First appeared in The OT Magazine issue 21, March/April 2018

Third year occupational therapy students at Coventry University, Sam Dick and Lisa McGowan, share their experiences of using the Kawa Model in a school classroom setting.

As third-level occupational therapy students from Coventry University we had the opportunity of a contemporary practice placement in a mainstream school named Southam College. As a result of the contemporary nature of the placement, we had to establish our own interventions and pathway.

From our referrals, it became clear there was a high number of pupils who were struggling to cope with feelings of anxiety. A study by Green et al. (2005) stated that about one in 10 young people experience a mental health disorder and anxiety and depression are the most common mental health difficulties and are often co-morbidities. That is approximately three students in a class of 30 who will feel unable to cope due to an inability to respond appropriately to everyday challenges.

The National Institute of Clinical Excellence (NICE) have placed an importance on early identification and treatment in their quality standard for the treatment of anxiety disorders, as they believe it will reduce strain on healthcare services in the future (NICE 2014). Although we are aware that many anxiety disorders go undiagnosed (NICE 2014), the government estimates that there is approximately 3,941 young people living with an anxiety disorder in Warwickshire, Southam Colleges Local County (Coventry and Rugby CCG 2015).

With this is mind we felt the need to address anxiety among the students as a preventive measure and to do this we decided to create a group using the Kawa model (Iwama 2006).

In these groups, we focused on a different occupation every week, and also did education around anxiety and provided some coping strategies for the students to use outside the group. These occupations ranged from drama to music and art. An interest checklist was used to find out which occupations the pupils found meaningful; assisting in the group session planning. None of the students receiving therapy had an official diagnosis of an anxiety disorder, but we were aware that an early intervention could work to prevent these issues from developing further.

We modelled our groups on Michael Iwama’s Kawa Model, where the metaphor of a river is used to describe someone’s life. In this river metaphor the water represents your life flow and the river bed and walls represent your physical and social environment as these contain and control your life flow. There are also boulders in the river, which are situations or challenges which obstruct your life flow and also driftwood, representing personal factors, which can help to break your boulders but can also be obstructive or inconsequential.

We chose this model due to its simplicity, we felt like this model would be relevant to the young people and its subjective nature would really allow us to see things from their perspective. Often anxiety disorders cause people to misinterpret situations and we wanted to be empathetic.

Use of the Kawa Model was also justified by its use of accessible language in comparison to other models which use some complex terminology, such as MOHO of CMOP-E (Polatajko, H.J. et al. (2007), Kielhofner (2008)). As a result we felt that Kawa would be the most suitable to use with this age range.

Getting Creative
We created Kawa River Models during the first and final weeks of the group. Various mediums, such as coloured pencils along with modelling clay and crafting equipment were supplied for the pupils to create their own individual models and to encourage creativity. While getting the pupils to create their own personal Kawa Models we both made one of our own, enabling us to build rapport and to ensure the students would engage. We then compared the two models from week one and week four to use as a subjective outcome measure. This allowed the pupils to be reflective of their own strengths, weaknesses and environments.

Using the Kawa River Model as an unstandardised outcome measure proved to be very useful, providing a quick and easy way to see if the pupils felt any changes in themselves following intervention. The Kawa River Model also enabled us to find a creative way to engage the pupils in a meaningful occupation of arts and crafts, while also enabling us to gather information from them in a way which they understood; it also highlighted some things which pupils did not discuss but were happy to add to their models.

On reflection, we believe that this model was an incredibly useful therapeutic tool, it seemed to suit this age range and condition extremely well and was a definite factor of the success we experienced from the groups. Some students said it was helpful in communicating what was wrong. We were aware that disclosing your issues to strangers is a difficult task, especially when the given age group are often considerably self-conscious; according to Eriksons theory of psychosocial development during teenage years we struggle with identity, making our own and others judgements of ourselves increasingly important at this time (Loughler (2001).

We believe the creation of the models was a helpful tool in creating that therapeutic relationship, and we noticed that some people had disclosed issues in their Kawa that they never would have told us verbally. It also helped us to prioritise what was meaningful to them, due to the size of their boulders or driftwood and what other components within the model that they interacted with. It also helped with building a partnership between the therapists and the young people.

We had some very creative variations of the model which was amazing to see. We had swamps and fish tanks and everything in between. All the students seemed to really enjoy the occupation of creating a model and we believe it made them identify their own boulders which they could then work on breaking down and removing. The creation of the Kawa River model was a fun and engaging tool that helped them to develop ownership of their therapy. A personal highlight was the opportunity to meet Michael Iwama at the OT Show and tell him all about our experiences with the model!