10. The Kawa (River) Model
Kee Hean Lim and Michael K. Iwama
In the pursuit of providing meaningful and relevant occupational therapy with an increasingly diverse global clientele, occupational therapists are being challenged to examine the relevance, construct and content validity of their contemporary models and practice frameworks. The Kawa Model, infused with its naturalistic and contextual philosophy, provides a radically different perspective of how occupation and the self are conceptualized. The Kawa Model recognizes the uniqueness, dynamic nature and diversity of each client’s occupational narrative and provides a framework within which occupational therapists can appreciate each client in the unique context of their day-to-day realities and circumstances, thereby gaining a greater appreciation of their complex occupational world.
• Each person’s experience of and meanings they attach to daily life are unique. Clients and occupational therapists alike carry diverse interpretations of occupation and of occupational therapy.
• Context and experience are important and central to understanding and shaping one’s occupational world and daily life narratives.
• Professional culture, standard practice frameworks and prescriptive assessments based on universal criteria can exclude as well as reinforce power differentials between client and professional.
• In the current climate of evidence-based practice there can be an over-emphasis on standardized clinical assessment and measurement, at the expense of appreciating clients’ lived experiences and wellness narratives.
• Client-centred occupational therapy begins, is based on, and ends with the client’s narrative of daily life experience.
• To be meaningful and relevant, occupational therapy must be both person- and context-focused, inclusive, enabling and culturally safe.
The great promise of occupational therapy, to enable people from all walks of life to engage/participate in activities and processes that have value, is simple yet profoundly complex and challenging to fulfil for the diverse clientele that typifies an increasingly global, postmodern world (Iwama 2007). Occupational therapists the world over have been challenged to provide occupational therapy that is relevant and responsive to the day-to-day realities of their diverse clientele. An examination of current occupational therapy models reveals that the values and meanings of occupation, like other socially situated constructs, have been ascribed mainly by people situated in the English-speaking Western world, who have a common context of shared experiences (Iwama, 2006 and Lim, 2008a). The meanings of human occupations are uniquely tied to socio-cultural contexts, varying from group to group, from person to person and from situation to situation. Given this degree of diversity and cultural relativity in occupation’s fundamental meaning, a single or universal interpretation of this core construct of occupational therapy is virtually impossible to maintain. How, then, will specific conceptual models in occupational therapy, largely constructed on such universal premises, explain, describe and guide occupational therapy approaches and processes for a diverse clientele in diverse contexts? How well do the learned and tacitly held ideas that essentially reflect middle-class, middle-North American and Western European ideals of self-determinism, competence, individual agency and autonomy explain the day-to-day realities and meanings of occupation for clients that do not fit these socio-cultural ideals?
Though many aspects of contemporary occupational therapy and its locations of practice have aligned with biomedicine, diehard occupational therapists have endeavoured to keep occupational therapy focused on occupation, preferring to shift occupational therapy’s focus and location of practice into the realm of clients’ day-to-day living issues and experiences (Iwama 2005a). Instead of focusing on pathology, symptoms and functional limitations, occupational therapists have maintained an interest in and focus on the consequences of these medically defined factors, on the day-to-day circumstances and needs of a diverse clientele. This is where the power of occupational therapy lies: in the relevance to the client’s day-to-day circumstances to enable people from all walks of life to engage and participate in activities and processes that have personal meaning and value (Lim & Iwama 2006).
Occupation-based occupational therapy is challenging to deliver, especially when diversity and cultural relativity are brought into the equation. Cultural variation and the challenges of diversity were not such strong concerns for the pioneering occupational therapy scholars when they first embarked upon constructing their practice models. Theoretical materials created in the past century in occupational therapy and rehabilitation appear to have been largely constructed on the premise of a relatively homogeneous clientele, whereby a one-size-fits-all worldview or single framework seeks to explain the experience of human occupation and occupational therapy practice for all (Iwama, 2005a and Lim, 2008b). What may work well for clients whose experiences fall within minor deviations from the norm/mean for a particular conceptual phenomenon may possess limitations for those ‘other’ clients who stand as outliers in the demographic mean curve, who may be either excluded or disadvantaged by the same standard. What happens when norms and imperatives of autonomy, personal causation and self-determinism are also foisted on to ‘outlier’ clients who come from a sphere of shared learning and experience that idealizes dependency, group harmony and collective determinism? How does the single-parent client of four young children, a young man with mental illness, and others who have survived circumstances of abject poverty and social marginalization relate to occupational therapy’s middle-class, Western principles and ideals of competence, self-agency and self-reliance (Walley Hammell and Carpenter, 2004 and Iwama, 2006)?
Delivering an occupation-based service for a diverse client population that makes sense of the value of activities and processes of daily life (occupation) in unique and diverse ways remains a daunting task for occupational therapists. Catering to the uniqueness of each client’s day-to-day occupational issues is difficult to enact when conventional theory and the approaches that this theory guides and explains are based on a questionable premise of homogeneity of clientele, their needs and universality of a given occupational therapy model.
Emerging issues of culture and cultural safety in occupational therapy theory and practice
Culture is more than individual-embodied features of ethnicity and race. It is broadly defined here as spheres of shared experience and the ascription of meaning to phenomena and objects in the world (Iwama, 2007 and Lim, 2008a). A broader definition that takes in social context qualifies the profession of occupational therapy as a sphere of shared experience, or cultural entity, as much as ‘Western’ or ‘Japanese’ might. Occupational therapy has its own unique sphere of shared experiences, a developing specialized language, tacit rules of professional conduct and acceptable rules for knowledge production, including theory development. For many occupational therapists, the cultural features and imperatives buried within conventional occupational therapy theory may go problematically unnoticed (Iwama 2005a). The preference for individual-centric views of daily life occupations, the imperatives of autonomy and independence in daily living skills and de-emphases on contexts that shape occupational meanings are often taken for granted and accepted as ‘normal’ — especially by those who have shared experiences in Western contexts of daily living (Lim 2008b). Unwittingly, occupational therapists find themselves enquiring about and filtering clients’ unique and rich narratives of their daily living contexts and circumstances through predetermined (and often sophisticated) concepts and principles belonging to someone else’s (unfamiliar) world view and interpretation of human occupation. Problems are identified and plans for intervention are then determined that can potentially stray or diverge from what the client actually regards to be meaningful, valued, worth knowing and worth doing. Often, the ideals of client-centred occupational therapy do not extend far enough into the rich, contextual cultural world of the client (Iwama, 2005c and Lim, 2006).
For many occupational therapists and their clients who fall outside of such mainstream cultural norms, universal models that have risen out of a dominant mainstream culture, infused with its own tacit standards and ideals of what is considered ‘normal’, ‘acceptable’ and ‘good’, can be regarded in some instances as being culturally unsafe (Lim & Iwama 2006). Ramsden (1990) highlights the importance and principles of cultural safety: a framework by which power relationships between health professionals and the peoples they serve are critically considered. The impact of historical, social and political processes on minority health groups holds important implications for equity wherever health issues of a particular group are being described, explained, mediated and evaluated by other people within their own standards (Jungerson 1992). This idea of cultural safety is especially pertinent to occupational therapists when taking their ideas and processes into new cultural domains, including into the lives of their diverse clients and contexts (Gray and McPherson, 2005 and Iwama, 2006). Often the recipients may be in weaker, disadvantaged positions and are discriminated against further by being compared and evaluated against standards and norms belonging to a different cultural context (Lim, 2005 and Lim, 2008a). Further, they may also lack the experience, knowledge and means to examine critically the veracity, utility and cultural safety of the procedures and materials imposed upon them.
There are also relevant issues of cultural safety in the interface between theory construction and theory application. When critical questions are asked about where the ideas have come from, on what realities these materials and ideas have been based, and who has participated in the production of such knowledge, valuable insight is gained into the cultural features of the epistemology and theory of a profession. Theories and models, often developed in academic settings, can be far removed from the very people, situated in diverse, dynamic and changing practice contexts, for whom these theoretical materials and models are universally intended and considered appropriate (Lim & Iwama 2006).
Empowering occupational therapy clients — the way forward
Reconfiguring client-centred practice may be difficult for both the seasoned therapist and conditioned client to come to terms with, as the current way of top-down delivery of occupational therapy often privileges the professional as ‘knowing best’ and the client submitting to the role of ‘patient’. The reliance on certain (universal) frameworks and the standardized tests that reify and accompany them can take some of the guesswork out of professional decision-making and enhance the efficiency of occupational therapy processes, but the occupational therapist must ultimately understand whether the client and their ‘story’ of day-to-day living and circumstances are being comprehended and that the ensuing occupational therapy is being truly client-centred and based on factors that are meaningful to the client.
Occupational therapists stand to benefit from theory, instruments, methods and approaches that enable clients to translate their real experiences of daily living into the therapeutic process, to form the basis on which occupational therapy is fashioned. Ideally, the client’s ‘story’ of their day-to-day occupational issues, constructed and told by the client, in their own words, ought to be enabled and centralized to form the basis to the occupational therapy process (Lim & Iwama 2007). Achieving this to any degree is not an easy or a simple undertaking, for it involves a series of difficult transitions for the professional therapist. Firstly, a change in power relation between the therapist and client is required. The familiar hierarchical power structure of professional and client is upended, and the heterogeneity and diversity of clients and their ‘stories’ become normal. The skills necessary for those engaged in occupational therapy will change from being technical experts capable of delivering standard procedures of assessments and interventions, to health professionals who are able to apply their knowledge and skills effectively according to the unique and diverse clients and their contexts that emerge in each complex therapeutic instance.
Achieving this will move occupational therapy further towards becoming client-centred and more equitable with regard to the power differential that commonly exists in therapeutic relationships, where the occupational therapist is situated as expert and the client is regarded as ‘patient’ (Ramsden, 1990 and Lim, 2005). Rather than forcing and fashioning the client to adapt to some standard requirements of occupational therapy, such an approach requires occupational therapy and occupational therapists to adapt and fashion their occupational therapy to the unique needs and specific requirements of the client. Imagine a process whereby the client ‘names’ the concepts of their occupational therapy model and explains the principles that tie these highly personal concepts together, in which the occupational therapy process is transformed into a collaborative one in which it is bound by the client’s occupational narrative. The client is now (acknowledged and respected as) the ‘expert’ of their own occupational narrative and the therapist becomes a partner or facilitator to enable better life flow.
The Kawa (River) Model
Such a significant departure from the tacit ways in which theory is normally structured and translated into occupational therapy practice, the empowering of client and their occupational narratives to form the basis of the occupational therapy processes and interventions to follow, represents a revolutionary breakthrough in conventional occupational therapy practice. For conventional practice until now has been to take a set of predetermined concepts and principles that tie these concepts into some plausible, standard narrative and impress these upon the client, assuming that the model was valid and unassailable.
Recently, a group of Japanese occupational therapists, grappling with the issues of incongruent occupational therapy theory and practice forms, embarked on a project that aimed to develop an alternative approach that would transform their occupational therapy and bring it more in line with their client’s day-to-day realities and experiences of disablement (Iwama 2006). The qualitative research processes they engaged in also unearthed the fundamentally overlooked issue of culture, theory construction and practice. These Japanese therapists with the aid of a Canadian therapists endeavoured to develop a conceptual framework that would not impose a universal narrative of occupation on every client but would actually reverse this process and value each client’s unique occupational narrative, reflecting a rich comprehension of the client in the context of their experiences and explanations of day-to-day realities. The qualitative research processes that gave rise to the Kawa Model and its fuller description can be studied in greater detail in The Kawa Model: Culturally Relevant Occupational Therapy (Iwama 2006).
A social constructionist perspective
The primary philosophical orientation underlying the Kawa Model is one of social constructionism. Burr (1995) highlights the fact that, from a social constructionist perspective, knowledge and the meanings of phenomena and their explanations (theory) are understood to be created between people who share common experiences and agree on interpretations of those phenomena. This is in opposition to the dominant view in the scientific and empirical traditions that truth and reality are singular (universal) and material, lie external to (or outside of) the self and are knowable through rational enquiry (Gergen 1999).
Burr (1995) argues that our current accepted ways of understanding the world are a product not of objective observation of the world, but of the social processes and interactions in which people are constantly engaged with each other. The implication of this alternative way of conceptualizing phenomena is that people’s understandings of issues, such as occupation and occupational performance, are said to be historically and culturally situated. Occupation and its enactment will therefore mean different things to different people situated in differing spheres of experience and circumstances (Iwama, 2006 and Lim, 2008b).
Ontological views: self in relation to context, environment and time
Culture can be identified at the core of most contemporary conceptual models of rehabilitation, and is particularly observable in how the ‘self’ is socially constructed and situated in relation to the surrounding environment or context. The interpretations and meanings we derive through what we do in the world may vary according to how this dualism of self vis-à-vis the environment is regarded and understood. These models construe the self as being not only focally situated in the centre of all concerns, but also understood to be rationally separate and superior in power and status to the environment and nature. Well-being is constructed to be contingent on the extent to which the self can act on and demonstrate its ability to control one’s perceived circumstances located in the environment. Failure or compromise in controlling the environment is construed with such terms as dysfunction and disability. These terms are often pejorative in a socio-cultural context in which the self is required to be competent, able and in control (of one’s environment and circumstances). In these worldviews, dependency can often represent an undesirable state of disability.
An independent self, centrally situated and agent upon a separate and subordinated environment, also appears to coincide with a particular sensation of time. When the self is centrally located in relation to the environment at large, one’s sense of entitlement to doing in the present (here and now) can also extend temporally into one’s future. The relation between intention, one’s immediate action on the environment, and some specific (future) objective is often rationally connected. It is not uncommon for people situated in the Western world to believe that they carry primary responsibility for their own destinies. ‘You make your bed and lie in it’ and ‘you get what you pay for’ are familiar adages, particularly in Western social contexts. It should come as little surprise, then, to see that independence, autonomy, equality and self-determinism are celebrated ideals that point to a common worldview and value pattern shared between mainstream rehabilitation ideology and the broader Western social contexts from which they emerged (Iwama 2006).
Lying in contrast to this worldview is the East Asian and Aboriginal one. In the primitive cosmological myth (Bellah 1991), the ‘self’ is not central nor unilaterally empowered but rather construed to be just one of many parts of an inseparable whole (Bellah, 1991 and Gustafon, 1993). In this view of reality, one does not need to occupy or wrest control of anything because in an integrated view of self and nature, one is already there amongst others. In this view of reality, health and disability states are also not imagined nor believed to be an individual-centred matter. Life circumstances are dependent on a broader whole, determined by a constellation of factors and elements located both within and outside of the physically defined body (Shakespeare 1994). The self is decentralized and not accorded an exclusive privilege to exercise stewardship, nor unilateral control, over one’s environment or circumstances. Hence, conceptual models in occupational therapy that are based on a tacit understanding of a central individual separate from a discrete environment are often incongruent with experiences of disability and well-being for many who are situated outside of mainstream Western social norms.
The Kawa Model follows the more ‘primitive’ ontological view of people and nature, drawing no clear distinctions or separations between selves and their contexts of reality. This is a dynamic view of human experience and meanings. The self and surrounding context share an inseparable co-existence in which changes to any one aspect of the self-context complex will affect the entire frame. Kawa is the Japanese term for ‘river’, and is employed as a metaphor for ‘life flow’. The river’s rocks, configuration of the river banks and driftwood in the Kawa Model combine uniquely, from instance to instance, to shape and determine the quality of the ensuing river flow. Such is the flow of life, as self and context fluidly change from instance to instance. Problems, the social and physical environments, one’s own personal attributes, strengths and limitations all combine to render a particular quality of one’s life flow. This is the Kawa Model, and occupational therapy’s subsequent mandate is to help the client enhance and balance the flow within their lives.
The power of metaphor
A metaphor can be understood to be a figure of speech in which an expression or symbolic image is used to refer to something that it does not literally denote, in order to suggest a similarity. ‘Life is a river’ or ‘people are complex machines’ are just two common examples of metaphors. Models can also be seen as metaphors, whether they be of ‘systems’ like machines, or ‘rivers’ of nature. Lakoff and Johnson’s seminal work in Metaphors We Live By (1980) illuminates the degree to which metaphor plays a fundamental role in matters of self-identity and one’s relation to the world. We not only communicate through metaphors but we also think through them. The occupational therapeutic relationship is structured and mediated through metaphor (Iwama 2006), and the Kawa Model serves as one particular metaphor through which the powerful processes of occupational therapy can be enacted.
When the Kawa Model was first developed, there was a tendency to situate the model in Japanese culture, and therefore it was assumed to be applicable to ‘Eastern’ clients and others located in East Asian contexts. Since its development, the metaphor of the river, used to depict life flow or the life journey, has been found to resonate with people beyond Asian societies. When the kawa metaphor is found to be a common link spanning the therapist’s and client’s spheres of shared experience, it can be exploited as an effective medium through which the process of occupational therapy can flow. The authors speculate that the explanatory power of conceptual models in occupational therapy has much to do with the power and resonance of the metaphor that underpins the model, in relation to the spheres of shared experience (culture) of the client and occupational therapist. The resonance of the river metaphor to diverse occupational therapy practice contexts, in a relatively short period of time since its publication, has been remarkable. The Kawa Model is currently being translated into six languages and utilized by occupational therapists located across six continents.
Original rendition of the model
The qualitative research process engaged in by a group of occupational therapists in Japan initially yielded a rather cumbersome, linear representation of their model along conventional, linear box and arrow structures (Fig. 10.1A). At that early stage, it became readily apparent that there were fundamental differences in how self and environment were imagined and represented in established (Western) models and actually lived and experienced by the group participants. For a model purposely to explain self and context, the central placement of a distinctly defined self, adjacent to a separate but distinct environment commonly seen in conventional (Western) models, was non-existent. Further consideration revealed comprehensions of self and environment or context that were more diffuse and inseparably integrated by the Japanese than by their Western counterparts. Consistent with a worldview that imagined self and the world with all of its elements as integrated parts of an all-encompassing whole, phenomena as complex as well-being and disability could not be adequately described and explained by linear diagrams that connect rationally defined categories through logical principles. These Eastern perspectives of wellness and disability states could not be readily contained in and explained by boxes/categories set in a logical sequence, familiarly observable in rational formulae or continua.