Kawa 'River' Model Presentation

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  • The Kawa metaphor enables us to see disability from a shared experience. When the ‘self’ is visualised as a ‘river’, all of the elements including ‘self’, circumstances and society are formed as elements of one, indivisible whole, which are difficult to understand in isolation (Turpin and Nelson, 2007).
  • Be ready for the question: well then, if models are culture bound, then isn’t this model created in Japan only appropriate for use in Japan with Japanese people? The answer is that because this model departs from conventional theory, in making it a flexible framework that focuses on the client’s narrative or perspective on their own situation, the cultural issues. The cultural appropriateness of this model rests on whether the river as a metaphor of the life journey resonates with the client and the therapist employing it.
  • Be ready for the question: well then, if models are culture bound, then isn’t this model created in Japan only appropriate for use in Japan with Japanese people? The answer is that because this model departs from conventional theory, in making it a flexible framework that focuses on the client’s narrative or perspective on their own situation, the cultural issues. The cultural appropriateness of this model rests on whether the river as a metaphor of the life journey resonates with the client and the therapist employing it.
  • Setting An acute specialist day hospital, providing short-term treatment for working age adults experiencing an acute episode of severe mental health difficulties, or presenting in ‘crisis’.   Client This case study makes reference to 'Ben', seen during a mental health placement. A pseudonym is used to maintain confidentiality   29 years old lived independently in the past, but due to a recent deterioration in his mental health, currently resides with his parents . Ben has an older brother who lives abroad and a younger sister living locally with her two children. Ben describes having a poor relationship with his brother. He bullied Ben physically and psychologically as a child.   Ben has a good relationship with his parents, sister and nephews. Diagnosed with chronic depression - This is diagnosed when a person meets the diagnostic criteria for depression for a minimum of two years (American Psychiatric Association, 2000; National Institute for Health and Clinical Excellence, 2007) (NICE). Currently in full-time employment, although reports being dissatisfied with his work. He is troubled by frequent feelings of pointlessness and is paranoid that he will lose his job.   Ben's occupational performance is greatly affected by his mental health difficulties. Ben is experiencing cognitive difficulties involving his concentration and memory. Due to low mood and lack of motivation, Ben isolates himself and avoids social interaction and activities with his family and friends. He reports often feeling helpless and unable to resolve daily problems. He views his life as pointless and unrewarding, believing that change is impossible. Depression is one of the few psychological disorders that can be classed as being fatal (Hammen and Watkins, 2008).
  • The Kawa Model is introduced to Ben during a creative expression group. The Kawa Model resonates in meaning to Ben due to his creative abilities and interest in Eastern philosophy and Buddhism. 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.
  • 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).
  •  
  • Intervention: Ben’s short-term goals (in 6 weeks) including purpose Ben to attend the day hospital every Thursday for 4 weeks (1 hour) to participate in the Goal Setting Group (closed group) To give Ben the skills to set SMART goals, identify and overcome obstacles To increase social interaction and communication skills To promote inclusion To improve coping strategies Ben to attend the day hospital each Wednesday (1 hour) throughout intervention to participate in the Creative Expression Group (semi-open group) To provide Ben with a safe environment to outlet his feelings through various mediums: (pottery, collage, paints, charcoal, pens/pencils) and to be freely creative without judgment To increase interaction and communication skills To promote inclusion Ben to attend the day hospital each Wednesday afternoon (1 hour) throughout intervention to participate in the Mindfulness Group (semi-open group) To help Ben to relax, particularly when feeling anxious To learn a new relaxation technique To help Ben to control his thought process To help Ben to switch off from his negative thoughts Ben to meet with the community employment support worker at her office, to explore employment opportunities based on Ben’s interests and experience To work towards long-term goal of finding alternative employment Ben to write a private reflective log/diary of his thoughts and feelings (including suspected symptoms from medication (daily) To help Ben to offload thoughts and feelings To help Ben to monitor his mental health To give Ben prompts for one-to-one discussions with the therapist/psychiatrist
  • The Kawa can be used in conjunction with other assessments and presented in the familiar table format if it makes things clearer to you
  • Other assessments used: Continual risk assessment is essential to ensure that significant risk of suicide or self-harm are managed, also considering the possibility of harm being incurred to others There is a need to assess Ben’s anxiety and depression levels on a regular basis, in order to understand how Ben feels and to minimise the risks identified. The Hospital Anxiety and Depression Scale (HADS) is a standardised , self-report questionnaire, designed to provide a fast, reliable and simple tool for use in medical practice Interest Checklist - In addition to these assessments, an adapted version of the Interest Checklist (Matsutsuyu, 1969) is used (appendices 11-12) to gather details of Ben’s interests, aiding the selection of activities that may help to maintain Ben’s engagement with occupational therapy treatment and the attainment of his goals (Creek and Bullock, 2008). an observational tool, The Assessment of Communication and Interaction Skills (ACIS) (Forsyth et al, 1998) is an observational assessment, which assists occupational therapists to gather data on the skills a person demonstrates when interacting and communicating with others in a specific occupation (e.g. groups). It was designed to measure the consequences of illness on interaction and communication abilities.
  • 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’.
  • I only actually found the one study carried out in Ireland. Michael Iwama advised me that there are about 8 studies going on now, 3 are currently being disseminated by the College of Occupational Therapists. There are also 8 narratives and case studies of the Model’s application in diverse practice contexts in the Kawa Model book (Iwama, 2006, p179). Michael Iwama points out that the Kawa Model is not a universal framework of the conventional kind that gets tested for reliability. It varies from one cultural context to the next, and so validation happens at the point of application. The client is the one who says ‘this model works! Or this model is lousy!’
  • A qualitative study which was conducted by occupational therapists in Ireland (Carmody et al, 2007), aimed to explore the effectiveness of the Kawa Model when used to guide intervention with two individuals with multiple sclerosis. Semi-structured interviews based on the Kawa Model were used with the participants before and after intervention. The initial interview involved participants describing their life using the metaphor of a river… e.g. ‘my river is calm at the moment, but there’d be a lot of waves underneath from years back…I think I have a couple of ship wrecks down there as well!’ and ‘I just see a river with no obstacles with good healthy beds in it flowing away at the moment, quite happy’. ‘ I think you couldn’t have a more natural way of explaining it…what I liked about the river is that I could see my problems and get them down on paper and get the sorted out one by one…it’s a great explanation of your life’.
  • Following the initial interview, the researchers developed and delivered occupational therapy intervention plans, delivering intervention over 8 weeks. Follow-up interviews, again based on the Kawa Model were completed. Participants’ drawings of their rivers were included as part of data collection. The authors also documented their experience of using the model in reflective diaries. Michael Iwama (2006) states that ‘for effective use of the Kawa Model it is favoured that the client is aware of ‘me in the world’, as opposed to ‘me against the world’. (p173)
  • Practice Report, Jon Fieldhouse (2008), Senior Lecturer at the University of West England, Bristol. Charts his personal journey of discovery regarding the Kawa as a community mental health team practitioner and as an educator. Worked with a UK-born Pakistani male living with his extended family. His derogatory voices and paranoid ideas were undermining his attempts to ‘get on with his life’, causing conflict and tension within his family. Offered occupational opportunities away from the family He found it puzzling when this seemed to deepen divisions in his family, the knock-on effect being communication between them too Using the kawa highlighted that the family was the context within which his occupations and roles derived most of their meaning. (part of a prized belonging and interdependence rather than individualism, and the positive sense of self that eluded him was an identity primarily achievable as a family member. A crucial part of how he expressed who he was) With this realisation, changed his clinical reasoning, seeing the client wholly in context, meant working with a family system. The river did not flow without its floor and walls. It had no form. He was an individual, but his occupational aspirations were to be able to function as an extended family member, and be accepted as such - but also with family members adapting their behaviour to accommodate the changes he made. OT progressed better from that point onwards The simple imagery, allowing direct access to the clients conceptual basis, prompted a shift in clinical reasoning and presented a practical solution, which worked
  • Education – Fieldhouse (2008 p104) found that the Kawa 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’ Helping them tackle that familiar dilemma –often felt most acutely when on practice placements – wondering how the theory learned at uni is applied in the workplace Any questions? Now I’m going to talk about an experience I had with a specific client on my mental health practice placement
  • Teresa Buchan, practice development/placement co-ordinator for AHP, Kent and Medway NHS and Social Care Partnership Trust, looks at using newly registered staff experiences of transition to influence change within a trust-based preceptorship programme The research found that a significant amount of data created from both the development event and the focus groups/interviews using the Kawa Model that can be used to influence the development of the preceptorship, support systems and the new preceptorship policy
  • Spain North America UK Ireland Chile Africa New Zealand
  • Quote from recent report on using the Kawa Model in practice and education, Jon Fieldhouse Models should not replace individual judgment and should be critically evaluated through use (Fieldhouse, 2008 p105)
  • To end this presentation, I’d like to encourage everyone to take a few moments to try this at home, or to review an existing case in you current caseload using the kawa framework
  • Here are references and links to relevant internet resources- discussion forum, the main website and the Facebook page so that you can easily access more information Letter from Michael Iwama
  • Kawa 'River' Model Presentation

    1. 1. The Kawa ‘River’ Model By Beki Dellow Presentation includes some slides produced by Michael Iwama (2010), used with his kind permission
    2. 2. Learning Outcomes <ul><li>Gain an overview of the Kawa ‘River’ Model </li></ul><ul><li>Case Study </li></ul><ul><li>Look at some relevant literature relating to the Kawa Model’s use in occupational therapy practice </li></ul><ul><li>Feedback and questions throughout presentation </li></ul>
    3. 3. Birth End of Life TIME Life is like a River…
    4. 4. Who founded the Kawa Model? <ul><li>Michael Iwama, PhD, OTC, associate professor at the University of Toronto, with occupational therapy practitioners in Japan </li></ul><ul><li>Developed in 2000 </li></ul><ul><li>Book published 2006 </li></ul><ul><li>12 + articles in peer-reviewed journals </li></ul><ul><li>10 Chapters in OT & Rehabilitation textbooks </li></ul><ul><li>Translated into 5 languages </li></ul><ul><li>Taught in over 500 occupational therapy programs internationally </li></ul><ul><li>Used in practice across 6 continents </li></ul>
    5. 5. 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
    6. 6. Environmental factors (‘Ba’, Physical & Social) Life Flow & Health KAWA Life Circumstances & Problems Personal Factors & Resources
    7. 7. Why was the Kawa Model developed? <ul><li>Conventional Models in Occupational Therapy </li></ul><ul><li>are cultural-bound in the (Western) model-maker’s experience which: </li></ul><ul><li>Privileges a minority (Western) world-view of occupation </li></ul><ul><li>Constructs the self & environment as distinctly separate </li></ul><ul><li>Are based on mechanical metaphors </li></ul><ul><li>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 </li></ul>
    8. 8. If models are culture-bound, then isn’t this model created in Japan only appropriate for use in Japan with Japanese people?
    9. 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. 10. When life happens… <ul><li>Rocks = life circumstances </li></ul><ul><li>Driftwood = assets and liabilities </li></ul><ul><li>Riverbed/walls and bottom = environment </li></ul><ul><li>“ 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” </li></ul><ul><li>(Iwama 2006, p143) </li></ul>
    11. 11. ENVIRONMENT PROBLEM ASSET / LIABILITY Channels through which water flows = Opportunities for occupational therapists to maximize life flow OT OT OT OT OT OT
    12. 12. Life is enabled to flow more strongly and deeply despite residual obstacles and challenges…
    13. 13. Occupational Therapy’s Aim Enabling and Maximizing “Life Flow”
    14. 14. Case Study – Meet Ben <ul><li>29 years old </li></ul><ul><li>Lived independently in the past, but due to a recent deterioration in his mental health, currently resides with his parents </li></ul><ul><li>Diagnosed with chronic depression </li></ul><ul><li>Currently in full-time employment, although reports being dissatisfied with his work </li></ul><ul><li>Troubled by frequent feelings of pointlessness and is paranoid that he will lose his job </li></ul>
    15. 15. Ben’s River – his life story
    16. 16. 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
    17. 17. Cross-section of Ben’s River – how life is now
    18. 18. 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)
    19. 19. Assessment <ul><li>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) </li></ul><ul><li>These combine to form a unique picture of Ben’s life at this point in time </li></ul><ul><li>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 </li></ul>
    20. 20. Goal Planning and Intervention <ul><li>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’ </li></ul><ul><li>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) </li></ul><ul><li>Goal planning with Ben, referral to psychiatrist to review medication and assess level of suicide risk </li></ul>
    21. 21. 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
    22. 22. Analysing Ben’s Kawa metaphors and planning appropriate interventions
    23. 23. Evaluation <ul><li>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’ </li></ul>
    24. 24. 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
    25. 25. Evidence-base: Kawa Model <ul><li>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 </li></ul>
    26. 26. Physical Health and Well-being <ul><li>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) </li></ul><ul><li>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’ </li></ul><ul><li>Planning The model aided facilitation of occupation-based goal setting and identification of the spaces for occupational therapy intervention </li></ul>
    27. 27. Physical Health and Well-being <ul><li>Intervention Facilitated the participants’ engagement in occupation-based therapy by allowing an understanding of what was important and meaningful to them </li></ul><ul><li>Evaluation Enabled review, evaluation and completion of the occupational therapy process </li></ul><ul><li>Limitations Challenges identified: therapist preconceptions of the Model and participant uncertainty in how to draw the river diagrams </li></ul><ul><li>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 </li></ul>
    28. 28. Mental Health and Well-being <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>The Kawa Model’s language and imagery are easily graspable by both students and practitioners </li></ul><ul><li>Highlights the great suitability of the Kawa as a tool in community mental health practice </li></ul>
    29. 29. Education <ul><li>Fieldhouse (2008 p104) </li></ul><ul><li>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’ </li></ul><ul><li>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 </li></ul><ul><li>Asking students to ‘stop trying to learn the model and to just try to think with some of its ideas’ was a helpful strategy </li></ul>
    30. 30. Preceptorship <ul><li>Recent Feature Article published in the July edition of the OTnews (Buchan, 2010) </li></ul><ul><li>Used newly registered staff experiences of transition to influence change within a trust-based preceptorship programme </li></ul><ul><li>80 participaants (Allied Health Professionals, nurses and social workers) attended workshops to discuss the various aspects of preceptorship </li></ul><ul><li>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 </li></ul><ul><li>A significant amount of data was created from the research to influence the development of the preceptorship, support systems and the new preceptorship policy </li></ul>
    31. 31. The Kawa ‘River’ flows Worldwide
    32. 32. Development of our Profession <ul><li>‘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’ </li></ul><ul><li>(Fieldhouse, 2008 p101) </li></ul>
    33. 33. What is expected of us? <ul><li>College of Occupational Therapists (2010) Code of Ethics and Professional Conduct – Section Six (6.1.1): Developing and using the profession’s evidence base </li></ul><ul><li>‘ You should be able to access, understand and critically evaluate research and its outcomes incorporating it into your practice where appropriate’ (p 33) </li></ul><ul><li>Health Professions Council (2008) Standards of Conduct, Performance and Ethics </li></ul><ul><li>Section 1 – ‘You must act in the best interest of service users’ </li></ul><ul><li>Section 5 – ‘You must keep your professional skills and knowledge up to date’ </li></ul><ul><li>Section 7 – ‘You must communicate properly and effectively with service users and other practitioners’ (p3) </li></ul>
    34. 34. Do you think you could add the Kawa Model to your toolkit?
    35. 35. Summary of Basic Principles <ul><li>Life is like a river … All things are connected… (self & environment, past-present-future) </li></ul><ul><li>Understand the complexity of client experiences – from their perspective, in their own words…through a reversal of power </li></ul><ul><li>Occupational Therapy is informed by the client’s day to day realities </li></ul><ul><li>Diverse worldviews necessitate diverse interpretations of ‘occupation(s)’ </li></ul><ul><li>Occupational Therapy = “Enabling Life Flow” </li></ul>
    36. 36. Your turn! How does your river flow? <ul><li>Rocks = life circumstances </li></ul><ul><li>Driftwood = assets and liabilities </li></ul><ul><li>Riverbed/walls and bottom = environment </li></ul>
    37. 37. References <ul><li>Buchan T (2010) Implementing Appropriate Support Systems OTnews 18 (7), 26 – 27 </li></ul><ul><li>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 </li></ul><ul><li>College of Occupational Therapists (201) Code of Ethics and Professional Conduct London: College of Occupational Therapists </li></ul><ul><li>Fieldhouse J (2008) Using the Kawa Model in Practice and in Education Mental Health Occupational Therapy 13 (3), 101 – 106 </li></ul><ul><li>Health Professions Council (2008) Standards of Conduct, Performance and Ethics London: Health Professions Council </li></ul>
    38. 38. References <ul><li>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 </li></ul><ul><li>Iwama MK (2006) The Kawa Model: Culturally Relevant Occupational Therapy Philadelphia: Churchill Livingstone Elsevier </li></ul><ul><li>Turpin M, Nelson A (2007) The Kawa Model: Culturally Relevant Occupational Therapy Australian Occupational Therapy Journal (54), 323 – 324 </li></ul><ul><li>http://www.kawamodel.com/ </li></ul><ul><li>http://kawamodel.phpbbnow.com/ (discussion forum) </li></ul><ul><li>http://www.therapytimes.com/content=0602J84C48769494406040441 </li></ul><ul><li>http://occupational-therapy.advanceweb.com/Article/KAWA-Model-Project.aspx (videos) </li></ul><ul><li>Facebook:http://www.facebook.com/photo.php?pid=288121&fbid=147680675266270&id=139318639435807&ref=nf#!/KawaModel </li></ul>
    39. 39. References <ul><li>Other useful references: </li></ul><ul><li>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 </li></ul><ul><li>Canadian Association of Occupational Therapists (1991) Occupational Therapy Guidelines for Client-Centred Practice Toronto, ON: CAOT Publications ACE </li></ul><ul><li>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 </li></ul><ul><li>Davies T (2009) Risk Management in Mental Health. In: Davies T, Craig T (Eds) ABC of Mental Health (2nd Ed) Oxford: Wiley-Blackwell </li></ul>
    40. 40. References <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Matsutsuyu JS (1969) The Interest Checklist American Journal of Occupational Therapy 23(4), 323-395 </li></ul><ul><li>Roger S (Ed) Occupation-Centred Practice with Children: A Practical Guide for Occupational Therapists Oxford: Wiley-Blackwell </li></ul><ul><li>Snaith RP (2003) The Hospital Anxiety and Depression Scale Health and Quality of Life Outcomes 1(29), 1-29 </li></ul>

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