Dharma Care - Pastoral Care and Counseling from Buddhist Perspectives
 
Grateful acknowledgment is made to Gil Fronsdal for his permission to include his translation of The Metta Sutta in his book The Issue at Hand: Essays on Buddhist Mindfulness Practice.
 
The DharmaCare Handbook series is based, in part, on translations of the Pali Canon by Bhikkhu Nanamoli, Bhikkhu Bodhi, Maurice Walshe, and Nyanaponika Thera.
 
© 2011 by Pamela Ayo Yetunde
All Rights Reserved.  No Part of this book may be used or reproduced in any manner whatsoever without the prior written permission of the Publisher.
 
Layout and design by Renise Black/Metaph4r Digital
 
Preface
 
          What does it mean for someone to care for another person?  On a very basic level, it means that the one who is responding to the perception that the other person needs something is doing so with the intention of being helpful or beneficial in some way.  In other words, the one who is responding senses that the other person is in pain, unhappy, confused, hungry, broke, afraid, sick, dying, lonely or in some other perceived or actual state of deficiency.  This sensing is the beginning of care, but care involves something more than just sensing.
          Care involves not only sensing a state of lack or deficiency in someone else, it involves forming the intention to act based on what has been felt.  The intention to act comes from a thought, a tug, and a pull at the heart and/or the gut that tells us on different levels that there is a problem or issue in need of attention.  Assessing, sensing and forming the intention to care moves us toward the other person, but the assessing, sensing and intending must accompany the communication of this process in order for it to be received.  How is care communicated?  This is the area where many people feel trepidation about whether what they intend to communicate will be received as it was intended.
          Communicating care is not formulaic.  Care can be communicated with silence to indicate deep listening and respect for what is being experienced, or it can be communicated with lots of talking when the silence becomes too much for the receiver to bear.  Care can be communicated with direct eye contact to show you are connected, or it can be communicated with downcast eyes to show respect for boundaries when there has been no invitation to be intimate.  It can be communicated with touch or without touch.  Communicating care is not formulaic, therefore we must take risks, in the interest of connecting with others, to demonstrate our care for them, and be willing to apologize when our attempt to communicate care is misinterpreted.  This is what it means to give care from the most basic perspective.  So what if we were to complicate matters by defining pastoral care?  What does that look like?  What does it feel like?
          Pastoral care involves all the elements of caring for others, including assessing, sensing, forming intentions and communicating those intentions, but what makes pastoral care pastoral is that the caregiver is assessing, sensing, forming intentions and communicating those intentions from the viewpoint of something believed to be greater than the caregiver and the care receiver.  Some call this “something greater” God,  Consciousness or Allah. Others call it Jesus, the Buddha, or any of a thousand other names.  If we get locked into an argument about what to call that something greater, we will miss out on understanding what it feels like to give pastoral care and what it feels like to receive it.  This handbook is about the feeling of pastoral care from the exchange of what in the Theravada Buddhist tradition are known as metta (loving-kindness) and karuna (compassion).  Given my emphasis in this handbook on metta and karuna, concepts that are universal, we can relax, hopefully, and not ascribe pastoral care to only one religious tradition.  And yet the approach to pastoral care described in this handbook is most definitely inspired by the Buddhist tradition. Why is this important to note?
          The U.S., like many other countries, is pluralistic.  Yet in most public settings where you find pastoral caregivers, an overwhelming majority were educated and trained by Christian seminaries.  If pastoral care departments are interested in serving a pluralistic community, it would be wise for leaders in the pastoral care professions to emphasize the universal concepts of loving-kindness and compassion over religious affiliations.  In fact, it appears that in a post racial segregation, post Women’s Movement, and present-day Gay Marriage movement, younger people in the U.S. are less interested in living discrete existences within their affinity groups — they are mixing it up more than ever.  I find this trend evolutionary and predict there will be no turning back.  If I am right about this, then it stands to reason that pastoral caregivers from different backgrounds will be increasingly accepted by the mainstream, and that Buddhism’s rich tradition of pastoral care will play a more prominent role.
 
Introduction
 
          In this handbook, you will learn about some of the principles of pastoral care from a Buddhist perspective.  By Buddhist perspective I mean from the teachings attributed to Siddhartha Gautama 2,600 years ago as recorded in the Pali Canon.  The Pali Canon is a collection of suttas (I liken them to sermons or lessons) on how to alleviate suffering, enjoy life and abide in other realms of existence.  Buddhism means the practice of awakening.  It is a process of evolving past hurt, pain, unhealthy attachment, unwholesome desires and personality limits in order to grow in loving-kindness, compassion, equanimity and joy.  Awakening is a set of practices that creates a dynamic exchange sparked by a desire to accept reality rather than be deluded, cultivate love where hatred can fester and grow, act with kindness where indifference, distance, and meanness can prevail, and feel compassion where apathy begins to takes hold.  This is also the principle outlined in St. Francis’ Prayer.  It bears mentioning because the Buddhist and Catholic traditions, though certainly very different,  share many universal principles.  This is true for other religions as well.  So what does Buddhism have to offer pastoral caregivers and the pastoral caregiving professions, including pastors, chaplains, pastoral counselors, and pastoral psychotherapists?
          Buddhism offers: mindfulness, formation in character, meditation, practices for dealing with anxiety and depression, the Eightfold Path to contentment, and a belief system that never invokes the name of God or gods to blame people for being sick, but instead puts the potential for healing squarely in our hands.  Buddhism offers healing hands and healing hearts, and the practice itself can be considered a healing art.  With these things in mind, let’s examine how Buddhist pastoral care can be efficacious to everyone, regardless of creed.
 
The Buddha as a Pastoral Caregiver
 
          In the Christian tradition, the word “pastoral” comes from the function of herding sheep.  The Bible includes stories about lost sheep being sought out in the pasture, found and returned to the flock.  This was the job of the herder or shepherd in the pasture — the pastor.  The lost sheep returning to the flock, guided by the shepherd, is a metaphor to describe the dynamic between people who have left the community of followers who believe in God and Jesus, and their leader, the pastor.  In the church, the minister is the pastor, responsible for gathering the believers, caring for their well being, and leading the believers or flock to their destination, heaven.  The image of the sheep and pastor carry a significant image in the Christian tradition.  In Buddhism, the significant image that describes this relationship is the cow and the cowherd.  The cows are like the sheep and the cowherd is like the herdsman or shepherd.
          In The Greater Discourse on the Cowherd (Mahagopalaka Sutta in the Majjhima Nikaya) it is said that the Buddha said a cowherd should possess 11 factors, making him capable of keeping and rearing a herd of cattle.  Those factors are:
 
1)      knowledge of form
2)      skilled in characteristics
3)      picks out flies’ eggs
4)      dresses wounds
5)      smokes out the sheds
6)      knows the watering place
7)      knows what it is to have drunk
8)      knows the road
9)      skilled in pastures
10)    does not milk dry
11)     shows extra veneration to those bulls who are fathers and leaders of the herd
 
          The Buddha gave this discourse to a gathering of monks about how to keep and raise a community of adherents.  The monks were not cowherds in the literal sense, but dharma teachers or would-be dharma teachers, counselors, and healers who taught people what they themselves had learned directly from the Buddha. The purpose of this handbook is to illustrate pastoral care from a loving-kindness perspective, but it makes sense here to briefly touch on the 11 factors of cowherding.
          It is said that the Buddha said to have knowledge of form, one knows that the materiality of a human body is made of the four elements — earth, wind, fire and water.
      To be skilled in characteristics, the cowherd knows when a follower is foolish and when a follower is wise.  Picking out flies’ eggs is a simile for removing things that get in the way of spiritual growth.  In order to dress wounds, the monk notices when his senses are engaged.  Noticing how he begins to cling and crave, he abandons those desires and practices restraint and renunciation.  Smoking out the sheds refers to how a monk teaches the dharma.  Is the ability to teach such that it helps remove ignorance?  Knowing the watering place is akin to the cowherd, as leader, also being a good follower, or cow, of wiser cowherds.  The knowledge of having drunk is the same as having been inspired and gladdened by the teachings.  Knowing the road is knowing the Eightfold Path.  Being skilled in pastures is knowing the Four Foundations of Mindfulness.  A monk who does not milk dry is like a guest who does not overstay his welcome.  The monk should take what is given only in moderation.    Lastly, the monk should show extra veneration for respected leaders and wise ones in the community of followers—the founders and leaders of the herd--through private and public acts of loving-kindness .  According to the Buddha, this is what a good pastor needs to be, do and understand to successfully keep his flock.
The Mahagopalaka Sutta is probably not as well known as other discourses because it was written with a small group of people in mind--—dharma teachers and leaders.  But despite its obscurity, it packs a powerful message about the pastoral aspect of teaching the dharma—it takes insight, skill, reverence, authenticity and understanding the true nature of being human.
 
     There are many stories about the Buddha, who went by the name Siddharta Gautama prior to his enlightenment.. According to one story, for example, his  father did everything in his power to hide the reality of suffering from his son, based on a seer’s prophecy that if young Siddhartha saw the extent of human life, he would become a caregiver, not the heir to his father’s wealth.  When Siddhartha saw that people age, become ill and die, he was shocked, so shocked that he renounced his high place in the community and fled to the forest for six years trying every way possible to see if old age, illness and death could be avoided.  After making himself sick trying to avoid sickness, he woke up to the true nature of being human.  His first thought was to keep what he had learned to himself, but as the sutta goes, he was visited by the god Brahma, who inspired him to share what he learned out of compassion for the pain and suffering of others.  In other stories, the Buddha was visited by Mara, the Indian equivalent of Satan, who attempted to persuade the Buddha to sin rather than teach.  Siddhartha was divinely inspired, despite these temptations, to gather cows as cowherd, and lead them to drink.
Bringing comfort in the Buddhist tradition is about good self-care, understanding that a caregiver who cares well for herself has a good idea about how others might care well for themselves.  Again, the caregiver’s role is to put the potential for healing squarely in the receiver’s hands, artfully.  How?  According to Siddhartha, it begins by simply sharing the truth of reality.  Sharing the truth of reality is the job of a teacher.  Teaching was one of Siddhartha’s ways of conveying information.  He also preached to a congregation.  Siddhartha was an itinerant preacher who went from grove to park, spreading his message of salvation from suffering.  But did he actually heal people?
The Buddha as Healer
 
          The bulk of the suttas do not suggest that Siddhartha laid his hands on people and cured them of physical diseases or restored abilities where disability existed, yet there are suttas that include stories of Siddhartha’s many lives and many superpowers.  Buddhism, like Judaism, Islam, and Christianity, is not a tradition completely removed from magical thinking, and like people from other traditions, many who call themselves Buddhists, especially in the West, privilege the practices over belief in the magical. Siddhartha’s ministry was mostly one of helping people understand how to live with more contentment.  Is arriving at contentment healing?  If contentment means less stress, less striving, less fear, a sense of satisfaction, no desire for things to be different than they are, then arriving at contentment is healing and being content is good health in the mental and emotional senses.
          According to a medical study done of women who had a mastectomy, those who were not content with the decision they made to have the surgery may have experienced depression due to dissatisfaction with their appearance, even when fully dressed.  These feelings of depression may also have been related to their perceptions of being in poor or fair health even when the cancer was cured.  (Journal of Clinical Oncology, Vol. 24, No. 9 (March 20), 2006: pp. 1350-1356).
          In Nursing Science Quarterly, researchers White, Peters, and Schim defined “well-being” as “a perceived condition of personal existence including persons’ experiences of contentment... (Nursing Science Quarterly, January 2011; vol. 24, 1: pp. 48-56.)
          Does contentment play a part in helping addicts recover and stay sober? According to researchers, there is a relationship between length of sobriety, spirituality and contentment for those who attend Alcoholics Anonymous meetings. Length of sobriety was significantly associated with spirituality in men and women, but as it relates to contentment, men’s contentment was significantly related to lower stress levels, but not for women.   (Addictive Behaviors, Vol. 29, Issue 9, December 2004, pg. 1857-1862.)  Can anorexia nervosa and bulimia coexist with contentment about the body?  No.  Contentment is healthy.
          Siddhartha did not address breast cancer, alcoholism (though he did teach against abusing intoxicants) or body image, but he did teach that the human condition includes a constant strand of discontentment or dukkha, and that the spiritual practice of awakening is to awaken to the fact that we have in our hands the ability to transform discontentment and prevent unnecessary dis-ease.  How?
 
Four Noble Truths and the Eightfold Path
 
          As the story goes, Siddhartha was fooled by his father into thinking life was full of young people who never got sick or died.  When he learned the truth, he fled to the forest for six years, tried all manner of ascetic spiritual practices to avoid the human condition, failed, then professed: 1) there is discontentment/suffering; 2) discontentment/suffering has its causes; 3) there is a way to eliminate these causes; and 4) eliminating the causes is through the Noble Eightfold Path.  The path includes:
 
• Right View         
• Right Intention
• Right Speech      
• Right Action
• Right Livelihood
• Right Effort        
• Right Mindfulness
• Right Concentration
 
Put simply, to achieve contentment, one must cultivate wisdom, act ethically and, with proper perseverance, develop one’s mind toward the liberation from clinging.  This handbook, however, is not a book about the religion of Buddhism—it is an introduction to pastoral care from the perspective of loving-kindness and compassion.
Loving-kindness
 
          In the Metta (translated as loving-kindness) Sutta it is written:
 
To reach the state of peace
          One skilled in the good
                   Should be
          Capable and upright
Straightforward and easy to speak to,
Gentle and not proud,
Contented and easily supported,
Living lightly and with few duties,
Wise and with senses calmed,
Not arrogant and without greed for supporters,
And should not do the least thing that the wise would criticize.
 
[One should reflect:]
 
“May all be happy and secure;
May all beings be happy at heart.
All living beings, whether weak or strong,
Tall, large, medium, or short,
Tiny or big,
Seen or unseen,
Near or distant,
Born or to be born,
May they all be happy.
Let no one deceive another
Or despise anyone anywhere;
Let no one through anger or aversion
Wish for others to suffer.”
 
As a mother would risk her own life
          To protect her child, her only child,
So toward all beings should one
Cultivate a boundless heart.
With loving-kindness for the whole world should one
Cultivate a boundless heart,
Above, below, and all around
Without obstruction, without hate and without ill-will.
Standing or walking, sitting or lying down,
Whenever one is awake,
 May one stay with this recollection.
This is called a sublime abiding, here and now.
 
One who is virtuous, endowed with vision,
Not taken by views,
And having overcome all greed for sensual pleasure
Will not be reborn again.
 
Translated by Gil Fronsdal in The Issue at Hand: Essays on Buddhist Mindfulness Practice
 
Formation
 
     Let’s break down the Metta Sutta into segments.  The first segment on reaching the state of peace is about a pastoral caregiver’s formation.  One interested in reaching states of peace is working the Right Intention aspect of the Eightfold Path.  To alleviate one’s suffering, one must have the intention to do so.  Having the intention to alleviate suffering is the definition of Right Intention, but intention is not enough.  One must also be “skilled in the good.” In other words, one must be experienced in living a wholesome lifestyle.  This involves Right Speech, Action, and Livelihood.
          Right Speech can mean refraining from all forms of communication, depending on what the caregiver perceives as wise action, or it could simply mean engaging only in speech that is truthful, timely, spoken with no intention of harming, but with the intention of being helpful, and gentle.  Right Action (which also includes speech) is also motivated by an intention to do no harm but be beneficial.  Right Livelihood is earning one’s keep with no intention of harming, not profiting from someone else’s unwholesome actions, and being of benefit to others.  A pastoral caregiver interested in being inspired and motivated by loving-kindness would do well to be formed in cultivating a mind and heart for peace, experienced in actually living peacefully, but loving-kindness requires more than this — it requires capability and character.
          For a pastoral caregiver to be capable and upright in the loving-kindness tradition, one would do well to also develop the other character perfections (as loving-kindness is just one of ten) including:
 
• Generosity
• Morality
• Renunciation
• Wisdom
• Energy
• Patience
• Truthfulness
• Resolution, Perseverance or Determination, and
• Equanimity
 
     One skilled in these areas is considered upright in this spiritual tradition.  In an upright caregiver, the intention to be peaceful and the actual experience of living peacefully are accompanied by active listening and a certain directness in speech. (I like to think of this as making an effort to be clear rather than confusing.) This directness is balanced with gentleness and humility. If I can privilege the value of any particular aspect in pastoral caregiving, it would be listening.  I have yet to meet a person who deep down did not want to be lovingly listened to, heard in some way or kindly and compassionately witnessed. Even those who initially said they did not want to share anything about themselves later confessed that they were just afraid that they would not be accepted in the condition they found themselves in.  Pastoral caregivers trained in this tradition know that whatever condition we find others in, it is not a condition that we ourselves can avoid.  To remember that we cannot avoid the human condition, there is a contemplation practice called The Five Remembrances:
 
1. I am sure to become old; I cannot avoid aging.         
2. I am sure to become ill; I cannot avoid illness.         
3. I am sure to die; I cannot avoid death.   
4. I must be separated and parted from all that is dear and beloved to me.
5. I am the owner and heir of my actions… good or bad.
 
     When offering pastoral care, remembering the impermanence of our true material condition  allows us to be fully present with those who are suffering. We remember that our experience is a shared experience, and that what may be causing the receiver’s suffering is already present in us, perhaps to a different degree or with a different shade, but present within us at that moment and always.  The purpose of this practice is to be content with what is and when content, we are easier to be with — we do not cause the receiver to become our caretaker.  With this knowledge and remembering, we listen differently, with empathy and with compassion arising naturally.  This is part of the process of developing loving-kindness.  In order to make this go more smoothly, it is important to be mindful of how we actually live.
          The Metta Sutta states that one should live lightly and with few duties.  This is countercultural in the United States, but a pastoral caregiver burdened by many responsibilities and tasks is not likely to have the energy (one of the perfections) to be loving or kind or a good listener.  The caregiver will more than likely think about the next thing they have to do while present with the receiver.  It is likely the receiver will notice this and interpret the interaction with the caregiver as obligatory at best, and uninterested at worst.  All these teachings are on the path to wisdom.The pastoral caregiver should be wise (omniscience is not required) and calm.  What is the benefit to the receiver of having a wise and calm caregiver?  More often than not, in my experience, a receiver wants something from the caregiver.  Never have I experienced ignorance being the thing they needed.  The right words at the right time (sometimes in the form of a cliché), an accurate observation of one’s condition and experience, when to tell the truth, when to let the receiver dwell in denial, when to comfort and when to challenge all require the experience and skill that leads to wisdom.  And what about calm senses?
          The calm caregiver, as opposed to the one who is agitated, nervous, or overly excited, is the one most likely to be fully present for the receiver and the receiver’s experience.  In Buddhism, understanding the self as impermanent means understanding that the sensations, objects, perceptions, interpretations and meanings that occur and arise through seeing, hearing, tasting, touching and smelling continually change.  Agitation can be transformed into calm through mindfulness.  Bringing awareness to sensations in the body and mind, and slowing down racing thoughts, rapid breathing, tense muscles and the jitters can be accomplished by awareness and deep breathing, focusing the mind on an object or image.  Calming also has the effect of dampening the need to project one’s personality outward, in other words, to be arrogant.
          The Metta Sutta states that reaching the state of peace requires that one not be arrogant and greedy for supporters.  Arrogance has many downsides,one of them being the amount of energy it takes for the receiver to adjust to such neediness on the part of the caregiver.  If the caregiver needs the support of the receiver, when ostensibly the caregiver is there to be of support, the relationship is twisted in such a way that the receiver who is in need has to put his or her own needs aside to give care to the professional.  This dynamic raises ethical concerns.
          In the formation section of the sutta, the last sentence in the first stanza states that one should not act in ways that wise people would criticize.  There is a collective wisdom about caring for others that transcends religions, cultures and generations but is also embedded in our religions, cultures and generations. We should be mindful to remember that as caregivers, we belong to a tradition and profession that has collected wisdom from the ages.  To be formed in this tradition involves some letting go of one’s own concepts of right and wrong in order to surrender to the human experience that transcends our own personal experience.
 
Reflection, Contemplation and Meditation
 
          The sutta states that one should reflect.  The practice of reflecting involves thinking and feeling.  It’s like the experience of being in a dream while you’re awake.  It’s not discursive as in connecting thoughts to create a coherent sentence.  It’s arriving at one thought and staying with that thought until it actually affects your way of thinking and being.  A pastoral caregiver in the Metta tradition should have a commitment to reflecting.  Reflecting on what?  “May all be happy and secure.”
          What does it feel like to reflect on a wish for the well being of all?  Knowing from experience the feelings of happiness and security, when I reflect (put myself in a dream-like state) on those feelings, imagining this feeling for all, I intensify the feeling.  I cannot bring to mind every living being in existence, but I can rid myself of feelings of resistance that arise when my mind discriminates against myself and others.  Should feelings of discrimination arise, I can also reflect:  “May all beings be happy at heart.” 
          To be happy at heart is not the same happiness that comes from getting needs and wants met — it even goes beyond feeling secure.  Happy at heart is about joy.  Touching on my own experience of joy, I move my internal experience from sympathy to empathy.   I go from guarded to emotionally vulnerable and because I do this, I feel tenderness and fear.  Why fear?  I’m reflecting on wishing joy for all.  If I’m really serious about all, that includes those who I feel have hurt me.  In my hurt, I learned how to protect myself from that person, or defend myself from similar attacks.  One way of protecting and defending is to withhold well wishes, love, affection, emotion, etc. from those who have hurt me.  A pastoral caregiver in this tradition is also asked to reflect on those who have hurt us, to wish for them deep joy.  Lastly, there is another category of beings -- we have not met them yet. 
          Living beings come in all shapes and sizes.  These shapes, sizes, sounds, beliefs, preferences, identities, personalities, etc. also form the texture of our prejudices, therefore the sutta says that one interested in reaching the state of peace should reflect positively on all beings no matter their strengths or weaknesses, no matter their height or width, whether you’ve seen these beings or have never seen them, no matter how close or far away they are from you and even if the being has yet to come into material existence.  Reflecting, as in a dream, that all beings be happy at heart, over time, transforms us from enemy to friend.  Pastoral caregivers in this tradition practice cultivating the quality of friendship toward all receivers no matter what.  The sutta states that one reaching the state of peace should not despise anyone anywhere.  Peace and hatred are mutually exclusive as are friendship and dishonesty.  The quality of friendship that comes with being a pastoral caregiver demands honesty.
          The Metta Sutta states:  Let no one deceive another.  Reflecting on the concept of deception, forming Right Intention, one makes a commitment to authenticity.  Why is authenticity so important in this tradition?  As the story of the Buddha’s life goes, Siddhartha’s father did everything in his power to deceive Siddhartha.  Immense suffering arose when Siddhartha learned the truth.  If caregivers are not honest with care receivers, caregivers become part of the problem — we create conditions for the eventual immense suffering people are likely to experience when they realize the truth, especially if that truth is the opposite of what the receiver has come to believe and accept.  Of course caregivers must be wise about what truths to tell, how to tell them and when, but authenticity is believed to be more comforting, ultimately, than obscuration.  The ability to be wise, honest and gentle is a great asset for the caregiver.
          When I think of images of pastoral caregivers, I think of sweetness, smiles, direct eye contact, affection and serenity.  Somewhere and at some time, the image of the pastoral caregiver has become a caricature — a one-dimensional, nice and non-confrontational pseudo-person.  In other words, pastoral caregivers are not supposed to feel anger, as if feeling angry is a sin or fault, indicative of poor spiritual formation.  One need not give up personhood to be a pastoral caregiver, but one need pay attention to what makes him or her angry, how often anger arises, and what is done in reaction or response to anger.  The sutta states:  “…Let no one deceive another or despise anyone anywhere; let no one through anger or aversion wish for others to suffer.”  I interpret this stanza to suggest that feelings of anger are permitted as long as hatred is not the consequence.  One way to avoid anger transforming into hatred is the practice of mindfulness.  Through mindfulness of feelings and sensations, we become aware of the tension and constriction in the muscles, and the sensation of heat in our skin.  Through mindfulness of breathing, we experience rapid breathing from the rise and fall of the chest, or the inability to take deep breaths to relax.  Through mindfulness of thoughts, we become aware of imagining pushing the other person away somehow, yelling at them, calling them names, cutting off the relationship, and or feeling a deep sense of satisfaction imaging that person failing, not getting what they want or being embarrassed.  Noticing some of these reactions or all of them, we then name it “anger.”  After we name it, we claim it.  We claim it to protect the care receiver from hatred, we claim it so that the receiver does not become the caregiver, and we claim it because we are the only ones who can transform it back onto the path of metta and karuna.
          The Metta Sutta is clear that loving-kindness is to be bestowed on every being by wishing them well, but the sutta does not stop there.  There must be an intense conviction to work toward cultivating loving-kindness.  If possible, it should be like the bond and attachment between mother and child.  Loving-kindness should be natural, fierce and pervade the universe at all times.  It should not be abandoned for a lesser state of being, ever.  That is the aspiration.  The pastoral care giver in this tradition should transmit and convey to the receiver a loving-kindness that is real.  It is embodied.  It does not discriminate.  It is not limited to the interaction between the caregiver and receiver, but pervades the space in which they meet.  This is how reflection and contemplation form the pastoral caregiver, yet there is another tool in the pastoral caregiver’s medicine bag — meditation.
Meditation
 
          Meditation is a spiritual practice shared by many religious traditions, but meditation is central to the spiritual life in the Metta tradition.  Why?  On a practical level, we learn to relax through meditation.  It is difficult to be loving, kind and compassionate when we are on edge.  On another level, meditation allows us to perceive more of what is happening in our lives and in others’ lives. This is important because pastoral caregivers need to perceive what is happening in them even as they perceive what is happening with the receiver.  This is how we form appropriate responses.
      Meditation, especially mindfulness of the body, allows us to understand how our bodies react to stimuli and forms a base of knowledge on how to understand how others’ bodies react.  It also reminds us of the essential commonality we share — we may have different opinions, different histories, different stories, but our bodies are made of the same elements.  Knowing our bodies are made of the same elements, and remembering that fact, the caregiver always has a point of reference, a point of commonality, and a source of empathy.
 
Mindfulness of the Body Exercise
 
     Mindfulness meditation of the body can be done with the body in practically any position:  sitting, lying down, standing or walking.  The point of the exercise is to put one’s attention on specific body parts, the various sensations throughout the body, and even imagining the various bodily functions that occur.  Here’s an exercise:
 
Sit comfortably in a chair in such a way that your body feels solid and supported.  Usually with feet flat on the ground, legs at a comfortable and natural distance apart, arms supported in such a way that there is not too much heaviness in the shoulders (arm rests or lap pillows are helpful), the chin tilted slightly toward the middle of the neck, the tongue at the roof of the mouth, with eyes gently closed.
With the body comfortable and alert, bring your attention to your toes.  Let your attention rest there for a few seconds before bringing your attention to your feet.  Rest there.  After resting your attention at your feet, bring your attention to your ankles, rest, then lower legs, rest, knees, rest, and upper legs.  In the mindfulness of the body practice, one is slowly moving their attention from the toes up toward the scalp, resting at each stop.  As you develop in this practice, you can imagine perhaps even feeling fluids in the body, like sweat forming in the hands, arm pits, and forehead.  You can feel the vibrations of the heart beating, or a pulse in the abdomen.  You can feel the pressure of gas building, bloating and releasing.   There may be throbbing, tension, pain and the absence of sensation.  Whatever is felt or not felt, mindfulness meditation of the body is grounding and allows us to remember our essential commonality — the body.  Pastoral caregivers are also called to attend to the body of the receiver, for it is the body (which includes the mind) where the receiver experiences this life.
 
Metta Meditation
 
          It is one thing to read the Metta Sutta, but it is another thing to embody it.  It is one thing to think it, but it is another thing to breathe it.  It is one thing to imagine it, and another thing to be it.  Embodying, breathing, and being loving, kind and compassionate takes practice in a society and culture that supports the notion of justice as punitive.  Much of the way we deal with our hurt, pain, disappointment and anger stems from an “eye for an eye” mentality. But as Gandhi one said “an eye for an eye makes the whole world blind.” We may have justice, but justice does not equal enlightenment.  As pastoral caregivers, we are called to pay attention to injustice, for many of whom we will care for have been treated unjustly.  The essence of our work is not justice making (though we certainly contribute positively to addressing certain wrongs) but escorting people on the path to wholeness.  Can we be pastoral escorts to the receiver if we harbor anger, resentment, hatred or indifference to the receiver’s wrongdoer?  It would be very difficult indeed, especially if our attention is on the wrongdoer.   Let’s reflect on the sutta again.
 
“May all be happy and secure;
May all beings be happy at heart.
All living beings, whether weak or strong,
Tall, large, medium, or short,
Tiny or big,
Seen or unseen,
Near or distant,
Born or to be born,
May they all be happy.
Let no one deceive another
Or despise anyone anywhere;
Let no one through anger or aversion
Wish for others to suffer.”
 
Let’s put these sentiments into a guided meditation.  Just like in the mindfulness meditation of the body exercise, get your body ready for meditation.  Bring your attention to your chest, your heart space.  Let your attention rest there until you feel a vibration.  If you don’t feel a vibration, do not worry.  Just note in your mind that you do not feel a vibration.  Say to yourself, “May I be happy.”  Take a few breaths.  Notice whether there is any resistance to your wish for you to be happy.  If there is resistance, notice it.  If resistance persists, gently shift your meditation to someone you know for whom there is no resistance. It may be that you can hold positive wishes for the receiver.  If you have no resistance to wishing yourself well, rest in this positive self-regard.  Starting a meditation practice can be difficult when there is resistance unexamined.  When examining resistance, be gentle and be true.  Resistance is just resistance…it is not the truth of existence, just resistance.  
          After resting after “May I be happy,” transition your attention to a living being for whom there is no resistance.  It may be someone you love dearly like a life partner, a child, parent or close friend.  Bring an image of them to your mind and say to yourself, “May ______  be happy.”  Rest.  Then bring your attention to someone who you don’t know well enough to have real positive or negative feelings towards.  Just like for yourself and the person close to you, you wish them well, “May ______  be happy.”  Rest.  If there is someone you don’t like, just like for yourself, your loved one, and the one you don’t know well, you wish for them the same happiness.  Bringing them to mind, rest with the feelings that come up for you when you bring them to mind.  Keep resting until you feel less tense.  “May ____  be happy.”  When thoughts arise that you believe justify your negative feelings, put your attention on your chest and heart space as a way of not getting caught up in your negative thoughts.  Be mindful of your body.  Recognize how difficult it is to love, be kind, and forgive those who have hurt, angered and disappointed you.  “May they be happy.”  And remember that no one said spiritual transformation would be easy.  Jesus implored God to forgive his persecutors for their ignorance.  We can wish all being happiness even if we can’t forgive them just yet.  We can wish that they experience forgiveness in the universe, even if we are not ready to release them from our negativity.  This is the meditation practice of metta.  Pastoral care giving is the service practice of love, kindness and compassion.
          The metta meditation practice can be extended beyond wishing ourselves and others happiness.  We can hold in our hearts a wish, a prayer, a chant or a meditation that all beings, including ourselves, feel secure, be healthy, and be free from suffering.  The Buddha said that one of the main components of suffering is clinging.  Clinging to hatred causes more suffering than hatred that comes and goes.  Why?  Modern neuroscientists have noted that clinging to thoughts makes it physiologically harder to let go.  It is as simple as that.
          Many pastoral caregivers in the metta tradition have sat in silent meditation retreats for several consecutive days reflecting on the sutta and practicing the loving-kindness meditation led and guided by dharma teachers.  For many, this practice has been a breakthrough to compassion, joy and liberation from suffering.  These retreats provide a solid foundation in the formation of metta pastoral caregiver.
Compassionate Care
 
          Having been formed in metta with mindfulness of the body and the metta and mindfulness meditations as breakthroughs to compassion, what does the compassionate pastoral caregiver do that may be different than other pastoral caregivers?  What we do may not be much different, but what we aspire to understand may be different if circumstances and wisdom suggests.  For example, there may be different ways of understanding care receivers. 
 
Assessing a need through deep listening and renunciation of proselytizing
 
          The Buddha said that there are three types of patients:  one who despite being well cared for, will not recover from illness.  Another type of patient is one who will recover whether or not he or she was properly cared for.  The other type of patient is one who will only recover because he or she got the proper treatment.  The Buddha likened these types of patients to types of people who could be more whole if they understood the Buddha’s teachings.  The one person/patient most in need of these teachings is the one who will most benefit from the teachings.  How, as pastoral caregivers, do we know who will best benefit?  Caregivers must discern the receiver’s issues as the receiver understands it.  Failing to understand the receiver’s issues as the receiver sees it risks precious time in establishing rapport. Metta pastoral caregivers know intuitively that the purpose of their work is not to prove who is right or wrong in their perceptions, but to join with the receiver, as much as possible, with their understanding of reality — at least initially.  Understanding that reality forms the basis for determining whether education is the medicine needed for the ailment of ignorance.  If ignorance is not the illness, education is not the cure.  The compassionate pastoral caregiver is mindful of the value of silence and listening for clues as to what is important to the receiver.
          The compassionate pastoral caregiver should be careful not to confuse an interest in communicating with a desire to be educated or proselytized.  Neuroscientists have discovered that it is the brain’s natural function to initially block perceptions that do not automatically conform to our sense of reality.  Therefore proselytizing can be expected to be met with resistance.  The patient/person for whom The Buddha’s teachings should be shared, is the patient/person for whom these teachings already mean something.  These teachings are not meant to be held as the truth, but as something that is meaningful to those who have found them helpful.  Some teachings from all traditions are meaningful to those who are a part of that particular tradition, therefore the compassionate pastoral caregiver should seek to know what teachings hold the greatest meaning for the receiver, not to teach them what they already know, but to remind them that they already have within them the internal psychic resource of meaning and meaning making.  Meaning is like a deep well that can quench the thirst for wholeness.  
Facing Illness
 
Spiritual and religious traditions, including the metta and karuna traditions, include stories about curing disease.  In some traditions, it is believed that only one person had the power to cure physical diseases, restore abilities and raise dead people to life.  In Buddhism, the disease to be cured was mental and emotional dis-ease, and the power to cure was in the hands of the afflicted — they just did not know or forgot they had the power. 
          In the Pali Canon, there is a story of an afflicted monk who was said to be gravely ill.  The Buddha said that if the monk remembered the ten perceptions, he might be immediately cured of his affliction.  The ten perceptions are:
 
1)  impermanence
2)  non-self
3)  foulness
4)  danger of disease
5)  abandoning
6)  dispassion
7)  cessation
8)  disenchantment
9)  impermance in all formations and
10) mindfulness of breathing.
 
For anyone not of this pastoral caregiving tradition, it is important to understand that the affliction to be cured is not physical disease, but mental and emotional dis-ease.  Looking at affliction as mental suffering, let’s apply the ten perceptions to one who is physically sick and is also suffering mental dis-ease, or non-contentment, to discover the efficacy of contentment. The instruction to the pastoral caregiver is as follows:
 
1)  Invite the receiver to reflect on the perception of impermance.  As reflecting on the Metta Sutta, the caregiver invites the receiver into a dream-like state where they keep their attention on the these facts:
a)       form is impermanent
b)      feeling is impermanent
c)       perception is impermanent
d)      volitional (images created in the mind) formations are impermanent
e)       consciousness is impermanent
 
The receiver is invited to reflect on and dwell in the fact that everything changes.  If reflecting on these facts brings acceptance, then the receiver is freed from clinging to the wrong belief that some things never change or should never change, like their health.
 
2)  Invite the receiver to reflect on the perception of non-self.  The concept of non-self is misunderstood by many who have tried to understand it without understanding the whole of the Buddhist teachings.  The Buddha taught mindfulness of the body, therefore it is not consistent with Buddhist teachings that there is no body.  I would recommend that the word “non-self” not be used; instead, the giver would probably do better to guide the receiver to reflect on the existence of consciousness, the part of the receiver that remains after dissolution of the body.  If the receiver understands the concept of non-self in a way that is healing, the instruction goes: 
 
a)       the eye is non-self
b)      forms are non-self
c)       odors are non-self
d)      the tongue is non-self
e)       the nose is non-self
f)       tastes are non-self
g)       mind-objects are non-self.
 
The receiver is invited to remember to not overly identify with the sense doors, that which is perceived through those sense doors, and that which is interpreted through those doors. Why is that?  Physical pain is experienced in the sense doors.  If the receiver overly identifies with the sense door as self, it is likely the pain will worsen, as well as prohibit the ability to gain perspective on the experience of pain.  The receiver becomes the pain itself, which makes it more difficult to dwell on consciousness.
 
3)  Invite the receiver to reflect on the foulness of the body.  The Buddha wasn’t much for hiding from any reality.  When we are physically sick and gravely ill, we begin to get in contact with the fact that our bodies are mushy, that the contents of our bodies stink, and that fluid oozes out in unattractive ways and unexpected places.  If we think our bodies are otherwise, the truth will be quite disturbing.  Rather than be reactive when fluids ooze and emit their odors, better to be proactive and reflect on the reality of our bodies.  The instruction is similar to the mindfulness of the body except we are instructed to reflect on:
 
a)       skin and flesh
b)      bones and bone marrow
c)       bowels and intestines
d)      excrement, bile, phlegm, pus and snot and
e)       urine.
 
There are a host of other aspects of the body to focus on, but if we reflect on the reality of the unpleasantness of the body, pastoral caregivers can help receivers face the fear of the loss of appearance and beauty.  With so much of our time spent on appearances and looking good, it is a gift to the receiver that the pastoral caregiver be able to accompany the receiver through this dramatic loss.
 
4)  Invite the receiver to reflect on danger (the widespread existence of disease).  Siddhartha was brought up by his father to believe that there was no such thing as disease for fear Siddhartha would be compassionate towards those who were afflicted with disease, and would therefore abandon his wealth and power.  In Western culture we “fight” disease.  We sometimes blame people for contracting diseases.  When people die from disease, we often say they fought a good fight.  All of this suggests that we have a collective resistance to the existence of disease.  How does being a part of this collective resistance help the person who actually has the disease?  We can understand why some sick people isolate themselves—we fight against an aspect of their condition because we reject it.  They overly identify with their illness, therefore they isolate before we get to reject them.  Do we think that by resisting disease we cure it?  Do we believe that passivity to disease is the only alternative to fighting it?  What about a middle way approach?  Rather than fight it or be passive in the face of it, we simply accept it and treat it.  How?  Invite the receiver to reflect:
 
a)       the body is the source of much pain and many dangers
b)      these dangers include diseases that affect the organs
c)       toothaches and coughs
d)      itching, scabs and jaundice
e)       cold, heat, hunger and thirst
f)       violence
g)      add whatever disease or ailment they are seeking treatment for.
 
5)  Invite the receiver to reflect on the presence of and abandon any thoughts of:
 
a)       sensual desire
b)      ill will
c)       violence
d)      evil
e)       unwholesomeness.
 
The caregiver’s role here is to guide the receiver away from discontentment of any kind.
 
6)  Invite the receiver to reflect on the feeling of dispassion.  In other words, having taken the receiver through the first five perceptions, they will have had a taste of dispassion, or letting go of craving.  The caregiver should ask them, “How does it feel to let go?”  or “When you let go of fighting your disease rather than accepting it and treating it, how did that feel?”
7)  Invite the receiver to reflect on the feeling of cessation, or the end of suffering.
8)  Invite the receiver to reflect on the feeling of disenchantment with the world.  Disenchantment is not hatred or dislike; it is the state of not being taken by illusions.  If one is not taken by illusions, they do not desire, crave, cling to, and crave more of that illusion.  They see illusion as illusion.
9)  According to the instructions, the receiver should, after proper pastoral guidance, be disgusted with all formations.  This seems harsh, especially out of context.  The context of these teachings is within a monastic order.  Monks in the Buddhist tradition were trained to adopt an aversion to the body to eliminate sexual desire.  Loving-kindness pastoral caregivers should be mindful not to impose teachings meant only for living a monastic lifestyle onto householders.
10)         Invite the receiver to practice mindfulness of breathing.  Mindfulness of breathing, after having reflected on the nine contemplations is a lot different than engaging in the exercise before reflecting because of the intense hindrances to meditation that can arise for an ill person in deep denial about their experience.  Typically it is taught there are five hindrances to mindfulness meditation:  sensual desire, ill will, sloth and torpor, restlessness and remorse, and doubt.
 
     Reflecting on the first nine perceptions, we can see that reflecting on foulness is a way to remove the hindrance of sensual desire.  Reflecting on abandoning helps remove the hindrance of ill will.  Mindfulness of breathing is a way to deal with sloth and torpor because it calms the body, helps clear the mind of agitation, and therefore provides rest, restoring energy to mind and body.  But what to do about restlessness and remorse?  Mindfulness meditation is an antidote to restlessness.  When dealing with remorse as a hindrance to mindfulness meditation, two avenues are worth traveling.  One, practice self-forgiveness and two, ask for forgiveness (if just in your heart) from those you have hurt.  Forgiveness, letting go of the power that past hurts and present resentments have over your willingness to engage with the perpetrators, can be difficult but is so liberating.  It is fair to say that there is no contentment without forgiveness.  It is also fair to say that oftentimes when the receiver becomes so ill that they begin contemplating their lives, issues of forgiveness arise.  People desperately want to be forgiven.  They want to enter the next realm, even if they are not sure whether there is another realm, with a clean slate.  I believe this is a universal tendency that pastoral care givers do well to remember.
Facing Death and Dying
 
          Pastoral caregivers in the metta and karuna traditions are usually exposed to teachings on death and dying.  Why is that?  Over the years we have learned that much suffering arises as the result of the fear of death and the experience of dying.  In our formation as pastoral caregivers, we are called and advised to tend to our own suffering and transform that suffering into the path of contentment, tranquility and liberation.  Our own experience on this path gives us deeper insights into caring for the receiver.  How we help them transform their suffering, even as they die, may be informed by how we transformed our own suffering.  The Metta Sutta states, “May all be happy and secure…all living beings, whether weak or strong.” Understanding the spirit of the sutta as being inclusive of all living beings, we can interpret the sutta to also include the dying beings that are still alive.  May they also be happy at heart and secure.  How can one who is dying be secure?  Let’s begin with The Buddha’s teachings.
          It is said that a holy high priest approached The Buddha to argue a point:  There is no one who does not fear death.  The Buddha did not agree.  The Buddha said that there are four kinds of people facing grave illnesses that grieve, lament, and moan over the loss of sensual pleasures (that which is pleasing to the senses).  The one who is not afraid of death is not afraid because he or she is free from lust for sensual pleasures, desire and craving.  The one who is not afraid is the one whose mind is absent of grief over loss and is free from the consequences of having done bad acts.  This fearlessness is also the manifestation of having done good acts.  They are free from doubting the value of their beliefs and practices.  This is the person who is not afraid of death.  It is the pastoral caregiver’s responsibility to incline themselves towards fearlessness in the face of the inevitable — death.  How is this practiced?
The pastoral caregiver, well-formed in this tradition, has engaged in a practice called The Five Remembrances.  The basic practice is a contemplation practice that involves stilling the body and reflecting for some time on five facts of their life:
 
1)  I am subject to aging, I cannot avoid aging.
2)  I am subject to illness, I cannot avoid illness.
3)  I am subject to death, I cannot avoid death.
4)  I will part from all who are dear to me, I cannot avoid this parting.
5)  My actions carry consequences, I cannot erase the impact of my actions.
 
The Five Remembrances, like many of the teachings attributed to the Buddha, was written in the Pali language.  The rendering above is a simple explanation of the crux of the practice.  Remembering the fact of the impermance of our physical self, followed by another humbling fact— I am powerless— holds the potential to lust less for sensual pleasures and grieve less over loss.    
I have found it important to state the fact of our physical existence and immediately follow it with the humbling fact (powerlessness) as a technique to not engage in denial, delusion or folly.  For example, I could contemplate, “I am subject to aging.”  pause, then allow the resistance to arise in the form of wishful thinking like, “Yeah, but I’m going to keep telling people I’m 29 when really I’m 40.”  This practice says, in essence, it is a waste of time to go there, just accept the humbling fact of your powerlessness, understanding it deeply, then live your life.
          When I introduced this practice to my meditation community, I introduced it in such a way as to illustrate the broadness of the Buddha’s teachings on the body, the personality, the identity and nature.  Later, recognizing that these teachings, in the hands of those who may be so depressed and suicidal that they are misconstrued as an invitation to kill oneself, I introduced the teachings as The Five Remembrances Plus One Precept:
 
• I will not cause the death of any living being.
 
• The composite materials in fire, water, wind, wood, soil, DNA, other elements, along with this personality and identity, all together called “I,” is subject to aging.
 
• The composite materials in fire, water, wind, wood, soil, DNA, other elements, along with this personality and identity, all together called “I,” is subject to illness.
 
• The composite materials in fire, water, wind, wood, soil, DNA, other elements, with this personality and identity, all together called “I,” is subject to death.
 
• The composite materials in fire, water, wind, wood, soil, DNA, other elements, with this personality and identity, all together called “I” will dissolve and separate from other composite materiality that is also subject to aging, illness and death.
 
• As I exist, I exist in relationship with the elements that make up all of life, therefore my thoughts, speech and actions carry consequences and karma. What is left after dissolution is karma and consciousness.
 
• I will not cause the death of any living being.
 
I believe it is important to begin and end this practice with the precept of refraining from killing because these teachings can be wrongly misconstrued as an invitation to prematurely bring about the inevitable.   Nothing about the the Buddha’s teachings would support such an interpretation.  Also, I expanded the facts to illustrate, from a mindfulness of the body reflection, that we all share, on a physical level, the same elements found in other natural things.  What we call “I” includes what we are made of, and also our ways of being, called the personality.  The “I” also includes how we see ourselves and how others see us–what we call identity.  Our bodies, our personalities, and our identities will dissolve, but in this tradition, something remains.  Some call it the soul, others call it spirit, some consciousness, ghosts, others atman.  In Taoism they say it is nameless.  Traditions share the belief that something remains after the dissolution of the “I” and it is the recognition of this something that pastoral caregivers are called to attend to.
     
Conclusion
 
          Pastoral care giving in the Buddhist tradition is about 2,600 years old.  Enlightened care involves the practices of metta and karuna.  It also involves cultivating wisdom that comes through the experience of giving pastoral care to a variety of people in a variety of circumstances.  Ultimately, pastoral care in the metta and karuna traditions means helping receivers experience contentment, for it is contentment that is healing.
          In Buddhism, one will find a long tradition of pastoring beginning with the Buddha as an itinerant teacher/minister/preacher of the truth as he experienced it— the dharma.  His primary pastoral role was teaching people the truth about human existence, and instructing them on how to live with more contentment.   The Buddha predates modern western medicine; therefore the suttas do not address healing and curing through medicine and surgery.  The Buddha’s healing terrain was the mind and he explored through his own mind how a contented mind eases bodily stress.   We now know, through modern science, how stress can lead to a variety of physical illnesses.   The Buddha had a few prescriptions for what ailed his followers.
The Buddha prescribed the Eightfold Path, loving-kindness, compassion, perfections of character, mindfulness, the ten perceptions, the Five Remembrances, and the practices of reflecting and meditating to help pastoral caregivers and care receivers interact in such a way as to be healing to both parties involved.  The formation of pastoral caregivers is not an overnight process, but the healing that can take place for a care receiver guided by a well-formed caregiver who is perceived by the receiver as authoritative, can be sudden.
          Dharma Care (Part I) does not include all of the Buddha’s teachings on pastoral care.  This handbook touches on just a few aspects of the teachings.  May this handbook be of benefit to you and those you serve in your family, community, spiritual home, hospital, hospice, prison, school, and anywhere you find people in need of pastoral care.
 
 
 
 
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