The Kawa ‘River’ Model

Reflective Practice

& Professional DevelopmentBeki Dellow

Occupational Therapist

Learning Outcomes

• Gain an overview of the Kawa ‘River’ Model

• Case Study

• Explore the Kawa Model’s use in reflective practice and professional

development/supervision

• The What If’s?

• Summary

• Questions

Life is like a River…..

Life at this moment in time

Birth/beginning of working life

End of Life/career

Time

Founder• 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

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

When life happens…• Rocks: Life circumstances or

problems

• Driftwood: Assets and liabilities or

strengths and weaknesses

• Riverbed/walls and bottom: Physical ,

social and cultural environments

• “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 to maximise life flow

OPPORTUNITY

OPPORTUNITY FOR CHANGE

Life is enabled to flow more strongly and deeply

despite residual obstacles and challenges…

Aim

Enabling and Maximising “Life Flow”

Case Study – Ben29 year-old male

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

Past Life, Identity, Relationships, Self…

Catastrophe, sudden changes

Suicidal - Near the end of life - ocean

The River diagram

allows the therapist

to understand Ben’s

life story, from his

perspective

Shattered mind and life

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

Evaluation

If time allows, the Kawa Model could be

effectively used to evaluate and complete the

therapy process. Patients could be asked to

draw another metaphorical diagram of their

‘river’ post intervention to identify any

changes to their ‘life flow’

The therapist becomes the student of the patient's

model, looking for ways to adapt and deliver therapy

that is relevant and meaningful to the patient

Health Professional

Sphere of shared experience

Patient

Sphere of shared experience

The patient builds a model to explain their day to day life

experience

Putting Patients First

COMMON

METAPHOR

Using the Kawa Model in reflection and professional

development

How I felt before moving and three weeks into my first OT rotation

One week prior to commencing new post

Three weeks later

Three months later…….

Breaking down the Rocks(Personal Development Plan)

• What are my personal

obstacles/challenges?

• What strategies and resources are

required to overcome these

obstacles and increase my life

flow/energy/performance?

• What is the criteria for review and

timescale?

Personal Development Plan

SWOT AnalysisDriftwood (Assets/Liabilities)Strengths

Weaknesses

Opportunities

Threats

River sides/Bed (environment)Strengths

Weaknesses

Opportunities

Threats

Water (Life flow/Energy)How do you feel right now?

SWOT Analysis

Analysing it further

Driftwood (Liability)

‘I am often self-critical’

When do I feel like this?

Why do I feel like this?

How can I overcome these feelings?

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

PreceptorshipFeature 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 participants (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

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

Physical Health and Well-being

A 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

Policy on Continuing Professional Development

All qualified staff are expected to be proactive in their

continuing professional development; that is in maintaining,

improving and broadening their knowledge, skills and personal

qualities in order to perform professional activities to the

required standard

Development of our Professions

‘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)

The Kawa Model in your professional Practice

The what if’s……..

What if the river runs dry?

What if the river is frozen?

What if there is no support or the environment restricts the flow?

What if the rocks are too big or too many?

Think about……….

• Palliative care

• End of life care

• Long-term conditions

• Neurology

• Mental Health

• Physical Health

Summary of Basic Principles

• Life is like a river … All things are connected… (self & environment,

past-present-future)

• Understand the complexity of experiences – from a service user’s

perspective, in their own words…through a reversal of power

• The Kawa Model is a powerful and effective tool for personal and

professional reflection/development

• The Kawa Model can be used as a framework in the development of

services and staff

Questions?

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

• Johns C (2006) Engaging in Reflective Practice: A Narrative Approach Oxford: Blackwell Publishing Ltd

• Taylor BJ (2010) Reflective Practice for Healthcare Professionals (3rd Ed) New York: Open University Press

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