Application of the Kawa Model in Geriatrics

What is the Kawa Model?

• A holistic conceptual model of practice
• Developed by a group of Japanese & Canadian occupational therapists
• The model uses the metaphor of a river as a platform to consider one’s strengths, barriers, and circumstances
• Emphasizes the interaction between an individual, his/her contexts, and inter-relations of self & others
• An alternative to Western models of care used to provide culturally competent care

(Iwama, Thomson, & Macdonald, 2009)

The Kawa model is a holistic conceptual model of practice. It was developed by a group of Japanese and Canadian occupational therapists. In this model, a river is used to symbolize one's life. The various parts of the river symbolize things like one's strengths or barriers, social or physical environment, and supports. The model emphasizes the interaction between an individual and his or her context and the inter-relation of the self and others. This model originated in the Eastern world. While Western models typically focus on the individual, the Kawa model focuses more on the context that impacts and shapes the realities and challenges of our daily lives. The therapist who developed this model felt that it was needed since all cultural contexts are not the same. For example, in our Western world, we focus on the individual, and independence is highly valued here. However, in the Eastern world where this model originated, there is more focus on being interconnected, and independence does not necessarily hold the same importance or value there. We have to remember that we treat clients from a variety of cultures, and it is important to recognize the impact of culture on the care experience. We should not project our own values onto our clients.

Various Components of the Kawa Model​ (Iwama et al., 2009)

The various parts of the river include the water, the river banks and bottom, rocks, and driftwood or debris. Each represents the different aspects of one's circumstances. Today, I will review each of those elements.

River Flow-"Water"

• Represents “life flow” or one’s subjective view of himself/herself, well-being, and context
• Flow is impacted by components of the river: walls, bottom, rocks, & driftwood
• Birth: the river begins when the water flows down from the mountains to create the river
• Death: the river ceases to flow or when the river releases into the ocean

(Iwama et al., 2009)

First, we will talk about the river flow or the water itself. The water in the river represents life's flow or one's subjective view of themselves, their well-being, and their context. As it is with a river, the flow of that river is impacted by various components like the walls, the rocks, bottom, and driftwood. If you think of your life as a river, birth is where the river begins, when the water flows down from the mountains to create that river, and then death is when the rivers cease to flow by either drying up or releasing into the ocean. You have to remember in this process that great flow does not necessarily mean independence. Again, that is our Western view. In some Eastern cultures, greater value is really placed on interdependence and belonging. The goal of occupational therapy is to increase the flow in the river. This will mean something different to each client depending on his or her culture and circumstances.

River Walls & Bottom

• Represents the social & physical environments/contexts
• Could be positive or negative
• Examples:
• Family members, coworkers, friends (could be a support or a hindrance)
  • A friend who drives you to appointments does your shopping, & lends emotional support after your hip surgery would be supported; whereas, a co-worker who doesn’t collaborate well on an assigned team project could be a hindrance.
• Home, work, physical environment
  • Negative examples: Not having a ramp; lack of handicapped parking; toilet seat is too low; cooking utensils stored out of reach    

The river walls and bottom represent the social and physical environments and contexts. These could be positive or negative. For example, thinking about social context, this could include family members, co-workers, friends, and those people who could serve as supports or hindrances in a situation. A friend who drives you to appointments or helps you with shopping after you have had hip surgery could be viewed as great support, but a co-worker who might not collaborate very well on an assigned team project could be viewed as a hindrance. You have to remember that in non-Western cultures, social relationships are really the primary determinant of life flow. If we look at the physical environment, this could be the home or work environment where the client is doing leisure activities. Again, the physical surroundings could be positive or negative. If a person has a disability, some negative examples would not be a ramp, a lack of handicapped parking, a too low toilet seat, or even cooking utensils or pots or pans that are stored out of reach. With more positive social and physical supports, water flow can increase to displace the "rocks" in one's life.

Rocks

• Represents life’s problems, or obstruction of water flow
• The size/composition of the rock symbolizes the degree of impact (i.e. a very large rock = a significant impact on one’s life)
• Can exist throughout life, appear suddenly, or resolve
• Examples:
  • Illness or injury
  • Financial difficulties
  • Work stress/demands
  • Death of a family member or friend  

The rocks are the problems that I will address next. Rocks represent life's problems or the obstruction of water flow. The size and composition of those rocks symbolize the degree of impact. If it is a very large rock, that would be something that would have a very significant impact on one's life. A smaller rock would be something with a very minor impact. It is important to note that this is the perception of the client. This is not from the doctor or the therapist's perspective. Once, I was treating a client with multiple sclerosis. Before using the Kawa model with her, I would have predicted that her physical limitations were her biggest problems, obstructing her flow. But after I applied the Kawa model, I soon realized that her anxiety related to overextending her husband was what she perceived to be her biggest concern. After I discussed this with her husband, he verbalized that he was worried about letting her down and not doing enough. Obviously things that he was dealing with would affect his ability to care for her and vice versa.

These rocks can exist throughout life. This might be something like a congenital disease. They could appear suddenly. Other examples might be cancer, a heart attack, or suddenly losing a job. Rocks can be minimized or worn down in some cases. Perhaps you cannot eliminate it, but they can be minimized via social supports in the environment or environmental modifications. Some rocks might resolve completely. This could the remediation of skills following knee surgery. Once you go through the rehab, you are back on your feet and resume your normal life roles and normal way of doing things. Other examples of rocks could include other illnesses or injuries, financial difficulties, work stress or demands, and even things like the death of a family member or other loved one.

Driftwood/Debris

• Represents personal attributes & resources
• Can be positive or negative; Driftwood can shift rocks (problems) to increase flow (positive) or can cause further obstruction (negative)
• Examples:
  • Values/character: dependability, loyalty, integrity, sincerity, kindness, devotion
  • Personality: extroversion, introversion, conscientiousness, agreeable
  • Knowledge/Experience: academic degree, 10 years as an OT, prior therapy for an injury
  • Skills: advocacy, gardening, financial planning
  • Material assets: money, adaptive equipment, adequate transportation   

Driftwood and debris represent personal attributes or resources. Again, these can be positive or negative. The driftwood can be positive if it helps to push those rocks out of the way or widening that flow in your river. Or, driftwood and debris can obstruct or jam up the river so that the water cannot flow. Examples of driftwood or debris could be things related to your values or your character like being dependable or loyal, having good integrity, being sincere or kind, or very devoted. Other driftwood includes personality traits, so being extroverted or introverted, being very conscientious, or agreeable. It could also be represented through things like knowledge or experience. This could be an academic degree or prior therapy for an injury. Maybe, the client has experienced this before, and they know what to expect this time. Other skills include advocacy or leisure skills like gardening, financial planning. Driftwood or debris can also include material assets. These are things like money, the availability of adaptive equipment, or adequate transportation. For example, being agreeable can help to shift rocks away or it could further obstruct the flow. On one hand, being agreeable could decrease conflict in a person's life, which could typically be seen as a positive. You might have less stress or anxiety if there is not a lot of conflict in your life. However, it could also obstruct flow if the person over-commits to things. They might not be a good advocate for themselves to get the necessary supports they need. So, driftwood and debris could be positive or negative in that way.

Spaces Between Obstruction

• Represents occupation & the focus on occupational therapy intervention
• Spaces represent opportunities for expanding flow and well-being
• Expands the client’s & care provider’s views beyond a focus on the rocks (problems)

Finally, the space between rocks or obstructions is where occupation and the focus of occupational therapy intervention is. You want to look at those spaces as opportunities for expanding flow and well-being. This model really helps us view the client holistically. We can see their problems, but they are tied tightly with one's context, supports, and barriers. As an occupational therapist, you have to think about how you might widen those spaces so the water can flow better. Sometimes in medically-based care, we focus exclusively on problems and our contrived solutions. These are things that we always do with little attention to the client's own strengths and social and environmental supports. We also can view things from our perspective rather than theirs. This model promotes the reframing of the client's problems in a more positive light, where the client has some control over his or her circumstances. To illustrate this point, I will give an example of an activity I completed with a group of therapists in order to educate them on how to use this model with a client. The purpose of the activity was merely educational. I was not necessarily expecting the therapists themselves to get something out of it. And so each therapist had sketched out their own model and then they began sharing with each other. This was a group of therapists that had worked together for a number of years and so they knew each other pretty well. They began to disclose personal things about themselves that they had never disclosed before during this task. Some of it was pretty private and sensitive. However, they felt that it was really easy for them to share by saying, "this is my rock," and then discussing what the problem was. It was a more positive way to frame it rather than saying this is my problem. They could look at those problems that they were disclosed in light of all of the positive things and the supports that they had in their life to address that.

Steps in Using the Kawa Model for an Individual Geriatric Client

1. Determine who your client is via the construction of the client’s individual river model
2. Ask for clarification on the client’s river model
3. Prioritize issues according to the client’s perspective
4. Further assess focal points of occupational therapy intervention
5. Complete occupational therapy intervention
6. Evaluate the outcomes of occupational therapy intervention   (Iwama, 2006; Teoh & Iwama, 2015)

Next, we are going to discuss the steps that you would use if you were going to use the Kawa model with an individual geriatric client. These steps would apply whether you are in long term care, home care, or a community-based setting of some sort. There are six steps, and I will review them briefly here and then go into a bit more detail on the next slides. The first step involves drawing or creating that model. You are having the client construct their river model and putting in the rocks and driftwood. In the second step, you are asking them to clarify so that you truly understand their perspective. In the third step, the issues are prioritized according to the client's perspective. Remember, what you deem to be the most important area to address might not be the client's priorities. After you have prioritized and determined what you are going to be working on with them, then you further assess those focal points of OT intervention that can be accomplished with standardized or objective assessments as needed. Then, you would provide the treatment. The last step is to evaluate the outcomes of that intervention. This process really mirrors that of the OT Practice Framework where the client is assessed, goals are established, treatment is provided and then the outcomes are evaluated. Then, the process may begin again depending upon the status at that time. 

Step 1: Construction of the client’s individual river model

• Guide: http://www.kawamodel.com/download/KawaMadeEasy2015.pdf
• Use as a qualitative assessment tool; No particular order; can build an occupational profile
• Progress from general to specific
• The activity itself may be therapeutic rather than simply an assessment 
• Describe each element of the model & invite the client to add to the drawing 

(Iwama, 2006; Teoh & Iwama, 2015)

Again, Step 1 is the construction of the client's individual river model. I have included the link on this slide to a PDF. This is a guide for the Kawa model. It is called the Kawa model made easy, and it is free and available for download with that link. It is a great resource and has suggested guiding questions that you can use. The model can also be used as a qualitative assessment tool to gain further information about the client. There is no particular order that you need to either ask the questions or have the client put the components into the drawing. You could ask about rocks first, and then you could move into things related to social and physical supports (the river walls or bottom). Then, you might go back to rocks if something comes up. It really should just be a fluid process, more like a discussion.