Buddhist Psychotherapy Author Dr. H. H. S. Nissanka
Reviewed by Rajah Kuruppu
Dr. H. S. S. Nissanka has revised his earlier publication entitled "Buddhist Psychotherapy" to include new insights gained by a large number of case studies of treatment of mental patients and also his experience as a lecturer at the Post Graduate Institute of Pali and Buddhist Studies of the University of Kelaniya during the last four years on this subject. The revised edition released a few months ago is a text book on Buddhist Psychotherapy.
A Fulbright scholar, Dr. Nissanka, has published many books on Buddhism and is currently conducting a Masters Degree course in Buddhist Psychotherapy at the Post Graduate Institute of Pali and Buddhist studies. He has successfully treated a large number of mental patients over the last four decades.
As explained by the author in the Preface, Buddhist Psychotherapy provides an alternative therapeutical model for Psychotherapy in general and Psychoanalysis in particular, based on the teachings of the Buddha, which stress the mental factor in the life of man. The author claims that the therapeutical method presented in the book is verifiable, testable and repeatable and therefore a scientific approach to cure mental diseases.
From the days of Sigmund Freud in the later part of the 19th century, several schools of Psychotherapeutical analysis has been developed. Buddhist Psychotherapy is a part of this evolution.
According to the system of Buddhist Psychotherapy presented in the book the cause of mental illness is attributed to mental defilements or Kleshas as mentioned in Buddhist texts. Normal people also have mental defilements, such as anger, suspicion, greed, ill-will, conceit, delusion, fear, miserliness and jealousy, but they are able to manage and control these defilements whereas the mentally unbalanced persons cannot do so and are overcome by these defilements. The object of Buddhist Psychotherapy is not to eliminate mental defilements and to make an Arahat of the patient but to enable them to control them and lead a normal life. The way to deal with mental defilements by seeing, restraining, using, enduring, avoiding, removing and developing are explained in the Sabbasava Sutta of the Majjhima Nikaya.
Buddhist psychotherapy can be practiced by trained psychiatrists and those with a basic knowledge in psychology but they should have concern and care arising from seeing and understanding the suffering of the mental patients and their immediate relations.
It is said that a practitioner of Buddhist Psychotherapy will have to seek the assistance of a Psychiatrist when a patient is extremely depressed or extremely violent. Buddhist Psychotherapy could do little until such a patient is medically treated and his ability of communication is restored. Sound communication between the patient and the therapist is important in Buddhist psychotherapy.
The author has developed and practiced this system of Buddhist Psychotherapy and claims considerable success. He identifies six steps for the treatment of a mental patient under Buddhist Psychotherapy as follows. 1) Development of communication between the therapist and the patient, 2) Development of body awareness by the patient, 3) Development of feeling awareness by the patient, 4) Probing the conscious and unconscious mind of the patient to expose buried memories mingled with defilements especially in the unconscious mind, 5) Analysis of relevant materials linked to the mental illness and the causes of the illness and these to be seen and known to the patient, 6) Rehabilitation and social integration of the mental patients who have successfully progressed on the first five steps.
The Buddhist system of psychotherapy is the practice of bhavana or meditation using both the tranquillity (samatha) and insight (vipassana) meditations but modified and structured to the needs of the individual patient which is described in the eight case reports at the end of the book. A mental patient could go through the six steps of Buddhist psychotherapy within a short period of 8 to 12 weeks having therapeutical sessions of one hour each week.
The first step of developing confidence between the patient and the therapist is most important since a conscious effort has to be made to motivate the patient to follow the treatment. In this connection, anicca or impermanence is explained to the patient to show that diseases are also impermanent and could be cured. The Dukkha or unsatisfactoriess caused to both the patient and the family by the disease and the need to cure is highlighted.
The importance of mindfullness for the realisation of Nibbana is stressed in Buddhism . In Buddhist psychotherapy, however, mindfulness is used for the therapeutical purpose of curing mental illnesses. The use of the four foundations of mindfulness, namely, the development of awareness of the body, feelings, mind, and mind contents are discussed at considerable length in different chapters as a cure by the control of the defilements that cause mental illnesses. The meditation on breathing awareness or anapanasati is said to be of considerable therapeutical value being easy to practice and comprehend. However, the traditional way of developing this meditation has to be modified to suit the mental patient.
After taking the patient through the first five steps of the treatment, rehabilitation and social integration when the illness is on the decline, is advised, where the members of the family should also play an important role. They are discussed under physical, psychological, social and economic rehabilitation. Some of the recommendations in this area are medical care by a physician for physical ailments, encouragement of daily exercises and cleanliness under physical appreciation of good actions of the patient, explaining the seven factors of enlightenment, keeping the room clean and attractive under psychological; supply of material needs, kindness and care for the patient by the family and taking the patient on social visits under social; and employment or some activities for the patient where he could earn some money, and the encouragement of the savings habit under economic.
In the course of the treatment, the therapist identifies the defilements or kleshas that cause the mental disease and thereafter the patient is also made aware of the causes. When this is realised by the patient an effort will be made by him to control these defilements.
Until recently it was thought that the teachings of the Buddha did not have much to offer in the field of economic and material development. However, a system of economics is now being developed based on the Dhamma. Similarly, perhaps for the first time, the author of this book has developed a system of psychotherapy for mental illness based on Buddhist principles such as the kleshas or mental defilements, the practice of the four foundations of mindfulness, meditation especially anapanasati, the seven factors of enlightenment, the impermanence of things, and the unsatisfactoriess of life.
The eight case studies at the end of the book, most of them included only in the revised edition, indicate some success in this approach but it may be too early to comment on its effectiveness on a general scale. The book is a valuable text book for those interested in the study and practice of Buddhist psychology.
The fact that the author had pursued the treatment of patients based on this system for over 40 years is an index of his confidence in it. Moreover, Buddhist psychology being included as a subject for the Masters Degree of the Postgraduate Institute of Pali and Buddhist Studies for the past four years confirms its acceptance in Buddhist academic circles.
It is hoped that the publication of the revised edition of Buddhist Psychotherapy would encourage others to engage in the study and practice of Buddhist psychotherapy which is free from the adverse effects of treatment by drugs.
His psychoanalytic insights remain contemporary despite early defectors such as Alfred Adler and Carl Jung. Another, Harry Stack Sullivan emphasised the fundamental significance of interpersonal relations in the development of neurosis. Bypassing psychodynamic processes, Ivan Pavlov, and later B. F. Skinner, laid the foundation for learning theory through their experimental work with laboratory animals, providing explanations for abnormal behaviours through a process of conditioning. These intrapsychic, interpersonal, and behavioural explanations did not simultaneously spell out biological correlates which were expected to unravel in the course of time. Parallel developments in descriptive psychiatry, which were to lay the foundation for psychiatric nomenclature, were occurring at the closure of the nineteenth century. Emil Kraeplin, credited as the father of descriptive psychiatry, had made meticulous descriptions of manifestations of groupings of mental disorder, bringing about a shift in thinking from a unitary concept of mental illness. Eugene Bleular, a contemporary of Kraeplin, identified a group of conditions characterised by a splitting of psychic functions, which he called Schizophrenias and proceeded to elicit their primary diagnostic symptoms; and Kurt Schneider, in the mid nineteenth century, brought about further refinement in the diagnosis of Schizophrenia by describing symptoms of first rank importance still used in contemporary psychiatric practice.
The last fifty years have seen explosive developments in the field of psychiatry. There has been an increasing trend towards the establishment of psychiatric units in general hospitals - a shift away from the physically, organisationally and professionally isolated mental hospital setting, which still plays a role in meeting the needs of the chronically disabled. The rationale behind this process of mainstreaming of mental health services was to reduce stigma attached to psychiatric illness, encourage people to seek help early and enhance equity of access to other health services by the mentally ill. Such a shift has been made possible by major advances in pharmacotherapy of psychiatric illness with the discovery of antidepressant, anxiolytic and antipsychotic medications. Recent years have seen further progress in this area with the development of novel psychotropic agents with equal or greater efficacy as the first generation medications but with a better side effect profile. The efficacy and safety of new generation psychotropic medication has reduced the use of the controversial electroconvulsive therapy which still remains an effective form of treatment, especially in psychotic depression where a rapid response is required. Parallel developments in neurophysiological research, which has led to the monoamine hypothesis in affective disorders and the dopamine hypothesis in Schizophrenia, have provided pointers to the biological basis of such disorders and have identified target areas in the action of psychotropic medication. Lately the application of brain imaging techniques such as position emission tomography (PET), single photon emission computed tomography (SPECT), functional magnetic resonance imaging (FMRI) and magnetic resonance spectroscopy (MRS) have revolutionised research into the biological basis of mental disorder. These scanning techniques have enabled researchers to study the regional blood flow, metabolic activity and number and function of neurotransmitter receptors in the brain associated with mental disorder and to examine their relationship with medication.
Psychotherapeutic approaches have seen a shift away from traditional long-term psychoanalysis, with an increasing trend towards short-term eclectic psychotherapy which incorporates an amalgam of psychoanalytic, supportive and cognitive- behavioural strategies.
A new generation of psychiatrists, at least in the developed world, work in liaison with their other medical colleagues in the general hospital setting. Their involvement is the result of research evidence that a high percentage (up to 30% in some studies) of medical and surgical patients present with a significant psychiatric morbidity. They are also being increasingly consulted in ethical decisions (e.g. assessment of patient competence, in relation to clinical practice in the general hospital setting).
The above is an oversimplified account of a journey through the tangled path in the history of psychiatry. Over the centuries, the thinking about mental illness was shaped by the moral, social and political climate of the era. Many battles of minds took place on the way. Countless hypotheses blossomed at different epochs and withered away with time. Within the psychiatric community itself, there were those like R.D. Laing and Thomas Szarz who raised doubts about the Scientific Status of psychiatry and suggested that our whole notion of mental illness was essentially a fiction.
The purpose of writing this column was to throw some light on a less travelled path and hopefully to generate some interest in the concept of mental illness.
Those who suffer from a major psychiatric disorder are the least vocal of all patient groups, and the last to stretch their hand for the scarce health Rupee.
For the young medical men and women who aspire to enter the profession of psychiatry, the speciality offers exciting prospects. There is no other branch of medicine that requires such a holistic approach, and draws on ones interpersonal skill in the art of practice. There is so much uncharted terrain for the research oriented. There is no such suffering that compares with the suffering mind; and no such reward than bringing solace to an unquiet mind.