The Kawa ‘River’ ModelThe Kawa ‘River’ Model

By Beki Dellow

Presentation includes some slides produced by

Michael Iwama (2010), used with his kind permission

Learning OutcomesLearning 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…Life is like a River…

Who founded the Kawa Model?Who founded the Kawa Model?

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

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

journalsjournals 10 Chapters in OT & 10 Chapters in OT &

Rehabilitation textbooksRehabilitation textbooks Translated into 5 languagesTranslated into 5 languages Taught in over 500 occupational Taught in over 500 occupational

therapy programs internationallytherapy programs internationally Used in practice across 6 continentsUsed in practice across 6 continents

Life Life Circumstances & Circumstances &

ProblemsProblems

Environmental factors

(‘Ba’, Physical & Social)

Personal Factors & Personal Factors & ResourcesResources

Life Life Flow Flow & & HealthHealth

How was the Kawa Model developed?How was the Kawa Model developed?4 Basic Concepts of the River Model4 Basic Concepts of the River Model

They are all inter-relatedThey are all inter-related

Life Life Circumstances Circumstances

& Problems& Problems

Environmental factors

(‘Ba’, Physical & Social)

Personal Personal Factors & Factors & ResourcesResources

Life Life Flow Flow & & HealthHealth

KAWKAWAA

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

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

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

Why was the Kawa Model developed?Why was the Kawa Model developed?

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

Occupational Therapy’s Magnificent Occupational Therapy’s Magnificent PromisePromise

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

Value…Value…(Iwama 2010)(Iwama 2010)

When life happens…When life happens…

Rocks = life circumstancesRocks = life circumstances

Driftwood = assets and Driftwood = assets and liabilitiesliabilities

Riverbed/walls and bottom = Riverbed/walls and bottom = environmentenvironment

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

ENVIRONMENTENVIRONMENT

PROBLEMPROBLEM

ASSET /ASSET / LIABILITYLIABILITY

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

OT

OT

OT OT OT

OT

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

Occupational Therapy’s AimOccupational Therapy’s Aim

Enabling and Maximizing “Life Flow”Enabling and Maximizing “Life Flow”

Case Study – Meet BenCase Study – Meet Ben 29 years old29 years old

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

Diagnosed with chronic depressionDiagnosed with chronic depression

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

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

Ben’s River – his life storyBen’s River – his life story

Past Life, Past Life, Identity, Identity, Relationships, Relationships, Self…Self…

Catastrophe, Catastrophe, sudden changessudden changes

Your Your Patient/ClientPatient/Client

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

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

Creative

Lack of confidence

Work

Family (helpful but can be too much)

Assessment 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 InterventionGoal 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 4) Personal Assets & Liabilities& 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

OTOT

INTERVENTIONINTERVENTION

OPTIONS / PLANOPTIONS / PLAN

OUTCOME OUTCOME EVALUATIONEVALUATION

InterventioInterventionsns

Analysing Ben’s Kawa metaphors and Analysing Ben’s Kawa metaphors and planning appropriate interventionsplanning appropriate interventions

EvaluationEvaluation

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

Cultivating my Cultivating my understanding of the understanding of the

client’s daily ‘normal’client’s daily ‘normal’

Health Health ProfessionalProfessional

Sphere of shared experienceSphere of shared experience

ClientClient

Sphere of shared experienceSphere of shared experience

Expressing my daily Expressing my daily reality from my own reality from my own

‘normal’‘normal’

Person-centered PracticePerson-centered Practice

COMMONCOMMON

METAPHORMETAPHOR

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

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

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

Physical Health and Well-beingPhysical Health and Well-being

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

EvaluationEvaluation Enabled review, evaluation and completion of the Enabled review, evaluation and completion of the occupational therapy processoccupational therapy process

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

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

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

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

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

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

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

Education Education

Fieldhouse (2008 p104)Fieldhouse (2008 p104)

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

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

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

PreceptorshipPreceptorshipRecent Feature Article published in the July edition of the OTnews (Buchan, Recent Feature Article published in the July edition of the OTnews (Buchan,

2010)2010)

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

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

The Kawa Model was used as a data collection tool to seek the experiences and 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 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. groups and semi-structured interviews to help guide the transition narratives. Participants were asked to review their personal transitions or ‘riverbeds’ and Participants were asked to review their personal transitions or ‘riverbeds’ and identify their needs and areas of potential developmentidentify their needs and areas of potential development

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

The Kawa ‘River’ flowsThe Kawa ‘River’ flowsWorldwide Worldwide

Development of our ProfessionDevelopment 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?What is expected of us?

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

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

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

Section 1Section 1 – ‘You must act in – ‘You must act in the best interest of service the best interest of service users’users’

Section 5Section 5 – ‘You must keep – ‘You must keep your professional skills and your professional skills and knowledge up to date’knowledge up to date’

Section 7Section 7 – ‘You must – ‘You must communicate properly and communicate properly and effectively with service users effectively with service users and other practitioners’ (p3)and other practitioners’ (p3)

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

Summary of Basic PrinciplesSummary of Basic Principles

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

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

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

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

Occupational Therapy = “Enabling Life Flow”Occupational Therapy = “Enabling Life Flow”

Your turn!Your turn!How does your river flow?How does your river flow?

•Rocks = life circumstances

•Driftwood = assets and liabilities

•Riverbed/walls and bottom = environment

ReferencesReferences 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

ReferencesReferences 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-Project.aspx

(videos) Facebook:http://www.facebook.com/photo.php?

pid=288121&fbid=147680675266270&id=139318639435807&ref=nf#!/KawaModel

ReferencesReferencesOther 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

ReferencesReferences 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