Origins of Buddhist Philosophy

In the sixth-century BC, crown prince Siddhartha was born in the foothills of the Himalayas. In his youth, he was ravished by the sights of disease, old age, death and a priest. Understanding that world is full of sufferings, the crown prince determined to seek the noble truth of life. At 29 years, he left his crown, wealth and loved ones, including his newborn son, to lead an ascetic life. After 6 years of excruciating suffering, Siddhartha reached a state of mind free from passions, disturbance and attachments. This enlightenment of Gautama Buddha is the foundation of Buddhist philosophy (Kalupahana 1992; Meadows 2003).

Buddhism in Sri Lanka

In the third-century BC, son of King Asoka entered the priesthood and brought the teachings across the straits of Palk to Sri Lanka (Perera 2016). Despite centuries of Portuguese, Dutch and British occupation, Theravada Buddhism continued to be the predominant religion (Department of Census 2012). Theravada Buddhism is believed to be the closest to the original teachings of Buddha from the two major traditions of Buddhism in the world. In Theravada tradition, supernatural powers are not considered as a solution for spiritual problems and there is no omnipotent creator God. Today, Buddhist teachings have spread to the West including Europe and North America. It appears that Buddhism has no definite boundaries and it would blend with the culture of the particular region.

The Core Buddhist Philosophy

The four noble truths state that life is full of sufferings (dukkha), there is a cause for this suffering (dukkha–samudaya), it is possible to stop suffering (dukkha–nirodha), and there is a way to achieve this (dukkha–nirodha–marga) (Kalupahana 1992; Meadows 2003). Birth, disease, ageing, death, sorrow, grief, wish and despair, which all living beings experience, comprise the sufferings. The cause for this is the attaching which involves desire, lust and clinging. Nirvana is the state free of any attachments where all sufferings could be eliminated within this life. An eightfold path (ariyo aṭṭhaṅgiko maggo) is described by Buddha as the way to reach this state, comprising correct views, aspiration, speech, conduct, livelihood, effort, mindfulness and concentration (Bodhi 2010).

Buddha taught that all conditioned things (Sankara), including ourselves and our possessions, are impermanent (anitya). Therefore, they lead to suffering (dukkha). There is no existence of an unchanging, permanent self in living beings and no enduring essence in anything (anatma). These comprise the three marks of existence that make the central theme of four noble truths and eightfold noble path (Kalupahana 1992; Bodhi 2010).

Mental Healthcare in Sri Lanka

The concept of mental illness related to Buddhist beliefs and Ayurveda medicine has existed in Sri Lanka for over twenty centuries (Gambheera 2011). Ayurveda is an ancient system of medicine with historical roots in the Indian subcontinent and now practised in all continents of the world. The British colonized Sri Lanka at the end of the eighteenth century. An ordinance to establish lunatic asylums was introduced in 1839 by the British governor, and the mentally ill were housed in a leprosy asylum initially. The colonial government established the first mental hospital in 1926, which is now upgraded as the National Institute of Mental Health (Gambheera 2011). The development of community psychiatry and managing the patients in a general hospital setting are emphasized at present. The psychiatry education is based on British textbooks and management guidelines. In addition, the postgraduate trainees are trained in the UK or Australia after the completion of MD and advanced training locally (Chandradasa and Kuruppuarachchi 2017). Therefore, the British influence on Sri Lankan psychiatry has lasted from the colonial era to date.

Buddhist Principles in Mental Health Care

Psychotherapy involves exploration of mood states, feelings, thoughts and behaviours of the help-seeking person similar to Buddhism (Grabovac et al. 2011). It could be considered as a form of learning with an intention to relieve psychological distress. Western psychotherapy and Buddhist philosophy analyses mental processes in great detail (Grabovac et al. 2011). The elaborative explanations in the 2600-year-old Buddhist analytical doctrine Abhidhamma coincide with many Western psychological ideations.

In behaviour therapy, deep breathing technique is used for relaxation. This method is similar to Anapanasati, the mindfulness of breathing. Children in Sri Lanka are trained in Anapanasati from younger days, the aim is to be aware of the breathing, and there is evidence that it improves the symptoms of anxiety (Yoo et al. 2015). In other forms of behaviour therapy such as activity scheduling and behaviour modifications, activities are planned to induce positive emotions. This is similar to components of the noble eightfold pathway, especially right action, right speech and right livelihood (Bodhi 2010).

There is a growing enthusiasm for mindfulness techniques in psychotherapy. Mindfulness is the non-judgemental awareness of the present moment and owning the current experience despite its negativity or positivity. Mindfulness-based cognitive therapy employs mindfulness and cognitive therapy techniques (Crane 2017). Similarly, Buddhist mindfulness meditation and cognitive principles have been used to treat individuals with depressive disorder and obsessive–compulsive disorder in Sri Lanka with success (de Zoysa 2011, 2013). Acceptance and commitment therapy uses techniques similar to the four noble truths and the concept of no-self in Buddhist teachings (Fung 2015). These are highly culturally acceptable principles to Sri Lankan Buddhists.

Mindfulness skills are a central part of the dialectical behaviour therapy. The developer Marsha Linehan herself was a Zen practitioner and designed this method for persons with borderline personality disorder presenting with self-harm behaviour (Linehan and Wilks 2015). Zen is a school of Mahayana Buddhism that originated in China. Borderline personality disorder presentations are less of a burden to services in Sri Lanka compared to the West (Bailey and Grenyer 2013). However, for associated self-harm behaviour, DBT techniques on mindfulness skills tend to be employed with significant success. Published studies assessing personality disorders are limited in Sri Lanka. In a study of female offenders referred for psychiatric assessment, only 8% was diagnosed with borderline personality disorder, which is considerably low compared to Western figures (Chandradasa et al. 2015). Nevertheless, many Sri Lankan prisons conduct mindfulness of breathing meditation programmes for the prisoners, who are believed to be having a higher prevalence of personality disorders compared to the general population (Prison Mindfulness Institute 2017).

Modelling employs social learning principles. Many Sri Lankan temples depict a portrait of the Buddha tending to a monk neglected by others due to being disfigured with skin eruptions. This states the importance of doing what is preached (de Silva 1984). There is significant stigma towards mentally ill even from their carers (Ediriweera et al. 2012). This has led to major psychiatric disorders presenting late to health services (Chandradasa et al. 2016). Mental health professionals lead by example in respecting the autonomy and rights of the mentally ill to demand respect for them from their carers and the wider society.

Rational emotive therapy by Albert Ellis uses emotional training methods to counter negative thoughts. This is similar to a meditation technique taught by Buddha called compassion meditation that tries to substitute hatred, ill will and anger to others with positive thoughts and compassion (Holt and Austad 2013). Buddhist-derived loving-kindness and compassion meditation has been known to improve psychological distress and interpersonal relationships (Shonin et al. 2015). Sri Lankan Buddhist nuns with physical disorders such as diabetes mellitus have been reported to use techniques such as compassion meditation to improve their psychological status and indirectly their glycaemic control (Wijesinghe and Mendelson 2013).

Many prominent psychoanalysts such as Carl Jung, Karen Horney and Erich Fromm studied Buddhist teachings. It is unlikely that a Sri Lankan patient would be managed with psychoanalysis as the sole therapy. This is due to the high number of patients being seen by a psychiatrist in Sri Lanka per day. Therefore, the time allocated for psychotherapy is limited (Chandradasa and Champika 2018). However, many psychotherapists would use psychoanalytic principles when conducting therapy. As Fromm described, psychoanalysis is a characteristic expression of Westerner’s spiritual crisis, which is conceptually similar to the concept of understanding the universal suffering described in Buddhism (Fromm 2013).

Supportive psychotherapy is used concurrently with pharmacotherapy and employs principles of Carl Rogers’ person-centred therapy. In Rogerian therapy, the therapist provides a safe environment to encourage self-growth as in Buddhist non-authoritarian way of guidance. Three poisonous elements in our minds, greed, hatred and delusion (lobha, dosa, moha), are countered in Rogerian therapy by unconditional positive regard, empathy and genuineness as in Buddhist teachings (Brazier 2013).

Buddhist nuns with chronic disorders are reported to use coping ranging from health seeking to resigned acceptance in the context of beliefs about impermanence. It appeared that considering impermanence as a fundamental feature of life and accepting the suffering helped them to deal with their distress related to the physical morbidity. The sense of coherence and generated meaningfulness of life was similar to the Western theory of salutogenesis by Antonovsky (Wijesinghe and Parshall 2016). Salutogenesis is an approach focusing on factors that support human well-being, rather than on pathogenesis that causes disease.

One of the most famous teachings of Buddha in Sri Lanka is the incident related to a princess named Kisa Gothami who lived in the days of Buddha. She lost her first and only child in infancy and roamed the streets with unbearable grief requesting people to resurrect her child back to life. She ended up in front of Buddha begging for help with her dead infant in her hands. Buddha stated he could only help her if she could bring mustard seeds from a household where no one has ever died. Kisa Gothami ran from house to house asking for mustard seeds. However, she could not find any household where death has never occurred and came to the realization that death is a universal truth that comes to all living beings. This led to her redemption and paved the way for her enlightenment (Obeyesekere 1985). This understanding of impermanence in the Buddhist allows the clinician to work with the person to help accept the loss, which is a major goal of grief counselling (Worden 2008). The traditional Buddhist funeral traditions include arranging almsgiving to monks in order to help the deceased achieve a better rebirth. This mourning process helps to express feelings and cope with distressing emotions.

Conclusion

Buddhism originated 2600 years ago, and the majority of Sri Lankans were Buddhists for over twenty centuries. The British established the modern mental health services in the country in the nineteenth century, and there is a continuing Western influence with many Sri Lankan psychiatrists obtaining training in the UK and Australia. The confluence of Western psychotherapy techniques and Buddhist teachings seems to provide a culturally acceptable mental health care to the Sri Lankan population. The Buddhist philosophy in a Western structure appears to be a suitable mode of management to many mental ailments.