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A BUDDHIST PERSPECT IVE ON MENT AL HEALT H Caroline Brazier Paper for Nurturing Heart and Spirit: A National Multi-Faith Sy m posium ; Held under the auspices of the Nim he Spirituality Project, Staffordshire Univ ersity and T he Spirituality and Mental Health Forum , Wednesday Nov em ber 1st 2006

INT RODUCT ION Buddhism is often seen as the most psy chological of the major world religions. It originated in a search for an answer to the problem of dukkha (affliction), the ex istential suffering that comes from sickness, old age and death. This search led Siddhartha Gotama, who was to become the Buddha and the founder of the faith, into a spiritual journey . It was as a result of this journey that Siddhartha ev entually receiv ed his transformativ e ex perience, his enlightenment.

The insight which came from the Buddhas enlightenment underpins a Buddhist approach to mental health. The insights that constitute the Buddhas first teachings offer a basis which has been elaborated and re-formulated in many way s, but still remains the central presentation of the Buddhist position. Detailed interpretation of these primary teachings has fascinated Buddhist scholars through the centuries, but their centrality remains undoubted.

The Buddhas original concern with the sufferings inv olv ed in human life became the focus for his teaching. In particular they prov ide the core of the key teaching, known as the Four Noble Truths. This teaching consists of four statements, the first of which 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 w ith w hat you do not like, being separated from w hat you do like, and not being able to get w hat you w ant. (Samy utta Nikay a 61 .1 1 .5) In other words, human life is unav oidably linked to situations which are distressing.

With affliction, crav ing arises. The Buddhas second Noble Truth addressed the arising of crav ing. In the sutras the description of the second Noble Truth ends with the phrase kama, bhava , abhava . It is my feeling that this latter statement prov ides a useful ty pology for the progress of mental distress. It describes how people progress through simple distraction to the construction of psy chological defences, and finally to the self-destructiv e mind states associated with sev ere mental distress in their response to afflictions. The three elements, kama, bhava and abhava, can be translated as sensory pleasures (kama ), becoming, or one can understand, self building (bhava ), and non-becoming (abhava ). These three words can be interpreted as describing the stages in a process of growing attachment. This clinging is itself a response to the affliction that has occurred. In other
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words, when trouble occurs, people habitually seek distraction and comfort, initially at the lev el of the senses. For ex ample, they might ov er-indulge in food or alcohol. Later, with frequent repetition of this habit of distraction, the process becomes the subject of identification and self-building. The sense of self creates a wall against raw ex perience, giv ing both identity and a restricted v iew of the world to support it. Ev entually , howev er, if trouble persists, ev en this self-building fails to prov ide sufficient distraction and breaks down into destructiv e impulses.

The self-building process is itself a source of dukkha . Creating and maintaining the self-perspectiv e multiplies pain as it is founded in delusion. Other Buddhist teachings can be seen in the contex t of the teaching of the Four Noble Truths as elaborating the processes whereby distressing or deluded states are created and maintained. Broadly these include teachings that ex plain the processes of Dependent Origination whereby the ordinary mentality is maintained through a cy cle of conditioned v iew. A number of key teachings elaborate these processes and show how people build their reality , and hence their self, through crav ing and attachment. This process can take on positiv e or negativ e forms. Our reactions to the object world are ones of attraction or av ersion. Such reactions are habitual and form the basis of ones ov erall 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 v iews and behav iours which, in turn, condition the maintenance of the cy cle.

The teachings of Dependent Origination and the cy cle 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, av idy a. Av idy a literally means not seeing, and this choice of word demonstrates the Buddhist emphasis on perception as a key element in constructing mental states. All these teachings are recorded in the Buddhist tex ts or sutras which describe the Buddhas ministry during the latter forty y ears of his life.

Many people in the West associate Buddhism especially with its mind training ex ercises. Undoubtedly meditation in its v arious forms has play ed a key role in dev eloping an elaborate and detailed sy stem of understanding the factors of conditioning and in dev eloping methods for unhooking ourselv es from the objects of crav ing. This process of unhooking is described in the third and fourth Noble Truths. Meditation and other mental ex ercises combined with study and analy sis of the teachings led to the a further collection of Buddhist tex ts called the Abhidharma, which were compiled shortly after the Buddhas 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 y ears of study and practice clearly hav e much to offer by way of guidance for those working in the field of mental health. This contribution has been recognised and there hav e been a number of significant attempts to draw on Buddhist teachings and methodology in Western psy chotherapeutic 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 contex t. More recently we hav e seen an influx of techniques such as the use of meditation, mindfulness and v isualisation, all of which hav e roots in Eastern, and often specifically Buddhist, practice.

In the last decade or two, as a more general interest in the interface between the psy chological and the spiritual has arisen, a number of Buddhist approaches hav e been introduced and taught to professionals working in mental health fields. These approaches, though all based on a Buddhist understanding, differ considerably from
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one another. This is because some rely more upon Buddhist methodology , whilst others focus on the theoretical understanding of mental process arising from Buddhist teachings, and also because they draw roots from different Buddhist traditions and from different Western schools of psy chotherapy . In the UK we can identify the v arious mindfulness based programmes deriv ing from the work of Kabat Zinn, the Core Process training of the Karuna Institute, and the programme in Buddhist Psy chotherapy run by my own organisation, Amida Trust. Also worthy of mention, though less well known in the UK, is the work of Dav id Rey nolds and the Todo Institute in Canada. Rey nolds approach, Constructiv e Liv ing, is based on two Japanese therapies, Naikan and Morita which apply Buddhist teachings in way s that offer an important and striking critique of many Western assumptions about mental distress.

Whilst there is not space here to ex plore in detail these different therapies, it is worth noting that some are now being widely used in mainstream establishments and hav e been subject to research ev aluation. In particular mindfulness based programmes hav e become popular in the West, whilst in Japan Naikan has been ex tensiv ely used in the prison sy stem. Similarly , V ipassana meditation retreats run by the Buddhist Goenka mov ement hav e also prov ed transformativ e for prisoners in India.

A BUDDHIST APPROACH T O MENT AL 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 hav ing 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 persons life. The Buddha taught much about life sty le. His teachings can all be taken as practical adv ice on how to liv e well. The lifesty le 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 liv ing and respect for liv ing things. This lifesty le is seen as foundational for the cultiv ation 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 v isionary or inspirational ex perience. In the ex perience 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 hav e 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 ex perience 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: - Behav iour conditions mental states; ethical behav iour conditions positiv e states;
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- The Repetition of habitual patterns of action and v iew lie at the root of mental states, - We feel a compulsion to cling to habitual v iews 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 addictiv e patterns as being the self. - Ev ery one is in a state of av idy a (delusion) so mental ill health is just a more ex treme v ersion of states we all suffer from. - Psy chotic states are ex treme v ersions of common mental states and are based on more ex treme 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 , inv iting a shift away from rigidity of v iew, encouraging deeper connection with others and with the env ironment. 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 psy chology based on the concept of non-self; an other-centred perspectiv e that emerges as a person becomes less caught up in maintaining their sense of identity and the corresponding world v iew that supports it. 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 lev el we can see this as refuge in the enlightened source of wisdom, in the truth of reality that is alway s av ailable for discov ery , and in the community of others. Bey ond the state of delusion, something real and wonderful is av ailable.

In my own tradition, Pureland Buddhism, the central practice is a practice of calling on this ev er present Buddha-ness, represented in the figure of Amida, the measureless Buddha. This tradition emphasises our ordinary state, which is enmeshed in karma and thus deeply deluded. Its acceptance of our imperfection carries with it a profound sense of our acceptability to Buddha, which is accompanied by a v iew of the univ ersal dimension that is radically non-judgemental. The object of our practice is the eternal quality of Buddha Amida. Amida is alway s clouded in the my stery by our copious distortions and limits of v iew, y et remains a foundation for our attention which potentially takes us out of self-preoccupation.

T HE BUDDHIST AT T IT UDE T O MENT AL ILLNESS: The Buddhist perspectiv e 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 interv enes in human affairs, and ev en where Buddhism comes close to this position with inv ocations of celestial beings or Bodhisattv as, the influence these figures might ex ert would generally be seen as benev olent and limited.

In Buddhism the suffering which people ex perience is of two kinds (although this distinction is not strongly made in the tex ts). Some suffering arises from our ex istential circumstances. As such it is unav oidable 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, howev er, is seen as a personal matter. Failure to address ones 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.
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In Pureland, the emphasis on faith is particularly relev ant here. This particular Buddhist approach is somewhat more pessimistic than that of other schools about our capacity to help ourselv es through the kind of mindtraining ex ercises 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 v iew of mental illness would be that if a person can simply reach some sense of the immeasurable presence of Amida bey ond their personal turmoil, a moment of faith, that contact will sustain them and achiev e ultimate salv ation. Psy chologically speaking we can see this as indicating the importance of ev en small breaks from the cy cle of self into contact with other reality .

This v iew encompasses a sense of commonality between humans. We are all enmeshed in our own karma, and thus similarly caught in states of delusion and confusion. There may be differences of form and 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 behav iour that arise from mental ill health, such as suicide, self- harm, anger and so on would be v iewed 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 behav iour creates the seeds for future actions. Thus a Buddhist v iew would, where possible, discourage a person from making ex pressions of anger in order to help them av oid feeding negativ ity in their mentality .

Similarly suicide and self-harm would be v iewed as lay ing dangerous patterns which potentially create downward spirals for the indiv idual, but also create karmic consequences for others inv olv ed. Such v iews can both be taken on the mundane lev el the child of a suicidal parent will themselv es run a greater risk of suicide, and on the metaphy sical lev el 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 abov e 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 of their deeds.

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 striv ing to reach clearer, more refined mental states, ones mind can suddenly fall into sev ere delusion, muddled thinking and ev en anger and negativ ity is v ery 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 v iew is common and impacts on peoples v iews of a number of ethical and medical dilemmas, such as, for ex ample, palliativ e care at the end of life, and the donation of organs. At a personal lev el, I cannot say the matter is one which troubles me greatly , since my own v iew would be that whatev er forces are operating in the matter cannot be solely dependent upon our phy sical condition at death if they are to affect our future bey ond this life.

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Buddhist v iews 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 ex amples are remarkably similar to modern therapeutic method. For ex ample, we find descriptions of working with fear and dread (Majjhima Nikay a 4) by a process resembling desensitisation. We see adv ice on different strategies for working with distractions and discomforts (Majjhima Nikay a 2) We see dream analy sis (Majjhima Nikay a 23) and many teachings that gav e ethical guidance and adv ice on liv ing harmoniously with others.

As with any religious sy stem the interpretation of tex tual and other material in the modern contex t and particularly in the field of mental health giv es much space for v ariations of v iew, and as with other religious positions, there is no Buddhist consensus on particular controv ersies, nor a single approach that can be adv ocated as the sole Buddhist v iew.

What Buddhists contribute is a richness of direct observ ation of mental process and an ethical underpinning which concurs in most way s with the broader ethical v iews of society . Bey ond its obv ious 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 v iew of compassion and wisdom as the corner stones of human improv ement. Such basic commodities as must indeed underpin whatev er attempt we make to be of serv ice to others.

FURT HER READING Buddhist sutras: there are many sutras (suttas) on the web. Those quoted here such as the Majjhima Nikay a can be found at http://www.accesstoinsight.org/

A few books on Buddhist approaches in psy chology showing a range of integrations: Brazier, C 2003 Buddhist Psychology , Constable Robinson UK Brazier, D 1 995, Zen Therapy Constable, UK Epstein, M. 1 996 Thoughts Without A Thinker Duckworth, London Kabat-Zinn, J 1 990 Full Catastrophe Living: Using the Wisdom of Y our 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 Rey nolds, D 1 980 The Quiet Therapies , Univ ersity of Hawaii, Honolulu

Caroline Brazier is an ordained member of the Order of Amida Buddha and is based at The Buddhist House, 1 2 Coventry Rd, Narborough LE1 9 2GR. Further information about the Amida Order can be found at w w w .amidatrust.com

Paper for Nurturing Heart and Spirit: A National Multi-Faith Sy m posium ; Held under the auspices of
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the Nimhe Spirituality Project, Staffordshire Univ ersity and The Spirituality and Mental Health Forum, Wednesday Nov ember 1 st 2006

APPENDIX In his book Naikan: grace, gratitude and the Japanese art of self-reflection, Greg Krech giv es the following list of elements contrasting features of a traditional Western approach to therapy with Naikan based methodologies. These features are ones that are v ery similar to those I would identify in the approach which we teach at Amida Trust.

From appendix for mental health professionals: Naikan and psy chotherapy

1 . Traditional: Focus on Feelings Naikan: Focus on Facts

2. Traditional: Rev isit how y ou hav e been hurt and mistreated in the past Naikan: Rev isit how y ou hav e been cared for and supported in the past

3. Traditional: The therapist v alidates the Clients ex periences Naikan: The therapist helps the client understand the ex perience of others

4. Traditional: Blame others for y our problems Naikan: Take responsibility for y our own conduct and the problems y ou cause others

5. Traditional: The therapist prov ides analy sis and interpretation of the clients ex perience Naikan: The therapist prov ides a structured framework for the clients self-reflection

6. Traditional: Therapy helps clients increase self-esteem Naikan: Therapy helps clients increase appreciation of life Tariki Books and Papers Buddhist Psy chology Tariki Ning Tariki Trust