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 Psy-

chotherapy 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 sa-
vours 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 psy-
chologists 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; re-
minding one of the 'dialogue-form' of the Buddha's dis-
courses, 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 poten-
tial. 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. Treatment of Insanity in Asia.

7. 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 rec-

ognition 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 Psy-
chotherapy 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 ill-
nesses 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. Accord-
ing 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 Psycho-
therapy is a stage in this evolution.

(5) Buddhist Psychotherapy can be practised as com-

plementary 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 de-
pressed. (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 pa-

tient who has successfully gone through the first
five steps given above.

(9) An experienced Buddhist Psychotherapist can com-

plete 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 psy-

chiatrists 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 de-

vices, 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 sub-
ject 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 there-
fore 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 estab-
lishing 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 re-
search; 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 dis-
orders (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 com-
paratively 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 Psy-
chotherapy" 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 clas-

sified under the following four groups.

(i) The hysterical personality

(ii) The depressive personality
(iii) The obsessional personality
(iv) The 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 " Psy-

chiatry 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 schizo-
phrenia probably causes more fear and misunder-
standing than any other. It resembles most closely
the layman's concept of " true madness" ......

(c) Symptoms of Schizophrenia

i Disorder of mood.
ii Disorder of thought.
iii Delusions.
iv Hallucinations.
V Disorder of volition.
vi Disorder of expression.
vii Withdrawal into a disordered inner
viii world
Motor disturbance.

(d) 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 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 ...... "

ii 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 pro-
vides 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 It is symptom oriented.
ii The therapy aims at relieving the
symptoms.
iii It is possible to fix time limit to go
through a course of treatement.
iv The therapist’s task is directive rather
than interpretative.
v The patient is motivated to change his
peculiar behaviour.
vi Physical as well as emotional symptoms
are dealt with.
vii Negotiations and explanations are basic
in this therapy.

b) Alan King, consultant behaviour psychothera -

pist gives the following as the aims of the
behavioural therapy.
i To improve the qualtiy of the life of the
patient.
 ii To establish the skills necessary for life in the
community.

iii To eliminate unwanted behaviour which

constitutes major management problems.

c) 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 be-
came 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 psycho-
logical 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) Pre-conscious
ii) The conscious
iii) 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 sev-

eral 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 regres-
sion, interpretation of dreams, repetetive errors,
hallucinations, lapses and compulsive behaviour.
Further, Freud discovered that patients use, particu-
larly 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
8) Freud stated that the human personality can be di -
 vided into three segments (i) id (ii) ego ("I" and
"mine" consciousness) (iii) super-ego. The "id" rep-
resents 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 psycho-
neuroses (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 de-
velop 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) per-
sonal 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 465-
471). Freud made the following, observation, "Many
attempts at treatment, in the beginning of psy-
choanalysis 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 try-
ing the method on all kinds of disorders." This im-
plies that Freud believed that schizophrenia is beyond
the scope of psychoanalysis. Some of the modern psy-
chiatrists 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 57-

65

(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)

i Kama Ummada - sexual dysfunction

ii Darshana - hallucination
iii Moha - mental retardation
iv Krodha - mania
V Yakkha - possession disorders
vi Pitta - melancholia
vii Sura - alcohol dependence
viii Vyasana - depression

(3) 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 Thamas - darkness = ignorance

ii Rajas - dust = kleshas = defilements
iii Satva - 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 ill-
nesses 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 dis-

covery 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.

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.
(4) 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.

Vataja Ummada = insanity caused by wind

ii Pittaja Ummada = insanity caused by bile.
iii Kaphaja Ummada = insanity caused by
phlegm.
iv Sannipata Ummada = Combination of
above three.
V Manobhavaja = phobias
vi Visaja = insanity caused by poison.
vii Bhutommada = insanity caused by spirit
possesion.

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.
(6) 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 psycho-

logical 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 com-
plex. 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 in-
vest 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 WITH
THE BUDDHIST
PSYCHOTHERAPY

Western Psychotherapy Buddhist Psychotherapy

1 Admits that there are factors causing mental

mental causes of men- illnesses
tal illnesses 2 Aims at discovering
"Kleshas" (mental de-
2 Aims at discovering filements) as primary
incidents as primary causes
causes
3 Uses analytic methods
3 Uses analytic methods 4 Uses medication only
on extreme cases of
4 Depends heavily on tension and depression
medication 5 The therapist's work
(treatment) will be over
5 No definite time limit within 6 to 15 weeks.
for treatment - may
6 Transference is well
continue treatment
guarded.
even for more than
twenty five years. 7 Treatment is free or the
therapist may charge a
6 Possibilities of small fee - A therapist
transferance are will have a limited
greater number of sessions -
from 6 to 15 weeks
only.
7 Treatment is costly
8 Professionally not es-
8 Professionally well tablished as yet.
established
9 No dependence after
9 Possibility of patient's the completion of
dependence is greater therapy
1 Admits psychological
 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 de-

composition 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 un-

derstood 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 be-
longing 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 Mindfulness (sati),
ii Inquiring into dhamma (dhamma Vicaya)
iiiStriving (Viriya)
iv 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 exten-
sively 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 doc-
trine 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) 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.
(2) 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.

(3) 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 bhava-
thanha.

(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 ii Samvara
iii Parivajjana 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 et-
ting drifted into stresses and tension or depression.
 8
(3) 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) Hysterical (iii)
Obsessional
(ii) 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, choles-
terol 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 be-
tween 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) Physical fatigue and stress.

(b) Physical weakness caused by prolonged
suffering
(c) Effects of psychiatric medication
(d) Nervous weakness caused by malnutrition.

(ii) Psychological Obstacles

(a) Lack of confidence in the therapist

(b) The patient's inability to see his own
suffering.
(c) The presence of one or many of the "five
hindrances" = "Pancha Nivarana".
(d) Transference of the patient's emotions (such
 as love and hate) to the therapist.
(e) 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 Lack of self confi

dence
ii Weakness due to ii Inability to see his own
prolonged suffering suffering

iii Effect of psychiatric iii Presence of the

drugs 'nivaranas' and
sanyojanas’

iv Nervous weakness iii Transference of

due to malnutrition 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.
(3) Generally every mental patient has a purpose of be -
 coming mentally ill. Mental sickness is a highly mo-
tivated 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 Breath in as much as you can.

ii Stop breathing - keep your lungs
filled with air that you have
breathed in.
iii Breath out.

Repeat the step No. 1 given above for about three to

five minutes.

Step Two: i Allow the breathing to take place

without any effort
ii Become aware that you are taking
long breaths when you are breath
ing long breaths.
iii 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 com-
munication.

(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 ill-
ness 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 - Yes/No

ii An illness will be worsened - Yes/No
iii An illness will remain the same
forever - 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 be-
tween 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 ap-
proach 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 be-

haviour 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. Psychi-
atric 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 observed this
breathing process even for a minute.)

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 ?

 (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 breath-

ing 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) Is my body bent or straight?

(b) Are my hands bent or straight?
(c) Are my legs bent or straight?
(d) Is my body relaxed now?
(e) Is my head relaxed?
(f) 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 con-
centration and body balancing. Mental patients who
have had prolonged psychiatric treatment will be
immensely benefited by this form of iriyapatha medi-
tation.

(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 feel-
ings.

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 -sukhaVedana

Unpleasant feelings - dukkha Vedana
Neutral feelings - neither sukha or
dukkha Vedana.

3.2 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?
iii Who was the most unpleasant woman you have seen
?

(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 What do you like - tea, coffee or a cool drink ?

iii 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?
 v Have you experienced angry feelings
with anyone? With whom?

8.2 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 ac-
tions spring from motivation (Cetanahan
Bhikkhave kamman vadami) Motivations are ba-
sically caused by raga (sexsual driven) dosa
(drives of anger) moha (delusions = deluded
drives), and also by alobha - urge of carity),
12
adosa (urge of love and kindness) and amoha
(urge of
 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 -see-
ing 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 you like to meet him or her again ?

Do you love your father ?
Do you love your mother ? or
Do you hate your father ?
Do you 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 ? With whom

did you play the hide and seek game ? Are you play-
ing any games these days ? What is the game you like
most ? What is the game that you don't like? Why did
you not like the game ?

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 Pa-

tient ?

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 uncon-
scious 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 Twinkling of an eye.
ii Biting fingernails.
iii Grinding teeth.
iv 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 psycho-
dramatic 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 memo-
ries 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 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)

ii 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 socio-
economic 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) Dassana = by means of seeing (the klesha or
nivarana)
(b) Samvara = by means of disciplining
(c) Patisevana = by using wisely the four
perequisits -food, clothing, shelter and
medicine)
(d) Adhivasana = by means of edurance
(e) Parivajjana = by means of avoidance
(f) Vinodana = by means of removal
(g) 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 psychoanaly-
sis. 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 Psy-
choanalysis 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) Kama raga = Desire for sensual pleasures

(b) Bhava raga = Desire to be
(c) Patigha = Strong anger against some one
(d) Ditthi = Strong emotional identification
with views or doctrines includ-
ing the idea of "1" and "mine".
(e) Vicikiccha = Strong involment in suspicion
(0 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 Kamasava= Intoxicant of craving for sensual

pleasures
ii Bhavasava = Intoxicant of urge to be.
iii 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 Sakkaya ditthi = holding on to T consciousness

ii Vicikiccha = Suspicion
iii Silabbata Paramasa = being carried away by
rituals (obsessional compulsive disorder)
iv Kama raga = Craving for sensual pleasures
v Vyapada = illwill (anger)
vi Rupa raga = Craving for material forms of
existence
vii Arupa raga = Craving for formless existence
viii Mana = Conceit (inferiority or superiority
consciousness)
ix Uddhacca = restlessness or having a scattered
mind
x 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 con-
scious 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 Sati = mind fuln ess.
ii Dhamma Vica ya = in ve stiga tion , inquiry
iii Viriya = striving
iv P iti = raptu re (beco min g happ y)
v P assadhi = tranq uility
vi Sarnadh i = concentra tio n
vii Upekkha = equanimity

(d) 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 analy-
sis). 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
14
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 Psy-
chotherapy on 2nd, January 2000.

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) Inability to grasp university lectures
(b) Avoidance of class mates and friends
(0 Locking himself in his room and keep on
staring at the roof of his room
(d) Developing an urge to commit suicide
(e) Nihilistic delusions were prevalent

(1) 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 de-
veloped 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 cre-
ated.
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 stu-
dent and the daughter a university student. Her hus -
band had been a school teacher who also ran a profit-
able 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 im-
permanent - which means that her illness is sub-
jected 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 Psy-
chotherapy. 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 un-
timely 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 psy-
chiatric 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 preg-
nant 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 re-
vealed 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) 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.

(3) 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 so-
ciety, 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 Is there anybody that exist permanently?

ii Is there any condition which is permanent?
iii 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 becom-
ing 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, psy-
chological. 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 the patient to grow plants and to tend

them daily.

(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 ob-
serving 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 ap-
pears 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 ob-
session.

(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 per-
manent?"
" 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 on-
scious 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 Psy-
chotherapy, 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 - Vol i - v

Digha Nikaya - Vol iii
Majjima Nikaya - 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 Invest-
ment - 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.
Jayatilleke K N - The Message of the Buddha -
BPS - Kandy.
Leonard Krasner & L P Ullman
Behaviour Influence and Person-
ality - Winster.
LyttleJack - Mental Disorders - Tindale -
Lond.
Mark Epstein - Thoughts Without Thinker -
Psychotherapy from Buddhist
Perspective - Basic books - NY. Maxwell Herald -
Psychotherapy - IPO Pub.
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.