INTRODUCTION
Buddhism is often seen as the most psychological of the major world religions. Its origins were in the search for an answer to the problem of dukkha (affliction), the existential suffering that comes from sickness, old age and death, which led Siddhartha Gotama, who was to become the Buddha, founder of the faith, into a spiritual journey. This journey eventually led to his transformative experience, his enlightenment.
It is the insight which came from the Buddha’s enlightenment which underpins a Buddhist approach to mental health. The insights that constitute the Buddha’s first teachings offer a basis which has been elaborated and re-formulated in many ways, but still remains the central presentation of the Buddhist position. The detailed interpretation of these primary teachings has fascinated Buddhist scholars through the centuries, but their centrality is undoubted.
The Buddha’s original concern with the sufferings involved in human life became the focus for his teaching which became known as the Four Noble Truths. The first of these four statements emphasised the reality of affliction. The noble truth of dukkha, affliction, is this: birth, old age, sickness, death, grief, lamentation, pain, depression, and agitation are dukkha. Dukkha is being associated with what you do not like, being separated from what you do like, and not being able to get what you want. (Samyutta Nikaya 61.11.5) In other words, human life is unavoidably linked to situations which are distressing.
With affliction, craving arises. The Buddha’s second Noble Truth described the arising of craving and its manifestation in attachments to sensory pleasures, to becoming (or one can understand, self building), and to non-becoming. It is my feeling that this latter statement provides a useful typology for the progress of mental distress through simple distraction to the construction of psychological defences, and finally to the self-destructive mind states associated with severe mental distress.
Other Buddhist teachings elaborate the processes whereby these states are created and maintained; the processes of Dependent Origination by which the ordinary mentality is maintained through a cycle of conditioned view. A number of key teachings can be seen to elaborate these processes and to show how people build their reality through craving and attachment. This process can take on positive or negative forms. Our reactions to the object world are ones of attraction or aversion. Such reactions are habitual and form the basis of one’s overall mentality. Oft repeated, they lead us to create samskaras, mental formations, which we come to identify with. These samskaras form the basis of our self. They lead us to habitual views and behaviours which, in turn, condition the maintenance of the cycle.
The teachings of Dependent Origination and the cycle of conditioning describe the way that all unenlightened people (and for practical purposes we can say all people) are held in a state of delusion, avidya. Avidya literally means not seeing, and the choice of this word demonstrates the Buddhist emphasis on perception as a key element in constructing mental states.
Many people in the West associate Buddhism especially with its mind training exercises, and undoubtedly meditation in its various forms has played a key role in developing an elaborate and detailed system of understanding the factors of conditioning and in developing methods for unhooking ourselves from the objects of craving, a process of spiritual development described in the third and fourth Noble Truths. This process of study and analysis led to the texts called the Abhidharma, compiled shortly after the Buddha’s time, and to many later works by philosophers and practitioners in India, China, Tibet and all the other major centres of the Buddhist world.
The Buddhist teachings and the practical knowledge which comes from two and a half thousand years of study and practice clearly have much to offer by way of guidance for those working in the field of mental health. This contribution has been recognised and there have been a number of significant attempts to draw on Buddhist teachings and methodology in Western psychotherapeutic practice. Early Western theorists, notably William James and Carl Jung, were influenced by Eastern thought, although such influences were often based on misunderstandings and limited context. More recently we have seen an influx of techniques such as the use of meditation, mindfulness and visualisation, all of which have roots in Eastern, and often specifically Buddhist, practice.
In the last decade or two, as a more general interest in the interface between the psychological and the spiritual has arisen, a number of Buddhist approaches have been introduced and taught to professionals working in mental health fields. These approaches, though all based on a Buddhist understanding, differ considerably from one another. This is because some rely more upon Buddhist methodology, whilst others focus on the theoretical understanding of mental process arising fro Buddhist teachings, and also because they draw roots from different Buddhist traditions and from different Western schools of psychotherapy. In the UK we can identify the various mindfulness based programmes deriving from the work of Kabat Zinn, the Core Process training of the Karuna Institute, and the programme in Buddhist Psychotherapy run by my own organisation Amida Trust. Also worthy of mention, though less well known in the UK, is the work of David Reynolds and the Todo Institute in Canada. Reynold’s approach, Constructive Living, is based on two Japanese therapies, Naikan and Morita which apply Buddhist teachings in ways that offer an important and striking critique of many Western assumptions about mental distress.
Whilst there is not space here to explore in detail these different therapies, it is worth noting that some are now being widely used in mainstream establishments and have been subject to research evaluation. In particular mindfulness based programmes have become popular, whilst in Japan Naikan has been extensively used in the prison system. Similarly, in India Vipassana meditation retreats run by the Buddhist Goenka movement have also proved transformative for prisoners.
A BUDDHIST APPROACH TO MENTAL WELL BEING:
One way of understanding a Buddhist approach to mental health is to look at another of its key teachings. Buddhism is described as having three pillars, or key elements. These are Sila, Samadhi, and Prajna. We can use this formulation to understand characteristic aspects of the approach.
Sila is generally understood to mean the discipline or ethical framework of a person’s life. The Buddha taught much about life style. His teachings can all be taken as practical advice on how to live well. The lifestyle which he prescribed for his disciples, which still forms a model for practitioners today, is one that is morally sound, concerned for others, grounded in sober living and respect for living things. This lifestyle is seen as foundational for the cultivation of healthy mental states. In keeping with teachings on the conditioned nature of mind, an ethical, non-indulgent life forms the ground upon which mental health can rest.
Samadhi as the second pillar of Buddhism is generally understood to mean the state of mind that arises when a person is spiritually grounded. Often this is specifically linked to meditation and concentration, but it is also well translated as a state of rapture, and can result from any visionary or inspirational experience. In the experience of samadhi we see both the state of calm and peace which is associated with spiritual alignment, and the more ecstatic states that can arise through spiritual practice which have the power to offer lasting change.
Prajna as the final element means understanding or wisdom. Literally the word means “seeing through” or seeing deeply. It is cognate with the western term diagnosis. In prajna we experience a deep integration of the knowledge which the Buddhist teachings offer. This includes insight into the impermanence of mental constructs, the samskaras, and the conditioned nature of our thinking.
From these three pillars and the other Buddhist teachings a number of points can be identified which are significant in the Buddhist understanding of mental well being:
- Behaviour conditions mental states; ethical behaviour conditions positive states;
- The Repetition of habitual patterns of action and view lie at the root of mental states,
- We feel a compulsion to cling to habitual views and states. Thus there is a sense in which we can see all mental problems as a form of addiction and the focus of these addictive patterns as being the self.
- Everyone is in a state of avidya (delusion) so mental ill health is just a more extreme version of states we all suffer from.
- Psychotic states are extreme versions of common mental states and are based on more extreme clinging to delusional factors which build the self structures.
A Buddhist approach to mental health is therefore likely to be based on loosening concern with identity, inviting a shift away from rigidity of view, encouraging deeper connection with others and with the environment. A person who is mentally healthy is not self-preoccupied, but is interested in the people and things around him or her. A Buddhist approach offers a psychology based on the concept of non-self; an other-centred perspective. It is grounded in the importance of looking for the reality of things. In terms of practice this can be linked to the centrality of taking refuge, the act that defines the Buddhist.
The Buddhist takes refuge in Buddha, Dharma and Sangha, i.e. in the founder, teachings and religious community. At another level we can see this as refuge in the enlightened source of wisdom, the truth that is always available for discovery, and the community of others. Beyond the state of delusion, something real and wonderful is available. In my own tradition, Pureland Buddhism, the central practice is a practice of calling on this ever present Buddha-ness, represented in the figure of Amida, the measureless Buddha. Thus the object of our practice is always clouded in the mystery by our copious distortions and limits of view, yet remains a foundation for our attention which potentially takes us out of self-preoccupation.
THE BUDDHIST ATTITUDE TO MENTAL ILLNESS:
The Buddhist perspective is not one that generally encompasses ideas of justice or retribution. Buddhists, at least in the West, do not generally posit a deity or supernatural force who can intervene in human affairs, and even where Buddhism come close to this position with invocations of celestial beings or Bodhisattvas, the influence these figures might exert would generally be seen as benevolent and limited.
In Buddhism the suffering which people experience is of two kinds (although this distinction is not strongly made in the texts). Some suffering arises from our existential circumstances. As such it is unavoidable and to be faced with fortitude. Other suffering arises from our conditioned minds. This can be addressed by learning to face the primary suffering and by breaking out of our habitual patterns of escape which compound the afflictions. The choice to do this, however, is seen as a personal matter. Failure to address one’s mental state is not seen as bad, but rather, as missing an opportunity which human rebirth offers. Where a person is in a mental state where practice is not possible, this would be generally seen as a state worthy of compassion, not condemnation.
In Pureland, the emphasis on faith is particularly relevant here. This particular Buddhist approach is somewhat more pessimistic than other schools about our capacity to help ourselves through the kind of mind-training exercises commonly associated with Buddhism. Here the interminable nature of our karmic heritage is recognised and people are seen as ordinary, fallible and in the grip of “fathomless blind passions”. Against this background, the view of mental illness would be that if a person can simply reach some sense of the immeasurable presence of Amida beyond their personal turmoil, a moment of faith, that contact will sustain them and achieve ultimate salvation. Psychologically speaking we can see this as indicating the importance of even small breaks from the cycle of self into contact with other reality.
This view encompasses a sense of commonality. We are all enmeshed in our own karma, and thus similarly caught in states of delusion and confusion. There may be differences of degree, but we can relate to those in high distress with a sense of fellow feeling and compassion which arises from our knowledge of our shared human frailty.
More problematic areas of behaviour that arise from mental ill health, such as suicide, self- harm, anger and so on would be viewed by Buddhists as sad occurrences, which in one way or another condition ongoing pain and distress. Theories of dependent origination and karmic consequence point to the idea that any behaviour creates the seeds for future actions. Thus a Buddhist view would where possible discourage a person from making expressions of anger in order to help them avoid feeding negativity in their mentality.
Similarly suicide and self-harm would be viewed as laying dangerous patterns which potentially create downward spirals for the individual, but also create karmic consequences for others involved. Such views can both be taken on the mundane level – the child of a suicidal parent will themselves run a greater risk of suicide, and on the metaphysical level – suicide may be seen as leading to a bad rebirth. In such cases, the response of other Buddhists would be gentle encouragement to a better course of action, but above all, compassion for the person who is taking the action.
It should be noted here that karmic consequences are generally linked with intentionality, so it is quite reasonable to argue doctrinally that in many cases a person who is mentally ill is not intending harm and therefore not subject to karmic consequences.
One area of difficulty that has led to recent discussion on a UK Buddhist discussion forum is the subject of dementia. For some Buddhists the idea that after a lifetime of striving to reach clearer, more refined mental states, one’s mind can suddenly fall into severe delusion, muddled thinking and even anger and negativity is very troublesome. Such concern is understandable where the practitioner sees the mental state at the time of death as being of great importance to future re-births. The latter view is common and impacts on people’s views of a number of ethical and medical dilemmas, such as, for example, palliative care at the end of life, and the donation of organs. At a personal level, I cannot say the matter is one which troubles me greatly, since my own view would be that whatever forces are operating in the matter cannot be solely dependent upon our physical condition if they are to affect our future beyond death.
SUMMARY
Buddhist views of mental health and mental illness emerge from the understanding of mental process offered by Buddhist teachings. The Buddha was pragmatic offering many practical methods for working with mental process. Some examples are remarkably similar to modern therapeutic method. For example, we find descriptions of working with fear and dread (Majjhima Nikaya 4) by a process resembling desensitisation. We see advice on different strategies for working with distractions and discomforts (Majjhima Nikaya 2) We see dream analysis (Majjhima Nikaya 23) and many teachings that gave ethical guidance and advice on living harmoniously.
As with any religious system the interpretation of textual and other material in the modern context and particularly in the field of mental health gives much space for variations of view, and as with other religious positions, there is no Buddhist consensus on particular controversies, nor a single approach that can be advocated as the sole Buddhist view.
What Buddhists contribute is a richness of direct observation of mental process and an ethical underpinning which concurs in most ways with the broader ethical views of society. Beyond its obvious contribution of methodologies for calming and focusing the mind, it offers an understanding that whilst critiquing some Western attitudes to the self, increasingly aligns with practical approaches being offered by secular agencies in the treatment of ill health. Most importantly, though, it is grounded in a view of compassion and wisdom as corner stones of human improvement. Such basic commodities as must indeed underpin whatever attempt we make to be of service to others.
FURTHER READING
Buddhist sutras: there are many sutras (suttas) on the web. Those quoted here such as the Majjhima Nikaya can be found at http://www.accesstoinsight.org/
A few books on Buddhist approaches in psychology showing a range of integrations:
Brazier, C 2003 Buddhist Psychology, Constable Robinson UK
Brazier, D 1995, Zen Therapy Constable, UK
Epstein, M. 1996 Thoughts Without A Thinker Duckworth, London
Kabat-Zinn, J 1990 Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness Delta, USA
Krech, G 2002 Naikan: grace, gratitude and the Japanese art of self-reflection Stonebridge Press, California USA
Reynolds, D 1980 The Quiet Therapies, University of Hawaii, Honolulu
APPENDIX
In his book Naikan: grace, gratitude and the Japanese art of self-reflection, Greg Krech gives the following list of elements contrasting features of a traditional Western approach to therapy with Naikan based methodologies. These features are ones that are very similar to those I would identify in the approach which we teach at Amida Trust.
From appendix for mental health professionals: Naikan and psychotherapy
1. Traditional: Focus on Feelings
Naikan: Focus on Facts
2. Traditional: Revisit how you have been hurt and mistreated in the past
Naikan: Revisit how you have been cared for and supported in the past
3. Traditional: The therapist validates the Client’s experiences
Naikan: The therapist helps the client understand the experience of others
4. Traditional: Blame others for your problems
Naikan: Take responsibility for your own conduct and the problems you cause others
5. Traditional: The therapist provides analysis and interpretation of the client’s experience
Naikan: The therapist provides a structured framework for the client’s self-reflection
6. Traditional: Therapy helps clients increase self-esteem
Naikan: Therapy helps clients increase appreciation of life