Applying the KAWA theoretical

model to Breathlessness
Management

Julie Burkin, Occupational Therapist, Lead Practitioner

KAWA Model Michael Iwama
http://www.youtube.com/watch?v=67PqinQ7qNM
Reference

www.kawa.com [accessed 28.11.2013]

Key Principles
Sense of person as an occupational being,
considering circumstances as the person sees them
Interprets a persons circumstances & clarifies
rationale and application of OT within their specific
social and cultural context
Surrounding context of life can enable & disable
people
The persons life circumstances, environment, assets
and liabilities are all inseparable parts of the person
Water life energy
A persons life energy, represented in the
model by water, is influenced by life
circumstances, environment, assets and
liabilities.

When life energy or flow weakens the

person is in a state of disharmony
Kawa Model

Uses metaphor / image of river to symbolise

life
Self is the focus seen and treated in context
of all elements in a persons life
Kawa Model life is like a river
Inseparable parts of the river
Rocks - life circumstances

Walls & bottom of river environment

Driftwood assets & liabilities

Kawa Model Rocks, Walls, Driftwood
Rocks
Life circumstances which act as impediments
to life flow. Perceived by person to be difficult
to change e.g. congenital conditions / sudden
illness / injury (diagnosis of lung cancer)
These impediments can be accentuated when
situated against the walls of the river e.g. a
chronic condition and the environment
(breathlessness and having to manage stairs)
Walls and bottom of river
Social environment those who share a
relationship with the person e.g. family,
friends, pets, deceased persons

Physical environment in which the person lives

and interacts
Driftwood
Personal attributes & resources e.g. values,
personality, special skills, immaterial and
material assets, living situation

Can positively or negatively affect life flow

Spaces in river opportunities for
change
Spaces between obstructions
Factors sustaining persons hope and desire to
continue
Opportunities to build upon
Effect of components on flow
Gaps in the river potential targets for OT
interventions
Gaps in river importance of
understanding context to set priorities
Stemming further obstruction &
maximising life flow
The Process of using the model
Appreciating the person in context
Clarifying the context
Prioritising issues according to the persons
perspective
Assessing focal points of OT intervention
Intervention
Evaluation
 KAWA Model used with
Breathlessness
Breathlessness Management Kawa Model

Person needs to be Interprets a persons

considered in social and circumstances within
cultural context in order persons particular
to understand the social and cultural
impact of context
breathlessness
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Person seen in and Breathlessness influenced

treated in context of all by all elements in a
elements in the persons life
persons frame
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Surrounding context can Surrounding context can

enable and disable the enable and disable the
person with person
breathlessness e.g.
family attitudes to /
perceptions of
breathlessness
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Breathlessness impacts Water is lifes energy.

greatly on a persons life When life energy or
energy flow is weakened, the
person is unwell or in a
state of disharmony
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

We may not take the As some of the river

breathlessness away contents are removed
but we can help the and the structure
person to manage it expands the channels
more effectively, become wider and the
enabling a sense of water is liberated to
control flow more strongly and
fully
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Essence of intervention is Essence of Occupational

to enhance or enable Therapy is to enhance
control and mastery or enable greater life
over the symptom, thus flow
reducing its impact
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Often build on these with Spaces between

the person who is obstructions are factors
breathless e.g. sustaining persons
identifying a self- hope of seeing a new
management strategy day
that they are already
using to increase
motivation to use
others
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Emphasis on what can be Water naturally flowing

done to manage through these spaces
breathlessness can help can work to erode the
to reduce anxiety and rocks and river wall &
increase confidence bottom
 KAWA Model used with
Breathlessness
Breathlessness management KAWA Model

Management of Concepts and contextual

breathlessness must be application of the Kawa
flexible & adaptable to model are flexible and
respond to changing adaptable
needs / give a range of
strategies for this
complex symptom
Case Study Mr X

71 year old male, retired

COPD diagnosed 1 year ago
Lives alone in sheltered accommodation house
Separated from wife 2 years ago
Son lives locally with wife and child
History of alcohol addiction gave up 1 year ago
Gave up smoking recently
Has had 18 admissions for SOB in 6 months
Enjoys fishing but no longer feels able to go
Mr X - Rocks
Breathlessness secondary to COPD
Cant play with grandson
Has long standing problem with alcohol
addiction but gave up 1 year ago
Panic / anxiety related to SOB
18 admissions in last 6 months
Wondering if life is worth living
Feels lonely and isolated
Mr X River walls & bottom
House stairs and bathroom upstairs only
Separated from wife
In sheltered accommodation activities
available but feels too SOB to attend
Financially struggling due to increase in fuel
bills of winter
Mr X - Driftwood
Fear of breathlessness
Am I going to die breathless
Perception of being a burden to family
Decreased confidence in abilities
Determination has given up drinking and
smoking
Pride wants to be independent and help self
Mr X - Water
Water continues to flow but to a lesser extent
through seams and gaps
Substantial obstructions in the form of rocks,
driftwood and river walls in bottom
Obstructions constructing flow
Mr X not functioning to full potential
Mr X - spaces
Has resilience & determination given up
alcohol and smoking
Opportunities for education
Wants to manage symptom
Keen to engage with other but just feels
unable
Intervention - rocks
Educate re: SOB & give strategies
Suggest energy conservation principles to aid
time spent with grandson
Re-assure patient that strategies will reduce
anxiety and increase sense of control
Acknowledge patient resilience in continuing
to manage alcohol addiction
Put in touch with local support services (AA)
Refer to local hospice day therapy
Intervention walls & bottom
Environmental assessment
Acknowledge loss of life partner
Explored possibilities of getting back into
activities
Pacing advice given to help increase activity
tolerance
Referred on to welfare advisor re: assessment
for relevant benefits
Interventions - driftwood
Challenge misperception Am I going to die
breathless
Reassured breathlessness is not harmful
Met with family to facilitate communication
Gradual engagement in activity and exercise to
increase confidence
Set realistic goals
Managed expectations by acknowledging SOB will
not be eliminated
Used motivational interviewing strategies to help
with sense of mastery over breathlessness
Outcome of interventions
Managed to remove some of the rocks and
driftwood
Reduced impact of river walls and bottom
Channels of river have become wider
Mr Xs life force has been liberated to flow
more strongly and fully
Mr X - outcome
2 re-admissions in 4 months
Using strategies with good effect
Attending day therapy at hospice
Going fishing with grandson
Uses local radio station to aid management of
SOB and panic in the night
Anxiety much reduced
Using diary to aid management of mood
julie.burkin@addenbrookes.nhs.uk