Main concepts and definitions of terms

The Kawa model is structured around the metaphor of a river and its elements. It uses the image of the water flowing through a river to represent ‘life energy’ or ‘life flow’. In this model, the purpose of occupational therapy is to facilitate this life flow in the context of a harmonious balance with all aspects of the river. The river itself is used to describe a person’s life history (Figure 7.1) and cross-sections of the river at different times in the person’s history (Figures 7.2 and 7.3) can reveal the elements in the river. These elements are the river floor and walls, rocks, driftwood and the spaces between these. Each element represents an aspect of the person’s life circumstances. The water flows through the channels that are created by the relative positions and sizes of the other elements. Change can occur in the river by alteration of the position, size and shape of the elements to increase or decrease the flow of the water. This potential for change is the basis for occupational therapy intervention.

FIG 7.1 The river.

From Iwama, The Kawa Model (2006) Churchill Livingstone, with permission from Elsevier Ltd.

FIG 7.2 Elements of the river.

From Iwama, The Kawa Model (2006) Churchill Livingstone, with permission from Elsevier Ltd.

FIG 7.3 Elements constricting water flow.

From Iwama, The Kawa Model (2006) Churchill Livingstone, with permission from Elsevier Ltd.

The river is used to represent the flow or energy of life. It could refer to the life of an individual person, a family or the life of an organization (Iwama, 2006). In the metaphor of a river, the importance of context in shaping the river is emphasized. Rivers start because the moisture from rain and melting snow etcetera flows toward the lowest point of the land. Depending on the surrounding geography, rivers commence with varying amounts and types of water flow. They also flow towards lakes (some of which might be dry in lands such as Australia) and the sea. The course that the river takes depends on the unique combination of the surrounding geography, the strength of the river’s water flow and anything that lies in the river such as rocks and driftwood. Similarly, the flow of the water can vary in different parts of the river as variations occur in the unique combination of the quality of the water flow and other elements of the river.

In the Kawa model, the river is used as a metaphor for the life journey, with birth being represented by the start of the river and end of life being the point at which the river flows into a larger body of water such as the sea. As Iwama (2006) explained, “An optimal state of well-being in one’s life or river, can be metaphorically portrayed by an image of strong, deep, unimpeded flow” (p. 143). As a metaphor for life, the river shows that people’s lives are shaped by the unique contexts into which they are born and live as well as aspects of their own character and skill. Just as the river makes twists and turns, people’s lives change in a variety of ways. Some of these changes can be anticipated, some are unexpected, some are shaped by the surrounding context and others are primarily shaped by the flow of the water, which changes the shape of the river floor and walls. Sometimes the flow of people’s lives is impeded by obstacles and at other times everything seems to flow easily. Some people are born into or live in circumstances that flow easily like a wide river and others’ lives are characterized by obstacles that impact substantially upon their life flow.

While the river as a whole represents a person’s life, a cross-section taken at various points of the river would show different arrangements of the elements of the river. In certain places, the river might be wide and deep and the water flow might be largely unimpeded by obstacles. In other places, it might be narrow and flow over rocks or drop in waterfalls. And still other places, the water flow might become impeded by debris or rock barriers that make the water stagnant. Similarly, the same section of river will look different at different times if the rainfall has varied and the river might run strongly or be almost dried up. In the Kawa model, attention is paid to both the river as a whole and to cross-sections at different places. In the cross-sectional view, the various elements of the river are used as metaphors for different aspects of life.

Elements of the river

The first element in the Kawa model is the water. The element of the river used in the Kawa model to represent life energy or life flow is water, or mizu in Japanese. In many different cultures, water has symbolic meanings that relate to life. It is possible that water is a seemingly universal symbol of life because it is biologically essential for sustaining human life. Iwama (2006) highlighted that, while water is considered to be pure, cleansing and renewing and is often associated with the spirit, culturally specific meanings for water also abound throughout the world. He encouraged people to explore what water symbolizes in the particular cultures with which they might be engaging.

Water has a fluidity that allows it to flow over, around and through a range of different obstacles and channels in its path. As a fluid, it has the capacity to both shape and be shaped by whatever surrounds or contains it. It can take on the shape of a container but it also has the power to shape things that it flows over or through. For example, the erosion that occurs in rocks that are exposed to water attests to its power to shape its surroundings. As Iwama (2006) stated, “Just as people’s lives are bounded and shaped by their surroundings, people and circumstances, the water flowing as a river touches the rocks, walls and banks and all other elements of the river in a similar way to which the same elements affect the water’s volume, shape and flow rate” (p. 144). He also explained how important this mutually influencing relationship between the water and its surroundings is to understanding collective culture. He stated, “collectively oriented people tend to place enormous value on the self embedded in relationships. There is greater value in ‘belonging’ and ‘interdependence’, than in unilateral agency and in individual determinism. In such experience, the interdependent self is deeply influenced and even determined by the surrounding social context, at a given time and place, in a similar way to which water in a river, at any given point, will vary in form, flow direction rate, volume and clarity.” (p. 145.)

Water also has the capacity to fill the spaces between other things and only needs small spaces in which to flow. As a metaphor for life, this might suggest that life flow is possible in even the smallest of avenues. From the perspective of this metaphor, the task of an occupational therapist is to look at all aspects of the person’s context of daily life and facilitate greater life flow. “When life energy or flow weakens, the occupational therapy client, whether defined as individual or collective, can be described as unwell, or in a state of disharmony” (Iwama, 2006, p. 144). An occupational therapist can use any elements of the river (and their combinations) to work towards facilitating life flow.

The next concepts are the river walls and river floor. In the Kawa model, the river walls and river floor are referred to as kawa no soku-heki and kawa no zoko, respectively. Just as the walls and floor of the river shape the course, depth and width of the river, these parts of the river are used in the Kawa model to refer to the contexts that surround clients, that is, their social and physical environments. Iwama (2006) made the point that “these are perhaps the most important determinants of a person’s life flow in a collectivist social context because of the primacy afforded to the environmental context in determining the experiences of self and subsequent meanings of personal action” (p. 146).

In discussing the river walls and floor, Iwama mainly attended to the social environment, possibly because of the importance of emphasizing the nature of a collectivist society to a Western audience. He stressed that the social environment chiefly refers to those people with which clients have direct relationships and he gave examples of what the river walls and floor might represent, such as family members, pets (that are very important to them), friends, workmates, classmates and so forth. He also emphasized that, in some cultures, the memories of departed family members can exert an important influence on people and that, in some cases, conversing with such departed relatives might constitute an important occupation for particular clients.

When using the Kawa model, the various elements of the river have to be considered together for occupational therapists to gain the holist perspective for which they strive. Therefore, when thinking about the river walls and floor, it is important to understand that there is no particular shape that is ‘optimal’. What matters is the amount of water that is able to flow through the combination, placement and interaction of the various elements of the river. For instance, rivers that have reasonably narrow or shallow walls and floor might allow for adequate water flow if there are no obstacles blocking its flow. Similarly, a deep river that has been dammed will restrict the river flow in a way that is unrelated to the natural shape of the walls and floor. Metaphorically, the environment will certainly shape the life flow of a person but this may be in a facilitatory or inhibitory way. Using the Kawa model, occupational therapists can look for ways to help shape the environment to facilitate the flow of the client’s river and to enhance the harmony existing between clients and their contexts.

The third element of the Kawa model is rocks. The Japanese word iwa, which means large rocks or crags, is used in the Kawa model’s representation of life circumstances that are perceived by the client to be problematic. These life circumstances are seen to impede life flow and are considered by the client to be difficult to remove. Just as rocks can disturb the flow of water because of their shape, size and placement in relation to the walls and floor of the river, rocks are used to represent such life circumstances in the lives of people. The rocks in a person’s life might be challenges that derive from bodily impairments that, in a particular environment, impede their life energy. Using the river image metaphorically, the unique size and placement of this rock in relation to the shape of the river walls and floor might impede the flow of the water. However, in a river with differently shaped walls and floor, the same rock might have a minimal effect on the flow of the water. Thus, it is important when using the model to discuss with the client the extent to which potential obstacles to life flow are actually perceived as impacting upon his or her life.

Many of the examples of rocks provided in the major publication on the Kawa model (Iwama, 2006) relate to impairments of body structures and function such as low motivation, anxiety, depression and history of relapse – all symptoms and consequences of mental illness – and brachial nerve injury and pulmonary emphysema; while others relate to problems of performance such as difficulties with activities of daily living and self care. However, other rocks listed are money and human relations, which illustrate that obstacles in one’s life can relate to things other than impairments of body structure and function. Each person’s life circumstances and contexts of living are unique and will differ among people.

The fourth element of the river discussed in the Kawa model is driftwood. The image of driftwood, ryuboku in Japanese, is used to represent:

Some of these examples of personal attributes and resources refer to features of an individual while others relate to that individual’s immediate context and circumstance. While driftwood is also described as representing personal assets and liabilities, the concept of personal attributes and resources probably conjures a better image of what the driftwood is used to represent in the model. The image of assets and liabilities is often interpreted from an existential perspective to refer to characteristics that are within the person rather than surrounding him or her whereas driftwood includes resources external to the person.

The utility of the concept of assets and liabilities lies in placing an emphasis on the fact that these attributes and resources can have a negative or positive effect on life flow. For example, Iwama (2006) provided a table listing examples of driftwood and, for each, positive and negative effects that each example might have on the life of an individual. Some of these are as follows: future expectations could have the positive effect of providing goals or something to look forward to, while potentially having negative effects by being a source of frustration, stress and worry; parents’ advantaged financial status could have the positive effect of assisting with equipment purchases and required home renovations while also possibly facilitating increased dependency and contributing to a lack of skill development on the part of the client.

Compared with rocks, driftwood is considered to be less permanent and a more fluid situation within the river. Driftwood can be carried along with the water current and, depending on their shape and number, can become caught on the rocks or combine to create a dam that restricts the flow of the water. However, when carried by the strength of the water flow, they can also dislodge obstacles or carve channels in the river walls or floor, thereby increasing the flow of the water.

The final, but centrally important, element in the Kawa model is the spaces between obstructions. These are called sukima in Japanese and help us to understand the focus of occupational therapy from the perspective of this model. The elegant title of the section of book in which spaces is discussed is “Sukima (space between obstructions) where life energy still flows: The promise of occupational therapy” (p. 151). In the Kawa model, the concept of sukima is based on an understanding of occupational therapy as a strengths-based approach. Rather than focusing on the remediation of problems, sukima emphasizes the importance of understanding where life is flowing in a client’s situation and strategically working to maximize that flow.

While reduction in the size and shape of obstacles might be a strategy that can be used to maximize the life flow, it becomes only one of many ways to enhance life flow in those places in the river where it already exists. Focusing on the spaces between objects rather than the objects themselves, the Kawa model emphasizes the potential to facilitate life flow in a range of ways including reducing the size and shape of problems, making channels in or changing the shape of the environment surrounding the client, and maximizing the power of the client’s existing assets and resources. Using the metaphor of the river, the spaces where the water flows have the potential to increase through the friction that can wear away or dislodge those things that surround and impede its flow.