The kawa model & reflective practice jan 2012


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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).
  • Person in hospital, on life support, no life flow/water, no rocks, driftwoodHow can we as health professionals help to bring the water back?
  • Coma?Locked in syndromeDementiaBrain InjuryGrief and lossAs health care professionals, how can we break the ice to help the water/life flow to flourish?HopeCareLove
  • Environment – river sides/bottomDrug dependencyAbuseNo familyPovertyIgnoranceFinancesMental HealthGrief and loss (emotional, physical – loss of health, loss of partner/child, loss of role, job)
  • Palliative care – ask your patient to describe how they want their river to look….leading out to the oceanLong-term conditionsNeurologyMental HealthPhysical Health
  • The kawa model & reflective practice jan 2012

    1. 1. The Kawa „River‟ Model Reflective Practice & Professional Development Beki Dellow Occupational Therapist
    2. 2. Learning Outcomes• Gain an overview of the Kawa „River‟ Model• Case Study• Explore the Kawa Model‟s use in reflective practice and professional development/supervision• The What If‟s?• Summary• Questions
    3. 3. Life is like a River…..
    4. 4. Life at this moment in time Birth/beginning of working life Time End of Life/career
    5. 5. Founder• 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
    6. 6. 4 Basic Concepts of the River Model Environmental Life factors Circumstances („Ba‟, Physical & & Problems Social) Personal Factors & Life Flow Resources & Health They are all inter-related
    7. 7. Environmental factors Life Circumstances(„Ba‟, Physical & Problems & Social) Personal Life Factors & Flow & Resources Health KAWA
    8. 8. When life happens… • Rocks: Life circumstances or problems • Driftwood: Assets and liabilities or strengths and weaknesses • Riverbed/walls and bottom: Physical , social and cultural environments • “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)
    9. 9. Channels through which water flowsOpportunities to maximise life flow ASSET / LIABILITY OPPORTUNITY PROBLEM FOR CHANGE OPPORTUNITY ENVIRONMENT
    10. 10. Life is enabled to flow more strongly and deeply despite residual obstacles and challenges…
    11. 11. AimEnabling and Maximising “Life Flow”
    12. 12. Case Study – Ben 29 year-old male 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
    13. 13. Past Life,Identity,Relationships, The River diagramSelf… allows the therapist to understand Ben‟s life story, from his perspective Catastrophe, sudden changes Suicidal - Near the end of life - ocean Shattered mind and life
    14. 14. 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
    15. 15. Goal Planning and Intervention•The therapist works collaboratively with Ben, using his Kawa diagramsto identify personal assets (strengths) and liabilities, problems andchallenges, 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 thatpotential spaces to increase „life flow‟ (areas for occupational therapyintervention) are limited. Ben‟s river is impacted with rocks (problems),virtually blocking the flow. A fuller and unobstructed river represents abetter state of well being (Iwama, 2006)•Goal planning with Ben, referral to psychiatrist to review medication andassess level of suicide risk
    16. 16. Evaluation If time allows, the Kawa Model could beeffectively used to evaluate and completethe therapy process. Patients could beasked to draw another metaphoricaldiagram of their „river‟ post intervention toidentify any changes to their „life flow‟
    17. 17. Putting Patients First Patient Health Professional COMMON The therapist becomes theThe patient builds a model to METAPHOR student of the patients explain their day to day life model, looking for ways to experience adapt and deliver therapy that is relevant and meaningful to the patient Sphere of shared experience Sphere of shared experience
    18. 18. Using the Kawa Model inreflection and professional development
    19. 19. How I felt before moving and three weeks into my first OT rotationOne week prior tocommencing newpost Three weeks later
    20. 20. Three months later…….
    21. 21. Breaking down the Rocks (Personal Development Plan)
    22. 22. Personal Development Plan
    23. 23. SWOT AnalysisDriftwood (Assets/Liabilities)StrengthsWeaknessesOpportunitiesThreatsRiver sides/Bed (environment)StrengthsWeaknessesOpportunitiesThreatsWater (Life flow/Energy)How do you feel right now?
    24. 24. SWOT Analysis
    25. 25. Analysing it further
    26. 26. 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
    27. 27. Preceptorship 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 participants (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
    28. 28. 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
    29. 29. Physical Health and Well-beingA qualitative pilot study conducted by occupational therapists in Ireland, aimed toexplore the effectiveness of the Kawa Model when used to guide intervention with twoindividuals 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
    30. 30. 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
    31. 31. 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
    32. 32. Policy on Continuing Professional DevelopmentAll qualified staff are expected to be proactive in theircontinuing professional development; that is in maintaining,improving and broadening their knowledge, skills and personalqualities in order to perform professional activities to therequired standard
    33. 33. Development of our Professions „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)
    34. 34. The Kawa Model in your professional Practice The what if‟s……..
    35. 35. What if the river runs dry?
    36. 36. What if the river is frozen?
    37. 37. What if there is no support or the environment restricts the flow?
    38. 38. What if the rocks are too big or too many?
    39. 39. Think about……….• Palliative care• End of life care• Long-term conditions• Neurology• Mental Health• Physical Health
    40. 40. Summary of Basic Principles• Life is like a river … All things are connected… (self & environment, past-present-future)• Understand the complexity of experiences – from a service user‟s perspective, in their own words…through a reversal of power• The Kawa Model is a powerful and effective tool for personal and professional reflection/development• The Kawa Model can be used as a framework in the development of services and staff
    41. 41. Questions?
    42. 42. 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• Johns C (2006) Engaging in Reflective Practice: A Narrative Approach Oxford: Blackwell Publishing Ltd• Taylor BJ (2010) Reflective Practice for Healthcare Professionals (3rd Ed) New York: Open University Press
    43. 43. 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
    44. 44. 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