absolutely fortuitous phenomenon, but because I was having clinical reasoning. I don't want to define what [clinical reasoning] is. I want to show you what it is (Jô Benetton).

[...] I can say a lot of concepts that I reached conclusions with the use of activities, including the definition of the concept of activity, of triadic relationship, of dynamics of the triadic relationship, all of these are concepts, of course, that were taken from this observational perspective (Jô Benetton).

The concepts that Jô Benetton proposed/invented from her studies and her reflections in and about practice, and which make up the theoretical-methodological apparatus of DOTM, are open. This means that they should not be used to define, explain, fill gaps or close possibilities, but rather to support a particular path that will be followed by the occupational therapist in partnership with each target subject in their uniqueness, so opening up possibilities so that the unusual can emerge.

Look what I got! [...] there were three terms, and I conceptualized and defined these three terms. Patient, therapist, activities. [...] I was able to see that the dynamics of these three terms made sense. [...] concepts of health, the position of exclusion and not the excluded. When I started to conceptualize each of these things, it profoundly influenced my clinical reasoning. When I talk about ethics, transference, association, memorization, observation, information, in the case of the occupational therapist. [...] This is the central core of everything, I think. I have a nuclear thought in this sense. [...] When a patient comes to me [...] I'm always trying to see who that subject is, what their situation is, where the exclusion point is, where the insertion point is. Insertion is very important to me. The person must always be included. [these concepts] are already part of me. [...] Practice knowledge. [...] this is already inside me; I talk to people with these concepts already inside my head. [...] these concepts are open, they do not define a subject, for example They are open (Jô Benetton).

Emergence of a way of thinking-doing in practice

Although in the 1970s and 1980s psychodynamic theoretical contents triggered an important transformation in their ways of thinking and acting, Jô Benetton and Sonia Ferrari began to realize that these contents did not respond to aspects that should essentially be considered in practice. Among them, they did not respond to the need to work with the concrete aspects of life and to think in a way that moves away from what is moral, pre-established, protocol and exclusively theoretical.

[...] if I think about the beginnings where I was [...] much more identified with psychodynamic thinking, there has been a fundamental change. Because in psychodynamic thinking what was much more at stake were subjective, intrapsychic issues. So, the entire focus of the interventions was to work with the internal world [...] and with little intervention in the external, in everyday life, in the necessary organizations, to deal with this. The traffic was different. [...] everything changed as it became possible to see that this internal vision alone was not enough to deal with the concrete aspects of life (Sonia Ferrari).

Everyone was thinking about a theoretical, pre-established aspect (Jô Benetton).

When morality is used, it has nothing to do with this, with the observed phenomenon, with practice, it has to do with the theoretical thing. [...] What I want to say is that really what is pre-established in a relationship of science, knowledge, life, doesn't work for me (Jô Benetton).

[...] follow a protocol? This is absurd, this does not exist, this for me is emptiness. [...] prevents the existence of clinical reasoning. Prevents thinking. A simple thing is to think. Observe and say 'wow, this exists', 'look how it was made', 'look…'. Prevent that. Admiration, curiosity, invention, fiction (Jô Benetton).

To focus on social insertion as the main proposal of occupational therapy, thinking about how to deal with the concrete aspects of life and how to consider the dynamics between the three terms of the triadic relationship, Sonia Ferrari emphasized that it was necessary to build a way of thinking, a specific clinical reasoning which, in turn, also brought specificities to their way of acting.

[Occupational therapy] has as its proposal concrete things, organizations, the construction of a place in society, possible insertions in the world. I mean, [psychodynamic theories] took care of one part, but they didn't take care of this other part, which was a purpose. So, to this extent, it is obvious that the way of understanding the patient, the way of using activities, the understanding of how the triadic relationship was established was changing a lot, this whole transition from understanding the activity as a mediator, so that I could understand the activity as a term of the relationship, as one of the terms of the triadic relationship and this movement of action and reaction. This completely changes interventions, and completely changes clinical reasoning (Sonia Ferrari).

When describing the way of thinking and acting that was being constructed, Jô Benetton and Sonia Ferrari talk about the construction of the DOTM itself. Jô Benetton highlighted the focus on ethics-aesthetics, on the need to open space for the unusual to emerge, to consider facts situationally, to seek to find the uniqueness of the people served and their ways of doing things and relating to people and objects.

I already had the idea that everything was about the situation, and the situation, for me, implied the social. [...] You cannot separate anything from the human condition. [...] The discovery of the singularity of the situations that exist, that are there, in the context. We have a job that deals a lot with reality. Reality enters our four walls every time the patient enters, with everything they have outside: social, political, economic, regional, whatever (Jô Benetton).

[...] clinical reasoning must be part of the unprecedented, of invention, of observation (Jô Benetton).

There's a word that I really like about the new science, which is singularity [...], the singular [...]. How are there new phenomena, new occurrences, the uniqueness of the use of objects, for example. I think this is fundamental, the singularity in the use of objects. And that goes for life. When you think of an older person who knits, crochets, which are handmade activities. This doesn't make any sense: 'Wow!'. But for the person it could be something else. There is a lot of self-placement in each object (Jô Benetton).

[...] find singularity, that's it, they will find it (Jô Benetton).

Ethics [...] is about looking inside what you do and discovering the beauty. [...] when I'm talking about ethics, I can't help but put aesthetics together. They are one. Occupational therapy is beautiful (Jô Benetton).

Discussion

Concern about the foundation of practice was growing on the international scene in the 1970s (Kielhofner & Burke, 1977). As an example, the Human Occupation Model – one of the most used and researched practice models in the field of occupational therapy – had been developing, taking into account the initial contributions of Mary Reilly in the 1960s, which was formally presented in 1980 (Kielhofner & Burke, 1980). In Brazil, training courses began to expand in the 1970s and, from 1990 onwards, national publications in the area began. There was an important focus on the foundation of the practice, from a critical perspective and centered on the Brazilian socio-political reality, based on dialogue with the human and social sciences (Galheigo et al., 2018).

Jô Benetton, in turn, followed a different path. Faced with a very indeterminate situation of not knowing how to practice occupational therapy, and the precariousness of bibliographic materials available in Brazil to support the practice, she began a project to build knowledge in occupational therapy. Their concerns were centered on resolving issues absolutely arising from practice, from a counter-hegemonic perspective, moving away from the biomedical and rehabilitation paradigm, away from protocol practices and focused on standardization. This research project, which is open and, therefore, still ongoing, can be considered the oldest research undertaking in the field of Brazilian occupational therapy and, possibly, one of the oldest in the world of the field itself.

In this endeavor, the author committed herself to study groups, internships and supervision with psychoanalysts, as well as translating texts by North American, Canadian and European occupational therapists, in addition to literature from psychiatrists, psychoanalysts, sociologists and anthropologists (Marcolino & Fantinatti, 2014). However, the basis of the knowledge construction process was anchored in the observation of occupational therapy events. It was not, therefore, a question of fitting the phenomena into theories, but rather of using them to think about the phenomena and, mainly, to find ways of acting that proved to encourage patients to carry out activities. By placing her own practice as an object of investigation – and the practice of her students and colleagues who began to train with her (Cardinalli, 2017) – also relying on the important partnership with Sonia Ferrari – a broad laboratory was established, which it allowed us to experiment with different ways of doing and observing the events of the therapeutic process. It is worth highlighting the partnership with Sonia Ferrari, in her constant affectionate and respectful presence, being the first occupational therapist to experience Jô Benetton's propositions in practice, thus receiving the recognition that “if it weren't for Sonia, I think the Method (DOTM) nothing would have turned out the way it did” (Mello, 2023, p. 78).

In this way, the process of building the DOTM and a new way of thinking-doing in practice was happening simultaneously, that is, at the same time as their ways of thinking about practice and acting in it were changing, the theoretical-methodological apparatus of the DOTM was also being constructed and, consequently, its ways of thinking, practicing and acting. In this sense, Jô Benetton reports the centrality of the act of allowing oneself to be surprised by the unusualness of practice, from the perspective that the new event demanded understanding, thus opening space for conceptual constructions that, in a new way, allowed a return to practice. It is, therefore, a virtuous cycle of perceiving, mainly through scrutinizing observation (Benetton, 1994), seeking to find existing theoretical propositions or analyzing the invention of something new, trying such ideas in practice and analyzing their repercussions and consequences, until the invented concept would prove to be fertile in other practical situations based on its effects in occupational therapy (Marcolino et al., 2021).

This process of taking experience as an object of study aligns with a pragmatist epistemological perspective, and particularly dialogues with Dewey's (1985) theory of investigation. Dewey (1985) argues that, so that there is no dichotomy between the knowledge produced and the nature of the phenomenon studied, it is essential that the investigation starts from primary experience, from the facts or objects of our daily experience, not yet intellectualized. The investigation process to transform an indeterminate situation into a determined one, therefore, demands a systematic path that is not limited to rational analyses. As new elements present in the experience are perceived, new ideas about them emerge, allowing new actions to be carried out. New actions enable the perception of other aspects, producing this virtuous cycle between new ideas and new actions, until the situation is determined – and everyone involved in the then indeterminate situation is satisfied (Dewey, 1985).

Marcolino (2022) points out Jô Benetton as a pragmatist author precisely because she invested in proposing a method that allows the complexity of practice to be incorporated, not based on representative or explanatory concepts of phenomena, but on operational concepts, which allow acting and thinking about practice based on the consequences of events, whose perspective of the people involved is included and considered. Marcolino (2022) also emphasizes that this is a non-dichotomous perspective, as it integrates processes of theoretical production and practical production, placing the production of knowledge and care in a complementary and inseparable way. This way of producing care and building knowledge seems aligned with the soil in which occupational therapy emerged, then flooded by humanist and activist perspectives, having at its root the connection with pragmatist thinking (Lima, 2021).

Furthermore, another pragmatist characteristic of Jô Benetton's work encompasses the valorization of singular and situational aspects, and the distancing of collective standards of normativity. According to Marcolino (2022), both in Dewey (1985) and Addams (1964), what is considered ethical is defined by its consequences in enriching experience and in designating what is good and brings well-being to those involved. In this sense, it is recognized that Jô Benetton's theoretical-practical production is ethical and aesthetic, based on the functionality and beauty of practical use in people's lives (Marcolino, 2022). Thus, while criticism and distancing from collective standards of normativity are allowed, an “experience of construction and integration” (Benetton, 2006, p. 23) is sought, in which the subject will construct meanings for their daily lives based on they understand that makes sense for their lives.

This non-dichotomous production between knowledge and practice, ethics and aesthetics, thus distances itself from occupational therapy perspectives that dissociate subjects from their environments, in the logic of “community, social, cultural and ecological de-responsibility of being-doing-thinking-feeling about the world in an individualistic perspective perpetrated by neoliberal capitalism” (Cardinalli et al., 2021, p. 03). Considering that contemporary capitalism disenfranchises the exercise of free thought and action (Stengers, 2018), it is understood that this way of practicing and producing knowledge adopted by the author can also be a form of resistance, as it seems to invest in the search for self-deviate or even break with automatisms and patterns, in order to support other forms of life (Lima, 2022), allowing others this same freedom to be and be in their own way in the world.

Final Considerations

This article aims to make visible the living process of building knowledge in occupational therapy carried out by Jô Benetton in partnership with Sonia Ferrari, a research enterprise lasting more than 50 years that placed occupational therapy itself as the object of studies in occupational therapy, and which culminated in the construction of a specific theoretical-methodological framework for and in Brazilian occupational therapy. This way of producing knowledge is discussed in the light of a pragmatist epistemology, in order to recognize Jô Benetton as a pragmatist author. Therefore, it is stated that the construction of knowledge in occupational therapy can occur in a non-dichotomous way between theory and practice, between knowledge production and care. By maintaining a strong ethical commitment to occupational therapy, embodied in the search for theoretical solutions linked to practice, Jô Benetton “gives life” to the knowledge that emerges from the field, contributing and favoring the construction of other epistemologies, while reactivating the ethical dimension -politics that strongly marked the emergence of the profession.

Future research may contribute to the advancement of the study of theoretical-practical perspectives that are not official in formal means of disseminating knowledge, whose logic privileges and makes visible publications only by professors-researchers. Future studies may also favor understanding the historical development of DOTM, such as the approaches and distances between psychodynamic perspectives; and also the elucidation of the conceptual construction of the various operational concepts of the DOTM, investigating the effect of this theoretical-methodological proposal on the practice of occupational therapists who use it as a reference, in order to reveal its repercussions in practice, taking into account the Brazilian context.

• 1
  In this article, the following spellings will be used: “Occupational Therapy”, with initials in capital letters, to refer to the profession, and “occupational therapy” with initials in lowercase letters to refer to professional/clinical/care practice, as suggested by Benetton (1994).
• 2
  Center for Occupational Therapy Studies, currently the Center for Specialties in Occupational Therapy
• Como citar:
  Mello, A. C. C., Araújo, A. S., & Marcolino, T. Q. (2024). The construction of the Dynamic Occupational Therapy Method: a non-dichotomous production between knowledge and practice. Cadernos Brasileiros de Terapia Ocupacional, 32, e3673. https://doi.org/10.1590/2526-8910.ctoAO286936732
• Funding Source
  This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001 and 88881.622977/2021-01 (Sandwich Doctorate) and received funding from the São Paulo State Research Support Foundation FAPESP 2021/14571-6.

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Edited by

• Section editor
  Profa. Dra. Adriana Miranda Pimentel

Publication Dates

• Publication in this collection
  07 Oct 2024
• Date of issue
  2024

History

• Received
  27 Dec 2023
• Reviewed
  22 Jan 2024
• Accepted
  05 July 2024