Considering Life (Inochi) Care: What Sort of Spiritual Care can be Adapted to Japanese Spirituality?
Public Symposium sponsored by the Rinbutsuken Institute for Engaged Buddhism and the Kyoto University Kokoro (Heart-Mind) Center Kyoto
September 15, 2016

Recently in Japan, there is increasing energy towards cultivating religious professionals for practice and service in various clinical (rinsho) environments. From the standpoint of the Rinbutsuken Institute for Engaged Buddhism, we have the basic goal to further develop this movement beyond the present dominant model of “spiritual care”, which derives from the Christian religious cultural tradition, to a more indigenous model of “life (inochi) care”, which is part of the Japanese religious cultural tradition. In this way, we as Buddhists are working with medical professionals to develop ways to contribute to the physical and mental security of ordinary people living in the midst of the sufferings of birth, aging, sickness, and death.

While the Rinbutsuken Institute’s Buddhist chaplaincy program has had students from all over Japan in its initial two full program cycles, this symposium was the first attempt to hold a public event outside of the Tokyo-Kanto region to raise greater regional awareness of the program. We are extremely grateful to the Kyoto University Kokoro (Heart-Mind) Center and one of its leading researchers, Prof. Carl Becker, for hosting and supporting this very meaningful event. The Center describes its core work as “promoting scientific research on the mind and consciousness, which spans the disciplines of psychology, neurophysiology, cognitive sciences, cultural studies and the humanities”. As it aims to develop community outreach solutions and to contribute to a humanity and mentality suited to life in the coming global era, the Rinbutsuken Institute found it an ideal partner for hosting its first public event in the Kansai region.

In order to appeal to a wide audience and demonstrate the ecumenical and inclusive nature of true Buddhist chaplaincy, we were blessed to have a diverse panel of speakers: Sister Yoshiko Takagi of the Sophia University Grief Care Institute; Dr. Gen Oi, Professor Emeritus of Tokyo University specializing in terminal care; Rev. Mitsuhiro Tanji, the President of the Rinzai Zen based Hanazano University who specializes in clinical psychology; Rev. Hitoshi Jin, Director of the Rinbutsken Institute; and Prof. Carl Becker.

Five Approaches to Spirituality

Christianity and Spiritual Care

Sister Takagi expressed her gratitude and joy that the symposium was an interfaith event. She herself has much respect for Buddhist teachings and their history in Japan. Some people have asked her why she often invites Buddhists to talk at her Catholic university, and she responds that since Japan is a Buddhist country, it is only natural to do so.

She then explained that there is always the challenge of how to explain the concept of “spirituality” to Japanese. For Catholics, “spirituality” is an every day term and concept, which comes in facing God and one’s relationship with Him. However, Japan, with its Buddhist and Shinto base, has traditionally never had this concept of a single creator God. In this way, Sister Takagi tried to explain “spirituality” as the greater source of life of our individual lives that all people are connected to. Therefore, the result of living our lives in connection with God makes our lives deeper and more meaningful. For Japanese, this connection is then not difficult to make as they have daily “spiritual” practices that keep them in connection with their ancestors or Buddhist deities, like Kannon Bodhisattva or Amida Buddha. Sister Takagi noted that we can also call spiritualty as “good mind” (yoi-kokoro) in order to find the meaning of suffering in our human lives as well as consider the existence that happens after death.

Sister Takagi finished her talk by explaining that spirituality is considered in the contemporary professional care world by groups like the World Health Organization (WHO) in terms of basic human well being. Spiritual pain and its resolution is considered one of the four basic areas of human health. In these terms, for Sister Takagi, spirituality is the intersection of the physical, the social, and the spiritual where we discover the greater source of life. The more we relate to this greater source of life, the more its feeds into other aspects of our lives. She noted that we can call this greater source of life anything we want and there are many ways to express or speak of the spiritual. In this way, spiritual care deals with spiritual pain, which is directly related with the meaning of life and the afterlife, something that religion has special skills in dealing with.

Neuroscience, Buddhism, and Caring for the Elderly

Dr. Gen Oi gave a fascinating talk relating medical science and Buddhism to care for the elderly. He began by noting how the Buddha reflected on his own decline and death at age 80 in the Mahaparinibbana Sutta of the Pali Canon. At this time and at others, the Buddha taught about one’s body and self being nothing but the Five Aggregates (kandhas) of form, feeling, perception, thought, and consciousness. However, he also taught about the 4 Nutriments (ahara) of Consciousness that form life:

Monks, there are these four nutriments for the maintenance of beings who have come into being or for the support of those in search of a place to be born. Which four? Physical food, gross or refined; sense contact as the second, intellectual intention the third, and consciousness the fourth.

Mahatanhasankhaya Sutta: The Greater Craving-Destruction Discourse
Majjhima Nikaya ? Middle Length Discourses
MN 38/M i 256

From this explanation of how awareness arises, Dr. Oi looked at the challenge of dealing with dementia in the elderly, which of course deals directly with the problem of awareness and consciousness. Dementia in Japan afflicts 1/3 of all people over 80 and 1/2 over 90. In 2013, 24% of Japanese over 65 experienced it, and by 2060 this rate is estimated to be 40%. One of the core issues among patients is the great anxiety and fear of slowly losing connection. Dr. Oi noted that it is thus very important to support them to maintain and develop communication. This is best accomplished by interacting with a patient’s modes of feeling rather than thought. Dr. Oi noted that looking at these Buddhist textual references again, these modes include touch (physical), sound (music), and facial expression (smile). The importance of these modes of feeling are revealed in studies on the healthy development of babies who get these three things at an early age.

Dr. Oi further explained that we have learned from neuroscience that 95% of what we experience is registered subconsciously. These conclusions dovetail with those in Buddhism, especially the ideas expressed in Yogacara. To summarize briefly the Yogacara thinkers took the theories of the body-mind aggregate of living beings that had been under development in earlier Indian schools and worked them into a more fully articulated scheme of eight consciousnesses, the most important of which was the eighth, or store consciousness (alaya-vijnana). The store consciousness was explained as the container for the karmic impressions (called seeds) received and created by living beings in the course of their lives. The thinkers of this school attempted to explain in detail how karma operates in an individuated manner. Included in this development of consciousness theory is the notion of conscious construction?that phenomena which are supposedly external to us actually cannot exist but in association with consciousness itself. The main implication of this notion is that the problems human beings experience in terms of ignorance and affliction are all due to the erroneous closure of consciousness brought about by our imagining consciousness, which actually serves to make it impossible for us to have a direct experience of reality.[1] From this interface with Buddhism and Neuroscience, Dr. Oi concluded that we live in a world of meaning and so the key with patients with dementia is to keep emotional connection with them.

Clinical Psychology and Care Givers in Disaster Areas

Rev. Mitsuhiro Tanji approached the topic of spirituality from the standpoint of clinical psychology. First, he reflected on popular images of spirituality, such as the sunset, a river in a forest, meditating outside, etc. He expressed some reservations that although Japanese are trying to reconnect with spirituality, there is a tendency to romanticize it and attach to it like a kind of “spiritual materialism”. In this way, we are seeing all sorts of workshops and training courses in spirituality and spiritual counseling being offered at incredibly high prices. Rev. Tanji noted that there are also an increasing number of associations in Japan studying spirituality and even two different transpersonal psychology associations.

There are a variety of clinically developed research tests for spirituality, like the Spirituality BAS Test, which indicate those with a stronger sense of spirituality are better able to cope with stress. This can also be seen in the long term success of the 12 Step Program of Alcoholics Anonymous and its numerous references to God and “a power greater than ourselves”. However, like Sister Takagi, Rev. Tanji spoke of the difficulties of defining the concepts of religion and spirituality in a specifically Japanese context. Looking at the influential work of Harold G. Koenig, a psychiatrist at Duke University in the U.S., he noted that Koenig’s definitions of religion and spirituality, especially in reference to a transcendent, higher power, do not really reflect nuances in the Japanese mind.

The aftermath of the 3/11 earthquake, tsunami, nuclear incident disasters has been pushing a deeper inquiry in these fields. Rev. Tanji noted that the first reaction to concerned people outside of the region was to become volunteers in the disaster areas. A number of clinical psychology groups in Kyoto sent volunteers to Fukushima for a week to help school counselors with traumatized children, like one boy who felt extreme guilt for leaving his grandmother behind to die while he escaped. However, these volunteer programs usually lasted only a week and could not offer much significant support for people with major trauma. Both the Rinbutsuken Institute’s Buddhist chaplaincy (rinsho-bukkyo) training program and the Tohoku University clinical religious professional (rinsho-shukkyo) training programs emerged out of this crisis and have sought to incorporate important aspects of psycho-spiritual care while training religious professionals in counseling work. These initiatives have begun influencing Japanese religious institutions, for example, Rev. Tanji’s Myoshin-ji Rinzai Zen denomination has started to train Buddhist priests in deep listening skills to act as volunteers in various emergency areas around the country.

From Spiritual Care to Life Care

Rev. Tanji’s talk led seamlessly into Rev. Hitoshi Jin’s presentation on the development of Rinsho Buddhism in Japan. In developing the Rinbutsuken Buddhist chaplaincy program, we have done significant research on chaplaincy programs around the world, specifically the Clinical Pastoral Education (CPE) system in the United States and the Association of Clinical Buddhist Studies in Taiwan. The Rinbutsuken Institute has created a formal partnership with the Association in Taiwan and its sponsors at the Buddhist Lotus Hospice Care Foundation and the National Taiwan University Hospice (NTUH) and Palliative Care Unit. Over the past three years, Rev. Jin and a small group of Japanese Buddhist chaplains-in-training have been able to do short intensive programs at NTUH to gain valuable experience in working in professional medical environments, which are still largely not accepted or allowed by Japanese medical institutions. Some of the elderly patients at NTUH are still able to speak Japanese from the war period, so Rev. Jin and his students have been able to not only learn from their Taiwanese monastic cohorts but also gain some experience working directly with terminal patients.

One of the most important aspects of the work being done in Taiwan is that they have developed their own indigenous concepts and practices for terminal care. As the previous speakers noted the problems of applying modern, western concepts of spiritual care to Japanese cultural contexts, the founders of the training program at NTUH felt the need to create a specifically Chinese and Taiwanese approach to psycho-spiritual care. Based on Buddhist concepts of meditative awareness and an understanding of the human as consisting of body, feeling, mind, and dharmas (i.e. the Four Foundations of Mindfulness as taught in the Satipatana Sutta), as opposed to the binary of body and spirit, they have developed the concept and practice of “awareness care”. The co-founder of the program, Ven. Huimin, explains, “Through deeply recognizing the four aspects of a patient, their own body, feeling, mind, and dharma, they can develop a keen awareness and equanimity. By practicing this kind of ‘awareness care’, we can help the dying person to purify their mind and at the same time enter the dharma of the fundamental practice of Buddhism.[2]”

In a similar vein, Rev. Jin noted that he has begun to use the term “life care” (inochi-no-kea), instead of “spiritual care” (supirichuaru-kea). Rev. Jin explained that the Japanese term for “life”, inochi, can be spelled using the Chinese character 命, but this has more the sense of physical life, one’s actual life span. Using the Japanese hiragana script いのち offers a broader meaning, encompassing existential aspects, like the Buddhist term dharma. As an indigenous term, it is evocative and leads to deeper reflection on its meaning, rather than the empty sound of a transliterated foreign word. Rev. Jin noted that this concept of inochi as spirituality is similar to Sister Takagi’s three fields of social, spiritual, and physical, but not as the their intersection, rather the entire realm of them. For Rev. Jin, spirituality as inochi is connected to the Sanskrit term prana, often translated as “breath” or “life force”.

Japanese Buddhist “Spirituality” and Grief Care

After these four main talks that addressed the nuances in developing psycho-spiritual care in a modern context in Japan, the symposium concluding with a lengthy reflection by our host Carl Becker and a panel discussion on the above themes. Prof. Becker has lived for the past thirty years in Japan, the latter half as a professor at the Kyoto University Graduate School of Human and Environmental Studies and the Kyoto University Kokoro (Heart-Mind) Research Center. During this time, he has participated in projects for Japan’s Ministry of Science and Technology and Ministry of Education, and cofounded the Japanese English Forensics Association, the International Association for Near-Death Studies, and the Society for Mind-Body Science. He also counsels suicidal clients, terminal patients, and bereaved students, and conducts workshops on improving medical communication and preventing nurse burnout. He thus has impeccable credentials for evaluating this attempt to develop spiritual care to more Buddhist and more indigenous Japanese contexts.

Prof. Becker began his response by challenging the speakers and the audience about the many people in Japan who have lost all connection with spirituality and as they age are experiencing increased levels of despair and suffering. He warned that the popular spirituality of praying at shrines and temples for this-worldly benefits, like passing exams or finding a husband, do not provide a tangible spirituality to deal with the deeper sufferings in life, especially as one nears death. Prof. Becker reminded the audience that caring for the aged and dying has been a concern of Japanese Buddhists for 1,500 years. From the 9th to the 19th century, Japanese priests kept records of the deathbeds of their most famous monks and parishioners.[3] He emphasized that this Buddhist tradition is not merely of historical interest; it holds tremendous resources for helping people to age and die gracefully, peacefully, honorably, in some cases even beautifully. Another important insight of Buddhism is that death seriously affects the bereaved and society as well as the dying person. The Japanese Buddhist tradition of ceremonies following the wake, at one week, three week, and seven week intervals, followed by the first summer Obon celebration and periodic ceremonies thereafter, serve as valuable occasions to address the grief of the bereaved. Prof. Becker noted that if these ceremonies fossilize into rituals that no longer attend to the needs of the bereaved community, they lose this important function. Much of Prof. Becker’s medical research over the years has shown that bereaved people who participate in follow-up counseling sessions escape many of the problems that typically follow the loss of a loved one. Those problems typically include depression, reduced immunity, increased sickness, absenteeism, accidents, even sudden death and suicide attempts.

Conclusions

In the final panel discussion, Rev. Daihaku Okochi, a Jodo Pure Land denomination priest and Senior Research Fellow at the Sophia University Grief Care Institute, followed up on Prof. Becker’s comments by asking, “What specifically is the kind of care that we are aiming for here?” In response, Rev. Tanji emphasized the centrality of deep listening, without a goal, but for understanding in order to create a human connection that is horizontal and not from a person above, like a well-adjusted psychotherapist or enlightened priest, helping someone below, like a traumatized patient with no spiritual resources of their own. He noted that this is very difficult work for the caregiver with high risks when one gets in close with someone’s fears.

Dr. Oi gave a fascinating response as a doctor who himself has become an elderly patient. This past year he had a serious illness but his efforts to develop his own spirituality actually enabled him to face his hospital stay in a joyous mood. He recalled the teachings of Vietnamese Buddhist master Thich Nhat Hanh about the total interconnection of all phenomena and seeing lost family members in the clouds. He noted that it is indeed not about our “being” but our “interbeing” as Thich Nhat Hanh teaches. This realization kept him bright and happy in the hospital, because he understood that everything was within him and that he lacked nothing. He concluded by then shifting the perspective to the macro level and emphasizing that “life (inochi) care” involves caring for the environment and working to stop global warming.

Sister Takagi spoke that after 31 years of being involved in terminal care, the hardest work is grief care and what comes after the death. The bereaved may feel that there is no god or ancestral spirit (hotoke) or anyone who listens to their pleas. As with Rev. Tanji and the other Buddhist speakers, Sister Takagi emphasized the very difficult but fruitful process of process of working together to mutually investigate suffering.

To conclude the entire symposium, Prof. Becker noted that as recently as sixty years ago, shortly after World War II, international Fear of Death surveys ranked the Japanese among the least death-fearing people in the world. Within the forty years between 1960 and 2000, among the dozens of countries surveyed, Japan had become the most death-fearing country in the world. So the challenge, he noted, is to come in touch with death again. He reflected on the situation 20 years ago and how having this kind of panel and discussion at Kyoto University would have been impossible. So he reflected that today’s event and the activities of all the panelists are good signs of change, while it would be even better if all universities in Japan could show an interest in these issues.

Written by Jonathan S. Watts, Research Fellow, Rinbutsuken Institute for Engaged Buddhism

[1] the Yogacara school 瑜伽行派. Digital Dictionary of Buddhism. Edited by A. Charles Muller.
[2] Huimin, “The Cultivation of Buddhist Chaplains Concerning Hospice Care: A Case Study of Medical Centers in Taiwan,” trans. Jonathan Watts (lecture, Dharma Drum Buddhist College, Taiwan, September 29, 2009) in Buddhist Care for the Dying and Bereaved. Eds. Jonathan S. Watts & Yoshiharu Tomatsu (Boston: Wisdom Publication, 2012). pp. 115-16. Link to chapter
[3] For more on this topic see Becker’s Breaking the Circle: Death and the Afterlife in Buddhism (Carbondale: SIU Press, 1992) and Death and the Afterlife in Japanese Buddhism. Edited by Jacqueline I. Stone and Mariko Namba Walter (Honolulu: University of Hawaii Press, 2008).