The Kawa Model Made Easy

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The KawaModelMade EasyA Guide to Applying the KawaModel in Occupational TherapyPractice (2nd edition)Teoh J. Y. & Iwama M. K.1

Copyright 2015 by Teoh Jou Yin (002435951-D)All rights reserved. This publication is for free distribution and may be reproduced,distributed, or transmitted in any form or by any means including photocopying,recording or other electronic or mechanical records, without the prior permission ofthe publisher, for noncommercial purposes only and attribution to original authors andcontributors. For more information, please contact [email protected]: 978-967-13863-0-9When citing this document, the preferred reference is:Teoh, J.Y. & Iwama, M.K. (2015). The Kawa Model Made Easy: a guide to applyingthe Kawa Model in occupational therapy practice (2nd edition). Retrieved from:www.kawamodel.com

ContentPagea. What is occupational therapy?01b. What is the Kawa Model?02c. The Kawa Model (Non-metaphorical Version) as an Assessment tool03d. Guiding Questions to Using the Kawa for Subjective Assessment05i.Water (Life Flow / Priorities)06ii.Rocks (Obstacles & Challenges)07iii.River Banks (Environments – Physical / Social / etc)08iv.Driftwood (Influencing Factors)09e. Creating Spaces: Using the Kawa Model to Guide the OccupationalTherapy Process10f. Recommended Reading / Other References12g. About the Authors13

What is occupational therapy?Occupational therapy is a health profession recognized by societies as having expertisein facilitating and enabling people to solve practical problems in everyday life so thatthey can engage and participate in roles, processes and activities that are important and ofvalue to them.The health professional delivering this specialized service is called an occupational therapist.What is the difference between occupational therapists and other health professionals?Conventional health professionals are concerned with pathology and other illness processeslocated in the human body.Occupational therapists are concerned with the consequences of those pathologies andissues on experiences and needs of daily life, including how they affect interactions withother people and the physical environment.How do occupational therapists work?First, they seek to understand what the consequences and effects of pathology and issues areon life experience occurring within their daily environments and also how those pathologiesand issues affect the people around them.Then they work with clients to restore, increase or maintain their capacity to engage andparticipate in daily life activities, not just pertaining to the client with the pathology orproblems themselves, but also with the persons around them, their physical environment,etc.A functional life devoid of meaning is merely existence, not living. Robots performtasks, people engage in life activities to create and derive meaning Charles Christiansen (2010)We spend a lifetime learning how to do things that are essential for the survival of our selves,families, communities or for pleasure and achievement. Some people in the Western andNorthern parts of the world have adopted a specialized term to describe this phenomenon andthey call it ‘occupation’.1

People and their environments and interactions in daily life are unique and highlycomplex, and so the process of occupational therapy necessarily begins with andrevolves around the client’s story of their daily life experience.What is the Kawa Model?Kawa is the Japanese word for ‘river’. The Kawa Model uses the natural metaphor of a riverto depict one’s life journey. The varying and chronological experience of life is like a river,flowing from the high lands down to the ocean. Along its meandering path, the quality andcharacter of its flow will vary from place to place, from instance to instance. Occupationaltherapists try to enable, assist, restore and maximize their clients’ life flow.The Kawa Model can be used as a conceptual model of practice, frame of reference,assessment tool and modality.The Kawa Model can be used metaphorically in its original form of a river, or in itsunderlying form of FIVE interrelated constructs:i.ii.iii.iv.v.River Flow - life flow and prioritiesRiver Banks - environments / contexts, social and physicalRocks – obstacles & challengesDriftwood – influencing factorsSpaces – Opportunities for enhancing flowLike a river where its source represents the beginning of life and its mouth meeting the searepresenting the end, the Kawa Model takes into consideration the past, present and futureneeds of the client.The Kawa Model (2006) was created by a team of occupational therapists in Japanled by a Japanese-Canadian occupational therapy scholar to enable occupationaltherapists everywhere to “just ask the client how they want to live their lives so that it is moremeaningful to them, and look together with them what they can do to achieve that.” (Teoh2010)The inclusive nature of the Kawa Model allows the occupational therapy client to beconsidered as a collective, meaning that it can be used on individuals, families, groups andorganizations.

The Kawa Model as an Assessment ToolThe underlying constructs of the Kawa Model can be utilized as a subjective assessment toolfor occupational therapy diagnosis, to identify what activities / roles / processes occurringwithin the client’s life contexts are important to them, and what issues they experience inrelation to their environments.The Kawa Model as a subjective assessment tool also allows the occupational therapist andclient to determine what supports and resources they have internally and externally which canaid or undermine the occupational therapy intervention.The Kawa interview doesn’t have to follow a particular order. The interview flow resemblesa river itself: You can be asking a River Bank question which leads to a River Flow questionwhich can lead to a Rock, leading back to River Flow again, etc -Meaning that the interviewcan be back and forth in nature, as indicated in the diagram below.Diagram 1.0: Underlying constructs of the Kawa ModelSpacesRiver WaterDriftwoodRiver BanksRocksSpaces

What matters in the Kawa interview is how the person explains the components that make uptheir life process, and not whether the therapist agrees with the client on whether something isRock or Driftwood. Remember, occupational therapy is all about the client’s river - abouttheir life experience, from their viewpoint. The clients will identify their issues and problemsand explain their meaning, to which occupational therapists can offer an approach that iscentered on the person’s day-to-day realities and that is ultimately meaningful to that person.So try to allow the client to express themselves freely. The aim of the model is not to follow aparticular procedure but rather in the explanations that the client gives about their experienceof day to day living.The Kawa Model’s Principles of UseHonouring the client and trusting emergence Be ready to discard all universal assumptions about the relevance and appropriatenessthis model, start working with your client from a clean, objective slate.If the model and the metaphor on which it is based fail to resonate with either theclient or occupational therapist, it should be modified or placed aside in exchange fora more appropriate and relevant model.The client’s narrative becomes the model on which we base the occupational therapyprocess. Trust that the client's narrative will emerge through a process of enabling himor her to do so.Be aware of your own cultural lens. Competent therapists will not only appreciate theculture embodied within the client but also the cultures at play within themselves,with the occupational therapy they have learnt and experienced and the institutionalconditions that set the mandate and structure for the therapeutic process.The centralized and decentralized self Does the client experience the self as separate from the environment or as anintegrated part of a greater entity? Clients who experience the self as separate mightdraw themselves on a boat on the river, but clients who experience themselves asintegrated parts of a whole frame will not see the need for this and regard the entirediagram of the river as the embedded in the environment and circumstance, withoccupation embedded into the river as well. How clients perceive their selves willthen influence their expectations of what they would like to get out of theiroccupational therapy.Clients who perceive their selves as distinct from the environment might be moreappreciative of values like autonomy, independence and control. Clients who perceivetheir selves to be integrated into a larger whole might appreciate values like balance,co-existence and harmony more. How occupational therapists work with their clientswill be largely dependent on the clients’ values.For more details, please refer to Chapter 8 (pp. 160) of the original Kawa Model textbook.

Guiding Questions to Using the Kawa for Subjective AssessmentWith the Kawa Model being essentially qualitative, it is impossible to have any fixed set ofquestions in place as an assessment tool. However, we can utilize guiding questions toexamine and explore the five underlying constructs of our clients’ Kawa.When looking to delve into meanings behind experiences, the key questions to askwould be “How?” and “Why?”Note: These questions are merely guides and suggestions. Some questions might not besuitable for your circumstances, and some questions may seem like they are asking the samething but in different ways. The purpose of these questions is just to give you some idea ofwhat you can ask and how you can ask them, but these are not all you should ask, and youdon’t have to ask all of them.We would like to encourage occupational therapists everywhere to come up with your ownquestions, suitable for your situation. And we would encourage you to share those questionsas well as your experiences and findings with other occupational therapists from other placesby emailing it to us at [email protected] or sharing with us via our Team KawaFacebook group http://FB.com/groups/TeamKawa so that we can make it available to others.You are more than welcome to produce a translated version of this manual and toproduce any related writing or research about the Kawa Model. However, we wouldappreciate if you let us know about your work (via email at [email protected] orour Team Kawa Facebook group at http://FB.com/groups/TeamKawa) so that others maybenefit from your work as well.By sharing your work on the use of the Kawa Model in your context, you are actually helpingto advance and develop the Kawa Model!

River Flow (Life Flow and Priorities)Suggested Guiding Questions1. If your life was a river, what does your river look like? How would you describe theflow of your river right now?2. Can you describe to me how you typically spend your day from the time you wake upto the time you go to bed?3. What do you enjoy doing? Why do you enjoy it?4. What makes you happy? How does it make you happy? Why?5. Have you experienced any significant changes in your life recently?(This is more suited for client who have adapted to congenital deficits or thosefrom the well population, i.e. caregivers. However, it can be assumed that suddenlyhaving to care for a family member with a disability would cause a majorchange in one’s life flow.)Could you tell me a little bit about them?6. How do you typically go around doing your everyday activities?Notes: River flow questions take the past, present and future (what clients wish to do orintend to do) into consideration.The client’s work history, medical history, life roles, processes (i.e. aging), self careand leisure activities, as well as other occupations, can all be considered part of theriver flow.The river flow can comprise of many little streams flowing into one. The river flow ofsignificant persons in the occupational therapy client’s life (caregivers, spouse, etc)should also be considered and incorporated where relevant.

Rocks (Obstacles & Challenges)Suggested Guiding Questions1. Are you having any difficulties right now? What are they? Why do you think (thosethings) are difficult for you? How is it difficult?2. Do you have anything in particular that you would like to do but you are unable to dobecause of your current situation? Why do you think you are unable to do them? Howare these things typically done? How is doing them right now different from back then?What would you like to be able to do?3. Is there anything about your life right now that you would like to change? What is it?Why? How would you like things to change? If things were better, what do you thinkwould be different?4. I understand what you have been through a lot lately and things can be a bitoverwhelming. Is there anything in particular which you are worried or unsure aboutthat you would like to discuss?Notes: Rocks can typically be categorized into (but are not restricted to) occupationalperformance difficulties, fears and concerns, inconvenient circumstances out ofoccupational therapy’s control, and impairments or medical concerns.As with River Flow, the Rocks of significant persons in the occupational therapyclient’s life (caregivers, spouse, etc) should also be considered and incorporatedwhere relevant.

River Banks (Physical and Social Environment)Suggested Guiding Questions1. Who are you currently living with right now?2. Who do you typically spend most of your time with? How do you spend your timewith them? What do you usually enjoy doing together? (As you can see, this questionleads us back to the River Flow.)3. Where do you typically spend most of your time? (This is yet another question thatcan lead back to the River Flow.)4. Can you describe to me the place where you live / work? How do you find yourability to get around there? (This can lead to Driftwood or Rock!)5. Do you live in a single storey / double storey terrace /