On the Diffusion of Buddhist-Mindfulness in Psychiatry in Thailand and the United States

ON THE DIFFUSION OF BUDDHIST-MINDFULNESS

IN PSYCHIATRY IN THAILAND

AND THE UNITED STATES

Thesis submitted by Nicholas Roberts

October 2007

In partial fulfilment of the requirements

for the Degree of Bachelor of Arts (Honours)

in the School of Anthropology, Archaeology and Sociology

at James Cook University

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Beyond this, I do not wish to place any restriction on access to this thesis.

………………………………. .…………………………….

Nicholas Roberts (Date)

Statement on Sources

Declaration

I declare that this thesis is my own work and has not been submitted in any

form for another higher degree or diploma at any university or other institution

of tertiary education. Information derived from the published or unpublished

work of others has been acknowledged in the text and a list of references is

given.

………………………………. .…………………………….

Nicholas Roberts (Date)

Acknowledgements

This thesis is the result of many people, and not just the effort that I have

made to complete it. I have thoroughly enjoyed writing this thesis and I could

not have accomplished it without the following support:

Dr Robin Rodd for his indefatigable support, contribution, and friendship in

personally supervising this thesis; Mr Tom Ryan (Barrier Reef TAFE) for

bequeathing his experience about Buddhist-Mindfulness; Dr Sharn Rocco (JCU)

for initial communiqué on topics. To Dr Rosita Henry, Dr Nigel Chang & Dr

Marcus Barber for their assistance and efforts when called upon. To other

lectures, staff (including Library Staff and Copy Services Staff), and friends who

I have shared time with, thank you. Special mention to Joe, Chris, and Ali for

your warm and integral friendships. Credit and gratitude to those authors and

scholars whose work I have utilised in this thesis.

To my family: my mother Sue, for her interminable love and devotion

throughout my life - I love you Mum; Peter the J for his support and belief; my

father Kerry and family - Francis, Kieran, Thea and Natalie; my b.brother

Andrew, my complimentary contrary - ‘long may you run’; to Jane Sr. & Gwen,

Glen, Michelle Z&A, Gizmo folk and Tracy kin – love & devotion always.

Most importantly, to my inner circle – we intimately traversed this journey

together. Jane, you have been the roots of my tree and its foliage through this

process. Your constant supply of love sustained and sheltered me through the

vicissitudes of this year. We have weathered many seasons together, and in

keeping with life, we shall weather many more. To Joshua and Xy, the flowers

and fruit of my tree. You are my love and dedication manifest, and you return

these qualities to me as you grow through life. May you mature into healthy

trees yourselves, receiving nurturance through generating love and kindness.

There is a sociological fact that

must be taken into account in any

understanding of cultural integration.

This is the significance of diffusion.

Ruth Benedict, Patterns of Culture, 1946, p210.

Abstract

In Thailand and the United States Buddhist-Mindfulness is being diffused in

psychiatry as a method and process. In each context, Buddhist-Mindfulness is

diffused to improve the efficacy of psychiatric treatment of mental illness. A

cultural contextualisation of Buddhist-Mindfulness and the psychiatric process

has taken place through the process of diffusion, altering the practice of

Buddhist-Mindfulness and the process of psychiatry. Research in Thailand

highlights how Euro-American psychiatric and mental health aetiology,

nosology, and treatment protocols have been replaced with Buddhist

determinants of health. In the United States, Buddhist-Mindfulness is becoming

‘operationalised’ through diffusion into the Empirical Clinical Psychiatric

Practice, reflecting the dominance of this process over Buddhist aetiology and

nosology of mental illness. Analysis using the notion of habitus and theory of

practice reveal why Buddhist-Mindfulness is diffused differently in each

context. I argue that cultural ontological and cosmological logic is utilised in

each context revealing the different form, function, and meaning of Buddhist-

Mindfulness. The motivation by practitioners in Thailand and the United States

to utilise cultural ontology/cosmology is to balance and restore meaning and

social stability because of rapid social change and the crisis it is presenting

taken-for-granted life-ways in Thailand and the United States.

Contents

List of Figures/Tables………………………………………………….……………………9

Glossary……….………………………………………………………………………………….10

Introduction………………………………………………………………………………………13

1. The Diffusion of Buddhist-Mindfulness into Psychiatry in

Thailand and the United States: Two Case Studies……………16

Buddhist-Mindfulness: a Definition………………………………………………………………………………………17

Case Study 1: Buddhist Counselling for Patients with Anxiety. Rungreangkulkij, S &

Wongtakee, W (2006)……………………………………………………………………………………………………………19

Case Study 2: An Open Trial of an Acceptance-Based Behaviour Therapy for Generalised

Anxiety Disorder. Roemer, L & Orsillo, S (2007)………………………………………….………………………21

Discussion………………………………………………………………………………………………………………….……….…23

Buddhist-Mindfulness-Based Psychiatry………………………………………….……………………………………26

2. Diffusion & Cultural Change………………………..…………………28

Diffusion: Definition, Application, and Research in the Social Sciences………………………….…29

Method & Process…………………………………………………………………………………………….……………………32

Cultural Change & Revitalisation: Ontology, Habitus & Ideology……………………….………………33

The Social & Historical Praxis of Suffering……..……………………………………………………………………38

3. Diffusion, Health-Seeking & Culture Change in Northeast

Thailand………………………………………………………………………………40

Buddhism, Health & Culture Change……………………………………………………………………………………41

Healthcare in Northeast Thailand……………………………………………………………………………..…………44

Health-Seeking in Macro-Cosmic Context…………………………………………………….………………………49

Medical Pluralism in Northeast Thailand: Form & Function…………………………………………………52

4. Diffusion, Health-Seeking & Culture Change in the United

States……………………………………………………………………….…………55

Scientific Crisis & the ‘Operational’ Status of Buddhist-Mindfulness…………………..……………56

Medicalisation & Capitalism in the United States…………………………………………….…………………59

Health-Seeking in Macro-Cosmic Context……………………………………………………………………………62

Medical Pluralism in the United States: Form & Function………………………….………………………66

5. Cultural Change, Psychiatry & Diffusion……………..…………68

On the Diffusion of Buddhist-Mindfulness in Psychiatry……………………….……………….……………69

Cultural Crisis & the Collective Past……………………………………………….………………………..…………74

Conclusion…………………………………………………………………………………………75

References…………………………………………………………..……………………………77

List of Figures

Figure 1. Diffusion as a Process of Communication…………………………29 Figure 2. Use of Ontology & Cosmology in Modern Culture Change………………………………………………………………….……..……36 Figure 3. Buddhist Aetiology of Suffering & the Liberation from Suffering……….……………………………………………………….…….……43 Figure 4. Identified Diagnostic Options in Northeast Thailand..….…46 Figure 5. Identified Causes of Illness & Suffering in Northeast Thailand……………………………………………………………………….……48 Figure 6. Psychiatric Aetiology of Mental Illness…………………………….57 Figure 7. Consequences, or Differences in Form, Function & Meaning to Buddhist-Mindfulness through Diffusion….……71 Figure 8. Worldviews Influencing the Consequences to Buddhist- Mindfulness…………………………………………………………….…………72

Glossary of Terms & Abbreviations

Pali (P), Sanskrit (S) & Thai (T)

anapan-sati (S) meditation technique: Mindfulness of Breathing.

annáta (P) no-self; knowledge that the self is constructed and is

impermanent and transcendent; Universal Law

anníca (P) impermanence; knowledge that all phenomena is

subject to change; Universal Law

aviccha (P) ignorance; attachment

baap (P) positive merit; good social action or intentions that

are karmically reciprocal

baan (T) literally meaning ‘village’ or ‘community’

bun (P) negative merit; like baap, but harmful social action

dukkha (P) suffering; conflict of conditioned existence; Universal

karma (S) [kam (T)] actions that are morally, socially, ethically relevant;

universal law of cause and effect

kwan (T) one of two souls the body contains; can be lost or

stolen; retrieved through ritual means

Mahayána (S) northern school of Buddhism

marga (P) eightfold noble path; leads towards nibbána

metta (P) loving-kindness; meditation technique that aims to

generate kindness and acceptance of all life

mor lam song (T) spirit medium; shaman

nibbána (P) [nirvána (S)] ultimate and final goal on Buddhist Path; release

from, and cessation of suffering

niróda (P) attainment of cessation of mental activity

pánna (P/S) wisdom; awareness of Universal Laws

phi (T) generic for a variety of helpful and malevolent

spirits; cultic like following and worship

samsára (S/P) the wheel of birth and death; law of being and

becoming

sati (S) mindfulness; clear awareness of activity

samudayá (P) realisation of the origin of suffering

tahná (P/S) craving; attachment

Theraváda (S) southern school of Buddhism

ti-lakkhána (P/S) three Universal Laws; philosophical teachings about

dukkha and how to attain cessation from dukkha

upadána (P/S) clinging; attachment

wat (T) buddhist temple

vipassana-bhavana insight meditation; stronger path to achieve

mindfulness and mental awareness

Abbreviations

AABT Acceptance-Based Behavioural Therapy

ACT Acceptance and Commitment Therapy

CAM Complimentary and Alternative Medicines

CBT Cognitive-Behavioural Therapy

DBT Dialectical-Behavioural Therapy

GAD Generalised Anxiety Disorder

ECPS Empirical Clinical Psychiatric Standards

MBCT Mindfulness-Based Cognitive Therapy

MBSR Mindfulness-Based Stress Reduction

Introduction

The diffusion of innovations occurs in all domains of global social and cultural

life, from within or without. The diffusion of innovations is a two-way flow

between cultures. Importantly, diffusion is a fundamental process of socio-

cultural adaption (Weinstein 2005). Contemporarily, the process of

globalisation is speeding up the process of diffusion between Euro-American

and non-Euro-American cultures (Hunter & Whitten 1976; Strinati 1995). In the

United States, ethnomedical and religious practices form the basis for current

paradigmatic shifts in science and medicine and are becoming increasingly

incorporated as therapeutic interventions. This application is highlighted by

efficacious results in treating states of ill health. Acupuncture, Indian

Ayurveda, Naturopathy, Shamanism, and Tibetan medicine are among a number

of ethnomedicines or religious traditions that are becoming incorporated with

or complementing existing biomedical and psychiatric services. In Thailand, the

same phenomenon is taking place. Traditional forms of medical and ritual

practice (Buddhism, spirit mediumship, exorcism) are being diffused with

biomedicine and psychiatry. In each context, cultural change and the lack of

meaning given to modern illness experience has motivated a retreat into

historical culture to affirm identity and balance biopsychosocial needs.

Psychiatry in the United States is currently incorporating Buddhist-Mindfulness

into practice. The diffusion of Buddhist-Mindfulness reveals what Dawson

(2006) describes as the ‘Western habitus’. Here, the “technologized

conceptualizations of the self, a depersonalized view of the cosmos, and a

metaphorization of the modern cultural field” have developed (Dawson 2006,

p1) historical and distinct ‘ways of seeing’ states of illness and illness

experience. Current shifts in scientific medicine and psychiatry in the United

States utilise ‘Eastern’ religion and other Complementary and Alternative

Medicines (CAM), ‘operationalising’ them into existing paradigms.

‘Operationalising’ is a process of experiment and abstraction that excludes

non-definable or non-experimental aspects of practices, distancing these

practices from their cultural origins (Moreland 1989). Dawson (2006) interprets

this as a “Westernisation of Eastern themes”, a process “structured along

enduring paradigms” (Boehnlein 2006, 644). This highlights an inability of social

institutions in the United States, including education, biomedicine, and

psychiatry to truly accept and embrace cross-cultural religion as religion

(Wallace 2007). Further, the rise and penetration of capitalism into social

institutions and social values (Harvey 2000), and the growing uncertainty in the

United States surrounding the efficacy of modern medicine to deliver adequate

healthcare (Bates 2002) has assisted in the development of CAM.

In Northeast Thailand, the diffusion of Buddhist-Mindfulness into psychiatry has

also transpired. Thailand is a Buddhist Kingdom that has remained relatively

isolated and insulated in Buddhist Southeast Asia for 500 years. Buddhism

represents a textual institutional and structural (Keyes 1984; Kirsch 1985;

Reynolds & Reynolds 1982) command over Thai society, and as a result has

been used to legitimate change and development for centuries. Medical

practice in Northeast Thailand is plural, and reflects a history of diffusion of

ethnomedical practices. The penetration of Thailand by Euro-American values,

institutions, and discourse over the last 150 years has dislocated many of the

traditional medical and transpersonal practices of Buddhism in Thailand.

Scientific medicine and psychiatry, which maintain high symbolic status in

Thailand are prominent examples, and have become part of the thriving

medical plurality here. However, Buddhism provides a philosophical and

practical dialogue on everyday experience in Thailand (Harvey 1990). Suffering

(dukkha) and the release from suffering (nibbána) are central aspects of

Buddhist philosophy and practice that combine with broader narratives linking

person-society-cosmos. Buddhist-Mindfulness is an integral cultural praxis

situated in a wider dialogue with Buddhist philosophy and personal lifeways in

Thailand. This is illustrated through the diffusion of Buddhist-Mindfulness into

psychiatry.

In this thesis I aim to determine why Buddhist-Mindfulness has been taken up in

each psychiatric context by examining the macro-global and local-social forces

that motivate this process. This thesis is based on a critical literature review.

The quality of ethnographic data permits an excellent ability to generate sound

conclusions on this topic. I define Buddhist-Mindfulness as a Buddhist practice

(that examines experience), and psychiatry as a socio-cultural system (that

treats mental illness). I argue that each is positioned in a critical engagement

with their larger socio-historical and cultural cosmological contexts. Chapter 1

presents one case study from each location (Thailand and the United States) to

emphasise how Buddhist-Mindfulness is applied in psychiatry through the

diffusion process. Chapter 2 explains the theoretical framework for the thesis.

Bourdieu’s (1977) theory of habitus and practice are employed to understand

why cultures are resistant to change and how culture reacts to change/crisis.

Kapferer’s (1988) theory of cultural ontology/cosmology utilisation to

legitimate change/crisis is employed to illustrate why the form, function, and

meaning of Buddhist-Mindfulness is different in Thailand and the United States.

Chapters 3 and 4 draw on ethnographic and historical data to analyse the

diffusion of Buddhist-Mindfulness into psychiatric practices in Thailand and the

United States respectively. Chapter 5 is a synopsis of the comparative

contextualisation of the diffusion of Buddhist-Mindfulness. Buddhist-

Mindfulness is incorporated in psychiatry in Thailand as a Buddhist practice and

in the United States as a scientific and medical process. I argue that prevailing

worldviews are ideologically recalled to legitimate social change and crisis,

change that ruptures the habitus, motivating a retreat to ontology/cosmology.

This process generates the distinct alteration of consequences that Buddhist-

Mindfulness receives through the process of diffusion in Thailand and the

United States.

Chapter 1

Buddhist-Mindfulness in Psychiatric Application:

Case Studies from Thailand

and the United States:

This chapter will highlight how Buddhist-Mindfulness is applied in psychiatry in

the United States and Thailand as a therapeutic intervention. Buddhist-

Mindfulness based psychiatric therapy is very popular in the United States.

However, only one therapeutic trial in Thailand has been located. This chapter

examines two case studies that utilise Buddhist-Mindfulness in clinical

psychiatry for the treatment of anxiety disorders. Rungreangkulkij &

Wongtakee’s (2006) pilot study of a Buddhist-Mindfulness based psychiatric

therapy in Northeast Thailand, and Roemer & Orsillo’s (2007) open trial of a

Buddhist-Mindfulness based behavioural therapy in the United States will be

examined to highlight the different application of Buddhist-Mindfulness in each

context. There are significant variations in the application of Buddhist-

Mindfulness as psychiatric therapy in each location. This is illustrated by

examining each case study individually to highlight the similarities and

differences in application in form, function, and meaning. Changes to Buddhist-

Mindfulness via the diffusion process are revealed through the trial aims, the

trial structure, and methods and terminology employed in the diagnostic,

therapeutic, and evaluative processes. This examination provides the

developmental basis for analysis in the following chapters.

Buddhist-Mindfulness: a Definition

Buddhist-mindfulness is a textual, philosophical, and cosmological aspect of

Buddhism. ‘Mindfulness’ (sati) is a cultivated state of mental awareness. It is

the human capacity to be aware and act upon this awareness. ‘Mindfulness’ is a

core and fundamental aspect of the Buddha’s thesis on suffering (dukkha),

providing philosophical and practical dialogue on suffering (dukkha) and the

release from suffering. ‘Mindfulness’ was developed by the Buddha 2500 years

ago following his liberation from suffering (nirvana), and has since been refined

in both the Mahayana (Northern School) and Theravada (Southern School)

Buddhist Traditions. The practice of ‘Mindfulness’ has flourished throughout

Buddhist culture in Asia. In many schools “it has become elevated to the hub of

the teachings (Titmuss 1998, p48). The aim of ‘Mindfulness’ and meditation

practice is to liberate people from physical and psychological suffering.

‘Mindfulness’ is directed towards cultivating awareness and acceptance of life

as-it-is-experienced (that is, Right Mindfulness). It is the most positive step

towards the liberation from ignorance, craving, and desire, the causes of

suffering (Titmuss 1998).

‘Mindfulness’ is the practice of focusing attention on the present moment of

experience, being non-judgemental and not striving towards solutions or goals,

accepting experiences, as they are experienced. To Buddhists, the mind is

cultivatable, and ‘Mindfulness’ is the most effective method to “bring the

different aspects of our being into focus” (Rinpoche 1992, p61). Buddhists

conceive of two minds: the everyday mind (illusory) and the nature of mind

(universal reality). The aim of ‘Mindfulness’ practice is to go beyond the

‘everyday mind’. Proper application of ‘Mindfulness’ can reveal the true

‘nature of mind’, as stated in various Buddhist texts, surpassing all ignorance

and craving to attain true awareness and insight into universal reality. On its

own ‘Mindfulness’ lacks the ability to cultivate deep wisdom. ‘Mindfulness’

must encompass meditation to enable correct cultivation of concentration,

awareness, and observation, factors that are crucial to successful meditation

and the attainment of the ‘universal mind’ (Harvey 1990; Rinpoche 1994).

‘Mindfulness’ is practised in congruence with meditative processes. Practice of

meditation and its incorporation with ‘Mindfulness’ is essential to achieving

true concentrated awareness in meditation. Effective practice aims to enable

‘Mindfulness’ to become a meditation in everyday life experiences. Two

examples of meditation are Loving-Kindness (metta) and Mindfulness of

Breathing (anapan-sati) meditation (Harvey 1990). Nhat-Hahn (1994) describes

how application of Mindfulness of Breathing (anapan-sati) is applicable as a

mediative practice in sitting or walking postures and in our interactions and

activities in day-to-day life. He decrees, “insight is not just knowledge but true

understanding” (Nhat-Hahn 1994, p101). The application of ‘Mindfulness’ as

waking-meditation promotes non-judgemental awareness and eventually

transcendence of suffering and illusory states of mind. The ultimate goal is the

liberation from suffering, or the achievement of enlightenment (nibbána) and

cessation of rebirths (samsára) in the various realms proscribed by Buddhist

cosmology (Griffiths 1986).

A recent explosion of Buddhist-Mindfulness (based) healthcare has occurred in

the United States. While Buddhism has been practised in a variety of ways in

the U.S since the 1950’s, modern psychiatry in the U.S has incorporated

Buddhist-Mindfulness into therapy. Psychiatric therapies based on Buddhist

paradigms of suffering (dukkha) are replacing and fusing with existing

cognitive-behavioural models. Buddhist-Mindfulness therapies promote

awareness and acceptance of pathological behaviour and experience avoidance

(Fronsdal 1999). Since the 1970’s, Buddhist-Mindfulness based programs have

operated in hospitals, clinical, workplace, and school settings in the United

States. John Kabat-Zinn, arguably the pioneer in the field of Buddhist-

Mindfulness based clinical intervention in the United States, opened a Stress

Reduction Clinic through the University of Massachusetts Medical Clinic. Self-

developed ‘Mindfulness Based Stress Reduction’ (MBSR) courses began here in

1979. MSBR is based on Buddhist-Mindfulness techniques and incorporates

Theravada Buddhist Insight (vipassana-bhavana) and mindfulness of breathing

(anapan-sati) mediation and Indian Hatha Yoga (Kabat-Zinn 1982; 2000; 2003).

A multitude of other programs have also been borne out of the original MSBR

program in the last decade, including Acceptance and Commitment Therapy

(ACT), Mindfulness Based Cognitive Therapy (MBCT), and Dialectical Behaviour

Therapy (DBT) (Baer 2003). The present aim is to ‘operationalise’ Buddhist-

Mindfulness as an Empirical Psychiatric method to treat and overcome mental

illness.

Case Study 1:

Buddhist Counselling For Patients With Anxiety.

Rungreangkulkij, S & Wongtakee, W (2006).

The aim of Rungreangkulkij & Wongtakee’s (2006) study is to determine the

efficacy of Individual Buddhist Counselling for Thai patients suffering diagnosed

anxiety disorders. Rungreangkulkij & Wongtakee (2006, p1) identify anxiety as

prevalent in Thailand, where 9.5% of the population is affected. They highlight

how socio-cultural change in Thailand has influenced anxiety levels. Socio-

cultural change has also altered the way Thai people seek medical treatment

and are inturn treated. Biomedical/psychiatric treatment is more widely

accessed than traditional medicines. Symptoms of anxiety are not always

detectible by psychiatric or General Practitioners. Physiological symptoms are

misdiagnosed as anxiety, while they are most probably a form of somatoform

disorder (see Okasha 2003). However, due to misdiagnosis (due to the similarity

of symptom to anxiety), patients are prescribed anti-anxiety medications.

Pharmaceutical addiction is a common problem in Thailand that has resulted

from anxiety disorder misdiagnosis.

Rungreangkulkij & Wongtakee (2006, p6) chose to incorporate Buddhist

discourse and practices into the counselling process “because it fits with the

clients’ belief and worldview”. They utilise the Buddhist concept of suffering

(dukkha), applying it in the therapeutic processes because it is relevant to the

process of healing. Another factor that influenced the use of Buddhist-

Mindfulness were trials in America, Europe, and Australia (Rungreangkulkij &

Wongtakee 2006, p2). Buddhism is already established throughout the health

system in Thailand, a fact that the authors express motivated them to

incorporate Buddhist discourse and practice into therapy. The goals of

Rungreangkulkij & Wongtakee’s (2006) study are to reduce or prevent mental

illness (anxiety), and to provide a framework of Buddhist/Mindfulness practice

for future psychiatric treatment.

The study was set in Northeast Thailand. The study was undertaken over a one-

month period. 21 patients/participants who had been treated for anxiety at

the local community hospital (30 beds) were involved. All patients were

Buddhists. All patients/participants were taking medication at the time of the

study. Demographic data (age, gender, religion, marital status, income,

occupation), anxiety measures (STAI: State-Trait Anxiety Inventory), and

participant diary and meditation logbooks were used to determine the efficacy

of the counselling process. The counselling process was on a practitioner/client

interaction. The practitioner is trained in counselling/psychiatry and

meditation (by a monk) and is a practising Buddhist and meditator. The

counselling process involves an initial 60-90 minute session and a follow-up

session one month later. Both counselling sessions had four structured phases:

1) Develop rapport between practitioner and patient. 2) Educate client about

symptoms, emotion, and suffering. Application of Buddhist philosophy (Three

Universal Laws; Four Noble Truths; Eightfold Noble Path) and mindfulness

meditation is introduced as the way to overcome suffering. 3) Practice of

mindfulness meditation and assessment of practice. 4) Session completion

through assessment of the patients’ understanding of their problems.

Data was analysed through a variety of statistical means (descriptive and non-

parametrical) and formulated into tables. Results considered demographic

data, contents of patient’s diaries, and the patients’ prescribed dosage of

medication. All subjects reported feeling calmer from the therapy, particularly

those who practised Mindfulness-meditation regularly. Two patients completely

stopped their medication, and fifteen patients required less medication than

before. Rungreangkulkij & Wongtakee (2006) concluded from this study that

Buddhist counselling has the ability to reduce levels of anxiety. They argue that

Buddhist counselling has the ability to change maladaptive behaviour and

habits through application of Buddhist principles (Three Universal Laws; Four

Noble Truths; Eightfold Noble Path; Mindfulness-meditation) into daily life.

They argue that their results prove this (Rungreangkulkij & Wongtakee 2006,

p5). Limitations are that the study was not a randomised trial. They call for

further studies to gain better understanding of the efficacy of Buddhist-

Mindfulness counselling of mental health disorders in Thailand.

Case Study 2:

An Open Trial of an Acceptance-Based Behaviour Therapy

for Generalised Anxiety Disorder.

Roemer, L & Orsillo, S (2007).

The aim of Roemer & Orsillo’s (2007) study was to test the efficacy of an

Acceptance-Based Behavior Therapy (ABBT) treating Generalised Anxiety

Disorder (GAD). Roemer & Orsillo (2007) acknowledge that GAD is the least

successfully treated anxiety disorder. The authors argue that previous

treatments, such as Cognitive-Behavioral Therapy (CBT) do not provide

adequate techniques to treat GAD. This conclusion warranted them to apply

new treatment (psychosocial) to assess GAD. ABBT is a modification of CBT.

The difference lies in the acceptance (Buddhist-Mindfulness) aspect of therapy

that centres this therapy on personal awareness of present cognitive

experience and experience avoidance. In CBT, purposeful change of cognitive

experience is the critical process of the therapy. In ABBT, cognitive experience

is accepted and made aware of unconditionally without any attempt to change

these experiences. Roemer & Orsillo (2007, p73-74) cite numerous studies and

authors who attest to the efficacy of integrating Buddhist-Mindfulness into GAD

therapy. The authors claim that ABBT is congruent with other Buddhist-

Mindfulness based therapies.

The trial was conducted at the Centre for Anxiety and Related Disorders and

Boston University, Boston, U.S.A over a three-month period. These included

pre, post, and follow up assessments of the clients. The authors and therapists

treated 16 clients in the ABBT trial. All patients were taking medication to deal

with anxiety and comorbid symptoms. Patients were initially assessed using

DSM-IV Anxiety Disorders Interview Schedule. Patients were also assessed

through various clinically applied measures to assess symptoms associated with

GAD. “Fear and avoidance of internal sensations” (Roemer & Orsillo 2007, p76)

were the main symptoms the authors posited to be significant aspects of GAD.

Treatment (following informed consent) consisted of individual therapy

comprising 16 sessions (first four at ninety minutes; following twelve at sixty

minutes; final two were tapered). Sessions 1-4 introduced clients to concepts

of ‘habit forming’ and ‘experience avoidance’ through handouts, presentations,

demonstrations, and finally through discussion.

In session 2, Buddhist-Mindfulness strategies were introduced. Clients were

encouraged to practice a variety of Buddhist-Mindfulness techniques, such as

breathing, muscle relaxation, and meditation. These practices were

incorporated from the beginning to the end of the sessions. Clients were

informed that Buddhist-Mindfulness techniques must be practised at home and

during the course of the client’s life for adequate changes to occur. “Clients

are taught that mindfulness is a skill and a process, rather than a desired end

state” (Roemer & Orsillo 2007, p79). Keeping a journal and writing about their

experiences was required throughout therapy to aid clients in clearly viewing

their avoidance and habitual tendencies, assessing their own emotional state

daily. The aim was for clients to live mindfully and become self-critical of their

actions towards their experiences. In this way the person becomes responsible

for their actions and illness.

Post-treatment assessment revealed significant reductions in fear, avoidance,

depressive and anxiety related symptoms. Two clients reduced their

medication, and two clients discontinued their medication altogether. A three-

month follow-up of the study (12 clients) showed one more client had

discontinued medication and an overall reduction in symptoms (worry, anxiety,

stress) and experiential avoidance from clients. Interestingly, depressive

symptoms were still prevalent after the three-month follow-up. Roemer &

Orsillo (2007) suggested that, overall, these findings indicate the potential for

ABBT and other Buddhist-Mindfulness based therapies to treat GAD. They agree

that further trials and more research are needed to clarify and determine if

their findings constitute significant changes in the treatment of GAD and other

associated disorders.

Discussion

Rungreangkulkij & Wongtakee’s (2005) pilot study of a Buddhist-Mindfulness

based therapeutic intervention in Northeast Thailand and Roemer & Orsillo’s

(2007) open trial of Mindfulness-Acceptance Based Behavioral Therapy in

America show considerable similarities and differences in the definition and

application of Buddhist-Mindfulness. Both studies applied Buddhist-Mindfulness

into the psychiatric process and cite its transformative potential in treating

anxiety disorders. Analysis of the trials’ aims, the trials’ structure, methods

and terminology employed in the diagnostic, therapeutic, and evaluation

processes of each trial reveals the different application of Buddhist-

Mindfulness. The form, function, and meaning of Buddhist-Mindfulness applied

in the two localities are dissimilar. This reveals a significant cultural-contextual

difference in the application of Buddhist-Mindfulness.

The function of applying Mindfulness-based intervention was comparable in

both trials. Each trial highlighted the potential efficacy of integrating Buddhist-

Mindfulness to treat anxiety. Each trial diagnosed and assessed patients

through standard psychiatric nomenclature. The aim of both trials was to

develop a more efficacious technique to alleviate completely or prevent

anxiety disorders. Previous research and application of Buddhist-Mindfulness

based therapy in the United States and Australia provided clinical evidence and

motivation for the application of Buddhist-Mindfulness into psychiatry in each

case. Buddhist-Mindfulness was defined by the two trials in a similar manner,

describing it as present-moment awareness, a non-judgemental acceptance of

life as it is experienced. Each trial highlights the importance of applying the

therapeutic process in the client’s life during treatment and by the client after

treatment to alleviate or prevent anxiety symptoms.

The aim of applying Buddhist-Mindfulness in each trial was to cure or prevent

anxiety. This aim was commensurable in both trials. However, the application

of Buddhist-Mindfulness was distinct. Rungreangkulkij & Wongtakee (2005, p2)

applied Buddhist-Mindfulness by utilising a Buddhist aetiology of suffering

(dukkha). While they modelled their therapy according to other Buddhist-

Mindfulness based therapies employed in the U.S and Australia, they structured

sessions around the Buddha’s thesis on suffering (dukkha) and the path to the

liberation from suffering. These were “the philosophical underpinnings of the

counselling sessions” (Rungreangkulkij & Wongtakee’s 2005, p2). Roemer &

Orsillo (2007) also apply Buddhist-Mindfulness in a manner built upon CBT and

other Buddhist-Mindfulness based therapies existing in the United States. In

contrast, however, there was no use of any Buddhist themes or any association

with Buddhism in their therapeutic application of Buddhist-Mindfulness, even

though their application of Buddhist-Mindfulness is derived from textual and

Theravada Buddhist philosophy and meditation practice (Roemer & Orsillo

2007, p75).

Each study contained explanation sessions between patients and practitioners.

The sessions functioned as an introduction to concepts and explanations of the

relationship between habit, behaviour, and anxiety. Rungreangkulkij &

Wongtakee (2005) applied the Buddha’s Three Universal Laws (ti-lakkhana);

impermanence (annicca), suffering (dukkha), and no-self (anatta); and the

concept of suffering (dukkha). This application was a Buddhist explanation of

the nature of suffering as habitual mental activity, describing how and why a

person suffers, and how a person can be liberated from suffering. Roemer &

Orsillo (2007) follow a very similar format to Rungreangkulkij & Wongtakee

(2005). They highlight the habitual, emotional, and behavioural actions

associated with anxiety, and introduce Buddhist-Mindfulness techniques to

patients to manage their anxiety. However, Roemer & Orsillo (2007) do not

associate any Buddhist relationship in anxiety aetiology nor do they apply

Buddhist philosophy or theory in this part of the therapeutic process.

The application of Buddhist-Mindfulness in each trial was to develop

acceptance of situations and experiences as they occur, without judgement or

expectation. Buddhist Mindfulness and Meditation techniques (Loving-Kindness

[mettá], Mindfulness of Breathing [ánápána-sati], and Insight [vipassaná]

Meditation {Harvey 1990}) were applied in each trial. These meditation

techniques are associated with Buddhist-Mindfulness and are consistent with

those practiced in traditional Theravada Buddhism. Rungreangkulkij &

Wongtakee (2005) apply Mindfulness Meditation in conjunction with The Three

Universal Laws (ti-lakkhana) (to teach that life is impermanent [annicca], that

suffering [dukkha] is an actuality of life, and that no-self [anatta] exists or is

attached to a body), The Four Noble Truths (patients can remedy their

suffering by becoming mindful of why they are suffering and what the causes of

their suffering are), and The Eightfold Noble Path (which leads on from the

Fourth Noble Truths and is the process to the liberation from suffering).

Conversely, Roemer & Orsillo (2007, p75) apply Buddhist-Mindfulness and other

Buddhist meditation techniques to treat anxiety from the format devised by

Kabat-Zinn (2003) in other Mindfulness/ acceptance therapies. This process

does not apply any Buddhist association.

The meaning of the application of Buddhist-Mindfulness is also distinct in each

trial. Application of Buddhist-Mindfulness in therapy could be described as

culturally consonant with the aetiological and philosophical delineation of

disease in each context respectively. Each application is consonant with its

cultural worldview in which it is practised. Thailand is a Buddhist Kingdom.

Rungreangkulkij & Wongtakee (2005, p6) argue that the Buddha’s teaching will

fit “with the client’s belief and worldview”. They contend that the application

of Buddhist-Mindfulness will prove efficacious and “increase compliance with

therapeutic instruction” (Rungreangkulkij & Wongtakee 2005, p2). While they

associate anxiety in Thailand as an effect of social and cultural change, the

meaning of anxiety and its treatment are presented as an exegesis of Buddhist

cosmological and existential philosophy regarding suffering and the human

condition. Roemer & Orsillo (2007) apply Buddhist-Mindfulness with no trace of

any religious, philosophical, or cultural association. Mindfulness is therapeutic

process that utilises Buddhist meditation and other Buddhist beliefs and

philosophy, but the contextual origins and meanings of this praxis are absent.

Buddhist-Mindfulness Based Psychiatry

Rungreangkulkij & Wongtakee’s (2005) pilot study of Buddhist mindfulness

based psychiatric therapeutic intervention in Northeast Thailand and Roemer &

Orsillo’s (2007) open trial of (Buddhist-Mindfulness) Acceptance-Based

Behavioral Therapy in the United States highlight how Buddhist-Mindfulness is

diffused into the psychiatric process. Both trials proved efficacious in

generating considerable reduction in symptoms associated with anxiety. Both

processes were therefore therapeutically successful because they improved

upon the previous methods used to explain and treat anxiety. However, the

application of Buddhist-Mindfulness was distinct in each trial. The diffusion of

Buddhist-Mindfulness in each context appears to be culturally and contextually

bound. This is clearly represented through the distinct medical aetiology

(methodological and theoretical guidelines) that each cultural context applies

to the practice of Buddhist-Mindfulness based psychiatry. Further analysis of

these distinctions will provide insight into the influence that culture has on the

diffusion of Buddhist-Mindfulness into psychiatry in Thailand and the United

States.

Chapter 2

Diffusion & Cultural Change

The diffusion of Buddhist-Mindfulness into psychiatry in Thailand and the

United States, as illustrated through the case studies in Chapter 1, are

contextually constrained and influenced by culture. Micro-cultural influence is

an important factor affecting the form, function, and meaning that Buddhist-

Mindfulness takes through diffusion in each cultural context. However, macro-

social processes motivate why the diffusion process occurs. A Macro-social

explanation will highlight why Buddhist-Mindfulness is being diffused in

psychiatry and what motivates this change. Each trial identified that socio-

cultural change, and the failure of the present psychiatric paradigm to treat

mental illness efficaciously, determined why the diffusion of Buddhist-

Mindfulness is taking place in Thailand and the United States. In this chapter I

explore why psychiatry in Thailand and the United States each incorporeate

Buddhist-Mindfulness differently. I do this by examining the contextual

difference that is located in the amalgamation of socio-historical ontological

and cosmological factors. Ontology and cosmology are history made meaningful

in the present by ideology, and the process of ontology/ideology incorporation

is to construct and interpret experience, and to maintain order. The

incorporation of ontology/ideology is motivated by change or the threat of

change to the existing social order or habitus. These are the conceptual

foundations employed to understand the contextual diffusion of Buddhist-

Mindfulness. Change motivates a drive to restore social order in a rapidly

changing world, to diffuse. And ontology/cosmology are utilised as the process

that gives meaning to and makes sense of change.

Diffusion: Definition, Application & Research in the Social Sciences

Diffusion is a process explained in Figure 1. It is the method “by which an

innovation is communicated through certain channels over time among the

members of a social system” (Rogers 1995, p5). An innovation “is an idea,

belief, or practice that is perceived as new by an individual or other unit of

adoption” (Rogers 1995, p11). An innovation is utilised because of its perceived

usefulness to the culture adopting it. Diffusion is established through “a

particular type of communication” (Rogers 1995, p17). Communication involves

information sharing or communal understanding between members of the social

system. The mutual acceptance of belief and values by a group will determine

what form, function, and meaning the diffused innovation will take. It is

Diffusion as a Process of Communication

Innovation Diffusion Consequences

Figure 1.

- Selection of Innovation

- Communication of Innovation

- Measured Over Time- Application and Alteration

Over Time

- Invention

- Suited to Cultural Context

Where Invented

- Changes to Innovation &

Social System

- Adaptive or Maladaptive

- Measured in Time

commonly accepted amongst diffusion researchers that innovations will change

and be reinterpreted in their new context through the process of diffusion

(Barnard 2000; Kroeber 1948 [1923]; Winthrop 1991). The socio-cultural system

will also change due to the diffusion of an innovation. Diffusion of innovations

tends to be top-down and do not always create benefit to all. Diffusion often

has extreme consequences to social and environmental health and the severity

will be different in each cultural context (McElroy & Townsend 1989).

The process of interpreting diffusion is not straightforward. This is due to the

socio-cultural differences inherent in each social context under examination.

Why the diffusion process occurs and what consequences to the social system

and the innovation result from diffusion continue to challenge researchers

(Rogers 1995). This fact is also compounded by the variety of research

traditions and research methodologies applied to study diffusion and resultant

culture change. Medical anthropology (McElroy & Townsend 1985), sociology

(Rogers 1971), and psychology (Berry 1990) represent a number of modern

diffusion research traditions. These traditions focus on how various aspects of

diffusion affect and are affected by various social and cultural factors including

art (Morphy 1994), foreign aid and development (Escobar 1995), health

(McElroy & Townsend 1989), migration, and religion (Mills 1997). Research

traditions that focus on cultural change through diffusion (and acculturation)

are often critical of the historical and modern studies of diffusion. Reynolds

(1971) highlights the need to increase the understanding of acculturation and

diffusion processes to create a useful and relevant theory. His work on religious

diffusion in the Philippines aimed to clarify current terminology for

acculturation/diffusion. Rogers (1995) explains the inability of diffusion

researchers and cultural-development agents to research the consequences of

the diffusion process, the third and arguably most important aspect of diffusion

research. This inability, he argues, rests with those who propose and enact

development projects, and with the researchers that fail to develop sufficient

long-term methodological and research-based projects into consequences of

diffusion cross-culturally. Sam & Berry (2006) highlight the inability of the

social sciences to adequately define the meaning and operation of

acculturation and diffusion as it is applied as a discursive and methodological

tool in psychology.

Within anthropology, de Sardan (2005) considers the need to develop an

‘Anthropology of Innovation’. de Sardan aims to clarify and unite the variety of

research methodologies and interpretations social scientists employ in

diffusion, acculturation, and innovation research. de Sardan’s (2005) critique of

the anthropological and sociological research traditions on diffusion,

acculturation, innovation, and the consequences of diffusion is timely. It

illustrates the need to make commensurate the various disciplinary concepts

into a methodologically precise and accurately defined approach to diffusion

research. What he articulates in his movement towards an ‘Anthropology of

Innovation’ resonates with Reynolds (1971), Rogers (1995), and Sam & Berry

(2006). It is clear that there is ambiguity regarding not only precise

interdisciplinary definition for diffusion (and acculturation), but also how to

study these phenomena as a process. de Sardan (2005) argues that there is

epistemological commensurability among these disciplines and a ‘reworking’ of

the various methodological and research objectives that these traditions have

applied to diffusion and acculturation research can be achieved within the field

of anthropology.

The amalgamation of various methodologies that focus on diffusion,

acculturation, and innovation would be an appropriate refinement considering

the broad research traditions with equally broad research basis. The

theoretical ‘reworking’ outlined by de Sardan (2005) would provide a baseline

that competently defines not just innovation, but the diffusion of innovations

(as designated by Rogers 1995). This would be a processual method, and all the

preceding and anteceding sub-processes of the diffusion process must be taken

into account. This would provide a transition beyond the methodological

limitations and departmental particularities that modern diffusion research

traditions exhibit. But this is not a straightforward task, considering the variety

of research traditions in existence. However, as Marcus and Fischer (1986, p8)

explain, there has been a “crisis of representation” within the social sciences

for the better part of their existence. They determine a need to examine the

various levels and domains of influence that are an effect of culture, inclusive

of scholarly theoretical and methodological predisposition. From the

perspective of Marcus and Fischer (1986) and de Sardan (2005), what is

important in this discussion is not a ‘shift’ but a necessary ‘clarification’ of the

diffusion of innovations in definition and process within Anthropology. With this

in mind, I do not attempt to clarify or resolve in totality the issues relating to

diffusion that I have raised in this thesis. I will examine what motivates the

diffusion of innovation in respect to socio-cultural history and a globalised

modernity.

Method & Process

In this thesis I propose to answer two questions. What are the macro-forces

that motivate the process of diffusion of Buddhist-Mindfulness into psychiatry

in Thailand and the United States? What are the mcro-social, cultural, and

historical driving mechanisms that influence the form, function, and meaning

of Buddhist-Mindfulness in each psychiatric application? I aim to explore this

problematic by utilising a theory of diffusion of innovation following de Sardan

(2005) and Rogers (1971; 1995), and Kapferer’s (1988) application of ontology

and cosmology to interpret social change and contextual meaning involved in

change. I define diffusion as the process of willing change; innovation as

borrowing a practice to control change; communication as the social movement

towards making change meaningful; and consequences as the new form of the

diffused innovation. A minimal theoretical framework will be utilised. I will

examine the diffusion of Buddhist-Mindfulness into psychiatry in the United

States and Thailand through the social incorporation of ontology and ideology,

whereby history is made meaningful in the present through rational action in

practice to construct and interpret experience and maintain order. This

method will suit an analysis of diffusion because diffusion is a socially adaptive

process that aims to maintain order when change or the threat of change/crisis

to the existing social order arises. I argue that the ideology to engage in

Buddhist-Mindfulness utilises cultural ontologies and cosmologies that will

create specific consequences to Buddhist-Mindfulness in each respective

context.

By examining the diffusion of Buddhist-Mindfulness into psychiatry in Thailand

and the United States, this comparative analysis will illustrate how macro-

global factors motivate micro-cultural action. This analysis will also highlight

the consequences to the innovation being diffused. Consequences are

determined as the changes to the form, function, and meaning of Buddhist-

Mindfulness through the diffusion process. I aim to illustrate the consequences

to Buddhist-Mindfulness that result from its diffusion. This is a movement from

traditional studies outlined by Rogers (1971; 1995), who defines consequences

in socio-cultural terms only. I argue that this examination of consequences will

highlight the difference in worldviews. Belief constrains and influences

ideological incorporation of ontology/cosmology in culture. This is the major

factor influencing the form, function, and meaning of Buddhist-Mindfulness in

the process of diffusion in psychiatry.

Cultural Change & Revitalisation: Ontology, Habitus & Ideology

To explain the diffusion of Buddhist-Mindfulness into psychiatry in Thailand and

the United States, three issues must be raised. What is ontology and cosmology

and why are they employed to maintain order and meaning in culture change

situations? What is ideology what is its role in engaging cultural ontologies

when habitus is ruptured? What relationship do ontology and ideology have with

health-seeking behaviour? To begin this analysis I situate this problematic with

a quote from Schutz (1970). He states:

“Man is born into a world that existed before his birth; and this world

is from the outset not merely a physical, but also a socio-cultural one.

The latter is a preconstituted and preorganised world whose particular

structure is the result of an historical process and is therefore different

in each culture and society” (Schutz 1970, p79)

From Schutz’ (1970) perspective, the present social world is historical, and

human beings in their present socio-cultural circumstances take their present

social world for granted. How people generate meaning and conclusions

regarding the universe and their place in it are determined by historically or

ontologically posited socio-structural and material culture.

Any analysis of reason and rationality in culture must primarily take into

account the role of ontology. Ontology is inquiry into the nature of being.

Cultural ontologies are “prior to deliberate conscious articulation” and form a

“preconscious orientation” (Bastin 2001, p23) to the world. Ontology

“describes the fundamental principles of a being in the world and the

orientation of such a being toward the horizons of its experience” (Kapferer

1988, p79). Ontologies inform social action. This makes the analysis of ontology

important, because of the role ontologies have in orientating social action,

intention, and experience. Importantly, ontologies are more often than not

undisclosed or unassumed by members of a culture. Cultures have multiple

ontologies that are mythical, textual, and topographic. These are accessible

through ideological processes. Kapferer (1988, p80) explains ideology as the

“selective cultural construction” of ontology or various ontologies, usually

“made in the circumstances of political or social action”. Ontologies are full of

potential, but their capacity is realised and manifest only when ideological

meaning is applied to them. This is the same for cosmologies. Ontologies and

cosmologies cannot exert meaning or force on their own, but must have

meaning and intention applied to them in practice to become emergent as a

social force. Ideology imparts meaning and intention to ontology and

cosmologies by applying a schematic structure to them, determined through

practice in the present social world.

Ontology is a vital part of the taken-for-granted or habitual aspect of self and

cultural construction and experience. Ontologies most commonly exist as

cultural practices, commonly identified as habitus. Habitus is defined by

Bourdieu (1977) as a structural and taken-for-granted modus operandi that

cultures and members of cultures generate and regenerate through practice in

fields of social action. Habitus represents the ontological aspect of culture in

practice. Bourdieu (1999, p109) explains habitus as the “internalisation of

externality” through a “dialect between habitus and institutions” (Bourdieu

1999, p111). Due to the persistence of a practice or set of practices over time,

and the construction of socio-structural and material structures in society

“property appropriates its owner, embodying itself in the form of a structure

generating practices perfectly conforming to its logic and its demands”

(Bourdieu 1990, p57). The socio-structural, material, and topographic aspects

of culture generate the successful performance of practice over generations.

This provides the taken-for-granted position where “that what has proved to be

valid up till now will continue to be so” (Schutz 1970, p80).

Habitus (or ontology for that matter) is not static. An inconsistent factor in

diffusion research applied by Rogers (1971; 1995) has been to postulate that a

form of cultural homeostasis or dynamic equilibrium can be constantly

achieved. Habitus is open to change from within or without, and is routinely

transforming. Change commonly occurs through events that result from

actions. Bastin (2001) explains that often events from outside the control of a

group propel them into action. In-group reaction to outside change is

ideological, a product of resistance of the group being acted upon. Ideology, as

previously stated, is a determined course of action that is based on ontological

reasoning. “Change”, explains Bastin (2001, p30), “provoke[s] repetition

through a retreat into tradition”. A retreat that Bourdieu (1999, p115)

substantiates “contains the solution to objective meaning without subjective

intention”. Social change pressures cultural reasoning to renegotiate personal

and social identity and meaning (Connor & Samuel 2001). A ‘retreat into

tradition’ to deal with these changes to make meaningful sense of them is a

common reaction when change and crisis threatens the established and taken-

for-granted social order. Meaning, as a social and collective notion, can be

rallied in times of change to legitimise action. Shared meaning constitutes an

integral aspect of the process whereby a collective past is made meaningful in

the present.

Kapferer (1988; 1997) states that to legitimise crisis, an ideological retreat into

mythological and cosmological aspects of culture occurs. This is explained in

Figure 2. Using examples from Buddhist Sri Lanka and Australia, Kapferer

Use of Ontology & Cosmology in Modern Culture Change

-Push towards rational & secular Knowledge - Ruptures habitus -Use of ontology & -Economic orientation to global - Self/Social/Cosmic cosmology in market over subsistence needs crisis cultural practice to identify with a -Media driven identity - Promotes a retreat collective cast and into ontology & legitimate the -Accepted authority of cosmology present crisis. nation-state

Figure 2.

(1988; 1997; 2001) illustrates the role ideology plays in legitimising ontological

and cosmological sources by reinterpretating them to motivate social action in

the present. This use of ideology in healing rituals and disputes regarding

nationalism aims to counter challenge to the social status quo. The chronicling

of Sinhalese Buddhist textual and mythic history is explained by Kapferer

(1988; 2001) as an example of ideological use of ontology for purposes of

legitimising violence and political aspirations against the Tamils. In these

instances, mythical deeds of monks and deities are reinterpreted and applied

to justify present action. Another common example throughout Buddhist

political history is where ‘sacred kingship’ has been used to authenticate and

legitimate political decisions in Buddhist terms (Hallisey 2006). In Australia,

Kapferer (1988) identifies similar tendencies as Sri Lanka, where the ANZAC

legends are used to legitimate social action when threats to the national

identity occur. Australian nationalism must embody individual and egalitarian

tendencies of persons, as ANZAC legends state, to maintain the moral order

and reconstitute social powers.

The ideology of ontology and cosmology is a characteristic of medical processes

and rituals that are Buddhist. From an ethnomedical perspective, Obeyesekere

(1985, p141) explains how Sri Lankan Buddhism “provides special occasions for

ontological reflections on despair”. Buddhist textual and visual meanings to

suffering (dukkha) are applied to interpret and explain illness experience. This

is also the case in Thailand. Examples reveal that lay explanation for

biomedical germ-theory and the genetic basis of diabetes contraction have

become ritually and mythically meaningful through situating new aetiological

and nosological categories to longstanding beliefs in sorcery, spirit

malevolence, and karma (Golomb 1988; Naemiratch & Manderson 2007).

Medical plurality affords Tibetan exiles in India “an infinite strategic resource”,

when modern values and pressures come to compete with existing medical

systems (Prost 2006, p126). In Japan, traditional therapies are incorporated

into psychiatric nosology and as aetiology for the treatment of mental illness.

Morita Therapy, an indigenous therapy of Japan, are inspired by

Buddhist/Shinto belief and are designed to address a culture specific illness,

taijin kyofusho (Nuckolls 2006). Ideology of ontology and cosmology are

utilised, as these examples reveal, because of challenges to the habitus that

disrupt the person-society-cosmos relationship. History is employed to amend

these ruptures to the taken-for-granted. Biomedical and psychiatric nosology

and aetiology are inadequately able to capture not only the experience, but

also the meaning of trauma and disorders in other cultural contexts (Hinton et

al 2007). This prompts a ‘retreat into tradition’ in response to the inability to

locate meaning in social and embodied terms in these cases.

The Social & Historical Praxis of Suffering

Ideological action, as it has been shown, engenders meaning to the present

when moments of crisis and change arise. By employing cultural ontologies and

cosmologies, a history that is collective in social memory and meaning

emerges. This is a dynamic relationship that is recreated mythically and

ritually, and where “the order of the body is identified and produced within

the order of the state” (Kapferer 1988, p78). When the habitus or the taken-

for-granted mode of cultural action is challenged during times of crisis or

change, there is a need to re-legitimate the ascribed social order. This occurs

through ideological reapplication of past mythical, cosmological, and textual

aspects of culture in practice. This is a process that has been proven valid and

successful throughout time, otherwise it would not be practised (Kapferer

1988; Schutz 1970). Importantly, the cultural field and its practices are not

static, but are dynamic and fluid. Habitus is not static and is constantly

changing and altering through the need to reincorporate ontology and

cosmology because of social change.

The diffusion of Buddhist-Mindfulness into psychiatry in Thailand and the

United States is interpreted by the conceptual theoretical foundation I have

outlined. The stimulus to incorporate Buddhist-Mindfulness in each context is

motivated by social change and the need to restore balance. This is articulated

through culturally specific meanings and practises. I argue that a microanalysis

of these cultural processes, positioned in macro-global context, will reveal

exactly why differences in form, function, and meaning occur. Macro-

motivation for diffusion in each context motivates the need to maintain order

in changing and uncertain times. The micro-cultural representation illustrates

the unique means by which people in Thailand and the United States negotiate

self and society in modernity. The diffusion of Buddhist-Mindfulness in each

context is the result of conscious (ideology) and non-conscious (ontology)

action in each context. The function of institutions, patterns of culture, and

their meaning is motivated by unique histories and worldviews that create the

differentiation revealed in the two case studies examined. These socio-

historical, material, and topographic social structures constrain and motivate

the form, function, and meaning of Buddhist-Mindfulness in each cultural

context.

Chapter 3

Diffusion, Health-Seeking & Culture Change

in Northeast Thailand

This chapter examines the diffusion of Buddhist-Mindfulness in psychiatry in

Thailand. I argue that this diffusion complements the plural nature of medicine

in Northeast Thailand. Moreover, it illustrates the importance of ‘Mindfulness’

as a Buddhist practice that examines experience, providing meaning to

personal and social illness experience. Medical plurality in Northeast Thailand

incorporates historical traditions that bear significant influence on

contemporary health-seeking behaviour. Northeast Thailand has a well-

established plural medical system that resembles an historical admixture of

therapies and discourses from ethnic Tai, India, and China. Buddhist

determinants of health, particularly through the concept of suffering (dukkha),

hold significant status among Thai people and umbrella other techniques. Euro-

American medicines have been utilised in Thai society for nearly two centuries.

Euro-American ethnomedicines are utilised as part of a plurality and not

exclusively for treatment. Therefore, health-seeking behaviour in Northeast

Thailand represents a history of diffusion of ethnomedicines. The current

assemblage of available services reflects the diffusive history of Thai medicine

where plural determinations of health preside. The incorporation of Buddhist-

Mindfulness to psychiatry is determined to represent another stage in the

process of Thai medical pluralism, and can only be understood when examined

within the matrix of health-seeking behaviour and medical practice.

Buddhism, Health & Culture Change

Northeast Thailand is geographically isolated from ‘modern’ Thai society. The

region suffers from a lack of access to and underdevelopment of resources and

infrastructure including education, medicine, and technological services. The

area has become dependant on the global market economy, mainly industrial

agricultural production, for employment and nutrition (Hoare 2004). The social,

cultural, and economic changes of industrialisation and modernity were

compounded by the 1997 financial crisis, generating undesirable health

consequences for the region. Primary health problems like malnutrition and

diseases such as respiratory, digestive system, infections and parasites are a

common form of pathology (Kauffman & Myers 1997). Many of these health

problems are avoidable. They are the result of inadequate infrastructure and

funding by the centralised Thai polity (Ionesgu-Tongyonk 1977; Rungreangkulkij

& Wongtakee 2006; Suwana 1969). Public and Private Health Clinics have been

common in Northeast Thailand since the 1980’s, and health professionals who

have been trained in appropriate biomedical and psychiatric diagnostic criteria

and terminology identify pathology and provide treatment for ailments.

However, social uncertainty and lack of money often inhibit people from

utilising these resources.

Biomedical and psychiatric diagnoses do not always correspond to, or are not

always commensurate with, lay determinants of health and illness (King &

Wilder 2003). This is a well-documented fact about psychiatry in its cross-

cultural application (Henningson 2003; Kirmayer 2006; Kleinman 1980, 1988;

Pilowsky 1997). People of Northeast Thailand rely on both Euro-American and

Traditional Thai medicine and practitioners when seeking treatment. In

Thailand “a tremendous diversity of diagnostic and therapeutic procedures”

exists, and “multiple aetiologies for a single illness” are commonplace (Golomb

1988[b], p761). Buddhism crosscuts all institutions and practices in

Northeastern Thai society and is entwined as part of a larger medico-religious

tradition that utilises various traditional medical techniques. Indian and

Chinese humoral and herbal theory (Naemiratch & Manderson 2007), ethnic Tai

belief’s in spirits, ghosts, witches, sorcery (Formoso 1996), and Euro-American

biomedical and psychiatric medicine are utilised to explain and reduce

suffering. In Northeast Thailand, health-seeking behaviour utilises traditional

medical practices and rituals more so than Euro-American ones. However, a

number of therapeutic methods may be employed at once where various

practitioners are sought by a person to obtain cures and meaning to illness

(Lyttleton 1996).

King (1999, p 221) highlights that “many South-East Asians have accepted the

technology of these [Euro-American] curative practices, but not their

premises”. The medico-religious aspect of Buddhism and its incorporation with

other beliefs and practices intertwine to explicate meaning and provide

techniques for the remedy of illness and misfortune. Meaning is acknowledged

as a substantial aspect of the diagnostic and healing process in Northeast

Thailand. Buddhism deals specifically with illness through the concept of

‘suffering’. Chen-kuo (1997, p298) maintains that suffering (dukkha) is a

fundamental edict of Buddhism, in which “the core of Buddhist practice

consists in meditating on the cause of suffering in order to overcome it”,

explained in Figure 3. Suffering (dukkha) in a Buddhist context is both

metaphysical and experiential. It includes the concepts of karma (kam) and

rebirth (samsára) as these concepts relate to text, cosmology, and the

vicissitudes of daily life (Harvey 1990). Buddhist beliefs freely interact with

aetiologies of fortune/misfortune and health/illness that involve spirit (phi)

malevolence, soul (kwan) loss, and possession or infliction by a sorcerer

(Golomb 1988).

Buddhist Aetiology of Suffering & the Liberation from Suffering

Three Universal Natural Laws (ti-lakkhana)

1.Impermanence (annicca)

Wisdom (panna) 2.Suffering (dukkha) Ignorance (aviccha)

3.No-Self (anatta) Attachment or Clinging (upadana)

Craving (tanha)

Four Noble Truths (Way to the cessation of suffering) Rebirth (samsára) 1. Life is Suffering (dukkha) (Hell/Animal Realm) 2. Origin, nature, creation (samudaya) of suffering 3. There is cessation (niroda) of suffering

4. Practical method to liberation from suffering Eightfold Noble Path (marga)

1.Right Understanding

2.Right Thought

3.Right Speech

4.Right Action

5.Right Livelihood

6.Right Effort

7.Right Mindfulness

Cessation of Rebirths (nibbána) 8.Right Concentration

Figure 3.

While modern medicine and medical facilities have penetrated Northeastern

Thailand, geographical isolation has facilitated the situation whereby

traditional Buddhist and animistic beliefs and practices remain strongly intact.

(Hoare 2004). Buddhism in Northeast Thailand associates a microcosmic/

macrocosmic relationship with the explanation and meaning of illness. The

body is positioned in relation to the cosmic order, and maintenance of this

relationship is vital in the construction, reconstruction, and maintenance of

self and society in a person-community-cosmos tripartite relationship. The

symbolism of the macrocosm/ microcosm is engendered as a curative element

in healing practice (Tambiah 1970; 1977; Whittaker 2002). In the process of

healing, the enactment of myths through this process of ritual is pertinent.

Taking this into account, I argue that ethnomedical resilience in Northeast

Thailand is the result of its relative geographical isolation where the practice

of Buddhism (and animism) as a ‘social-existential’ embodied culture is

occurring. Practice occurs on a needs basis to maintain order and security in

out-of-habitus-times. Analysis of the two case studies presented in Chapter 1, I

contend, will reveal how each of these phenomena unites to enable a

persistent traditional ethnomedical practice. This will illustrate why Buddhist-

Mindfulness was diffused with psychiatry as constituted in a Buddhist

framework.

Healthcare in Northeast Thailand

Several scholars have commented on Northeast Thailand’s geographic isolation

from centralised, urbanised and cosmopolitan Thailand. This focus has often

described rates and level of diffusion of modern health institutions and

discourse and how this has come to affect Northeast Thai society. More often

than not, these accounts paint a negative picture (Krongkaew 1995; McVey

2000). Research has revealed how isolation from the central bureaucracy has

established disadvantageous social, health, and economic disparities. Being

subordinate to the centralised polity, rural health development is often in the

hands of the Thai Government or NGO’s, and while local determinants of

health and healthcare is considered in development projects, change is usually

imposed from without (King 1999). Van Esterik (1998) maintains that this

attitude in Thailand is the result of a history of developmental ideology, the

perceived efficacy of Euro-American ‘scientific’ medicine, and the social status

of such medical practice.

Social perceptions of Euro-American medicine and meanings attributed to

specific diseases have filtered through to the village level via development

programs, NGO groups, the media, and word of mouth from patients. While

highlighting current determinants and levels of social health in Northeast

Thailand, these analyses have failed to show why multiple health care options

are accessed and utilised by people of Northeast Thailand, rather implying that

they simply do exist. As Lyttleton (1995) explains, modern illnesses,

particularly HIV/AIDS, are entwined with traditional meaning and causes of

illness. Why traditional beliefs regarding illness, and practices to explicate

illness, persist even though biomedical and psychiatric intervention is

commonplace, are not revealed by many analyses of Northeast Thailand.

Initial investigation reveals a well-established traditional medical system

already in place in Northeast Thailand. A thriving medical pluralism exists

between traditional Thai and Euro-American medicine (biomedical and

psychiatric), highlighted in Figure 4. Research from other regions of Thailand

suggests similar conclusions to those revealed in the Northeast (Golomb 1988;

Muecke 1976; Weisberg 1982). Patients are acknowledged to have a high

degree of autonomy and agency selecting services and treatments, and are

highly conscious about what types of therapy to utilise for which ailments.

Choice in health-seeking appears to be based on a set of selective criteria that

involves personal and social components relative to modern and historical

considerations and the array of therapeutic options available. Lyttleton (1996)

locates personal agency within the broader framework of embedded social

meanings and responsibilities. He illustrates that Buddhist ideology,

particularly relating to karma (kam), underscore lay beliefs and explanations

concerning illness and healing. Further, belief that some illnesses are caused

by spirits (phi) maintains the need for spirit healers (mor lam song) and

diviners to explain illness and cure patients. Both sources of cure involve

elaborate rituals and negotiation of social and cosmic powers that are

constituted within the broader culture and cosmos (Lyttleton 1996).

Identified Diagnostic Options in Northeast Thailand

Buddhist

Biomedical/Psychiatric Preventative/Propitiatory

Humoral Herbal

Supernatural/Spirit Medium

Figure 4.

Critically, Lyttleton (1996) differentiates two modes of experience that inform

healthcare seeking behaviour in Northern Thailand: diagnosis/treatment and

explanation/understanding. Keyes (1985, p169) remarks, “Western medical

practice is perhaps unique in its effort to interpret illness [textually] without

reference to the problem of suffering”. He explains that illness negates a

consciousness shift in a person, where the person is forced out of their taken-

for-granted mode of consciousness. Referring to Northern Thailand, Keyes

(1985) explains that patients require an explanation (possibly through several

practitioners) to make sense of their illness (state of present consciousness)

Multiple Therapeutic

Dynamic

and provide a course of action to achieve balance (commonsense perspective)

once again. It is well documented that in Northeast Thailand meanings of

illness go beyond purely medical textual interpretation, to religious and

cosmological explanations and interpretation of illness experience (Keyes 1985;

Tambiah 1977; Whittaker 2002). The utilisation of traditional medicine,

traditional medical practitioners, and traditional medical beliefs by patients is

for explicitly other reasons that the utilisation of Euro-American medicine

cannot address.

These modes of experience (diagnosis/treatment - explanation/understanding)

evidence themselves in health-seeking behaviour, experience of illness by

patients, and in the practitioner’s personal determination of their therapeutic

role. For example, psychiatric patients often cite possession, attack by spirits

and ghosts, or bad karma (kam) as the cause of diagnosed mental illness

(Burnard, Naiyapatana & Lloyd 2006). In some instances, diagnosed psychiatric

patients who believe they are possessed (and communicate with their spirit)

are treated reverently by other patients and even doctors, particularly if their

spirit is well known and powerful (Lyttleton 1996). Yet at the same time, Thai

psychiatric patients who link spirit possession to their symptoms can be

diagnosed as hypochondriacs or have convulsive or conversion disorders

(Kasantikul & Kanchanatawan 2007). Patients considered psychosomatic are

generally referred by medical practitioners to spirit mediums or monks for

treatment, or they chose personally to seek treatment with these traditional

practitioners because their initial consultation with Euro-American medicine

failed. This is a common trend when patients chose Euro-American medicine as

the first course of care and where traditional therapy and practitioners provide

a ‘second opinion’ when/if the initial consultation proves unsuccessful. Success

is relative to the patient’s perspective (Lyttleton 1996).

Euro-American and traditional Thai medical institutions and practitioners

exhibit various explanatory models for illness treatment and modes of

behaviour, explained in Figure 5. Patients and healers each have the option to

consult from a variety of sources for illness explanation and meaning and

readily utilise a variety of therapeutic techniques. Purely biomedical and

psychiatric practice is commonplace throughout the region in private or public

hospitals. However, in many State-run hospitals “Buddhism… clearly permeated

all aspects of nursing and health care” (Burnard & Naiyapatana 2004, p759).

Nursing practitioners believe that being a nurse makes good merit (bun), a

Buddhist belief related to karma (kam). Further, the ethical and moral

teachings of the Buddha were central to being a nurse practitioner and

understanding patients experiential needs (Burnard & Naiyapatana 2004). Spirit

mediums and Buddhist Monk healer/practitioners employ a ‘market-niche’

method to their practice (strikingly similar to capitalist methods). Healers may

be ‘divinely summoned’ or gain skill (and respect) through a lineage of healer/

practitioners. Monks and spirit mediums dabble in both Buddhist, animist, and

Euro-American (biomedical/ psychotherapy) techniques. They apply this variety

Identified Causes of Illness & Suffering

Karma (previous lives)

Action (bun/baap) Sorcery Malevolence

Spirit Possession Genetic Disposition

Ghost Attack Modern Social Change

Soul Loss

Figure 5.

Multiple

Aetiological

Dynamic

of ritual techniques to combat supernatural malevolence and sorcery

accusations and guard their skills and clientele resolutely (Golomb 1986).

Healer status is achieved through healing efficacy, usually obtained through

community acknowledgement of the practitioners’ healing ability (Golomb

1986; 1988).

Health-Seeking in Macro-Cosmic Context

Thailand exhibits a history of various socio-culturally embedded philosophies

and practices that inform health-seeking behaviour. Nonetheless, scholars have

long acknowledged Buddhism as the major socialising agent in Thai society.

Kirsch (1975, p181) explains, “the Buddhist worldview… provides a general

paradigm for all human life”. Keyes (1984, p226) iterates that “Buddhist

values…constrain and motivate” the roles of men and women within Thai

society. Socialisation in Thailand begins in childhood, where personal and social

praxis are instilled. The impression of social values traverses a person’s

lifetime. Access to material and spiritual resources is gendered, and age and

gender determine social responsibility and etiquette (Lyttleton 2002). Various

stages of importance (rites of passage) are marked by ritual events. As

Whittaker (2002, p32) declares, the construction of personhood is embodied

through these rituals, where “inscription of ideological values structuring

social, economic, and moral power relations” take place.

Buddhist precepts of karma (kam) and merit (bun/baap) are intimately

immersed in the ritual and social processes of Northeast Thailand. These

precepts define personal and social action, responsibility, and access to

material and spiritual resources (Ingersol 1975). Defined social roles and

obligations are informed through textual, mythological, and cosmological

traditions, “traditions [that] have expressed and nurtured Thai universalism

one the one hand, and Thai Buddhist particularism on the other” (Reynolds

1978, p195). Buddhist text, myth, and cosmology have become relatively

inseparable over the centuries through their diffusion as social action. The

elementary and foundational concepts of Buddhism (karma, samsára, dukkha,

and nirvana) can all be determined through a cosmological exegesis when

interpreted in context (Tambiah 1970). These concepts have been incorporated

into the pantheon of Buddhism and are articulated in social contexts as sacred

art and architecture (Hall 1998; Paul 1976; Tambiah 1970).

A symbolic microcosmic/macrocosmic connection permeates through to

Buddhist concepts of the self. The relationship between body, society, and

cosmos function as the integrative component between the personal, the

social, and universal laws/processes in village and national life (Laughlin,

McManus & d’Aquili 1990). Architectural and artistic structures in Thai society

reflect these social and political objectives. In Thailand, the concepts of

rebirth, karma, and suffering have been fused into a cosmological discourse,

‘The Sermon of the Three Worlds ’, and the admixture of religious and artistic

tradition (Khmer, Burmese, Chinese, and Euro-American) represent the

diffusive history of Thailand. Over five centuries of diffusion of other-cultural

beliefs, practices, and stylistic representation (including Euro-American)

permeates traditional and modern Thai structural design. Architectural

symbolism is a social organizational agent. It motivates village and temple

design and location, informs processes of ritual, and social action (Reynolds &

Reynolds 1982) in both village and urban contexts throughout Thailand. Askew

(2002, p220) explains that Buddhist architecture of the village (baan) and

temple (wat) have been utilised throughout history, and into the present as “a

site for the reproduction of key traditions associated with place and also life

cycle”.

Cosmological symbolism has functioned as a form of social organisation and

integration in Thailand since Sukhothai in the 14th century (Jackson 1989; Ray

2006). A ‘galactic polity’ has endured in Thai political and social structure

since Sukhothai in the 14th century, where the development of a ‘cosmological

topography’, featuring a central administration and hierarchically based social

structure and organization, circumnutating a centralised ‘sacred kingship’

(Reynolds & Reynolds 1982; Tambiah 1976). Social structure; between person,

village and state, reflects the Buddhist cosmology. This cosmology, interpreted

as “biological-organic” (King 1983, pxi), accepts that all phenomena are

interconnected and are conditioned through subjugation to universal laws of

cause and effect. Various universes exist, and are recognised as a “living body”

that is cyclical and infinite in both temporal and spatial demarcation, and

where human “existence is set” and is regulated by inherent cosmic laws (King

1983, pxii). The cosmic laws of Buddhism are causal and are regulated through

action. These laws vary and relate to psychological, physiological, biological,

moral, and spiritual conduct and action.

The law of Karma (kam) [moral/ethical causation] is the most pertinent

Buddhist cosmic law, and the “knowledge of this moral law enables us to

discover the cause of suffering and the release from it” (Ratanakul 2002).

Suffering (dukkha) and the removal of suffering is the central thesis of the

Buddha. The explanation for suffering and the way to be liberated from

suffering is outlined and explained in The Four Noble Truths (and The Eightfold

Noble Path), which the Buddha recognised through his enlightenment

experience (Harvey 1990). The Buddhist path is distinctly concerned “with a

[search for] truth that can have a practical effect in the release from

suffering” (Ratanakul 2002, p117). Karma (kam) is used to explain suffering,

and also fortune/misfortune, health/illness, or social status among other

existential and social problems in Buddhist society (Spiro 1967; 1971). More

importantly, it explains on a metaphysical level rebirth (samsára) and a

person’s past lives, all of which predicate one’s present karma, and which are

the result of ones action in their past lives (Ingersol 1975). Rebirth (samsára) is

the process of being and becoming; it is the cycle of lives that all beings

undertake until their liberation through enlightenment. Rebirth is significantly

cosmological as it describes the universe and the various levels of existence

that one can be born into. The type of rebirth one receives is predicated upon

action, or the law of Karma. A person’s Karma (kam) determines the rebirth

received, determining the level of suffering a person receives.

Personal social action is determined as good (bun) and bad (baap), usually

defined as ‘merit making’. The role of merit and merit making is a highly

esteemed and exercised practice in Thailand. Tambiah (1970, p53) decrees

that merit (bun) and de-merit (baap) making has developed into an institution

in Northeast Thailand “by which villagers conceptualise, evaluate, and explain

behaviour”. Merit is a Buddhist based tradition that exists at a public and

private level and concerns the individual, village, and national government

(Mulder 1969). Ingersol (1975) identifies that merit and identity are intricately

connected, and that making and storing merit is a multifarious aspect of Thai

village life. You are born with amounts of merit, you can make merit, store

merit, give merit, and lose merit. Merit is both obligatory and selective, and is

used to gain personal and social value in this life, and implicates the type of

rebirth received in the next life. Merit and Karma are intricately connected.

Merit is action in this life that is socially and cognitively contingent in this life.

More importantly, it will affect a person’s rebirth, thus level of suffering, in

their next life.

Medical Pluralism in Northeast Thailand: Form & Function

The preservation and perseverance of traditional Buddhist values in

Notheastern Thailand is obvious. Medical plurality is not diminished by Euro-

American diagnosis and treatment measures, but is maintained by the lack of

psychosocial meaning they apply. This is particularly due to the focus on

biological theory as the determinate of ill health. However, as Reynolds (1998,

p116) explains, “it has become increasingly difficult to speak of the country as

remote”. This is a geographical and religious statement. While Buddhism

penetrates the various levels of therapeutic process in Northeastern Thailand,

impregnating illness experience and healthcare seeking motivations with

meaning (particularly in regards to the discourse on suffering [dukkha], karma

[kam], and merit [bun/baap]), modern values are influential. None the less,

the meaning and the motivation behind personal action is the direct result of a

Buddhist socialisation process in Northeastern Thailand that has been occurring

for centuries. A person is defined by their karma (kam), a phenomenon that is

at the same time a priori and teleological. A person is bound by their past, but

can be liberated by their present action (bun/baap), as explicated in the

universal laws (Ratanakul 2002). Cosmologically speaking, a person has freedom

to act, and these actions can determine why they suffer now, and how much

they will suffer in their next life.

Notwithstanding, how a person acts is clearly articulated by social rules and

obligations that are both traditional and modern. As a result personal

existential needs are more often than not subjugated by social ordinations.

However, this does not remove personal agency from people. On the contrary,

health-seeking behaviour in Northeast Thailand reveals that while social rules

obligate people to behave in particular fashion, these requirements also

provide the means by which personal agency can be utilised to gain control of

‘suffering’ within the social and universal order. The incorporation of modern

Euro-American institutions and values has not altered this practice, but has

challenged these longstanding patterns of culture to adapt to them. The

diffusion of Buddhist-Mindfulness in psychiatry signifies that when “practical

meaning that cannot be obtained from those steeped in medical texts alone” is

sought after by patients seeking explanation for ‘suffering’ (Keyes 1985, p169).

This represents the process whereby Buddhist ontological and cosmological

concepts, particularly the discourse on suffering (dukkha), are applied to give

greater meaning the mental illness experience. The diffusion of Buddhist-

Mindfulness as a Buddhist practice is integral to the maintenance of the

personal and social order within the cosmos, and reflects the need for a

Buddhist cosmological significance to illness experience.

Chapter 4

Diffusion, Health-Seeking & Culture Change

in the United States

This chapter examines the diffusion of Buddhist-Mindfulness in psychiatry in the

United States. This is illustrated through analysis of modern and historical

socio-cultural influences that I argue motivate and drive this diffusion. This

analysis is similar in format to Chapter 3. Health seeking behaviour is explained

to illustrate how illness is experienced and made meaningful in the United

States. Following Hahn & Kleinman (1983), I define psychiatry and biomedicine

as Euro-American ethnomedicines. As ethnomedicines, they are also a

sociocultural system; they interact and reflect a larger socio-historical and

cultural cosmological context through critical engagement with the wider

macro-society. I situate Buddhist-Mindfulness among a number of other

Complementary and Alternative Medicines (CAM) and religious traditions that

are currently being diffused into United States society. Their diffusion reflects

the socio-historical structures of Christianity, science, and capitalism,

structures that make up the habitus and worldview of the United States, and

motivate why Buddhist-Mindfulness is diffused in psychiatry differently than it

is in Thailand.

Scientific Crisis & the ‘Operational’ Status of Buddhist-Mindfulness

Science and medicine in the United States are currently experiencing a

paradigm shift. The model of the universe, how it works, and how humans can

work within the universe is being amended (Ratanakul 2002). This

transformation is influenced by ‘Eastern’ concepts of reality, and subsequently

‘Eastern’ discourses of health/ill health experience have entered into medicine

and psychiatry. This new paradigm is described as the “rediscovery of Asian

philosophy, particularly the Buddhist tradition”, and is depicted as “the second

renaissance in the cultural history of the West” (Varrela, Thompson & Rosch

1993, p22). From a macro-perspective, the diffusion of non-Euro-American

ethnomedical and religious traditions is another ‘patch-up’ to manage the

current crisis that the Euro-American worldview faces (Holbrook 1981). In

micro-context, this involves the integration of medicine and psychiatry with

various ethnomedical and religious traditions (including Buddhist-Mindfulness)

in clinical and theoretical contexts. CAM’s are determined to share “common

threads” with Euro-American medicine, a view that supports their merger

(Arond 2006, p1450). While branches of scientific medicine and psychiatry in

the United States have been diffusing CAM into existing psychiatric and medical

programs for decades, the current diffusion is taking place at an increasing rate

(Baer 2005).

Buddhist-Mindfulness is the most popular of the CAM repertoire. Empirical

clinical scientific studies identify Buddhist-Mindfulness as a ‘breakthrough’ in

theoretical and clinical studies. Psychiatric application of Buddhist-Mindfulness

still utilises traditional aetiology (as Figure 6 reveals), but has merged and/or

annexed Buddhist theory with existing cognitive (Varrela, Thompson & Rosch

1993), consciousness (Burton 2005), and neuropsychologically based (Newberg

& Iversen 2003) research. Clinical application has provided therapeutic relief

Psychiatric Aetiology of Mental Illness

Learning Behavioural

Biological Genetics; Neurology

Thought Processing; Cognitive

Unconscious Affects Context Social Affects

Figure 6. for psychological and physiological conditions and a host of other ailments of

modernity such as anxiety (Miller, Fletcher & Kabat-Zinn 1995), chronic

pain (Kabat-Zinn, Lipworth, Burney & Sellers 1986), depression (Segal, Williams

& Teasdale 2002), eating disorders (Kristeller & Hallett 1999), and stress

(Shapiro, Schwartz & Bonner 1998). In current application, Buddhist-

Mindfulness is interpreted and employed as a form of “medicine, therapy and

social work” (Fronsdal 1999, p494). This illustrates how Buddhist-Mindfulness is

interpreted and employed in the United States today.

Buddhist-Mindfulness is being interpreted and translated in the United States

from a therapeutic viewpoint, rather than a medico-religious one. Young-

Eisendrath & Muramoto (2002, p4) declare that in the United States, the

modern dialogue with Buddhism has been driven by a “therapeutic endeavor”

where Buddhism is viewed “from a therapeutic stance”. In psychiatry,

therapeutic efficacy of clinical trials has propelled the use of Buddhist-

Mindfulness into mainstream therapy in the United States to prolific levels.

However, Buddhist-Mindfulness is indubitably a context-specific practice that

originally emanates from Buddhist culture (Tambiah 1970). Buddhist-

Mindfulness is a textual, culturally, and context specific practice found as part

of a larger system of philosophy, myth, ritual, and religious Buddhist practice

throughout Asia (Harvey 1990). However, in recent decades, both Buddhists

and psychiatrists express that Buddhist-Mindfulness can be used therapeutically

in a non-religious way (Kabat-Zinn 2003; Rinpoche 1992; Rinpoche 1994). This is

because Buddhist-Mindfulness emanates from a textual tradition in Buddhism

where it has a “non religious, non philosophical” context (Titmuss 1998, p8).

From this rationale, a purely textual interpretation of Buddhist-Mindfulness has

become acceptable. This therapeutic application overtly reflects a non-cultural

context specific interpretation of Buddhist-Mindfulness by Euro-American

practitioners, Buddhists, and the lay population.

From analysis of a variety of medical research using Buddhist-Mindfulness, a

contextualisation of Buddhist-Mindfulness as therapy is taking place in the

United States. In science, as in psychiatry, the crisis of an outdated paradigm is

driving this. Subsequently, there is enormous pressure on Buddhist-Mindfulness

to conform to strict clinical scientific standards. The process of

‘operationalisation’ is reducing Buddhist-Mindfulness to a purely pragmatic

form to conform to the definitions and standards of scientific empiricism

(Kabat-Zinn 2003). This process could be described as supercilious. One

psychiatrist claims, “if religious and spiritual traditions are to enter empirical

clinical psychology, they must be ours” (Hayes, 2002, p105). Mindfulness-based

(and other CAM) intervention in psychiatry must “be free of the cultural,

religious, and ideological factors associated with Buddhist origins of

mindfulness” (Kabat-Zinn 2003, p149) before it can be accepted into clinical

practice. This is the process of converting Buddhist-Mindfulness to its

‘operational’ form. Kabat-Zinn (2000; 2003) and other Buddhist-Mindfulness

practitioners have begun to distance Buddhist-Mindfulness from their original

Buddhist context. Interestingly however, they still associate Buddhist

philosophy, concepts, and semantics with the methods they use and the results

one should expect in therapy, something they claim not to be doing.

The current “working [operational] definition of mindfulness” (Kabat-Zinn

2003, p145), while applying the central principles and practice of Theravada

Buddhist-Mindfulness, is isolated from the philosophical, cultural, and

cosmological framework in clinical application. Not only is Buddhist-Mindfulness

being converted to an ‘operational’ form, psychotherapists are instructing

Buddhists on what is missing in their understanding of subjectivity and mental

health (Rubin 1999). Titmuss (1998, p5) is critical of this kind of arrogance on

the behalf of psychiatry, declaring, “a tradition that is barely a century old

cannot expect to have the same depth of experience and realisation as a

tradition 2,500 years old”. Many centuries of clinical distance have been placed

between religious and scientific determinants of health in the United States,

disassociation through “ideological and institutional barriers” (Levin 1994,

1475) to socio-cultural and psychosocial determinants of mental health.

Interestingly, Newberg & Lee (2005) illustrate that Buddhist-Mindfulness,

among other ‘subjective’ based consciousness, religious, and ethnomedical

practices are not entirely reducible or ‘operational’ due to problems with

definition and objectivity in scientific standards. The problem of adequately

defining and measuring Buddhist-Mindfulness still plague its ‘operational’ status

(Brown & Ryan 2004; Hayes & Shenk 2004; Roemer 2003). The clinical

application of Buddhist-Mindfulness is in its genesis, and it can be expected

that more modification to this practice will occur in the attempt to

‘operationalise’ it and apply it within clinical standards.

Medicalisation & Capitalism in the United States

The ‘subjective’ problem encountered in ‘operationalising’ CAM and other

religious practices in scientific disciplines in the United States is a problem at

the core of science and medicine as disciplines. Subjective reality, as argued

by science, is not definable. The inability to define subjectivity has led to a

modern subjectivity in the United States based on scientific materialism and

medical rationalism (Good 1994; Wallace 2007). Anthropologists recognise a

macro-societal discourse in all societies. A ‘top-down’ effect impacts on local

socio-institutional and individual interpretation and experience of illness (Baer

2005). Foucault (1975) most prominently posited a social hierarchical

relationship between people and power in Euro-American societies. He

proposed that a culturally constructed and constituted ‘medicalisation’ has

resulted from Euro-American medical, particularly clinical, history. The process

of secularisation in society initiated “a transfer of moral regulation” (Turner,

1992, p22) to science and medicine from religion. Foucault (1972: 49) argued

that a medico-scientific ‘gaze’ has resulted, where “practices…systematically

form the objects of which they speak”. Foucault insinuated this

‘medicalisation’ of human society, particularly between the populace and the

state, as a result of the ‘gaze’. Human bodies and behaviour have become

classified and controlled through a medical ethos.

Porter (2006, p7) argues with Foucault, alleging that modern scientific

medicine has “driven itself to medicating normal life events”. This results from

a need by modern medicine to redefine itself and an overabundant social

acceptance of medicine, science, and technology. Furedi (2004, p12) claims

that modern medical institutions and science are cultivating vulnerability,

declaring, “people’s experience is interpreted through the medium of the

therapeutic ethos”. Subjectivity in the United States, they iterate, is being

managed and/or controlled by organisations and governments who are reliant

on and promote science and technology. Modern subjectivity is being

channelled in a medical direction, largely focused on the body. The processes

used to manoeuvre subjectivity are scientific and technological. Socially

subjective manipulation of bodies and minds also intertwines with capitalistic,

media, and market oriented process. Harvey (2000, 294) argues that the

current identity crisis afflicting many people in the United States propels

people to consume and remodify their bodies in a response to the “time-space

compression” that capitalism has created. This crisis of identity is of the self,

particularly as self-concepts relate to body image and social expectations. The

current crisis also affects science, medicine, and psychiatry, creating a vacuum

that is being filled by non-Euro-American ethnomedicines, religions, and

philosophies (Rindfleish 2007). A ‘spiritual revolution’ is argued to be beginning

in the wider society within the United States, highlighted by various forms of

religious movements and CAM utilised by the lay population (Tacey 2003).

A new form of medical plurality is occurring in the United States. This involves

the utilisation of multiple health aetiologies to cure and provide meaning to

illness. Plurality in health seeking behaviour is not new to the United States.

However, the social conditions that engender and motivate plurality in medical

care are. Attention is predominantly focusing away from Euro-American

medicines towards other cultural ethnomedinces (Rindflesh (2007). The ‘new’

link between religion and health, and the accepted inadequacy of Euro-

American medicines to provide meaning to illness experience perpetuates many

medical fields and social institutions in the United States, including psychiatry

(Galanter 2005; Johanson 2006). The term ‘spirituality’ has taken over from

‘religion’ because spirituality allows “the freedom to create one’s own notion

of the sacred or ultimate reality” (Hartz 2005, p4), that is meaningful,

transcendental, and loving. However, the paradigmatic shift in the United

States regarding the role of religion and spirituality in medicine and illness

experience is largely ideological and is still governed by a prevailing habitus,

motivated by a worldview that clearly aims to dominate and regulate new

enterprises. Consequently, materiality retains a stronghold over the

transcendental (Hartz 2005). Even though newly diffused ethnomedical or

religious traditions accommodate a meaningful and transcendental philosophy,

this is ‘watered down’ through its ideological interpretation and incorporation

with a pre-existing social discourse on ‘what is religion/spirituality?’ and ‘what

is health in relation to religion?’.

Ethnomedical and religious/spiritual traditions can only be described as being

modified by pre-existing paradigms on religion and health, and for general

consumption for people of the United States. Faldon (2004) argues that the

‘domestication’ of ethnomedicines and religious traditions enables a working-

with scenario for existing medical, scientific, and lay practice in the United

States. Domestication involves “a process by which the foreign is rendered

familiar and palatable to local tastes” (Faldon 2004, p72), and where “Eastern

themes are adapted for Western consumption (Dawson 2006, p8). Brazier

(2001, p80) insists, “Buddhism is being retailed to the Western world as a quest

for enlightenment”. This quest for enlightenment in the United States is not of

the transcendental ‘self’, but of an immortal ‘body’. The ideation of

immortality (not a new belief) contemporarily embraces a scientific and

technological thesis of the body as manipulable and transformable through

medical intervention. Genetic and neurobiological bases for disease and

consumer capitalism, when set against the historical backdrop of a lineal,

individual, and progressive worldview, fuels the acceptance of a society

comfortable with body manipulation. A spiritual-medical view of reality,

focused on the ‘body’ and the ‘image’ of the body constrain how contemporary

health seeking behaviour in the United States functions, influenced by a variety

of forces like science and consumer capitalism. Modern body image and ideals

are motivated by classical art, scientific and medical discourses and

commercial interests like fashion, fitness, and celebrity media (Urla &

Swedlund 2007). Gendered norms and influences of popular culture are

motivating people to act out phantasmagoric bodily and social roles like that of

‘Barbie’. These social discourses iterate an ideology of perfection and

chameleon-like possibilities of the body, driven by a consumer culture that has

come to be imbued with a medical ethos.

Health Seeking in Macro-Cosmic Context

Modern discourses of the body, medicine, and the cultural-other are

legitimated and transmitted through the accepted wisdom of science and

technology, an uncontrollable consumer society, and the power of modern

forms of media (Williams 2003). Set against the context of the body in history,

this is another process whereby human bodies are rendered meaningful by the

societal powers that govern them (Turner 1995). This concept is understood

more clearly when situated within the worldview of the United States. Dawson

(2006) argues that the overarching worldview in the United States and Europe

is encapsulated in the ‘Western habitus’. This habitus incorporates Christian,

scientific, technological, and capitalist influences. Dawson (2006, p2, 3) argues

that the ‘Western Habitus’ has developed through the combination of “multiple

fields of force (in space and time)…to constitute the modern Western

worldview”. He explains that this habitus comprises a “technologized

conceptualization of the self, a depersonalized view of the cosmos, and a

metaphorization of the modern cultural field” (Dawson 2006, p1). This habitus

has naturalised the tendency to diffuse or selectively adopt and modify

‘Eastern’ traditions. Diffusion of ‘Eastern’ practices by the United States is

constituted in the ‘Western Habitus’. Rather than accepting practices as they

are, a “Westernization of Eastern themes [rather] than an Easternisation of the

Western paradigm” occurs (Dawson 2006, p3). “Eastern themes” are “adapted

for Western consumption” explains Dawson (2006, p8), through “selective

appropriation and subsequent tailoring” that identifies with, correspond to,

and affirm “established predilections of the Western aesthetic”.

The Euro-American worldview is conditioned by an ontological and cosmological

logic. By cosmology I refer to be a culturally conditioned account of the

universe and Man’s place in it, not the cosmology of physics (however the role

of scientific practices like physics is imperative to this determination). Euro-

American cosmology is described as “mechanical” (King 1983, px). The

‘mechanical’ universe is understood as a process, lineal and limited, and the

laws that govern the universe are determined to be discoverable and

harnessed. King (1983, pxvi) notes that this cosmic view structures and

motivates Euro-American thought and action. It has generated a modern

society that has become “scientifically-technologically orientated”. Science-

based technology has been argued to be a religion in the United States, with

science as the religious form, and technology as its discourse (Roy 2005).

However, the application of a ‘total scientific cosmology’ has been criticised as

inadequate as a total representation of culture in the United States. This is

“through the inadequacy of modern science to provide meaning” (Laughlin,

McManus & d’Aquili 1990, p233). “Science provides a view of the world…that is

intentionally disconnected from the direct, everyday experience of people”

(Laughlin, McManus & d’Aquili 1990, p234), a worldview that has undoubtedly

abstracted human knowledge from experience. Many science-based disciplines

accept this, and it has been highlighted as a prominent reason for the present

paradigm shift in Euro-American science and medicine towards ‘Eastern’

concepts of reality (Ratanakul 2002; Varrela, Thompson & Rosch 1993).

A variety of beliefs and practices inform the United States worldview. The

insufficiency of science (and technology) to generate a total worldview has

been filled by the diffusion cosmologies and worldviews of non-United States

cultures and Indigenous Indian nations for centuries. Christianity (in its variety

of forms), science, technology, and capitalism are the most significant. Modern

science and medicine dominate the modern worldview of the United States.

Science and medicine are an extension of Ancient Greek, Renaissance,

Enlightenment, and modern physics rationale. Logic and reasoning of Ancient

Greece (Roninson & Groves 1999; Kenny 1993), Descartes Cartesian dualism

(Strathern 1996), Newtonian mechanics, Galileo’s physics (Coles 2000), the rise

of clinical medicine (Foucault 1975), and Einstein’s theory of general relativity

(Coles 2000) are major rationales that have been the influenced major

paradigmatic shifts in Euro-American scientific/medical theory and practice.

Tambiah (1991) explains that since the Enlightenment, European thought

pursued speculative and intellectual commentary on religion (including

Buddhism and Christianity). Enlightenment rationale is manifested in

contemporary scientific/medical rationalism in the United States, and has

come to dictate the way people experience illness (Tambiah 1991).

Contemplation created a gulf between religion and science, one that had by all

rights begun with the partitioning of physis and logos in Ancient Greece (aided

by the Renaissance re-discovery of Greek knowledge).

The modern worldview in the United States is still heavily symbolised by a

Christian theistic and scientific subject/object dualistic interpretation of

reality (e.g., good verse evil) (King 1983). However, centuries of dualistic

thinking and a rationalistic attitude based on empiricism of scientific method

influences modern ideology in the United States (Foucault 1975; Nuland 2000;

Scheper-Hughes & Lock 1987). This reveals how disease/illness reality is

constructed, enacted, and experienced in modern United States society.

Christianity and science have shared a history of united ideas and practice

together (Imperato 2002; McGrath 1999), however science and religion divided

during the Enlightenment in Europe due to the scientific focus on naturalism

(and refusal of supernaturalism). European and United States society became

secularised, a revolution apparent in the education system where science and

religion have become separate domains and are often at odds with each other

(Butts 1950; Wallace 2007). Contemporary public education in the United

States confirms this reality through science and religion, where science is

edified as ‘fact’, and religion as ‘belief’ (Wallace 2007).

Capitalism can be described as an essential component of the ‘Western

habitus’, refining what science had begun before its entrance on the social

platform and total-global dictator for life as a mode-of-production. The rise of

capitalism 300 years ago in industrial Europe, and its more recent post WWII

expansion, has had a substantial impact on the United States (Ganbmann 2006).

Preston (1979) highlights how capitalism has generated a “stress on personal

freedom, often expressed in the term individualism has been such a potent

force in our culture in the last three centuries” in the United States. More

recently, Harvey (2000) discerns that capitalism has become a metaphor for

modernity, defining sociality and selves in individual, lineal, progressive, and

modifiable terms. Marx initially highlighted the role capitalism played in

“continual revolutionizing of the methods of production” through its “intimate

connection with science and technology as a major productive force”

(Bottomore 2006, p61). Science and technology supported the capitalist

revolution in Europe and the United States from the 18th century, continuing to

support each other producing a capitalist ethos to modern society. Capitalism

has influenced the secularisation of science and raised it above status of

Christianity and other religious or cultural knowledge globally. It was an

influential factor in the colonial period and has continued into modern age,

motivating the desire to produce and attain wealth, particularly at the expense

of others.

Medical Pluralism in the United States: Form & Function

This chapter has revealed that scientific and medical institutions in the United

States are appropriating other cultural determinants and beliefs about the

universe. This process involves the ideological incorporation of a variety of

ontological and cosmological logics. This is driving how Buddhist-Mindfulness is

diffused into psychiatry in the United States. Psychiatry, as a branch of medical

science, applies an ‘operational’ logic to develop practices. Psychiatry employs

this mechanistic, biologically focused, and socially void interpretation of

reality, as does general science. As a result, Buddhist-Mindfulness is being

diffused through the practice of psychiatry (and medicine) without any

Buddhist connection. The diffusion of this and other CAM and religious

traditions into scientific medicine and psychiatry imply a paradigm shift in

modern scientific medicine and psychiatry, one that is experimenting with

‘Eastern’ interpretations of the universe. The United States exhibits historical

process by science and medicine to amend failing paradigms by diffusing other

cultural beliefs and practices. This highlights the ontological and cosmological

factors that are employed through ideological reasoning by science and

medicine in the diffusion of other cultural practices.

Diffusion of Buddhist-Mindfulness in psychiatry, along with the ‘domestication’

of CAM and religious traditions involves a scientific, medical, and capitalistic

drive that intentionally transforms these practices. There is a specific forces on

the body and its plasticity, one that correlates to the manipulation of CAM by

science and medicine. The matrix of medical practices and modern health-

seeking behaviour in the United States is a direct representation in micro-

context of a bricolage United States worldview. Consumer capitalism,

marketing of CAM, and their bodily consumption by people of the United States

is a major feature that contributes to the separation of health and religion, and

the confusion over determinants of illness between health and religion. The

present diffusion of Buddhist-Mindfulness and other CAM is not a new practice

in the United States. CAM and other religious traditions are interpreted as

medical/scientific practices, and are deprived of their original cultural milieu.

CAM and religious traditions are determined and applied as observable material

reality only. Through the process of ‘operationalism’ by scientific institutions in

the United States, the cultural and historical content is lost and their original

meaning is subverted.

Chapter 5

Cultural Change, Psychiatry & Diffusion

This chapter compares and contrasts the diffusion of Buddhist-Mindfulness in

Thailand and the United States. Examination of the diffusion of Buddhist-

Mindfulness in the psychiatric process in Thailand and the United States reveals

how cultural factors influence the process of diffusion, particularly the

consequences to Buddhist-Mindfulness. Each context has seen the diffusion of

Buddhist-Mindfulness in psychiatry to improve the efficacy of mental health

treatment. Each context has utilised Buddhist concepts of mental health,

causes of mental illness and the remedy of mental illness. Through comparison

it emerges that while each application of Buddhist-Mindfulness share the same

aim, the form, function, and meaning is distinct in each context. Each context

utilises the same practise (Buddhism/Psychiatry) for the same purpose

(reduce/cure mental illness), just in different ways. This is precisely due to the

influence of the prevailing worldview that informs culture-specific response

and action in each context. This reveals that it is necessary for each context to

maintain its original discourse on, and practice of medicine, and sees the

diffusion of the new medical system into an existing medical paradigm. I argue

that this process is adaptive and is essential to the maintenance of traditional

social order in times of change.

On the Diffusion of Buddhist-Mindfulness in Psychiatry

“Modernity”, as explained by Tanabe & Keyes (2002, p7), “entails an

irrevocable rupture with a habitus rooted in an unquestioned cosmology”. This

fissure of the taken-for-granted in Thailand and the United States has

prompted the diffusion of Buddhist-Mindfulness in psychiatry in each context.

The consequences to Buddhist-Mindfulness through the process of diffusion are

the result of a retreat into historical dimensions of culture. I argue that

cultural histories are employed ideologically in the process of modern identity

construction and negotiation. Through ethnographic analysis of Thailand and

the United States, this thesis has revealed the increasing importance placed on

social re-construction because of the constant need to renegotiate identity in a

modern and rapidly changing society. As Kapferer (1988, p85) articulates, “the

ideology of ontology is most evident in times of crisis”. Each context, Thailand

and the United States, produces and displays culturally and context-specific

historical dimensions of sociality regarding health. These elements configure

the different cultural praxis and consequences that Buddhist-Mindfulness

enjoys through its diffusion in psychiatry.

I argue that the macro-level motivation for the diffusion of Buddhist-

Mindfulness into psychiatry in Thailand and the United States is motivated by

global social change that is the effect of local social changes. Moreover, there

is a strong need for the illness experience to have meaning, which is not

provided for by psychiatry in either context. Modern social change and the

need for meaning in illness experience have been central themes running

through this thesis. These themes have been illustrated in the case studies and

were subsequently revealed through ethnographic analysis of health-seeking

behaviour and the social regulation of illness experience in Thailand and the

United States. Analysis of ethnographic data in Thailand has revealed that

modern globalised social change affects mental illness. Psychiatry (and

biomedicine), as agents to the globalising process (Kirmayer 2006), have

dislocated local understanding of health and illness, and also failed to provide

adequate meaning to the illness experience in each context. In Thailand, this

has enabled the practise of medical pluralism to proliferate. As a result,

health-seeking behaviour has continued along traditional channels, utilising

Euro-American medicine as part of the medical matrix there. In the United

States, the redevelopment of existing scientific and medical paradigms, and

the inclusion of CAM into the medical market, is generated by the failure of

current medical paradigms to supply adequate meaning in illness experience

and the existential crisis this has created. The social-wide desire for meaning,

driven distinctly by the lack of meaning in people’s lives, is directed towards

scientific and medical institutions. Accordingly, the ‘medicalisation’ of United

States society is prompting people to find meaning in medical and scientific

institutions and values.

The consequences of the diffusion of Buddhist-Mindfulness are remarkably

different in form, function, and meaning. This is explained in Figure 7. The aim

of diffusing Buddhist-Mindfulness in psychiatry in Thailand and the United

States was to develop a mental health practice and process that will improve

existing methods and treatment of mental illness. It has been discovered

through this thesis through careful examination that the diffusion of Buddhist-

Mindfulness in Thailand and the United States are distinctly different.

Remarkably, each context finds the utilisation of Buddhist-Mindfulness Based

Psychiatry for exactly the same purpose but with different therapeutic

methods, practises, and meaning. This has generated unique consequence to

Buddhist-Mindfulness. In the United States the practice of Buddhist-Mindfulness

has been manipulated by being ‘operationalised’ to suit Empirical Clinical

Psychiatric Standards (ECPS). The result is a form of ‘Mindfulness’ that is void

of any cultural/religious cosmological or existential significance, conforming to

psychiatric aetiology and nosology of mental illness. In Thailand, the

application of Buddhist philosophy and practice has superseded the

conventional (ECPS) psychiatric process. Buddhist aetiology and nosology of

suffering (dukkha) has replaced the psychiatric specifications of mental illness

aetiology and nosology.

Consequence, or Differences in Form, Function & Meaning

to Buddhist-Mindfulness through Diffusion

Thailand United States

Form - Buddhist-Mindfulness & Meditation used - Buddhist-Mindfulness & Meditation used in

in accordance with Theravada Buddhist ‘Operational’ status in accordance with

Tradition in Thailand was applied to the Empirical Clinical Psychiatric Standards

Standard Clinical Psychiatric Process was applied to the Standard Clinical

Psychiatric Process

Function - Treatment of anxiety - Treatment of anxiety (GAD)

Meaning - Removal of Suffering (dukkha) - Treatment of anxiety (GAD)

Figure 7.

Comparison of the diffusion of Buddhist-Mindfulness in Thailand and the United

States, with the ethnographic data, reveals that the diffusion of Buddhist-

Mindfulness in psychiatry in Thailand and the United States are influenced by

the habitus and its prevailing worldview in each context. The process of

diffusion has produced the culture-specific consequence to Buddhist-

Mindfulness revealed in this thesis. This is illustrated in Figure 8. Buddhist-

Mindfulness, and the cosmological and experiential notions of suffering

(dukkha) cannot be diffused in psychiatric practice in the United States without

a significant loss or alteration to them. Conversely, Euro-American psychiatric

practice and mental illness aetiology and nosology cannot be diffused without

difficulty in Northeast Thailand. Thus, the diffusion of Buddhist-Mindfulness in

psychiatry in Thailand in Buddhist form, and in the United States in scientific

form, disclose the foundational ontological and cosmological logic that informs

the habitus of each culture. I argue this is because each culture ideologically

employs unique aspects of ontology and/or cosmology to maintain cultural

identity during the changes that are affecting each context. Critically, I argue

that this process illustrates that it is necessary for Thailand and the United

States respectively to maintain their original and dominant paradigms on

mental illness and suffering during times of crisis. Buddhist-Mindfulness must

be diffused into the already existing and functional medical paradigm. This is

an adaptive process that I argue is essential to reinstating and maintaining the

social order and prevailing worldview.

Worldviews Influencing the Consequences to

Buddhist-Mindfulness

Thailand United States

- Polyphasic Consciousness - Monophasic Consciousness

- Biological/Organic Universe - Mechanistic Universe

- Interconnected - Individual

- Circular Time - Linear Time

- Spatially Infinite Universe - Spatially Finite Universe

- Reciprocal Role With the - Aim to Control the Forces Universe of the Universe

Figure 8.

Thailand and the United States each exhibit a distinct mental illness aetiology

and nosology. This is illustrated by the context-specific application of historical

aspects of culture to cope with or transcend illness experiences. Tyson &

Pongruengphant (2007, p1) explain that Buddhist “cosmology yields a

fundamental disagreement between Western psychological theory and

Buddhist’s conception of suffering”. The process of diffusing Buddhist-

Mindfulness in psychiatry in each context reveals that the United States

situates health on the level of the body and ego, and Thailand situates health

on a transcendent level of self and mind which can be eternally liberated.

These distinct processes of diffusion highlight that Thailand and the United

States utilise unique and pre-existing socio-cultural structures to explicate

health aetiology and treatment. In the United State, the refusal to apply

cultural significance to Buddhist-Mindfulness by psychiatry highlights the

dominance of the scientific paradigm in medicine. The ‘operationalising’ of

Buddhist-Mindfulness runs counter to current psychiatry and cognitive scientific

claims that these institutions are accepting a link between religion and health.

Buddhist–Mindfulness has consequently become a ‘medical’ practice, a cultural

terra nullius, tailored to the consumptive needs of a culture that seeks the

restoration of health/order in constant improvement of the body. Conversely,

in Thailand the total diffusion of Buddhist-Mindfulness in the Theravada

Buddhist format illustrates the cultural significance ‘Mindfulness’ and Buddhism

has in Thailand. Buddhist-Mindfulness retains its religious and cosmological

substance and is utilised as both a form of health care and as a guide and

process to eternal liberation from suffering (nibbána) in its psychiatric

application. This is a renegotiation of Euro-American values with Buddhist

values to deal with illness and misfortune as they iterate Buddhist concepts of

self, society, and cosmos in Thailand.

Cultural Crisis & the Collective Past

Through examination of the diffusion of Buddhist-Mindfulness in psychiatry, this

thesis has revealed that Buddhist-Mindfulness is manipulated in each context to

fit with the prevailing worldview. Health-seeking behaviour and discourse

about health is strongly conditioned by modern social and cultural-historical

forces. How people experience illness and the action selected to remedy illness

in Thailand and the United States are socially and historically regulated. As

Turner (1996, p214) declares, medical knowledge and practise “reflects the

overall patterns of values and institutions within a given society”. It has been

demonstrated in this thesis that the motivation to diffuse Buddhist-Mindfulness

in psychiatry in Thailand and the United States is an adaptive function to

restore order and balance to self and society in a modern and rapidly changing

global and local-social landscape. Additionally, the need for the illness

experience to be imbued with greater meaning, also prompted by social change

and the failure of psychiatric treatment has been shown to stimulate this

diffusion.

Contextual social and historical factors produce the consequences to Buddhist-

Mindfulness in each psychiatric application. This thesis has defined

consequences as any modifications to Buddhist-Mindfulness through the process

of diffusion. By analysing the contextual variations in the socio-cultural systems

and cultural histories of Thailand and the United States, the unique

transformations of Buddhist-Mindfulness in each context are established. The

theoretical and conceptual foundation utilised the concept of habitus and the

incorporation of ontology and cosmology to explain how and why meaning is

generated and legitimated. Social identity and solidarity has been revealed as a

critical aspect in culture during times of modern social change and crisis.

Conclusion

The diffusion of Buddhist-Mindfulness in psychiatry in Thailand and the United

States has been examined in this thesis to highlight how the process of

diffusion occurs and why innovations receive different consequences in

different cultural contexts. In this thesis I have determined why Buddhist-

Mindfulness has been diffused in each psychiatric context by examining the

macro-global and local-social forces that motivate this process. This thesis is

based on a critical literature review utilising quality ethnographic data that

permitted an excellent ability to produce sound conclusions on this topic.

In Chapter I it was established how Buddhist-Mindfulness was applied

differently in psychiatry in the United States and Thailand as a therapeutic

intervention. This was demonstrated through two case studies [Rungreangkulkij

& Wongtakee (2006) and Roemer & Orsillo (2007)] that applied Buddhist-

Mindfulness in clinical psychiatry for the treatment of anxiety disorders.

Chapter 2 provided the theoretical basis for this analysis. I argued that the

difference of each application of Buddhist-Mindfulness in psychiatry is affected

by culturally-contextualised socio-historical ontological and cosmological

factors. Consequences to Buddhist-Mindfulness are the result of the contextual

worldviews, and the need to maintain order and meaning in society. Chapter 3

revealed the dominance and persistence of Buddhism in historical and modern

Thai society, examining the Buddhist exegesis on suffering (dukkha) and the

role Buddhism plays in the construction of self and society in Thailand. Chapter

4 exposed the dominance of scientific and capitalistic discourse in the United

States. The ‘operationalising’ of Buddhist-Mindfulness revealed a history of

selective borrowing and modification by scientific and medical institutions.

Chapter 5 provided the final analysis of this thesis. Though examination of the

diffusion of Buddhist-Mindfulness in psychiatry in Thailand and the United

States, this thesis has revealed how ontology and cosmologies are used to

generate and legitimate meaning and certainty in times of social change and

crisis. The consequences to Buddhist-Mindfulness reflect these unique

worldviews. The institution of psychiatry, the psychiatric process, and the aims

of psychiatry are pliable when they are situated in different cultural contexts.

Analogously, the pliability of Buddhist-Mindfulness has also been revealed when

it is situated in psychiatry in another cultural context like the United States.

Long-term consequences to Buddhist-Mindfulness cannot be assessed in this

thesis. It is clear that the drive towards a global homogeneity of scientific,

technological, and consumptive cultural practice has the power to significantly

alter local medical and religious praxis. Further research into the processes of

diffusion is welcomed. In particular, why diffusion occurs and what

consequence innovations receive. Additional investigation into the diffusion of

Buddhist-Mindfulness and the modification of other ethnomedical and religious

practices will improve our understanding of the process of diffusion and the

consequential factors that diffusion to cultures and innovations.

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