1.
The Kawa „River‟ Model
By Beki Dellow
Presentation includes some slides produced by
Michael Iwama (2010), used with his kind permission

2.
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

3.
Life is like a River…
Birth
TIME
End of Life

4.
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

5.
How was the Kawa Model developed?
4 Basic Concepts of the River Model
Environmental
factors Life
(‘Ba’, Physical & Circumstances &
Social) Problems
Personal Factors & Life Flow &
Resources Health
They are all inter-related

6.
Environmental
factors Life
Circumstances
(‘Ba’, Physical & & Problems
Social)
Personal Life
Factors & Flow &
Resources
Health
KAWA

7.
Why was the Kawa Model developed?
Conventional Models in Occupational Therapy
are 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

8.
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…

9.
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)

10.
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)

11.
Channels through which water flows = Opportunities for
occupational therapists to maximize life flow
OT
OT OT
OT
OT ASSET / LIABILITY
OT
PROBLEM
ENVIRONMENT

12.
Life is enabled to flow more strongly
and deeply despite residual obstacles
and challenges…

13.
Occupational Therapy‟s Aim
Enabling and Maximizing “Life Flow”

14.
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

15.
Ben‟s River – his life story

16.
Past Life,
Identity,
Relationships,
Ben‟s River diagram
Self…
allows the therapist
to understand his
life story, from his
perspective
Catastrophe,
sudden changes
Your
Patient/Client

17.
Cross-section of Ben‟s River –
how life is now

18.
Ben‟s River LOST
Self destructive
Lack of qualifications
No transport
Capability
Fear of failure
Poor concentration
Self-understanding
Finances
Lack of opportunities and
Creative
interests
Lack of confidence
Poor motivation
Unable to find
enjoyment in anything
Work Mental health
Family (helpful but can be too How society is constructed Emptiness
much) Lack of purpose
Why?
and direction
Confusion

19.
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

20.
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

21.
Occupational Subjective Objective Assessment
Components Assessment Assessment Outcomes
Outcomes Tool Choice
1) Life Flow &
Health / Overall
Occupations OT
2) Circumstances &
Problems INTERVENTION
3) Environment OPTIONS / PLAN
(Social & Physical)
Interventions
4) Personal Assets
& Liabilities
OUTCOME
EVALUATION

22.
Analysing Ben‟s Kawa metaphors and
planning appropriate interventions

23.
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‟

24.
Person-centered Practice
Client Health
Professional
COMMON
Expressing my daily Cultivating my
reality from my own METAPHOR understanding of the
„normal‟ client‟s daily „normal‟
Sphere of shared experience Sphere of shared experience

25.
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

26.
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

27.
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

28.
Mental Health and Well-being
Practice 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

29.
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

30.
Preceptorship
Recent 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

31.
The Kawa „River‟ flows
Worldwide

32.
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)

33.
What is expected of us?
 College of Occupational  Health Professions Council
Therapists (2010) Code of (2008) Standards of Conduct,
Ethics and Professional Performance and Ethics
Conduct – Section Six (6.1.1):  Section 1 – „You must act in
Developing and using the the best interest of service
profession‟s evidence base users‟
 Section 5 – „You must keep
 „You should be able to access, your professional skills and
understand and critically knowledge up to date‟
evaluate research and its  Section 7 – „You must
outcomes incorporating it into communicate properly and
your practice where effectively with service users
appropriate‟ (p 33) and other practitioners‟ (p3)

34.
Do you think you could add the Kawa
Model to your toolkit?

35.
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”

36.
Your turn!
How does your river flow?
•Rocks = life
circumstances
•Driftwood = assets and
liabilities
•Riverbed/walls and
bottom = environment

37.
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

38.
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-
Project.aspx (videos)
 Facebook:http://www.facebook.com/photo.php?pid=288121&fbid=147680
675266270&id=139318639435807&ref=nf#!/KawaModel

39.
References
Other 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

40.
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