In the Community

Exploring Kawa: A collaborative pilot program

Lisa Brewer, Andrea Ondish, Jill Brown, Jill Ewend, and Kadie Schultz, Volume 29 • Issue 10 • October 2024, 36-41 10/01/2024

The Kawa Model is recognized in the field of occupational therapy as an approach that supports culturally responsive assessment and intervention through increased understanding of diverse populations. Dr. Michael Iwama developed the model with a team of occupational therapists in the 1990s, with an emphasis on harmony between person and environmental factors that influence health and well-being (Iwama, 2006). The term Kawa means river in Japanese and is a metaphor to symbolize the flow of life. Additional constructs of the Kawa Model include driftwood (individual assets and liabilities), rocks (personal challenges), and the riverbed (physical and social contexts). This metaphoric model can be especially useful in facilitating self-reflection with neutral terms that elicit more details than a typical interview (Newbury & Lape, 2021; Paxson et al., 2012). Ober and colleagues (2022) highlight use of the Kawa Model for a wide range of needs, including mental health, multiple sclerosis, post-traumatic stress disorder, aging in place, and even teambuilding among rehabilitative professionals.

Application of the Kawa Model in this collaborative pilot program includes individuals with developmental disabilities, the Marshall M Fredericks Sculpture Museum, and the Saginaw Valley State University (SVSU) MSOT department.

Applying Kawa in Three Sequential Art Sessions

Initial discussions for collaboration began following an exhibit on the art of inclusion at the Marshall M Fredericks Sculpture Museum at SVSU. Feedback on the exhibit was overwhelmingly positive, and the SVSU MSOT department was invited to discuss potential programming ideas for community outreach. SVRC Industries offers programs for individuals with developmental disabilities including employment assistance and community-based activities in the Great Lakes Bay Region. Groups from SVRC frequently visit the museum and the MSOT department was asked to collaborate on programming ideas for participants.

The Kawa Model was mentioned early in the collaboration, and it became clear that facilitating activities based on this model could help build relationships and foster self-awareness among community participants and occupational therapy students. It was decided that more than one art session would be beneficial, and Kawa elements would be introduced using basic terms. For example, the meaning of driftwood was adapted to represent strengths (see Figure 1), as opposed to using the detailed description that includes assets, liabilities, beliefs, and values.

Figure 1: A Simplified Description of Kawa Metaphors

Water	The flow of life
Rocks	Problems and challenges
Driftwood	Strengths
Riverbed	People and things in the environment (may or may not be supportive)

Some participants explored concepts in more depth, depending on individual levels of understanding, but simplified descriptions helped avoid confusion as concepts were introduced.

A plan emerged using three sequential art sessions over several weeks to build relationships and increase self-awareness (see Table 1).

Table 1: Exploring Kawa Using Three Sequential Art Activities

Art Lesson Plans	Questions and Statements to Facilitate Self-Reflection
Activity 1 Discuss and make a list of individual assets and strengths. Some may be related to characteristics within yourself, but others can be things related to your environment. Trace outlines of hands. Words or images of strengths can then be drawn within—or around outlines of their own hands. (see Figures 4, 5, and 6)	What do you like most about yourself? What are your strengths? How do your strengths help you? I am proud of myself because… What people help support you in your life? What things are you thankful for? Family? Friends? Places? Activities?
Activity 2 Participants pick several sticks or driftwood and rocks from a bowl. Discuss sticks (strengths and assets) and rocks (challenges and barriers) to generate a list. Strengths from the previous activity can be reviewed. Participants trace the rocks and sticks and then label their drawing with the most meaningful challenges and strengths. They may also paint or label the actual rocks and sticks. Components can be saved for potential use in Activity 3. (see Figures 7, 8, and 9)	What are your challenges? Name something you want to improve in your life. What are your goals? I want to learn how to…. What things do you need to achieve your goals? Skills? Time? Support? Money?
Activity 3 Participants start their Kawa composition by painting the river, then picking out sticks and rocks to be added. These can be objects or ideas from Activities 1 and 2 Participants are encouraged to label strengths (wood), challenges (rocks), and contextual variables (riverbed). Rocks and sticks are added with hot glue guns and assistance as needed. (see Figures 10, 11, and 12)	If life is like a river, what is your river like? Is your river fast or slow? Is it curvy or straight? Is it wide or narrow? Who or what makes up your environment? Who do you enjoy being with? Who provides support to you when needed? What things in your life are you grateful for? Family? Friends? Things? Activities? What rocks or challenges are in your river? What would you like to improve in your life? What do you need to achieve your goals? What driftwood or traits do you have? What do you like most about yourself? What are your strengths?

All art activities were completed at the Marshall M Fredericks Sculpture Museum where occupational therapy students were paired with community participants. Two groups from SVRC participated in the KAWA pilot. These groups were chosen because their schedules aligned with the museum’s availability, as well as MSOT student and faculty schedules to meet over the course of three Wednesdays during the semester. Each 90-minute session began with 10 minutes to explore the museum and talk with one another before starting the art activities. sessions ended with a snack, and participants were encouraged to share their artwork with others in the group.

Grading Activities for Community Participants and Graduate Students

The graduate occupational therapy students taking part in this collaboration had completed a Kawa painting in a previous semester that depicted their perceived strengths, challenges, and contexts (see Figure 2). However, students had not previously taken part in a series of Kawa art projects, and had not applied the model to an actual person other than themselves. These activities provided an opportunity for students to act as facilitators engaging with community participants as they discussed strengths and challenges. Students provided guiding questions to facilitate self-awareness (see Table 1). Due to inclement weather and scheduling conflicts, the final Kawa paintings were completed separately (students and community participants participated in the third activity on different days). Despite this challenge, positive outcomes were noted for students and community participants. The graduate students were in their final semester of coursework prior to Level II fieldwork, and the Kawa activity provided opportunity for reflection as they prepared for the transition (see Figure 3).

Figure 3 - This KAWA project was completed by an MSOT student as part of this collaboration and provided an opportunity for self-reflection before starting Level II Fieldwork.

Figure 2 - This KAWA painting was completed by an MSOT student prior to this collaboration as they were first introduced to the model.

Outcomes for Community Participants

During the planning phase of the collaboration, potential outcome measures were discussed. In addition to using the Kawa Model to increase self-awareness (among both students and community participants), the team was also interested in other aspects of art engagement such as stress, social interaction, and well-being. The UCL Museum Wellbeing Toolkit provides scales to assess levels of well-being related to participation in art activities (Thompson & Chatterjee, 2013). One of the scales was adapted for the first two art activities (see Table 2) and relied on self-reported changes in mood and emotions—pre- and post-participation in the art activities.

In activity 1 SVRC participants and MSOT students traced hands and listed personal strengths within the outlines such as bowling, cleaning, and helping people.

In this example from activity 1, the participant’s perceived strengths included singing, cleaning, and being helpful.

Table 2: Simplified Outcome Measure Adapted From UCL Museum Wellbeing Toolkit

	Yes	Somewhat	No
Are you happy?
Are you feeling safe?
Are you enjoying the company of other people?

Note. Provided before and after art activities.

Data reviewed after the first and second activity showed most participants checked yes for all questions for both pre- and post-activities. In order to obtain more specific information regarding individual outcomes, observations were noted. For example, two participants initially had difficulty with social engagement, demonstrating no eye contact and minimal verbal interaction. By the third session, both were able to answer some questions and demonstrated intermittent eye contact. Table 3 describes observations of community participants. In addition, application of the Kawa Model resulted in exploration of personal strengths and challenges. Some strengths shared by SVRC participants included knitting scarves, drawing action figures, winning medals at Special Olympics, bowling, cleaning, and being kind. Some challenges noted included cooking, doing laundry, technology, making friends, reading, writing, and transportation.

In activity 1 some participants added drawings, in addition to words, to symbolize strengths as seen in this example with a depiction of a family.

In activity 2 sticks and rocks were traced. SVRC members and MSOT students were paired up and each completed their own project while talking with one another about their personal strengths and challenges.

Table 3: Observations During Art Activity Sessions

Participants	Observations: Activity One and Two	Observations: Activity Three
*Participant A*	When asked to list strengths, participant A listed things he liked (such as movies or food), but not necessarily things he considered strengths. When prompted, “What things are you good at?” or “What are you proud of?” He did not articulate specific strengths. Participant A demonstrated limited use of one upper extremity and often required cues to use the affected extremity as a stabilizer.	By the third art activity, participant A was able to identify specific strengths such as showering and dressing independently. He stated that he is not always great at drying himself off, which demonstrated self-awareness. When donning his jacket, he expressed that he was proud of his ability to zip his jacket with only one hand.
*Participant B*	Participant B got up frequently from the chair, walked out of the room several times, and did not remove coat or hat during activities.	Upon arriving for the third activity, participant B removed coat and hat and remained in the room for the 90-minute art session.
*Participant C*	Participant C frequently asked for assistance during activity 1 and demonstrated difficulty initiating and continuing the task, requiring frequent verbal cues and hand-over-hand assistance.	By the third art activity, participant C required just intermittent verbal cues and no physical assistance.

Conclusion

This program provided a semi-structured format for improving self-awareness, as well as understanding among SVRC participants and MSOT students. The process of creating art has the potential to enhance self-awareness, increase understanding of individuals, and improve overall well-being.

In this example of activity 2, the yellow stick represents being outgoing (perceived strength) and the small red rock is labeled “less pop” (perceived challenge).

Another example of activity 2 shows reading, writing, using the remote and oven as challenges (rocks) and staying calm, being friendly and music as strengths (sticks).

This KAWA project from activity 3 shows a painted river, with sticks labeled with strengths (walks, library) and rocks with challenges (slow down, be patient, organize).

Future endeavors with the KAWA model include expressive art and social participation opportunities at the SVSU Marshall M Fredericks Sculpture Museum that will take place with SVRC participants and second year MSOT students. We look forward to the ongoing creative collaborations that use art as an occupation to increase self-awareness, increase understanding of individuals, and enhance overall well-being.

Cooking and golf are listed as challenges (rocks) in this creative example of activity 3, while showering and making the bed are perceived strengths (sticks).

In this creative example of activity 3 the river appears to take over the canvas and many sticks and rocks were added to represent perceived strengths (good friend, brother) and challenges (cooking and laundry).

References

Iwama, M. (2006). The Kawa Model: Culturally relevant occupational therapy. Churchill Livingstone-Elsevier Press.

Newbury, R., & Lape, J. (2021). Well-being, aging in place, and use of the KAWA Model: A pilot study. Annals of International Occupational Therapy, 4(1), 15–25. https://doi.org/10.3928/24761222-20200413-02

Ober, J. L., Newbury, R. S., & Lape, J. E. (2022). The dynamic use of the Kawa Model: A scoping review. Open Journal of Occupational Therapy, 10(2), 1–12. https://doi.org/10.15453/2168-6408.1952

Paxson, D., Winston, K., Tobey, T., Johnston, S., & Iwama, M. (2012). The Kawa Model: Therapists’ experiences in mental health practice. Occupational Therapy in Mental Health, 28, 340–355. https://doi.org/10.1080/0164212X.2012.708586

Thompson, L. & Chatterjee, H. (2013). UCL museum wellbeing measures toolkit. https://www.ucl.ac.uk/culture/sites/culture/files/ucl_museum_wellbeing_measures_toolkit_sept2013.pdf

Lisa Brewer, OTD, MOT, OTRL, is an Associate Professor of Occupational Therapy at Saginaw Valley State University in Saginaw, MI. She obtained her MOT from Duquesne University and specializes in early intervention for children with autism. Lisa completed her OTD from the University of St. Augustine

Jill Brown, PhD, is an Associate Professor of Occupational Therapy, for the MSOT Program at Saginaw Valley State University. Jill has community-based and acute care clinical experience and has worked as a Grant-Funded Occupational Therapy consultant to advocate for trauma-informed school systems. She earned her MSOT degree from Saginaw Valley State University, and her PhD in Occupational Therapy from Nova Southeastern University.

Jill Ewend, OTL, is a Simulation Laboratory Associate at Saginaw Valley State University in Saginaw, MI. She completed her BS in Occupational Therapy from Western Michigan University. Jill has many years of experience providing occupational therapy services for individuals with mental health, orthopedic, and neurological conditions and she specializes in working with adults with traumatic brain injuries.

Andrea Ondish received her BFA from Marywood University in Painting, Drawing, Printmaking, and Illustration, and an MA from Eastern Illinois University in Painting and Printmaking. She completed her MFA at Indiana State University in Printmaking. She has been the Curator of Education at the Marshall M Fredericks Sculpture Museum since 2001 and is also Adjunct Faculty in the Art Department at Saginaw Valley State University. 

Kadie Schultz, MSOT, OTRL, CBIS, ITOT, is a Simulation Lab Associate for the MSOT Program at Saginaw Valley State University. Kadie is a graduate of the MSOT Program at SVSU and has a background in inpatient rehabilitation with an emphasis on neuro rehabilitation. Kadie is a Certified Brain Injury Specialist and an ImPACT Trained Occupational Therapist, specializing in concussion rehabilitation and management of symptoms.