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This chapter and the next one focus on quantitative research that examines the relationship between Buddhist beliefs/practices and mental health. The purpose is to identify and document the evidence on which to make recommendations for application to clinical practice (Chapter 8). The research will be presented for two periods: early research (1950-2010) and recent research (2010-present). Excluded here are studies of Western forms of mindfulness meditation not firmly grounded within traditional Buddhist beliefs and practices (a literature that has been extensively reviewed elsewhere). While almost all of the research presented here is quantitative, a few qualitative studies have been included to provide a deeper understanding of how Buddhism is related to mental health.
The review of early research in the present chapter is based on studies identified in two editions of the Handbook of Religion and Health. The first edition of the Handbook provided a systematic review of the world literature on religion and health, and identified 6 studies on religious involvement and mental health in Buddhists published prior to the year 2000 (Koenig et al., 2001). The second edition of the Handbook systematically reviewed quantitative research conducted between 2000 and 2010, identifying 16 studies on religion and mental health in Buddhists (Koenig et al., 2012).
Before reviewing that early research, a comment about methodology is necessary. Since almost no measures of Buddhist beliefs and practices existed prior to the year 2000, the amount of research on religiosity and mental health among Buddhists during that period is limited (only 6 studies). When religiosity was assessed among Buddhists during this time, it was typically measured by scales developed for Christian populations. Words in those scales such as church, God, and Bible were modified for a Buddhist population.. In 1997 a scale designed specifically for assessing religiosity in Buddhists was published. This was the 11-item Buddhist Beliefs and Practices Scale (Emavardhana and Tori, 1997). Unfortunately, the full instrument has been difficult to obtain, and other than providing a few of the questions on the scale as examples, the full scale was not reported in the article. The psychometric properties of the scale have been reported, although details are few (Tori, 2004, p 41). As a result, not much research has used the scale when examining relationships between religiosity and mental health in Buddhists.
The 26 studies summarised below are categorised into those examining coping with stress, anxiety, depression, and suicide, substance use/abuse, psychological well-being/life satisfaction, quality of life/self-rated health, personality traits, and intervention studies.
Coping with Stress
Torture and abuse. Holtz (1998) compared 35 refugee Tibetan nuns (76%) and lay students (24%) in India who has been arrested and tortured in Tibet because of their religious beliefs, and compared them to 35 Tibetan controls who had not received such treatment. Anxiety symptoms, depressive symptoms, somatic complaints, and social impairments were assessed using the Hopkins Checklist-25. Although anxiety symptoms were higher in those experiencing torture compared to controls (54% vs. 29%), there was no difference in depressive symptoms between the tortured and the controls. Investigators were intrigued by the finding that those experiencing torture do not have more depressive symptoms. They hypothesised (based on explanations provided by participants) that Tibetan Buddhism helped the 80% of refugee Buddhist nuns by providing an explanation for suffering (due to karma from previous lives) that gave meaning to what they had experienced. By accepting and dealing with their situation in a proper manner and performing good works in this life, they believed that this would provide positive karma that would improve their next lives. Researchers referred to the Buddha’s teaching that one’s own suffering is little compared to the suffering of others, and in fact, could be utilised to reduce the suffering of others. One of the most sacred spiritual doctrines in Buddhism is that one’s own suffering is unimportant and must be transcended. These beliefs, investigators hypothesised, contributed to the psychological resilience seen in the tortured refugees.
In another study of survivors of torture, Keller and colleagues (2006) collected information on a convenience sample of 325 patients attending a Bellevue Hospital/New York University program intended for such victims. Participants included 23% Buddhists, 28% Christians, and 44% Muslims; average age was 34 years and the most heavily represented country was Tibet (22%). Depression, anxiety and PTSD symptoms were assessed using standard measures. Over 80% of patients met criterion levels for significant anxiety, 85% for depression, and 46% for PTSD. Religious affiliation was associated with severity of psychological distress. Buddhists (almost all of whom were from Tibet) experienced fewer PTSD symptoms than Christians (p<0.05) or Muslims (p<0.10). Buddhist affiliation, however, was not associated with depressive or anxiety symptoms. Researchers concluded that “Tibetan Buddhists appear to be less prone to PTSD symptoms than other survivors of torture, despite experiencing comparable traumatic experiences” (p 193).
Sachs and colleagues (2008) interviewed 769 Tibetans residing at the Tibetan Refugee Reception Centre in Dharamsala, India, to examine the relationship between types of trauma and anxiety, depressive, somatic, and PTSD symptoms. Most participants (83%) were ages 16-25 years, male (85%), and never married (95%); over half (52%) worked as either a monk or nun in Tibet; 11% reported being tortured; and 75% experienced religious restrictions in Tibet. Coping behaviours were assessed using the Daily Coping Scale (Stone & Neale) made up of eight categories of coping, one of which was religious coping. In addition, three religious Tibetan Buddhist practices/beliefs were enquired about: (1) meditation, (2) seeking divinations from lamas/performing special prayers/visiting temples, and (3) explaining the trauma as due to karma. Among all coping behaviours, religious ones were the most common, with all three Tibetan Buddhist practices/beliefs reported by over 90% of participants, more prevalent than even seeking emotional support from loved ones, friends or professionals (77%). Overall, coping activity was associated with more depression, anxiety, PTSD, and somatisation. Unfortunately, associations between religious coping behaviours (apart from overall coping) and psychological symptoms were not reported.
Caregiver stress. Sethabouppha and Kane (2005) conducted a qualitative study that examined the experiences of 15 Thai Buddhist family caregivers of seriously mentally ill family members. The purpose was to better understand the Buddhist perspective on caregiving. Mentally ill family members being cared for ranged in age from 22 to 50, about half were women, and the majority had less than a grade school education. Five themes were uncovered from the interviews: (1) caregiving is based heavily on Buddhist belief (karma, merit, demerit, past life and rebirth, and dharma); (2) caregiving involves compassion (caring, support); (3) caregiving requires management of emotions (through distraction, religious practice, withdrawal, tolerance, positive thinking, help seeking, and following the Noble Eightfold Path); (4) caregiving requires acceptance (incurable illness, sickness is natural); and (5) caregiving involves suffering (physical burden, emotional distress, economic problems, social problems, knowledge deficit). Researchers concluded that Buddhist beliefs are intimately related to the capacity to care for mentally ill family members.
Medical Illness. Tzeng and Yin (2008) surveyed 1,031 medical patients and family visitors at a medical hospital in southern Taiwan (three-quarters of participants were family visitors). Primary religious affiliations of participants we Confucianism, Buddhism, Taoism, Christianity, and Islam (percentage of each group not given). Examined were religious practices used by medical patients or family members to help cope with the medical illness. Religious practices included praying to Buddha (45%) or to other gods of Chinese folklore (24%), and attending a church or temple service to offer prayer (57%) for the medical condition. Approximately one quarter of participants prayed to the gods of two or more religious traditions. The most common religious resources that participants indicated they might need during hospitalisation were religious care provided by a physician or nurse (45%), religious services provided by other hospital staff, clergy, or volunteers (28%), and a place to pray such as a prayer room or chapel (19%). Researchers concluded that the majority of patients and family members were involved in prayer or attending religious services as a way of coping with the medical illness.
Tsunami survivors. Hollifield and colleagues (2008) surveyed 89 Sri Lankan adults (average age 45 years) approximately two years after the 2004 Asian tsunami. Assessed were trauma exposure, anxiety, depression, PTSD, and somatic symptoms, along with coping behaviours used to deal with these symptoms. Among participants, 21% were diagnosed with PTSD, 16% scored above the cutoff for significant depression, and 30% scored above the cutoff for significant anxiety. The most common coping behaviours reported by participants as very or extremely helpful were (1) utilising their own strength (70%), (2) family and friends (56%), and (3) religious practices (53%). Bodhi-puja was reported by 44$ to be very or extremely helpful. Bodhi-puja involves veneration or worship of the Bodhi tree, which has been a common Buddhist practice in this region since a sapling of the original Bodhi tree (under which the Buddha attained Enlightenment) was brought to Sri Lanka from India in the third century BCE.
Wickrama and Wickrama (2008) analysed data on 325 mothers of tsunami-affected families in southern Sri Lanka collected 3 to 4 months after the 2004 tsunami. PTSD symptoms and depressive symptoms were assessed. Although religious affiliation of participants was not given, over 70% of the population of Sri Lanka are Therava Buddhists. Results indicated that 20% had symptoms qualifying them for a diagnosis of PTSD, while 38% scored above the cutoff of 16 on the CESD for significant depressive symptoms. Religious activity was significantly and inversely related to PTSD symptoms (B=-0.16, t=-3.32), but was unrelated to depressive symptoms (B=-0.09, t=-1.80) after controlling for other resilience factors (cohesion and support from family members, number of children, community support, hardiness). Researchers concluded that family support and religious participation were helpful in reducing the detrimental effects of the tsunami on participants’ PTSD symptoms. Explaining the effect of religion, they stated: “Buddhists possess relatively more “awareness” about unavoidable constant change and instability of living and nonliving things and tend to appraise disastrous events and circumstances less negatively because they believe that these events are unavoidable and unalterable life circumstances” (p. 1004).
Levy and colleagues (2009) also interviewed 264 tsunami survivors (90% Buddhist, average age 38, 65% losing close family members, 29% physically injured) six months after the 2004 tsunami devastated Sri Lanka. The purpose of this study was to examine beliefs they had concerning the cause of this disastrous tsunami. Of particular interest was “karma” or “sins of a previous life.” Outcomes examined included PTSD symptoms. Results indicated that belief in karma did not significantly influence PTSD symptoms after adjusting for pessimistic explanatory style (which karma was unrelated to) and other multiple other covariates including demographic factors, magnitude of exposure, social support, baseline health, depressive symptoms, and whether or not participant had received counselling. However, belief in karma increased risk of poor self-related health by nearly threefold (2.78, 95% CI=1.69-4.55, p<0.0001). For a review of Buddhist practices used to recover in the aftermath of tsunamis, see Falk (2010).
Anxiety, Depression, and Suicide
Worry/anxiety. In order to compare Buddhist and Christian older adults on worry/anxiety and examine the relationship between religiosity and mental health in each group. Tapanya and colleagues (1997) surveyed 52 Christian elders (ages 65-90 years) in Canada and 52 Buddhist elders in northern Thailand (ages 65-89 years). This is one of the first studies (if not the first) to examine the relationship between religiosity and mental health in Buddhists. The Penn State Worry Questionnaire (PSWQ) was used to assess worry/anxiety, and the 20-item Gorsuch-Venable Intrinsic-Extrinsic Religiosity (IE) scale assessed religiosity. The words church, God, Bible were modified for Buddhists in the Thai version of the IE scale. After controlling for gender, results indicated no difference between Christian and Buddhist elders on PSWQ score. Buddhists scored significantly higher on extrinsic religiosity (ER) than Christians, whereas there was little difference between groups on intrinsic religiosity (IR). An inverse relationship was found between intrinsic religiosity and worry (semi-partial r=-0.24, p<0.01) in the combined sample. This was especially true in Buddhists (r=-0.37, p<0.01). ER, on the other hand, was positively related to worry in Buddhists (r=0.29, p<0.05), but not in Christians. Investigators hypothesised that the positive relationship between ER and worry in Buddhists was because interest in the extrinsic aspects of religion may create more worry because of basic Buddhist beliefs. Whereas redemption and forgiveness for one’s actions is possible in Christianity, the law of karma in Buddhism does not allow escape from the consequences of one’s actions (where there is no help from a saviour). For Buddhists, only perseverance toward enlightenment will bring liberation and redemption from the cycle of death and rebirth. Thus, greater extrinsic religious behaviour related to activities at church/temple might not help to alleviate responsibilities for one’s actions or relieve guilt in Buddhists. Among the things that each group worried about, church or temple was ranked #2 among the six greatest worries among Buddhists, but was not listed among the six greatest worries among Christians.
Depression.
Limlomwongse and Liabsuetrakul (2006) followed a cohort of 610 pregnant Thai women (88.2% Buddhist) from prior to delivery until 6 to 8 weeks postpartum examining depressive symptoms. Participants were recruited from the University Hospital in South Thailand. The prevalence of significant depressive symptoms (assessed by the Edinburgh Postnatal Depression Scale) was 20.5% during pregnancy and 16.8% on the postpartum follow-up. Predictors of change in depressive symptoms included demographics, obstetric history, previous psychological problems, planned/unplanned pregnancy, perception of pregnancy complications, and other attitudes towards pregnancy and delivery. After controlling for these predictors using logistic regression, non-Buddhists were over twice as likely to experience significant depressive symptoms on follow-up compared to Buddhists (OR=2.1, 95% CI 1.0-4.0, p=0.03). This effect emerged after controlling for negative attitudes towards pregnancy.
Yeager and colleagues (2006) analysed data from the Survey of Health and Living Status of the Elderly in Taiwan, a random sample of 2930 community-dwelling adults aged 50 or over. Relationships between religious involvement and health were assessed, including depressive symptoms (CESD). Religious affiliation of participants was Taoist/traditional folk religion (50%), Buddhist (28%), none (15%), and other religion (8%). Religious involvement was assessed using a number of measures including frequency of religious attendance at temple or church; belief in heaven/hell, existence of a living spirit after death, existence of life after death, and belief that then afterlife is better than now; and frequency of six religious practices: (1) pray/burn incense, (2) worship gods/Buddha at home, (3) read scriptures, (4) watch/listen to religious programs, (5) pray to “Lord, gods, or Buddha,” and (6) ask for guidance from “Lord, gods, or Buddha” before important decisions. After controlling for baseline depression and 16 other predictors, regression analyses indicated no relationship between religious affiliation (Taoist/traditional, Buddhist, Other, or none), religious attendance, religious beliefs, or religious practices and depressive symptoms on 4-year follow-up.
Suicide. In our systematic review of quantitative studies published prior to 2010, we identified four studies that examined religiosity and suicidal thoughts, attempts or completed suicide. All four studies were conducted in China. In a study of 320 college students in China and 452 college students in U.S., Zhang and Jin (1996) examined the relationship in each group between religiosity and suicidal thoughts. Religiosity was assessed by religious attendance, private religious activities, self-rated religiosity, and religious belief. Controlling for multiple other predictors, while religiosity was significantly associated with fewer suicidal thoughts in U.S. students, it was associated with more suicidal thoughts in China.
In a case-control study, Zhang and colleagues (2004) examined risk factors for suicide (including religious beliefs) among 66 consecutive completed suicides in rural China compared to 66 controls matched on age, gender, and living location. Two informants were used to collect information from for each case of suicide (completed within past 12 months). Religious beliefs were assessed by having a religion (yes vs. no), belief in God, and belief in an afterlife. Most participants had no religion (86% cases, 96% of controls), although Buddhism and Taoism are the two largest religious groups in China. Controlling for other suicide risk factors, researchers found no difference on any of the three indicators of religious belief between completed suicides and controls.
In another case-control study, this time involving 74 urban suicide attempters and 92 controls in Northeast China, Zhang and colleagues (2006) compared self-rated religiosity and religious affiliation between cases and controls. Most participants had no religious affiliation and described their religiosity as none or weak. Of participants with a religious affiliation, two-thirds (65.2%) were Buddhist. Religious affiliation and self-rated religiosity did not significantly differ between cases and controls. In the same study, Zhang and Xu (2007) examined relationships between religious affiliation and self-rated religiosity and degree of suicide intent among suicide attempters. A Chinese version of the 8-item Beck Suicidal Intent Scale assessed suicidal intent. Suicide intent in women was significantly higher in those who were more religious (p=0.02), and a similar but weaker association was found in men (p=0.09). However, after controlling for age, mental disorder, superstition, perceived gender inequality, and marital status, these differences became non-significant.
Thus, of four studies identified here, three found no association and one reported a significant positive association between religiosity and suicidal thoughts, attempts or completions.
Substance Use/Abuse
Assanangkornchai and colleagues (2002) examined differences in religious beliefs and practices among (a) 91 alcohol-dependent persons, (b) 77 hazardous/harmful drinkers, and (c) 144 non/infrequent drinkers (controls) in Thailand. Participants were recruited from inpatient and outpatient settings, and from hospital personnel, friends, and relatives. Note that Thailand is second only to Cambodia in countries with the highest percentage Buddhist (nearly 90%). No difference was found between the three groups in terms of having been raised in a religious family, religiosity of parents, parent participation in religious activities, having religion forced on them as a child, or participation in religious activities as a child. Men without alcohol problems, however, were currently more likely than hazardous/harmful or alcohol dependent men to perceive themselves as moderately or strongly religious (86% vs. 74% and 75%, respectively), more likely to indicate Thai men should observe the Fifth Precept (i.e., avoidance of distilled or fermented intoxicants causing carelessness) (28% vs. 8% and 14%), and more likely to say that one should always abstain from drinking on a holy day (35% vs. 13% and 9%). When analyses were adjusted for age, marital status, education, working status, social class and area of residence, the strongest predictors of being a hazardous/harmful drinker and alcohol dependent were self-perception as moderately or strongly religious (OR=0.41, 95% CI=0.20-0.86, and OR=0.48, 95% CI=0.24-0.97, respectively), belief that religious teaching always influences daily life (OR=0.30, 95% CI=0.14-0.83, and OR=0.50, 95% CI=0.21-1.06), and interest in studying the Buddha’s teachings (OR=0.51, 95% CI=0.28-0.93, and OR=0.81, 95% CI=0.47-1.41). However, those serving as a “temple boy” as a child were more likely to be alcohol dependent (OR=2.04, 95% CI=1.14-3.61). The authors explained that temple boys live together as a group in a dormitory, and have fewer restrictions and greater opportunity to use alcohol.
Psychological Well-being/Life Satisfaction
Kim (2003) examined the relationship between religious involvement and psychological well-being in South Korea, where 23% are Buddhist, 20% are Protestant, 7% are Catholic, and 49% have no affiliation (according to the 1995 Korean National Statistical Office survey cited in this report). Kim analysed data from a random sample of 1,613 adults by Gallup Korea in 1997, which included information on religious affiliation and life satisfaction. Life satisfaction was assessed on a scale from 1 (low) to 10 (high). Uncontrolled analyses revealed that life satisfaction was highest in Protestants (6.5), then Catholics (6.4), then those with no religious affiliation (5.9), and finally Buddhists (5.8). The author points out that this may have been due to differences in education and income, since Korean Buddhists have less education than Catholics or Protestants.
In a study of social capital, Yamaoka (2008) analysed data from a random sample of 8,665 adults living in Japan, South Korea, Singapore, five cities in China, and Taiwan, examining relationships between religious faith and life satisfaction, somatic symptoms, and self-rated health. Religious faith (without description) was assessed using a single item that was dichotomised for analysis (present vs. absent). Religious faith was present in 24-25% of participants in Japan, 7-27% in China, 26-41% in Hong Kong, 71-78% in Taiwan, 76-82% in Singapore, and 43-50% in South Korea. Logistic regression models were used to analyse the data controlling for other predictors. Religious faith was associated with a higher number of somatic symptoms (OR=1.35, 95% CI 1.21-1.51) and poorer subjective health (OR=1.14, 95% CI 1.01-1.29), but there was no relationship with life satisfaction (OR=1.03, 95% CI 0.89-1.19).
Quality of Life/Self-Rated Health
In one of the first studies comparing Buddhists and non-Buddhists on mental health, Fazel and Young (1988) examined the quality of life of 59 Tibetan refugees (Mahayana Buddhists) and 66 native Hindus in Northern India. Quality of life was assessed using 17-items taken from the Perceived Quality of Life inventory (Andrews & Withey). Results indicated that quality of life was significantly higher among Buddhist Tibetan refugees compared to native Hindus (p<0.001, uncontrolled). This was especially true among the “labourers” class (in contrast to the shopkeepers class, where no differences in QOL were observed). Researchers concluded that “While both Hindus and Tibetans subscribe to the fatalistic attitude of Karma, the Tibetans report greater life satisfaction. If one looks beyond the superficial similarities in the concept of Karma, however, it becomes clear that Tibetans adopt a “proactive” posture as opposed to the “reactive” fatalism of the Hindus” (p. 229). Explaining what “proactive” means, researchers indicated that Buddhists emphasise aspect of daily life that help them gain positive karma, whereas Hindus find reasons for their misfortunes in their karma.
With regard to self-rated health (known to be heavily influenced by mental health), Krause and colleagues (1999) analysed data from a national probability survey of 2,153 older adults in Japan, examining relationships between religious activity, self-rated physical health (SRH), and altruism (helping others). Most Japanese are Shinto, but approximately three quarters also practice Buddhism. Average age of participants was 70 years (56% women, 69% married, mean education level 10 years). With regard to private religious practices, 80% sometimes or always participated in prayers and offerings to ancestors; one-third sometimes or always read scriptures (Buddhist scriptures or the Bible); and 18% sometimes or always watched or listened to religious programs on TV or radio. Altruism (“support provided to others”) was assessed with two questions that asked about frequency of listening to others talk about their troubles, and frequency of encouraging and comforting those undergoing hardships. SRH was assessed using a 3-item index. Results indicated that greater religious practice among mem (but not women) was associated with more altruistic activities. Religious practice was associated with better SRH in both men and women. The effect of religious practice on health in men was mediated (explained) largely by providing support to others (altruism).
Personality Traits
Saroglou & Dupuis (2006) examined the relationship between personality characteristics, cognitive structure, importance of values, and religiosity in 105 Buddhists living in Belgium. Participants were recruited from Buddhist centres in Belgium belonging to the Tibetan Vajrayana tradition. Psychological characteristics assessed were need for closure (preference for order, predictability, decisiveness, discomfort from ambiguity, closemindedness), agreeableness (kind, sympathetic, cooperative, warm and considerate), and “values” using standard measures of these constructs. Religiosity was assessed using a 14-item Investment in Buddhism Scale (IBS) developed by the authors that included frequency of practice (both collective and individual), self-identification as Buddhist, interest in Buddhism, finding a way of life through Buddhism, working on oneself in Buddhism, and willingness to share Buddhism with others and their children. In addition, religious quest was assessed using the Quest scale (Altemeyer & Hunsberger). Results indicated that “need for closure” and “closemindedness” were inversely associated with Buddhist collective religious practice, and Buddhist “inner directedness” was inversely associated with preference for predictability. All measures of Buddhist religiosity on the IBS were associated with high scores on agreeableness. IBS also tended to be positively associated with preference for tradition, conformity universalism, and benevolence, but was negatively correlated with need for security, power, achievement, and hedonism (especially).
Buddhist Interventions
There have been many, many studies of mindfulness meditation (or Mindfulness Based Stress Reduction, MBSR) largely conducted in Western countries and in non-Buddhists. The results of these studies have been summarised in a series of meta-analyses or systematic reviews reported both before 2010 (Grossman et al., 2004; Weaver et al., 2008; Chiesa & Serretti, 2009) and after 2010 (Kuyken et al., 2016; Spijkerman et al., 2016).
We focus here, thought, on interventions specifically focused on Buddhist beliefs and practices usually conducted in Buddhist populations. This is primarily because of the “huge differences between the Western and Eastern approaches” (Schmidt, 2011, p 23) that result from Western mindfulness being largely stripped of its religious components (i.e., the Eightfold Path, particularly the first five moral precepts).
Emavardhana and Tori (1997) tested the effects of Vipassana meditation on psychological adjustment among two cohorts of 222 and 216 young Thai persons (average age 18 years), compared to a young adult Thai control group (n=281). Vipassana meditation is one of the oldest forms of Buddhist meditation that developed within the Theravada tradition. Similar to mindfulness meditation, it involves mindful observation of whatever arises in consciousness. Participants in the first two cohorts attended a seven-day Vipassana meditation retreat as part of activities supported by the Young Buddhist Association of Thailand. Each day was similar and began at 4:00 AM. Complete silence was observed at all times. All activities including eating and walking were done in a state of heightened awareness. The day was spent with alternating periods of sitting and walking meditations, mindfulness exercises, listening to brief sermons, and performing morning and evening prayers. Small group discussions were also held with the meditation master. The day ended with an hour of sitting meditation and evening chanting. Controls and meditating groups were similar in age, gender, education, percent high school students, and demographics, but controls received no intervention of any kind Both groups completed test forms before and after the seven-day retreat or observation period. Results indicated that compared to controls, meditators after the retreat scored higher on self-concept, positive ego defense mechanisms, maturity, tolerance of common stressors, and Buddhist beliefs and practices. Buddhist beliefs and practices were associated with greater self-esteem and less impulsiveness.
Tori (1999) compared the effects of attending a 3-day Roman Catholic retreat (n=102), a 3-day Buddhist retreat (n=102), or a control condition (n=102) in 306 teenage Thai girls (average age 16 years). Thai girls in the roman Catholic retreat group were from a large parochial high school in Bangkok. Participants attending the Buddhist retreat were part of the Young Buddhist Association of Thailand or were from elsewhere in the country. Those in the control group attended government secondary schools in Bangkok. The Adjective Checklist was used to compare the emotional state of girls before and after the retreat (emotional maturity, achievement, sympathetic warmth) with controls. The Catholic retreat involved liturgical ceremonies, prayer, sermons, and discussion groups. In contrast, the Buddhist retreat involved complete silence, alternating periods of sitting and walking meditation, a sermon, and paying respect to Buddha. Results indicated that Thai girls attending the Buddhist retreat showed significantly greater change scores on emotional maturity and sympathetic warmth (but not achievement) compared to Thai girls attending the Catholic retreat or those in the control condition.
Margolin and colleagues (2006) examined the efficacy of a spiritually-focused intervention for improving motivation for HIV prevention among 72 non-Asian methadone-maintained patients in New Haven, CT. All participants (ages 21-56) were opiate dependent using heroin for an average of 17.7 years prior to entering the methadone treatment program. They were randomised to either standard care plus eight weeks of the intervention (n=38) or standard care alone (n=34). The intervention was 3-S Therapy, which authors described as a manual-guided spiritually-focused psychotherapy using a Buddhist framework (the Eightfold Path). In this study, the 3-S therapy was administered in eight weekly sessions, either as individual sessions (n=20) or as group therapy sessions (n=18). Measures administered at baseline and post-treatment (2 time points) were a computerised reaction time task, spiritual/religious practices (four items assessing private religious practices and two items measuring public religious practices), a measure of the 10 Buddhist perfections, measures of motivation for HIV prevention and HIV risk behaviour, and a qualitative posttreatment interview. Eighty-five percent of participants completed the 8-week study. Computerised reaction time, spiritual/religious practice, expression of spiritual qualities in daily life, and motivation for HIV prevention increased and HIV risk behaviours decreased from baseline to follow-up in the intervention group (with al time by group interactions significant at p<0.05).
Rungreangkulkij and Wongtakee (2008) examined the effects of Buddhist counselling in 21 participants with anxiety disorder in northeastern Thailand (average age 42, all Buddhists). Buddhist counselling (administered by a graduate nursing student) was based on the “three universal natural laws”: the law of impermanence (anicca), the law of suffering (dukka), and the law of selfishness or not self (detachment from the physical world and the ego) (anatta). Assessed were anxiety symptoms using the State-Trait Anxiety Inventory (STAI). Each session lasted 60-90 minutes and was organised into four stages: (1) developing rapport, active listening, and demonstrating compassion; (2) education using stories and explaining the universal natural laws; (3) practicing mindfulness meditation during the session (and at home); and (4) conclusion and assessment of participants’ perceptions, beliefs and understanding. A total of two sessions were held separated by one month. Participants were assessed at baseline, post-intervention, and at 2 month follow-up with the STAI administered by a nurse. After the three-month period STAI scores decreased significantly (p<0.001). Investigators concluded that the study indicated that counselling based on Buddhist principles had the potential to benefit patients with anxiety disorders.
Summary
The above reports are the only studies published prior to 2010 that could be located in our systematic exhaustive review of the literature (Koenig et al., 2012). There were 22 observational studies and 4 clinical trials. Five of the 22 observational studies were descriptive or qualitative, suggesting that Buddhist beliefs and practices are used widely to cope with psychological stressors Five quantitative studies compared Buddhists and non-Buddhists, with three finding that Buddhists had better mental health than non-Buddhists, one finding worse mental health (likely due to lower educational and income level), and one finding no difference. The remaining 12 studies examined the association between religiosity and mental health among Buddhist population (or Asian populations with a large proportion of Buddhists). Of those, four (33%) reported positive associations with better mental health or fewer suicidal tendencies, three indicated a negative association (25%), one reported mixed results (positive with intrinsic religiosity, negative with extrinsic religiosity), and four found no association. While all four intervention studies described above showed significant effects, the methods were limited by either having no comparison control group or the control group did not receive a comparable amount of social attention as the intervention group. Thus, the benefits found for these interventions may have been due to higher levels of social contact and attention or simply due to the passage of time.
These studies suggest that the mental health of Buddhists is as good as (if not better than) that of non-Buddhists, that religious practice among Buddhists is sometimes (four of twelve studies) associated with better mental health and perceptions of health, and that Buddhist-based intervention are frequently effective in reducing distressing emotional symptoms in Buddhists compared to no treatment.
Conclusions
This systematic review of quantitative (and some qualitative) research conducted up through 2010 examined studies that compared Buddhists and non-Buddhists on mental health (and substance use), explored the relationship between religiosity and mental health in Buddhists, and examined the effects of Buddhist interventions on mental health outcomes. These early studies suggest that Buddhists often have better mental health than non-Buddhists (especially in situations of high stress or torture). Buddhist beliefs/practices are sometimes associated with better mental health and sometimes with worse mental health. Buddhist interventions uniformly lead to a reduction in symptoms of mental distress (at least among studies reviewed here). Limitations in research methodology, however, prevent any definitive conclusions in this regard. What about more recent research?