The International Journal of Psychosocial Rehabilitation
Warmth and Challenge as Common Factors among Eastern and Western Counselors?
Buddhist Lamas’ Responses to Western Questionnaires

Peter Elsass1, Michael Helge Rønnestad2, Christian Gaden Jensen1, & David Orlinsky3

1 Center for Humanistic Health Research, Department of Psychology, University of Copenhagen.
2 University of Oslo
3 University of Chicago

Elsass P, Rønnestad MH,  Jensen CG & Orlinsky D. (2017) Warmth and Challenge as Common Factors
among Eastern and Western Counselors? Buddhist Lamas’ Responses to Western Questionnaires

 International Journal of Psychosocial Rehabilitation.Vol 21 (2)  57-69


Funding for this work has been received from Carlsberg Foundation and Danish Council for Independent Research.

Karma Lhundup and Thupten Phuntsok. Tibetan Torture Survivor Program (TTSP). The Department of Health, Central Tibetan Administration. Dharamsala. India.
And to Ea Carøe and Antonia Sumbundu for their practical help and inspiration in the project.

Our purpose was to investigate the internal consistency of Western oriented counseling questionnaires in a sample of Tibetan Lamas, and thereafter to investigate these Lamas self-perceptions and practice as spiritual counsellors and thus adding to  our understanding of what might be common factors in counseling practice across cultures.
A sample of high ranking Tibetan Buddhist Lamas responded to The Five Factor Mindfulness Questionnaire, FFMQ (N= 68), to selected parts of the Development of Psychotherapists Common Core Questionnaire (DPCCQ) (N= 74), and an open-ended questionnaire requesting a description of the Lama’s counseling practice (N= 74).
Our study differs from other questionnaire studies foremost by the sample consisting of high ranking Tibetan Lamas doing psychosocial work. With respect to the complexity of Buddhist spiritual counseling, our results nevertheless suggest that counselor relationship styles of ‘warmth’ and ‘challenge’ may be common factors in both Western and Eastern counseling.

Keywords: Counseling. Questionnaires. Mindfulness. Cross-culture.

There are substantial theoretical and methodological challenges involved in the study of Western counseling methods in an Eastern context. Healing practices in the East mostly take the form of spiritual counseling offered by religious clerics as a form of ‘pastoral care’ concerning both the social, personal psychological and spiritual religious problems of believers. For example, in Buddhists monasteries high-ranking Lamas do receive people in a separate room outside the prayer halls in order to listen to their problems and give them guidance and support.

Few empirical studies of the similarities and differences between counseling in the West and East have been done. Some exceptions are described below.
Christopher, Christopher and Charoensuk (2009b) used several measures designed to assess the Western conceptualization of mindfulness in a sample of 22 Thai Therava-da Buddhist monks. For comparative purposes they also included small samples of college students from Thailand (a predominantly Buddhist culture) and the U.S. However, internal consistency values were reported only for Thai and American student samples and not for the Buddhist monks. Their study provided evidence for the cultural validity of the mindfulness questionnaires, such as the Mindfulness Attention Awareness Scale (MAAS) and the Kentucky Inventory of Mindfulness Skills (KIMS), in this population, and relationships between facets of mindfulness and other constructs were documented as generally expected on theoretical grounds. In another study, Deng, Liu, Rodriguez and Xia (2011) investigated the psychometric properties of a Chinese version of Five Facet Mindfulness Questionnaire (FFMQ) in a non-clinical student sample and found acceptable internal consistency and the test-retest reliability, suggesting that the Chinese version of the FFMQ has acceptable psychometric properties and is a valid instrument for the assessment of mindfulness (Christopher, Christopher, et al., 2009a). However, in a study by Jong (2013) among Chinese adults, the FFMQ subscales showed lower Cronbach alpha coefficients than in the US validation study of Baer, Smith, Hopkins, Krietemeyer and Toney (2006).

Another kind of empirical study of similarities and differences in counseling between the West and East has been done with the Development of Psychotherapists Common Core Questionnaire (DPCCQ) (Orlinsky et al., 1999). This instrument was initially formulated to assess psychotherapeutic practice and development by a group of American and European psychotherapists/researchers but their international studies have included therapists from Asian countries such as South Korea, China, India and Malaysia.

Since a number of Western practitioners (e.g. Germer, Siegel & Fulton, 2005) have argued that the attitude of mindfulness is an important part of most psychotherapy practice, empirical studies of mindfulness and therapeutic practice might be compared. Furthermore, Bentley (2008) argued that mindfulness training may be an important tool for the educating young Western therapists and declared that the commons factors for effective psychotherapy include an aspect of mindfulness (e.g., the ability to strategically control attention so as to genuinely empathize with a client).

The aims of this study:

Our general interest is in how Eastern counsellors respond to the Western conception of mindfulness and Western conceptions of psychosocial interventions. Our purpose was to investigate the internal consistency of Western oriented counseling questionnaires in a sample of Tibetan Lamas, and also investigate these Lamas self-perceptions and practice as spiritual counsellors, thus adding to  our understanding of what might be common and specific factors in counseling practice across cultures

With the support of an introduction letter from His Holiness the Dalai Lama, 74 high-ranking Lamas responded to two Western questionnaires, an open-ended written inquiry, and for some a videotaped interview about their work.

The Five Factor Mindfulness Questionnaire (FFMQ), (Baer, et al., 2006). As suggested by Ember and Ember (2001), the items of the FFMQ were first translated into Tibetan and then back-translated into English. The original translation was performed by the author TP and the back-translation by the author KL, both bilingual Tibetan Lamas.
Development of Psychotherapists Common Core Questionnaire (DPCCQ) (Orlinsky et al., 1999). Selected parts of the DPCCQ were used that focused on therapists’ relational manner and therapists’ goals. The translation procedure was identical to the one for FFMQ.

An open-ended questionnaire. The Lamas were asked to describe their counseling practice in their own words.

The internal consistency of the FFMQ was calculated using Cronbach’s alpha statistic, and on DPCCQ items that combined the affiliation and control dimensions of relational manner.

Participants consisted of 74 Tibetan high ranked Lamas of Geshe status, including 5 women and 69 men from 6 different monasteries in North and South India: Nechung Monastery, Gaden Cheoling Nunnery, Namgyal Monastery, Gyuto Tantric Monastery, Gaden Jangtse Monastery, and Depunk Monastery. Geshe status corresponds to a master degree with a dissertation and a defense. The average time for these participants leading to the Geshe status was 3.9 years. The duration of practice as a spiritual counselor was distributed as follows: 7 (7 to <10 years); 15 (10 to <15 years); 26 (15 to <20 years); 26 (20+years).  All 74 participants answered the DPCCQ, but 6 lamas were not present when the FFMQ was administered.

The six monasteries were contacted by the two authors XX and XX. The letter of support from His Holiness the Dalai Lama informed the administration at the monasteries of the purpose: ‘To understand aspects of mindfulness and counseling among Tibetan Lamas by the use of Western Questionnaires’. Only the monks who were engaged in counseling in Buddhist asylums or of lay people were included in the study. Their participation was anonymous. As the questionnaires were time consuming, they were administered on two occasions with an interval of one to three weeks. The authors XX and XX distributed and collected the questionnaire, and made detailed written notes of any comments made by the Lamas. On some occasions the Lamas’ work with the self-report questionnaires were videotaped. After data collection, the two Tibetan co-authors also gave their comments and evaluation of the questionnaire study directly to the video camera.

1. The mindfulness questionnaire study
The FFMQ was selected as the most comprehensive mindfulness measure, as it was based on common factors extracted from a pool of items from five other mindfulness questionnaires (Mindfulness Attention Awareness Scale, Freiburg Mindfulness Inventory, Kentucky Inventory  of Mindfulness Skills, Cognitive and Affective Mindfulness Scale, and Southampton Mindfulness Questionnaire). The developers of the FFMQ (Baer, et al., 2006) conducted exploratory and confirmatory factor analyses on all of the items from these measures to derive the five subscales of the FFMQ, which tap into the following aspects of mindfulness: (1) Observing (noticing internal and external stimuli, including sensation, emotion, cognition, visual perception); (2) Describing (noting or mentally identifying internal experiences with words); (3) Acting with awareness (focusing on one’s current activities, as opposed to behaving automatically or absentmindedly); (4) Non-judgment of inner experience; (5) Non-reactivity to inner experience. Items were rated on five-point Likert scale.

The FFMQ has been one of the most widely used scales in previous studies of mindfulness. Studies have demonstrated its psychometric properties in different samples (Baer, et al., 2008), and recent reviews provide empirical support for its validity in measuring the mindful experience (Baer et al., 2008; Lykins & Baer, 2009; Piet & Hougaard, 2011). It has been translated into different languages and validated in various populations (Deng, et al., 2011; Lilja et al., 2011; Veehof, Ten Klooster, Taal, Westerhof, & Bohlmeijer, 2011). Several recent randomized controlled trials have used FFMQ to measure changes of mindfulness before and after mindfulness-based interventions, and have revealed different patterns of change in the five components of mindfulness (Duncan et al., 2012; Hou, Wong, Lo, Mak, & Ma, 2014; Robins, Keng, Ekblad, & Brantley, 2012; Vollestad, Sivertsen, & Nielsen, 2011).

2. The therapeutic practice questionnaire study
Sections of the DPCCQ which address therapeutic practice were included in this study. The DPCCQ is a comprehensive, multi-part instrument designed to assess different aspects of the therapists’ experiences of therapeutic work and professional development. Detailed descriptions of the instrument can be found elsewhere (Orlinsky, Ambühl, Rønnestad et al., 1999; Orlinsky & Rønnestad, 2005). The instrument is organized in nine sections and includes 370 items mainly with a structured response format. At present, data from more than 11,000 therapists of varying professions, nationalities, theoretical orientations and experience levels have been collected. Factor analyses of item sets have generated both first and second order factors used to generate scales of satisfactory reliability. Different item-sets have been found to differentiate between numerous parameters such as therapist experience level, gender, theoretical orientation and work-setting (Orlinsky & Rønnestad, 2005). Sections of the instrument have been found to predict client-rated working alliance and therapy outcome (Nissen-Lie, Monsen, Ulleberg, & Rønnestad, 2012) and differential alliance and outcome in short and long term psychotherapy (Heinonen, Lindfors, Härkänen et al., 2013; Heinonen Lindfors, Laaksonen & Knekt, 2012). For our study of the Lamas, three central sections of the DPCQ were included focusing, respectively, on therapeutic goals, therapists’ reports of their professional relational manner (how they relate to clients), and coping strategies when difficulties are experienced.

Professional relational manner:
The quality of the therapeutic relationship has consistently been demonstrated to predict therapy outcome (Crits-Christoph et al., 2013; Orlinsky, Rønnestad, & Willutzki, 2004). In the DPCCQ, 16 items to measure relational manner were based on Leary’s (1957) circumplex analysis of interpersonal behavior, which meaningfully combines the two bipolar dimensions of affiliation (attraction/rejection) and control (dominance/dependence). To assess therapists’ relational manner, respondents were asked to describe their style or manner as therapists when relating to clients on a 4-point scale ranging from 0 (not at all) to 3 (very much).

Therapeutic goals: Therapeutic goals serve an instrumental function that provides direction and purpose for both therapists and clients, and an evaluative function, as criteria for assessing therapeutic effectiveness (Orlinsky & Rønnestad, 2005). The goals included in the DPCCQ represented various theoretical orientations. For this study, respondents were asked to choose the four goals in a list of 16 that they assessed ‘to be generally most important’ in their counseling. Examples of goals are to help clients ‘Have a strong sense of self-worth and identity’; ‘Improve the quality of their relationships’; ‘Understand their feelings, motives and/or behavior’, ‘Integrate excluded or segregated aspects of experience’, ‘Experience a decrease in their symptoms’, or ‘Develop courage to approach new or previously avoided situations’.    
3. The open ended self-presentation study

An open-ended questionnaire was administered to allow Lamas to describe their practice when seeing clients who seek their help for psychological problems. The instruction stated: “Describe in a few words how you help people with psychological problems and symptoms of e.g. anxiety or depression, which are not directly related to spiritual problems”. Category sorting by two judges (the first and second author) was used to explore the responses of 70 of the seventy-four Lamas who gave their responses. The responses of each Lama were jointly coded, first categorizing the actual and concrete behavior of their intervention task, and then the content of the task categories.

1. The Mindfulness questionnaire Study
The internal consistencies (Cronbach alpha) for the FFMQ is presented in Table 1. None of the subscales of the FFMQ obtained a satisfactory level of Cronbach’s alpha statistic. The subscales of ‘act with awareness’ and ‘observe’ had alphas of .37 and .30, respectively, and the alpha values for the remaining three subscales were below .10.

Table 1. Cronbach alpha for FFMQ subscales

Describe                                  0.05.
Act with awareness                 0.37.
Observe                                   0.30.
Non-reactivity                         0.09.  

Non-judgmentally                   0.07
2. The therapeutic practice questionnaire study
Professional relational manner. Table 2 shows the mean values of therapists’ self assessments when relating to clients. The item scales ‘challenging’ and ‘warm’ received the highest ratings, slightly below a mean value of 2 (‘much’), followed by ‘friendly’ and ‘directive’. Stated differently, between 69% and 65% of the Lamas rated themselves as ‘high’ or ‘very high’ on these characteristics (2 or 3 on the 0-3 scale). These results indicate a majority of these Lamas perceived themselves as both agentic (challenging, directive) and supportive (warm, friendly) in how they relate to clients.

Table 2 -Tibetan Lamas: Self when Relating with Clients




% Much/Very much

































































































 Omitted professional relationship items: Permissive, Pragmatic, Receptive

The limited N of this study did not permit a sound factor analysis of the relational manner items, but previous factor analyses of the relational manner items of the DPCCQ resulted in affiliation and control scales with acceptable internal consistencies.  Table 3 shows the item means, standard deviations and Cronbach alpha values for approximations of the affiliation and control scales as these are represented among the Lamas in this study. An internal consistency of .77 is satisfactory, while a values of .62 is marginal, but above a convention of minimum .60 for use in exploratory analyses.

Table 3 DPCCQ-Factors of ‘Self relating to Clients’
 Factor I:                                                 Factor II
                                     X        sd
Tolerant                       1.73        .89                             Authoritative                 1.56     1.07
Warm                          1.93        .98                             Cold                            1.40       .92
Protective                    1.54        .93                             Demanding                   1.72       .94
Nurturant                    1.46         .93                             Skillful                          1.38       .96
Intuitive                      1.45       1.00
Effective                     1.71       1.03
Committed                 1.79       1.01
Directive                    1.85        .95
Cronbach alpha           .77                                           Cronbach alpha           .62

Therapeutic goals.
The Lamas were asked to indicate the four goals that they assessed to be generally most important for their clients. The results are presented in Table 4. The goal of helping clients to “have a strong sense of self-worth and identity” was endorsed as the most important goal, specifically by 45% of the Lamas. This goal was also endorsed by the highest proportion (60 %) among a sample of therapists from a large majority of  Western countries (Orlinsky & Rønnestad, 2005). This stands out as relatively common goal for therapists across cultures. The four goals selected by the lowest proportion of Lamas were helping clients “Integrate excluded or segregated aspects of experience”, “Understand their feelings, motives and behavior”, “Identify and pursue their own goals” and “Experience a decrease in their symptoms. ”

Table 4 -Tibetan Lamas: Practice Goals
How important do you think it is for most of your patients to realize the following goals?  
Have a strong sense of self-worth and identity. 45.2 1
Learn to behave effectively in problematic situations. 43.8 2
Develop courage to approach new or previously avoided situations. 39.7 3
Develop better ability to meet important familial and social responsibilities. 35.6 4
Think realistically about the meaning of events in their lives. 27.4 5
Allow themselves to experience feelings fully. 26.0 6
Evaluate themselves realistically. 24.7 7
Clarify their overall sense of values, priorities, and philosophy of life. 21.9 8
Resolve or cope with confusions caused by conflicts in cultural ideals and expectations. 20.5 9
Develop a more tolerant and accepting attitude toward others. 17.8 11
Learn to recognize and change how they create or contribute to their own problems. 17.8 11
Integrate excluded or segregated aspects of experience. 17.8 11
Identify and pursue their own goals. 16.4 14
Reason validly about the probable consequences of their behavior. 16.4 14
Understand their feelings, motives and/or behavior. 16.4 14
Experience a decrease in their symptoms. 9.6 16
Omitted goal items:
Improve the quality of their relationships.
Modify or control problematic patterns of behavior.
Moderate their excessive, or irrational emotional reactions.
Resolve emotional conflicts in relation to you as their therapist.

3. The open-ended questionnaire about the Lamas counselling
 Analysis of the Lamas’ responses to “Describe in a few words how you help people with psychological problems and symptoms of e.g. anxiety or depression, which are not directly related to spiritual problems” resulted in 9 task categories and 7 content categories. Examples are given in Table 5 and 6. Dharma is the teaching of four noble truths about suffering, the origin of suffering, the ending of suffering, and the path to its ending. The content category ‘General Dharma’ refers to a general, common sense description of the teaching of Buddha. ‘Specific Dharma’ refers to statements which point to concrete or specific parts of the teaching of Buddha. Responses were coded as ‘Universalism’ if there was a reference to what people have in common beyond a Buddhist context. 

Table 5. Examples of the nine task categories.
Give advice/guide: “To help people I just try to give simple advice that is suitable to his or hers own problems, like all phenomena are impermanent, and their nature is to cause suffering. Because of that, people should follow the good path.”
Explain: “First I try to find out what the persons exact problems are; after that I am trying to say like: Each and everyone has problems. Some people  they have a lot of problems,  so compared to them your problem is nothing. I try to explain that  all  creatures have problems of birth,   aging,   sickness and death, and that we all have the same capability to solve these problems.
Give examples: “I just try to help them by giving examples about general problems everybody have, even the richest man in the World. If we have little desire, then we don’t face all these problems. So I give examples of how problems itself is created by one’s own way of thinking.”
Implicit prescriptions: “I am helping by not teaching directly Dharma, but indirectly I give examples that is relevant to their problems in a way that really help them. E.g. on how problems are created by their ‘own’ so the person can think in a positive way.”
Reflection: “I try first to make people realize their problems and to reflect of the cause of their problems. Sometimes I say to people: Try to do nothing but to reflect.”
Teaching: “I am helping by teaching the Dharma, but not directly but indirectly, for example following the advice written in the text ‘Practice of Buddhistsatva. For example, I always teach (that) everything is dependent to each other. If we accumulate negative actions, the result of that negative action is suffering.  If  we accumulate good actions,  the result of that action is happiness. So we should know the actual meaning of the Karma.”
Social work: “I can’t advise people without relating it to the Buddhist Ideology. Whenever people need money, I just give them some money, and when people get sick, I help them to go to the hospital.”
Tell stories: “I give advice by telling good stories which are related to our daily life. E.g. I tell about another person created a lot of problems by his way of negative thinking.”
Listen: “First I listen to hear exactly the problems the person. Then I try to give advice or guidance according to the problems.”

Table 7 shows the numbers and percentages of task categories described by the Lamas. Two categories, ‘Give advice/guide’ and ‘Explain’ were endorsed by 40% and 37% respectively, and are clear examples of the directive and instructive nature of the Buddhist counseling practice. The other categories may be interpreted to be variations of this directive/instructive mode of counseling, except for ‘Social work’, ‘Reflection’, and ‘Listen’. The last two task categories, which are typical of Western oriented therapies, were endorsed by only 8.6% and 1.4% of the Lamas, respectively.

Table 6 Examples of the 6 content categories
General Dharma: Problems are created by their ‘own’ so: think in a positive way, and [you] have to know the actual cause of the problem. If a normal person who has depression feelings: I try to explain how important human values and human inborn powers [are]. We human beings can do anything if we try our best and use our energy in a proper way.
Specific Dharma: For these kind of people (i.e. with depression or anxiety)  I always teach [that] everything is dependent on each other. So, if we accumulate negative actions, the result of that negative action is suffering. If we accumulate good actions, the result of that action is happiness. So, we should know the actual meaning of Karma.
Universalism: I am trying to say that all people have various problems and all people have same feelings, so you don’t need to worry. We all have the same capability to solve these problems.
Food and Shelter: I find it very important to take care of the persons need for good food and housing
Family issues: Very often people do have problem with their wife or husband, so I tell them to be nice and take care of each other

Specific reference to anxiety and depression: Very often people are do have of night mares and anxiety. I try to tell them how to relax.

The number and percentage of content categories are shown in Table 8, which makes clear that ‘Dharma teaching’ is the most dominant content of the Lamas’ counseling.

Table 7. Number of task categories and percent endorsement by Lamas
                                                 N                     % *
Give advice/guide                     28                    40.0
Explain                                    26                    37.1
Give examples                           8                    11.4
Implicit prescriptions                  8                    11.4
Reflection                                  6                      8.6
Teaching                                    3                     4.3
Social work                               2                     2.9
Tell stories                                2                      2.9
Listen                                       1                       1.4
*Per cent refers to proportion of Lamas who report using different acts.
Percentages does not add up to 100 due to double codings.

The Mindfulness questionnaire
Although several writers have shown the mindfulness subscales of the FFMQ to be valid for evaluating mindfulness-based training in Thailand, China and Japan, our study of Tibetan Lamas in India do not support this, as none of the subscales of the FFMQ came close to an acceptable Cronbach alpha. There may be several reasons for this discrepancy:

(1) There were significant differences in sample characteristics. The samples studied by Christopher, Charoensuk, Gilbert, Neary, and Pearce (2009) consisted of undergraduate students in a private university in Bangkok and young Thai monks, while the samples studied by Deng et al., (2011), Jong (2013), and Sugiura et al., (2012) consisted of Chinese undergraduate and graduate students, and Japanese university students. It is likely that the comprehensive knowledge of Buddhism that the high ranking Lamas in our study bring a different background to evaluating the validity of mindfulness scales.

(2) Several of the Lama’s expressed difficulties with answering the mindfulness scale. Their remarks concerned problems in distinguishing between their subjective responses and the ‘official’ Buddhist response. The instruction given had stated:  “Please rate each of the following statements using the scale provided. Write the number in the blank that best describes your own opinion of what is generally true for you.” A frequent comment was: “It was difficult for me to mark my own opinion of what is generally true for me. It is more easy for me to give a mark where it should be placed according to the Dharma teaching.” Another reaction to the five point Likert scale was: “We Tibetan people do not support the viewpoint, that some persons should be more or less than other people. Therefore I have set my mark in the middle point”. Another often mentioned difficulty includes statements meant to assess mindlessness (e.g., ‘‘I do jobs or tasks automatically, without being aware of what I am doing’’). The special attitude of detachment of the ego, which is an important element of the Western understanding of mindfulness, did not make sense and evoked laughter by some of the respondents (XXXX).

(3) The Western understanding of Buddhism may differ from that of Eastern Buddhism. Mindfulness is a core element in Tibetan Buddhism, but as an ever-present state of mind and attitude in the Tibetan daily conduct rather than as the isolated result of meditation. In Tibetan Buddhism, mindfulness is only one of many inherently interrelated factors of the complex Buddhist Dharma. To measure mindfulness effectively in that context one should not only assess a subject’s awareness, concentration, or acceptance, but also their ethical conduct and lived experiences. This concern has been echoed by Western researchers  (e.g., Bergomi, Tschacher, & Kupper, 2012; Grossman & Van Dam, 2011) who have been skeptical about the utility of including items in a mindfulness measure. Christopher et al. (2012) have especially argued that the usefulness of mindfulness questionnaires should be questioned, given issues of poor predictive validity (Cash & Whittingham, 2010; Christopher, Neuser, Michael, & Baitmangalkar, 2012; de Bruin, Topper, Bögels, & Kamphuis, 2012) and unexpected association with other variables (Fernandez, Wood, Stein, & Rossi, 2010). The present study confirms the difficulties noted by Christopher et al. (2012) of including Western constructed items in an Eastern context to assess a person’s ability to describe or label experiences using words on a measure mindfulness.

The therapeutic practice questionnaire
Common relationship factors. In emphasizing ‘warmth’ and ‘friendliness’ (ranked 2nd and 3rd), which are well established relationship characteristics (Orlinsky & Rønnestad, 2005), Buddhist Lamas resemble most Western therapists who tend to view these characteristic as central to the bond aspect of the working alliance (e.g. Bordin, 1979). However, Western therapists vary among themselves with respect to how ‘challenging’ and ‘directive’(ranked 1st and 4th by the Lamas) a therapeutic relationship should be, typically reflecting differences in theoretical orientation as well as personal style (e.g., Heinonen & Orlinsky, 2013). For the Buddhist Lamas, there was a more consistent emphasis on ‘challenge’ and ‘directiveness’ as characteristics of the therapeutic relationship. This may be due to the fact that the Lamas’ spiritual counseling is based on teaching clients’ to understand their circumstances in terms of the Buddhist Dharma and challenging them to adhere to the Buddhist Dharma in their lives. The Dharma text serves both to guide and direct one’s life, and to deepen an understanding of one’s own uniqueness. To follow the Dharma is to accept one’s inner core-self as it is, but from a Western perspective there is an apparent paradox in both teaching the Dharma (directiveness) and encouraging acceptance of the inner core of self (non-directiveness). 

Therapeutic goals. Four of the five goals with the highest rank reflect spiritual aspects of the counseling that the Lamas provide: achieve ‘Self-worth/identity’, ‘Behave effectively’, ‘Develop courage to approach avoided situations’, and ‘Think realistically’. These seem to reflect a strong sense of enhancing the inner core self (the ‘inner Buddha’), and behaving according to the Dharma. These stand in contrast to the goals endorsed by the lowest proportion of the respondents which are more individualistic, and resemble typically Western values which aim to help clients ‘Understand their feelings, motives and behavior’, ‘Identify and pursue their own goals’, and ‘Experience a decrease in their symptoms’.

Open ended questionnaires
The qualitative section of the study showed, firstly, that the tasks the Lamas employed in their counseling practice were primarily directive/instructive and used little reflection and listening; and, secondly, that the content of most Lama statements were coded as Dharma teaching, either general or specific. As noted above, Dharma is the teaching of four noble truths and concerns suffering and liberation from suffering through true enlightenment, which can only occur if the habitual tendency to perceive the immediate presence of phenomena is properly recognized.  

Limitations and Concluding Comments: Western questionnaires in an Eastern context
This paper intended to investigate the internal consistency of Western oriented counseling/therapy questionnaires in an Eastern counseling tradition and thereby to understand better what might be common or specific factors across cultures. These are worthy and important goals.  However a questionnaire study of this type can only scratch the surface of the complexity of Buddhist teaching and counseling. There are about 28,000 traditional Buddhist scripts in loose pages, around 14,000 scripts in book form, and 250 volumes in which the Tibetan masters have written their commentaries (Karma Lundrup, p. 258 in Elsass, 2011). To represent this complexity in the form of questionnaires and brief interviews is impossible. Scholars especially note potential confounds when comparing Likert-type self-report scale scores across cultural groups (Heine, Lehman, Peng, & Greenholtz, 2002). For example with problems of response style reflecting a cultural tendency to either overuse or to avoid the extreme end-point responses on scales (Cheung, Cheung, & Leung, 2008). Borrowing from the Buddhist scholar Buddhaghosa (cited from Christopher, et al., 2012; Grossman, 2011) Buddhist and Western styles of counseling might be described as “near-enemies” or “false friends” (faux amis) because they possess qualities that may outwardly or superficially appear very similar, but be profoundly different when subjected to careful scrutiny. 

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