The Dynamic Occupational Therapy Method as a theoretical-methodological framework for telehealth practices: a qualitative study

Abstract

Introduction  Telehealth in occupational therapy expanded significantly during the COVID-19 pandemic. The literature highlights the need to develop creative, less bureaucratic, and person-centered practices. The Dynamic Occupational Therapy Method (MTOD) proposes a non-protocol, dynamic, and situated practice, which may provide insights into advancing the incorporation of communication and information technologies.

Objective  To analyze the challenges, learnings, and strategies of occupational therapists in delivering on-line care supported by the MTOD.

Method  An exploratory qualitative study was conducted with 13 occupational therapists who use the MTOD. Data were collected through a characterization form and semi-structured interviews, which were thematically analyzed.

Results  Most participants identified as cisgender women, white, residing in the state of São Paulo, with additional participants from Rio de Janeiro and Ceará. They had more than 20 years of professional experience, working as self-employed practitioners in private practice, across different fields and with diverse age groups. The qualitative results addressed: insecurities and openness to new learning within cyberculture; new skills for singular and situational digital inclusion through educational actions; the singularities of the target subjects and work with fourth terms; the triadic relationship in hybrid technological clusters; and the MTOD as a framework for creative, flexible, and safe practices.

Conclusion  The MTOD proved to be sensitive to the realities of telehealth practice, being applied dynamically and demonstrating versatility and adaptability, while providing theoretical-methodological support for occupational therapists. As a phenomenon of contemporary practice, it is expected to broaden reflections within both the professional field and the knowledge base of occupational therapy.

Keywords:
Occupational Therapy; Telemedicine; Procedures

Resumo

Introdução  A telessaúde foi impulsionada na terapia ocupacional no contexto da pandemia de covid-19. A literatura indica a necessidade de construção de práticas criativas, menos burocráticas e centradas na pessoa. O Método Terapia Ocupacional Dinâmica (MTOD) propõe uma prática não protocolar, dinâmica e situada, podendo oferecer pistas sobre como avançar na incorporação do uso de tecnologias de comunicação e informação.

Objetivo  Analisar os desafios, aprendizados e estratégias de terapeutas ocupacionais na oferta de atendimentos on-line sustentados pelo MTOD.

Método  Foi desenvolvida uma pesquisa qualitativa de natureza exploratória com 13 terapeutas ocupacionais que trabalham com o MTOD, por meio de um formulário de caracterização e de entrevistas semiestruturadas analisadas tematicamente.

Resultados  A maioria das participantes se identifica como mulher cisgênera, branca, residente no estado de São Paulo, havendo também participantes do Rio de Janeiro e do Ceará, com mais de 20 anos de experiência profissional, atuando como trabalhadoras autônomas em prática privada, em diferentes campos de atuação e com distintas faixas etárias. Os resultados qualitativos abordam: inseguranças e abertura para novas aprendizagens na cibercultura; novas habilidades para uma inclusão digital singular e situacional por meio de ações educativas; as singularidades do sujeito alvo e o trabalho com quartos termos; a relação triádica em aglomerados tecnológicos híbridos; e o MTOD como referencial para práticas criativas, flexíveis e seguras.

Conclusão  O MTOD mostrou-se sensível à realidade da prática em telessaúde, sendo utilizado de modo dinâmico e evidenciando versatilidade e adaptabilidade, com respaldo teórico-metodológico para terapeutas ocupacionais. Trata-se de um fenômeno da prática contemporânea e espera-se ampliar as reflexões para o campo profissional e do saber em terapia ocupacional.

Palavras-chave:
Terapia Ocupacional; Telessaúde; Procedimentos

Introduction

Telehealth can be understood as the use of information and communication technologies (ICTs) to deliver healthcare (Bender et al., 2024). With technological advances, this practice has been discussed in recent decades, including in occupational therapy, as an alternative model to in-person care (Leidemer & Peruzzolo, 2021; World Federation of Occupational Therapists, 2014; Zahoransky & Lape, 2020). However, faced with the challenges of social isolation imposed by the COVID-19 pandemic, the profession, in addition to reflecting on its contribution to coping with the pandemic, began to develop new actions using technology as a resource for care and for the continuity of follow-up with individuals who require occupational therapy. This modality was atypical for Brazilian occupational therapists, as it was neither part of professional practice nor included in their education.

In 2020, given the global need to use technological resources for occupational therapy care, the World Federation of Occupational Therapists (WFOT) updated its position statement (World Federation of Occupational Therapists, 2020). The use of telehealth by health professionals was also recommended by the Pan American Health Organization (Organização Pan-Americana da Saúde, 2020), and the Brazilian Ministry of Health, through Law No. 13.989/20 (Brasil, 2020a), regulated telehealth as a strategy to ensure the provision and continuity of treatment for users. Several terms are used for this model of care, such as telemonitoring, teleconsultation, and telecounseling. The World Federation of Occupational Therapists (2020) recommends the term telehealth for occupational therapy care that promotes health, regardless of the context in which professionals practice. Telehealth practices may employ different resources, such as videoconferencing, remote monitoring, virtual interactions using apps and gaming technologies, as well as data transmission. In this model, evaluation, intervention, monitoring, supervision, and counseling can all be performed (World Federation of Occupational Therapists, 2020).

Telehealth services must follow the same standards as in-person services, complying with all jurisdictional, institutional, and professional regulations, and adhering to the policies that govern occupational therapy practice in each country (World Federation of Occupational Therapists, 2020). In Brazil, the Code of Ethics and Deontology of occupational therapy prohibited the provision of non-in-person therapeutic consultations. However, in 2020, because of the pandemic, the Federal Council of Physical Therapy and Occupational Therapy revoked this restriction through Resolution No. 5167 (Brasil, 2020b).

Several national and international studies (Almathami et al., 2020; Caetano et al., 2020; Hung & Fong, 2019; Núñez & Águila, 2024a, 2024b; Zahoransky & Lape, 2020) highlight both benefits (lower costs, expanded access, and interventions centered on the realities of the home and caregivers) and barriers (internet access, availability of equipment and materials, acceptance of telehealth, and inadequacy of physical or relational spaces) to the use of telehealth resources.

Núñez and Águila (2024a) describe obstacles identified by occupational therapy students and faculty, service users, and team members in Chile when implementing telehealth practices during the COVID-19 pandemic. These included inadequate physical spaces for addressing intimate matters, family intrusions, and difficulties in acquiring materials. Conversely, they also identified that families could act as co-therapists, that there were gains in conducting everyday activities, and that it was possible to provide emotional support in the face of suffering caused by the pandemic. In a study with students in training during the pandemic, Núñez and Águila (2024b) emphasize the occurrence of significant learning processes, such as building bonds, developing creative and flexible practices, and appropriating ICT resources.

In Brazil, during the pandemic, there were advances in qualitative research with case reports and experiences of occupational therapists in telehealth practice (Chalegre & Melo, 2021; Fernandes et al., 2021; Ferrari et al., 2022; Ricci et al., 2020; Santos et al., 2021). Although telehealth practice is relatively recent, experience during the pandemic showed that it was possible to reach different population segments.

This new practice scenario and its challenges, likely accelerated by the demands of the COVID-19 pandemic, place us before the phenomenon of cyberculture. Cyberculture is the culture that emerges with the use of the internet and influences modes of subjectivation, shaping our social participation (Ferigato et al., 2017). Today, our lives are immersed in cyberculture, and this context brings new demands for occupational therapy. On the one hand, it is necessary to consider the social exclusion of the “disconnected,” but on the other, there is an opening for the creation of new intervention strategies that incorporate all available tools to promote emancipation and social inclusion, considering not only internet access but also skills in interpreting and handling information (Ferigato et al., 2017).

It is therefore essential to recognize that the virtual environment is part of reality. According to Lévy (1996), the virtual is not opposed to the real, but must be understood as actual. Even after the intensification of daily virtualization during the COVID-19 pandemic, we still tend to think that being virtually present is not being truly present, because of the separation between physical space and the distinction between time and space. However, Lévy (1996) argues that when we are virtually synchronized with the other, despite these differences, we create a real space where new means of interaction in time and space emerge. The virtualization of the body and senses implies that each body becomes part of a vast hybrid and globalized hyperbody, and our senses engage in sharing photos, videos, and audios. The boundaries between private and public blur, and nothing is clearly defined (Lévy, 1996).

Thus, thinking about occupational therapy in times of cyberculture requires going beyond the acquisition of technological resources for treatment. It is necessary to situate the profession more broadly within contemporary culture. In this context, occupational therapists are called to improve their digital competencies (Madsen et al., 2020).

According to Proffitt et al. (2021), knowledge must advance regarding the use of telehealth for evaluation and intervention in occupational therapy, aligned with studies on cyberculture and the everyday life of the assisted individuals. Scott’s (2020) reflections on professional learning during the pandemic highlight the need to be more creative and less bureaucratic, to value person-centered care, to provide services in new ways such as telehealth, and to consider social determinants of health.

According to Scott (2020), during the pandemic the profession gained recognition by positioning occupations as a health issue, demonstrating its competence and the need to advance knowledge. In this regard, the Dynamic Occupational Therapy Method (MTOD)—a specific occupational therapy method that advocates for non-protocol, dynamic, and situated practice centered on the uniqueness of individuals (Benetton et al., 2021)—offers insights into how occupational therapy may advance in incorporating the use of ICTs in care. Did professionals who adopt the MTOD use the telehealth modality during and after the COVID-19 pandemic? What reflections have they been developing in this regard?

The Dynamic Occupational Therapy Method

The Dynamic Occupational Therapy Method (MTOD) has been developed since the 1970s by Jô Benetton and collaborators, grounded in the investigation of clinical practice to produce explanatory theories of phenomena and methodologies that support occupational therapy care. Its delineation began with Jô Benetton’s doctoral dissertation in 1994 and was refined after her postdoctoral studies in 2000 (Marcolino & Fantinatti, 2014).

In the MTOD, the triadic relationship—composed of the occupational therapist, the target subject, and activities—constitutes the central nucleus for the development of care actions. This relationship is sustained in a setting that encompasses both objectivity (materials, the room, the external environment) and subjectivity (Benetton, 1994). The setting is built within the relationship between the occupational therapist, the target subject, and the activities, and can therefore be carried to wherever this relationship is established (Benetton, 2006), transcending the physical spaces of rooms and institutions.

As the first element of the triadic relationship, the occupational therapist must have knowledge of the culture in which she lives, and it is her responsibility to initiate the triadic relationship and sustain the therapeutic process (Benetton et al., 2021). To this end, Benetton (1994) emphasizes the importance of developing a scrutinizing gaze that searches for information. It is a gaze invested with affection and attentiveness, which enables the apprehension of elements that can later be used in communication (Benetton, 1999). This is not restricted to visual observation alone but involves the whole body and perception in this investigative and caring process in an inseparable way (Benetton, 2023).

The second element of the triadic relationship, the target subject, is someone with a need or desire to engage in occupational therapy (Benetton, 1994). In this regard, the understanding of their needs and desires does not occur through a medical-clinical diagnosis or service demands, but through the preparation of a situational diagnosis (Benetton, 1994; Benetton et al., 2021). The situational diagnosis aims to understand the target subject through the description of their current situation, including their everyday life, activities, needs, desires, and relationships (Marcolino, 2016).

The activities, in turn, constitute the third element of the triadic relationship (Benetton, 1994). They simultaneously fulfill a dual function: sustaining the educational action in occupational therapy, since it is through activities that an affective relationship of learning is established, and fulfilling the therapeutic function, enabling the learning of what one needs and wishes to do. This entire process is dynamic and iterative (Araujo et al., 2024).

The establishment and management of the triadic relationship allow the target subject to experience new situations and new ways of relating, in a space of historicity in which activities considered important begin to be incorporated into everyday life, resulting in processes of expanding healthy spaces (Benetton, 1994). For many people, this expansion of participation requires involving other significant and relevant individuals in the life of the target subject in the triadic relationship. These individuals are invited to compose the relationship and are thus considered fourth terms. In this case, it is not limited to providing guidance to family members, teachers, or teams, but to creating new movements with them, constructive movements of new associations that enable the target subject to be, to do, and to relate in their own way (Marcolino et al., 2020).

A first study on the use of the MTOD in the telehealth modality was presented by Ferrari et al. (2022). It consists of an analysis of occupational therapy practice with a group in a mental health day hospital, considering the reality faced by patients adapting to a new routine without daily travel to the hospital during the COVID-19 pandemic. The article describes the group process, which begins with instruction on the use of the online platform and evolves to function creatively, with activities chosen by participants. The possibilities of activities were expanded through screen sharing and the use of other virtual applications for interaction. Ferrari et al. (2022) also highlight the development of the occupational therapist’s skills in managing online activities, ensuring flexibility and participant inclusion.

The need to investigate occupational therapy practice in telehealth and to strengthen theoretical-methodological structures is identified by Ferrari et al. (2022) as a gap, pointing to directions that led to the development of this study. For the MTOD, the investigation of practice and its phenomena is fundamental for the construction of knowledge in occupational therapy, enabling theoretical-methodological advances. This article, therefore, discusses the results of a study aimed at understanding how the MTOD has been applied in the telehealth modality.

Method

Type of study

This study sought to understand the meanings and phenomena experienced by occupational therapists who use the MTOD in telehealth, providing a synthesis of these experiences. A qualitative and exploratory approach was adopted for the study design. According to Prodanov & Freitas (2013), qualitative exploratory studies are especially appropriate for contemporary and complex phenomena, such as the use of telehealth. To examine how the MTOD has been applied in the telehealth modality, the study accessed reflections and opinions of occupational therapists regarding their experiences (Ajjawi et al., 2024).

Ethical aspects

The study was approved by the Research Ethics Committee (CEP) of the Federal University of São Carlos (UFSCar) (approval no. 5.867.305). All participants signed an informed consent form. To expand the dialog with cyberculture, the concept of the cyborg, proposed by Haraway (2023), was employed. According to this concept, we are all constituted by a network of human and non-human associations, making it difficult to separate what is human in an increasingly technological world. Thus, to ensure confidentiality, participants were identified by cyborg names generated by artificial intelligence.

Participants

The study included occupational therapists trained in the MTOD with experience in telehealth in Brazil. Inclusion criteria were having completed MTOD training and at least one case attended in telehealth. Occupational therapists trained in the MTOD but not using it as a theoretical framework were excluded. After approval by the CEP, contact was made with the coordination of the Centro de Especialidades em Terapia Ocupacional (CETO), the institution responsible for specialized training in the MTOD, offered in a two-year course. CETO sent the project and the invitation to participate by e-mail to trained occupational therapists. In parallel, the research was also disseminated through social media.

Data production

Data were collected in two phases. The first consisted of an online questionnaire, applied between April and June 2023, which gathered numerical and descriptive sociodemographic and professional data (age, gender identity, race or color, state and city, years of professional experience, type of work, income, target population, other postgraduate degrees, year of MTOD training, experience with telehealth, number of persons attended, format of service delivery, platform used). It also collected narrative data on challenges and potentialities perceived in the use of the MTOD in telehealth, through two open-ended questions. The questionnaire resulted in 18 responses, of which 17 participants agreed to take part in the second stage, consisting of semi-structured online interviews. However, only 13 interviews were conducted because of scheduling difficulties. The interviews were conducted via the Google Meet platform, recorded, and transcribed with the support of Descript^® software.

Both the characterization questionnaire and the interview guide, which contained questions about telehealth experience (training, type of experience, main changes observed, composition of the situational diagnosis, establishment and management of the triadic relationship, reflections on activities and processes of meaning-making, current experience, challenges and potentialities, and the future of telehealth), were submitted for review by three researchers from the Laboratório de Terapia Ocupacional e Saúde Mental (LaFollia) at UFSCar, and adjustments were made regarding the order of questions.

Data analysis

Quantitative data from the questionnaire were analyzed descriptively only (Gil, 2002). Qualitative data (narrative responses from the online questionnaire, 13 interviews, and their transcripts) were thematically analyzed in three stages: pre-analysis, exploration of the material, and interpretation of the results (Minayo, 2014). Atlas.ti^® software was used to organize, systematize, and support the qualitative data analysis (Silva Júnior & Leão, 2018). The analytical process involved an initial deductive approach, followed by an inductive phase, in which themes were identified both from direct answers to the questions and from broader analysis of the interviews. In the end, the themes identified were examined considering the theoretical framework of the MTOD: for instance, information related to everyday life, the situational diagnosis, and the specific context in which a person was situated was organized around the theme of the target subject.

Reflexivity

All authors have training in the MTOD, which could have introduced bias into the study. To minimize this risk, the research team maintained a reflexive stance throughout the process (Stanley & Nayar, 2023). Professionals without MTOD training contributed at various stages, including the final project presentation at LaFollia, the review of the interview guide by an external researcher, and the participation of a faculty member not specialized in the MTOD on the qualification exam committee. This robust and reflexive methodological approach aimed to ensure that the study was conducted rigorously and impartially, while critically and thoroughly exploring the nuances of MTOD application in telehealth.

In addition, to increase reliability, the results were sent to participants by e-mail with the following request: What did you think of the results of this study? Did they help systematize reflections on telehealth practice using the MTOD? Are there points with which you disagree? Of the 13 participants, six responded to the e-mail, noting that the results were interesting and capable of generating meaningful reflections regarding the MTOD. They emphasized that the information presented was consistent with their practical experiences and studies and highlighted that the MTOD was comprehensively addressed in the research, covering its main features and applicability across different therapeutic contexts.

Results

Characterization of participants

Of the 13 participants, one identified as a cisgender man and twelve as cisgender women; nine participants identified as white, three as mixed race, and one as Black (Instituto Brasileiro de Geografia e Estatística, 2022).

Regarding geographic distribution, 11 participants resided in the state of São Paulo (seven in the capital and four in the interior), one in the state of Rio de Janeiro, and one in the state of Ceará. In terms of professional experience, seven participants had 21 years or more, two had between 11 and 20 years, three between 6 and 10 years, and only one had fewer than six years of practice. All participants worked in private practice (either in their own offices or private clinics). Their gross monthly income ranged from 4 to 20 minimum wages. As for academic background, most (nine) had completed a specialization or residency program, three were pursuing doctoral degrees, and three had completed master’s degrees. Participants had completed MTOD training at different points, from as early as 1990 to as recently as 2022. Regarding experience with telehealth, most participants (12) began providing telehealth services during the pandemic and continued afterwards.

The target populations assisted by the occupational therapists were diverse, covering different fields of practice, with emphasis on the mental health field and various age groups, as shown in Table 1.

Table 1
Target populations reported by participants.

N	Participant	Description of target population
1	CybPilot	Individuals with psychological distress
2	CybGenius	Older people
3	CyberCore	Children, adolescents, and adults in the fields of neurodevelopment, mental health, and hospital care
4	ByteSage	Persons with mental disorders and impairments in everyday life
5	RoboTech	Persons of all ages, with or without medically diagnosed conditions
6	RoboMarks	Adults with mental distress; supervisor at a CAPS Adult center and faculty member
7	NeoCyber	Children with intellectual disabilities
8	Neuronexus	Autistic children, adolescents, and adults with mental health conditions
9	CybZen	Primarily children and adolescents diagnosed with Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, mood disorders, and psychological distress
10	Omegaplex	Persons with mental health disorders and chemical dependence
11	CyberIntellect	Persons with disabilities
12	CyberExplorer	Adolescents, adults, and older people with mental health conditions
13	CyberArt	Persons with autism, psychosis, and conditions related to gerontology, from children to adults

• Source: Prepared by the authors.

Regarding MTOD training, two participants had graduated before 2000, six between 2001 and 2010, and five between 2011 and 2022. Concerning telehealth, 11 participants started providing services during the pandemic and continued afterwards; one began during the pandemic and, at the time of the study, worked exclusively in telehealth; and one provided telehealth services only during the pandemic.

Qualitative results

Five themes were identified: 1) Cyberculture – from insecurity to openness to new learning; 2) Educational action – singular and situational digital inclusion; 3) The target subject and fourth terms; 4) The triadic relationship in online occupational therapy; 5) The MTOD as a framework that supports telehealth practice.

1. Cyberculture – from insecurity to openness to new learning

Although our lives are immersed in the culture inaugurated using the internet, employing ICTs in occupational therapy treatment was not part of Brazilian professionals’ reality. In this theme, participants described how they overcame initial insecurities and transformed them into a process of learning and professional development that enabled them to expand their knowledge of cyberculture resources.

Thus, because of the pandemic, all study participants reported the need to provide telehealth services, expressing insecurity both in the context of public calamity and in the use of ICTs in professional practice.

One point we cannot lose sight of: this was not a project where someone was trying to study this modality, it was not an offer, it was not a choice, it was almost compulsory. (CybGenius)

I was completely unprepared. For me it was very distressing, I was very insecure. (CyberCore)

Faced with the need to use telehealth and their lack of preparation, the occupational therapists turned to clinical supervision and self-directed studies, learning from practical experiences to improve their care.

I did not have specific training, but I had supervision with an occupational therapist, and I kept asking questions [...] and planning. (ByteSage)

One participant reported having completed a telehealth training course during the pandemic, noting that it was not specific to occupational therapists.

[...] some training sessions offered by the USP during this period of the pandemic, they started this initiative to train for telecare. You would choose the area you wanted: childhood, psychological distress, grief [...]. It included all health professions, nothing specific to occupational therapy. (Omegaplex)

Initially, there was a feeling of strangeness, as if something were missing in the virtual care. Over time, participants emphasized many learnings, ranging from exploring which equipment and technological resources to use, to adapting them to the specificities of occupational therapy sessions.

It was more difficult at the beginning, but then I think I learned how to do it. [...] At first it was very strange to look only at this little screen, I thought: is the person paying attention to me? Are they looking at me through a window from nowhere? It felt like something was missing. (CybZen)

[...] bringing the therapist together with these technological issues. How do you turn the camera, so the lighting is better? [...] you must [...] pay closer attention to these issues, which I did not know before. For example, the audio requires more precise equipment, so I had to acquire technological resources [...]. (RoboTech)

CybZen stressed the importance of being available to learn new activities within the context of telehealth, based on what is built in the triadic relationship. In doing so, she herself entered cyberculture: virtual museum tours, participation in online events, and the use of data storage and sharing tools.

I had never thought about doing a virtual museum tour, and that was one of the activities I did with a patient. I had never attended a career fair, and [...] I had patients preparing for college entrance exams, so we signed up. These were activities I had not considered before, but they were part of what we were experiencing [...]. (CybZen)

The therapist also learned! I learned how to use Google Drive. I have a patient, and we keep adding activities to the drive throughout the week. [...] She told me, ‘[...] I need someone to hold my hand and take me along.’ So, we came up with the idea of the drive, which I feed by posting some questions [...]. One of the activities was to build a professional Instagram. So, we have on the drive: don’t forget to take the photos. (CybZen)

The participants emphasized that paying attention to developments in cyberculture expanded the possibilities for activities in their sessions.

Whenever I learned about some virtual exhibition taking place somewhere in the world, I would bring the suggestion to the group. Whenever I saw something new that could enrich the group, I offered it to them. (CybPilot)

2. Educational action – singular and situational digital inclusion

Educational action in the MTOD is one of the functions linked to activities, since it is in the openness to learn what is needed or desired that new movements toward the required transformations begin. In this theme, the contents related to teaching-learning processes were organized, highlighting the careful responsibility of the professionals to adapt the virtual environment—and the necessary learning within it—to the realities and needs of the people being assisted. Additionally, the participants emphasized the need to improve professional skills (attention, observation, and communication), which were even more demanded in the virtual environment.

Thus, the educational action of occupational therapists was always centered on the singularities of each case or on the situationality of the context: in the choice of the online platform for interaction, in the teaching-learning process involved, in the acquisition and improvement of professional skills, and in the use of other technological resources.

Twelve of the 13 participants used more than one platform (Google Meet, Skype, Zoom) for their sessions, considering the digital inclusion of the subjects, the resources of each platform, and the situation of each person or family.

It was mixed! I used and still use Skype. Currently I use Skype and Google Meet. At the time, I used Skype, Meet, and Zoom, because many family members did not know how to use them, so I had to have all of them. (NeoCyber)

Educational actions initially focused on digital literacy, enabling the target subjects to enter cyberculture. This was fundamental not only for telehealth sessions, but also for expanding the possibilities of other activities and interactions during the pandemic.

We made extensive use of tutorials, [...] showing the step-by-step on the screen, teaching the activity. [...] educational action was very present. It was educational action from teaching the activities [...] to teaching how to be in this virtual environment, what privacy they needed, [...] how to use the devices, how to navigate the screens. (CybPilot)

The teaching and performance of activities immersed in cyberculture were already part of the sessions before the pandemic: communication through applications, video calls, online shopping, and requesting transportation through apps.

Thinking about digital inclusion, I was already progressing with all patients before the pandemic, encouraging, facilitating, creating some strategies for them to use cell phone technology, the apps. So, [...] making video calls, [...] using WhatsApp, [...] calling an app-based car, [...] online shopping [...]. (CyberGenius)

The participants emphasized how much educational actions supported the therapeutic function, by teaching new skills and activities for the use of tools in the digital world, always centered on how each person learned and on their reality.

“[...] it was no use saying, ‘swipe up,’ I knew that would not be intelligible. So, with each patient, I tried to understand and adapt that language, such as going back to the home screen [...] for one of the patients the background was the beach, she has a beach house, so it was ‘go back to the beach’ [...].” (CyberGenius)

To sustain the therapeutic function through educational actions, the participants indicated that online sessions required improvement of their own attention, observation, and communication skills.

My actions are very much guided by being able to notice that when I take an action to see the reaction associated with that action, I have to be a little more attentive. (RoboTech)

I had more difficulty at the beginning and then I think I learned how to do it. [...] At first, it was very strange to look only at that little screen, I thought, are they paying attention to me? Are they looking through a window from nowhere at me? It seemed like something was missing. (CybZen)

CybGenius reflected that, in in-person sessions, there are processes of nonverbal communication, while in online sessions it became necessary to check verbally whether what was happening was being understood.

Perhaps in person, in the therapeutic relationship, we would exchange a look, an expression, or we would laugh at a situation that happened there, and perhaps in the video it has to be said more concretely, expressed with words. (CybGenius)

[In online sessions] We have to adjust language and posture in terms of observation. What became more important was not to let anything go unnoticed, not to assume that something was being understood without checking verbally. (CybGenius)

3. The target subject and fourth terms

In this theme, the contents were organized around the potential of telehealth to provide a more comprehensive understanding of each person’s situation, composing the situational diagnosis from perceptions about the individual’s everyday life, family, and relationships, especially regarding how each family experienced the burdens and suffering of the COVID-19 pandemic. In addition, the participants reported that, beyond acquiring knowledge, they were also able to include relevant people in the very dynamics of occupational therapy, as a new term—the fourth term—that is added to the triadic relationship.

Thus, they emphasized that, in online sessions, it was possible to expand the possibilities of composing the situational diagnosis: to know the home and other spaces of the target subject’s everyday life; to understand how relationships with those living together were established, since the sessions generally occurred in the domestic environment and often required the presence of family members or caregivers. This made it possible to gain a better understanding of the everyday life of the entire family.

[…] you end up seeing a dimension of everyday life from another perspective when the person is at home. So, it is interesting to notice the movements that happen in that private sphere, […] the place the subject occupies in the family, what type of difficulties appear there […]. (CyberIntellect)

An adolescent patient […] complained a lot […] about her mother […] about not having space, that the mother always intruded. This becomes clear because, suddenly, we were in the session and the mother called her, she did not stop to think that this girl was in a session. (CybZen)

Particularly during the pandemic period, families with children and people requiring more care experienced overload, as evidenced in CybZen’s account:

[…] at the time of the pandemic, mothers […] reported a very great overload. There were mothers who said that while they left the child for one hour in therapy, they were able to do other things, and now? In addition to everything else, they had to do the activities with the therapist […]. (CybZen)

The presence of family members and others in the target subjects’ daily lives was a recurring theme in the participants’ accounts. This broadened the possibilities not only of knowing these people, but also of including them in occupational therapy, under the proposition of the fourth term.

Changing the dynamics, because it is no longer just me, the subject, the activities. […] So, this becomes something that is part of your reasoning […]. For example, sometimes you have to ask the family: ‘wait a little, let him answer, let’s see where he looks […].’ There is the positive side of this, that you perform this more educational function, of [establishing] better partners […] in communication. (CyberIntellect)

The families were different from what I expected, I thought it would be difficult because of the severity of the patients, but the families were very engaged. […] the families wanting to talk, to participate in some way, to support what we were building in the sessions. (CyberExplorer)

Still within the perspective of the fourth term, all participants reported having conducted sessions involving other people connected to the case, such as family members, multidisciplinary teams, and schools.

There were sessions with people connected to the case, other teams, family members, and the clinic team. (Omegaplex)

4. The triadic relationship in online occupational therapy

In this theme, the virtual environment was taken as an object of reflection and explored in its potential to generate affects and activities that moved across multiple spaces, without the need to define what was virtual or in-person.

RoboTech reflected on virtuality not from the dichotomy of in-person/real vs. virtual, but as the condition of care. She compared this new space to the strangeness and discomfort experienced in institutional environments without a space of their own for occupational therapy, such as strongly biomedical hospitals.

It requires us to have more stamina, but I think it is also not different from a place in the institutional environment, aseptic, those rooms that are all white, when I worked in the hospital, they were cold rooms, with gynecological beds […]. So, I think these are conditions specific to this type of care. (RoboTech)

Nevertheless, even in virtuality, it was possible to establish intense experiences, to generate movement and affect, and to structure routines.

At the beginning, the interventions were very much based on the need to think of a more structured routine, in that pandemic context. (CyberExplorer)

She lived far away, in a rural area, and she was unable to do anything […] it was a moment when many people were dying, a whole collective process of illness. And she could not find the strength, she felt many pains, even when holding a pan to fill it with water. But it was so interesting because I worked with her body step by step, […] with educational action, […] to reach movement, to guide the sequence in the activity. And she did it, preparing her beans while listening to the music she liked, mentioning something that was affective for her, how she was feeling. And she began to organize herself, to integrate while doing. Even being there with her virtually, I was truly present. (CyberArt)

The activities conducted in the triadic relationship were described in multiple ways, combining in-person and virtual environments, both in the therapist’s office or home and in the client’s setting. Thus, exclusively virtual activities (museum visits, games through screen sharing) and non-virtual activities (laundry, cooking) were described, showing the movement of the triadic relationship according to the needs and desires in a hybrid setting.

I used […] many activities that relied on computer resources, […] games that could use screen sharing, some activities more based on choices that we could make with shared images and videos […]. (CyberIntellect)

Another situation of doing something enjoyable together, in an extremely difficult week, and cooking was already a pleasurable activity in this person’s life, so I went to my office, then to the kitchen in my office, and the person was in her home. (CyberExplorer)

My patient had been post-stroke for many years, but […] was very insecure about speaking and writing. […] What I wanted to work on most with her at that moment [was] that she could speak […] when she saw herself unable to speak and unable to write what she wanted, she became anguished and desperate, and she froze. So, my goal with her was ‘shall we talk?’ I called her on her home landline and later we switched to the mobile phone, [which] gave her more mobility and more privacy. And we stayed every week for an hour and a half in weekly sessions […]. (CybGenius)

In this cluster of technologies, online shopping and delivery applications were also activated based on the desires and needs of the target subjects.

So we kept reinventing ourselves, from buying materials, sharing the screen with the person, and the person receiving the materials at home […]. (CyberExplorer)

[…] ‘I need to buy a medicine,’ and we organized ourselves […] the Uber […] picked up the prescription, bought it, delivered it at home. (CybGenius)

On the expansion of health spaces and everyday activities, the experience narrated by CybPilot illustrates the potential of virtual tools to expand into other encounters and activities in everyday life.

We created a group with us and all the patients. There they communicated, said how they were, asked each other questions, talked among themselves. Gradually, without our interference, they suggested things to do. […] a group of friends who still meet today, they started virtually by watching films together. So there was this expansion […] these virtual spaces that they appropriated, managing to deal with everything they were going through. (CybPilot)

Even so, CybPilot shared reflections from patients who described, in detail, the differences between being in a triadic relationship in person, receiving the attentive and affective gaze of the therapist, and being in a virtual relationship.

For some patients, this adaptation from in-person to virtual was difficult. I remember patients who said, ‘I really miss the room, the place, the things there.’ One patient said, ‘I really miss it, it’s fine, I am doing my things here, doing the activities here, but I really miss your gaze.’ […] She said, ‘here I cannot capture in the same way your gaze at what I am doing, at the activities, because it is different.’ It is different to show you, different from having you next to me, watching, being able to follow the entire process of carrying out the activity. (CybPilot)

5. The MTOD as a framework that supports telehealth practice

This theme brings together participants’ reflections on the MTOD in telehealth, understood as a framework that helped them think and practice occupational therapy in this new context in a flexible and creative way. Participants reported that it was not necessary to modify the theory or the technique to provide care through telehealth, since the MTOD offered theoretical support for this new modality.

This broad possibility that the MTOD offers, at no time was I worried about doing something wrong, at no time was I thinking, “wow, I am moving away from the MTOD, I am inventing a way that is unsafe, that is risky, that has no clinical reasoning, that has no technique.” Throughout the whole time I felt very supported. (CybGenius)

The main aspects that sustained these statements were the flexibility and adaptability of the MTOD, professional safety and confidence, as well as a robust theoretical-practical structure that supports practice in diverse contexts.

The MTOD has always proposed this flexibility regarding context, its population, and the target subject. It precisely proposes this challenge, that it can accompany the therapist wherever they go and thus structure theoretical-practical knowledge. Therefore, there is a provision that this core, these constructions, will not be shaken in their structures. (RoboTech)

The MTOD helps. Honestly, if I had another training background, maybe I would not have been able to provide care in this way. I cannot imagine rigid, protocol-based care functioning well in this telehealth framework. The theoretical foundation of the MTOD enables one to move across different activities, different ways of building this relationship, different spaces created. [...] (CybZen)

As for activities within the triadic relationship, participants pointed out that telehealth expanded what CybPilot called the status of the activity, broadening the repertoire of activities for occupational therapists and their reflections on how to use them to initiate the relationship. For them, the way activities are conceptualized and understood in the MTOD was what supported these actions.

The MTOD provides that I can use virtual activities [...], but as activities in the therapeutic process, the status of the activity expanded, yet it was still supported by what the MTOD provides. (CybPilot)

Which activities would be possible, which activities could I perhaps propose, present, sometimes even suggest, and which activities the other could also bring into this relationship. How all this fits into the triadic relationship, I found that it was possible, and maybe I have, with the patients, learned many other activities and expanded the repertoire of activities. (CybZen)

Discussion

The discussion of the findings seeks to situate them both in relation to the theoretical-methodological structure of the MTOD, highlighting aspects of telehealth practice that reveal how it was applied in this modality, and in dialog with the literature. We understand this as a contemporary theme, and our findings also reflect a broader reality, regardless of theoretical specificities.

Regarding training in the MTOD, considering that its final delineation occurred after the year 2000 (Marcolino & Fantinatti, 2014), most participants were trained when the method was already consolidated. Another relevant result is the diversity of populations assisted, which demonstrates that the MTOD is an occupational therapy framework whose application is not restricted to specific practice fields (Benetton et al., 2021).

However, the most significant characterization result may be the nature of the practice accessed in this study. In a country of continental dimensions and marked social inequality (Agudelo et al., 2020; Ricci et al., 2020), it is necessary to understand that the results presented here reflect the reality of professionals working in autonomous private practice. Only one participant in the second stage of the study combined this work with employment in the public service. Although studies on the occupational therapy workforce in Brazil are scarce, both Cestari et al. (2024) and Albino et al. (2024) indicate a strong presence of professionals who apply the MTOD in public services. Still, it is plausible that occupational therapists in private practice were more inclined to participate in a study on the theme of telehealth.

Although the Brazilian governmental structure for the use of ICTs in health was already operating before the COVID-19 pandemic (Brasil, 2011), this knowledge was not translated into the use of telehealth resources for direct patient care (Lisboa et al., 2023). Telehealth was officially incorporated into the profession only in response to the needs imposed by the pandemic (World Federation of Occupational Therapists, 2020). Although other professions already employed this modality, it was not common in many countries, and all participants reported feeling apprehensive at the beginning of telehealth sessions. This was primarily because it represented a compulsory action in a period of public calamity, and because of the need to manage a new care modality in that context.

This scenario resonates with several studies (Almathami et al., 2020; Ferrari et al., 2022; Madsen et al., 2020; Núñez & Águila, 2024b), which indicate the necessity of improving digital competencies and reducing access barriers. According to Proffitt et al. (2021) and Cason (2012), learning and digital literacy are formative needs, and the participants in this study demonstrated initiative in seeking training, supervision, and openness to activities and resources within cyberculture. Supervision, widely employed in occupational therapy, particularly in Brazil, is considered essential for professional development within the MTOD, as shown by Araujo (2022) in a study with expert practitioners. As Anil et al. (2023) emphasize, telehealth requires both clinical and technological knowledge.

Our results highlight the development of specific skills, such as the need to remain more present and attentive, constantly verifying whether communication was being understood. Benetton (1994) presents scrutinizing observation (observação perscrutadora) as an essential skill for occupational therapy care supported by the MTOD. It involves being present and capturing information about the target subject in the process of performing activities and constructing the triadic relationship, not only through vision, but through the whole of perception. Thus, the participants’ reports suggest that scrutinizing observation in telehealth requires even greater attention, since what is available to be perceived lies within the depth of the screen in front of them. While this format enables access to new aspects of the person’s reality (which compose the situational diagnosis), it also restricts embodied knowledge (fundamental for perception and communication) common in face-to-face sessions.

With respect to communication, other studies also emphasize the need to establish effective practices adjusted to the telehealth context (Anil et al., 2023; Núñez & Águila, 2024a, 2024b). For the MTOD, every educational action is inherent to the therapeutic function (Benetton, 1994). This means that transformation and the search for solutions to human needs, when constrained in their activities, are centered in the process of teaching and learning within the triadic relationship (Marcolino, 2007). This characteristic remained present in telehealth, since participants’ educational actions focused on teaching new skills and activities, enabling the use of digital tools according to each person’s learning style and reality.

As Araujo et al. (2024) point out, ethical-aesthetic reasoning in the MTOD is constructed from the singularity and situationality of each target subject. Thus, care supported by the MTOD, even in this modality, remains aligned with the proposal of offering interventions centered on people’s realities (Núñez & Águila, 2024a; Priyadharsini & Chiang, 2020; Zahoransky & Lape, 2020).

In this sense, knowing the target subject is central to the development of occupational therapy. In the MTOD, this process occurs through situational diagnosis, which identifies the subject’s current situation in its multiple aspects, whether limiting or expanding the possibilities for performing activities. In the context of telehealth, the participants reported a greater possibility of understanding the subject’s everyday lives, particularly in the situation of facing the COVID-19 pandemic. Núñez & Águila (2024b) indicate limitations and challenges related to the settings for occupational therapy in telehealth, which are often inadequate, such as lack of space at home to address intimate matters or interference from family members during sessions. For the MTOD, these aspects must be considered within the person’s situation and included in the analysis of needs and desires, thereby refining the situational diagnosis.

In this direction, the participants highlighted the inclusion of family members or other relevant persons in occupational therapy care as a fourth term that expands the triadic relationship, as provided for in the MTOD framework (Benetton & Marcolino, 2013), not limited to the perspective of orientation. From another perspective, Núñez & Águila (2024a) also evidenced this feature, including family members as co-therapists in response to the reality imposed by the COVID-19 pandemic. In addition, telehealth facilitated access to other people associated with the case, such as schools and other professionals, following the MTOD’s principles regarding the inclusion of fourth terms. The ease of accessing teams through telehealth was also noted in Caetano et al. (2020), Almathami et al. (2020), and Núñez & Águila (2024b).

The participants of this study also reported expanding the repertoire of activities performed virtually, which increased possibilities for learning and care. The understanding that occupational therapy in the MTOD occurs wherever the triadic relationship occurs, and that the performance of activities drives new movements in this relationship (Benetton et al., 2021), offered the necessary flexibility for professionals to experience the dynamism provided by the virtual environment.

This finding allows us to discuss the setting in the MTOD in telehealth. The setting is characterized as a dynamic, objective, and subjective space that encompasses the triadic relationship (Benetton, 2006). In this study, it was possible to identify a setting that expands into a large cluster combining subjective and objective technological elements of different natures, creating a real space, as proposed by Lévy (1996). The movements of the triadic relationship occurred both through landline telephone and through access to the other person’s screen. These results help us overcome the dichotomy between in-person/real and virtual. The cluster of technologies present in the participants’ accounts of their telehealth practices expands the understanding of setting as a subjective-objective space, whose objectivity incorporates a multiplicity of interconnected digital technologies to the extent that they are mobilized to sustain the activities performed in the triadic relationship.

As this is an exploratory study, not all constructs of the MTOD theoretical-methodological framework were addressed in depth. Nonetheless, the MTOD framework was considered essential for enabling the participating occupational therapists to sustain their practices in a flexible, dynamic, and creative manner. Araujo et al. (2024) emphasize that the MTOD allows the integration of multiple essential elements for intervention, promoting an approach centered on the individual’s singularity and on their specific context. These findings directly resonate with other studies on telehealth in occupational therapy, such as Scott (2020), for whom telehealth summons us to be less bureaucratic and more creative and dynamic, and Núñez & Águila (2024b), who highlight learning related to creativity, mental flexibility, and adaptability required by telehealth.

Thus, listening to the reflections of occupational therapists who work under the assumptions of the MTOD means making visible what is being theoretically and methodologically outlined for this group of professionals. However, such reflections may also express the experiences of many other occupational therapists who, inventively, embraced the risks of feeling and relating online. As emphasized by Benetton (1994), the construction of the MTOD arose from the analysis of practice phenomena, leading its theoretical-methodological constructs to be sensitive to the realities of occupational therapy practice. In this way, we hope that our results highlight a phenomenon of contemporary practice in occupational therapy and contribute to broadening reflections in both the professional and academic fields of the discipline.

Final Considerations

This article discusses how the MTOD has been used in the telehealth modality. The assumptions of the MTOD proved sensitive to the reality of occupational therapy practice, being applied dynamically, showing versatility and adaptability, and providing a theoretical-methodological foundation for occupational therapists, both in its current use and in moments of fragility, such as the COVID-19 pandemic.

The study also advances propositions on the setting in the MTOD, unveiling how virtuality opened new possibilities for intervention, enabling the transcendence of the dichotomy between in-person and virtual, and creating a real and dynamic space that expanded the possibilities of gathering multiple technologies in sustaining the triadic relationship, an aspect open to future investigations.

The results indicate similarities with other studies regarding formative needs, learning, and literacy in the use of technological resources, revealing a phenomenon of contemporary practice in occupational therapy. Occupational therapists were able to adapt their interventions to address a wide spectrum of needs, including people with various mental health conditions, older people, children, and people with disabilities. Future studies may analyze the effectiveness of the MTOD in the telehealth modality for specific populations.

The flexibility of the MTOD favored the integration of technological resources into therapeutic practice, ensuring continuity of care. Professional supervision played a crucial role in the transition to the digital environment. The practice of telehealth with the MTOD allowed for a singularized approach, centered on the subject and their reality. The active presence of family members and multidisciplinary teams was also facilitated by telehealth.

In the present study, there was a predominance of occupational therapists working in private practice, a limitation that points to the need for research on the use of telehealth by occupational therapists in the Brazilian Unified Health System (SUS). Moreover, not all aspects of the MTOD were comprehensively explored by the participants, such as meaning-making through associative pathways. Studies employing methodologies capable of accessing, with greater narrative detail, the experience of telehealth within the MTOD are welcome. Similarly, investigations are recommended that explore the perception and/or meanings that the target subjects of occupational therapy attribute to telehealth interventions supported by the MTOD.

In any case, even though the situational nature of our findings limits any possibility of generalization, which is not the aim of an exploratory qualitative study like this, they may nevertheless highlight a phenomenon of contemporary occupational therapy practice, fostering reflections for other contexts and frameworks.

• How to cite:
  Lopes, K. P., Araujo, A. S., & Marcolino, T. Q. (2025). The Dynamic Occupational Therapy Method as a theoretical-methodological framework for telehealth practices: a qualitative study. Cadernos Brasileiros de Terapia Ocupacional, 33, e4002. https://doi.org/10.1590/2526-8910.cto408740022
• Data Availability
  The data that support the findings of this study are available from the corresponding author, upon reasonable request.
• Funding Source
  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) – Finance Code 001.

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Edited by

• Section editor
  Prof. Adriana Miranda Pimentel

Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2025

History

• Received
  02 Dec 2024
• Reviewed
  19 Apr 2025
• Accepted
  05 Aug 2025