The Kawa ‘River’ Model

By Beki Dellow

Presentation includes some slides produced by

Michael Iwama (2010), used with his kind permission

Learning Outcomes

Gain an overview of the Kawa ‘River’ Model

Case Study

Look at some relevant literature relating to the Kawa Model’s use in occupational therapy practice

Feedback and questions throughout presentation

Birth

End of Life

TIME

Life is like a River…

Who founded the Kawa Model?

Michael Iwama, PhD, OTC, associate professor at the University of Toronto, with occupational therapy practitioners in Japan

Developed in 2000 Book published 2006 12 + articles in peer-reviewed

journals 10 Chapters in OT &

Rehabilitation textbooks Translated into 5 languages Taught in over 500 occupational

therapy programs internationally Used in practice across 6

continents

Life Circumstances &

Problems

Environmental factors

(‘Ba’, Physical & Social)

Personal Factors & Resources

Life Flow & Health

How was the Kawa Model developed?4 Basic Concepts of the River Model

They are all inter-related

Life Circumstances

& Problems

Environmental factors

(‘Ba’, Physical & Social)

Personal Factors & Resources

Life Flow & Health

KAWA

Conventional Models in Occupational Therapyare cultural-bound in the (Western) model-maker’s experience which:

• Privileges a minority (Western) world-view of occupation• Constructs the self & environment as distinctly separate• Are based on mechanical metaphors

Each person’s experience of daily life is unique and should be the context to which occupational therapy should be adapted. Conventional models and approaches are often applied in a ‘one-size-fits-all’ manner in which the client’s experience of daily life is forced to comply to the theory-maker’s standard view

Why was the Kawa Model developed?

If models are culture-bound, then isn’t this model created in Japan only appropriate for use in Japan with Japanese people?

The Kawa Model privileges the Client’s worldview & perception of their day-to-day realities; told in their own words & ways. The client actually names the concepts & explains the

principles, making the narrative bound to the client’s culture…

Occupational Therapy’s Magnificent Promise

To Enable people from all streams of life, to engage and participate in activities and Processes that have

Value…(Iwama 2010)

When life happens…

Rocks = life circumstances

Driftwood = assets and liabilities

Riverbed/walls and bottom = environment

“An optimal state of well-being in one’s life or river can be metaphorically portrayed by an image of a strong, deep, unimpeded flow”(Iwama 2006, p143)

ENVIRONMENT

PROBLEM

ASSET / LIABILITY

Channels through which water flows = Opportunities for occupational therapists to maximize life flow

OT

OT

OT OT OT

OT

Life is enabled to flow more strongly and deeply despite residual obstacles and challenges…

Occupational Therapy’s Aim

Enabling and Maximizing “Life Flow”

Case Study – Meet Ben 29 years old

Lived independently in the past, but due to a recent deterioration in his mental health, currently resides with his parents

Diagnosed with chronic depression

Currently in full-time employment, although reports being dissatisfied with his work

Troubled by frequent feelings of pointlessness and is paranoid that he will lose his job

Ben’s River – his life story

Past Life, Identity, Relationships, Self…

Catastrophe, sudden changes

Your Patient/Client

Ben’s River diagram allows the therapist to understand his life story, from his perspective

Cross-section of Ben’s River – how life is now

LOST

Self destructive

Lack of qualifications

No transport

Poor concentration

Poor motivation

Unable to find enjoyment in anything

Finances

Lack of opportunities and interests

How society is constructed

Why?

Confusion

Mental health

Emptiness

Lack of purpose and direction

Capability

Fear of failure

Self-understanding

Ben’s River

Creative

Lack of confidence

Work

Family (helpful but can be too much)

Assessment

• The Kawa metaphor allows the therapist to gain further insight into Ben’s life flow and health (river water), personal assets and liabilities (driftwood), life circumstances/problems (rocks) and environment (river sides/bed)

• These combine to form a unique picture of Ben’s life at this point in time

• Using the Kawa Model, the purpose of occupational therapy is to gain an understanding of Ben’s metaphorical representations and his occupational circumstances, clarifying their meaning and aiming to facilitate Ben’s life flow

Goal Planning and Intervention

• The therapist works collaboratively with Ben, using his Kawa diagrams to identify personal assets (strengths) and liabilities, problems and challenges, temporary issues and environmental factors (physical, social, political and institutional) which effect his ‘life flow’

• Upon further analysis of Ben’s Kawa diagrams, it becomes clear that potential spaces to increase ‘life flow’ (areas for occupational therapy intervention) are limited. Ben’s river is impacted with rocks (problems), virtually blocking the flow. A fuller and unobstructed river represents a better state of well being (Iwama, 2006)

• Goal planning with Ben, referral to psychiatrist to review medication and assess level of suicide risk

4) Personal Assets & Liabilities

3) Environment (Social & Physical)

2) Circumstances & Problems

1) Life Flow & Health / Overall Occupations

Assessment Outcomes

Objective Assessment Tool Choice

Subjective Assessment Outcomes

Occupational Components

OT

INTERVENTION

OPTIONS / PLAN

OUTCOME EVALUATION

Interventions

Analysing Ben’s Kawa metaphors and planning appropriate interventions

Evaluation

If time had allowed, the Kawa Model could be effectively used to evaluate and complete the occupational therapy process. Ben could be asked to draw another metaphorical diagram of his ‘river’ post intervention to identify any changes to his ‘life flow’

Cultivating my understanding of the

client’s daily ‘normal’

Health Professional

Sphere of shared experience

Client

Sphere of shared experience

Expressing my daily reality from my own

‘normal’

Person-centered Practice

COMMON

METAPHOR

Evidence-base: Kawa Model

It is evident that there is limited published research on the effectiveness of the Kawa Model in practice in a Western context, and on occupational therapists’ experience of using the Model

Physical Health and Well-beingA qualitative pilot study conducted by occupational therapists in Ireland, aimed to explore the effectiveness of the Kawa Model when used to guide intervention with two individuals with multiple sclerosis (Carmody et al, 2007)

Assessment The guiding nature of the Kawa Model enabled the occupational therapy process, helping to build a therapeutic relationship and gain detailed occupational profiles of the participants using the river metaphor ‘a good information gathering tool’

Planning The model aided facilitation of occupation-based goal setting and identification of the spaces for occupational therapy intervention

Physical Health and Well-being

Intervention Facilitated the participants’ engagement in occupation-based therapy by allowing an understanding of what was important and meaningful to them

Evaluation Enabled review, evaluation and completion of the occupational therapy process

Limitations Challenges identified: therapist preconceptions of the Model and participant uncertainty in how to draw the river diagrams

Conclusion The Kawa Model may be identified as a mediator of person-centered practice as it led the participants to identify problems or impediments of the flow of water in their rivers and facilitated their engagement in the process of therapy

Mental Health and Well-beingPractice Report: Fieldhouse (2008) charts his personal journey of

discovery regarding his use of the Kawa as a community mental health practitioner and senior lecturer/educator

The Kawa metaphor supports currently ‘high profile’ features of community mental health practice (recovery, social inclusion, person-centeredness, strength-based assessment, and positive risk management) – these can be ‘fed into’ the model and, therefore, worked with

The Kawa Model’s language and imagery are easily graspable by both students and practitioners

Highlights the great suitability of the Kawa as a tool in community mental health practice

Education

Fieldhouse (2008 p104)

The Kawa Model was ‘accessible enough for students to embrace early on, yet also sophisticated enough to draw them forward in their clinical reasoning. It seemed to enable them to bridge the gulf between theory and practice’

Students working in groups to develop intervention plans based on a fictional-based mental health client, realised the Model’s ‘simplicity’ and had enabled some highly sophisticated clinical reasoning to take place

Asking students to ‘stop trying to learn the model and to just try to think with some of its ideas’ was a helpful strategy

PreceptorshipRecent Feature Article published in the July edition of the OTnews

(Buchan, 2010)

Used newly registered staff experiences of transition to influence change within a trust-based preceptorship programme

80 participaants (Allied Health Professionals, nurses and social workers) attended workshops to discuss the various aspects of preceptorship

The Kawa Model was used as a data collection tool to seek the experiences and needs of newly registered staff within their first year of practice (in both focus groups and semi-structured interviews to help guide the transition narratives. Participants were asked to review their personal transitions or ‘riverbeds’ and identify their needs and areas of potential development

A significant amount of data was created from the research to influence the development of the preceptorship, support systems and the new preceptorship policy

The Kawa ‘River’ flowsWorldwide

Development of our Profession

‘It is important to ensure practitioners (who, after all, are uniquely placed to see what interventions ‘work’ and what service users’ needs actually are) can contribute fully to ‘shaping’ the knowledge-base of the profession. It ensures both practice and education can be responsive to change’

(Fieldhouse, 2008 p101)

What is expected of us?

College of Occupational Therapists (2010) Code of Ethics and Professional Conduct – Section Six (6.1.1): Developing and using the profession’s evidence base

‘You should be able to access, understand and critically evaluate research and its outcomes incorporating it into your practice where appropriate’ (p 33)

Health Professions Council (2008) Standards of Conduct, Performance and Ethics

Section 1 – ‘You must act in the best interest of service users’ Section 5 – ‘You must keep your professional skills and knowledge

up to date’ Section 7 – ‘You must communicate properly and effectively with

service users and other practitioners’ (p3)

Do you think you could add the Kawa Model to your toolkit?

Summary of Basic Principles

Life is like a river … All things are connected… (self & environment, past-present-future)

Understand the complexity of client experiences – from their perspective, in their own words…through a reversal of power

Occupational Therapy is informed by the client’s day to day realities

Diverse worldviews necessitate diverse interpretations of ‘occupation(s)’

Occupational Therapy = “Enabling Life Flow”

Your turn!How does your river flow?

• Rocks = life circumstances

• Driftwood = assets and liabilities

• Riverbed/walls and bottom = environment

References Buchan T (2010) Implementing Appropriate Support Systems OTnews 18

(7), 26 – 27

Carmody S, Nolan R, Chonchuir NI, Curry M, Halligan C, Robinson K (2007) The Guiding Nature of the Kawa (river) Model in Ireland: Creating both Opportunities and Challenges for Occupational Therapists Occupational Therapy International 14 (4), 221 – 236

College of Occupational Therapists (201) Code of Ethics and Professional Conduct London: College of Occupational Therapists

Fieldhouse J (2008) Using the Kawa Model in Practice and in Education Mental Health Occupational Therapy 13 (3), 101 – 106

Health Professions Council (2008) Standards of Conduct, Performance and Ethics London: Health Professions Council

References Iwama MK (2005) The Kawa River Model: Nature, life flow, and the

power of culturally relevant occupational therapy. In: Kronengerg F, Algado SA, Pollard N (Eds) Occupational Therapy Without Borders – Learning from the Spirit of Survivors Edniburgh: Churchill Livingstone

Iwama MK (2006) The Kawa Model: Culturally Relevant Occupational Therapy Philadelphia: Churchill Livingstone Elsevier

Turpin M, Nelson A (2007) The Kawa Model: Culturally Relevant Occupational Therapy Australian Occupational Therapy Journal (54), 323 – 324

http://www.kawamodel.com/ http://kawamodel.phpbbnow.com/ (discussion forum) http://www.therapytimes.com/content=0602J84C48769494406040441 http://occupational-therapy.advanceweb.com/Article/KAWA-Model-Proje

ct.aspx (videos)

Facebook:http://www.facebook.com/photo.php?pid=288121&fbid=147680675266270&id=139318639435807&ref=nf#!/KawaModel

ReferencesOther useful references:

Bjelland I, Dahl AA, Haug TT, Neckelmann D (2002) The Validity of the Hospital Anxiety and Depression Scale. An Updated Literature Review Journal of Psychosomatic Research Vol./is. 52/2 (69-77) 0022-3999

Canadian Association of Occupational Therapists (1991) Occupational Therapy Guidelines for Client-Centred Practice Toronto, ON: CAOT Publications ACE

Coelho HF, Canter PH, Ernst E (2007) Mindfulness-Based Cognitive Therapy: Evaluating Current Evidence and Informing Future Research Journal of Consulting and Clinical Psychology 75(6), 1000-1005

Davies T (2009) Risk Management in Mental Health. In: Davies T, Craig T (Eds) ABC of Mental Health (2nd Ed) Oxford: Wiley-Blackwell

References

Forsyth K, Lai J, Kielhofner G (1999) The Assessment of Communication and Interaction Skills (ACIS): Measurement Properties British Journal of Occupational Therapy 62(2) 69-74

Forsyth K, Salamy M, Simon S, Kielhofner G (1998) A User’s Guide to The Assessment of Communication and Interaction Skills (ACIS) (Version 4.0) Chicago: The Model of Human Occupation Clearinghouse

Matsutsuyu JS (1969) The Interest Checklist American Journal of Occupational Therapy 23(4), 323-395

Roger S (Ed) Occupation-Centred Practice with Children: A Practical Guide for Occupational Therapists Oxford: Wiley-Blackwell

Snaith RP (2003) The Hospital Anxiety and Depression Scale Health and Quality of Life Outcomes 1(29), 1-29