Notes about cases supervision based on the Dynamics Occupational Therapy Method (MTOD) and occupational therapy education

Abstract

Clinical practice involves all professionals dealing with diagnosis, treatment, rehabilitation and secondary prevention. Teaching occupational therapists subsidized by theoretical-practical contribution to the clinic is important when thinking about the social insertion of patients, which is the ultimate objective of Occupational Therapy. The occupational therapy clinic, developed in several contexts, should be geared to the subjects, their needs and possibilities, through the accomplishment of activities and creation of health spaces. Given the importance of the discussion about training in Occupational Therapy, this paper proposes to approach experiences of cases supervision attended in clinical school, using the Dynamic Occupational Therapy Method (MTOD). We used the experience report, through which it is possible to provide an approximation with the subject and to extract relevant points about case supervision and the occupational therapists teaching. Learning and teaching activities are two components of occupational therapy training that are present in the relationship of young therapists with patients and also with the supervisor since, in both situations, they are experiencing new activities. The activities can be therapeutic and educational, creating health spaces, and this understanding is inherent to the occupational therapist to ensure their presence in the triadic relationship. The supervisor’s challenging action, according to the MTOD, is to bring the future occupational therapist closer to the target subject of this work, connecting theory to technique in the triadic relationship between therapist-patient-activities and promoted by a positive, non-centered transference, not focused on the disease but in the subjects and their activities.

Keywords:
Occupational Therapy; Mental Health; Supervision

Resumo

A clínica envolve práticas de todos os profissionais que lidam com diagnóstico, tratamento, reabilitação e prevenção secundária. Formar terapeutas ocupacionais subsidiados por aporte teórico-prático para a clínica é importante, pensando na inserção social dos pacientes, objetivo final da terapia ocupacional. A clínica do terapeuta ocupacional, desenvolvida em diversos contextos, deve ser voltada ao sujeito, às suas necessidades e possibilidades, por meio da realização de atividades e da criação de espaços de saúde. Dada a importância da discussão sobre formação em terapia ocupacional, este trabalho se propõe a abordar experiências de supervisão de casos atendidos em clínica-escola, a partir do Método Terapia Ocupacional Dinâmica (MTOD). Fez-se uso do relato de experiência, por meio do qual é possível proporcionar uma aproximação com o tema e extrair pontos relevantes sobre a supervisão de casos e a formação de terapeutas ocupacionais. Formando terapeutas ocupacionais, podemos dizer que aprender e ensinar atividades são dois componentes presentes na relação dos jovens terapeutas ocupacionais com pacientes e também com a supervisora, já que, nas duas situações, estão vivenciando a aprendizagem de novas atividades. As atividades podem ser terapêuticas e educativas, podendo criar espaços de saúde, e esta compreensão é inerente ao terapeuta ocupacional, para que, na relação triádica, este fazer aconteça. A desafiadora ação da supervisora, a partir do MTOD, está em aproximar o futuro terapeuta ocupacional, sujeito-alvo deste trabalho, conectando a teoria à técnica, na relação triádica, existente entre terapeuta-paciente-atividades e promovida por uma transferência positiva, não centrada na doença, mas no sujeito e nas suas atividades.

Palavras-chave:
Terapia Ocupacional; Saúde Mental; Supervisão

Introduction

The professional career as a multi-professional resident in Family Health teams, occupational therapist in a Municipal Mental Health Ambulatory and regional articulator of mental health in State Health Management provided important experiences for professional life, especially to teaching future professionals.

Being in the clinic and developing the clinic with psychiatric patients, the need for theoretical-clinical deepening became greater, leading to the search for training in the Dynamic Occupational Therapy Method (MTOD), considering that this could subsidize the theoretical and practical reference in the attendance of the cases, as well as to strengthen the construction of the function of the occupational therapy in this service and also in the support of the theory of the technique.

In the exercise of management, it was possible to experience a challenging workplace. After all, what network is this about? What public policies are these? For whom are they? How does this care work? Being in this place of articulation of policies and activities of permanent education for health professionals of a certain region composed of a determined number of municipalities brought significant and critical learning to all involved (GOZZI et al., 2014). Besides the inherent learning of the function, this experience allowed a genuine dialogue with other health professionals belonging to the teams, who would also like to work in a different way and critically rethink their professional work.

In the daily life of this work, the judicial actions were definitely the weak point, but they incited debates and brought subsidies to the discussion of cases with whom, often, had no idea what the suffering can cause in the life of a person and his family, of the losses in their daily lives, and the perception that the simple determination of “Accomplish!” often does not solve the problem of the lack of systematic attendance of the case for the services available in the public network. Here, it some gaps are identified in the training of these health professionals who also need a clinic based on a theoretical-methodological practice for effective care.

Then, the network appears. Once, a professor at the Psychology Department of UNESP/Assis did a “provocation” at an event, trying to explain which network is the one we talk about in mental health. It can be that one of lying down, it can be that one of fishing, the one that holds the ball in the goal, which holds the hair of a young or not so young woman. Suddenly, it is possible to visualize all these meanings enunciated by a word, which implies an action - so important to us, occupational therapists. Thus, a guiding thread that approaches all these senses is the possibility of sustaining something by the interlacing of its points. It is also the Network of Psychosocial Attention (RAPS), which, besides to its points, it must have something that supports it, which has a lot of clinical practice (MATEUS; MARI, 2013; LEAL; MUÑOZ, 2014).

Currently, the insertion of the author also occurs in a multi-professional team of a Clinic School, linked to the University, where ambulatory care is provided, including mental health. Even though the “Ambulatory” component is not provided in the direct flow of the conventional care network recommended by the recent mental health regulations, there is nothing to prevent this equipment from composing the case or territory network, since the extra-hospital remains in practice and in the training of students for the network.

After a contest for a teacher in the Department of Occupational Therapy at UFSCar, the approval has come. One more challenge was coming out. How to train future occupational therapists for the network, whatever the point of attention?

The activities of supervising the internship of the occupational therapy course were initiated in a lively and exciting way, due to the possibility of supervising the students in the stage of their training that involves the professional practices. The idea was to train health professionals and occupational therapists to practice their profession with dignity, ethics, and quality. Thus, from this point on, the students/trainees are the target subject of this essay. However, some aspects raised a certain concern: How to do this? How to welcome these students who came to continue an outpatient adult mental health occupational therapy ambulatory service? Who were these patients? How should this supervisor act?

Being training in the MTOD, the professional theoretical assumptions are adequate for this teaching. Therefore, this essay will focus on the training of the supervisor for the great and responsible task of training occupational therapists in the professional internship phase.

The first challenge faced was to teach students that occupational therapists care about people and the activities, thinking about their daily lives - they still did not think about expanding health spaces. There is a very commonly repeated idea in students before they begin the mental health internship: “I do not know how to do many activities. The mental health internship causes us to do many craft activities with patients, much more than in other areas”.

Today, this phrase is understandable, although other areas also use activities to observe their patients in their daily lives. Understanding this disquiet in students is important because it really is important to know activities to teach patients and observe them doing. At MTOD, activities are used in several areas and there is a qualitative and quantitative plasticity in these activities so the observation and collection of information about how this subject performs activities can happen.

In this sense, attentive, critical and systematized observation is something the occupational therapist must sensitize, retaining information, so that “all a prospective behavior” can occur, educating their associative memory. Observed and retained,

[...] events can and should be associated, since, unlike verbal language that quickly favors associations, doing things may not seem to be a chain of ideas or accomplishments (BENETTON; MARCOLINO, 2013, p. 648-649).

The accomplishment of activities and the process of association of events in the therapeutic process generate a space of historicity. In this space of living, affective and warm historicity, this narrative that tells the story of this dynamic relation has the participation and social insertion of the subject as its final objective. It was the path taken by the author as an occupational therapist who provided the substrate for his training as a supervisor.

The professional internship is characterized as a phase of the training of the student of occupational therapy, in which they can experience professional practice in an ethical and responsible manner, joining acquired knowledge and those that also occur in this internship of their training. After all, it is a theoretical-practical internship for the teaching of clinical practice, supported by a theoretical-methodological reference.

In this space, there are students from different periods of the undergraduate course in occupational therapy, in a school clinic that is characterized by ambulatory care. Individual and group sessions are held, in which the teacher is the supervisor of the internship. Such supervisions have evidenced that the students bring the vision of the activity as therapeutic by themselves, responsible for the remission of the symptoms, for the appearance of feelings verbalized and for the needs of this activity to be analyzed and prescribed by the occupational therapist.

Contextualizing, one of the curricular activities of the students involves a unit of supervised practices in occupational therapy, which is the first contact of the students with the specialties before the internships. In this initial scenario, the student finishes supervising the activities carried out by the supervisor and also by the trainees, besides to proposing questions about the practice of the activities carried out both in collective supervision and in an appropriate reflection spaces. Meanwhile, the trainees are responsible for individual attendance, planning, and execution, as well as for monitoring group activities performed by the supervisor.

In this sense, the medical diagnosis is characterized for some students as the guide of therapeutic actions, rather than the repercussion of illness in people´s lives. This is undoubtedly a major issue to be addressed at this internship of the training of these trainees.

The following excerpts are from the field journals of trainees and students to reflect on their role as supervisor. It should be noted that these excerpts were transcribed ipsis litteris, that is, literally. The students involved in this essay authorized the use of excerpts from their field diary, with their identities kept confidential, as well as those of the patients they attended. These field diaries - a strategy used to construct the clinical rationale of the trainees - highlight some observations of the students, in front of the subject in doing activities.

When M. began to make the stitch in the fabric, she had some difficulties, but I decided to leave to see her resolve and to what extent she would go without asking for help. But all the time she asked for help and I answered: think a little because you already did it. Then she tried and most of the time she could solve it alone, sometimes she would be helped (P. trainee attending M.).

At the beginning of the care, S. seemed willing and nervous when she visualized the paints, brushes and other materials on the table. He was curious about the objects, but he did not manipulate any of them without my guidance. I presented the proposal of the activity and tried to leave it at ease to explore the materials. Initially, she showed considerable difficulty and restricted herself to a single color and used a single corner of the paper. At that moment, I presented the various paints and possibilities and she tried to use other paints and in different ways (Trainee G. attending S.).

The supervisor’s action is then in the provision of tools and strategies so care is not only the performance of activities, but allows the creation of a triadic relationship and the teaching of clinical practice, and how to put this relationship in motion (BENETTON; MARCOLINO, 2013).

The great question then lies in the use of all this richness of patient observation by performing activities to establish and improve the triadic relationship and, of course, to offer continence space, health spaces and potentialities, and possibilities of social insertion to these people (MATTINGLY, 2007).

One of these steps helping to systematize what has been observed is the elaboration of the situational diagnosis, which offers a circumstantial photograph of a certain moment in the subject´s life (BENETTON, 2006; TITO; MORAES, 2007). The trainees learn to elaborate this diagnosis also offering an overview of the patient´s situation for the next trainees, but mainly putting their perceptions on this relation.

There is also an apparently restricted repertoire of students regarding the knowledge of the techniques of performing activities. There were few experiments, few examples, and few previous experiences often restricted to experiences in subjects during the course. The supervisor´s role is to teach them several techniques of accomplishment of activities, that can instrumentalize them for the clinical practice.

Faced with these difficulties, including in understanding the activity as an instrument of the occupational therapist, the trainees use the verbal approach with patients much more than the activities. As a supervisor, the topic is discussed, pointing out that joint activities can provide patients much more than dialogue - or monologue, both by the trainee and the patient - on matters that do not always make sense to them. Such procedure can be exemplified in the following report:

I say that he needs to try new things, if he allows himself to experiment, that really work tires, but that it is important to create our independence and autonomy. At that point, I try to use the women to convince him, saying that no woman will want to marry a man who spends all day on the couch playing video games, besides, I question how he wants to get Q. (of the group) to do something he has no money, I wonder if he’s going to be asking money from his mother forever. J. says he wants to change, so I say he has to do something for it, wanting is the first step, but that is not enough. He is silent for a while as we walk (Trainee N. attending J.).

In this small report, we can see how many times the trainee mentions the words “I say” and “say”. The recognition by the word is in the culture of the world and the meeting of meaning by the word. Occupational therapists need to take a path to finding meaning by performing activities.

This learning is about the use of activities within the triadic relationship. What is it for? How to help? How do you invite this achievement? Understanding that the verbalization does not mobilize so much for the action, the trainee is able, to accompany him in his newest project throughout the visits: the performance of artisanal products for commercialization. Suggested by him, the trainee then supports the proposal, offering space, strategies, techniques, materials, and support for this achievement.

I suggest that we finish the card already started two weeks ago and put several materials at your disposal to decorate them. J. chooses sequins and glitter but he says not knowing how to use it. I teach the side of stringing the sequins and what is the easiest way to play the glitter on the card. It is easy the way of how to do it and finishes the card alone, sprucing up the edges, the pine tree and making the ground with green glitter. I compliment saying that the color combination was very good and he also seems satisfied with the result. J. decides to start a new card and give the idea of ​​making another Christmas symbol, not the Christmas tree because all the others were like that. He likes the idea and as the garland we made on the women’s group was on the table, he asks if he can make a card with a garland. I ask him how he wants to do it and I suggest material. I realize that he is always interested in using different materials and experimenting with new techniques, something that did not happen at first. I’m very happy about this (Trainee N. attending J.).

Thus, talking about work no longer makes so much sense, but his attitude in making the cards to sell shows far more possibilities for constructive change and seeing the world, his skills and discoveries that, along with the trainee, the patient can then walk a path of new things.

Some Considerations

The supervisor´s challenging action from the MTOD is to bring the student, future occupational therapist and subject-target in this essay, from the theory of technique into the triadic relationship, formed by therapist-patient-activities, promoted by a positive transference, not centered on diseases, but on the subject and its activities. Thus, the therapist has an active posture - active, affective and technical - that provokes the existence of the positive transference to the activities performed by the subject and it can also be evaluated in the process and in the relationship.

In this specific case, the professional internship will be responsible for the practical training, as well as for the theoretical training of these students, which is possible from the MTOD. What is or should be implicit in this process is the teaching of a theory of technique, which creates and sustains concepts, based on lived experiences and observation of facts (empiricism), which generates learning for the practice.

One of the exercises in this process is in the appropriation of the supervisor of the contributions of the theory of technique to which we refer (BENETTON, 2006, p. 60):

1. Integration of the subject for social insertion;

2. Activities as part of the subject in the world;

3. Activities as an instrument/therapeutic function and educational action;

4. Triadic relationship, mediated by activities;

5. The associations that the triadic relationship allows to do;

6. Participation of the subject in the analysis of the performance of the activities and the existence of the fourth term in the triadic relationship, mainly related to the social;

7. The posture of the active therapist;

8. The positive transference and the construction of a healthy and active daily life.

Often, in the contact with these cases, the supervisor react as reacted in similar cases in previous situations, what attitudes he thinks about taking from his experience and offers strategies to the trainees for the continuity of care.

This referenced clinic can happen at any point in that network that supports this care. After all, the objective of the training is also to train general professionals, who can work in different services, with the target population of occupational therapy, the one that is in a position of exclusion. These subjects (patients and professionals) are in different points of the network.

Observation, information, association, historicity space and narratives (BENETTON, 1994) can and must be present in different areas of occupational therapy: mental health is just one of them. From basic care to the bed in a general hospital, we cannot forget that a careful, efficient, emancipatory and, above all, social practice is necessary.

The trainee has the opportunity to experiment and learn the clinical practice, from the mental health area, and he can expand to other fields. AsCampos (2001) describes, the complexity of the demands brought to the mental health services requires an articulation of the work in professionals to try to handle caring for people and not just their symptoms.

According to Campos (2001), a small number of works in the health area in Brazil raised the importance of clinic and care in public health services, specifically the forms of care to the mental health user. This silence cannot be denied. After all, it says much about the situation found in services that are responsible for the replacement of a so-called asylum logic, in which a lot about politics is heard, but little about a clinic, in fact, caregiver.

The clinical practices are not only medical, but those performed by all professionals who deal daily with diagnosis, treatment, rehabilitation and secondary prevention. What draws attention is that, in order to make a clinic that cares for the subjects in their needs, it is necessary to deny or even idealize the disease that exists there and its repercussion in life. The subjectivation of these demands that reach the services is the solid aspect that justifies the action to share responsibilities of this clinic, when in a team (CAMPOS, 2001).

For this reason, training occupational therapists concerned with care and subsidized by a theoretical-practical contribution to clinical practice is very important, considering, mainly, the expansion of health spaces and the social insertion of patients (final objective of occupational therapy) (MARCOLINO, 2016), and in the change of the asylum logic already so deeply rooted in our senses and (AMARANTE, 1995).

The MTOD offers subsidies for the accomplishment of a clinic directed to the subject, its needs, and its possibilities. It systematizes the clinical reasoning of the occupational therapist and considers daily life as an important aspect of care.

Forming occupational therapists, we can say that learning and teaching activities constitute a present component in the relationship of young therapists with patients and also with their supervisor since in both situations they are experiencing learning new activities. As Benetton (2006), points out, the activities can be therapeutic and educational and can create important health spaces. It is inherent to the occupational therapist this understanding that, in the triadic relationship, it happens.

For this reason, the observation of the therapist’s preparation of activities in the MTOD is an important source of information. This systematic and rigorous observation allows the therapist to approach the circulation of affections in this relationship (MARCOLINO, 2012). Thus, evaluating and analyzing this performance of activities happens through the situational diagnosis, which takes a photograph about the situation of the subject at this moment in his life, his abilities and difficulties, achievements and desires that still exist.

Another interesting way of teaching would be to insert experimentations and learning activities in the internship, so a student teaching another how to do it and a third student observing and taking note would allow the exercise of systematic observation. This may be a proposal.

This toolbox will be uploaded by young occupational therapists after the internship. The supervisor waits and glimpses this path being walked. After all, these concepts can and should be present in any part of the network, which, by sustaining its points through its interlacing, it has the main objective of caring, enabling healthy spaces and allowing social insertion.

Finally, there is a small reflection that invites to think about the potentiality of occupational therapists and that care, opening cages and creating healthy spaces of life and the student’s liberating learning.

The fear

One morning, we got a little Guinea pig. He got home in a cage. At noon, I opened the cage door. I returned home at dusk and found him just as I had left him: cage inside, clinging to the bars, trembling because of the scare of freedom (GALEANO, 2002, p. 111).

Acknowledgements

I thank Jô Benetton for contributing to the reflection of this text, who taught me that occupational therapy has nothing abstract, since it is, before any definition, simple and procedural. He has taught me to be an occupational and supervisory therapist. I thank Sonia Ferrari, with her sweetness and delicacy, who allowed me to try out new activities and to make several new personal and professional discoveries.

References

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• TITO, J. C.; MORAES, G. C. Diagnóstico Situacional uma possibilidade de avaliação em Terapia Ocupacional. Revista do Centro de Especialidade em Terapia Ocupacional, São Paulo, v. 10, n. 10, p. 48-52, 2007.

Publication Dates

• Publication in this collection
  Apr 2018

History

• Received
  29 Oct 2016
• Reviewed
  17 Apr 2017
• Accepted
  02 June 2017