Recovery from depression through Buddhist wisdom: An idiographic case study

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Recovery from Depression ThroughBuddhist Wisdom: An Idiographic CaseStudyFung Kei Cheng PhDa

a Department of Social Work and Social Administration, TheUniversity of Hong Kong, Hong Kong, ChinaAccepted author version posted online: 22 Jul 2014.Publishedonline: 22 Jul 2015.

To cite this article: Fung Kei Cheng PhD (2015) Recovery from Depression Through BuddhistWisdom: An Idiographic Case Study, Social Work in Mental Health, 13:3, 272-297, DOI:10.1080/15332985.2014.891554

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Social Work in Mental Health, 13:272–297, 2015Copyright © Taylor & Francis Group, LLCISSN: 1533-2985 print/1533-2993 onlineDOI: 10.1080/15332985.2014.891554

Recovery from Depression Through BuddhistWisdom: An Idiographic Case Study

FUNG KEI CHENG, PhDDepartment of Social Work and Social Administration, The University of Hong Kong,

Hong Kong, China

Results from the recent growing trend in using mindfulnesstraining to deal with depression report an evident decrease indepressive symptoms. The present idiographic case study exploresthe lived experience of how a woman with depression recoveredthrough Buddhist teachings and practices. This single case adoptedmultiple data sources, including interviews, autobiographies, agenogram, and an autobiographical timeline. Member-checkingand peer analysis are employed to enhance the trustworthiness.The first-hand data, analyzed through interpretative phenomeno-logical analysis, reveal the perceived factors causing the infor-mant’s depression, as well as benefits gained from Buddhist prac-tices, and the insight learned from experiencing depression; bywhich insight self-benefiting altruism can accomplish personalgrowth by converting suffering into assets that help others. Thisexploratory research offers an alternative view through which tounderstand depression and non-medication treatments throughBuddhist ideas, and also proposes future research directions.

KEYWORDS bodhisattva, gratitude, karma, meditation, person-centered therapy

INTRODUCTION

Depression has become a “leading cause of disability worldwide” (Marcus,Yasamy, van Ommeren, Chisholm, & Saxena, 2012, p. 6), which urges

Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wsmh.

Address correspondence to Fung Kei Cheng, Department of Social Work and SocialAdministration, The University of Hong Kong, Room 534, 5/F, The Jockey Club Tower,Centennial Campus, Pokfulam Road, Hong Kong, China. E-mail: [email protected]

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Recovery From Depression Through Buddhist Wisdom 273

professional practitioners to hunt for resolutions. Rooted in Buddhismand secularized by Western psychotherapists (Kumar, Feldman, & Hayes,2008; Marchand, 2012; Piet, Wurtzen, & Zachariae, 2012; Teasdale, Segal, &Williams, 1995), mindfulness-based programs have been developed for treat-ing depression (Crane & Williams, 2010; Kabat-Zinn, 2003, 2011; Piet et al.,2012), and focus on the core concept of self-awareness of bodily sensoryinputs, feelings, emotions, thoughts, mind in-flow and out-flow (Aho, 2008;Marchand, 2012; Piet et al., 2012), and without passing any judgment onthe present moment (Aho, 2008; Bingaman, 2010). Stimulated by positiveresearch outcomes, the researcher has been able to gain a deeper under-standing of such frugal and non-medical methods, which can lower publichealth expenses.

In spite of these studies vindicating the significance of Buddhist practicesin depression treatment, personal patient recovery experiences have rarelybeen examined. This research explores the first-person recovery experienceof a patient who recovered from severe depression by means of Buddhism,and the Buddhist elements that influenced her recovery. This exploratoryinquiry may hint at a better practical utilization of Buddhist wisdom, whichpotentially extends the horizons of Buddhism increasingly used in mentalhealth interventions by care practitioners, such as in social work (Brenner &Homonoff, 2004; Canda & Phaotong, 1992; Leung, Chan, Ng, & Lee, 2009;Yick & Gupta, 2002).

DEPRESSION TREATMENT BY BUDDHIST PRACTICES

Buddhism originated in India 2,500 years ago by the Buddha, a term meaning“Enlightened One” (Harvey, 1990, p. 1). His 49 years of preaching focusedon explaining the formation of the delusive and insubstantial phenomenalworld, reflecting on the impermanence and transience of life, and aimed torelieve sentient beings from suffering. The Buddha repeatedly expoundedon the four noble truths (Gethin, 1998): the nature of suffering, the causes ofsuffering, the means of eradicating suffering, and the cessation of suffering.Suffering is incurred through ignorance of the temporal nature of all beings,and through desire, and egotism. Buddhism then offers a set of practices bywhich to let go of desire, minimize self-centeredness, and accept life’s diffi-culties. These pragmatic elements have been adopted for healing purposes(Conze, 1953).

Buddhist ideas are being incorporated into body–mind approachesfor depression treatment, and there are reports of significant reductionsin depressive symptoms, such as Dejian mind–body intervention (Chan,Cheung, Tsui, Sze, & Shi, 2011; Chan et al., 2012), and integrative body–mind–spirit intervention for Indian patients (Sreevant et al., 2013) as well asfor Taiwanese clients (Hsiao, Lai, & Chen, 2009). Also, research has exam-ined the effectiveness of mindfulness-based interventions in various aspects,

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such as the effectiveness of meditation on loving-kindness (Fredrickson,Cohn, Coffey, Pek, & Finkel, 2008), compassion (Allen & Knight, 2005),equanimity (Bitner, Hillman, Victor, & Walsh, 2003), for treating patientswith non-melancholic depression (Manicavasgar, Parker, & Perich, 2011),and for preventing a relapse of distress symptoms among cancer patientswith anxiety and depression (Piet et al., 2012), when enhancing awarenessand concentration (Deng, Li, & Tang, 2012), and decreasing their propensitytoward rumination, which worsens negative emotions (Kumar et al., 2008).Group-based meditation is also an obvious tactic for tackling depression(Harnett et al., 2010; Munshi, Eisendrath, & Delucchi, 2012) because peersupport plays an important role (Hopkins & Kuyken, 2012). Furthermore,within organizationally offered meditation programs, employees who haveexperienced prior episodes of depression tend to lessen their risk of relapse.As a result, they are able to improve their working relationships, minimizeabsenteeism, and increase productivity (Fredrickson et al., 2008; Lau, Colley,Willett, & Lynd, 2012). This indicates the positive impacts of dealing withdepression on both the individual and organizational levels.

Despite suggestions that have been made regarding integrating theselow-cost treatments into traditional therapies (Marchand, 2012) due to suchdecrease in depressive symptoms (Crane & Williams, 2010; Michalak, Burg,& Heidenreich, 2012) and improvement in overall health conditions (Wiist,Sullivan, St. George, & Wayment, 2012; Wiist, Sullivan, Wayment, & Warren,2010), these studies have focused on using meditation skills (Salzberg,2009) that may not necessarily be effective for every client (Kaori & Park,2009). Furthermore, they tend to disregard other direct Buddhist factors thatinfluence therapeutic effectiveness, such as thought transformation throughchange of worldviews, lifeviews, and perception of self, which are related todeeper insight into long-term effectiveness gained from Buddhist wisdom.

Apart from mindfulness, other Buddhist components and practices havebeen borrowed for us in depression interventions; for instance, drawing man-dalas (Henderson, Rosen, & Mascaro, 2007) (geometric patterns created forspiritual rituals in Tibetan Buddhism), the four factors for stream-entry (thatis, asking good teachers, thinking in a proper direction in light of dharma,and learning and practicing dharma) (Shi, 2012), acceptance (Hayes, Boyd,& Sewell, 2011; Soonthornchaiya & Dancy, 2006), and compassion (cover-ing appreciation, gratitude, and love), including self-compassion (Raes, 2010,2011). In comparing 98 Tibetan Buddhist practitioners to 438 non-Buddhists(O’Connor, Berry, Stiver, & Rangan, 2012), the Tibetan participants showlower apparent levels of anxiety, depression, and self-blame due to theircompassionate mind not only toward themselves, but more importantly,toward others. Their less depressive symptoms result from compassion,which guides an individual to tackle intrinsic (i.e., the illusion of permanentself) and extrinsic (i.e., attachment to eternal objects) weaknesses (Epstein,1993). Proposing the use of Buddhism to combat depression, Obeyeseker

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(1985) observed the prominence of sociocultural–psychological factors inthe Buddhist community in coping with mental disorders; which is quitedistinct from the pathological basis of the Western medical system.

Blando (2009) examined the application of Buddhism from counselingclients in sexual minorities, illustrating the bereavement case of a homo-sexual male whose depression worsened after the death of his partner. Hefacilitated changes in his client’s perception toward life, by applying theBuddhist teachings of impermanence and transience, non-self (ever-changingself), and suffering. In accepting the concepts of non-self, uncertainty in life,and inevitable suffering, the client lessened his self-centeredness, diminishedhis grief, and faced the reality of his loss. He then learned to love and carefor himself, and share happiness with others. Although this case illustratesthe usefulness of Buddhism in helping people with depression, too few first-hand accounts of how the client applied Buddhist teachings to his recoveryfrom depression. In order to gain a deeper understanding of the relationshipbetween Buddhist wisdom and recovery from depression, a qualitative casestudy has been employed in the present research.

THE PARTICIPANT

Esther Lee, a middle-aged Chinese female, was brought up by her grand-mother, who always scolded her, after her mother got re-married andemigrated to Britain. Her lonely childhood in her household of three (whichalso included her elder brother) produced an unquiet mind full of fear,anxiety, and loneliness, resulting from introversion, withdrawal, repression,resentment toward her mother, and feelings of insecurity and guilt.

Esther was educated in Hong Kong and studied at a university inAmerica, where she got married. She felt slight, intermittent depression, butwas not aware of particular symptoms. Beginning in 1990, after her divorce,Esther suffered from severe depression, attempting suicide four times withinhalf a year. Although she took medications prescribed by a psychiatrist andvisited a clinical psychologist, she continually suffered from cyclic relapses,which brought her to the darkest period of her life (refer to Figure 1).Notwithstanding, she was capable of earning her living till she got re-marriedin 2000, but she encountered her fourth relapse half a year into her secondmarriage; and medical measures were ineffective for her. Life during thisrelapse was filmed in a television play, showing how the family suffered andhow powerless her caregiver was to help her.

As a professing Christian from her teenage years, Esther always prayedfor recovery, but in vain. This continued until 2000, upon her return toHong Kong, when she began learning Buddhism, which enhanced her self-awareness and tranquillity, and allowed her to settle her uneasiness anddetect early signs of oncoming relapse, which critically aided her recovery.

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FIGURE 1 Informant’s autobiographical timeline.

Moreover, by practicing the Buddhist teachings of being a bodhisattva (onewho passionately alleviates the afflictions of sentient beings), she has enthu-siastically helped people with emotional disorders, as she considers altruismto accomplish her life meaning, which is a mission of suffering. In addition toher passion to participate in community services to promote mental health,Esther has published two autobiographies (Leading an ordinary life, 2002;Depression is like this: Confessions of a patient with depression, 2008), anda book (Depression has no fear, 2011) about her sorrowful experience ofhow she coped with depression. Her writing serves self-benefiting and altru-istic purposes: first, she forgave her mother’s negligence of her childhood bygaining a better understanding of her mother after carefully reviewing herlife; and second, her personal experience encourages patients and directlyvoices the fact that patients affected by mental illnesses are never alone.

RESEARCH METHODOLOGY: AN IDIOGRAPHIC CASE STUDY

A “single idiographic case study” (Bramley & Eatough, 2005, p. 225) aims tounderstand a “unique, complex entity” (Ponterotto, 2005, p. 128), and inter-pret a story (Levy, 2008) through a holistic and in-depth account (Bramley &Eatough, 2005; Runyan, 2006), especially for a particular social fact (Krauss,2008) for which there are no clear boundaries between the phenomenonand its context (Yin, 1989). These characteristics of this “individual-centered”(Luthans & V., 1982, p. 380) method suited the present qualitative research,

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Recovery From Depression Through Buddhist Wisdom 277

addressing a topic in an exploratory manner (Eisenhardt, 1989; Tellis, 1997;Tsoukas, 1989), because it not only creates insight (Soy, 1997) into usingBuddhist resources in mental care interventions by examining the lived expe-riences of the participant, but also gains a deeper understanding of whatBuddhist ideas other than meditation reinforce recovery and prevention ofdepression.

Case Selection

Based on an “information-oriented selection” (Flyvbjerg, 2006, p. 230), thisstudy invited this specific participant for three reasons. First, various publiclyavailable information exhibited the participant’s narrative; for instance, herautobiographies (Lee, 2008; Lee & Lee, 2002), a book (Lee, 2011), featurearticles, and media interviews. Second, she was open to reflecting and shar-ing her life story with the researcher about how her depression subsidedthrough Buddhist teachings and practices. Third, she was no longer harmfulto herself, was functioning at a high level of social life, and was emotionallystable enough to participate in the multiple data collection sessions.

Data Sources and Data Collection

The present research was approved by the Human Research EthicsCommittee for Non-Clinical Faculties, The University of Hong Kong. It usedmultiple sources (Yin, 1989, 2003) for data collection: First, four face-to-face, in-depth, and semi-structured interviews (totalling 255 minutes) wereconducted in Hong Kong, using Cantonese, which is the Chinese dialectmost often spoken there, under a case study protocol that details the setoperational design, including fieldwork objectives and procedures, sampling,and guiding questions in interviews (Yin, 2003, 2009). Second, a genogram(McGoldrick, Gerson, & Petry, 2008) drawn together with the informantcontributed to strengthening mutual rapport (Beck, 1987) and enhancingthe understanding of her family relationships. Third, the autobiographicaltimeline graph (refer to Figure 1), plotted by the informant, displayed herself-evaluation of critical life events (Leung, 2010). Fourth, her autobiogra-phies were used as part of the data collection and analysis, which alignswith the methodology of interpretative phenomenological analysis (Smith,Flowers, & Larkin, 2009). Lastly, her radio interviews from the public domainwere accessed.

Data Analysis

The unit of this within-case analysis was an individual (the participant),with whom the interviews were tape-recorded and transcribed in Chinese.Interpretative phenomenological analysis fits the idiographic approach

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(Bramley & Eatough, 2005; Eatough & Smith, 2006; Shinebourne, 2011;Shinebourne & Smith, 2009; Smith et al., 2009), particularly for investigatingan insider’s subjective meaning (Clare, Rowlands, Bruce, Surr, & Downs,2008; Smith, 1996), and especially for open accounts that have no priorassumptions regarding the research topic (Nithsdale, Davies, & Croucher,2008).

The analysis was undertaken through four procedures, including immer-sion of raw data, examination of semantic contents, and development andintegration of emergent themes (Smith et al., 2009), with the aid of ATLAS.ti7, a computer-assisted tool (Lonkila, 1995) for analyzing various forms ofqualitative data (Friese, 2012). The phases of data analysis cover the follow-ing: first, the transcriptions were read repeatedly to engage with the dataand develop the tone of the analysis; second, specific content was identi-fied from descriptive, linguistic, and conceptual perspectives through whichthe transcriptions were viewed; third, the connections, inter-relationships,and patterns of the data were mapped to themes; and lastly, three “super-ordinate themes” (Smith et al., 2009, p. 96) were developed that emergedfrom seven lower level themes.

Rigor

Triangulation (Eisenhardt, 1989; Humble, 2009) was conducted in this studyin order to substantiate the trustworthiness of the data through diverse datagathering, cross-checking, and co-analysis (Patton, 2002). First, multiple datasources were collected, as previously depicted. Second, member-checking(Doyle, 2007; Flick, 2007) was employed in order to: (1) confirm the inter-pretation of the informant’s responses during interviews; (2) proofread thetranscriptions to confirm their accuracy; and (3) validate the data interpre-tation through the informant’s involvement in the data analysis. No majoralterations in the transcriptions or data analysis were required by the infor-mant. Third, two analysts (the researcher and a peer analyst) analyzed thetranscriptions separately and compared the codes, achieving minimal cod-ing variations and an inter-rated reliability (Liamputtong & Ezzy, 2005; Seale,1999) of 0.92, which indicated a significant level of correlation between thepeer analyses (Hanssen-Bauer, Aalen, Ruud, & Sonja, 2007; Shrout & Fleiss,1979).

RESULTS AND ANALYSES

The data that emerged unveiled three super-ordinate themes and seventhemes (refer to Table 1). The quotations in this section were cited fromthe interview transcriptions, not from Esther’s autobiographies.

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TABLE 1 Results of the Analyses

Super-ordinate themes Themes

Perceived factors causing herdepression

• Deluded thoughts• Cycle of birth and death, and karma

Benefits gained from Buddhistpractices

• Buddhist practices• Outcomes of conducting Buddhist practices

Insight learned from experiencingdepression

• Gratitude• Being a bodhisattva• Self adjustment

Perceived Factors Causing Her Depression

The causes of depression are “multidimensional” (Peteet, 2010, p. ix); how-ever, Esther was prone to describe depression as a sickness of the mind(Lee, 2008, 2011; Lee & Lee, 2002), as if her mind had been controlled by ademon (Lee, 2011; Lee & Lee, 2002). In losing autonomy, she developed anunquiet mind full of worries, anxiety, fears, and loneliness. This uneasinesscame from her false perceptions of reality, or what referred to as deludedthoughts in Buddhism, by which she would continue the cycle of birth anddeath (limitless future lives) and suffering in the world.

DELUDED THOUGHTS

In Buddhism, “deluded thoughts” (Watson, 1997, p. 68), refer to ignorancein failing to perceive reality “as it really is” (Pruett, 1987, p. 145), failure tosee the truth of phenomenal reality, as being conditioned, transient, anduncontrolled by an individual’s will (Conze, 1953), therefore developing“false concepts, confusions” (McRae, 2004, p. 110) of oneself and reality,and yielding afflictions (Conze, 1953; Wallace, 2010).

Esther recalled that her deluded thoughts were produced by the distancebetween her desires and reality. While she was eager to have a warm fam-ily, her childhood was unhappy due to a strange mother–child relationship,and her marriage failed. These unfulfilled desires caused her depression.Moreover, the more Esther ruminated over the loss of her mother’s love, themore she longed for what she did not have, and the more she victimized her-self. The more resistance she embraced, the more attachment she grasped,and the more her anxiety made her feel exasperated, which reinforced herdeluded thoughts, painfully suppressing in her unrealistic dream, and wors-ening her depression. Rejecting those misfortunes made it more difficult forher to manage her mental illness.

CYCLE OF BIRTH AND DEATH, AND KARMA

The concept of cycle of birth and death, in Buddhism, explains the manylives of an individual, in which what individuals have done in past lives will

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have an impact on their future lives; that is, karmic effect (Keown, 2000).Karma denotes that the present life of an individual is associated with whatone has done in previous lives, and will in turn influence their future lives.Esther followed her Buddhist master’s instructions (Lee & Lee, 2002) forcuring her depression, which was rooted in the cycle of birth and death andkarma, by helping others.

He (her Buddhist master) told me that I might have been a fairy maidenin my previous life. At that time, I was not obedient, and did a lot of badthings; and so, in this life, I have to make retributions for my bad karma.. . . He also said, “In spite of your experience and your severe depression,you still survived, therefore now you should accumulate merits.”

Accepting this karmic effect, Esther agreed that her suffering from depressionin this life was inevitable. Of importance is that she indicated that she saw hersuffering as a mission, thereby she peacefully making up for her wrongdoingin her past lives through helping patients affected by emotional disorders.This allowed Esther to activate her “built in” (Zuess, 1999, p. 10) healingsystem and transformed her depression into “creative life-energy” (Zuess,1999, p. 14), as with many other recovered patients with similar experiences(Jamison, 1996; Martin, 2000; Styron, 1990, 1996).

Benefits Gained from Buddhist Practices

In her personal experience with Buddhism, Esther suddenly felt fearless andspiritually tranquil when listening to Buddhist music playing in a Chinesemedicine clinic where she was visiting a practitioner regarding her relapse.She felt a closeness to Avalokitesvara (a greatly compassionate bodhisattva)(Lee & Lee, 2002), who was looking after her. Since then, she has beenlearning Buddhist practices.

BUDDHIST PRACTICES

Esther began to chant Buddhist scriptures, such as the Heart Sutra and theMetta Sutta, recite buddha names, read dharma books, learn meditation, andjoined associated retreat activities (Lee, 2011). She followed Buddhist rules toidentify what she was permitted to do, and incorporated Buddhist practicesinto her daily life (Lee, 2011) to train her concentration by practicing med-itation in the forms of mindfully walking, cooking, weaving, and cleaningfloors.

Through practicing mindfulness and meditation, Esther slowed downher life rhythm, reduced her anxieties, began to keep pace with the present,changed her mindset, and rectified bad habits, resulting in improvement inher interpersonal relationships.

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Recovery From Depression Through Buddhist Wisdom 281

Although she claims to be a Buddhist, for Esther, Buddhism is a phi-losophy or spirituality, rather than a religion, which allows her to be freeto accept Buddhist teachings without ideological restrictions. This differsfrom how she treated Christian rituals in the past. She has continued doingBuddhist practices, but on an on-and-off basis, which does not prohibit herfrom advancing her practices and gaining insight.

OUTCOMES OF CONDUCTING BUDDHIST PRACTICES

Buddhist practices aim at coping with oneself and one’s desires (Gethin,1998), as Esther understands it, because people tend to create barriersfor themselves. Through practicing Buddhism, she has improved her self-awareness (Lee, 2011): “With increased self-awareness, when I’m nervous,or uneasy, or anxious, I know it. Then I will remind myself to slow downand work out the causes of the problem.”

Furthermore, these practices include concentration training, focusing onthe present (Lee, 2011) by paying attention to breathing in and out, throughwhich Esther could realize the true reality of her existence, about which sherelated:

Concentration is doing well what there is [to do] at the present moment.. . . If you concentrate on doing something, live at the present moment,and do everything mindfully. . . . If you concentrate on the presentmoment, you will be happy at this moment. [You] will be very happywhen you don’t think about the past or the future, but just [about] thepresent moment.

Having enhanced her self-awareness and concentration, Esther was sensitiveto her feelings and to changes in her feelings, which has enabled her tobetter understand her own needs and feel peaceful and calm. Achievingcalmness, an antidote in dealing with distress (Lee, 2008, 2011) allowing herto maintain a quiet mind and lessen her uneasiness, she felt delighted withher new-found positive life view, worry-free state, emotional stability, andgratitude.

Esther, in her serenity, re-discovered her strengths and inner resources,and thus related that her depression was engendered by her misperceptionsregarding herself. She had felt inhibited in the expression of her own feelingsin order to get the attention of others. She had distorted herself to please hergrandmother when she was a child, as well as her ex-husband later; but allthis had totally failed. Even worse, her divorce directly triggered her depres-sion because she did not accept her failure (Lee & Lee, 2002). However, herincreased self-awareness and ordinary mind re-activated her inborn energy,which re-developed her confidence and openness to accept her mishaps

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and then let them go (Lee, 2011). She felt freed from her predicament, andbecame stronger and more independent.

Owing to her peaceful mind, openness, sensitivity, and reflections,Esther resolved her discordant mother–daughter relationship, which relievedher long-lasting sorrow related to her internal struggle of guilt and resent-ment toward her mother (Lee, 2008). She loved her mother but wasaffectively distant from her (Lee & Lee, 2002). She was eager to receive hermother’s care but resisted heeding when her mother stayed with her. Theseambivalences created a vicious cycle of complaints toward her mother alongwith self-criticism, and produced an emotional burden that deteriorated herself-identification (Holdstock, 1993). Upon writing her first autobiographyand honestly reviewing her life in tranquillity, she let go of her grumblesand forgave both herself and her mother. She became relaxed and at ease,and comforted her mother in frank conversation, confessing, “I don’t oweyou anything, nor do you owe me anything. You don’t need to worry aboutit. Please let go of it. . . . [You] don’t owe me anything. I also think that Ihave fulfilled my responsibility as a daughter, and I feel relaxed and free.”

Insight Learned From Experiencing Depression

Buddhist teachings and practices offered a solution for Esther’s depression, inwhich she declared her recovery. This served not only to cure her emotionaldisorders, but also changed her life style and life views, cultivating openness,relaxation, and a worry-free state.

GRATITUDE

Instead of being sorrowful, experiencing depression became a “quest forvision” (Zuess, 1999, p. 3) and a source of gratitude for Esther. Throughdepression, she realized what life really is, enriched the values of her life,and reintegrated her experience, proclaiming, “I am thankful for such expe-riences. I think that all the suffering I underwent in the first half of my lifewas to enable me to do what I have to do today. . . . I am really thankful forthat.”

To show her thankfulness for experiencing depression (Martin, 2000),Esther now treasures suffering as a path of development wherein real life isever-changing (Lee & Lee, 2002). When she began to be able to cope withlife changes, she made meaning out of suffering, which enriched her life,and she credited what she had and did not take those things for granted:

If suffering is unavoidable, . . . Life indeed requires much experience ofsuffering. . . . One cannot achieve growth without experiencing suffering.. . . Suffering is what enables me to understand the impermanence of lifeand its suffering. Eight or nine out of ten happenings are unsatisfactory.

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The problem lies in how we face them. . . . Through this illness, Ihave been able to understand the suffering and happiness in life andto treasure all that I have now.

This passive acceptance of her growing pain forced Esther to defense-lessly accept the truth, simply because it was inevitable. Admittedly, if shehad had a choice, she definitely would have not experienced the illness.This reluctance to accept distress is understandable and reasonable (Frankl,1946/2006). Furthermore, after her recovery, Esther converted her negativeencounters into positive assets, by which she could respond to her karma,fulfill her wish to make retribution and serve other people.

BEING A BODHISATTVA

In Buddhism, being a bodhisattva (one who enthusiastically helps others)is also a Buddhist practice centered around performing altruistic behavior,and the bodhisattva spirit refers to self-benefiting altruism (Thurman, 1998),through which benefit is gained from one’s own altruistic activities.

Esther also emphasized self-help, including self-loving-kindness andself-compassion, which is the basis of altruism. She illuminated this ideain the following statement:

Love yourself and then you can love others. If you can be more com-passionate with yourself, then you will know how to deal with this thingthat makes you unhappy or dissatisfied. You must be compassionate toyourself before you can observe others with a compassionate mind. Thenthere will not be unsettled emotions. Now I know how to love myself.

Based on the success of this self-help, Esther, a “wounded healer” (Stone,2008, p. 48), became dedicated to helping individuals with emotional disor-ders by sharing her personal experiences, because she could empathicallyrespond to similar pains that they were experiencing; and thus she is a livingexample of the possibility of recovery from mental illness.

Consequently, Esther realized the mutual benefits she receives whenhelping others, in gaining more insight, and in developing stronger capabili-ties related to serving others. In this respect, helping others and the benefitsgained from helping others are twin rewards received from “altruism as atherapeutic agent” (Brazier, 1993, p. 72). She related the following statementregarding this concept.

You’ll forget your own misery when you open up your mind to observeand care about others. . . . It is apparent that they need my help. Yet

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as a matter of fact, helping them helps myself simultaneously. My self-awareness has gradually increased. With such help to myself, I will notrelapse into my previous mode of thinking, but instead see my abilityenhanced.

SELF-ADJUSTMENT

Believing depression to be a result of deluded thoughts (Lee, 2011), as dis-cussed earlier, Esther observed that the true enemy of oneself was in factone’s own self. Everything is determined through oneself, as she related inthe following:

We’re our own enemies, our greatest enemies. We’re the ones to bringto ourselves all fortunes and misfortunes. By always thinking back andforth, we make ourselves unhappy because we easily bring our pastunhappiness forward into the future, and project our past misfortune onto the future.

Thus, self-adjustment represented a solution (Lee, 2011); including sen-sible relaxation and freedom, acceptance, tolerance, light attitudes towardone’s changing environment, detachment (Lee, 2008), and the utilization ofnon-duality to eradicate her binary viewpoint. When Esther skilfully adjustedher views, she became anchored in hopefulness and in a simple life. Shefinalized her conclusion by saying: “Although I’ve experienced so much, I’mstill full of hope toward life. . . . It has made me realize that life is beautiful.I’m more and more convinced that life is beautiful in its simplicity.”

For Esther, suffering was not a barrier, but was instead a gift (Jamison,1996; Moore, 1996), which became an asset by which she attained self-recognition and self-worth. She sees afflictions as positive factors thatincrease her spiritual development because adversities can optimize poten-tialities (Rogers, 1977). Furthermore, through gratitude and treasuring thethings that she has, she has reconstructed for herself a positive self-concept,and transformed herself from a withdrawn person into a brilliant person whocan look after herself and help others be at ease and be worry-free.

DISCUSSION

As derived from the emerging data, the findings conclude with a recoveryframework for recovery from depression through Buddhist wisdom (refer toFigure 2), seeking to transform unquiet minds into quiet minds, involvingmind management and self-benefiting altruism. Through learning Buddhistteachings and performing Buddhist practices, the informant gained a betterunderstanding of both herself and reality, and acquire inspirational insight

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Factors inducing anunquiet mind

RecoverySickness of mind /

depression

A quiet mind

Deluded thought

Cycle of birth anddeath, and karma

Self-benefitingaltruism

Benefits gained from Buddhist practices

Buddhist practices Outcomes

Gratitude Being a bodhisattva Self adjustment

Insight learnt from experiencing depression

Mind Management

Causes Coping Methods Outcomes

FIGURE 2 Recovery from depression through Buddhist wisdom.

learned from her depression experiences. Thus she became dedicated tomanaging her own mind and serving other people. Helping others enabledher to achieve self-benefiting altruism: that is, the more she contributedto others, the more she gained self-benefits; through which she overcamedepression.

Mind Management

Ignorance related to the inability to “[face] reality as it exists within the self,as well as external reality” (Rogers, 1946, p. 417), creates deluded thoughts(Ramaswami & Sheikh, 1989; Rogers, 1980b; Wallace, 2010) that produceunrealistic desires and yields sickness of the mind. From the Buddhist per-spective, this falls into the cycle of birth and death and karma, whichendlessly incurs suffering (Goleman, 1975; Samuel, 1999; Santina, 1984).Therefore, perceiving reality as it is a way to eradicate “self-created suffering”(Dalai & Culter, 1999, p. 123).

Reality in the empirical world is ever-changing, indicating that change isnormal (Conze, 1953), in which “life, at its best, is a flowing, and chang-ing process in which nothing is fixed” (Rogers, 1961, p. 27). All things“have no fixed form[s]” (Watson, 1997, p. 91); for instance, “this body isimpermanent, without durability” (Watson, 1997, p. 34). Such transience isnon-autonomous (Mizuno, 2003), and changes are inescapably affected byunforeseeable agents. Understanding the nature of reality helps individualswith depression let go of their grievances and maintain hope because thereare favourable chances that may yet lie ahead.

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While the external world is out of the control of an individual’s will,conducting Buddhist practices contributes to the management of one’s innerworld, or the mind, including cognitive and behavioral dimensions. In thearea of cognition, understanding the implication of the cycle of birth anddeath helps understand the formation of afflictions that result from karma(Keown, 2000), which is the major thought affecting both mental illnessesand patients and their family caregivers, who are influenced by Buddhism(Hinton, Tran, Tran, & Hinton, 2008; Sethabouppha & Kane, 2005). Karmiceffect yields satisfactory and unsatisfactory encounters in the present life,corresponding to a person’s behavior in past lives (Reichenbach, 1990).Sufferers believe that their ailments are due to their wrongdoings in previouslives and that they need to do good in order to counter the bad effects. Thisdrives them to perform Buddhist practices, such as repentance, chanting, andmeditation, through which sufferers further experience Buddhist teachings,including those of impermanence, and karma. The most crucial implicationis that they must take responsibility both for what they have done in thepast and what they are doing in the present, which will reflect itself in futureoccurrences—good behavior with good returns. In order to avoid receivingbad returns, they prevent themselves from acting out bad behavior. Thus,they control their own minds and reduce unnecessary desires. As a result,they are able to attain a peaceful mind.

Self-Benefiting Altruism

By performing Buddhist practices, sufferers gain self-benefits, includingenhancement of self-awareness, tranquillity, a worry-free state, and wis-dom. And yet, Mahayana (a school of Buddhism) Buddhists are devotedto helping other people, through following the bodhisattva path, in which abodhisattva is an individual who selflessly helps others. When sufferers serveothers, they not only embody “inner, subjective, existential freedom” (Rogers,1967, p. 52), but they also live as a person “in real contact, in real reci-procity of the world” (Anderson & Cissna, 1997, p. 103). When they connectwith other people, they reconfirm their self-identity, which in turn sup-ports a meaningful life and reduces the pressure of misfortune (Paloutzian,2005).

Being a bodhisattva, one who practices the bodhisattva path with thefour immeasurables, including loving-kindness (Fredrickson et al., 2008),compassion (Gilbert, 2010), empathetic joy, and equanimity (Bitner et al.,2003), represents the ideal for Mahayana Buddhists. Scholarly studies reporttherapeutic effects on mental illnesses resulting from the practice of both thefour immeasurables (Blando, 2009) as a collective unit, as well as the inde-pendent components practiced separately, as essentials of personal growth

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(Wallace, 2010) and helping behavior; which are cultivated toward them-selves and extend outward to others (Wallace, 2004), thus benefiting thepractitioners. This results in self-benefiting altruism, contributing to recoveryfrom depression, as demonstrated in the informant’s experience.

Limitations

The present idiographic case study is concerned with first-person interpre-tations of recovery from depression through Buddhism, and does not aimto generalize its findings to this specific population of mental illnesses.Moreover, this research looked into the effectiveness of Buddhist involve-ment following the later period of the informant’s depression; that is, afterher suicidal attempts. Thus, the need for further exploration of these effectsduring a patient’s most critical episodes is suggested.

Implications for Future Research Directions

HEALING EFFECTS OF ALTRUISTIC ACTIVITIES

Social connection and a happy life correlate positively (Dalai & Culter,1999), and altruistic activities nurture better bonds with others. Individualswith emotional disorders may re-develop self-value and self-identity, and re-gain self-esteem and self-recognition through community service. Throughsocial participation, they can expand their vision and become involved inthe worlds of other people, thereby reducing their discomfort and stress,resulting in intensified feelings of self-enhancement (Luks, 2001; Musick,Herzog, & House, 1993; Treadgold, 1999) and well-being (Poulin et al., 2010).However, the therapeutic effects of helping behavior from Buddhist perspec-tives seem to have been examined but seldom, at which topic the currentstudy hints.

MINDFULNESS TRAINING

Research on using mindfulness or meditation as an intrinsic part of integrativemedicine (Williams-Orlando, 2012), or in complementary and alternativemedicine (Barnett & Shale, 2012; Cuellar, 2008) for treating emotional dis-orders has shown effective outcomes (Baer, 2003; Brown & Ryan, 2003;Teasdale et al., 1995). However, most such research has focused on thesitting form of meditation in a specific setting. Buddhism, particularly inthe Zen tradition, emphasizes incorporating meditation within one’s dailylife during the present (Gunaratana, 2009; Herrigel, 1948/2006; Kabat-Zinn,2005; Tart, 1990); for instance, through mindful eating, sewing, gardeningor sport, which is possibly likewise applicable to prevention and remedialinterventions.

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CHANTING AND PRAYING

By reciting passages of holy scripture, as a kind of religious coping (Barnett &Shale, 2012; Braam et al., 2010; Knabb, 2012; Moran et al., 2005; Pargament,Poloma, & Tarakeshwar, 2001), a chanter pays complete attention to the text,resulting in mental peace (Dhammanada, 1993) through long-term practice(Gunaratana, 2009). However, this study reports that the informant experi-enced disparate results from chanting and praying in different religions. Hervariance might be caused by her level of religiosity (Kasen, Wickramaratne,Gameroff, & Weissman, 2012) in Christianity compared with Buddhism,which urges further exploration.

INTEGRATION WITH PERSON-CENTERED THERAPY

Buddhist teachings on impermanence, suffering, and freedom from suffer-ing comply with the phenomenological-oriented person-centered approach(Cooper, 2007; Corey, 2009), emphasizing numerous realities (Rogers, 1980b)connected to personal experiences (Cooper, 2007), along with the achieve-ment of “existential and creative inner freedom” (Rogers, 1967, p. 66). Rogerslikely incorporated Buddhist wisdom into person-centered therapy (Tophoff,2006), in particular Zen Buddhism (Rogers, 1980a, 1980b), but very fewresearch projects have discussed the relationship between these two dis-ciplines. Studying this topic may extend the traditional person-centeredapproach to the treatment of depression in a different direction.

CONCLUDING REMARKS

This idiographic case study explored first-hand narratives of recovery fromdepression through Buddhism. The results reveal that Buddhism offers aset of teachings and practices that produces thought transformation, acceptsreality, engenders forgiveness, attains serenity, enhance self-awareness, andconverts adversity into life meaning through helping behavior, as a part ofBuddhist practices, which not only benefits service recipients but also serviceproviders; namely, self-benefiting altruism. Furthermore, this study proposesdirections for future research, including study on the therapeutic effects ofhelping behavior from Buddhist dimensions, various forms of meditationtraining and different religious coping strategies to tackle depression, andpotential integration of Buddhist philosophy into person-centered therapy.In conclusion, this research analyzed the process of mind management set-tling an unquiet mind full of fear, anxiety, and complaints into a quiet mindcharacterized by a worry-free state and inner satisfaction, thus portrayingdepression treatment differently, from the Buddhist perspective.

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ACKNOWLEDGMENTS

I express my gratitude to Ms. Esther Lee, who shared her personal expe-riences with me and agreed to use her real name in this article. I alsothank Dr. Wei Rui Xiong for co-analyzing the data; an anonymous translatorwho proofread the translation of the interview material from Chinese intoEnglish; Professor Raymond Paloutzian, Venerable Daoyi, and Dr. Xin ShuiWang for their invaluable comments. In particular, I have deep appreciationfor Professor Samson Tse’s contribution to this work.

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