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
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