Journal of Religion and Health, Vol. 38, No. 4, Winter 1999
Hindu Counselling in the Netherlands ALPHONS M. G. VAN DIJK ABSTRACT: Increasing participation of Muslims and Hindus in church-state relations in the Netherlands is bringing about a slow change in the different cultural and historical backgrounds of "non-indigenous" religious traditions and in their self-esteem and religious attitudes. We may call this participation, and especially the changes it causes, a good example of Systemzwang, the systematic power of the dominant but historically grown social and cultural order in which newcomers are expected to fit. This process of external influence will be demonstrated by the example of the development of the traditional Hindu priest, the pandit, to a modern professional pastoral or Hindu-spiritual counsellor and by the mutual-learning process of the religiously different pastoral professionals in the semi-governmental service organizations.
Introduction The integration of Europe today is often considered a macro process among states or nations, socio-economic systems, religions, and larger cultural groups and languages. Some people believe in the new dimensions; others are highly critical and distrust all over-centralized power. Individual citizens have their own sometimes highly critical experiences and opinions of this integration, which they feel as having been imposed on them. These different visions are a part of the ongoing tension between the tendency of globalization of life styles, attitudes and organizational structures and the opposite tendency of "going local," paying attention to local groups or minority rights. A comparable tension exists between the tendencies of unification and pluralism, even multiculturalism. These tensions do not merely exist on the socalled macro or micro levels. In-between there are also meso processes going on, some on a larger, some on a smaller scale, where after a time newcomers meet and even try to participate in existing intermediary systems. One of these smaller intermediary systems is the professional organization of pastoral or spiritual counsellors in the Netherlands. The newcomers are Hindu pandits.
Alphons M. G. van Dijk, Ph.D., is at the University of Humanist Studies in Utrecht, Netherlands. 319
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Religion or world-view in the Netherlands as a statistical, social, or cultural phenomenon More than half the Dutch citizens no longer consider themselves members of one of the Christian churches. For the majority of them, religiosity or worldview has become a matter of individual choice and subjective attitude. For some years now the government has no longer been registering citizens according to their membership in an acknowledged church or world-view organization. The churches have to rely on their own administration system for membership roles. For reasons of privacy, some big state-university hospitals also no longer register the religion or worldview of their patients, who in turn are supposed to express their own desire for pastoral or spiritual counselling. Upon their arrival, they are informed about all facilities. Because the government does not gather data on religious preferences the statistical number of the Muslim and Hindu minorities in the Netherlands, who have migrated from other countries with different administrative systems and historical and religion state relations, is not known and can only be guessed at. At the same time these groups lack their own reliable system of registration as Muslims or Hindus within their own circle, at least from the government viewpoint. To date, and notwithstanding their quest for some unifying organization, Muslims and Hindus still do not have any church-like model of organization and administration such as Dutch society and the governmental system are accustomed to. The question for minority religious groups is how to go about this task, particularly if they want to be treated and financially supported by the national or local government in the same way and to the same degree as the churches and the Humanist League and as was officially supported by a governmental commission (Hirsch Ballin, 1988). This commission considered equal treatment to be a logical consequence of the Dutch Constitution. In order to be able to subsidize or pay the salaries—directly or indirectly by semi-governmental institutions—of official Muslim or Hindu professional pastoral counsellors in the Army, in the Penitentiary or the Health System, as is the case with their Catholic, Protestant, humanist and Jewish colleagues, the government demands an official representative body, an acknowledged religious or world-view organization with a recognized membership. Until now the migrant religions of Islam and Hinduism, with their different historical and cultural traditions, have lacked any such organization. Hinduism as a typical orthopraxis lacks even basic declaration of what it stands for. Together with large differences in socio-religious organization, this may be one of the most important points of comparison between the new Dutch Hinduism and the long-term indigenous Christian churches, with their historically developed systems of organization and theological reflection.
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Religion: Diminishing or changing? To consciously devote oneself to a religious or world-view organization (as, for example, the Humanist League, which, according to the Dutch Constitution must be treated as equal with the churches) seems to be mostly, although not exclusively, a matter for older people. Although religion in the sense of church attendance may be decreasing, as all reports of the SCP (the Dutch Sociaal Cultureel Planbureau) show, religion in the sense of a diffuse (and, for traditionalist observers, invisible) element of social and personal life and personal inspiration (Luckmann, 1970) is very much alive, as a quest for meaning dealing with what ultimately concerns people. Belief in some ultimate god or goal remains remarkably high in the Netherlands and has been constant for decades. This means that the historically monopolistic features of church organization, characteristic of the large Roman Catholic or the Dutch Reformed Churches and imitated by the Humanist League, no longer provides the unique model of religion or even of religiosity or world view. The types of religiosociological organization are becoming increasingly diverse. Churches are competing in a common marketplace of religious producers and providers and consumers. Expressed in terms of secularization, to merely pay attention to the decline of church attendance, as most sociologists have done, seems to result in a neglect of other aspects of the phenomenon, as for example the changing of religious organization and the increase of pluralization connected to the privatization on or individualization of religion. Religion, as defined implicitly or explicitly by sociologists, may be changing. Seen from an anthropological perspective, religions can be conceived along two different lines, with different functions. The first is that of a kind of explanatory or explicatory system, providing evidence on how things are and why they are as they are and how they should function in the present and the future, which means, how can a religious believer or group influence the course of things in order to make life more secure? Religion may also justify events or situations (Berger, 1967). But there is also another type and function of religion, though neither type excludes the other and both mix in everyday life. It is the type of religion which, roughly speaking, may prevail in modern scientific and individualized societies. Here, religion may also provide a sense of community, especially community with the cosmos or "the all, the course of life," ultimate reality. This aspect of religion has to do with meaning, with inner orientation, with the feeling of existential well-being rather than with the manipulation of life (Tennekes, 1990, p. 49). Religion as a system of meaning, a striving for emotional balance in such areas as personal responsibility, severe illness, and death, seems to be the major concern of professional client-centered pastoral or spiritual counselling as it is practiced in Dutch institutions. This profession of pastoral or spiritual
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counselling has developed since the early sixties and is strongly dominated by humanist psychology (Fromm, Erikson, Rogers, Maslow). Two questions arise about this second type of religion and focusing on the Hindu minority: 1) What will happen if Hinduism in the Netherlands undergoes a slow change from by and large a system and praxis of explanation and influence (the first function of religion), with emphasis on the pandit as a ritualist and priest, to an increasingly meaning-giving system, with emphasis on the pandit as a guru (in the broadest sense of the word), a spiritual guide or companion in the quest for meaning (the second function of religion)? 2) What will happen if a Hindu pandit participates in that new type of pastoral or spiritual counselling which belongs to the second function of religion? I use the term "spiritual counselling" to place it alongside the term "pastoral," of Christian usage. I prefer the broader term, spiritual counselling, because it upholds a certain difference, compared with social-therapeutic counselling or psychotherapy on the one hand and is, on the other, broad enough to be used to include the humanist, world-view-inspired counselling, which is so widespread in the Netherlands. The term "spiritual" may have some New Age associations, but I am not addressing those in this paper. Therefore, on the whole I use pastoral and spiritual as twin terms. The present situation Although the traditional Dutch division of society into denominational compartments (which in Dutch sociological and historical literature are called "pillars"), each with its own religious, cultural, and social organizations and institutions, is slowly weakening, this disappearing phenomenon still gives minority religions, of distant origin, such as Islam and Hinduism, the politically acknowledged right to receive financial help from a religiously neutral government, to shape their own social and cultural institutions, just as do the traditional churches and the Humanist League. The Muslim and Hindu population is represented in the army, in penitentiaries and in health-care institutions. Recently, pilot projects have been started with a few imams and pandits as members of the integrated pastoral/spiritual counselling services of some of the university hospitals, as directly or indirectly state-supported functionaries. This is not just a question of providing governmental or semigovernmental facilities to minority religions in the same way and to the same degree as the traditionally recognized denominations. Increasing participation in church-state relations in the Netherlands is bringing about a slow change in our understanding of non-indigenous religious traditions, their self-
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conception, self-consciousness, and religious attitudes. We may call this Systemzwang, the systematic power of the dominant but historically developed social and cultural order in which newcomers are expected to find their place (Dijk, 1996). This will be shown by the example of the development of the traditional Hindu pandit/purohit into a modern professional pastoral counsellor and by the intercultural communication and mutual learning-process of the different pastoral professionals in semi-governmental service organizations. The basic two questions cited above return. The traditional Hindu pandit in Surinam and in the Netherlands In the last quarter of the nineteenth century, poor Indian workers, most from the United Provinces and Bihar of British India, migrated to the Dutch colony of Surinam, formerly Dutch Guyana in Central America. In their long boat trip and the harsh conditions they had to contend with in the new country, they lost the most marked characteristic of their traditional caste system, ritual purity. But in their quest for a new identity in an ethnically diverse and non-Hindu country, they gathered around the Brahmins among them, who in turn held on to what was left of their old Indian privileges. The Brahmins profiled themselves as priests or ritualists, astrologers, religious storytellers and moral explicators of the old epics, sometimes as healers, and to a certain degree as house or family gurus, advisers in all aspects of family life. For a long time after the migration, temples (mandirs) failed in Surinam Hinduism, as did the ascetic guru, who in traditional Indian Hinduism usually functions in opposition to the Brahmin priest. Within a short time, the Brahmin pandit reached a position of monopolistic power in the new Hinduism in Surinam (Dijk, 1996). Prolonging the old Indian Jajmani-system, one of mutual but different and caste-bound services among inhabitants of a village or region, the new Surinam pandit, who may not even have been educated as a pandit or priest, gathered a group of client families around him. For them, he functioned as a family guru as well as a purohit (priest). The Hindu religion in Surinam was a house and home religion. Rituals were performed indoors or on private property and only rarely and much later in temples. Around 1930, the reform movement of the Arya Samaj, coming from the motherland, India, and the neighboring country, British Guyana, became rather successful. It rejected both the Brahmin-caste-bound panditship, as well as caste itself. It also rejected what it considered to be idolatry, the worship (puja) of anthropomorphic deities. But in challenging the Brahmin pandit, it created a new type, and thus focused itself anew on panditship as such. From the 1970s onward, a large group of about 90,000 Hindus migrated from Surinam to the Netherlands, the second migration of a community in a hundred years. With integration as its goal, the Dutch government tried to
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spread the group over a large part of the country, but to no avail. Twenty-five years later, the majority are to be found in the west, in the provinces of North and South Holland. But let us concentrate on the pandit, and especially on the pandit as a phenomenon in the traditionalist mainstream among the Hindu minority, the so-called Sanatana Dharma, the Timeless or Everlasting Order or Harmony, which is supposed to underlie all processes in the phenomenal world. Although commonly used in Surinam and Dutch Hinduism, the title of pandit is misleading. In traditional Hinduism, pandit means scholar or learned person. But this role is just one part or aspect of the many and varying roles which the Surinam and Dutch pandit, as the title is commonly used, really plays in his monopolistic position. He normally functions as a house or family priest (purohit), providing the main rites de passage (samskaras or sacraments) as for example in birth rites and rituals of name-giving, the initiation, wedding, and funeral rites. He is also a worship priest (pujari), offering worship to the family gods of his client families and sometimes performing temple worship. He may also recite various texts from the Holy Vedas (as the Arya Samaji pandit also does), from the ancient and venerable epics, the Mahabharata and Ramayana, as well as from the Puranas (which the Arya Samaji pandit refutes), and explain them to his audience. He knows prayers or mantras for special occasions. He functions as an astrologer to guide clients to times and activities which may prove prosperous or are best avoided. Sometimes he also functions as an exorcist, healer, and interpreter of dreams. Because of his supposedly great knowledge about human life and social situations, he may also, as house or family guru, become a kind of psychologist (as one informant called him) or adviser in all kinds of family issues. In order to play all these roles sufficiently well, there must be regular contact between him and his client families. Such contact was manageable in the small-scale and mainly agrarian situation in Surinam, but is far more complicated, even endangered, in modern, industrialized Holland. Changes in the pandit-client situation in the Netherlands It is at this point that the second migration, which started in the early 1970s, caused geographical, social, and psychological problems for the pandit and his client families. Of course, migration to the Netherlands could not but sever some of the Surinam-born pandit-client relations (jajmani-relations). After the migration, the spreading of groups of client families and individuals over the entire country, another geographical problem arose—pandits who had migrated with their clients had to travel extensively in order to visit them and perform their rituals. It could hardly be avoided that clients, particularly the younger ones of the second generation, would complain about the growing anonymity of the family pandit. Nowadays, literature on Dutch Hinduism
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speaks of busy travelling "ritual or religious entrepreneurs," who, through lack of the income they were used to in agrarian Surinam have become shrewd price-conscious functionaries. Another problem developed because of the higher level of education in the second generation combined with the growing individualization and movement to societal levelling. More and more, young people started to question both the symbolism and the length of performance of traditional rituals. The lack of really trustworthy and widespread knowledge of Hindu tradition and wisdom, as well as of modern life in a highly industrialized modern society, combined with the specialized and professional knowledge and skills of the pandits seems to be a major impediment to the creation of a new type of Hinduism in the Dutch situation. This is the portrayal in the literature on Dutch Hinduism, written both by Hindu and non-Hindu scholars (Dijk, 1996; Burg, 1993). In order to substantiate this description, we are in need of systematic research, both quantitative and qualitative, which has not been undertaken to date (Dijk and Kuipers, 1994). There are some signs of a new and different development concerning the role and position of pandits. In a society in which belief appears to becoming more and more a question of personal attitude and individual choice, and in which religion is slowly changing from explanation and need for security (type I) to meaning (type II), smaller groups of Hindus are moving from traditional ritual to the study of old Hindu wisdom and to the practice of yoga. Some have become interested in the so-called Guru Movements: Sai Baba, the Hare Krishna Movement, or the Brahmarishi Mission. These signs may be interpreted as a change from the traditional Hindu type of priest-bound ritual religion to what Stark and Bainbridge (1985) call Client or even Audience Cults. Followers of such cults are oriented to what might be called mysticalmeaning systems, which sometimes seem to be experienced more intensively in the vicinity of gurus considered more trustworthy than entrepreneurpandits. Another development, albeit on a smaller scale, is the shift from acceptance of the Brahmin-caste priest (in some Sanatani circles), the traditional janmavada pandit (the pandit-by-right-of-birth), to the acceptance of the karmavada pandit (the pandit acknowledged on the basis of his behavior and activities). In sociological terms, this can be described as a change from "attribution" to "achievement." By behaving in a more Brahmin-like way than the average Brahmin, namely by studying the ancient knowledge and wisdom of Hinduism more than most ordinary pandits do, and by renouncing meat, fish, eggs, alcohol, nicotine, and illicit sex-relations, these karma-vada pandits evoke and correspond with the old Indian ideal of the arya (noble) person, a living example to others, showing them how to behave on their way through life toward freedom or salvation (moksha). With the manifestation of this new type of self-appointed or charismatically anointed pandit, the traditional jajmani type of pandit (family pandit) is being challenged by a new and more
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democratic type (the Arya Samaji's even have some female pandits, called pandita), who slowly but surely is finding acceptance through better knowledge, a more modern behavior and inspiration, with emphasis on pastoral qualities. Guruship, guidance and pastoral counselling In traditional Hinduism the guru is normally seen as a spiritual preceptor. But this does not mean that he (normally, the traditional guru is male) is supposed to seek his own disciples. A real guru does not yearn for admirers; he is a "homeless" person, without any conventional bindings, either on the material or spiritual level. The disciple, not the guru, takes the initiative. The traditional Hindu approach assumes the guru should be sought because he has become more god-like or Self-realized by some form of yoga or meditation. He becomes a heavyweight (from guru, which means heavy), a door to the godhead, to realization or liberation. He provides a powerful perspective (darshan) on the ultimate aim of life. As both a human being and a manifestation of god, he functions as the outer guru who awakens or evokes the inner guru, dormant in the inner processes of the disciple. The inner guru is the means by which the one, highest and absolute guru, the Supreme Brahman, can be reached and realized. But the disciple must accomplish this himself. He must make the journey. The outer guru is but a medium. He is not to be worshipped as momentous person or individual, but rather as the Door to Perception. He is to be trusted entirely, because such a trust in his higher spiritual realization functions as a way of self-renunciation, the growing self-emptying of the disciple on his way to self-realization. The basic attitudes of the disciple toward his guru are obedience (shushrusha) and faith or trust (shraddha). The guru on the other hand is expected to live in a way in which vision, teachings, and actual behavior are perfectly congruent and integrated (Walker, 1968; Zimmer, 1973). Notwithstanding this ideal vision, traditional Hindu wisdom acknowledges the social and psychological ambivalence of the guru-disciple relation. But it has left it to the free market of karma processes—each individual finds or gets the guru he seeks or longs for! To learn this may be part of the life-long journey to self-realization. This may cause problems with concepts of pastoral or spiritual care and client-centered pastoral counselling as practiced in Dutch professional circles. Public institutions employing a pastoral or spiritual counsellor demand a certain standard of academic education and professional training as well as some cooperation or even sharing of vision among the several and different counsellors an institution may employ. Within Dutch Hinduism there may be a slow shift from the traditional pandit as ritualist to the pandit as a trustworthy spiritual guide or companion in a confusing pluralist and industrialized society. We have also seen that old
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Mother India may rediscover or reclaim some of her migrant children in the Netherlands through the influence of Neohindu Guru Movements. These two phenomena are two different ways of developing what might be called the guru dimension of Dutch Hinduism. The Dutch indologist Schouten, highly critical of the second way, writes: "It may be questioned if this development does justice to the intrinsic and special development of the Hindustanis. Their history of many decades in Surinam and their admirable acculturation (or acclimatization) to Dutch society may have brought them more than the Indian outsider observes" (Schouten, 1994, p. 119). In other words, the attention to spiritual guidance or company as the broadest description of the so-called gurudimension, a phenomenon which is growing among Dutch Hindus, should not be confused with the actual attention to Neohinduist gurus from India. The latter is just a (sometimes critically evaluated) expression of a deeper need, which is more in line with the first. How the pandit functions among the various Hindu groups, and within the so-called strictly religious realm, is no matter for the government or other secular institutions. But the situation changes the moment the secular government or semi-governmental institution provides the salaries of the officials who are "sent" (this is the legal term) by the acknowledged churches and the non-Christian religious bodies or world-view organizations in order to work inside these institutions. Institutions are responsible for the quality and professionalism of their practitioners. According to the official formula, the sending body, the religious or world-view association, is responsible for the material content of pastoral or spiritual counselling, while the providing institution must take care of the formal aspects and the conditions thereof. Until now this formal distinction seems to have worked fairly well. But this entire conceptualization has been historically conditioned by a widespread but still particularized concept and image of how professional counselling should be carried out. Although the pastoral or humanist counsellor is supposed to be well educated in and inspired by his own world-view or religious tradition, with other collective aspects, it is practically assumed that he should be client-centered. But there are implications for assuming a client-centered approach. What kind of mental associations or implicit ideology do professionals have in using and expressing such a principle? All pastoral or humanist counsellors are expected to have followed a course such as Clinical Pastoral Education, or its equivalent. Such a course is a mixture of basic knowledge of psychoanalysis and psychopathology, theory and praxis of so-called humanist psychology, and of training in counselling. The views of Erich Fromm, Carl Rogers, and Abraham Maslow about anti-authoritarian religiosity and self-realization or self-actualization along the lines of the human-potential movement had a strong impact on the practice of this type of counselling (Carver and Scheier, 1992; Heitink, 1997). The main idea here is client-centeredness, to guide, or rather to accompany, a client on his often interrupted or endangered quest, through illness, existential problems, and death, for personal meaning. This
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process should follow the lines of the personal and internalized religion or worldview of the client. The counsellor should act as a professional who helps the client to articulate or regain his personal meaning-system insofar as this system does not conflict with the counsellor's own personal religion, worldview or meaning system, or with his responsibility towards the association that "sent" him. Thus pastoral or spiritual counselling is a process during which two narratives meet, with emphasis on the client's. Clients can freely choose among all the different denominational counsellors of an institution. As a special service, the counsellors also have a certain task within the cure-and-care institution with regard to its other activities, sometimes religious, such as educating and informing employees, participating in ethical reflections, or discussing material provisions such as food (vegetarian for Hindus, hallal-slaughtered for Muslims, kosher for Jews), or clothes (in terms of ritual purity or symbolic meaning). From priest to guru? The pandit as pastoral professional If this brief description of pastoral or spiritual counselling in Dutch institutions is correct, the question arises as to how the Hindu pandit will find his place and role in such an historically developed and specialized professionalized field. Some pandits have recently started work in this field. One of them shows his awareness of possible tensions: The presence of the pandit is very dominant, because he is considered to be authoritative. His position is between the divine and the existential, but patients who are driven by despair may demand too much from him. Sometimes he— unconsciously—behaves with too much compliancy, with all the effects this causes. The pandit, who is considered to be infallible and reverential, can unconsciously damage the confidence of his patients (Ramdhani, 1996, p. 333). And:
It is also ( . . . ) very important that the pandit in this situation of accompaniment does not behave as if he is standing on a pedestal. There is a real need for an equal discussion between two human beings. In such a situation the patient gets a response to his signals and will not hesitate to open up, because he feels he's in good hands (ibid.). This young pandit gives us a good impression of what Dutch pastoral or spiritual counselling circles expect a Hindu pandit to do if he wants to participate in professional and institutional counselling. He has perhaps internalized the basic views of what is supposed to be modern counselling. But he is still conscious about the basic Hindu assumption that he himself, as a pandit or guru, is a mediator between the divine and the existential. He is not just, or even
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predominantly, a functional and professional counsellor on behalf of a "sending" party, inspired by its religious traditions or world views. According to him there is much more to be found between heaven and earth. This corresponds with what we have understood about the traditional idea of guruship. When we compare it with indigenous Dutch ideology and prevalent practice of pastoral or spiritual counselling, we have to realize that in Hindu counselling the transcendent or vertical line is and will long remain more important than it might be in much present-day Christian and humanist counselling. If this is right, it shows us another aspect of the process. Especially when we look for the denominational mixture of the various counsellors in several pastoral or spiritual counselling services in the larger hospitals or other such institutions, we should realize that to successfully integrate all these officials so that the cooperation between them is optimal, this integration must be a two-way process. This situation demands a new type of understanding of Hindu guruship, a development from authoritative guidance to inspiring accompaniment. This immediately raises the question of the mutual aspects of the integration process. If we look at the denominational mixture of the various counsellors in these services, we come to realize that successful cooperation is not just a matter of giving Hindu pandits an opportunity to adapt to and adopt existing standards and concepts of professional spiritual counselling. From the Hindu point of view, they must also expect some understanding of their specific mixture of the form and matter of their spiritual guidance or accompaniment from the officials of established denominations. The dominating concept of professional counselling is neither neutral nor fully "objective." The remaining question is, Will the Hindu community, and particularly pandits, accept this dominant, system-immanent challenge, or will they reject or at least change it, and if so, how? What special kind of counselling will Dutch Hinduism develop in secular institutions? Conclusion Let us put all the shifts in the role of the pandit together. First, there was the shift from pandit as ritualist (purohit/pujari) to the guru-like aspects or roles of panditship. Secondly, there was a shift from the Brahmin pandit to the casteindifferent pandit, a shift from privilege to function. Thirdly, there was the possible weakening of traditional pandit-client relations. In these three shifts there appear two extreme types: On the one hand, there is the traditional castebound male Brahmin pandit who functions mainly as a ritualist, having panditclient relations with a more or less fixed group of client families, working in private houses or temples, with clear status and private income (the traditional purohit and pujari). On the other hand, there is the male or female and casteindifferent pandit, with individualized and freely chosen client relations, who as a semi-government-paid professional deals with existential problems by spiri-
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tual accompaniment, working in public institutions, with acquired status and professionality (the "guru" type, as a Hinduism-inspired and officially "sent" professional Hindu spiritual counsellor). In fact, there are several gradations or combinations among these extreme types. Incidentally some clients or patients combine the two extreme types, developing inspiring discussions of existential meaning in some public institution with Hindu professional counsellors and rituals with the family pandit as a purohit at home, after temporary or permanent discharge from the institution. But this implies a professional differentiation in roles and types of panditship. Unless the Hindu population in the Netherlands actively resists this development and organizes its official religious functions and activities along other and more consciously chosen lines, the Hindu professional and institutional counsellor will find his own place and direction. Actually, he already exists in a small number of hospitals. His manifestation in this way will have repercussions in the fulfilment of all the other and more traditional aspects and roles of panditship. This may not be a process with a clear intrinsic logic. But at least it is an understandable outcome or product of the dominant historical Dutch system of state-church relations in combination with the specialization and differentiation in roles and function that seems to be characteristic of what sociologists call modernization. According to some informants, a modest pilot experience in one of the health-care institutions shows that the very supply of a new function, that of the Hindu spiritual counsellor, creates after some time a higher demand from the side of the patients, compared with the situation before he arrived.
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