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What, then, does the mental health professional, pastoral counsellor or Buddhist clergy do with this information? I begin with a case vignette to illustrate a situation that helping professionals may find themselves in when seeking to help Buddhist clients.
Case Vignette
Mr. James Wong has been seeing a mental health counsellor for several months now. James has experienced several traumatic losses over the past year, including the death of his son in a car accident, decreased income from a failing business, and mental problems at home. Always an anxious person, these changes have caused him to feel more anxious, and he is now overwhelmed and becoming less and less able to function. While antidepressants from his psychiatrist have helped, symptoms remain. As part of the intake history, his counsellor asked James if he had any religious or spiritual beliefs that are important to him. James had said that he was raised in a Buddhist family and that he and his wife were active on and off in their temple, but he doesn’t follow Buddhist practices as he should. Seeking to identify nonpharmacological resources that might help relieve his distress, the counsellor asked James if his Buddhist beliefs played a role in his life now. James acknowledges that his religious faith is important to him and his family. His counsellor asked him to explain. James described how his Buddhist beliefs have provided him comfort after the death of his son. When the counsellor asks if James had ever engaged in any for of meditation, he said he had not. The counsellor then suggested he read The Miracle of Mindfulness (Hanh, 1999) and consider practicing daily meditation, and also to read What the Buddha Taught (Rahula, 1974) to help him further understand the religious roots of mindfulness as originally practiced within the context of the Eightfold Path.
The suggestions I make in this chapter are based on knowledge about Buddhist beliefs and practices discussed earlier, evidence from systematic research, clinical experience with faith-based interventions, and simply common sense.
1. Take a Spiritual History
When encountering Buddhist clients, ask if Buddhist beliefs and practices are important to them either now or in the past (including during their youth) If not important at all, then the subject may be dropped. If even somewhat important, take a detailed spiritual history to learn about those beliefs and practices. Taking the time to ask about their religious beliefs and practices is by itself an intervention that will underscore their importance and boost the effectiveness of those beliefs as a resource for coping.
The spiritual history above should always be taken on initial evaluation, or soon afterwards. The purpose of the spiritual history is to identify the specific Buddhist beliefs of the client, the importance of those beliefs to the person, and the extent to which beliefs and practices are adhered to. Finally, both good and bad experiences with Buddhism across the client’s lifetime should be explored. This information will be valuable in deciding on the treatment approach and in providing treatment that meets the minimum standard of showing respect for clients’ personal beliefs and values (as required by mot credentialing organisations in the U.S.). Mental health professionals should assume nothing in this regard, but rather have each client educate them about (a) what role their Buddhist beliefs/practices play in life, (b) how these beliefs help them to cope with their illness or associated life stressors, (c) if a non-traditional healer or faith healer has been sought previously for treatment (and the results), and (d) how Buddhist beliefs or practices may be initiating, worsening or maintaining the illness. In particular, it is important to understand what the client feels is the underlying cause of the illness, especially the role that “bad karma” may be playing.
Taking a spiritual history is the most important recommendation that I can make when treating Buddhist patients. If the therapist is uncomfortable asking about religious issues (i.e., taking a spiritual history) then such resistance must be overcome with training and practice.
2. Asks about the Family/Broader Community
Buddhist clients will each come out of a particular family and community of friends and support persons. Unlike Westerners who treasure their independence and self-sufficiency, Buddhists (like Hindus) are often heavily dependent on relationships within the family and the community (as part of South Asian culture). Therefore, religious beliefs and religiosity of the client’s family of origin, and the religious beliefs and religiosity of the client’s support system need to be inquired about as well. This will give the clinician a sense of whether changes made during therapy will be supported (or opposed) after the client leaves the therapist’s office. Although client confidentiality should be maintained at all times, and most clinical encounters will involve only the client and the treating professional, there will be times when the therapist will need to ask permission from the patient to include the family during the assessment and the treatment.
3. Be Supportive
Be respectful and supportive of the Buddhist client’s religious beliefs/practices that he or she finds helpful (or might find helpful in the future) as a way of coping with emotional issues. However, always do so from the client’s perspective. If the client is receptive and open to healthy religious practices, and these beliefs/practices are not clearly pathological, then they may be encouraged. If the client shows any resistance, don’t push; however, it may be informative to gently explore where the resistance to religious beliefs/practices is coming from in a future session. Never give clients the impression that they are not religious enough, since they probably get plenty of that from family members or those in their religious community. Whether you are a psychiatrist prescribing biological therapies or a therapist providing counselling, the mental health professional should be viewed by the client as neutral, interested in, open to and supportive of the client’s Buddhist faith tradition, but always on the client’s side and never judgemental. This advice also applies to Buddhist clergy who may be counselling members of their temple or religious community.
4. Provide a Safe Place
Provide an open and safe place where clients can talk freely about their religion, good or bad, without judgement. Maintain a respectful, interested, and receptive attitude at all times with regard to the client’s Buddhist beliefs and practices (whether the person in currently active in their faith tradition or not, whether he or she speaks well of their tradition or not).
5. Utilise Buddhist Resources
If the client is religious and the therapist plans to provide a secular psychotherapy, then that therapy should (as noted above) be supportive and respectful of the client’s Buddhist beliefs. There may also be times during secular psychotherapy when the client’s religious beliefs can be utilised to support changes in attitude and behaviour. Knowing about those religious beliefs/practices (as described in earlier chapters) will be helpful, as will a detailed spiritual history to identify ones that are particularly important to the Buddhist client. Consultation with knowledgeable experts in Buddhism may be needed as well, particularly if beliefs are to be challenged (see below).
When encountering Buddhist patients who are open to learning more about Buddhist beliefs, suggest that they read something that describes the core beliefs of their particular branch of Buddhism. Many of these core beliefs directly address issues related to emotional and mental suffering. Buddhists from all traditions will find common ground in the Dhammapada (the translation by Carter and Palihawadana is simple and easy to read for Buddhists fluent in English) Suggest they read 2-3 verses each morning, and then spend 15-20 minutes thinking about their meaning and how they might be applied in the day ahead and the problems currently being faced. Encourage them to spend no more than 30 minutes total each day on this activity. During the next visit, ask about what they learned.
6. Consider a Religiously-Integrated Theory
If clients prefer this approach and therapists are willing and qualified, religiously-integrated cognitive behavioural therapy (CBT) from a Buddhist perspectives should be considered for those with emotional disorders. There are resources that may help the therapist or Buddhist clergy in this regard. This includes a Buddhist CBT manual, along with therapist and patient workbooks, and an introductory video, that can be accessed at the Centre for Spirituality, Theology and Health website, all without charge (CSTH, 2014). Religiously-integrated CBT, including that from a Buddhist perspective, is an evidence-based treatment that has documented effectiveness in the treatment for depression, especially in highly religious patients (Koenig et al., 2015).
Therapists and pastoral counsellors should also consider other evidence-based Buddhist treatments such as Vipassana meditation (Emavardhana and Tori, 1997), 3-S Therapy (Margolin et al, 2006), Buddhist counselling (Rungreangkulkij & Wongakee, 2008), Buddhist group therapy (Rungreangkulkij et al, 2011), mindfulness-based treatments (Chen et al, 2013), and even recommend going on a Buddhist retreat (Tori, 1999) (see Buddhist Interventions in Chapters 6 and 7).
7. Less Formal Approaches to Integration
A less formal approach to integrating Buddhist beliefs into therapy might involve asking Buddhist patients what they know about the Four Noble Truths and the Eightfold Path. Next, ask them if they would be open to discussing each of the eight steps with you. Go over only one step in each session, and if they are open, suggest they think about and practice the step during the time before the next session (and then report on their experiences). Be alert for any discomfort or resistance, and gently explore this with them. Never be coercive, and if the therapist senses persistent discomfort with this method, and then stop and proceed with more standard secular counselling.
Another approach is to suggest that Buddhist patients spend 15-20 minutes each day in mindfulness meditation (samma sati) or concentration meditation (samma samadhi), but only after they have read something that explains how these practices are integrated within the Eightfold Path. Indicate that when mindfulness is practiced within such a religious context, that the benefits are likely to be much greater than if the only goal is pain relief or distraction (although not yet fully proven through systematic research, such as conclusion is reasonable based on what is known so far).
8. Accommodate the Environment
In office or hospital settings, every effort should be made to accommodate the environment to make it easier for Buddhist patients to practice their religion (or indicate evidence that they therapist is sensitive and supportive). This may include placing a copy of the Dhammapada (Carter & Palihawadana, 2000) or The Miracle of Mindfulness (Hanh, 1999) on a table i the waiting room. In the hospital, this may include accommodating the chapel so that Buddhist patients feel comfortable worshipping in this setting.
9. Challenge/Re-Educate
If the client’s Buddhist beliefs or practices are contributing to their psychopathology, and this is confirmed following consultation with an expert from the client’s local Buddhist congregation (after the client provides consent), then the following approach is suggested. First and foremost, the mental health professional should inquire further about the role that particular religious beliefs are playing in supporting psychopathology. The therapist should listen respectfully, gathering as much information as possible about the natural history of how religion became intertwined with the emotional problem. This must be done in an open and receptive manner and without confrontation (at least initially during this information gathering stage). There will come a time, once the therapeutic relationship is firmly established and the client feels safe and accepted, when gradual, gentle, and persistent “Socratic questioning” may help to guide the client towards a “healthier” use of their Buddhist beliefs/practices. I emphasise gradual, gentle, ad persistent questioning by an informed therapist within an atmosphere that is safe and comfortable. Arguments over religious beliefs will almost always be unsuccessful and will adversely affect the therapeutic alliance.
10. Proceed Cautiously and Gently
As noted above, always proceed cautiously and gently when exploring religious beliefs and practices with Buddhist clients, especially as noted above when challenging Buddhist beliefs, but also when making suggests regarding readings or practices at home (and when processing the resulting experiences with clients). Don’t be reluctant to explore with the client any discomfort or resistances that emerge (either within the therapist or the client), but be sure this is done with the utmost of sensitivity. All interventions must be client-centred, not therapist -centred. As noted earlier, allowing Buddhist clients to explore their own beliefs and practices in a safe and supportive atmosphere at their own pace may be more important than any advice given by the therapist. Listening carefully and creating a safe space to explore those beliefs is the therapist’s primary goal.
11. Consult or Refer
If addressing religion or integrating it into the treatment seems indicated in a Buddhist client, and the therapist lacks the desire or experience to do so, consideration should be given to consultation with, co-therapy with, or referral to a Buddhist chaplain or pastoral counsellor. If clergy trained to provide counselling from a Buddhist perspective are not available, then the therapist should consider obtaining additional training in this regard (see CSTH, 2014).
12. Non-Religious Buddhists
If the client was raised in a Buddhist family but is not actively religious, then the mental health professional should proceed with secular psychotherapy that is respectful of the client’s personal and cultural beliefs. Aggressive attempts to reconnect the person to his/her Buddhist faith tradition should be avoided If the client was once religious and has not become socially isolated or is despairing for lack of meaning in life, the therapist might gently ask if the client has considered re-establishing connections with a local faith community. The therapist may help the client weight the pluses and minuses of such re-involvement, but again always from the client’s perspective and following the client’s lead.
Conclusions
In this chapter I have made a number of suggestions on how to apply knowledge about Buddhist beliefs/practices and information from systematic research to the care of Buddhist clients with emotional or mental health problems. The most important recommendations stressed here are to take a detailed spiritual history, be supportive and respectful of the person’s Buddhist beliefs, utilise those beliefs/practices (when not pathological) in the treatment, and always utilise a client-centred approach that is sensitive and gentle. If re-education or confrontation is needed to address religious beliefs or practices that are contributing to the client’s illness, then the therapist should proceed cautiously and usually only after guidance has been sought from experts in the Buddhist tradition.