BUDDHIST PSYCHOTHERAPY Revised Edition H. S. S. Nissanka MA. (Pitts.), Ph. D. (Jadv) Foreword Prof. L. P. N. Perera Former Vice Chancellor University of Jayewardenepura BUDDHIST CULTURAL CENTRE 125,Anderson Road, Nedimala, Dehiwela, Sri Lanka Tel: 734256,728468,726234 Fax: 736737 URL No. www.buddhistcc.lk E-mail No. bcc@ sri.lanka.net Preface This is a rewritten edition of the book Buddhist Psychotherapy which was originally published by Vikas Publishing House in New Delhi in 1993 and it had gone into three reprints and a paper - back edition. Since then, this writer has gained new insights into the subject through a large number of case studies (treatment of mental patients) and lecturing at the Post Graduate Institute of Pali and Buddhist Studies, University of Kelaniya during the last four years. Anually over 50 foreign and local students follow the M. A. Degree Course in Buddhist Psychotherapy at the above mentioned institute and the need for a text book on the subject was felt. Hence the original book was rewritten to be used as a text book on the subject. This book provides an alternative theoretical model for psychotherapy in general and psychoanalysis in particular. This model in based on some principles drawn from the teachings of the Buddha and therefore the name "Buddhist Psychotherapy" was given to it. The basic nature of the human mind, irrespective of colour and creed, is common to every human being. The message of the Buddha is universal and therefore the system of Buddhist Psychotherapy is applicable universally without destroying or disturbing religious faiths to cure mental illnesses and to develop mental health. "Buddhist Psychotherapy" can be practised by trained psychiatrists and by those who have a basic knowledge in psychology; but both of these categories- the psychiatrists and the laymen should essentially have kindness (concern and care) which results from seeing and knowing the suffering undergone by the mental patients and their immediate relations. The therapeutical method given in this book is veri fiable, testable and repeatable. Therefore this writer maintains that this is a scientific approach to curing mental illnesses of various categories including schizo phrenia. May this book contribute even in a small way, to relieve the sufferings of mentally sick people the world over. It is with a deep sense of gratitude that this author recalls the valuable suggestions to improve this theo retical model, given by the late Ven. Bhikkhu Piyadassi Nayaka Maha Thera, Vajiraramaya, Colombo and the late Prof. K. N. Jayatilleke, the Head, Dept, of Philosophy, University of Peradeniya, Sri Lanka. And to the late Prof. L.P.N. Perera, former Vice Chancellor, University of Jayewardenepura for writing the foreword to this book. Finally this writer thanks Ven. Kirama Wimalajothi Nayake Thera, Director, Buddhist Cultural Centre, Nedimala, Dehiwela, Sri Lanka for Publishing this book and to Rukmani, my wife for going through the manuscript. Dr. H. S. S. Nissanka 19, Kundasale, Sri Lanka. Tele (0094) 08-420789 Foreword Mtadern civilization has imposed many strains on man, and those in the psychological realm are, perhaps, among the most serious. The innumerable demands of modern life give rise to many tensions in both the mind and the nervous system. Psychopathological and neuropathological problems are now receiving increasing attention at the hands of students of these subjects. And, as declared by the Buddha over 2500 years ago, and as emphasized by that great American psychologist, William James, the realities of the mind are as important as, or per haps more important than, the realities of the body. Hence the significance of mental health and mental culture as advocated in Buddhism. There is also some evidence to indicate that in the new vision of reality now emerging on the world's intellectual horizon, an awareness is gaining ground, as a modern physicist puts it, "of the essential interrelatedness, and in terdependence of all phenomena - physical, biological, psychological, social and cultural" which transcends "cur rent disciplinary and conceptual boundaries.” (v. Fritjof Capra, The Turning Point, Science, Society and the Rising Culture, London 1982, p. 285). In this context, exam ining the contribution of a world religion like Buddhism in the field of psychotherapy, is bound to be a very re warding exercise since it should have a significant bear ing on the totality of human experience. Buddhism looks upon man as a psycho -somatic unit, the balanced functioning of which is considered necessary for the attainment of the objectives recommended by the Buddha. This would involve the recognition (now increas ingly admitted in modern medicine) of a fundamental in terdependence between mind and body at all stages of ill ness and health. Since the mind and body react on each other, the health of both are equally important. However, as the Dhammupada puts it, "the mind is the fore-runner of all phenomena" ( Dh, I:l&2) and this means that in the Buddhist perspective the framework within which health should be looked at, takes mental health into account first. And mental health needs physical, psychological and so cial support, which means that mental health itself is not a one dimensional phenomenon. It involves an interplay between mind, body and environment. Thus, health, in general, may be said to result from a balance - a dynamic balance involving the physical and psychological aspects of man as well as his interactions with his natural and so cial environment. The task of psychotherapy, therefore, is multidimensional, demanding a broad, holistic approach if it is to be successful. This is the message of this publi cation; this is what Dr. H.S.S. Nissanka, the author, wishes to convey within a Buddhist frame of reference. In the ultimate analysis, psychotherapy deals with hu man consciousness, and human consciousness is of prime concern to Buddhism. While the Buddhist view of con sciousness goes beyond the framework of contemporary science, it is by no means inconsistent with the modern systems concepts of mind and matter. Buddhism is con cerned with the perfectibility of man, which, it maintains, is possible only through an upgrading of his conscious ness. A pre-requisite towards such an effort, as well as for general physical health is mental health, since illness in its essence, is a mental phenomenon. That this is so, is being more and more realized today. This means that, as Buddhism sees it, perfect health is really a condition of the mind. This is borne out by the Buddhist theory that the only individuals perfectly healthy are the Buddhas and the Arahants who, while being subject to physical pain ( dukkha), have transcended mental pain ( domanassa). All other beings are at various points below that level. Thus, to the average worldling ( puthujjana), psychotherapy should be helpful in regaining lost health by a psycho-so- matic balance effected through the mind. Human consciousness, being the main concern of Bud dhism, the teachings of the Buddha basically deal with mental culture, and this implies that an elimination of mental problems at the very beginning is a sine quanon. This would necessarily involve a therapeutic approach. And, an important idea emerging through Dr. Nissanka's contribution, is the manner in which all the teachings of the Buddha could be considered to be of therapeutic value. The very "dialogue-form" of the Buddha's discourses savours of a psychotherapist's approach to a patient requir ing attention. The Buddha was the physician and the sur geon of the psyche. It is not without significance that the "surgeon supreme" (bhisakko sallakatto anuttaro) who, as borne out by the Canon, believed in treating the cause ( nidana) and not the symptoms of the human predicament, foreshadowing as it were, the basics of modern psychotherapeutical treatment. Furthermore, while all human disorders are basically mental, in the Buddhist view, .they stem from one or more of three unhealthy mainsprings of human motivation, viz. greed or attraction ( lobha), hatred or repulsion ( dosa) and non-understanding or delusion ( moha). Dr. Nissanka deals with these factors exhaustively to demonstrate how they could be of value in understanding a patient. At a time like the present, when the focus of psychology in general is shifting from psycho logical structures to the underlying processes, Dr. Nissanka's observations in this respect are quite sig nificant. Buddhism is a spiritual discipline. And,as admitted by advanced scientific thinking, with its holistic approach to health, spiritual disciplines, if properly practised, could promote health. Dr. Nissanka recognizes this fact by dis - cussing mindfulness in the Buddhist perspective. Further more, he notes that in the various forms of awareness ( anupassana) recommended in Buddhist therapy, the aware ness of an ‘I’ consciousness is not involved,thus imparting a unique distinction to Buddhist Psychotherapy, a de parture from Western methods. Dr. Nissanka emphasizes that what is most important "as the first step in treatment is the development of co operation and communication between the therapist and the patient." This is also obviously the first step that psychologists like Jung, Maslow and Assagioli, who have moved away from the Cartesian bio-medical model to be more in tune with the holistic approach of advanced sci ence, would advocate, and is completely Buddhistic; reminding one of the 'dialogue-form' of the Buddha's discourses, as referred to earlier. The essence of this approach is to look at the patient as an individual capable of growth and self-actualization, and to recognize the human potential. the development of which is the main objective of Buddhism. As evident from this publication, Dr. Nissanka has marshalled his facts and thoughts quite well. Though mostly in translation, he has quoted in extenso from the Buddhist canonical texts to support his arguments. And his objective is to pave the way for a system of psycho therapy in keeping with the fundamental tenets of Buddhism. The value of this publication is also enhanced by the fact that Dr. Nissanka speaks with his own experience in the field of psychotherapy - experience gained through an approach from the Buddhist's point of view. The case histories cited provide fascinating and instructive material for the general reader and practitioner alike. Taking all these factors into account, it could be stated that this contribution of Dr. Nissanka in the field of psy chotherapy from the Buddhist angle - a contribution to which I have the honour and privilege of providing this Foreword - is a long felt desideratum. I have read his pages with much pleasure and profit, and am sure many a reader will benefit the same way. PROF. L.P.N. PERERA, Ph.D., Formerly Professor of Pali & Buddhist Studies and Vice-Chancellor, University of Sri Jayewardenepura, Sri Lanka. Contents 1. Preface 2. Foreword 3. An Introduction to Buddhist Psychotherapy. 4. Western Psychotherapy 5. Western Psychoanalysis 6. 7. Treatment of Insanity in Asia. The need for a new approach to Psychotherapy 8. Teachings of the Buddha as the Basis of Buddhist Psychotherapy 9. Objectives and Targets of Buddhist Psychotherapy 10. Development of Communication 11. Development of Body Awareness 12. Development of Feelings Awareness 13. Development Mind Awareness 14. Analysis of Mind Contents The Curative Process 15. Rehabilitation and Socialization 16. Case Studies 17. Bibliography 18. Index INTRODUCTION TO BUDDHIST PSYCHOTHERAPY (1) Buddhist Psychotherapy is a system of treating men tal patients which had been experimented with and developed by the author during the past forty five years. Various mental illnesses including schizophrenia can be and have been cured by this therapeutical method. (2) This system of psychotherapy received academic recognition as the author was invited by several univer sities in Sri Lanka, India, and Nepal to give lectures on " Buddhist Psychotherapy ". The book on this sub ject was first published by Vikas in New Delhi in 1993 and it went into several editions. The Post Graduate Institute of Pali and Buddhit Studies of University of Kelaniya , Sri Lanka invited the author to conduct an M. A Degree Course in Buddhist Psychotherapy in 1997 and in 2001 and 2002, there were students following this course from 12 countries in the East and West. A student of this method will get the following benefits: 2 (i) Mental illnesses can be cured by this method. (ii) It will enable one to understand people - the working of their conscious and unconscious minds. (iii) A sound knowledge of this method of treatment will help one to maintain and develop one's own mental health in our present stressful society - it will help one not to be mentally ill. (3) It is now a well established fact that mental ill nesses can be caused both by physical and mental factors or by a combination of both. Mental illnesses caused predominantly by physical factors have to be treated medically using methods such as chemotherapy (medication), electroplexy and psycho-surgery; illnesses caused by mental factors have to be treated psychotherapeutically. According to this system of Buddhist Psychotherapy, the mental factors that cause mental illnesses are iden tified as mental defilements - " the kleshas", but in dealing with kleshas one has to understand - one has to see and know both one's own body and mind. The mind, even in its normal state, is full of kleshas or defilements. (4) From the days of Sigmond Freud - the father of modern western psychotherapeutical and analytic school - several schools of psychotherapeutical analysis have been developed. Buddhist Psychotherapy is a stage in this evolution. (5) Buddhist Psychotherapy can be practised as complementary to existing western psychotherapeutical methods. A practioner of Buddhist Psychotherapy will have to seek the help of a psychiatrist on two occasions - (i) When a patient is extremely depressed. (ii) When a patient is extremely violent unless such a patient is medically treated and re stored the ability for communication, the system of Buddhist Psychotherapy can do very little. (6) This method of treating mental patients is called Buddhist Psychotherapy because it is based on the teachings of the Buddha. The basic vision behind this method is to be found in the following dis courses by the Buddha: i Satipatthana Sutta - the Discourse on Mindfulness (Majjima Nikaya No. 10) ii Sabbasava Sutta - the Discourse on All Mental Cankers (M.N. No. 2) iii Vatthupama Sutta - the Discourse on the Simile of Cloth (M.N. No. 17) Besides the above, the basic teachings on "anicca"(impermanency) " dukka" (disharmony), " paticca - samudpada" (dependent origination) " panca - nivarana" (five mental hindrances) and "dasa sanyojana" (ten fetters) are incorporated into this method of psychotherapy. (7) Buddhist Psychotherapy is universal in its scope; mental patients whether they are black or white, whether they are Christians or Moslems or Hindus, whether they are Marxists or atheists, can be treated by this new menthod because people all over the world are alike when it comes to causes of mental illnesses. All are with kleshas that may cause mental illnesses. This method can be applied without caus ing them to change their religious faiths. Definitely it is not a means of conversion. (8) Six Steps Buddhist Psychotherapy consists of six steps that a mental patient has to go through. i) Development of communication between the therapist and the patient. ii) Development of body awareness by the patient. iii) Development of feeling awareness by the patient. iv) Probing into the patient's conscious and uncon scious mind and bringing to light materials (memories mingled with kleshas) buried particu larly in the unconscious mind. v) Analysis of the selected materials that are linked to the mental illness - the causes of the illness are made to be seen and known by the patient himself. vi) Rehabilitation and socialization of the mental patient who has successfully gone through the first five steps given above. (9) An experienced Buddhist Psychotherapist can complete this psychotherapeutical effort within eight to 10 sessions each running from one to one and a half hours per week. It may take five or six sessions more to treat a patient whose level of intelligence and per - ceptiveness is lower. Apart from the weekly sessions the patient has to fol low daily the instructions given by the therapist un der each of the above mentioned six steps. All this cannot be successful if the patient is not motivated to achieve recovery. For daily practise of instructions, family support is sometimes necessary. (10) Even after the initial recovery of mental health, there can be relapses of the mental illness. In such a case the patient has to be brought back to the therapist for further guidance. In treating cases of relaps, the therapist has to use his discretion and have a combination of two or more steps at each sessi on. Here, again, the importance of rehabilitation has to be stressed. (11) The final target of Buddhist Psychotherapy is to make a mental patient a normal human being who can man age his kleshas such as anger, suspicion, greed, melevolence, and jealousy. This system has both positive and negative approaches. In its positive approach a patient is guided to at least two of the seven factors leading to enlightenment (Sapta Bojjhanga Dhamma). namely (1) the practise of mindfulness (satisambojjhanga) as given in the Satipatthana sutta and the practice of ’’ viriya" which means striving (viriyasambojjanga) to complete the six steps of Buddhist Psychotherapy and (2) control and reduction of kleshas that caused the mental illness. (12) The Buddhist system of Psychotherapy is nothing but getting the patient to practise meditation; it deviates from the traditional forms of meditation such as "Samatha" (concentration) and "Vidarshana" (analyti cal understanding). The Buddhist Psychotherapy uses both these forms of meditation but they are modified and structured to suit the mental patients who have lost control of their bodies and minds. How this is done is described with illustrations (case reports) in the rest of this book - "The Buddhist Psychotherapy". 2. HISTORY WESTERN PSYCHOTHERAPY (1) There are, to my knowledge, five systems of psycho therapy which are being practised in the world to day. They have been developed during the last two centuries in the western world. (2) Five Systems of Psychotherapy (a) Chemotherapy : Medical practioners, mostly psychiatrists use chemicals or chemical compounds to create a balance between the body and the mind of a mental patient. This is the most popular and intensly used method of psychotherapy. (b) Electroplexy: Here, using special electrical devices, the mental patients are given electric shocks of short duration. This is the second mostly used method in the world. As it is also a specialized therapy, only the psychiatrists should use it. (c) Psycho - surgery : Brain operations are done with a view to altering certain behaviour patterns of the mental patients. Since the risk involment is greater, the system of Psycho-surgery has not been very popular. Under this system specific glands are also operated to normalize behaviour patterns of mental patients. (d) Psycho - analysis : Mental patient's mind is probed into to discover the mental causes of the mental illness. By means of psycho-analysis, it is attempted to make the patient aware of the causes of his mental illness. It is believed that with self knowledge resulting from psychoanalysis, the mental illness would be cured or ameliorated. (e) Behavioural therapy : Behavioural scientists (social psychologists) have advanced a system of therapy through which they aim at changing or removing the symptoms of the mental illness so that the normal behaviour would be restored. (3) It took nearly two centuries for the five above men tioned methods to develop to their present level. All these methods are tought in the faculties of medicin e in the universities of East and West. A new subject has emerged - Psychiatry-which is a compulsory subject for the basic medical degrees. Now these meth ods can be studied under post graduate programmes also. (4) Up to the beginning of the 19th Century the western world had no system of psychotherapy. There was a prevailing belief that mental illnesses were caused by evil spirits. Therefore "the doctors" who thought that they have the power to drive away the spirts pos sessed by the patient, were the only persons to whom the people could go. It was a common treatment in European countries to drill the skull of the patient and leave a hole so that the evil sprit could go out or escape. Some physicians believed that the mental illnesses were in the blood of the patient and therefore they let out his blood and infused blood from a healthy person. (5) Practically in every country in the Western World mental patients were treated as anti-social criminals. They were dumped into the mental asylums; kept chained on to the walls. Some patients, as a way of treatment were exposed to sun, rain and even snow in open courts. Those patients in the open courts were a source of amusements to the people who flocked to the fences as they would go to see animals in a zoo. (for details see : Psychiatry Today by David Stafford Clark) (6) In 1733, an English physician George Cheyne, pub lished a treatise on nervous disorders. This work cre ated new public interest in mental patients. (7) In 1814 in England, a committee of inquiry was ap pointed to look into the pathetic conditions of the mental asylum - the York Asylum . This committee reported on the inhuman methods of treating mental patients. A similar study was made at Royal Bethle hem Mental Hospital in London by its medical superintendant John Connolly. (8) In 1815, a select committee was appointed under the chairperson James Birch Sharpe, a member of the Royal College of Surgeons to recommend meausures to improve the treatment of mental patients. Thus in the western world, England gave the lead in establishing more humane mental hospitals. In France, Anton Mesmer advanced a theory of magnatism aimed at treating mental patients. In 1784 Academy of Sciences in France investigated Mesmer's use of magnetic wand to treat mental patients and declared that it did not produce proper treatment. But the theory of magnetism as a therapy led to new experiment called "Hypnotism" in late 19th century. In England, surgeon James Braid took to hypnotism as a method for treating mental patients. In France, physician Charcot opened a clinic to treat mental patients by using hypnotic method. Sigmond Freud, reputed neurologist too, used this method at Vienna in Austria. Some neurologists like Dr. Meynert challenged Freud on the efficacy of hypnotism as therapy. The great debates took place in several places in Europe over this subject. Bernhiem, a pupil of Charcot too joined Freud. Later on, Freud gave up hypnotism and turned to the technique of free association to discover the causes of mental illnesses. In 1882, Tuke and Bucknill in England published a text book called "Psychological Medicine". Emil Kraepelin and Eugen Bleuler contributed a lot to the development of clinical psychology. Kraepelin observed three forms of mental illnesses. (a) Dementia praecox (an illness which leads to dis- integration of personality - This illness is now known as schizophrenia.) (b) Manic depressive psychosis. (A mental disorder which alternates between period of excitement and depression) (c) Paranoia (an illness with delusions and persecutions) (11) During the period from 1885 to 1920, psychoanalytic method developed by Freud led to the development of new approaches to psychotherapy by Carl Jung and Alfred Adler who were pupiles of Freud. The establishment of American Psycho-analytic Association is also a land mark of the development of psychotherapy in modern times. (12) In the western world psychotherapy never got stag nated. During the last 125 years psychotherapy - now better known as psychiatry - became a subject of research; lots of new drugs for mental illnesses have been already discovered and new more psychotic drugs are being available at comparatively cheap prices. As mentioned earlier, five branches of psychotherapy have been developed. (13) Treatment of mental patients on humane mannar, is a big contrast to the methods of treatment for mental patients in the western world up to the end of the 19th century. Therapeutical Developments (14) During the 20th century lot of researches have gone on two directions - (i) scientific study on mental disorders (mental illnesses) to determine the psycho, physical conditions of specific mental illnesses and the causes that brought out those illnesses, (ii) scien tific study of the chemical reactions of psychothera peutic drugs and their efficay in restoring mental health of the patients. This is an on going healthy development that we find in the West. This resulted in producing psychotherapeutic medicines at comparatively cheap prices and identification of various mental illnesses. At private clinics and at public and private hospitals, now people can obtain psychotherapeutical treatments which are more hu mane in contrast to the practices that we found up to the begining of 20th century in dealing with mental patients. 15 Along with psychotherapeutical treatments several systems of psycho-analysis also got developed in the West. These schools can be devided into two groups - (i) personality oriented schools (ii) symptom oriented schools. Prof. Anthony Storr is one of the exponents of the personality oriented individual psychoanalysis. Prof Storr's book - "The Art of Psychotherapy" meant for post graduate students of medicine, describes how the analytical therapy should begin in an appropriate consultation room. Mental patients, according to Prof Storr, can be classified under the following four groups. (i) (ii) (iii) (iv) The The The The hysterical personality depressive personality obsessional personality schizoid personality, Hysterical Personality Prof. Storr : "The hysterical personality is dominated by the urgent need to please others in order to master the fears of being unable to do so. This results in restless activity, dramatization and exaggeration, se ductiveness either social, overtly sexual in manner (often creating dissappointment in the other person) and immature and unrealistic dependence on others. According to Storr, the most characteristic feature of a hysterical symptom is that it serves a purpose of which the patient is unaware because such symptoms spring from the patient's own unconscious. Hysteric patients act on inner compulsions (for details see the section on psycho -analytic therapy). Depressive Personality Writers on psychotherapy are in agreement on the point that there are two groups of patients who suffer from depression of varying degrees. They are known as "neurotic" and "psychotic". Neurotic depression is usually caused by a perceivable external event experienced by the patient. A neurotic patient does not get deterioration of his personality where as psychotic patient's personality gets deteriorated due to purely psychological factors - due to certain psycho-somatic conditons. Therefore, psychotic depression is described as " endogenous." Obsessional Personality People of obsessional personality type are those who are prone to develop obsessional orcomplusive symptoms. Dr Lyttle: " Obsessive complusive neurosis is an uncommon mental disorder in which unwelcome thoughts persistently intrude into consciousness and give rise to the urge to carry repetative actions." Schizoid Personality Character traits of "schizoid personality " as described by Storr are quite different from the personalities of hysterical, depressive and obsessional groups, while the hysterics seek attention the depressives are preoccupied with obtaining assent and the obsessionals engage in putting up defences. The schizoids are deeply disturbed persons who have withdrawn into themselves and they shun any kinds of human intimacy. Authorities on this mental illness agree that its causes are not very well known. (15) Schizophrenia Illness (a) Prof. Robert J. Waldinger, the author of " Psychiatry for Medical Students" makes the following observations on schizophrenia (see PP 77- 100). "Schizophrenia has been described as the cancer of mental illness, in fact the two conditions are similar in many ways. We do not know what causes schizophrenia or how to prevent it; our efforts at managing the illness once occurs have had limited success ...... What is schzophrenia? It is a syndrome that involves a highly altered sense of inner and outer reality to which the afflicted person responds in ways that impair his or her life.” (b) Dr. Jack Lyttle, in his book "Mental Disorders" makes the following observations on schizophre nia (see PP 57-85) Of all mental disorders schizophrenia probably causes more fear and misunderstanding than any other. It resembles most closely the layman's concept of " true madness" ...... (c) Symptoms of Schizophrenia (d) i ii Disorder of mood. Disorder of thought. iii iv Delusions. Hallucinations. V Disorder of volition. vi Disorder of expression. vii viii Withdrawal into a disordered inner world Motor disturbance. According to Dr. Lyttle, there are variations of Schizophrenia such as the following: (i) Simple Schizophrenia : In this, delusions and hallucinations are absent. This illness takes place during adolescence. Emotional blunting and loss of will power lead to progressive de terioration of personality. (ii) Hebephrenic Schizophrenia: This illness takes place in late teens. Dullness, apathy, delusions and hallucinations of the auditory type appear. Outburst of giggling and laughing and preoc cupation could also be observable. (i) Catatonic Schizophrenia : This is rare, but occurs in females of late teens and mid - twenties. The patient losses to the point of immobility. Hallucinations, irrelevant coining of words and stupor are the major symptoms of this illness. (ii) Paranoid Schizophrenia : This illness takes place at a later age (30-50 years) and the presence of delusion persecution mania and auditory hallucinations are its main symptoms. The patients of this illness will be hostile, suspicious and aggressive towards others. (16) Treatment i ii According to Prof Waldinger, there is no cure for this tenacious disease. He observes:" The current major treatment modalities - medicines and psychosocial therapies including hospitali zation -are all of limited efficacy and all have the potential to be harmful as well as helpful. Nevertheless, carefully designed treatment pro grammes can help many schizophrenic patients regain loss functioning and a greater sense of psychological well-being ...... " Dr. Price is of opinion that psychoanalysis should be avoided in the treatment of schizo phrenic, but he has not given any reason for it. He recommends hospitalization because it provides a suitable environment conducive to proper care of the patient. iii As stated by Dr. Price, the sudden developments of stammering, tics, psychogenic aches and pains, involuntary urination, premestrual ten sion, muscles rigidity or loss of muscels control can be treated by a combination of chemotherapy (medication) and psychotherapy including psycho-analysis. (17) Behaviour Therapy a) Several writers on behavioural therapy are in agreement on the following characteristics of behaviour therapy. i ii iii iv v vi vii It is symptom oriented. The therapy aims at relieving the symptoms. It is possible to fix time limit to go through a course of treatement. The therapist’s task is directive rather than interpretative. The patient is motivated to change his peculiar behaviour. Physical as well as emotional symptoms are dealt with. Negotiations and explanations are basic in this therapy. b) i Alan King, consultant behaviour psychothera pist gives the following as the aims of the behavioural therapy. To improve the qualtiy of the life of the patient. c) ii To establish the skills necessary for life in the community. iii To eliminate unwanted behaviour which constitutes major management problems. Leonard Krasner and Leonard Ullmann, the behaviour therapists maintain that "the Freud ian and client oriented procedures do not deal with the disturbed behaviour." The behaviour therapist attempts at changing the change-worthy behaviour by providing with positive and negative reinforcements. The behaviour therapy does not go into the history of the illness or into antecedents. Its emphasis is on the here and now, the prevailing conditions at the time of the treatment. d) Behaviour therapy is a form of rehabilitation in which reinforcements are provided to encourage the patient to engage in socially desirable activities. One such reinforcement is the technique of giving 'token economy cards' for the patient's performance of socially good actions. Each of such card has a value - a money value. For instance, if card's value is Rs. 1.00 if the patient has collected 10 cards a day, he will get Rs. 10/- at the end of the day. Behavioural therapy uses several techniques such as " systematic desensitization" and implosive therapy." (see Herald Maxwell: Psychotherapy - pp 91-96) Required Readings 1. Jack Lyttle - Mental Disorders - pp57-65, 221-227 2. Anthony Storr - The Art of Psycho therapy P.82 - 113 3. John Harding Price - A Synopsis of Psychiatry 200-210 4. Herald Maxwell - Psychotherapy - pp 91-97 5. Leonard Krasner & L.P. Ullmann - Behaviour Influence and Personality - pp 261-288 WESTERN PSYCHOTHERAPY PSYCHOANALYSIS (1) Psychoanalysis is one of the five methods that devel oped in the West particularly during the 20th cen tury. Psychoanalysis is a well recognised branch of medical studies throughout the world. Under psychoanalysis, a patient's mind is looked into for the purpose of discovering the causes of mental illness which are buried in the unconscious mind of the patient. Sigmund Freud, Alfred Adler and Carl Jung were the pioneers of this method of treatment. (2) Freud, along with his pupils - Jung and Adler first used with hypnosis to treat mental patients but later gave up this method and turned to the technique of " Free association". Following this method, Freud became convinced that " sex" was the root of mental illnesses; but Jung and Adler did not agree with him and developed their own theories on the subject. (3) 3 Freud studied various symptoms of different types of mental illnesses which were the results of psychological causes. Studies of the symptoms of mental illnesses led Freud to discover the nature of human mind - the existence of three layers of the mind i) ii) iii) Pre-conscious The conscious The unconscious Now it is a universally accepted fact that the greatest contribution of Freud to the development of psycho therapy was his discovery of the phenomenon called the unconscious. (4) In the course of two decades, Freud developed several methods for reaching the unconscious. " Free association" is one such method and Freud found it much superior to 'hypnotic method'. 5) Freud focussed his attention on symptoms of mental illnesses and believed that symptoms come up from the unconscious of the mental patient; further he stated that root causes of mental illnesses are to be found in the unconscious. He maintained that the memories of past experiences of the patient concerned are linked to incidents in his past, particularly of his childhood and adolescence. Due to various pychological reasons, some patients found it difficult to keep on remembering certain memories alive, and therefore they let such memories go into their unconscious mind. 6) The unconcious is an area of the mind which is very difficult to reach or to get to know and see. Freud made use of several techniques such as age regression, interpretation of dreams, repetetive errors, hallucinations, lapses and compulsive behaviour. Further, Freud discovered that patients use, particularly in dreams, symbolic language that has links to the causes of the illness. 7) Freud maintained that in a person sexual development takes place by stages. - (i.) Infantile or oral stage (ii) Anal stage (iii) Phallic stage (iv) Homosexual stage Freud stated that the human personality can be di - 8) vided into three segments (i) id (ii) ego ("I" and "mine" consciousness) (iii) super-ego. The "id" represents the unconscious which is guided by two prin ciples - pleasure principle; pursuit of pleasure and avoidance of pain; the ego protects the body and mind while the super ego censors the behaviour prompted by the id. Further, Freud maintained that there are two life forces or energies - i the libido and ii the thanatos (positive wishes and negative wishes) 9) Freud classified nervous problems into two groups - actual neuroses (physically developed nervous disorders) and ii psychoneuroses (mentally developed nervous disorders). He recognised three forms of psycho-neuroses - (i) conversion hysteria (ii) anxiety hysteria (iii) obsessive compulsory neurosis. Freud maintained that these three forms of illnesses can be treated by means of psycho-analysis. 10) According to Freud, patients react to psychoanalysis positively as well as negatively. Some patients develop methods of resistance to it by means such as transference of patients’ emotions (love and hate etc) on to the therapist; or by means of developing amne sia so that they can keep the causes of the illness un exposed. 8) Very few psychiatrists use the psychoanalytic method; but the psychiatrists all over the world use psychotic drugs (medication) as the easiest way of therapy. Further, they say that psychoanalysis is very costly and in the West only those who can spend about a minimum of US Dollars 2000/= can afford psychoanalytic treatment. There are case reports of patients who have received psychoanalytic treatment for more than twenty years. 9) a) Freud's psychoanalytic approach is not a retarded form of treatment as it is an evolutionary method of treatment. For instance Alfred Adler developed the school of individual psychology and he saw two psychological laws - (i) superiority complex and (ii) inferiority complex; any one of them may cause mental illnesses. b) Carl Jung maintained that human behaviour is not dominated by sexual libido as expounded by Freud. He neither accepted Adlers' theory of su periority and inferiority complexes. But Jung ac cepted Freud's theory of the conscious and un conscious mind. But further he maintained that there are two forms of unconsciousness - (i) personal unconsciousness and (ii) collective uncon sciousness; in personal unconsciousness there are the repressed experiences of the individual con cerned. In the collective unconsciousness there are premitive ways of action and feeling inherited by the individual through his culture. Jung main tained that in every civilized individual there are hidden uncivilized traits. Further, Jung advanced a new theory of two types of individuals namely extrovert type and intro vert type. Jung observed that extroverts put the blame on others for his actions while the intro verts put the blame on himself even when the others are responsible for certain actions. 10) All the above metioned pioneers of psychoanalysis have accepted the importance of dreams and their symbolic meanings in understanding the causes of mental illnesses. Jung, in addition, believed in the prophatic nature of dreams. 11) Freud visualized the limitations of psychoanalytical theory. In his book - A General Introduction to Psychoanalysis (1959), (Perma - book edition - pp 465471). Freud made the following, observation, "Many attempts at treatment, in the beginning of psychoanalysis were failures because they were under taken with cases altogether unsuited to the procedure; which nowadays we should exclude by following certian indications ..... In the beginning we did not know that paranoia and dementia praecox (present name:schizophrenia) when fully developed are not amenable to analysis. Yet we are still justified in trying the method on all kinds of disorders." This implies that Freud believed that schizophrenia is beyond the scope of psychoanalysis. Some of the modern psychiatrists generally believe that psychoanalysis is not suitable to treat schizophrenia; and therefore, they turn to medication and electronic shock therapy which are the easiast methods of treatment in which large numbers can be treated within shor* neriods of time Suggested Readings (1) Sigmund Freud - A General Introduction to Psychoanalysis - Perma Book - pp 87-222. (2) Clare Thompson - An Outline of Psychoanalysis - pp 25-38, 77-131, 137-184 (3) Lyttle Jack - Mental Disorders - Tindale - pp 5765 (4) David Stafford Clark - Psychiatry Today Pelican - pp 222 - 255 (5) Anthony Storr - Art of Psychotherapy Pelican - pp 77 - 144 (6) Herald Maxwell - Psychiatry Wright - pp 91-97 (7) Robert J. Waldinger - Psychiatry for Medical Students - Medical publishers (Chennai) pp 483 - 512 (8) James D. Page - Abnormal Psychology Tata Mcgraw Hill - (New Delhi) - pp 179-207 - 4 TREATMENT OF INSANITY IN ASIAN REGION (1) Dr. D V J Harischandra, the Consultant Psychiatrist, in his book " Psychiatric Aspects of Jataka Stories", reveals that most of mental disorders of modern times (as discovered by the researchers in the West), were known to people of ancient India and Sri Lanka. Dr Harischandra maintains that many forms of psychotherapeutical diagnoses found in the Jataka Stories are valid even today. (2) Dr. Harischandra has found 8 mental disorders in Dheeramukha Jataka Story. I quote below from his work mentioned above, (see: P 65-66 of the above mentioned book) (3) i ii Kama Ummada Darshana - sexual dysfunction - hallucination iii Moha - mental retardation iv Krodha - mania V Yakkha - possession disorders vi vii Pitta Sura - melancholia - alcohol dependence viii Vyasana - depression The well know Ayurvedic treatise " Charaka Samhita" mentioned 8 forms of mental disorders. These disorders are similar to those found in Dheeramukha Jatakaya. In the Ayurvedic texts compiled in Sri Lanka, 22 forms of mental illnesses are mentioned. Charaka maintains that mental disorders are caused by three factors as given below. i ii iii Thamas Rajas Satva - darkness = ignorance - dust = kleshas = defilements - imbalance of vata = wind pitta = bile and kapha = phlegm pitta = bile and kapha = phlegm (4) More than 2500 years ago, Gautama Buddha was the first person to draw a distinction between mental illnesses and physical illnesses. He said that it was very difficult to find some one in sound physical health but it was indeed far more difficult to find a com pletely mentally healthy person (see: Roga Sutta Anguttara Nikaya) (5) More than 2000 years ago, in India, a wonderful discovery was made on the subject of the causes of men tal illnesses as given in Charaka Samita. The three, causes are (i) 'rajas' = defilements (2) thamas = darkness=ignorance (3) satva = the imbalance of wind, bile and phlegm. The mental causes have to be known and seen by means of the analysis of the mind contents. But in Ayurveda no such analytical system of treatment has been developed to date. (4) In spite of the great discoveries by the Buddha and Charaka of India in the Eastern Region, it is strange that no one thought of developing a system of psycho-analysis in the East. Long before the west, in the eastern countries, sev eral chemotherapeutical systems were in practice. Use of dicoctions, application of medicinal pastry (isa kudicchi) on the head and use of medicinal oils etc. are some of the chemotherapeutical systems in vogue in the east. In the field of chemotherapy, the easterners have shown their skills in discovering the medicinal properties in herbs. For instance, the herb called "amukra" = ashvagandha) is used in the dicoctions for mental illnesses. This plant especially its roots are used for western treatments of mental patients. (5) The ayurvedic treatise Madhava Nidhana mentions seven types of mental disordes. ii iii iv V vi vii Vataja Ummada = insanity caused by wind Pittaja Ummada = insanity caused by bile. Kaphaja Ummada = insanity caused by phlegm. Sannipata Ummada = Combination of above three. Manobhavaja = phobias Visaja = insanity caused by poison. Bhutommada = insanity caused by spirit possesion. (6) Madhava Nidhana has recommended chemotherapy (use of dicoctions, oils etc) for above mentioned cat egories of 1,2,3,4 and 6. For phobias and spirit pos sessions this book of medicines has recommended "shanti karma" such as recital of mantrams, devil dance and offerings to invoke blessings by the spirits and deities. A medical treatise written in Sri Lanka nearly seven hundred years ago - "Yogarnavaya" has a section on mental illnesses and it is called "Ummada Chikitsa." The whole section runs to only two printed pages ! Even here chemotherapy (medication) and "Shanti Karma" are reommended as treatment for insanity. (7) There are in Sri Lanka, forms of mental therapy that have come down the ages as closely guarded family secrets. Some of those traditional physicians have their own mental wards (they are called hospitals) where mental patients are treated as indoor patients. Strangely, some of those traditional mental hospitals are run by Buddhist monks. In ancient Sri Lanka, the subject of medicine was taught even to the laymen by those Buddhist monks at their temples or tra ditional schools called 'pirivenas". (8) Practically, in every country in Asia there are forms of treating mental patients that have come down the ages. Unlike in the western countries we do not find scientific research even on traditional medicines. But the westerners have researched on medicinal herbs that are being used for treating mental patients. One such a plant is "amukkra" = Withania Somnifera (bo tanical term) = Aswaganda (in Sanscrit). A large number of medicinal plants recommended in Ayurveda for treating mental patients in India and Sri Lanka are being taken regularly to the western countries for making psychiatric medicines. (1) As mentioned in the chapter No 2, five methods of psychotherapy have grown in the West. It is now common knowledge that mental illnesses can be caused by either mental or physical factors or by a combination of both. Chemotherapy, schock therapy and psychosurgery deal with the body; by these methods, the western psychiatry aims at providing even behavioural changes, the removal of symptoms of mental illnesses. (2) Psychoanalysis and behavioural scientific methods aim at changing the unhealthy mind of a patient. However, these two methods are not helpful in going deeper into the psychological complexities of the mental patient. (3) In the western systems of psychotherapy, the psychological causes of mental illnesses are not clearly percieved. For instance, psychoanalytical schools of the west believe in accepting memories as causes of mental illnesses - such schools are incident oriented in recognizing the causes of mental illnesses; they do not think it necessary to go beyond the primary incidents which alone they believe to be the causes of mental illnesses. (1) Some schools of psychoanalysis do not go beyond the psychological complexes such as inferiority complex. This writer believes, however, that solely by making the patient aware that he has an inferiority or superiority complex or is an introvert or extrovert, it is not possible to change the psychological causes that brought about a particular mental illness. (2) Chemotherapy, schock-therapy and psycho-surgery generally ignore the psychological causes of mental illness; but aim at removing symptoms by treating the mental patient physically. (3) Psychoanalytic treatment is very costly. To repeat: James D Page, in his book "Abnormal Psychology" (pp 196-7) makes the following observations." The practical applicability of psychoanalysis as a method of therapy for psychoneurosis is extremely limited. One significant restricting factor is the high cost. Only patients who have at least US $ 2000.00 to invest in their neuroses are eligible for thorough treat ment. A second and related restriction is the time factor. Since each patient is seen one hour a day, five days a week, for an average period of 18 months, a hard working psychologist can treat completely about five patients a year" A third limitation is that it is not effective in many cases. (4) Freudian psychology - the id, ego an superego theory does not make any useful contribution to the task of discovering the dynamics of a diseased mind. ^8) Western psychoanalytic schools generally speak of defences used by the patients to prevent the therapist discovering the real causes that are buried in their unconscious. Much has been written about defences such as transference of patients emotions on to the therapist. Another defence mechanism is amnesia patial or full scale forgetfulness. But the western schools of psychoanalysis have failed to identify the psychological dynamics that are behind such defences used by mental patients. (9) Prolonged consultation may lead to other dangers. For instance, a patient may get permanently attached to his therapist and become a dependent invalid, also there is a possibility of patient's losing faith in the therapist thereby communication between the two could break down. (10) In spite of various efforts by institutions and govern ments to develop mental health and cure mental ill nesses throughout the world, people suffering from mental illnesses are rapidly on the increase. Therefore a new system of psychotherapy is needed - a system which can work independent of other therapies or as a system which can be complementary to the existing Five systems of psychotherapy. (11) The system of Buddhist psychotherapy as described in this post graduate course (M. A. Degree Course) has been developed as an attempt to remedy the shortcomings of existing psychotherapeutical systems in the world during the last two centuries. A COMPARISON OF WESTERN PSYCHOTHERAPY THE WITH BUDDHIST PSYCHOTHERAPY Buddhist Psychotherapy Western Psychotherapy 1 2 Admits that there are mental causes of mental illnesses Aims at discovering incidents as primary causes factors causing mental illnesses 2 Aims at discovering "Kleshas" (mental defilements) as primary causes Uses analytic methods Uses medication only on extreme cases of tension and depression 3 Uses analytic methods 3 4 4 Depends heavily medication 5 The therapist's work (treatment) will be over within 6 to 15 weeks. 6 Transference guarded. 7 Treatment is free or the therapist may charge a small fee - A therapist will have a limited number of sessions from 6 to 15 weeks only. 8 Professionally not established as yet. 9 No dependence after the completion of therapy 5 No definite time limit for treatment - may continue treatment even for more than twenty five years. 6 Possibilities transferance greater 7 Treatment is costly 8 Professionally established 9 1 on of are well Possibility of patient's dependence is greater Admits psychological is well 6 TEACHING OF THE BUDDHA AS THE BASIS OF BUDDHIST PSYCHOTHERAPY (1) Recommended Readings i Discourse on Mindfulness (Satipatthana Sutta) Digha Nikaya - No 22, Majjima Nikaya Vol. 1 - No. 10 ii Discourse on All Cankers - Sabbasava Sutta - M. N. No 2. iii Discourse on Defilements - Vatthupama Sutta M.N.17 iv Discourse on Breathing Awareness - Anapana Sati Sutta - M . N . Vol. 3 - Anupada Vagga No. 8 v Discourse on Five Hindrances - Anguttara Nikaya vi The Removal of Distracting Thoughts Vitakkha Santhana Sutta - M.N. Vol 1 - No. 20 vii Heart of Buddhist Meditation Ven. Nyanaponika Thera viii Buddhist and Freudian Psychology - P. de Silva Satipatthana Sutta All the above mentioned recommended readings stress on one point - the need to cultivate mindfulness. Ven. Nyanaponika, in his book - "The Heart of Buddhist Meditation-defines the word "Satipatthana" thus: In the compound Pali term 'Satipatthana', the first word sati (Sanskrit : Smriti) has originally the meaning of memory = rememberances. In the Buddhist usage, however and particularly in the Pali scrip tures, it has only occasionally retained the meaning of remembering past events. It mostly referes there to the present, and as a general psychological term, it carries the meaning of "attention" or "awareness" patthana = keeping present = keeping near." In this study, the writer uses the word 'Satipatthana' as "de velopment of awareness." (The Heart of Buddhist Meditation Nyanaponika - 1953-p.4) (3) The Satipatthana Sutta was delivered by the Buddha in a village called "Kammasa - damma in Kururata - a place in present New Delhi City - about 10 km. away from the Central Railway Station in New Delhi (4) The Buddha introduced Satipatthana Sutta in the fol lowing words : "This is the only way, Monks, for the purification of beigns, for overcoming of sorrow and lamentation, for the destruction of suffering and grief, for reaching the right path, for the attainment of Nibbana - namely the four foundations of mindfulness." (5) At present, however, we are concerned with 'Satipatthana' to be used for therapeutical purpose only - that is to cure mental illnesses. We cannot go very far in gaining spiritual achievements such as 'Jhanas' or realization of 'Nibbana'. In case of mental patients, Satipatthana has to be toned down and begin with a slower approach. (6) Kayanupassana (Development of body-awareness) Satipatthana Sutta guides us correctly to start with the development of body awareness - to be aware of one's own body or that of another person or persons . One's own body or that of another person is an object which can be touched and seen - the body is a tangible object. Therefore it is easy to begin concentra tion on it. (7) The Buddha, in Satipatthana Sutta, has recommended the following six methods of developing body awareness. i Developing awareness of breathing process. (anapana sati) ii Developing awareness on the postures of the body - sitting, standing, walking and sleeping postures, (iriyapatha) iii Development of clear comprehension of ones own actions such as talking, thinking and bodily functions. (Sampajana) iv Development of seeing and knowing the impuri ties of the body, (patikula manasikara) v Development of awareness of the elements of the body, (dhatu manasikara) vi Development of awareness of the process of decomposition of the body, (nava - sivathika manasikara) (8) Vedananupassana (Seeing and knowing feelings) It is also easy for a mental patient to see and know his feelings associated with his body and mind. This sutta makes it clear that people generally experience three kinds of feelings - i pleasurable ii unpleasant iii neutral (neither pleasurable nor unpleasant) These feelings - paticularly the first two can be understood by mental patients without much difficulty. A normal person in guided meditation, can get to know and see several grades of feelings. Even pleasurable feelings can be divided into two groups - i mundane pleasure (samisa sukha) ii spiritual pleas ure (niramisa sukha) In Bahu -Vedeniya Sutta, (M.N. Gahapati Vagga - No. 2) the Buddha has identified the existance of following grades of feelings; firstly, the basic division is the afore mentioned three groups. However the Buddha has sub-divided these basic groups into five; then into eighteen, then into thirty two an finally in to 108 grades of feelings (vedananu passana) (9) Cittanupassana (Seeing and knowing the Mind) After the cultivation of awareness of feelings the Satipatthana Sutta recommends us to observe our own thoughts. One who practices meditation on the mind, will see his own thoughts and identify them as belonging to one of the following - thoughts of lust and desire, thoughts without lust and desire, thoughts of hate, thoughts without hate, thoughts of ignorance, thoughts without ignorance, shrunken thoughts, dis tracted thoughts, concentrated thoughts, developed thoughts ......... etc. Thus, he develops mindfulness of thoughts. (Here Satipatthana Sutta does not men tion the identification of thoughts which are both in the conscious mind (sampajana manosankhara) and the unconscious mind (asampajana manosankhara). This Sutta stresses the importance of seeing and knowing the mind and its contents (thoughts = caitasika) in onself or the mind of others. (8) Dhammanu passana (Seeing and knowing oneself through the Dhammas) (a) One who observes the mind will also see the con tent and the nature of his own thoughts. He will ob serve whether one or many of the five Hindrances (Panca Nivarana) are operative or not operative in his own mind. The five hindrances are : i Kamachanda = strong drive for sensualpleasures ii Vyapada = strong drive of anger iii Thenamidda = strong tendency to sloth and drowsiness. iv Uddacca Kukkucca = A powerful tendency to be of scattered and distracted mind. v Vicikicca = A powerful tendency towards doubt and suspicion (b) Under Dammanupassana, one may go still further and observe in oneself the levels of one's own seeing and knowing the following Dhammas: i Four Noble Truths - Caturarya sacca a. Truth about one's own suffering (dukkha) b. Truth about several factors arising together to cause suffering c. Truth about the non-arising together of several factors d Truth about the way to the ceasation of one's own suffering. Comments : A mental patient and his mental illness can be looked into on the basis of caturarya sacca for instance : A patient should be made aware that he suffers on account of his mental illness. This is opening his eyes to his own dukkha. That his illness is the result of several factors (causes) of patient's life coming together (Samudaya Sacca). According to Satipatthana Sutta, the one and the only way to ceasation of suffering is the practice of the four fold mindfulness. Therefore by getting the patient to see and know - to be mindful of the cause of his mental illness, is the way to cure his mental illness. (magga sacca) When the patient has become so mindful as to see and know the cause of his illness, the cure comes of its own. The patient suffers no more of his illness (nirodha sacca). The five Aggregates of Clinging. Satipatthana Sutta, among other Dhammas, gives the doctrine of clinging on to the following five aggregates. i Physical form (rupa skandha) ii Feelings (Vedana) iii Perception (Safina) iv Thoughts (Sankhara) v Consciousness (Vinfiana) (Comments : For mental patients, the development of awareness of the five aggregates (panca - skandha) is beyond their reach. This approach is possible when they recover from the illnesses or in case of mental patients whose level of intelligence is very high.) (b) Satipatthana Sutta under the Dhammanupassana refers to development of awareness on the six sense bases : eye, ear, nose, tounge, skin and mind. (c) Finally Satipatthana Sutta recommends the devel opment of mindfulness on the seven factors of en lightenment (Sapta - bojjanga dhamma). They are: i ii iii iv Mindfulness (sati), Inquiring into dhamma (dhamma Vicaya) Striving (Viriya) Rapture - joy (piti) V Tranquillity (passadhi) vi Concentration (Samadhi) V Equanimity (Upekkha) Comments : The whole system of Buddhist Psychotherapy is mostly based on the development of mindfulness in the mental patient. It uses the system of meditation called "anapana sati bhavana extensively which is toned down to the level of comprehensibitily of the mental patients. Along with this form of bhavana factors such as striving (viriya) and concentration (samadhi) get developed in the pa tient. A psychotherapist will find that it is not so difficult to get the patient get nearer and nearer to "Sapta bojjanga dhamma" as given in the Satipatthana Sutta. (9) The ultimate objective of using or following the doctrine of mindfulness is to help the mental patient to be aware of the klesha that caused his mental illness. The Buddhist Psychotherapy does not aim at getting rid of the Klesha that caused the mental illness or removal of all the Kleshas. From the therapeutical point of view it is essential to enable the patient just to manage the klesha that caused his illness. Sabbasava Sutta Discourse on the Intoxicants (Cankers) (1) (2) (3) This discourse delivered by the Buddha at Jetavana Monastery in the City of Sravasti in North India is found in the Majjima Nikaya, as sutta No. 2. The Buddha started the sermon thus: Bhikkus, I say that the asavas (mental defilments or intoxicants) can be got rid of by the one who sees and knows the 'asavas'. In him who knows and sees that the 'asavas' have not arisen, no asavas will arise in him, in him who sees and knows asavas (mental defilements) are in him, the asavas in him will vanish. In this sutta, the Buddha has clearly identified a sali ent principle of psychology, that the mind can be purified by the development of passive awareness - by seeing and knowing one's own asavas or mental defilements. According to the Buddhist scholar monk, Ven Nyanatiloka of German birth, asava literally means influences, or biases. This sutta gives a list of four asavas namely i. Kamasava = Sensual desire driven bias ii Bhavasava = Driven by a strong desire to be Ditthasava = Driven by a strong desire linked to ideas, view or ideologies iv Avijjasava = Driven by one's own ignorance of realities of the mind and the body. (4) At the beginning of this discourse, the Buddha has spoken of seven methods for getting rid of asavas - the mental defilements: they are as follows : i Dassana = by seeing and paying attention or get ting vision on 'asavas' ii Samvara = by means of desciplining the mind and body iii Patisevana = by means of using of four requi sites wisely (food, shelter, clothes and medicine) iv Adhivasana = by means of enduring discomforts and pains v Parivajjana = by means of avoidance of people and places (environment) that promote and in crease asavas. vi Vinodana = by means of removing asavas and their contributary factors. vii Bhavana = by means of the development of the four fold mindfulness and cultivation of Sapta Bojjanga Dhamma. 5 In case of a mental patient, to get him to know how the four 'asavas' - kama, bhava, ditthi and avijja that exist in him is a difficult task. When the patient has successfully practiced body awareness (kayanupassana) and feeling awareness (vedananu passana), the therapist has to go along with him to the 4th step of treatment - the awarness of the mind (cittanupassana). It is at the fifth step of treatment the awareness of the mind - forces working in him (dhammanupassana) have to be taken up. 6. At the fifth step, the guidance provided in the Sabbasava Sutta will be very useful. Through dis cussions, the therapist has to help the patient to see whether any of the four asavas is present in him. The therapist has to explain to the patient that there is a difference between an act of kama and a 'kamasava'. An act of kama or a thought of kama is an isolated one where as kamasava, the kama acts or thoughts are taking place just like a flow of water in a stream. Similarly the other three asavas - bhavasava, ditthi asava and avijja asava also will be working in a patient just like a flow of water in a stream. For in stance: a mental patient may be carried away by his own flow of 'kama' - thinking, saying or indulging all the time kama which means sensual desires including desire for sex. (7) How to break the flow of asavas in a mental patient who has successfully gone through the first four steps of Buddhist psychotherapy? The Sabbasava Sutta has enunciated a principle of psychology with which the 'flow' can be stopped - one can purify one's mind by becoming aware of the impurities in one's own mind. In following this principle, the therapist has to help the patient, to see the asava the flow of kama in the patient, the very seeing and knowing 'asava' will cause the disappearance of the same 'asava', for instance, if the patient is obsessed with the idea of his being superior or if he is overwhelmed by a desire to reach higher status, or else a desire to be (bhava thanha) the very knowledge of the existance of bhava thanha in him will cause reduction or disappearance of bhavathanha. (8) For a patient who has reached the fifth step of treat ment under the system of Buddhist Psychotherapy the presence of one or more asava in him, will not be a difficult thing for him to see and know. (9) The difference between an ordinary person (one who is not a mental patient) and a person who is caught up in asava is that the ordinary person will not find it difficult to see asava or kleshas in him whereas, an asava driven person (a mental patient will be emersed only in a particular asava), For instance, he will be deriving pleasure out of his asava. . (10) As mentioned earlier, the Buddha has spoken seven methods with which the asavas - the causes of mental illnesses can be put under control and finally g et rid of those causes completely. In case of mental patients, the following four out of the seven methods can be used for therapeutical purposes without much difficulty. i Dassana iii Parivajjana ii Samvara iv Bhavana (11) At the fifth step, lot of material gathered at the fourth step will be available. The therapist should take up incidents and memories of the patient linkedto a par ticular asava, and the therapist has to get the patient to recognize the asava in his own actions or memo ries. When a few such events are exposed to the patient, he will begin to see and know the existance of asava in him. This self knowledge will provide a break through. (12) In some patients flow of bad actions (akusala karma) will be coming forth from his mouth or from his par ticular limb such as a hand or a leg. If the patient speaks angrilly or if he is using abusive language, the only organ of his or her body to control is his or her mouth. The therapist has to tell his patient that he or she should try to keep his or her mouth shut even if the urge to use abusive language is great; he should be made to be conscious of the need to control the mouth. (13) If the patient finds it difficult to control his mouth, the method of'parivajjana' should be made use. Parivajjana means avoidance. In the application of this method, the patient should be removed away from the provocative environment. Some patients do get into the bad mood when they see some people with whom the patients have had nasty experiences. There fore one way of the calming down a mental patient is to remove him from the aquainted environment. (9) Bhavana is the fourth method to try out with the men tal patients. At this stage, we should recollect that the Buddhist Psychotherapy starts with meditation. From the step of development of communication, up to the step of analysing the mind, we have continued with the 'anapana sati' Bhavana which is basic to the system of Buddhist Psychotherapy. A mental patient who has successfully reached the fifth step will be able to practice the four fold meditation recommended by the Buddha - meditation on (i) Body (2) Feelings Mind (4) Dynamics of the mind. (10) A combination of the approaches given in the Dis course on mindfulness and the Discourse on 'asavas' will provide a fine bases for Buddhist Psychotherapeutical work. OBJECTIVES AND TARGETS OF BUDDHIST PSYCHOTHERAPY (1) According to the system of Buddhist Psychotherapy a mental patient has to be taken through the six steps of treatment (listed in the first chapter of this book) within a short period of 8 to 12 weeks having therapeutical sessions of one hour duration per week on the appointed date. At the first step of developing communication be tween the patient and the therapist a conscious effort has to be made to win the confidence of the patient so that he could be easily motivated to follow the six step method aimed at curing the patient's mental ill ness. (2) Mental patients are recognized by their abnormal behaviour. There are various forms of abnormal be haviour which are identified by names of illnesses such as hysteria, depressive psychosis, schizophrenia etc. There are two major characteristics of mental patients: (i) loss of ability to control one's own physi cal movements, emotional urges and feelings. (2) g etting drifted into stresses and tension or depression. (3) 8 The psychotherapist should aim at restoring normalcy and mental health. In normal people we find mental defilements (Kleshas) such as anger, suspicion, jeolousy etc, but they are able to manage those kleshas or control them where as in case of mental patients, they cannot manage their kleshas; they are being car ried away by their own kleshas. The system of Buddhist Psychotherapy does not aim at making the men tal patients free from the kleshas to make them "arahants;" but it aimes at making mental patients capable of controlling their kleshas and of being energetic, sensible and with a fair degree of self awareness Objectives and Time Targets i Reduction of tension or depression - In cases of acute tension or depression, psychiatric medica tion should be given (for this, the patient should be sent to a psychiatrist) ii Creation of catharsis (purging the unconscious of the patient) iii Development of communication with the patient. iv Probing into the conscious and unconscious mind of the patient. v Getting the patient into the stream of knowing and seeing the kleshas that caused his mental illness. vi Rehabilitation under the following headings : (a) physical (b) phychological (c) social and (d) economic. (5) At this point we may recall, as shown by Dr. Anthony Storr, that mental patients can be placed under any one of the following: (i) Obsessional (ii) Hysterical (iii) Depressive (iv) Schizoid. The above four groups of patients can be classified under the following two groups: (i) Psychotic (ii) Neurotic. (6) Except the depressive patients, all the others are gen erally tend to build up tension as time goes. Depres sive patients will withdraw from society some times ending with suicides or attempted suicides. They may fall into inertia or general amnesia. (7) Without reduction of tension or depression by means of medication, analytical psychotherapy will be of no use. Before one begins with Buddhist Psychotherapy or for that matter any form of analytic therapy, the patient should be referred to a medical practioner to check on the patient's levels of blood-sugar, cholesterol and blood pressure and if the patient's levels of blood-sugar, cholesterol and pressure are high, he should be treated by a medical practioner. Cases of questionable characters should be tested even for H. I.V. deseases. (8) Tension of the patient can be three dimentional - (i) strained feelings (ii) strained body (iii) strain ed mind. While being given medicines the patient should be guided to practice excercises for body relaxation. (9) Tensions and depressions are not mental illnesses but they are symptoms of mental illnesses which could be caused by physical or psychological causes or by a combination of both. (10) Reduction of tension or depression and the creation of catharsis in the patient have to be achieved within the first three to five sessions of one hour duration each. The entire course of treatment has to be fin ished within eight to twelve weeks. (11) Withing the course of first four weeks, the therapist must be able to understand the patients' personality types to which the patient is proned. The Buddha has classified people into the following four groups. (i) Raga type - Sensual desire driven type (ii) Dosa type - Anger driven type (iii) Moha type - Delusion driven type (iv) Mana type - Having an urge to compare oneself with others - conciet type. (12) The therapist should use different methods that suit a particular personality type in his study of the mental patients. (13) Even after the completion of the six step course of treatment, the therapist should warn the patient as well as his family people about the possibility of relapses of the mental illness, in which case, the patient should be brought back to the therapist for further treatment. (14) Thus at each step of treatment the therapist should be aware of the time targets and objectives. Buddhist Psychotherapy Step No. 1 8 DEVELOPMENT OF COMMUNICATION BETWEEN THE THERAPIST AND THE PATIENT (PART 1) (1) For the system of Buddhist Psychotherapy to achieve its objectives, development of communication between the patient and the therapist is absolutely es sential. Although this is the first step of therapy, the communication process should continue even beyond the sixth step of treatment. (2) Difficulties: Mental patients generally cooperate with the thera pist but there are some who are incapable of coop eration with the therapist due to one or more of the following reasons : (i) Physical Obstacles (a) (b) (c) (d) Physical fatigue and stress. Physical weakness caused by prolonged suffering Effects of psychiatric medication Nervous weakness caused by malnutrition. (ii) Psychological Obstacles (a) (b) (c) (d) Lack of confidence in the therapist The patient's inability to see his own suffering. The presence of one or many of the "five hindrances" = "Pancha Nivarana". Transference of the patient's emotions (such (e) as love and hate) to the therapist. The presence of one or many of the ten fetters = dasa - sanyojana (3) In order to remove the obstacles or fetters mentioned above, it is necessary to collect data on the patient. Such data has to be collected from his / her family members, friends and from medical records, school records etc. (4) Consultation Room : (i) The consultation room must be free from distrac tions - there should not be any gadgets (such as tape recorders and cameras) which may arouse suspicion in the patient. The therapist should not take down notes while conversing with the pa tient. (ii) The therapist should sit in front of the patient face to face while having the consultation sessions. If the patient tries to entice the therapist by looking strait in to his eyes, the therapist should ask the patient to keep his/her eyes closed while talking. (iii) If the patient is very boisterous or extremely de pressed no communication is possible. In such a case, therefore, the patient must be first referred to a psychiatrist for medical treatment as men tioned early. When the tension or the depression is reduced by means of medication, practising Buddhist Psychotherapy should start normal sessions with establishing communication. When the tension or the depression is reduced to a manageable level, the dosage of drugs must be reduced gradually in cousultation with the psychiatrist. Commencement of the First Session. i At the first step or for that matter, till the end of the third session (step of treatment), the therapist should avoid any reference to the patient’s illness. The patient will respond to the therapist's questions on subjects of interests to the patient, eg: festivals, games, social events, incidents in his / her neighbourhood and the like. This approach will put the patient at ease. ii Ask questions on his favourite food, drinks, dresses, movies, teledramas, picnics etc. He will be happy to talk on things that interest him. iii If the patient, on his own, talks of his illness or pains at this stage, the therapist should hear him without any comments on what he says. iv Some patients may refuse to receive any treatment saying that they are "eternally condemned to be mental patients." In such a case, a discussion on the doctrine of "anicca' = impermancy, will be very helpful for the patient, to realise that his mental illness too is subjected to the law of’anicca”which means that his illness too is subject to change and therefore his illness is perhaps curable. (v) If the patient does not respond to the conversa tion on 'anicca' the therapist should, at this stage, try to make him aware of suffering undergone by the people because of illnesses. Then the therapist should very gradually move on to the subject of the patient's own sufferings. (vi) After about 30 minutes of conversation a break is necessary for the patient as well as for the thera pist. A cup of tea or coffee or a cool drink should be very welcome at this stage. Thereafter, the therapist should suggest that both of them should spend some time on breathing exercises, eg., breath in as much as you can; stop - keep the breath within for about one or two minutes and then let the air (breath) out - this should be repeated about 10 times. (vii) ln case of patients who are unable to speak (as a result of the illness) try to get responses even by gestures and signs to the following questions. Do you know why you can't speak? Since when? Do you know anyone else who can't speak? Since when he or she is unable to talk? Did anyone ask you not to speak a word? Are you afraid to speak? To begin with it is advisable to get the answers in writing or drawing or by gestures. (viii) Before closing the first sessions, the therapist should find some plus points in the patient; he should make some pleasing comments on good points such as neatness, politeness, punctuality, cooperation with the therapist etc. (ix) The therapist should say that he found the ses sion very interesting and it would be profitable for both - the therapist and the patient to listen to each other. (x) Ask whether he would like to come again; if he says ' yes', give him the next appointment. DEVELOPMENT OF COMMUNICATION WITH THE PATIENT (PART 2) (1) As discussed earlier, there are the following physical and psychological obstacles to developing commu nication with the patient. Physical Psychological i Fatigue & Stress i ii Weakness due to prolonged suffering ii iii Effect of psychiatric drugs iii Presence of the 'nivaranas' and sanyojanas’ iv Nervous weakness due to malnutrition iii Transference of emotions. (2) To deal with the purely physical obstacles the patient should be first referred to a medical practitioner for treatment before starting the course of psychotherapy. It is advisable to get the patient medically tested on blood pressure, blood sugar, cholesterol and the ESR. If the above medical reports indicate that the patient is not physicaly healthy, the patient must be asked to get treatment from a physician. While the patient is thus being treated medically the Buddhist Psychotherapist could start his course of treatment simultaneously. Generally every mental patient has a purpose of be - (3) Lack of self confi dence Inability to see his own suffering coming mentally ill. Mental sickness is a highly motivated aspect of behaviour but the patient does not know about it. For example, a person may become mentally sick due to a desire for revenge from another person close to him; due to a desire to punish someone close to him, or to draw attention to himself. (4) (i) Communication has to be built up in the following traingular manner: As the above diagram indicates there must be flow of information from T to P from P to T and from T to F and from F to T and from F to P, from P to F. (ii) Flow of information does not happen generally. In order to understand the patient, the therapist should listen first to the members of the family of the patient objectively. In some cases, the family members may not tell the whole truth about the patient. (iii) There are obstacles preventing the therapist from understanding the patient. Transference of emotions of the patient on to the therapist is a well known obstacle that the therapists all over the world have to face. For example, the hate that exists in the patient, may direct the hate on to the therapist. Similarly, love and affection and even sexual desires may be directed on to the therapist. The therapist with his experience with several mental patients can assess the degree of suffering that is there in the patient now in the consultaion room. On seeing the suffering that is there in the patient, 'karuna' - sympathy and concern will be generated in the heart of the therapist and the radiation of it will be noticed by the patient. Seeing the suffering (dukkha sacca) of the patient thus will bring about a transformation in the hearts of both the patient and the therapist and that will prevent even transference. The initial data given to the therapist by the patient himself and by the members of his family should be considered very carefully and objectively by the therapist before such data can be accepted as the truth. The therapist, at the start of developing communica tion, has to regard the patient as an unknown entity; and has to begin communication with the patient with a great eagerness to know him and relieve him from suffering due to illness. If the patient is ready to talk, the therapist should start a conversation on a topic that will please and interest the patient. It is not difficult for an experienced thera pist to guess at first sight, the character type to which the patient belongs. As mentioned earlier, there are four major character types which are prone to mental illnessess. They are: (i) Raga type -sexsual desire driven type (ii) Dosa type - anger driven type (iii) Moha type - delusion driven type (iv) Mana type - those who compare themselves with others all the time. The therapist should select topics according to the character type. For instance, a 'raga type' may like to talk on men, women and sex etc. Similarly one belonging to 'dosa type' may like to talk on topics con nected with aggression, using abusive language; a 'moha type' may like to indulge in unreasonable talks and acts, a 'mana type' may like to talk about his acts in terms of his superiority or inferiority to others. (8) Encourage the patient to talk on any subject of his choice and while he is talking the therapist should make the patient feel that the therapist is interested in listening to him. (9) If the patient does not talk, spend five minutes on anapanasati bhavana. For instance; on concentrating on one's own breathing process. The therapist should first demonstrate the following steps of anapana sati. Step One: i ii iii Breath in as much as you can. Stop breathing - keep your lungs filled with air that you have breathed in. Breath out. Repeat the step No. 1 given above for about three to five minutes. Step Two: i ii iii Allow the breathing to take place without any effort Become aware that you are taking long breaths when you are breath ing long breaths. Become aware that you are taking short breaths when you are taking short breaths. Get the patient to practice step No. 1 together with the therapist for about five times. Similarly, both the therapist and the patient should practice together the step No. 2 also. (10) Describe some imaginary incidents attributed to some patients who were unable to talk - those who had lost their ability to talk. Ask questions on those imaginary incidents and try to get the patient to communi cate his answers even by bodily gestures or by writ ing, drawing or by mimicking. (11) Ask about books that he had enjoyed reading or tel evision programmes that he had enjoyed. In these ways get the patient to talk even one or two words at the first session. In cases shuch as these, more than one session should be devoted to developing communication. (12) Ask the patient whether he likes to come back for a 'chat'. If he says ' yes' the date and time for the next session should be given to him. If his response is negative, spend a few more minutes trying to make him aware that he suffers because of his illness and that he should do something to alleviate all the suffering in himself and also in his hear and dear ones. Show him how much his parents and close relations do suffer because of his illness. (13) As pointed out earlier in this chapter some patients may not respond to the therapist's questions on the ground that his illness cannot be cured, that his illness is a permanent one, the therapist at this stage should explain the truth about the impermancy, that every thing is changing and therefore, even his ill ness is an impermanent one, that means his illness too is changeable which may mean curable. If the concept of change (anicca) is made meaningful to the patient, the chances are that he will consent to come for the next session for consultation. (14) If the patient does not take any interest in the conver sation on the doctrine of 'anicca' get him to answer questions such as the following: (a) What happens to a flower in the evening that has blossomed in the morning? Is there any flower which does not wither? Is there any fruit that re mains in the branch forever? Have you seen any boy or girl who does not change in some way? (b) Is there anything that you can touch or see that is unchanging? Are you an unchanging person? Do you know of any feeling which lasts forever? Have you seen anybody in whom any changing has not taken place or is not taking place? (c) Do you think that your illness is an unchanging entity or a process? In case of an illness what changes could there be? Give your answers: i An illness will be cured ii An illness will be worsened iii An illness will remain the same forever - Yes/No - Yes/No - Yes/No (d) Don't you see that every thing including your own illness is subject to the law of change - the law of anicca ? Yes/No (15) With the above question allow the patient to remain about five minutes alone. Thereafter, ask whether he would like to meet the therapist again. If the patient says 'yes' to a meeting, once again fix the next ap pointment. The development of communication between the patient and the therapist that has taken place at the step number one of the system of Buddhist Psychotherapy, should be continued even beyond the step number six so that the patient will feel free to contact the therapist whenever his services or guidances are needed by the patient. 9 DEVELOPMENT OF BODY AWARENESS (Kayanupassana) (1) A mental patient's mind is sick. As a result, the sick mind makes his body also sick. It is difficult for a mental patient to see and know his sick mind because the mind in not a tangible component of a person. But it is comparatively easy to get a mental patient to see and know his own body which is a tangible ob ject of meditation. 2. In Satipatthana Sutta, the Buddha has stated that one should begin the cultivation of mindfulness with the body - the body of oneself or the body or bodies of another person or people. But the Satipatthana approach has to be toned down in order to make it comprehensible to mental patients. 3. As repeatedly shown earlier, one becomes a mental patient due to mental or physical causes or both. Physical causes have to be removed mainly by medi cation (chemotherapy), shock therapy and psycho surgery. Mental causes have to be removed by the application seven methods of dealing with mental impurities (the kleshas) prescribed by the Buddha in Sabbasava Sutta. All people - normal and abnormal have kleshas in them; the difference between a normal person and a abnormal person is that the normal person is capable of managing his kleshas whereas an abnormal person is unable to manage his kleshas. 2. In order to see and know one's own kleshas one has to cultivate mindfulness (sati). This is a difficult task for the mentally sick people. Therefore, one has to cultivate 'sati' gradually. As given in Satipatthana Sutta, one must begin cultivation of mindfulness with one's own body or the body of another pers on. 3. The Loss of Body Awareness i Mental patients tend to lose body awareness and therefore they lose control of their own bodies. ii Due to lack of body awareness tension in the body gets increased or may lead to depression. iii While tension may lead a patient to criminal behaviour while depression may lead a patient to withdraw from society or even to commit sui cide. iv Prolonged psychiatric medication may weaken the patient's body including his nervous system. 4. Preparation for Developing Body Awareness i Gradually reduce the intake of psychiatric drugs given for reduction of tension or depres sion; that does not suggest that psychiatric drugs should be stopped completely. Psychiatric treatment is absolutely essential when a mental patient is in a state of extreme tension or depression. The patient must be free from hunger and thirst. The patient's blood sugar, blood pressure and cholesterol levels have to be medically checked up and the doctor's reports should be submitted to the psychotherapist at the next session. It is advisable to obtain an ESR medical report in case of patients who have had sex relations with questionable men and women. This is to rule out social diseases including AIDS for which there are especial medical tests. If the pressure, sugar and cholesterol levels are high, such patients should be treated by medical practioners, suspects of social diseases and AIDS should be referred to relevant medical authorities. The patient should be advised to have regular body washes and baths and wear clean dresses. If the patient is in a state of extreme depres sion or tention, he must be seen by a psychiatrist or a medical practioner. The patient must be guided to have kayanupassana meditation only when the above mentioned measeres have been taken. The Satipatthana Sutta has recommended the following six ways of developing physical awareness. i Meditation on breathing process (anapana sati) ii Meditation on the four body postures, (iriyapatha) iii Meditation on four fold comprehension of one's actions (sampajana) (a) Think of consequences of your actions (Satthaka) (b) Think whether the intended action is proper(sappaya) (c) Think whether your intended action is congenial to the environment (gocara) (d) Think whether your intended action is of ignorance and delusion (asammoha) iv Meditation on the parts of the body of the pa tient or of others' bodies, (patikula manasikara) v Meditation on the four elements - apo = water, tejo = heat, vayo = wind and pathavi = substance (Dhatu - manasikara) vi Meditation on the process of decomposition of the body of anyone (Sivathika) Out of the above mentioned six ways of developing body awareness, meditation on breathing process is of great therapeutical value. It is easy to practise and easy to comprehend. However, the traditional ways of developing anapana sati have to be modified to suit mental patients. Development of body awareness is the second step of the system of Buddhist Psychotherapy. A patient should be brought to this step only after taking the patient through the first step namely the development of communication between the therapist and the patient. How to introduce meditation on breathing to the mental patient ? Get the patient to sit relaxingly in a chair in the con sultation room. Ask a few questions such as the fol lowing. i What is the activity that goes on from birth to death in the body of a person ? (The answer should be : "the breathing process.") ii What are the other functions in the body that go on from birth to death ? (Blood circulation and digestion) iii Of these three functions (breathing, blood circu lation and digestion) what can you observe right now ? (Breathing) iv If the breathing process stops completely what will happen to the body ? (Die) i Have you abserved your breathing process for thirty minutes ? .... for 15 minutes ? for 10 minutes ? for 5 minutes ? for 1 minute ? (Many mental patients have not breathing process even for a minute.) observed Let us begin to observe the breathing process. ii What happens to your belly when you breathe in? (Answer: The belly expands ) iii What happens to your belly when you breathe out? (Answer : The belly contracts.) iv What happens to your chest when you breathe in? (Chest expands) v What happens to your chest when you breathe out? (Chest contracts.) vi What happens to your nose when you breathe in ? this (Nose expands) vii What happens to your nose when you breathe out? (Nose contracts) Apply the same type of questions to various parts of the body of the patient in relation to his breath ing process. Parts of the body such as head, hands, legs, eyes, ears, neck, shoulders etc. (i) Get the patient to observe the movements of his body both internally and externally. Externally : The movements of eyes, eye lids and lips should be observed, focus on external body movements such as stretching and bending parts of the body such as legs, hands, knees and neck etc. Internally the blood circulation, pulses and heart beats etc. (ii) Instruct the patient to control his breathing in the following ways: (a) Please start breathing in and breathing out very slowly and slowly about 10 times (Do not count breathing) (b) Please start breathing in and breathing out faster and faster (about 10 times) (iii) Please breathe in as much as you can and stop breathing any more, hold on to your breathing as far as you can and then breathe out in the same mannner. As you go on doing this breathing awareness excercise, try to increase the quantity of air coming into the lungs and hold on to air in the lungs as much as you can. The special points to remember relating to this excercise : (a) More and more air coming into the lungs means that lot of oxygen is pumped into the lungs and therefore oxygen will purify the blood. (b) This form of meditation will give exercise to the internal organs such as lungs, heart, kid neys, intestine etc. (c) This meditation will help to normalize blood circulation and blood - pressure. (11) Instruct the patient to practise the following ex ercise early morning after a cup of tea or coffee or a glass of water. The patient should lie in the bed horizontally (without a pillow). Bend your knees; hold your knees with your hands; breathe in to the fullest capacity and press yours knees towards your chest; hold on air in the lungs for about one minute and release the air, stretch the knees and legs come back to the horizontal posture (sleeping posture). Instruct the patient to repeat this excercise for about 10 times. This excercise will help the patient in the following ways. (a) Purification of blood. (b) It will give the patient a degree of self confidence. (c) Establish the ability to control the body. (d) Relaxation of body and mind. (e) Since the patient becomes aware of his breathing process, he is engaging in anapana sati meditation which is a meritorious act. (12) Instruct the patient to practise forms of medita tion on breathing twice a day - morning and evening, for about 10 to 15 minutes at a time. After a couple of days of practising anapana sati bhavana, get him to practise the following medi tation on the postures of the body (13) Iriyapatha - Body Postures i If the expected results from meditation on breathing were not achieved, the patient should be in structed to follow a modified form of meditation on the four postures of the body of the patient. The four postures are : standing, sitting, sleeping and walking. ii Get the patient to see what happens to the body when sitting posture is changed into standing and standing in to walking and walking into standing and standing into sleeping. The therapist should, at the consultation room, demonstrate the changes taking place while standing posture is changed into sitting posture and get the patient to describe the changes. iii The purpose of iriyapatha meditation is for the patient to see and know what happens to his body the parts of the body while changing from one posture to another. iv To make the patient aware of the body changes ask questions such as the following. When the patient is in sitting posture: (a) Are your feet touching the ground ? (b) Can you place your feet firmly on the ground? (Do so) (c) Are your knees bent or straight ? Keep your knees bent (d) Is your trunk bent forward or backward or straight ? (e) ls your head bent forward or back word ? Keep your head strait. (f) In what posture are you now ? If you do not experience any difficulty while in the sitting posture, please be seated for about five minutes and relax. (14) Ask similar questions on other postures also. As for awareness on sleeping posture, get the patient to ask questions such as the following (sleeping awareness has to be practised at home and not at the consultation room) (a) (b) (c) (d) (e) (f) Is my body bent or straight? Are my hands bent or straight? Are my legs bent or straight? Is my body relaxed now? Is my head relaxed? Are my hands relaxed? (ask such questions on other parts of the body.) 15 Walking on a plank of about 12 feet or more in length and about 3 or 4 inches in hight. Get the patient to walk on a plank and gradually in crease the time duration. This exercise needs concentration and body balancing. Mental patients who have had prolonged psychiatric treatment will be immensely benefited by this form of iriyapatha meditation. (14) There are four other forms of meditation on the body but they may not be suitable for mental patients. They are : (a) Catu - sampajana = Four ways of knowing before one acts. (b) Patikula manasikara = Seeing and knowing parts of the body internally and externally (c) Dhatu manasikara = Contemplation on the four elements of the body. (d) Sivathika manasikara = contemplation on the decomposition or disintegration of the body. (15) Finally, one should remember that this 'kayanupassana' is not for reaching spiritual hights but for calming down and normalising physical be haviour of the mental patient concerned. The above given methods are for restoring mental health and normalcy. Step No. 3 10 DEVELOPMENT OF FEELING AWARENESS (Vedananupassana) (1) Normalcy and Abnormalcy in Experiencing Feelings. 1.1 A normal person is capable of experiencing feel ings through his six sense bases - eyes, nose, ears, tongue, skin and mind. 1.2.1t is also normal behaviour to cling on to pleasur able feelings while getting away from places and people that cause unpleasant feelings. 1.3 In normal people, their lives are a constant strug gle to achieve two ends - (i) seeking and clinging on to pleasurable feelings (ii) discarding, forget ting and suppressing unpleasant feelings. (2) 2.1 Abnormal and mentally sick people may not ex perience either pleasant or unpleasant feelings. They may be incapable of drawing a distinction between pleasant and unpleasant feelings. 2.2 Abnormal or mentally sick people are not aware that they have suppressed their unpleasant feelings. 2.3 Mentally sick people generally act on their emo tions and impulses; in certain cases, they are irra tional in experiencing and re-living in feelings. (3) Categories of Feelings 3.1 Pleasant feelings Unpleasant feelings Neutral feelings 3.2 -sukhaVedana - dukkha Vedana - neither sukha or dukkha Vedana. According to another classification there are two kinds of feelings: i Worldly feelings - samisa Vedana ii Spiritual feelings - niramisa Vedana 3.3 The Buddha has seen 108 kinds of feelings that one can experience. But for psychotherapeutical purpose it is sufficient to identify the pleasant and unpleasant feelings that the mental patient has experienced in the past. 3.4 Feelings are "arisings" = sanskaras, a feeling arises due to certain factors coming together - a sense base an object and contacting should come together, to give arising to a feeling. 3.5 Feelings are momentary experiences - they do not exist on a permanent basis - a feeling arises, stays on for a moment and diminishes. This is true for every body whether normal or abnormal. (4) 4.1 A mental patient or a person with a tendency to be a mental patient may, unconsciously push his or her very unpleasant or painful memories into his or her own unconscious where those feelings will remain, together with the memories associ ated with those feelings; it is the memory which goes into the unconscious and gets stored up. A particular memory is pushed into the unconscious by the patient because that memory is painful. 4.2 A mental patient with prolonged suffering due to his illness may lose the capability of experienc ing a feeling. And also, after a prolonged treat ment with psychiatric drugs a patient may, due to chemical reactions produced in the body of the patient, lose the capability of experiencing feelings at later stages of the illness. 4.3 In order to escape from the painful memories at the beginning of the illness, a patient may find solace in amnesia - (the loss of memories) or may get into fantasies. Some people who have painful memories find shelter under "panca nivaranas" for instance, a mental patient with painful memories may get into 'thinamiddha' - a neurotic condition which can be described as extreme depression. When a patient is suffering from depression the attention will be focussed on the depression and not on the painful memories which the patient has unconsciously hidden. How to Develop Feeling Awareness? 5.1 In the development of feeling awareness, a normal person may be able to follow the traditional "satipatthana " method but in case of mental patients it has to be modified so that a mental patient may find it easy to develop feeling awareness. 5.2 Three ways of Developing Feeling Awareness (a) By conversation: The therapist should begin conversation with the patient by drawing his attention on to his past memories of events and incidents. For instance: By asking questions such as the fol lowing : i What did you eat for your breakfast yesterday? ii What did you eat for breakfast today? iii What did you have for lunch yesterday? iv How many curries did you have? v What was the tastiest curry that you have eaten recently? (b) By identification: of pleasant and unpleasant memories of past events - get the patient to remember eatables, dresses and people associated with pleasant and unpleasant feelings. For instance: i Who was the most beautiful girl you have seen recently ? ii Where did you have the tastiest cup of tea recently? Who was the most unpleasant woman you have seen ? iii (c) By Observing: the pains in the body that the pa tient could experience while he is on 'anapanasati bhavana' - get the patient to observe body pains that the patient could experience while breathing in and breathing out. For instance: Get the patient to have long breathing in and breathing out. While breathing in did you experience a pain? Is it a mild pain? - 'yes' or 'no' Is it a severe pain? - 'yes' or 'no'. (6) Anapana sati and feelings 6.1 Anapana sati bhavana is very useful to revive ca pability of identifying physical pains in different parts of the body of a patient. This bhavana on feelings can be done effectively if 'kayanupassana 'meditation has been done as instructed by the therapist. As if some one focuses the beam of a torch on to different parts of the body, the patient's attention must be directed on to the patient's body to see whether he has body pains. This has to be done in association with breathing in and breathing out. When the patient has observed whether there is pain in his body o r not, his attention should be drawn on to his tasting capability. This can be done by getting the patient to answer questions such as the following: i Do you like lot of sugar in your cup of tea ? ii iii What do you like - tea, coffee or a cool drink ? Is there a difference between a cup of tea and a cup of coffee in taste ? 6.2 Meditation on breathing can be practised even in the consultation room itself. The therapist should demonstrate how to breathe in and breathe out very loudly. The patient must be advised to keep his eyes and mouth closed while meditating. At the beginning, the therapist and the patient, for about 2 minutes, must meditate together as stated above. Thereafter, for about 8 minutes, the patient should meditate alone. This meditation must be followed by a series of questions such as the following: i While breathing in, did you notice any pain in your chest? - yes/no ii While breathing out did you notice any pain in your chest? - yes/no Such questions may focus the patient's attention on to pains in other parts of his body and that will lead to feeling awareness. 6.4 After focusing the patient's attention or aware ness on pains, discuss the memories of pains and tastes that the patient has had in the past. Ask questions such as the following: i What was the most pleasant experience you remember now? ii Who was the most beautiful person you have seen? iii The tastiest cup of tea you have had? iv The most painful experience? Feelings linked to external objects 7.1 Ask questions such as the following: i Have you experienced pleasant feelings with people? With whom? can you name him or her? ii Have you experienced unpleasant feelings with people? With whom? Can you name him or her? iii Have you experienced pleasant feelings related to property? house, car, video, etc. iv Have you experienced unpleasant feelings related to property ? With what? v Have you experienced any pleasant feelings related to ideas? With what? (ideas such as good, my religion, my country, my political party etc.) 8. Suppression of feelings 8.1 i Have you ever suppressed your feelings? yes/no. ii Have you felt shy of any feelings you have experienced? yes/no Can you describe any of such feelings? iii Have you spoken to any one of your shy feelings? iv Do you get angry when someone causes you unpleasant feelings? 8.2 v Have you experienced angry feelings with anyone? With whom? i Have you run away from people who caused unpleasant feelings? ii Have you gone to meet people who make you happy? Can you name them? iii Have you gone to a hotel, again and again in search of a particular dish? iv Is there a song that you like to listen again and again? Can you sing that song? Please sing that song! 9 Therapeutical Effect of Feeling Awareness 9.1 Under the step number three of Buddhist Psycho therapy efforts were made under the headings No.l - 8, to revive the mental patient's feeling capacity. 9.2 Since memories associated with unpleasant feel ings that are buried in the patient's unconscious mind, cause the mental illness, the very discovery of such unconscious memories leads to reduc tion of tension or depression of the mental patient. This may lead even to "catharsis" 9.3 Development of the awareness of feelings, whether they are pleasant or unpleasant, will help the patient reach normalcy. 10. Meditation on feelings should be continued, at least for one week till the patient is taken to the step number four of Buddhist Psychotherapy - Chittanupassana. Step No. 4 DEVELOPMENT OF MIND AWARENESS (Cittanupassana) (1) What is the Mind ? i The mind is an active force consisting of thoughts and drives (dynamics). Thoughts can be divided into two groups: Conscious thoughts (sampajana mano sankhara), unconscious thoughts (asampajana mano sankhara). Also, the mind can be described as a bundle of memories which are residues of past actions-(Karma) of past thinking, speaking and doing. ii The mind is one of the six sensory bases of a be ing (a living creature). The other five are, eyes, nose, tounge, ears and skin. Therefore one can experience feelings generated by the sensory base of the mind too. iii The mind is a forerunner of thoughts and actions (mano pubbangama dhamma). Thoughts and actions spring from motivation (Cetanahan Bhikkhave kamman vadami) Motivations are basically caused by raga (sexsual driven) dosa (drives of anger) moha (delusions = deluded drives), and also by alobha - urge of carity), adosa (urge of love and kindness) and amoha (urge of 12 wisdom = ability to see and know things as they are). Mental patients too are capable of having motivations based on the above mentioned six sensory bases. iv Seeing and knowing the causes of the mental ill nesses by the patient himself is the key to curjng mental illnesses (See: Sabbasava Sutta) (2) How can a mental patient be made to see his own mind which is not a tangible thing? i This question comes under the step number 4 of treatment of mental patients who by this time, have gone succesfully through the first 3 steps development of communication, body awa reness and feeling awareness of the method of Buddhist Psychotherapy. This means, by this time, the mental patients are capable of understanding -seeing and knowing his own mind. At least they will be physically capable of sitting quietly and watching their own thoughts. ii Methods of Seeing the Mind : (a) First focus on the conscious mind by asking ques tions on the patient's past incidents which he may recall easily. Begin asking questions on activities (experiences) of the immediate past. For example, ask questions such as the following: What did you have (eat) for your breakfast this morning? What did you have for your dinner last night ? Spend about 10 to 15 minutes asking such questions which should lead more and more back in time gradu ally and progressively. (a) Get memory responses of the patient to a few selected words such as : accident, a scolding, sweet, anger, a girl, a man, father, mother, wife, a nice song etc. (b) Ask questions related to specific people such as : Do you have friends ? (If you have,) Who is your best friend? Is it a boy friend or a girl friend? When did you meet him or her last? What was he or she wearing? What colours were there in his or her dress? Were you pleased to meet him or her? Do Do Do Do Do you you you you you like to meet him or her again ? love your father ? love your mother ? or hate your father ? hate your mother ? Spend about 10 minutis asking such questions on the people who matter to the patient's life. (c) Ask questions on games such as the following: Have you played games ? What were the games that you have played. (Select some specific games) and ask: With whom did you play? How long did you play ? How long ago did you play? Do you remember playing with any one when you were around 15 years of age ? Around 10 years ? Around 5 years ? Around 3 years ? Have you played hide and seek game did you play the hide and seek game ? ing any games these days ? What is the most ? What is the game that you don't you not like the game ? ? With whom Are you playgame you like like? Why did Go on asking such questions covering the day to day life of the patient for about 10 to 15 minutes at one session so that more and more conscious memories could be dug out from the patient. It is comparatively easy to get the patient to talk about his own conscious memories. (3) How to Penetrate into the Unconscious Mind of a Patient ? Eight methods are given below. The therapist should select the appropriate methods that would suite the personality type of the patient. However, the method of dream - analysis should be utilised invariably. i Word Testing Observe the immediate reactions of the patient to selected words by getting him to say what comes to the mind immediately on hearing the word. The patient should keep his or her eyes closed till the word testing is over; it should run to about 10 minutes. The therapist should have selected a set of words in keeping with the patient's character type. For example, in case of a 'raga' type use words such as the following : eyes, lips, beautiful. hands, legs, dancing, playing, music, song, dreaming, etc. Use another set of words such as the following in case of a 'dosa' type : Scold, murder, fight, burn, destroy, gun, knife, blood, wound Use a set of words to suite a 'moha' type: Dark, sleepy, suicide, a hallucination, a dream, a phobia, frightening. Use a set of words such as the following in case of a 'mana' type. Superior, inferior, uglier, meaner, baser, very good, very bad, noble. ii Mistakes and errors : Observe the mistakes and errors of speech made by the patient in his conversations and writings. Such mistakes may reveal unconscious attitudes to people and ideas possessed by the patient. For instance, he may distort the name of his own wife. Unconsciously he may say "Kabala" (old and mean fellow ) referring to his wife whose name is "Kamala" - the real name. A wife may call the servant boy by the name of her husband. Some times patients may mis-spell a word giving another meaning. These errors and mistakes can be observed while the patient is engaged in conver- sation with the therapist. iii Facial reactions Observe the facial reactions of the patient when he speaks about particular people. For instance : while talking about a person, the patient's face will go reddish; eyes will get wet with tears. Such reacti ons may be indicating a guilty feeling about what he had done or said. iv Dreams (a) Get the patient to narrate dreams that he could remember - the dreams of remote past or of recent past. It is good to start narrating dreams of recent past and go backward covering dreams even of childhood days. (b) Get the patient to repeat description of a dream that he has already described. Observe if there are any changes introduced in the repetition - additions, omissions,and errors etc. For instance a repetition of a dream may bring new people into the dream or drop some people who were there in the first description. (c) If the patient says that he cannot remember any dream dreamt by him, the therapist should come out with dreams dreamt by other mental patients. Also, the therapist should create some dreams that may appeal to the patient - the dreams that will go with the character type of the patient. (d) Take special note of repetative dreams dreamt by the patient. Most of the repetative dreams are linked to the root cause of the mental illness. (e) Get the patient to interpret his own dreams or ask for the meanings of the dreams dreamt by him. (v) Incidents of the Patient’s Life Ask the patient whether there were any incidents of which he is shy to talk about or ashamed of. Ask whether he can describe the incident without going into details. If the patient goes up to a point and stop, at this stage, the therapist should say that he could imagine all that happened till the end of the incident. Some patients may describe the incident without any restrain; they may enjoy narrating the incident giving details. Such behaviour - being shy or enjoying may indicate the character type or the presence of any one of the five 'nirvaranas' or kleshas in him. (vi) Catharsis (a) Describe the process of catharses (purging the unconscious) and its importance as a therapeutical measure. (b) When the patient is narrating an incident of his life or dreams and hallucinations that he has ex perienced, observe the facial reactions and also see whether he is reliving in the incident. Whether the process of catharsis takes place should be taken note of by the therapist. For instance: the patient may have been sexually assaulted by somebody; get the patient to narrate the incident; at a certain point, the patient may break down and refuse to talk about it any more. In such a situation, the therapist should not question any further but indicate that the therapist could imagine what really had happened. At this point catharsis is sure to take place while exposing the patient's unconscious mind. (c) Ask the patient whether there are any more such incidents, and if there are, if he does not mind, get him to describe those incidents also. (d) Ask the patient whether he has any secrets that he has not told anyone. (e) If the patient appears to be hiding some of his secrets the therapist should create imaginary incidents involving "raga thanha" = craving for sen sual pleasures 'bhavathanha' = craving to be and 'vibhava thanha' = craving to destroy and attribute them to some imaginary patients, when the therapist is narrating such imaginary incidents, observe the body language of the patient - particularly the changes of facial expressions of the patient. i Unusual Bhavioural Traits. Observe the unusual behavioural traits of the patient that may indicate the materials in the unconcsious of the patient. ii Behavioural traits i ii iii iv Twinkling of an eye. Biting fingernails. Grinding teeth. Constant turning of the neck. v Sudden changing of postures such as getting up, walking about or sitting. vi Constant adjustment of dress. vii Fidgeting with pen, necklace etc. viii Anguishedly looking at the roof or at the ceiling. ix Restlessness. viii Action in Freedom i Get the patient to do free drawingand painting ii Get the patient to narrate stories of his own creations. iii Get the patient involved in psychodramatic activities. iv Role playing and mimicking. Points to Remember (a) Therapist should be careful not to allow the pa tient to discuss his mental illness at this stage; say that the therapist is not interested to know about the illness at present. (b) No materials of the conscious or unconscious mind should be analysed at the step No.4 of the system of Buddhist Psychotherapy. (c) The materials unearthed at step No.4 should be treated as strickly the private property of the patient. 12 ANALYSIS OF THE MIND CONTENTS (Dhammanupassana) (1) At step No. 4 of Buddhist Psychotherapy contents of the conscious and the unconscious mind have been unearthed. The therapist should pick up some mind contents, mostly memories of the patient - the memories which appear to have links with the mental ill ness. An experienced therapist will be able to select some of these memories by means of inference. (2) At step No. 5 of Buddhist Psychotherapy, the follow ing targets or objectives have to be achieved. (a) Determining the personality type of the patient (b) Discovering the mental causes of the illness (c) The normalization of the patient's psycho somatic functions. (d) Getting the patient into the stream of seeing and knowing the causes of the illness. (e) Development of "kusalakusala vinfiana” - be coming conscious of good and bad actions (karma) by the patient. (f) Creation of complete catharsis in the patient. (g) Completion of analytical understanding of the mental illness. (3) Personality Type (a) At the beginning of the 5th step, the therapist should initiate a discussion on the general type of personalities. Ask the patient to identify himself with any of the following personality types. i Raga carita - one who craves for sensual pleasures ii Dosa carita - One who is carried away by anger iii Moha carita - One who is carried away by ignorance iv Mana carita - One who is carried away by an imagined sense of being superior or inferior (These personality types are given in the text Anguttara Nikaya - catutta vagga.) (b) The raga type belongs predominantly to one of the following: i Kama thanha - those who crave for sexual or sensual pleasures. i Bhava Thanha - Those having an urge to be (rich, powerful ministers etc.) ii Vibhava Thanha - Those having an urge to destroy.(urge to commit suicide) The patient will have a clear perception of the per sonality type to which he belongs. This perception can be sharpened by getting the patient to look at some of the selected memories that were unearthed at step No. 4. The therapist could narrate an actual case history and show how that patient recovered from his illness. It will be very useful if the therapist could select a case history which is somewhat similar to that of the patient. i ii Before starting analysis of memories and the related behaviour patterns, the therapist should have a general discussion on the mental difilements (kleshas) that normally cause mental illnesses. He should give the patient a list of kleshas such as the following : - craving, lust, anger, hatred, delusion, conceit, fear, suspicion, jealousy, miserliness, disgust, repentance, ill will etc. (Vatthupama Sutta gives a list of kleshas) Every personality type has a predominant klesha such as mana or i 11 will or craving. When one's the personality type is determined , it is easy to see the kleshas that has caused the mental illness. iii At this stage, the therapist should tell the patient that for some thing to take place, there should be several factors coming together and in case of mental illnesses klesha is certainly one of those factors. One is not likely to become a mental patient mainly because of having the klesha in him. He should be told that, apart from klesha, several psycho-physical and socioeconomic factors also contribute to his becomin g a mental patient. However without the presence of a klesha, the other factors may not be strong enough to make him a mental patient. Therefore, seeing and knowing the predominant cause (the klesha) is all important for therapy. Methods of Discerning Mental Causes i When the therapist meets the patient at the step No. 5, the patient should be guided to contemplate on breathing (anapana sati bhavana) for about 5 minutes. This is in preparation of psychoanalysis. Lot of materials (memories and observations) are to be used, at this step, for the purpose of discerning the mental causes of the illness. ii Select the memories and observations which in dicate the patient's links with the following three root causes. (a) Raga = being carried away by sensual desires (b) Dosa = being carried away by anger (c) Moha = being carried away by ignorance. It is not difficult to identify the memories of events promoted by raga (sexual craving) or anger. The memories which cannot be identified with raga and dosa will fall in to the category of moha. It has to be noted here that the patients who are being caried away by 'mana' = conceit can be identified under 'moha'. This identification on the ba sis of the three "akusala mula" (raga, dosa and moha) will help the therapist to see the kleshas that have caused the mental illness. The behaviour traits of the patient may indicate the predominant klesha which has caused the mental illness. For instance, some patients keep on turning and twisting their fingers and that indicates a deep rooted anxiety in patients. By inference the therapist could guess the cause of a mental illness. In other words, this is a way of knowing the causes of illnesses by means of trial and error. For instance, a patient's behaviour and also his memories may indicate the presence of a klesha such as suspicion. Mental patients of any kind - patients with different types of mental illnesses, do have motives. In fact, any mental illness is a highly motivated pattern of actions. Try to identify the motivation of a given mental patient. For instance hysteria may take place in a person who wants to punish some one, a dearer and a closer person - by getting his or her right hand paralized by means of unconscious behaviour. Desire to punish may indicate the klesha of revenge. ii Get the patient to give his explanation of the memories unearthed from his mind by the therapist. For instance, if the patient has dreamt of dead bodies, ask the patient to give his interpretation of seeing the dead bodies. The underline klesha here could be the klesha of fear. iii Repetative actions and dreams may indicate a pre dominant klesha. In a repetative dream there can be a hidden klesha. For intance a repetative dream of a motor car accident may indicate a fear in the unconscious. Obstacles to seeing and knowing the kleshas. i There are five neurotic conditions which prevent from seeing and knowing the kleshas that have caused mental illness. These five neurotic conditions are known as 'panca nivarana' They are as follow : (a) Kama chanda = indulgence in sensual pleasures all the time (b) Vyapada = being carried away by one's own anger all the time. (c) Thinamiddha = being in a state of depression all the time (d) Uddacca Kukkuccha = being distracted, being unable to concentrate all the time : (e) Vicikicca = being suspicious all the time. At the step No 5, (which may run to even three to five sessions) the therapist should explain the existence of five psycho - neurotic conditions and their specific characteristics. Thereafter, the therapist should ask the patient to identify the obstacle in him. For instance a patient may see the existence 'vicikicca' = suspicion in him. This is a very important excercise of great therapeutic value. ii A klesha such as lust or jealousy can be obscured by any one of the five nivaranas such as suspicion. For instance, a patient will be prevented from seeing and knowing a klesha that has caused the mental illness by the presence of "thinamiddha" or kamachanda. The patient will be thinking and functioning all the time under the influence of the nivarana; his sole attention will be guided by the nivarana; and therefore he will be prevented from seen (he klesha which has caused the mental illness. Two Methods to Deal with Nivarana (i) Get the patient just to observe the presence of any nivarana in himself. The patient should be guided to see the nivarana concerned, in the way one notices, say, any leaf falling from a tree. We do not get ourselves involved in the falling leaf. Similarly, it is possible just to see a particular nivarana when it is there in the mind. It is important to keep in mind that seeing a particular nivarana and seeing the memory of that nivarana are two different things. Another thing to keep in mind is that any nivarana, for instance, say, kamachanda, following the nor mal pattern of existance - it arises, it stays and it diminishes (uppada, thithi and bhanga). It is a delusion to see nivarana being present all the time; what is there is not the actual nivarana but the memories of the nivarana - a clinging on to the memories of the original nivarana. Therefore, even a nivarana is not and cannot be a permanent condition. There are no permanent conditions or things. Therefore to think that even a mental patient is permanently covered by a nivarana itself is a delusion. A mental patient who is capable of reaching level of step No. 5, will be able to destinguish between the memories of a nivarana and the actual neurotic condition (the real nivarana ) such as thinamiddha or vicikicca. This is the first method of dealing with nivarana of mental patients. (ii) Sabbasava Sutta gives seven methods of how to deal with kleshas. The same methods can be applied to deal with the nivaranas of the mental patients. It is not necessary to apply all the following methods in the therapeutical e fforts. But, the first method = 'dassana' is to be applied first. Seven Methods (a) (b) (c) (d) (e) (f) (g) Dassana = by means of seeing (the klesha or nivarana) Samvara = by means of disciplining Patisevana = by using wisely the four perequisits -food, clothing, shelter and medicine) Adhivasana = by means of edurance Parivajjana = by means of avoidance Vinodana = by means of removal Bhavana = by means of meditation. The therapist who by now knows the character and the mind of the patient should recommend any one or two of the seven methods given above for him to practise: he should be guided gradually till he comes to see his klesha as it arises in him. In some cases, four of the above methods including dassana have to be applied. Similarly, the patient should be guided to see the nivarana in him. For instance, when kamachanda or Vyapada (anger) is there in him he should just recog nise or see that the particular nivarana is there in him. At this stage some patients may ask the therapist as to what he should do to dispel the nivarana . At this stage there is nothing else for him to do regarding the nivarana; but keep on seeing or observing it for a week or ten to twelve days. When the patient gets to the stream of seeing the nivarana, he should be guided to follow the rest of the seven methods gradually until the particular nivarana is made inactive in the patient. This Sabbasava approach is the most effective mental treatment that this writer got to know by means of trial and error for several years of his psychotherapeutical experimentations. Another grave obstatcle is the phenomenon called "transference” originally discovered by Sigmond Freud, the father of modem system of psychoanalysis. Here the patient may transfer his or her emo tions such as love or hate on to the therapist; this may prevent the therapist from seeing the actual cause of the mental illness. A way out of this impasse is given in the chapter on the development of communication with the patient. If the therapist is aware of the intensity of suffering of the patient, "karuna" - the arising of compassion in the therapist will take place. This karuna will ra diate from the therapist's face and the patient seeing it will have the effect of stopping his directing the emotions such as love and hate on to the therapist. (10) Interpretation of Dreams. (i) Dreams provide a key to the unconscious where the causes of the mental illness are located. Repeated dreams particularly indicate the actual (not imaginary) causes of mental illnesses. Therefore, recurring dreams should be taken up first. (ii) The language of the dream may be the plain lan guage used by the patient; or it could be symbolic language. Dream symbols may change from culture to culture while a very few symbols may be of uni versal character. (See the chapter on Western Psychoanalysis where techniques of interpretation of dreams are discussed and also read the case histories given in this book.) (iii) By means of interpretation of dreams of the pa - tient, the causes of his mental illness, hidden in the unconscios can be brought to light; and the klesha can be seen and known by the patient himself under the therapist's guidance. ( I I ) Linkage between memories and the Seven Inclinations (Sapta Anusaya Dhamma.) The therapist should select memories having a bear ing on the mental illness, and look at cach and every such selected memory on the basis of "sapta anusaya dhamma" which are given below. Anusayas are in clinations or tendencies lying dormant (like sleeping serpents) in the unconscious of the patient. Hence they are not found in the conscious mind and there fore the patient is not aware of them but they may push the patient to act unwisely or ignorantly. (a) (b) (c) (d) (e) (0 Kama raga = Desire for sensual pleasures Bhava raga = Desire to be Patigha = Strong anger against some one Ditthi = Strong emotional identification with views or doctrines including the idea of "1" and "mine". Vicikiccha = Strong involment in suspicion Avijja = The inability to see the kleshas in one's self. An experienced therapist may observe the presence of one or two predominant inclinations or tendencies (anusaya) in a mental patient - tendencies such as suspicion or anger. The difference between an anusaya and klesha is that an anusaya remains in the unconscious and it influences the person concerned to act but it cannot be noticed by the person concerned whereas a klesha can be observed easily. For instance the anusaya of "anger” is not observable whereas the klesha of anger can be noticed or observed easily by the person concerned. For a detailed account on anusaya, see Prof. Padmasiri de Silva's Buddhist and Freudian Psychology - PP 56 - 62. The anusayas are described as "biases" or "la tent tendencies" The irrational behaviour of mental patients can be understood is terms of "sapta anusaya dhamma” - the seven latent or dormant tendencies Asava Dhamma - Intoxicants There are memories in the unconscious of all human beings. Particularly in case of mental patients some memories in their unconscious, act as intoxicants. For instance a memory of a sexual pleasure - a sexsual act may prevent a mental patient to be vigilant or mindful and be attentive to other things or happennings in his immediate environments. "Samma Ditthi Sutta" of Majjima Nikaya speaks of three asavas : i ii iii Kamasava= Intoxicant of craving for sensual pleasures Bhavasava = Intoxicant of urge to be. Avijjasava = Intoxicant of being ignorant. The Sangiti Sutta of Digha Nikaya mentions of four asavas. It has added an asava called 'ditthasava' in toxicant of holding on to a view (ditthi). At the step no 5 of Buddhist Psychotherapy the thera pist has to help the patient to analyse his own memo ries that have linkage to his illness. Some times it becomes very useful to identify and categorise the patient’s memories on the basis of four asavas given above. This approach will be particularly useful in cases of mental patients who behave like people un der intoxicants. (13) "Dasa Sanyojana" Approach If the therapist could not make a break through even after using all the methods mentioned above,he should try out the 'Samyojana' approach. The Buddha has spoken often fetters which bind peo ple to the wheel of existence (samsara) They prevent people from seeing and knowing their own kleshas. Mental patients are fettered by one or more of the Sayojanas which are listed below. (See Anguttara Nikaya - Section four) i ii iii iv v vi vii viii ix x Sakkaya ditthi = holding on to T consciousness Vicikiccha = Suspicion Silabbata Paramasa = being carried away by rituals (obsessional compulsive disorder) Kama raga = Craving for sensual pleasures Vyapada = illwill (anger) Rupa raga = Craving for material forms of existence Arupa raga = Craving for formless existence Mana = Conceit (inferiority or superiority consciousness) Uddhacca = restlessness or having a scattered mind Avijja = ignorance Some of the above mentioned fetters can be detected particularly in every mental patient. Some obsessional patients hold on to ritualistic behaviour forms such as, for example, washing hands ten times before meals. Similarly some patients are fettered by suspicion which prevents them from seeing things in their true perspective. For instance a suspicion in a wife may prevent her from seeing that her husband is in nocent of false allegations. Similarly, a mental pa tient with suspicion fetter may not be able to see the klesha that has caused the mental illness. (14) (a) All these methods described above are various ways of analysing the materials drawn out of the pa tient's mind. The purpose of such analysis is to get the patient to see and know the causes of his mental illness. The primary causes of mental illnesses are kleshas. (b) It is not necessary to apply all the methods given above to the task of understanding a mental patient. First start with the "three akusala mula" approach. Failing that the therapist should try out other methods one after the other till he gets the patient into the stream of seeing and knowing the klesha that has caused the mental illness. (c) Our first effort was to understand the patient's past actions of which memories are present in the patient’s mind, particularly in the unconscious mind. Therapeutical psycho-analysis comes to an end when the patient is able to see and know the klesha (the cause of the illness) at the moment of its arising (please remember that already the patient’s both conscious and unconscious minds have been probed into.) (d) The step of Dhammanupassana - the analytical step can be completed withing one to four weeks. Buddhist psychotherapeutic method does not advo cate prolonging therapeutical work beyond 16 weeks; in fact, all the six steps can be completed generally withing 8 to 10 weeks. (15) (a) Finally, one session should be devoted to show ing the patient a positive approach to life for the pur pose of his personality development. As a result of having been mentally sick for some time, his body and his personality would have got weakened. Therefore the body now needs physical nutriments while the personality needs psychological nutriments (b) The Buddha has spoken of seven ways of person ality development. See Samyutta Nikaya - Bojjanga Samyutta. They are called Sapta Bojjanga Dhamma. During the treatment under steps 2 to 5, the patient has gradually acquired mindfulness. (c) Of the seven methods of development, the thera pist should recommend at least two or three for the patient to practise. Sapta Bojjanga i ii iii iv v vi vii (d) Sati = mind fuln ess. Dhamma Vica ya = in ve stiga tion , inquiry Viriya = striving P iti = raptu re (beco min g happ y) P assadhi = tranq uility Sarnadh i = concentra tio n Upekkha = equanimity Fo r a men ta l pa tien t who has b y now almo st reco vered fro m h is illne ss, practise o f 'sati' (mindfu lne ss) and 'viriya ' (strivin g) mu st be reco m mended. One wa y o f cultiva ting 'sati' is to get the patient to go on p rac tisin g anapana sati b havana. P ractise of viriya can be incorp orated into anapan a sati bhavan a. For insta nce the time sp ent on bhavan a can be in crea sed, go in g on gradually fro m 3 min i \es at the beg innin g to ab o ut 30 minu tes. Develop ment of sati and viriya will re sto re health - a developn ent over whic h the pa tient will be hap p y (acqu ire pTtiV (e) More positive gu idanc e will be pro vided un der step No. 6 which aims at rehab ilitation an d socializa tio n of the pa tien t. (f) What ha s be en de scribed abo ve is a therapeu tic al u se of Dh a mmanup assana. Thus the four ways of de ve lop ment of mindfu lness given in th e Satipatthan a su tta h a ve been mod ified and ap plied tc relieve the suffering un dergone b y the men tal patient . The Satipa tthana dha mma is the one and th e only wa y to the cessation of su ffering. This is an exp erimen tally realized fac t of life. 13 REHABILITATION AND SOCIALIZATION (1) After tak ing th e patie nt th rough the first five step s of th e Buddhist P sycho therapeu tical process (i) Deve lop ment o f c ommun icatio n (ii) Bo d y aware ness (iii) Fe eding awareness (iv) Min d awareness (v) Analysis of mind con ten ts - the patient ne eds fu r ther g uidance for reh abilitation and socializa tion as now the patien t's illn ess should be wan ing. (2) We have to take fu rthe r measures to suppo rt the cura tive pro cess taking place in him - these are suppor tive mea sure s (u pakaraka k riya). This has to be done in four sp ecific sub ject areas - (i) The ph ysic al (ii) The psycho logical (iii) T he socio log ica l, a nd (iv) T he econo mic. (3) Physical Rehabilitation (i) After the co mp letion o f the first five steps o f therap y, the p atien t should be referred to a medic al pra ctition er fo r a p h ysical check up on eye sigh t, b lood pressure, d iabetis and chole ste ro l. On the re sults of th is check up the patient shou ld be pro vided with med ical care b y a ph ysic ian. An y oth e r ph ysical ail men t in the patient too shou ld be medically treated at this stage . (ii) If the pa tien t co mp la ins of lo w vitality he should be p ro vided with nutrimen ts such as vita mins and pro te in as reco mmended b y the ph ysic ian . (i) The psychotherapist should recommend daily ex ercises including some yoga exercises to the patient the physical exercises should be done daily. It is very therapeutical to get the patient engaged in some games such as badminton and swimming which will provide the opportunity to exercise, laugh, shout in happiness and forget his long days of physical sufferings. (ii) Encourage the patient to be practically clean with regular baths and washes; also he should be en couraged to wear clean and nice dresses and also en gage in good health habits such as brushing teeth af ter every major meal. (1) Psychological Rehabilitation (i) Provide guidance to improve self confidence in the patient. Constant appreciation of any good action or behaviour on his part by the members of his family and friends will give him much needed self confi dence. (ii) Explain to the patient that he himself and others will be pleased when he is neatly and attractively dressed: (i) Provide him with enjoyable songs, reading mate rials such as cartoon stories and novels. Encourage him to watch TV programmes and also listen to the radio programmes. (iv) Encourage him to keep his room (if possible, the entire house,) neat and attractive - especially the bed room including his bed and other furniture. (v) Encourage the patient to visit beautiful places such as gardens, river banks, places of religious worship such as temples, mosques, kovils, churches and per form religious practices such as pujas that are in keep ing with the patient's religious affiliations. vi Explain ihe doctrine of'Sapta-Bojjanga' and recommend at least two of them for daily practices. And also encourage the patient to practise anapana sati bhavana daily. Social Rehabilitation (i) The patient’s immediate family must be advised to treat the patient with kindness and care. (ii) Get the patient’s immediate family to supply his material needs - food, medicine, clothes etc and if possible with a seperate room for the patient. (iii) Members of the family should eat together with the patient at meal times and show him care and af fection by serving him curries etc. (iv) Members of the patient's family should be en couraged to take the patient along with them in their social visits to the houses of their relations and friends. (v) Wherever it is possible, they should address the patient by his pet name and indicate their love and affection. Economic Rehabilitation (i) The therapist should explain to the patient and to his relations the usefulness of occupational therapy. In short, get the patient to find employment or to en gage in some activity that will make him earn some money. As the behavioural school of Therapy has suggested, the patient should be given a token (which has the value of, say, Rs. 10.00 per token) for each good job of work done by the patient during each day. This method is sui table for children and adults of very low intelligence and not for intelligent adults. (ii) Encourage the patient to save money earned by him about one fourth of his monthly earnings should be deposited in a savings book and this savings book should be kept with the patient. (iii) Encourage the patient to have some economic targets such as having ten thousand or one lakh in his savings book. (iv) Link the patient's economic targets to getting married or building a new house or buying a car etc. Relapses (i) There is always a possibility of a relapse of the mental illness. In such a case, the patient's relations should be advised to bring the patient again to the psychotherapist for further treatment. v (ii) Before treating a case of relapse, the patient should be referred for medical check up and if the medical reports are bad, he should be put under medical care. (iii) The relapses are caused by the following factors: a) Rehabilitation measures have not been done properly. b) Discontinuation of daily meditation and daily physical exercises. c) The cause - the klesha - has not been properly seen and known by the patient. (iv) The therapist should have two or three more sessions with the patient using a combination of steps No. 4 and No. 5 (probing into the mind and content analysis). This process will enable the kleshas to be brought 'out' SO that the patient will see the klesha and know the klesha as it arises. (v) During the above therapeutical work the therapist should reactivate the process of catharsis. (vi) Encourage the patient to continue the rehabilitation at least for another three to six months. CASE STUDIES A Case of Melancholia (i) (1) History of the case There is a general acceptance that melancholia is a mental disorder found in the age group of forty to sixty five years. All the symptoms of this mental dis order were found in a medical student who came to me for treatment. But he was only 23 years old. He came for treatment under the system of Buddhist Psychotherapy on 2nd, January 2000. 14 Buddhist psychotherapeutic work was completed on the 13th of February 2000. Because of the illness of melancholia, he had given up his studies at the medi cal faculty at the University of Peradeniya, Sri Lanka. On 23rd February, 2000 he went back to the Univer sity but was asked by the authorities to go before the medical board; had a set back because the psychia trist on the board refused to say that he was fit to resume studies. The psychiatrist concerned had doubts of this illness could ever be cured. (2) Symptoms: The patient had the following symptoms: (a) Inability to concentrate on his studies (b) Feeling of acute depression (c) Constant headache and lack of appetite (a) (b) (0 (d) (e) (1) Inability to grasp university lectures Avoidance of class mates and friends Locking himself in his room and keep on staring at the roof of his room Developing an urge to commit suicide Nihilistic delusions were prevalent Treatment (f) Allowed continuation of psychiatric drugs but in dicated that efforts must be made to be without s uch drugs. (ii) At the first step of treatment, communication be tween the therapist and the patient were successfully established. He was willing to come for the second session and was made to see and know how much suffering is there in him; and also he was made to realise that his illness too is subjected to the law of change (anicca). The patient went through the first three steps of therapy - communication, body awareness and feeling awareness. Up to the end of the third session there was an all round improvement. (2) Data Collection: At Step No. 4 his conscious and unconscious mind was probed into. A lot of material was dug out. Sev eral relevant memories were taken note of. The fol lowing dream was repeatedly dreamt by him even before he was put under psychiatric treatment. He dreamt the following dream. He entered a public lavatory in a densly populated city - a city similar to his home town, Kandy. He entered the toilet but there was no space for him to place even one foot, the place was full of human excreta and urine, it was such a disgusting sight that he wanted to rush out of this dirty place but there was no door - no outlet. He was made to suffer at this place until he awoke from the dream. The above dream indicated the background to his ill ness and also in it the root cause of his trouble was symbolically expressed. The purpose of the dream was to punish him for a ' wrong thing' that he has done. Lessons learnt from childhood at Buddhism classes in the school and also at the Sunday (religious) school had developed in him a consciousness that he should not do wrong things. Due to unavoidable cir cumstance he had to agree to a dishonest act to which his father too was a party. (The details cannot be re vealed here in consideration of the patient's welfare). The dream indicated that he had inflicted punishment on himself for his own wrongful act (akusala karma). (5) Treatment Further discussions with him revealed that the whole complex mental problem - the melancholia - was developed unconsciously by the patient himself. Every symptom that was found in him was shown to be linked to the 'akusala karma' mentioned above. Thus, the psychology of this young man's mental illness was explained to him. In the communication process be tween the patient and the therapist, catharsis was created. Following points too were explained to the patient: (i) Even an akusala karma (wrong act) is imperma - nent; the act as well as its effects too are imperma nent; therefore, the whole trouble would fade away from him as time goes. (ii) He was suffering day and night due to his mental illness and his close relations too were suffering due to his mental illness. (iii) The mental illness - melancholia - has been caused by his own kleshas (mental defilment) namely the dishonesty and the repentence. These two kleshas had been covered by a 'nivarana' namely the "thinamiddha" (the neurotic condition of sloth and torpes = acute depression). Further discussions were held to show him that the depression was uncon sciously manipulated for the purpose of covering up the two kleshas which caused mental agonies. With this self knowledge, the depression was gradually reducing. The patient was referred to a general medical practioner who treated him for his physical ailments. Rehabilitation : The parents were advised to help their son to be re habilitated under the following four heads : physical psychological, social and economic. For physical rehabilitation, he was encouraged to engage in swimming, playing badminton, having regular baths and body washes and wearing clean clothes. He should continue the medical guidance provided by the general physician. It was made al most compulsory for him to meditate on breathing (anapanasati). Relapse The patient and his parents were told that there was a possibility of relapses in which case, the patient should see the therapist immediately and in fact, the patient had relapses and had two more sessions with the therapist. The father, in order to get quick cure, took his son to Colombo for hypnotic treatment. The patient communicated this fact over the phone and informed that trip to Colombo was a useless one. In the first week of December 2001, the father informed the therapist that the son leads a normal life at home although he had to give up his university education. The need for economic rehabilitation was stressed at the accidental meeting between the therapist and the patient's father who reported that the son has stopped taking psychiatric drugs and capable of managing himself well. A Chronic Case of Depression (ii) (I) Histroy: At the time of coming for treatment under the system of Buddhist Psychotherapy the patient was 45 years old, a mother of two children - the son a medical student and the daughter a university student. Her hus band had been a school teacher who also ran a profitable business. The patient’s husband had died leaving the burden of running both the family and the business on this lady who was then about 35 years old. A few months after her husband's death, she became mentally ill and h ad been given western psychiatric treatment for about 10 years but there had been no improvement. (2) Symptoms She complained of a terrible loneliness. She was de pressed, unable to sleep and occasionally she burst out in sobbing and in meaningless talk, lost weight and became ugly, lost her appetite and had sudden burst of anger, attempted committing suicide. (3) Treatment On 15th May 2000, she came for treatment under the system of Buddhist Psychotherapy. In the course of the therapist's discussion with the patient (at the first session) she was able to understand the follow ing realities about the illness: a) There was suffering in her, both mentally and physically b) She had a mental illness for which she had been given western psychiatric treatment but there had been no cure. c) That there is nothing in the world which is per manent and therefore, her illness too must be impermanent - which means that her illness is subjected to change - that is it can be cured. d) That the patient was ignorant of how her illness was caused. (4) She was given a brief introduction to the system of Buddhist Psychotherapy and asked whether she would be willing to be treated. She agreed to come again and the second interview was fixed for 22nd of May 2000. (5) She was allowed to continue with the psychiatric drugs but was advised to reduce the use of drugs (10 pills a day) gradually. In March 2001, she reported that she had given up taking the psychiatric drugs al together and was feeling fine. (6) The next two sessions were devoted to focussing her attention on to her own body and her feelings in ac cordance with the steps Nos. 2 and 3 of Buddhist Psychotherapy. During this period she began to experi ence relaxation. (7) At step No. 4, the probing of her conscious and un conscious mind was started. She had several dreams in which her husband was wearing a black coat. In one dream he was seated at the dining table with the two children and another young man - a relation of hers. To get over loneliness she had had several alms givings in memory of her husband. Before his death, she was generally a happy house wife except for one incident when she found that another woman teacher was getting interested in him. On the request of the wife, he got a transfer to their home area and thereaf ter they lived a satisfying family life until the untimely death of her husband. (8) The patient's memories were traced as far back as her adolescence. Various incidents were tracked down. The materials unearthed indicated that she belonged to the 'moha' - ignorant character type. The repetative dream of her husband and two children and another person was taken up for anyalysing. Who was the other man in the dream? This question was asked emphatically, and she was emotionally up set. Who was the other man? The patient referred to an incident that took place, immediately after her husband's death. The young man in the dream was the relation who had suggested to have a secret affair with her. She was shocked and did not give in to his request, but later she felt that she should have dismissed him more rudely than she did. She began to repent for not doing so. Also she had a fear that her dead husband’s spirit was there watching all the time. This belief resulted in count less sleepless nights and in the course of time she became a mental patient. (9) In the course of discussions, the presence of two kleshas - fear and repentance - emerged. She admitted that her depression was none other than the nivarana of 'thinamiddha'. How to get rid of the two kleshas and the nivarana was further discussed. The seven methods of dealing with mental difilements that were given in the Sabbasava Sutta were explained to her. She accepted the two methods - dassana = seeing the kleshas and samvara = controlling actions and speech, as instructed, she very diligently watched her own mind to recognize her kleshas and the nivarana. (10) From the 15th of May 2000 to 27th June 2000 she came for regular weekly sessions. On 14th August 2001, she reported over the phone that she leads a normal life. On 4th December 2001, she reported that she had a relapse and her son took her to a psychia - trist who put her on the same old drugs. While taking drugs she continued her meditation and she found that there was no need to use drugs and stopped them completely. She was reminded of the need to be rehabilitated under the four points - physical, psychological, social and economic. On 27th April she reported that she was feeling fine and no drugs are needed. Conversion Hysteria of a Different Type (iii) (1) History A second year university student (21 years old), studying agriculture was brought by her mother for treatment on 28th July 2000. She came regularly for treatment sometimes, twice a week, and the last session took place on 1 st October 2000. She had a relapse of the illness and came for consultation on 16th November 2000, thereafter, she attended a further two sessions. It was reported that she was able to do her studies well at the university and occasionally she attended a traditional meditation centre at Nilambe near Kandy in Sri Lanka. (2) Symptoms She had persistant headaches, occasional feelings of nausea, inability to concentrate and comprehend the class - room lectures, had waves of pain running through the entire body; experienced a feeling of dis gust while at home and a great dislike towards her mother, she had occasional fits of sobbing. She avoided friends and class - mates as far as possible. She experienced an urge to run away from home and become a bhikkuni (a nun). (3) Diagnosis a) After the first session, communication betwen the therapist and the patient was established to a satis factory degree and the patient was referred to a very competent physician to find out whether there are physical causes for her body-pains; several medical tests including ESR to rule out HIV infections, were conducted. This physician, in the presence of the pa tient 's mother and the psycho-therapist explained to the patient that he did not find any physical cause for her illness. b) The first step of treatment was completed on 4th July 2000. The next two sessions were devoted to developing her physical awareness and feeling aware ness using ’anapana sati bhavana' techniques. While meditating on feeling she realized that she has had a persistant body ache. It was clear to the therapist that unless and until the catharsis takes place, these aches and pains would continue. c) Probing into the patient's both conscious and un conscious mind, was carried out for more than four sessions. She spoke very little and even that was in terrupted by her occasional bouts of sobbing. She described a dream dreamt by her previous night. In the dream she was watching a colourful procession with hundreds of elephants, drummers and dancers. The procession had to cross a river and it disappeared under water; reappeared on the other bank of the river and moved on. She was quite happy in describing the dream; this meant she was capable of enjoying such sights. d) As the dream did not reveal much of her problem area the unconscious - other methods (that had been described in this book under chapter 11) had to be used to probe into her unconscious. The patient's mind (recollections) was regressed gradually up to the age of five years. Her problem began when she was about 9 years of age. At that time, the whole country was suffering from great strain due to the JVP (at that time a very active terrorist group) up risings of 1998 - 91 and the government's ruthless retaliatory measures. The patient's father, then a graduate school teacher was involved in the activities of a pro -China revolutionary group and therefore the police was after him and he went into hiding. This situation caused im mense fear and tension in her and also in her elder sister and the mother. When the country reached some normalcy, the father returned home; but he too was not the same person that they knew earlier. Quarrels between the mother and the father developed; one day, in an uncontrollable fit of anger, the father tried to cut the throat of the mother; the patient and her sister struggled with the father, managed to push the mother into a room and locked her up. The above mentioned incident had caused a terrible disturbance in her mind. The father and mother had occasional reconciliation and a younger sister was born, who naturally absorbed most of the mother's attention. This too became a disturbing factor to the patient. Treatment Treatment began in the following manner: (a) Developement of breathing awareness. Through anapana sati bhavana attention was focussed on bodily functions and feeling in keeping with the step No. 2 and 3 in the system of Buddhist Psychotherapy. (b) The importance of catharsis was explained to her (c) The patient's memories in both the conscious and the unconscious mind of the patient were unearthed and while the patient was describing her me mories of experiences, the process of catharsis was taking place in the patient. (d) The patient was asked to identify the personal ity type to which she was belonging. The mental patients do belong to one of the four personality types: i) Raga personality ii) Dosa personality iii) Moha personality and iv) Mana personality. She said that she belonged to the Mana type and she had a tendency to compare herself with others (the classmates etc). (e) By studying the memories, the patient was helped to identify the kleshas that caused the illness or contributed to making her a mental patient; the kleshas thus recognised were: fear, feeling of in feriority and anger (her anger was directed against her mother). (f) The functions of the 'panca nivarana' were ex plained to her and she recognised 'thinamiddha' (depression) as the nivarana in her. She was using the 'thinamiddha' to cover her kleshas. Further, it was explained to her that any nivarana is a psycho-neurotic condition in the patient and unconsciously she was motivated to hide her kleshas mentioned above. (g) As a therapeutical act, the patient was guided to have passive observation of the kleshas and the nivarana as they arise in the course of her day to day work. (h) By analysing the patient's mind it was shown to her that the body pain that she experienced was in fact, was the transfer of the pains in her unconscious on to her own body, almost with immediate effect - in short, her pain of mind was transformed into her pain of body. This can be described as conversion hysteria. Generally all people having hysteria have purpose of becoming physically as well as psychologically ill. The patient took a couple of week to realized the de velopments in her. Relapses : (a) The patient and her elder sister (then a final year medical student) and parents were told about the the need to rehabilitate the patient under four headings (described in this book). (b) The possibility of a relapse was also explained to them and in which case they should arrange another session of consultation with the therapist. (c) The patient was encouraged to help the mother to run the home well and visit places of worship and beautiful gardens etc. During the days of university vactions, she was encouraged to meditate at a traditional meditation centre. There was allround improvement in her but had two relapses; and came for consultation. At the time of writing this report, her mother spoke to the therapist to inform that her daughter was doing well at the university. This was reported on 2nd January 2002. (1) History : She was an unmarried good looking girl. At the age of 24 she had been hospitalized and was treated for schizophrenia. For two years she had undergone psychiatric treatment; then one day she ran away from her home with the fear that some one was chasing after her. She was admitted to a private hospital in the night of 20th Dec. 1998. Her parents too stayed with her in the room. She went to the toilet, locked herself up and jumped through the window on to the ground which was 12 feet below the floor of the room. With the help of the police she was looked for more than two hours and finally she was found hiding un der a lorry parked in a bylane. Further western treat ment was continued but had had no good effect. Therefore she was brought for treatment under the Buddhist Psychotherapy in mid February 1999. (2) Symptons: She had a strong suspicion particularly directed against her own mother; repeatedly said that she was not her mother and she was trying to kill her by poi soning, had auditory illusions of hearing voices and other hallucinations particularly in the nights. She said that people at her home were conspiring against her, suffered from lack of sleep and loss of appetite, had no sense of cleanliness. She spoke of having had sex relations with her boy friend and of being pregnant by him. Short periods of normalcy was followed by periods of restlessness and agitations. (i) First she was sent to a gynaecologist for a preg nancy test. There was no pregnancy. A general medi cal practioner had tests and said her blood sugar, pressure and cholesterol were normal and the E.S.R. test indicated that she had no social diseases. It took three sessions to cover the first step of treat ment under which she developed confidence in the therapist. She made very slow progress under the first three steps- development of communication, body awareness and feeling awareness by means of anapana sati bhavana. These are the three prerequisits for the contemplation on the mind - cittanupassana - probing into both conscious and unconscious mind. (ii) By probing into the conscious mind using the technique of free association (expounded by Freud) several memories were drawn out including the fol lowing: (a) A vision of a fearful she-devil emerged through the locked up door of the room where the patient slept. (b) Hearing noises of some strange people conspiring to kill her. (c) Being frightened of a she-devil, she (the patient) was yelling out, sometimes even during the day time. (a) She believed that her mother had hidden a charm = 'huniyama' under the mattress of her bed. (ii) The patient's quick responses to words such as 'accident', ' mother', 'father', 'poison' indicated that her childhood had not been a happy one. (iii) She related several repetitive dreams. In one such dream she felt that some one was following her and therefore she ran away from her home until she found that she had come to the edge of a rock on the river bank and could not run anymore; at this point she woke up from the dreamy sleep. Such dreams indicated that there was a deep rooted fear and suspicion in her unconscious. (iv) The patient was encouraged to continue medita tion on her body and feelings at least a few minutes every morning and evening. Her talking of her own suspicion and fear with illustrations created a catharsis in her. She was encouraged to stop medication (psychiatric drugs) gradually. After about 10 sessions she was able to manage herself without drugs. (v) Out of four personality types, she said that she belonged to a mixture of'raga' and 'dosa' types. Fur ther questioning helped her to realize that she was belonging to 'moha' personality type - the personality type driven by her own ignorance of realities. (vi) Analysis of her memories and emotional responses revealed that the major klesha that caused the illness was suspicion (vicikicca). It was also revealed that the klesha of suspicion was traceable to even as far back as her childhood days. A Way Out The patient was given the following clear instructions: (a) Whenever she heard or saw hallucinatory vi sions or fearful noises, she should remember (say to herself) that klesha of suspicion has arisen in her; when an impulse to accuse her mother came up, she must say that the klesha of suspicion was behind that impulse too. (b) The patient was prevented from seeing her klesha of suspicion because it had been covered by a 'nivarana' of 'kamachanda' which is a psycho-neurotic condition of having her mind pre-occupied by sex thoughts all the time except when she got fearful hallucinatory visions. Therefore, she was instructed to see when sex thoughts came to her mind and tell herself that there is nivarana of kamachanda that has arisen in her to prevent her from seen the klesha of suspicion in her mind. (c) The patient was encouraged to visit places of religious worship and particularly spend some time just been seated under a Bodhi Tree in the temple and she should be accompanied by a close relation of hers. She was encouraged to spend even a few minutes there to meditate on breathing (three forms of anapanasati bhavana has been given in earlier chapters of this book) (d) (3) Meditation on breathing and on four modes of behaviour ' iriyapatha' = walking, standing, sleeping and sitting will lead to the develop ment of fourfold awareness as given in the satipatthana sutta. The development of dhammanupassana helped the patient to manage herself. On 4th January 2002, the mother of the patient informed the therapist over the phone, that her daughter is now quite a normal person; she had completed a course in preschool education and also she was studying for the BA degree as an external student. The patient and her parents came for a common ses sion in which they were told about ways and means of rehabilitation of the patient. (This was the first case of schizophrenia treated by means of Buddhist Psychotherapy. Thereafter several cases of schizophrenia were treated with more effi ciency and confidence. A Case of Manic Depressive Psychosis (v) (1) Case History A thirty four year old unmarried female patient was brought by her parents for treatment under Buddhist Psychotherapy on 14th October 2001. She had been under psychiatric treatment for nearly 20 years; had been warded at Mulleriyawa Mental Hospital several times. She suffered from a chronic form of depres sion whcih fluctuated between extreme depression and high-tension; as soon as anti-depression medicines were given, she immediately got into a state of hyper tension. (2) Symptoms When anti-depression drugs were given she became over-active, could not control herself, used obscene language even before her parents, accused parents for causing her illness and could not control her impulses to shatter everything she laid her hands on. The urge to commit suicide was so great that she made several efforts to commit suicide. When as soon as anti-hypertension drugs were given she lapsed back into a state of chronic depression. When in this state, she lost her appetite, had feelings of nausia, suffered from lack of will to live, continu ous headaches and body pains, and was constantly crying and sobbing in a state of withdrawal from society, having no desire to be physically clean or to have baths or washes or wearing clean clothes, hav ing an urge to be unattractive and repulsive and to commit suicide. (3) Treatment (a) On 14th October 2001, a session on develop ing communication between the therapist and the patient was held. The patient was encouraged to describe the history of her illness and the type of treatment she received during the past 20 odd years. She was able to give names of drugs given by different psychiatrists. Thereafter, her attention was focussed on her physical and psychological suffering. When her attention was focussed on the intensity of her suffering, she broke down twice and started sobbing. (b) The discussion on suffering was followed by a discussion on the concept of impermanence. The fol lowing questions were put to her: i ii iii Is there anybody that exist permanently? Is there any condition which is permanent? Could your illness be a permanent condition? With such questions she was made to understand that even her illness could be changed which means could be cured. At this stage she became hopeful of becoming a normal healthy person. She expressed her de sire to come for treatment regularly. (4) At the 2nd and 3rd sessions her attention was focussed on her body and feelings - kayanupassana and vedananupassana. She was given specific instructions on the practice of anapanasati bhavana at home. She was able to develop mindfulness on her body and feelings to a satisfactory degree. The patient was encouraged to visit her friends but it was revealed that she had no friends. It was also found that she had an aversion to staying at home; therefore she was advised to spend a quiet time at the Bo tree in the village temple accompanied by her mother or sister. That she did. (5) Probing into the conscious and unconscious mind was started on 11 th Novermber, 2001. A lot of memories from her childhood up to the age of 14 were unearthed. By looking at the memories of her adolescence she said that she belonged to the raga type of personality. Responding to several questions put to her, she said that she had no prior knowledge of the bodily changes that took place during puberty, she was frightened to see blood at the first menstruation. For some time, this fear persisted in her mind. In order to cover up this fear she started masturbation at regular intervals. She had imaginary sex relations with boys. She be lieved that she had an intercourse with a boy who was a regular visitor to her house. As time passed she developed a guilty feeling about her unrestrainable sex desires gratified by masturbation. From her childhood she haboured a jealousy against her younger sister who had received more attention from the parents. From that time onward, the patient had devel oped an antipathy against her parents which had gone into her unconscious. In course of time, she came to blame her parents for her failure at the Advanced Level Examination. At the age of 14 and 15, she had suffered from head aches and lack of sleep; menstrual blood, guilty feelings of sex experiences (real and imaginary ) - all combined made her feel disgusted and depressed which led to psychiatric treatment. At first she responded to psychiatric drugs and was able to manage herself nearly four years without drugs. But in her early twenties the depression returned. Thereafter, it was a constant struggle to deal with depression and violence; it had come to a point that a balance between these two conditions was an impossibility with western drugs. Detection of the Causes (kleshas) Starting from l lth November, 200l till 2nd December 2001, the materials (memories) unearthed from her conscious and unconscious mind were analysed together with the patient for her to see and know the causes of her mental illn ess. The memories unearthed from her life up to mid twen ties, made it clear that the predominant klesha was her craving for sexual pleasures. What made her men- tally ill was not that craving but a strong feeling of disgust (patikula) and remorse (vippatisara) for her early) misdeeds. Memories of past deeds started pouring out during the waking as well as sleeping hours and such memo ries were painful. She had no knowledge of how to face such painful memories. She had been bewildered by the effects of psychiatric drugs. When one set of drugs was given she was carried away by hypertension and when another set of drugs were given to counteract the hyper-tension she was carried away by depression. In fact what she was unconsciously developing was the psycho - neurotic condition called the 'thinamiddha' - the meaning of this Pali word coincides with that of chronic depression. 'Thinamiddha' is one of the five hindrances (panca-nivarana) that cover up the defilements (kleshas) in the mind. Therefore, the function of thinamiddha, in case of the patient under discussion was to cover the painful memories caused by kleshas such as disgust (patikula) and remorse (vippatisara). By means of taking shelter ufider 'thinamiddha' she was unconsciously struggling to hide the disgusting memories; and her failure to do so, caused her endless suffering. When anti-depression drugs were given she got an urge to come out with filthy words,scold her parents and to attempt to commit suicide. Further Guidances lndepth analysis of this case made the therapeutical method very clear. The patient was instructed to ob serve in herself the appearances of'thinamiddha' and the mental defilements of 'disgust' and 'remorse' whenever they arose in her. This way of seeing the mind is called 'dassana' - one of the seven methods of cleansing the mind as given in the Sabbasava Sutta. When the patient was made to see and know the 'nivarana' and the kleshas in herself, her past painful memories started coming out, thus, initiating the thera peutical process called catharsis. At the session held on 2nd December 2001, she and her father were given specific instructions on how to rehabilitate under four methods namely physical, psychological. social and economic. They were given the warning that relapses are possible in which case they should contact the therapist promptly. Since then the patient contacted the therapist over the phone a number of times for clarification and further guid ance. On the 2nd of December, the following instruc tions had been given: (a) The psychiatric drugs must be continued, but in consultation with the psychiatrist, the drugs have to be reduced gradually and stop completely when the patient's behaviour becomes normal. (b) Seeing and knowing (observing) the 'thinamiddha' and the kleshas of disgust and remorse should be continued. (c) The forms of meditation that had been introduced at steps 2 and 3 must be practised every day for at least 5 to 10 minutes. (d) Guidance provided under step number 6 should be followed. (e) For any physical illness the family doctor should be consulted. (f) At least once a week the patient must visit places of religious worship and beautiful places such as gardens. (g) Encourage them daily. the patient to grow plants and to tend (10) On 13th December 2001, the patient informed the therapist over the phone that her depression has re appeared in a big way. She was given the following points to consider. (i) There are two kinds of depressions: a) physical and b) psychological. As she is in the process of seeing and knowing the kleshas and the nivarana a psychological depression was not likely to take place. c) What she was now experiencing could be the physical depression resulting from prolonged physical suffering, effects of psychiatric drugs, lack of proper neutrition and above all the effects of the severe cold she was having. She was advised to be treated by a medical practitioner (the family doctor). (ii) On 21st December 2001, the patient complained that she got a relapse of a severe depression and asked for an appointment on the next day. On 22nd she had a long consultation session. It was revealed that as she was in the process of seeing and knowing the two kleshas - the disgust and remorse - these two kleshas could not be causing her any more serious trouble. Therefore, there was the possibility of another klesha or a set of kleshas have come up causing her present depression. What was it? Further analysis of data - the memories and emotions involved in them - it was revealed that there was an urge to take revenge from her parents (there were unreasonable as well as rea sonable grounds for it) by means of her becoming a mental patient. The relapse of the depression had been motivated to take revenge from her parents, the pa tient agreed with the new discovery. Promptly she approached her father who accompanied her and said, "father, please forgive me for the suffering caused by me to you and mother it was motivated by an urge to take revenge from you and my mother.” During the last week of December 2001 and the 1 st of January 2002, she communicated with the therapist over the phone several times when she could not manage herself. She was advised to continue - to keep on observing the arising of the 'new' klesha - the revenge as it arises in her. At the time of writing this report (mid January 2002) there was fast recovery from her mental illness. On 15th January 2002, she informed the therapist very happily that she had overcome her mental problem. By the end of April 2002. she got a relapse - she had not responded well to even psychiatric drugs. It appears that she suffers from bipolar disorder and new efforts are made on an experimental basis. On 3rd June 2002 she informed the therapist that she has overcome physical and mental pains. A Case of Unconscious Fear Leading to Two Miscarriages (vi) (1) History When this therapist was conducting a refresher course for the teachers of Buddhism for Advanced Level (pre-university) classes of the whole island of Sri Lanka (in 1976) at the Buddhist Teachers College, Mirigama, a couple participating in the refresher course asked for permission to discuss a personal problem of theirs. They said they had been married for nearly six years but so far not a single child of theirs survived the early months of pregnancy. After the loss of the first child (unborn) they consulted a gynaecologist regularly and took special care but lost the second unborn child also. When the couple met this therapist at Mirigama Teachers College the wife was in the 5th month of pregnancy. The couple said that they were afraid of losing even third child. So they pleaded with the therapist to rescue them from this miserable situation. (2) Treatment Without taking this unfortunate mother through all the six steps of Buddhist Psychotherapy, on the basis of an experimentation, went straight to probing into her conscious as well as unconscious mind. (The hus band was asked to keep away from this session.) She came out with a recurring dream in which a co bra was chasing after her and she ran and ran round her house to escape the cobra. The first abortion took place immediatily after this dream. When she was in her 5th month of pregnancy she had the same dream and lost that child too. The following conversation took place between the therapist and this troubled teacher. "Did you really see the cobra?" "Yes, I did" "How long was the cobra?" "I did not see the full cobra." "How long was the part of the body of the cobra that you saw?" "About six inches." Here, it was presumed that the cobra is the symbol of the male sex organ. Several questions were asked to find out whether she had experienced a fear of a sexual attack by a male. By means of questioning restrospectively she was able to recall memories of several incidents of her childhood. When she was about 12 years old, she had to go through a lonely stretch of jungle daily on her way to school. She had constant fear of serpents or brewers of illicit liquor, frequenting this jungle, would attack her. As a clild she dreamt of cobras chasing her and the illicit brewers trying to molest her. In the dangerous repetative dream that led to the loss of two unborn children, the fear of real cobras and sexual attack was clearly seen but so far it was in her unconscions. The very sight of the cobra of the size of a six inch penis could have been so powerful as to cause a great shock in her womb - a powerful shock to cause the miscarriage. All these possibilities were explained to her and the whole interpretation of the dream was intelligible to her. Further it was explained to her that in the dream there was nothing other than her own frightful memories of going through the dangerous patch of jungle - there was no other external agency in it. When this teacher came for the 3rd session, her face indicated that she was mostly relieved of her fear of miscarriage. She was given instruction on practicing meditation on breathing daily. She was given the fol lowing instructions. (a) Follow the medical advice given by the gynae cologist, see him regularly. (b) Recite the Discourse of Loving Kindness before going to sleep daily. (c) Go to any religious place - a Temple or a shrine and make a vow for the safety of both the child and the mother. (d) Keep the house and its vicinity neat and beauti ful. (e) Keep the body neat and fresh by regular bath ing and washing. The husband came to the Education Ministry in Colombo (where the therapist was working) several times and reported that so far there was no problem and they were hopeful of seeing their child this time. A few months later the husband came to the therapist's room in the Ministry to report that at last they have become parents. The psychotherapeutical guidance was complementary to the treatment by the gynaecologist. (1) History When this therapist was a school teacher, in the year l 969, a boy of seventeen years came to him. He was a tall, well built healthy looking boy. He said that he was unable to concentrate on his studies and was afraid that he would come down at the forth coming public examination. Further he said that he suffered from lack of sleep and described the following obsession. (2) Symptons When he (the patient) took a book to read, he was compelled to look through every page of the book, and if there was a cover to the book, it had to be re moved and examined to see whether there is anything behind the cover. Then only he could start to read. Even then many other similar distractions came up. Even in the school he had to lift up the chair and the desk to see whether there is anything under them. When he sat at the dining table, he followed the same routine. He was afraid that others would notice his obsessions. When he went to sleep, the pillow case had to be removed and replaced. The mattress had to be removed, peep under the bed and replace it. He had to keep the bedroom slippers on the ground, go to bed, then get down again and take the slippers, look under them and then go to sleep. In every activity connected with his life, he was faced with such an obsessive desire to see what is behind or under any-thing and everything. He was aware that he could not study because of this uncontrollable urge. He was afraid that he would end up being in a 'lunatic asylum.’ When he came to the therapist he had signs of obsessional neurosis. There was a twitch in his right eye while the lower lip trembled slightly. There was occasional stammering. There was no family history of obsession. He was very shy of girls and could not sit with a girl even is a bus; he would get up and go away. During the first two sessions these facts came to light. He came out with severa l memories. He was standing on a suspension bridge over the river Mahaveli at Lewella in Kandy. He was feeling embarrassed and painfully shy when he saw women bathing in the river but did not have the courage to go away from that place. First he said that he could not remember any dream but later on he remembered three dreams. In one dream he saw a naked girl running into her house but he saw only her back view. In another dream, he was digging in to the ground floor of a house in search of a treasure but w as afraid to dig deep, therefore he closed the pit and went away. Treatment: The therapist gave the interpretation to his dreams. It was obvious that he was obsessed to see naked girls. For a long time he had been suppressing this desire. As a result it ha d gone into his unconscious but the urge to see took different forms such as looking under the bed etc. He admitted that he belonged to the "raga character" type. The therapist took the patient with him to visit the Kandy General Hospital under the pretex of seen a patient-a relation of his. At some wards he saw digusting and pathatic sights which shook his mind. On his way back from the hospital, looking at some commercial posters, he said, 'Sir it is strange ! I don't get the urge to remove these posters". He was instructed to practice anapana sati bhavana early morning and at the time of going to sleep in the night. He was made to understand the links between the obsessions and his desire to see a naked girl. This desire here is called "Kama Raga". He was advised to tell himself, at the time of having obsession, that here a Kama Raga has arisen in me." After the final session with the patient compulsions did not bother him; he sat for the public examination and got through it. About four years later he ca me to the Education Ministry. "Sir, Do you remember me? "Why not! No more troubles? "No Sir, I came to tell you that I am doing well and became a father this morning ?" ” Congratulations" The therapist said. A Case of Depressive Psychosis (viii) 1 History When the therapist was a post graduate student at the university of Pittsburgh, USA in 1968, he addressed the Rotary Club of Pittsburgh on invitation. The sub ject of his lecture was, "Psychotherapy - East and West." On the same day evening a father of a 19 year old Roman Catholic girl spoke to him over the phone about his daughter who was in the pychiatric ward of the Pittsburgh University Hospital. He said that his daughter was in the psychiatric ward for more than two years without any improvement and requested him to treat the daughter according to the "Eastern Psychotherapy. Next Sunday this therapist was taken to the psychiatric ward by the parents of the patient and she was introduced to him at the visitors' room and the parents allowed them to talk and left the room. The following is the summary of the first discussion with the patient. " You came to help me ! Yes ! Who are you ? I am a post graduate student of International Af fairs, and I am not a medical practioner ! " So ! I am being treated by leading psychiatrists of Pittsburgh; Even they have failed to help me. That means 1 am destined remain a mental patient"! " What were you studying ?" " Medical Technology." " Don't you want to go back to the college ?" " Don’t you see that I am sick! Sick of life !" " Aren't you getting treatment?" " Plenty! Pills and pills ....... I am destined to lead a patient's life " " Permanently ?" " Yes, permanently" " Is there anything permanent in this world?" " Yes" " What?" " God" " Yes that is granted - God is permanent !" " Is there anything - any tangible thing which is permanent?" " Now I see! everything is changing?" " What about your illness? Is it a permanent entity like God?" At this point, she got up from her seat; came up to the therapist, took his right hand with both her hands and placed it on her forehead and said " Sir, please help me.... I see you can help me." Thus, this therapist had a great break through!. Through anapana sati bhavana, her attention was focussed on her own body and feelings during the next two sessions. If the hospital authorities were satisfied that the daughter had achieved some improvement, the father was asked to get permission to take the daughter home on next Sunday for 3 hours. Permission was granted and the therapist ha d about 4 sessions with her at her home. The patient's memories were tracked down up to the time of her nervous break-down. She described her memories of sleepless nights and her fear of being an insomnia patient. She had dreamt of not being able to sit for the examination, dreamt of being in a lonely house without a car, and continously missing buses when she had to come down town. In one dream she had gone completely blind and there was no one to help her, dreamt that she had fared very badly at the exa mination. These dreams indicated the actual state of her mind just before the nervous break down. The actual break down took place after she had had an argument with her boy friend. The materials drawn out of her both conscious and unconscious mind did not indicate 'raga' and 'dosa' as the causes of her mental illness..For her to see the state of her mind, materials drawn out from her mind (cittanupassana) were analysed and interpreted. She was able to see that as a result of her inability to see - as a result of her own ignorance (avijja) she became mentally sick. Several questions were put to her without allowing her to answer them. The questions such as: i Why did you experience sleepless nights? ii Why did you think that you might miss the ex amination and the bus? iii Why did you think that you were alone in the house? v Why did you compare yourself with others of your class/ vi Why were you taken to the mental hospital? vii Why did you fall mentally sick? Further discussions revealed that she became men tally sick mainly because of her klesha of ignorance (avijja) which means that she was carried away by her own klesha - the klesha of ignorance of why and how things happened. By means of inquiring into her own actions and their motivations, self awareness was developed in her. The therapist left the USA in the last week of December 1968. The patient wrote to the therapist several letters reporting how she was progressing. In the last letter she said that she went back to the college and at the final examination, she got straight 'B's. The recovery was possible so quickly because of the support given by her parents. The rehabilitation un der 4 headings were seen to by her parents. A Case of Oedipus Complex (ix) (1) History and Symptoms: . A boy of fifteen years, studying at a prestigious school in Kandy, was undergoing treatment at a psychiatric ward in the General Hospital of Kandy in 1967. His treatment was supervised by non other than a Professor of Psychiatry. The Professor had expressed doubts as to whether this boy could be brought to normalcy at all. The boy had many difficulties. He was obssesed with attacks of difficult breathing that he was subject to and he feared that he would die of such an attack. The frequency of these attacks went on increasing; he also had an irra tional fear that he would die of an electric shock or by being struck by lightening. Therefore, he was afraid to touch any metal, even a spoon or a knife, he feared to sleep on the hospital bed with its iron frame-work. (1) He could not read as he developed a continous tick in the eyes. He was not pleased with the treatment at the hospital - in fact, he expressed lack of confidence in the doctors who treated him. A well known Professor of Philosophy at the request of the boy's parents, volunteered to keep him at his residence in the University of Peradeniya. On the first day at the Professor's house the boy complained that he was going to die of breathing difficulties.' The Professor sought the help of this therapist. This was in April 1967. (2) Treatment After the preliminary contacts, this therapist discussed the idea of impermanency. He, though brought up in a devout Christian family, was able to understand the nature of his illness in terms of impermanency. He was very quick to grasp the point that even an illness was inpermanent, hence it was subject to change. Within the next two weeks, the boy's attention was drawn on to his body and feelings by means of anapana sati bhavana. During the first week itself the boy's conditions were improved. Probing into his c onscious and unconscious mind was carried on success fully. These sessions were held not at a consultation room but at the Botanical Garden of Peradeniya. The boy described how happily he slept with his mother in the same bed till he was thirteen years old. As a result of his reaching adolescence he started getting nocturnal seminal emissions with erotic dreams of girls and women. Since then, he found it uncomfortable to share the bed with his mother. He gave various excuses for not coming to sleep with the mother, at the same time he could not hide the fact that he was extremely fond of his mother. (3) He narrated, among others, his repeated dream of the incident on the stair-case. He was going up the stair - case and his father was coming down on it. The son's right hand struck an eye of the father and the eye-ball came out. This dream indicated an antipathy towards his own father. His mother was a teacher at a prestigious girl's school in Kandy and his father who did not wear western dresses, was running a small shop in the village. Therefore, this boy was ashamed of his father. Several memories of the boy indicated the attachment to his mother and dislike for his father - a true oedipus situation. (4) The following facts were discovered in the course of analysis of the boy's memories and impulses. (i) His attack of breathing difficulty and near death experience could be a defence mechanism. To be conscious of the desire to be with the mother and hatred towards his father was unpleasant and painful. (ii) Memories of father and mother were shelved into his unconscious. (iii) Imagination of death by lightening and electric shocks became pre-occupations. Continuation of his frightful situation brought about psycho-somatic disorderly functions such as continued tick in the e ye. (iv) Merely to say that it was due to the oedipus complex that he became mentally ill. is a meaning less thing. More indepth study is necessary. (v) With further questioning the material drawn out of the boy's mind made it clear to him that he belonged to the 'raga' - character type. (vi) As for the kleshas, he had both 'raga' with re gard to his mother and 'dosa' with regard to his father. (vii) Unconsciously the boy was punishing himself for having almost sexual attachment to his own mother and anger against his own father. (6) He responded well to the above mentioned points. Within two weeks tick in the eye disappeared. He was no longer afraid to touch metal. To prove this, in the presence of the Professor and this therapist and his parents, went to the well with a bucket and came back with it full of water, he touched a crow bar and walked without slippers. (7) The boy and the parents were guided to rehabilita tion. When he came back from the house of the Professor, the parents happily and warmly received him at his home. Two months later he was sent back to the psychiatric ward of the Kandy General Hospital for a check up and found that he had fully recovered from his illness and the parents obtained a medical certificate to this effect which enabled the boy to resume his studies at his school from where, a few years later he entered the Engineering Faculty of the University of Peradeniya. Years later on, the parents reported to this therapist that their son is an engineer and leads a happy married life. A Case of Phobia Mistaken as Schizophrenia (X) (1) History On 26th September 2000, a 19 year old boy, an Advanced Leval student of a leading boys' school in Kandy was brought for treatment under the system of Buddhist Pscychotherapy by his mother. The teachers of his class had noticed that this boy's behaviour was abnormal for some time. He was feeling drowsy, could not grasp the lessons - he was not attentive at all. (1) The boy's parents were advised by teacher-coun- sellor of the school to show their son to a psychiatrist and the psychiatrist found the following symptoms. (i) Being suspicious of people; particularly his own mother. (ii) Lack of sleep and appetite. (iii) Heard whispering by some body (iv) lncoherance in speech (v) Hallucinations The psychiatrist was convinced that this was a case schizophrenia as the above mentioned symptoms had been there in him for more than six months. Therefore, he was given standard drugs for schizophrenia and due to the effects of these drugs it was impossible for him to concentrate on his studies as he developed headache and nausia. Treatment (1) At the first step of treatment under Buddhist Psychotherapy, his confidence in the therapist was es tablished to a satisfactory degree. Development of body and feeling awareness had very slow progress; probing into the mind (conscious and unconscious), continued for about three sessions. His suspicion had been directed to his own mother. For nearly 10 years he thought that his mother was having an affair with an uncle in the village. When this memory of suspicion was probed into, it was found that his own mother has had about 21 such affairs. When the boy's father was questioned about the allegation, he said " Sir, I don't believe that his mother would do such a thing, in fact, the son too told me about it." (ii) The boy's memories were regressed to his child hood days - up to the age of 3 years. He was a happy child until the second son was born; naturally the newly arrived child received all the attention of everybody. The boy felt that he was not cared for by anyone, he became very jealous and lonely.This situation gradually led to the development of fear - a fear of losing his mother. As time passed his fear turned into a phobia which had crept into the boy's uncon scious. (iii) Further analysis of the memories of the boy bought to light that the real klesha - the real cause of the illness was fear - the fear of losing his mother. Since this fear was baseless or unreasonable, it turned out to be a phobia. (iv) This klesha - the fear - was very uncomfortable; therefore, a defence mechanism - the nivarana of suspicion - was unconsciously used by this boy. At this point, the reader should remember that the major func tion of any of the five nivarana's is to cover up klesha to prevent the person concerned from seeing and knowing the klesha. (5) When this explanation was given to the boy (the pa tient) he was laughing to himself and said " how silly I am!". Promptly he asked what should be done to get rid of this phobia - the unreasonable fear of losing his mother. The boy was advised to concentrate to see and know the nirvarana of suspicion, whenever the suspicion - about the mother is arising in him, he should say to himself, "Here, the nirvana of suspicion, is arising in me.". When he is in the process of knowing seeing, his suspicion would fade away. Then only it would be easy for him to see the klesha of phobia (fear). He said he would try to be vigilant of the klesha as well as the nirvarana. (6) On 16th November 2000, the father and the son had a common session which was the last one of the therapeutical weekly sessions. It was revealed that what the son was suffering from was not the fright ening mental illness called the schizophrenia but a simple phobia. Father was given a briefing on the process of rehabilitation in keeping with the 6th step of Buddhist Psychotherapy. They were warned that a relapse may be a possibility in which case they should contact the therapist promptly. In mid August 2000, the father brought the son for a check up on whether he had had a relapse. They were given further instructions on how to keep on watch ing the nivarana of suspicion and the klesha of pho bia. About three months later father reported that the son could not sit for the Advanced Level examina tion because he was not fully prepared to sit the examination with confidence; but otherwise he was O.K.! On February 24th 2002, this writer met this boy at a seminar on stress management held in Kandy. He was looking quite healthy and happy and said that he and his parents were very grateful to the writer and they were planning to visit him very soon to express their gratitude for pulling him out of the schizophrenia syndrome - the so called cancer of the mind! "arogya parama labha” Health is the greatest gain' Gauthama Buddha BIBLIOGRAPHY Buddhist Texts: Canonical Anguttara Nikaya Digha Nikaya - Majjima Nikaya - Vol i - v Vol iii Vol i - iii Mahavagga Samyutta Nikaya - Vol i - iii Non - canonical Vimukti Magga - The Path of Liberation Visuddhi Magga Secondary Sources American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders Anthony Storr The Art of Psychotherapy Seker & Warburg - London, de Silva Padmasiri - Buddhist and Freudian Psychology -Lake House Investment - Colombo. Clark David Stafford - Psychiatry Today- Penguin Books - Middlesex. Freud Sigmund - A General Introduction to Psychoanalysis - Perma Books NY. Harischandra DVJ - Psychiatric Aspects of Jataka - Stories - Galle. The Message of the Buddha BPS - Kandy. Leonard Krasner & L P Ullman Behaviour Influence and Personality - Winster. LyttleJack - Mental Disorders - Tindale Lond. Mark Epstein - Thoughts Without Thinker Psychotherapy from Buddhist Perspective - Basic books - NY. Maxwell Herald Psychotherapy - IPO Pub. Jayatilleke K N - Matara Sri Nanarama Maha Thera Seven Stages of Purification BPS - Kandy. BUDDHIST PSYCHOTHERAPY Dr. H. S. S. Nissanka, a Fulbright scholar obtained his M.A., Ph. D. degrees from the universities of Pittsburgh and Jadavpu respectively. He is an internationally known scholar and author of 25 books including “Sri Lanka’s Foreign Policy”, “International Relation and Geopolitics”, “Sri Mahabodhi Tree in Anuradhapura” and “Buddhist Psychotherapy” all published by Vikas in New Delhi. Dr. Nissanka’s “The girl who was Reborn” (Godage) was the first rebirth case study in Sri Lanka and his recent book “Gauthama Buddha” (Gunasena) is a study of the life of the Buddha from a new perspective. He was an experienced teacher a senior lecturer at Sir John Kotalawala Defence Academy and a Provincial editor of the Associated Newspapers of Ceylon Ltd. Presently he conducts an M. A. degree course in Buddhist Psychotherapy at the Post Graduate Institute of Buddhist and Pali Studies of the University of Kelaniya, Sri Lanka. Over a period of 40 years Dr. Nissanka has treated a large number of mental patients successfully.