Analysis of discourses on the practice of occupational therapists with children residing in the better childhood protection network (Mejor Niñez)

Abstract

Introduction  Since 2021, when the violation of fundamental rights of minors is judicially determined, the Specialized Child and Adolescent Protection Service "Mejor Niñez" has implemented protective measures. This institution has introduced new guidelines, incorporating occupational therapists into professional teams in protective residential facilities.

Objective  To contribute to the limited bibliographic corpus on occupational therapy in Chile within the context of protective residential care, aiming to highlight this professional field.

Method  A descriptive-analytical methodology was employed, characterized by a qualitative-quantitative approach with a predominance of the qualitative perspective. An ethnographic approach was used to gather information from occupational therapists working in the residential protection programs of Mejor Niñez. Data analysis used the Collective Subject Discourse method, complemented by theoretical perspectives from the anthropology of health, the body, and violence, to enrich the interpretation from an interdisciplinary and critical viewpoint.

Results  The findings underscore the importance of therapeutic rapport in humanized interventions, highlighting the perception of professional competence as a key factor in job retention.

Conclusion  Risk factors such as (over)adaptation to stress, vicarious trauma, compassion fatigue, and burnout emerge, affecting the well-being of occupational therapists and creating tensions that affect job retention.

Keywords:
Child; Child Welfare; Violence; Health; Occupational Therapy

Resumen

Introducción  Desde el año 2021, cuando se determina judicialmente la vulneración de derechos fundamentales de un menor, el Servicio de Protección Especializada a la Infancia y Adolescencia "Mejor Niñez", ejecuta medidas de protección. Esta institución ha generado nuevas directrices, incorporando a terapeutas ocupacionales en equipos profesionales de residencias de protección.

Objetivo  Contribuir al limitado corpus bibliográfico sobre la terapia ocupacional en Chile en el ámbito de las residencias de protección, buscando visibilizar este campo profesional.

Método  Se utilizó metodología descriptiva-analítica, de naturaleza cualitativa-cuantitativa con predominancia del enfoque cualitativo. La aproximación etnográfica permitió recopilar información de terapeutas ocupacionales que laboran en dispositivos de protección residencial de Mejor Niñez. Para el análisis de los datos, se utilizó el método del Discurso del Sujeto Colectivo, complementado por perspectivas teóricas de antropología de la salud, del cuerpo y de la violencia, con el fin de enriquecer la interpretación desde una visión interdisciplinaria y crítica.

Resultados  Se destaca la relevancia de la vinculación terapéutica en intervenciones humanizadas, subrayando la percepción de competencia profesional como un factor clave en la permanencia laboral.

Conclusión  Emergen factores de riesgo como la (sobre) adaptación al estrés, trauma vicario, fatiga por compasión y el burnout, que impactan la integridad de la persona terapeuta ocupacional y generan tensiones que influyen en la permanencia laboral.

Palabras Clave:
Niño; Protección a la Infancia; Violencia; Salud; Terapia Ocupacional

Resumo

Introdução  Desde 2021, quando se determina judicialmente a violação de direitos fundamentais de uma criança, o Serviço de Proteção Especializada à Infância e Adolescência "Mejor Niñez" implementa medidas de proteção. Esta instituição tem gerado novas diretrizes, incorporando terapeutas ocupacionais nas equipes profissionais das residências de proteção.

Objetivo  Contribuir para o limitado corpus bibliográfico sobre terapia ocupacional no Chile no âmbito das residências de proteção, buscando dar visibilidade a este campo profissional.

Método  Utilizou-se uma metodologia descritivo-analítica, de natureza qualitativo-quantitativa com predominância do enfoque qualitativo. A abordagem etnográfica permitiu a coleta de informações de terapeutas ocupacionais que atuam em dispositivos de proteção residencial do programa Mejor Niñez. Para a análise dos dados, utilizou-se o método do Discurso do Sujeito Coletivo, complementado por perspectivas teóricas da antropologia da saúde, do corpo e da violência, com o objetivo de enriquecer a interpretação a partir de uma visão interdisciplinar e crítica.

Resultados  Destaca-se a relevância do vínculo terapêutico em intervenções humanizadas, sublinhando a percepção de competência profissional como um fator-chave na permanência no trabalho.

Conclusão  Emergiram fatores de risco, como a (sobre)adaptação ao estresse, trauma vicário, fadiga por compaixão e burnout, que impactam a integridade do terapeuta ocupacional e geram tensões que influenciam na permanência no emprego.

Palavras-chave:
Criança; Proteção da Criança; Violência; Saúde; Terapia Ocupacional

Introduction

The Chilean child protection system faces a critical reality due to the multifaceted impact of violence against children. This highly complex phenomenon highlights the need to reduce its prevalence (Fondo de las Naciones Unidas para la Infancia, 2023). In this context, the Observatory for Trust (Observatorio para la Confianza, 2022) affirms that violence is rooted in traditional child-rearing practices in Chile, increasing the demand for state resources allocated to addressing child abuse. By mid-2022, this situation resulted in a waiting list of more than 14,000 children and adolescents with violated fundamental rights (Defensoría de la Niñez, 2022).

Since 2021, when a family court judge determines that a minor's fundamental rights have been violated, protection measures are implemented by the "National Service for the Specialized Protection of Children and Adolescents: Mejor Niñez (Better Childhood)." This state agency replaced the National Service for Minors (SENAME), which for 40 years was responsible for two particularly sensitive areas: the protection of vulnerable children and juvenile justice. SENAME's management was marked by numerous criticisms and serious complaints regarding its performance (Cámara de Diputados, 2013; Fundación Infancia, 2017; Sepúlveda & Guzmán, 2019).

The National Service "Mejor Niñez (Better Childhood)", in fulfilling its institutional mission, articulates its actions along five strategic lines, the fourth of which focuses on alternative care, a context within which this research is framed¹ . This line of action is characterized as an "exceptional measure for children and adolescents who have been temporarily separated from their families by court order, and may be carried out in institutional residences or with foster families" (Servicio Nacional de Protección Especializada a la Niñez y Adolescencia, 2024a).

To fulfill its work, "Mejor Niñez (better childhood)" work with accredited partners, primarily non-profit organizations from the private sector, to provide housing, food, and clothing, in addition to ensuring the well-being and safety of children and adolescents, offering support and resources to families in vulnerable situations (Servicio Nacional de Protección Especializada a la Niñez y Adolescencia, 2024b). According to figures from September 2024, 4,918 children and adolescents reside in protection centers (Servicio Nacional de Protección Especializada a la Niñez y Adolescencia, 2024c, 90% of which are managed by private institutions, some of which are 50% overcrowded (Toro, 2023).

In the institutional modernization process initiated in 2021, reforms have focused on strengthening intervention activities for minors in these residential facilities; in this context, this research specifically explored the incorporation of occupational therapists into intervention teams historically comprised of social work and psychology professionals (Defensoría de la Niñez, 2022).

The presence of occupational therapists in residential care homes in Chile is a relatively recent phenomenon, showing an increase in the presence of this profession, closely linked to changes in the new institutional framework. Nationally, their incorporation dates back to 2016 (Corporación Crece Mejor, 2017), while in the Los Ríos Region, this participation began in 2017 (Cárcamo & Vera, 2022). This scenario becomes relevant when considering that the state residential care system has been in operation for more than 40 years and that more than 50 years have passed since the first cohort of occupational therapists graduated from the University of Chile, in the country's capital.

In this sense, this article aims to contribute to the limited literature on occupational therapy in Chile in residential care homes, seeking to raise awareness of this professional field through an ethnographic approach. The recursive interaction between several contextual and human elements associated with the health agency, the biopsychosocial perspective, and the pragmatic approach are presented. It also aims to show the potential advances arising from the transition toward a new institutional framework for protection.

Methodology

This is a descriptive-analytical study, qualitative-quantitative in nature, with a predominance of a qualitative approach, as it allows for the exploration of the practices, challenges, and motivations of occupational therapists. An ethnographic approach (Guber, 2015) was used transversally to understand social reality as a dynamic and constantly changing space (Cook & Reichardt, 2005). This methodology allowed for a diversified profile of experiences, facilitating analysis and the identification of patterns that enable generalization of content (Bertaux, 1999). The construction of knowledge and the results were based on constant dialogue, interaction, and sustained observation, accompanied by a process of critical reflection (Guber, 2015).

The ethnographic approach to the field of study was developed over more than seven years, allowing the principal researcher to interact daily with part of the group of occupational therapists during their fieldwork. This prolonged immersion allowed for the development of socio-affective bonds, generating a body of knowledge that integrates scientific and experiential perspectives. This approach facilitated a deeper understanding of the complexity of everyday work and the experiences lived, from the perspective of those who experience them (Guber, 2015). The findings were analyzed using the Collective Subject Discourse methodology (Lefèvre & Lefèvre, 2012).

The research focused on the city of Valdivia, Chile, where the principal researcher established contact primarily with occupational therapists from the Universidad Austral de Chile. Contacts from other regions and universities were managed through email, instant messaging, and social media, using the institutional registry of program offerings available on the website of the National Service for the Specialized Protection of Children and Adolescents (Servicio Nacional de Protección Especializada a la Niñez y Adolescencia, 2024d).

The sample consisted of 10 professionals with experience working in residential care homes, considered the main inclusion criterion. Each participant received an informed consent form detailing the study objectives and the ethical principles of confidentiality, anonymity, and voluntariness, to ensure their autonomy and free choice of participation. The study was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2013) and international ethical guidelines for health research involving human beings (Consejo de Organizaciones Internacionales de las Ciencias Médicas, 2017).

First stage

For the characterization phase, a sociological survey was used, recognized as an appropriate social-scientific technique for studying subjective and verbalized phenomena, accurately diagnosing the reality under research (Vallejos, 2011). This allowed for a non-probability, purposive sample, limiting the relationship characteristics of the population (Otzen & Manterola, 2017). The inclusion criteria were occupational therapy professionals with work experience in residential care homes of the National Service for the Specialized Protection of Children and Adolescents (Mejor Niñez, formerly SENAME), in which 20 professionals from diverse geographical areas participated.

The procedure, entitled "Characterization of Occupational Therapists and Their Experience with Child Abuse," was structured as an individual survey, distributed through an online form on the Microsoft Forms platform, part of Microsoft Office 365. The link to complete the survey was shared by the researcher via email and instant messaging to professionals who had graduated from different universities nationwide (in Chile), as well as to students in their final year of training who had completed internships in the field.

The survey was organized into two sections. The first was intended for general characterization and included questions about contact information, place of residence, age, university of origin or graduation, work experience with vulnerable children (specifying location and duration in months or years), and theoretical training in child abuse, specifying the source of said training (courses, self-study, etc.). The question about work experience in residential care facilities allowed for filtering for the second section, thus meeting one of the inclusion criteria.

The second section, titled "Experiences in the Residential Protection System for Better Childhood (formerly SENAME)," obtained detailed information on the challenges faced in these facilities. It focused on the modality of the experience (internship, contract, fees, etc.), number of working hours, salary range, main duties performed, most relevant challenges, and willingness to be interviewed by the researcher.

This section established the main inclusion criterion: having more than one year of work experience and being actively working in the residential protection system at the time of being contacted for ethnographic interviews. As a result, a sample of 10 professionals was formed.

Second Stage

In accordance with the established inclusion criteria, twelve meetings were held, prioritizing horizontality and affinity between the researcher's profession and the participants' experience in the field (Bourdieu, 1999). Data collection was conducted through ethnographic interviews, recognized for their flexibility and ability to adapt to the interviewees' reality, which favored the spontaneity of the stories, the emergence of a criterion of reality, and the exposition of common sense in the discourses (Guber, 2015).

As a potential, this allowed the researcher to avoid directing the narrative, adapting the order of the topics discussed, and eliminating or incorporating new topics according to the relevance of each participant. This fostered a balance between affective order and intellectualized behavior, facilitating social interactions in accordance with the three elements proposed for ethnographic interviews by Guber (2015): evenly suspended attention, which involves being receptive without focusing exclusively on a particular aspect; free association, which allows ideas and observations to flow without imposing preconceived categories; and deferred categorization, which consists of postponing the classification of the collected information until a later phase of the research process.

The ethnographic interview script covered topics related to professional career and motivation, daily experiences and challenges, perceptions of professional work, institutional functioning and implementation, and the importance of the profession in that work context. In terms of saturation, the research practice was mediated by a recurring reflexive process (Guber, 2015), and it was considered that this phenomenon was achieved with the tenth person interviewed.

The analysis of the stories was done according to the Collective Subject Discourse (CSD) methodology (Lefèvre & Lefèvre, 2012), a qualitative methodology that allows for the analysis and representation of a group's collective thinking, facilitating the extraction, organization, and synthesis of diverse opinions into a unified discourse that seeks to reflect the collective position while preserving the particularities of each individual. This analysis process was done in three stages: the literal transcription of the audio-recorded content; the identification of Key Expressions (KE), which are literal fragments of the discourse that represent relevant and recurring ideas; and the formulation of Main Ideas (MI), which constitute interpretations of the KE and expose the essence of what the group expresses on a given topic, allowing the collective perspective to be visualized through first-person singular discourses.

The data organization sought to preserve the richness of the discourse, respecting the original emphasis and conjugations in the transcripts, allowing diverse MIs to complement and influence each other. The statements were faithfully transcribed, respecting the emphasis, intonation, and verbal and gender conjugations of each interlocutor, so that different gender conjugations can coexist within a single CSD, depending on the experience of each interviewee.

Each participant showed considerable interest, describing and problematizing the content, which allowed the analytical process to capture not only the semantic meaning but also complementary aspects documented in the field notebook. This contributed to a deeper understanding of the shared experiences. In this way, the research shows the diverse ways of conceiving the world and the notions of what occupational therapists claim to do, highlighting the plurality of challenges, professional contributions, and motivational elements that facilitate continuity in these scenarios, thus representing these "new interlocutors" in an adapting system.

Results

First Stage

The analysis of sociodemographic data allowed us to outline a general profile that was critical for understanding the research context. The information obtained was essential for establishing the inclusion criteria for participants in the second stage of the study.

A total of 20 professionals from diverse geographic areas participated, specifically from central, south-central, and southern Chile. Regarding the age, 65% of the participants were between 20 and 30 years old, with an average of 28 years, and their ages ranged from 24 to 36 years. This age distribution suggests a young population, likely at the beginning of their careers, which could influence their approach and intervention strategies when working with children victims of violence.

Regarding professional experience, an average of 3.5 years was reported at the time of the survey, with a range from 1 to 8 years. In particular, experience in residential systems, which is a key aspect for continuity in section two of the research, averages 2.5 years, with extremes ranging from 1 to 8 years. This experience is key, as it suggests that participants have relevant practical knowledge that can enrich the analysis and recommendations derived from the study.

Regarding the graduating schools, the data show a clear trend based on the geographic location of the research. The Universidad Austral de Chile stands out with 25% (5 participants), closely followed by the Universidad Santo Tomás (Valdivia, Temuco, and Viña del Mar campuses), the Universidad de Chile (Santiago), and the Universidad Andrés Bello (Santiago and Concepción), each with 15% (3 participants). In third place is the Universidad Central de Chile (Santiago) with 10% (2 participants), while the Universidad San Sebastián (Santiago), the Universidad de Antofagasta, and the Universidad de Viña del Mar contribute 5% (1 participant each). This distribution suggests a diversity of academic backgrounds and pedagogical approaches that could influence the professional practices of occupational therapists.

Regarding the number of contracted hours, it is evident that 50% (10 participants) work full-time, that is, 45 hours per week; 25% (5 participants) work part-time (22 hours) and the remaining 25% (5 participants) work between 30 and 33 hours per week. Regarding salaries, although there is a correlation between the number of hours worked and the salary earned, it is relevant to observe that 32% (6 participants) of those surveyed placed their salary in the range of $750,001 to $1,000,000 for a full-time job (45 hours per week). This salary range aligns with market expectations, as pointed out by the participants, suggesting a perception of adequacy between their income and the value of their work in the professional context.

The analysis of the contractual arrangements of the occupational therapists participating in the study reveals significant patterns in their work organization. It is observed that 70% (14 participants) of the respondents identify their contractual arrangement as a fixed-term or open-ended contract. In contrast, 30% (6 participants) work on a fee-based basis. This distribution suggests a trend toward greater job stability among those with formal contracts, as well as a correlation between the greater number of hours worked and the fixed-term or open-ended contract arrangement. This could suggest that professionals with more stable contracts tend to work longer hours.

Regarding theoretical training in the field of child abuse, the majority of participants show a significant commitment to training in this area. When asked, "Do you have theoretical training in child abuse?", only 15% (3 participants) reported having no training of any kind in this area. In contrast, 85% (17 participants) answered having received training of different kinds. Within this group, the "courses and training" option was the most frequently mentioned, with 48% (10 participants) of the preferences. This highlights the importance that occupational therapists place on continuing education on such a critical issue as child abuse, which can influence the quality of their interventions.

Regarding the roles they perform, different preferences were identified, encompassing both individual and group interventions. Respondents mentioned, among their main duties, therapeutic support and the development and implementation of routines, as well as administrative tasks including preparing reports, entering benefits into systems, and managing individual files. Meetings are also part of their responsibilities. Secondly, group services, such as workshops, were mentioned as a significant duty in their work.

In addition, in the section on "other roles" the diverse responsibilities assigned to occupational therapists were highlighted, which fit the specific reality of their role in the workplace. These responsibilities included replacing (often permanently) other team members, as well as performing roles in specific areas, such as "health manager" and "education manager." Responsibilities also included training tutors (former direct care educators), conducting home visits, and presenting cases at hearings, among others.

Within the context of occupational therapists' professional experience, multiple challenges are identified that affect their daily work. Table 1 presents a breakdown of these challenges, which are grouped into six distinct categories. An option for "other challenges" was also included to allow participants to express difficulties that did not fit into the previously defined categories. It is important to mention that a total of 74 answers were recorded in this section, as respondents were able to select multiple options that more accurately reflected their work experience.

Table 1
Main challenges that characterize their professional experience.

Main challenges in their work	Quantity Answers	Percentage
Relationship with the SENAME/Mejor Niñez team	18	24.3%
Direct intervention (individual or group)	12	16.2%
Administrative duties	12	16.2%
Therapeutic bond	9	12.1%
Relationship with the residency team	12	16.2%
Other challenges	11	14.8%
Total	74	100%

• Source: Survey Characterization of Occupational Therapists and their experience with child abuse, 2023. Prepared by the authors.

The most notable challenge was "Relationship with the SENAME/Mejor Niñez team," which received 18 mentions, representing 34.3% of the answers. This finding suggests that interaction with child protection institutions is a critical and potentially problematic aspect of occupational therapists' work. Furthermore, 11 answers (14.8%) were recorded in the "other challenges" category, emphasizing that many of the complexities experienced were related to validating the professional role before institutional representatives during situations such as supervision. This aspect also includes the requirement to fulfill different roles, such as training direct-care staff, coordinating the health area associated with managing medical checkups, and managing medications.

Regarding other challenges, it was observed that those related to "direct intervention," "administrative duties," and "relationship with the residential team" received 16.2% of preferences each. These difficulties seem to be transversal and are likely associated with the inherent demands of the occupational therapist's job profile. On the other hand, "therapeutic alliance," although selected only nine times (12.1%), is perceived as a role-specific challenge. This could be interpreted as an expected difficulty, linked to the characteristics of the intervention area and the profile of the users, suggesting that, although relevant, this challenge is not considered highly intense compared to other aspects of professional practice.

In accordance with the objectives of this research, the analysis of the collected data allowed for a filtering process that resulted in the selection of 10 professionals for a subsequent phase of the study. Inclusion criteria prioritized those with the most work experience in residential settings. It was emphasized that, on average, these professionals had four years of experience since graduating from their respective educational institutions and an average of 2.5 years of experience in the residential system, which constituted their first or second work experience.

Regarding the geographic location of the selected participants, a significant representation was found from the central, south-central, and southern regions of Chile. Cities such as Valparaíso, Viña del Mar, Santiago, and, particularly, Valdivia emerged as focal points, also considering the researcher's location. This geographic distribution facilitated the conduct of interviews in the participants' workplaces and in person, enhancing the quality and depth of the data obtained.

An analysis of the sociodemographic characteristics of the participants in this study showed a gender distribution that included seven women and three men. This finding is relevant in the context of occupational therapy, as gender can influence the perception of the professional role and the way therapeutic relationships are established. In addition, two of the participants identified themselves as mothers who care for infants, developing their roles within formal biparental relationships. On the other hand, the majority of respondents chose to identify themselves as "single without children," maintaining long-term formal relationships or casual, casual ones.

The average age of the participants was 27, showing that they were in the young adulthood range. This aspect is critical, as the developmental stage of these professionals can affect their approach and the strategies used during the therapeutic process. The participants' youth suggests a potential willingness to incorporate new practices and approaches into their work, which could enrich their performance in the field of occupational therapy.

The variables of gender and age are presented in this study due to their potential impact on the professional development of the participants, especially regarding the establishment of the therapeutic alliance and other relevant aspects of their practice. Table 2 provides a summary of the characteristics of the 10 professionals who were considered suitable to participate in the second stage of the research, allowing for a better understanding of how these sociodemographic variables may influence the professional context in which they operate.

Table 2
Interviewee characteristics.

Interviewee	Gender	Years of profesional experience	Years of experience in the residential system	Type of residency	Hours / Contract
1	Female	4	2	RVA adolescents ♀	44 / permanent
2	Female	6	4	RVA adolescents ♀	44 / permanent
3	Female	3	2	RVT adolescents ♂	36 / permanent
4	Male	2	1	RVA adolescents ♀	44 / permanent
5	Male	3	1	REM-PER ♀	44 / permanent
6	Male	8	7	RVT adolescents ♂	44 / permanent
7	Female	5	2	RVA adolescents ♂	44 / temporary
8	Female	5	2	REM-PER ♀	40 / permanent
9	Female	2	2	REM-PER ♀	22 / temporary
10	Female	3	1	RVA adolescents ♀	44 / temporary

• Source: Survey Characterization of Occupational Therapists and their experience with child abuse, 2023. Prepared by the authors. Note: Residential spaces are organized by biological sex. ♀: Female residence; ♂: Male residence

The analysis of the residential care modalities in which occupational therapy professionals participate reveals a remarkable diversity of projects. These modalities are classified using specific acronyms, which represent different types of residencies and programs designed to serve different age groups and needs. The main modalities identified are the following:

REM PER: This type of residential care refers to the Residential Care Home for Children aged 6 to 18 years and older, which offers a specialized protection program. This approach is designed to offer a safe and supportive environment for children and adolescents who require special attention due to situations of vulnerability.

RVA: The Family Life Residential Care Home for Adolescents aged 14 to 18 years and older is designed to provide a family environment that fosters the comprehensive development of adolescents, promoting their autonomy and social reintegration.

RVT: The Family Life Residential Care Homes for Early Adolescents aged 8 to 14 years and older aim to serve a younger age group, offering a safe space that fosters emotional stability and the development of social skills in a family-friendly environment.

The technical guidelines governing these types of residential care are centered on two fundamental objectives: restoring the right to live in a family and repairing the harm suffered by adolescents due to vulnerable experiences. These guidelines seek to guarantee an emotionally safe residential space that fosters the healing process, allowing young people to overcome their adverse experiences and effectively reintegrate into their family and social environments.

It is important to mention that, although all the interviewees work with adolescents, six of them also participate in projects serving the second-year population, encompassing children from six to twelve years old. This combination of care for different age groups reinforces the versatility and commitment of the professionals in their work, suggesting a skill to adapt to the diverse needs of the population they serve.

As a conclusion, the diversity of residential care modalities in which the professionals work reflects the complexity and richness of occupational therapy work. The attention to different age groups, along with a focus on reparation and restitution of rights, underscores the importance of creating supportive environments that promote the emotional and social well-being of young people in vulnerable situations.

Second Stage Results

To collect material for this research, a total of 12 meetings were held with participants, 8 of which were held in person in the city of Valdivia and 4 via videoconference using the Zoom platform. This strategy allowed for the inclusion of participants from different places in south-central Chile, such as Santiago, Viña del Mar, and Valparaíso. It is important to mention that, in the case of two interviewees from Valdivia, two sessions were held, given that the content discussed in the first meeting was considered of high quality and contextual variables prevented exhaustive exploration in that first meeting.

Throughout these meetings, a total of more than 20 hours of audio recordings were obtained. The management of this material was done with a rigorous ethical approach, prioritizing the confidentiality and anonymity of the participants, who signed an informed consent document guaranteeing their privacy and the integrity of the data collected.

Regarding the organization of the CSDs, they were organized in an interconnected way, considering the most relevant topics for the participants and the research objectives. This approach facilitated the prioritization of content that had the greatest emotional resonance among participants.

Based on the manual transcription of the content, and following the CSD methodology proposed by Lefèvre & Lefèvre (2012), a selection of dialogues was made for the purposes of this publication. Table 3 presents this selection, which includes six CSDs, distributed into two CSDs for each Key Expression (KE). The exclusion criterion applied was the identification of those CSDs that were considered complementary to other KEs. It is important to mention that each CSD retains its original numbering, allowing for clear reference to the encounters in which they were generated.

Table 3
Key Expressions and Main Ideas.

Key Expressions (KEs)	Main Ideas (MI)
1. Practices that Characterize Everyday Life	1.1 Connecting from the Human is Fundamental.
	1.2 To what extent is it history and to what extent is it a choice?
2. Tensions of everyday practice	2.1 We are strangers and we know little
	2.2 It is like being in a trench
3. Issues that support the work	3.1 Feeling that you are making a contribution
	3.2 It is a roller coaster

• Source: Own elaboration.

This methodological approach guarantees that the information presented is representative and meaningful, providing a detailed view of participants' experiences and perceptions regarding the topics addressed in the research.

Practices that characterize everyday life

Connecting from a human perspective is fundamental

CSD 1:

It's important to consider that stories of abuse generate hopelessness and low self-esteem in the girls. It's a huge challenge because they may be starved for affection, but they may also be very reclusive and emotionally closed off. Besides the fact that they don't want to be in a nursing home, that they feel pain or anger, and that they're tired of their lives. As a professional, it's important to understand their ambivalence and help them cope with it. So I tell them: I'm going to help and support you while you're here. Take advantage of learning new things; you won't be alone. In that sense, your human qualities and how you use them to support the girls, gain their trust and approval, are more important than technical or theoretical knowledge. You can't achieve anything without them trusting you; if you don't have a good relationship, it's very difficult to work with the girls. For this area, the human connection is key.

To what extent is it history and to what extent is it a choice?

CSD 2:

You can't separate the child from their history of vulnerability; they're part of a whole. You have to recognize that they grew up in environments where there's a lot of vulnerability. Much of their life has been linked to traumatic experiences. The environment really influences them, and through that, you begin to understand some behaviors. The difficulty in exploring new things, feeling safe in venturing out and trying, and overcoming them if something goes wrong while exploring. Also, avoidance behaviors related to problems they haven't been able to overcome, such as substance use or not using protection during sex. We may know the history of vulnerability, but we won't always clearly see how it manifests in the girl's behavior. Within the residential context, one must be realistic, because there are extremes. Girls who manage to be resilient and completely turn their lives around, boys who are extremely vulnerable and continue their lives as if nothing happened, and others who you simply know you won't be able to save, that you arrived too late, or that it's not yet the time for them, that they're still understanding what happened to them, and... how your story is impacting your life.

Tensions of daily practice

We are unknown and know little

CSD 3:

We are a new profession in the system, and there are no clear guidelines to guide our work or to make our role known. The position is complementary; it is a recommendation, since the strength lies in the psychosocial team. Everything is decided on the fly and depends on each residence. There remains the feeling that, for the Service, we are primarily in charge of routines, and by having less administrative burden, we have more opportunities to intervene. We are the wildcard professional since we can do almost everything: support in crises, act as a guardian at school, organize routines, and provide individual and group care. I have had to face many difficulties understanding the limits of my profession, along with the right to limits of the child and myself. It is a challenge to adapt to the role and expectations, since it is difficult to understand what we do and, consequently, it is hard to value our contribution on a daily basis. Fortunately, our biopsychosocial training allows us to find common ground with the team, allowing us to validate ourselves and adapt to needs. It will take a couple of years until our integration and our roles become more standardized.

It is like being in a trench

CSD 4:

I felt frustrated and anxious at first, but then I realized it's to be expected. I had to manage my frustration as part of the learning process, realizing that I'm working with children who have been harmed, who are not in good mental health, and who often don't receive adequate treatment. There's a sense of mental and physical exhaustion due to complicated dysregulations that happen frequently and require your intervention to deescalate. This involves being insulted, pushed, or threatened unexpectedly, witnessing destruction with flying glass and chairs, and even facing attempts to cross boundaries in sexual or erotic terms. Crisis interventions are the most exhausting because they emotionally overload the nursing home's staff and social system. This means constantly having to self-manage emotional tools to provide support and reassurance, even putting all that above one's own emotionality. I've often had to endure crying and fear, but they're more part of the problem than the solution. It's part of the job, after all. It's like being a firefighter and being afraid of fire. It's like the dark side of the job. Despite that, the worst frustration isn't related to the girls. The girls aren't the main or only part of the chaos; perhaps it's the most expected.

Issues that support the work

Feeling that you are making a contribution

CSD 5:

We provide cross-cutting support in sensitive areas such as routine, mental health, network management, and psychomotor stimulation. Promoting a structured routine prevents excessive idleness, which is closely related to crises and self-harm. Although it can't always be strictly followed, it's critical to keep a balance so that children can choose activities that make sense to them. By being close and playful with the children, we contribute to basic activities such as helping them grasp a pencil and spoon, reducing difficulties in transferring water from a container to a glass, or even teaching them the rules of a game. We can help them motivate themselves and develop emotional expression skills to avoid outbursts or meltdowns and establish hygiene and eating routines, especially if they come from disorganized environments. I met a girl who never had a toothbrush, and severely malnourished children who need to be helped to incorporate schedules and routines. As time went on, I realized there wouldn't be quick changes, but rather small ones. Experiences of vulnerability are part of their foundation, and working with meaningful activities for children is fundamental. It helps them value themselves, develop self-esteem, and feel capable of changing their present and future. It prepares them for life and gives them the tools to learn how to live.

It is a roller coaster

CSD 6:

It's like getting on a train that won't let go. You can feel fear, sadness, joy, anger, rejection, tenderness, or frustration. Sometimes all at once in the same afternoon. I've thought about looking for another job, but it's hard to leave them, knowing they're going to feel abandoned. It's hard to shoulder that burden. The time I spend with them reinforces the feeling of being part of their lives, and although it generates a lot of affection, it's also extremely exhausting. There was a lot of violence among the children when I arrived. I worked with fear, since the physical attacks were directed at adults. It means working with the constant uncertainty that something could ruin your planning, endanger your safety and everything you've achieved. There's a constant tension in the air. It's working with high adrenaline, in the logic of putting out fires, sometimes with great urgency, containing the chaos so it doesn't cause more damage. It's a feeling that traps you and makes you lose track of time. You don't know if you're strong enough to endure something like that until you experience it. You question everything, but you keep going because you contributed something, even if it's small. A dissociative mechanism develops to cope with reality and be sensitive to the good or insensitive to the bad. It's incredibly complex to explain it like this, but my inner world became so disorganized that I had to work with my own history and my childhood to overcome those experiences.

Discussion

The research, whose descriptive-analytical methodology, qualitative-quantitative in nature, and predominantly qualitative, allowed for a comprehensive approach to the phenomenon under study, where bibliographic knowledge is limited. For the characterization phase, a sociological survey was used to establish a diagnostic profile of the participants (Otzen & Manterola, 2017). The second stage, characterized by the application of ethnographic interviews (Guber, 2015), favored a fluid development of the process, facilitating encounters and access to the content presented (Taylor & Bogdan, 1987). Regarding the anthropological perspectives of violence, the body, and health, their integration allowed for a comprehensive understanding of the findings.

In the first KE entitled: "Practices that characterize everyday life", the anthropology of violence and the body allows us to understand how violence affects people, particularly in their childhood (Álvarez, 2013), facilitating a comprehensive understanding of the impact of violence on perception, bodily experience and identity, considering that the body is a sociocultural construction and not merely biological (Le Breton, 1990). In this sense, the following elements stand out: life stories, therapeutic relationship, use of the therapist as a tool and intervention challenges related to both the therapist and the children with whom they work.

The importance of MI is emphasized: "connecting from a human perspective is fundamental," which highlights expressions associated with "human connection" and "daily accompaniment," considered key elements for the development of the therapeutic relationship (Aponte et al., 2009). This reflects the impact of violence on childhood biographies and, therefore, the need to support intervention practices centered on corporeality, associated with elements of good treatment (Sanz, 2016) and respectful parenting (Lecannelier, 2019). Elements of trust and predictability are emphasized as mediators of healthy human connection (Barudy & Dantagnan, 2005).

Regarding the anthropology of health, this allows us to understand how comprehensive recovery processes are facilitated in this setting. The recursive relationship between the elements of: the adult figure of the professional (Aponte et al., 2009) and the use of oneself as a therapeutic tool (Hagedorn, 2000) present in CSD 1 is emphasized as one of the main challenges of daily work, related both to traumatic sequelae and to the physical and social environments characteristic of residential spaces (Barrientos et al., 2021). In this sense, it is stated that the mechanistic and functionalist dichotomy that has characterized the training of professionals and the understanding of health phenomena, prioritizing what is measurable over practices that consider social and biographical aspects (Gil & Bassi, 2021; Le Breton, 1990) is strongly stressed in this scenario.

In this regard, the MI entitled "To What Extent Is It History and to What Extent Is a Choice?" reveals that the work of therapists involves facilitating processes that help children and adolescents find meaning in their lives, an essential aspect raised by Frankl (2021) in environments of extreme vulnerability. CSD 2 shows that this process is addressed through therapeutic activities, both individual and group, that take place throughout each day. In this sense, it is emphasized that finding meaning is not only complicated, considering the biographies and expressions of complex trauma (González & Ríos, 2020), but is also critical for articulating the therapeutic relationship and supporting intervention processes in the short, medium, and long term, therefore promoting recovery from the after-effects associated with traumatic experiences (Lecannelier, 2021).

From a bodily and health perspective, the element of "using oneself as a therapeutic tool" is recognized as fundamental, as it allows therapists to support children and adolescents in their recovery from histories of abuse. This approach also allows them to develop processes of searching for meaning in daily life, facilitate new experiences, acquire knowledge and strengthen skills, and cultivate positive expectations about their future, in line with what Szmulewicz (2013) and Valenzuela León et al. (2022) have pointed out.

In the second KE, "Tensions of everyday practice", stories are presented that reveal that professional daily life is strongly influenced by two elements: the first, from a bodily perspective, is related to the complexities of children and adolescents (Barudy, 2006; Boon et al., 2015; Barrientos et al., 2021), and the second, evidenced in this research, is associated with contradictions and shortcomings inherent to the functioning of the residential system and the new institutionality of Mejor Niñez, added to the lack of knowledge of occupational therapy in the field of residential protection, as mentioned in CSD 3.

The MI "We are unknown and know little" emphasizes the challenges of the lack of a job profile, but also describes the diversity of contributions related primarily to biomedical (Valderrama, 2019) and biopsychosocial (Brito et al., 2019) aspects, especially in the new areas required by recent institutionalization (Defensoría de la Niñez, 2023). In this regard, CSD 3 highlights the importance of occupational therapy in this field, a relevant aspect for the interviewees and consistent with the strengths of the profession described by Galheigo (2012) and Giraldo (2016), associated with both healthcare pragmatism and the importance of the biopsychosocial perspective in healthcare approaches.

Regarding the MI "It's like being in a trench," CSD 4 exposes the constant urgencies, difficulties, dangers, and exhaustion that therapists experience in situations that regularly generate tension (Hagedorn, 2000; Szmulewicz, 2013; Valenzuela León et al., 2022). This MI evokes a sense of "abandonment or loneliness" that professionals feel when faced with problems that cannot be resolved through the new institutional framework of Mejor Niñez, directly affecting the well-being of children and adolescents (Defensoría de la Niñez, 2023) and, recursively, the corporality of the therapist.

From a corporeal perspective, this scenario proposes the use of different coping resources, highlighting the adaptive mechanism of dissociation (Boon et al., 2015), which allows professionals to mitigate the impact of extreme and damaging experiences on their physical, psychological, and emotional integrity. This dynamic is similar to the dissociative strategies that vulnerable children and adolescents have developed to continue their lives (Barrientos et al., 2021). In addition, remaining in residential care is associated with health problems, especially mental health issues, exposing professionals to vicarious trauma, compassion fatigue (Lewis & King, 2019), and burnout (Saborío & Hidalgo, 2015). These phenomena are linked to the demands of caring for people with different difficulties in overcrowded environments with few opportunities for institutional self-care (Defensoría de la Niñez, 2023).

The third KE, "Issues that support the work," arises from the need to highlight the stories that reflect the motivations that facilitate permanence in this work envirnememnt, despite the adversity described above. During the ethnographic interviews, the presence of deep and intimate emotional elements was evident. The MI "Feeling you're making a contribution" has to do with the sense of professional competence proposed by Kielhofner (2008). In CSD 5, interviewees state that perceiving "positive impacts" on the recovery processes of children and adolescents generates emotions such as "joy" and "hope." According to Szmulewicz (2013) and Valenzuela León et al. (2022), these emotions are constitutive of the therapist's identity and foster professional performance, mediating their permanence in these environments.

This analysis highlights two groups of elements: the first, related to pragmatism in occupational therapy (Morrison Jara, 2022), which underlines the positive influence of "direct intervention" and "using oneself as a therapeutic tool" (Hagedorn, 2000), both considered critical tools in therapeutic practice and elements that reinforce the sense of professional competence (Kielhofner, 2008).

The second group is associated with "vocational factors," which relate to the choice of area and professional profile to work in environments of vulnerable children. The stories show a conscious or unconscious tendency to "want to help," which coincides with the motivations described by humanistic psychology regarding the biographical factors that drive the choice of caring professions (De Castro & García, 2008). In addition, stories are presented that emphasize the professional role as a promoter of "social justice," a distinctive aspect of occupational therapy (Hagedorn, 2000).

In this context, and recursively, Berroeta's (2015) argument describes that the two groups of elements in question reinforce the "sense of belonging" and "attachment to place," which act as mediators of professionals' permanence in residential settings.

Additionally, the MI titled "It's a roller coaster" refers to the intensity, diversity, and unpredictability that generate a kind of "stress addiction" as an adaptive mechanism (Boon et al., 2015). This phenomenon is characterized by progressive tolerance to the adrenergic rush produced by extreme situations, which are mostly associated with behavioral dysregulation and/or decompensation of preexisting mental health disorders in children and adolescents.

CSD 6 describes the "normalization of chaos" as a concept that defines the existence of (hyper) sensitivity to the "good" and (hyper) insensitivity to the "bad." This phenomenon is presented as a process of idealization of everyday professional life, which includes the "romanticization" of chaos and unpredictability. This dynamic resembles what the French sociologist Baudrillard (1995) describes in relation to the capacity of one's own representations to replace reality, distorting what is considered authentic in everyday experiences.

Likewise, this process is also linked to healthcare pragmatism in occupational therapy, as described by Morrison Jara (2022), and to the appropriate use of the therapeutic self, as proposed by Hagedorn (2000). The recursive interaction between both elements in the professional field allows therapists to develop the ability to be practical and focus on solutions in the face of chaos, managing what contributes to well-being and regulating what might be less appropriate. In this way, adaptation to everyday stresses is facilitated, which, in turn, strengthens the sense of competence (Kielhofner, 2008) and the sense of belonging to the place (Berroeta, 2015).

Final Considerations

This qualitative, descriptive-analytical research, developed using an ethnographic approach, has provided a deep understanding of the practices, challenges, and motivations of occupational therapists working in residential care facilities in Chile, especially in the context of the implementation of the new "Mejor Niñez" institutional framework. Using tools such as floating attention, free association, and deferred categorization (Guber, 2015), a reflective research practice has been facilitated, fostering a diversity of experiences through the Situated Discourses of Contexts (CSD) methodology.

This process has enabled the identification and analysis of social representations and symbolic constructions that characterize the occupational therapy profession and the advances made within the framework of the institutional transition. In this regard, "human connection" and "daily support" stand out, as well as the "biopsychosocial perspective" and "healthcare pragmatism" as key elements. These aspects, supported by practices of good treatment and respectful parenting, are essential to the development of effective therapeutic relationships and to the vocational motivation of therapists in their daily work with children and adolescents in the state protection system, which affects their long-term retention in these environments.

Likewise, the biopsychosocial approach and pragmatism typical from occupational therapy are presented as substantial contributions that enrich teamwork and intervention processes, suggesting the need to establish a specific institutional role profile, not yet existent at the time of this research. The main roles observed focus on preparation for independent living, given the therapists' constant and direct contact with the children's daily lives, reinforcing the relevance of this practice in the environment described by the Office of the Ombudsman for Children (Defensoría de la Niñez, 2023), which reveals a significant gap in the care of children and adolescents under state guardianship in Chile.

Among the most notable challenges are the effects of violence on children and the contradictions of the protection system. These elements, along with the limited recognition of occupational therapy in residential environments, are linked to negative effects on therapists' mental health, including vicarious trauma and burnout. In this context, it is observed that university training in social areas is insufficient, although some institutions, such as the University of Chile, the Austral University of Chile, and the Andrés Bello University, have made significant progress in integrating these aspects into their curricula, promoting social justice and human rights approaches.

Although a progressive incorporation of occupational therapists has been observed since 2021 within the framework of "Mejor Niñez," these advances are perceived as slow and superficial. Consequently, the findings of this research not only enrich the bibliographic corpus of Chilean occupational therapy, especially in a social field related to Human Rights, but also open new perspectives for academic training and the development of inclusive interventions contextualized to Chilean social reality. This highlights the need for greater integration of occupational therapy in spaces of social action, which could foster a more critical, reflective practice committed to social justice and Human Rights.

• 1
  This article is part of the Master's thesis in Anthropology entitled "Discourses that characterize the work of occupational therapists with children residing in the better childhood protection network" (ex SENAME)”.
• How to cite:
  Olivarez, L. C., & Cirineu, C. T.. (2025). Analysis of discourses on the practice of occupational therapists with children residing in the better childhood protection network (Mejor Niñez). Cadernos Brasileiros de Terapia Ocupacional, 33, e3961. https://doi.org/10.1590/2526-8910.ctoAO405639612

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Edited by

• Section editor
  Prof. Dr. Mónica Díaz Leiva

Publication Dates

• Publication in this collection
  26 May 2025
• Date of issue
  2025

History

• Received
  01 Oct 2024
• Reviewed
  14 Jan 2025
• Accepted
  15 Feb 2025