From Bibaktamna to Treatment

Method — A narrative review centred on the interpretation of the classics. No formal quality appraisal was performed.

• Classical sources: the 1901 Sinchuk edition of the 東醫壽世保元 Dongui Suse Bowon (Longevity and Life Preservation in Eastern Medicine) as held in the Korean Medicine Classics Database (mediclassics.kr). Because the 格致藁 Gyeokchigo and the 東醫四象草本卷 Dongui Sasang Chobongwon are not included in the Korean Medicine Classics Database, they are cited from the digital transcription of the 東武著作集成 Dongmu Jeojak Jipseong (Collected Works of Dongmu) held in the author's clinic library, collated character by character against a separate digital transcription of the Gyeokchigo and the scanned Lee Kyung-sung transcription (1999, based on the 1940 edition). Their translations are marked as the author's own.
• Sasang psychology literature: Kang Yong-hyeok, 四象心學 (Sasang Simhak, Sasang Psychology; 2010), and lecture records of Taeyul (Kim Do-sun).
• Earlier papers: nine of the author's papers on bibaktamna, the Gyeokchigo and the clarity and turbidity of the mind (心地淸濁), published on Sowonjae, were downloaded and collated.
• Comparative literature: PubMed meta-analyses (searched 2026-09-27).
• Distinction in presentation: in each paragraph, what the original text states is kept separate from what this paper proposes when carrying it into clinical practice.

1. Summary

In the author's earlier papers, 鄙薄貪懦, bibaktamna—the four modes of moral degeneration described by Yi Je-ma (1837–1900), namely meanness (鄙), shallowness (薄), greed (貪) and cowardice (懦)—was described as a personality pathology in which self-awareness is sealed off. Of those papers, the one comparing bibaktamna with the DSM-5 left the route to resolution at this level blank, recording it as "not discussed by Yi Je-ma", while the series on 局, 面 and 局回 drew a line by stating that making a hardened 局 flow again depends on "the inside of that 局 itself". The present paper examines that gap within the limits of what the classics allow.

It must first be made clear that no sentence in the classics states explicitly that bibaktamna is to be treated. The classics nevertheless contain scattered material from which an intervention can be conceived. This material comprises: the constitution-specific discernment that remains even in the most unworthy person ([3-11]); four distinct corrective directions addressed to the person with bibaktamna (謹, 退, 緩 and 實 in the 獨行篇 Dokhaeng-pyeon, the chapter on Solitary Conduct); the temporal stages in which medicine and self-cultivation are combined, together with the recounting of days after a relapse ([11-3] and [13-25]); the prognostic statements of the Chobongwon concerning the possibility of recovery (後悔, remorse, and the priority given to treatment); and the caution against pressing hard upon the wickedness of others ("惡惡不可迫").

From this material the paper sets out five items that make up an intervention hypothesis: entry, target, direction, relationship and time. The order of the five items and the conditions for moving between them are not specified here; they are to be designed in Part 4. The central finding of this paper is that the classics do not describe bibaktamna only as something those around the person must guard against; they also set out corrective directions addressed to the person concerned.

---

2. Context of the Question

The nine earlier papers approached bibaktamna from several directions. They offered a definition and a structural analogy with DSM-5 personality disorders; a four-part series running through 局 guk—the hardened place, the fixed position in which the mind has set; 面 myeon—the contact surface at which that hardened position meets others; 局回 gukhoe—the return, the way the hardened position turns back upon itself; and 暴傷 poksang—violent injury, the damage done to the body by sudden, excessive emotion; and a comparison between the clarity and turbidity of the mind (心地淸濁) and Jung's concept of individuation. Along the way, several conclusions had already been reached: the attitude that people around the person should adopt (keeping distance without rejecting), 反誠 banseong—turning back to sincerity, the ceaseless returning of the mind to its own integrity—in place of retaliation, and the conclusion that 恒寧靜 hangnyeongjeong—constant calm and stillness of mind—is itself the medicine. What remains missing is intervention directed at the person with bibaktamna.

At this point one of the earlier papers needs correcting. The paper comparing bibaktamna with the DSM-5 interpreted it as "a state in which each constitution has lost its dominant function". The definition in the original text reads as follows.

人趍心慾, 有四不同, 棄禮而放縱者, 名曰鄙人. 棄義而偸逸者, 名曰懦人. 棄智而飾私者, 名曰薄人. 棄仁而極慾者, 名曰貪人.

(When people follow the desires of the mind, there are four ways in which they differ. One who abandons propriety and indulges himself is called a mean person; one who abandons righteousness and seeks only ease is called a cowardly person; one who abandons wisdom and contrives private schemes is called a shallow person; and one who abandons benevolence and pursues desire to the extreme is called a greedy person.)

— 東醫壽世保元 Dongui Suse Bowon, "Discourse on the Four Beginnings" (四端論), [2-2] (mediclassics.kr/books/182/volume/1#content_42)

四象心學 explains this article by saying that a Taeyang person becomes a mean person not by abandoning the benevolence (仁) with which he is endowed, but "by forsaking propriety, his most inferior virtue". Part 1 of the 局 series likewise read the abandoned virtue as "the virtue that each constitution is born weak in and ought to cultivate". This paper follows that interpretation. The difference bears directly on the design of intervention, because the task then becomes not the recovery of a lost strength but the cultivation of the side that was weak from the start.

---

3. What the Literature Says

1. Entry: the discernment that remains, and the description of distress

The classics record, for each constitution, a form of discernment that remains even in a state of extreme foolishness and unworthiness.

太陽人, 雖至愚, 其性, 便便然猶延納也, 雖至不肖, 人之善惡, 亦知之也. 少陽人, … 雖至不肖, 人之知愚, 亦知之也. 太陰人, … 雖至不肖, 人之勤惰, 亦知之也. 少陰人, … 雖至不肖, 人之能否, 亦知之也.

(Even if a Taeyang person is utterly unworthy, he still knows how to distinguish good and evil in others. A Soyang person likewise knows how to tell the wise from the foolish in others, a Taeeum person the diligent from the idle, and a Soeum person the capable from the incapable.)

— Dongui Suse Bowon, "Discourse on Expansion and Enrichment" (擴充論), [3-11] (mediclassics.kr/books/182/volume/1#content_78)

What the text says is that a constitution-specific sense for evaluating other people remains even in the most unworthy state. This paper's proposal is to use this as the point of entry into the clinical interview. Patients who are reluctant to talk about themselves will still voice judgements about the people around them, so the conversation can begin there. In his lectures, Taeyul also expounded this article, explaining that the Taeyang person looks at whether someone is good or bad, the Soyang person at whether someone is clever, the Taeeum person at whether someone is diligent and the Soeum person at whether someone can get things done, and adding that "because each has such a different eye for people, when they collide it is almost impossible for one human being to understand another" (Taeyul lecture collection p.210 (pages illegible in OCR were collated with and restored from the digital manuscript of the same lecture, 「심학공부 (녹취)」, Simhak Gongbu (transcript)) [transcript]). However, neither this article nor this lecture supports using the axis along which a patient evaluates others as grounds for determining the patient's constitution. The hypothesis that such judgements offer an entry into conversation must be kept separate from any basis for constitutional diagnosis.

Volume 1 of the Gyeokchigo contains a passage describing the mental states of four types of person.

薄夫之心常憂患也 … 頑夫之心常恐懼也 … 懦夫之心常忿懥也 … 鄙夫之心常好樂也

(The heart of the shallow man is always anxious and troubled; the heart of the obstinate man is always fearful; the heart of the weak man always harbours resentment; and the heart of the base man is always given to liking and pleasure. — author's translation)

— 格致藁 Gyeokchigo, Vol. 1, 「儒略」 Yuryak (Outline of Confucian Learning) (Dongmu Jeojak Jipseong transcription, collated with the Gyeokchigo transcription and the Lee Kyung-sung transcription (1999); not included in the Korean Medicine Classics Database)

These four types carry different names from the 鄙, 薄, 貪 and 懦 of the "Discourse on the Four Beginnings". The sentences that follow in the same Yuryak passage link each of the four mental states to a deficiency of virtue. The sentence reads: "不智則無助而憂患, 不仁則不立而恐懼, 無禮則格戾而忿懥, 無義則偸惰而好樂". Its meaning is that one who lacks wisdom (不智) becomes anxious and troubled (憂患), one who lacks benevolence (不仁) becomes fearful (恐懼), one who lacks propriety (無禮) becomes resentful (忿懥), and one who lacks righteousness (無義) sinks into liking and pleasure (好樂).

When this is placed alongside the definitions of the "Discourse on the Four Beginnings", the correspondence holds only in part. The shallow man (薄夫, lacking wisdom) shares the deficient virtue of the shallow person (薄人, who abandons wisdom), and the obstinate man (頑夫, lacking benevolence) shares that of the greedy person (貪人, who abandons benevolence). The weak man (懦夫), however, is linked to a lack of propriety and the base man (鄙夫) to a lack of righteousness, which cross over with the cowardly person (懦人, who abandons righteousness) and the mean person (鄙人, who abandons propriety) of the "Discourse on the Four Beginnings". There is also a textual variant. Kim Man-san's annotated edition (1997) exchanges the base man and the weak man in this passage (格戾者不入 鄙夫之心常忿懥, 偸惰者不行 懦夫之心常好樂), and on that reading all four pairs agree with the "Discourse on the Four Beginnings". The three transcriptions collated for this paper (the Dongmu Jeojak Jipseong, the separate Gyeokchigo transcription and the Lee Kyung-sung transcription) all agree on 懦夫 with resentment (忿懥) and 鄙夫 with liking and pleasure (好樂), so this paper follows them and records Kim Man-san's reading as a variant. This paper therefore does not read the passage as a description of bibaktamna, and restricts it to related types of person described in Volume 1 of the Gyeokchigo. What the passage does establish is that at least three of the mental states of these virtue-deficient types (anxiety, fear and resentment) are described as states that are uncomfortable for the person as well. Since what brings people to the consulting room is usually distress of this kind, or symptoms in which it has become manifest in the body, this paper proposes that such distress can serve as an entry point for motivation to treatment.

2. Direction: what the Dokhaeng-pyeon says to the person with bibaktamna

In the 獨行篇 Dokhaeng-pyeon (Chapter on Solitary Conduct), among the sentences that describe bibaktamna, there is one paragraph setting out corrective directions addressed to the person concerned.

鄙者之心宜謹而不宜慢也, 謹則資身之策專也, 慢則招奸之術毒也. 薄者之膽宜退而不宜進也, 退則愛物之誼嘉也, 進則誣賢之量敢也. 貪者之志宜緩而不宜急也, 緩則反本之悔得也, 急則虐民之計險也. 懦者之意宜實而不宜凌也, 實則修身之誠到也, 凌則自尊之癡成也.

(The heart of the mean person should be prudent and not arrogant: if it is prudent, his plans for supporting himself become single-minded; if it is arrogant, his arts for inviting treachery become venomous. The gall of the shallow person should step back and not push forward: if it steps back, the principle of cherishing things becomes admirable; if it pushes forward, the audacity to slander the worthy grows bold. The will of the greedy person should be unhurried and not hasty: if it is unhurried, it attains the remorse that returns to the root; if it is hasty, its schemes to oppress the people become dangerous. The intent of the cowardly person should be substantial and not contemptuous: if it is substantial, it reaches the sincerity of self-cultivation; if it is contemptuous, the folly of self-exaltation is brought about. — author's translation)

— Gyeokchigo, Vol. 3, 獨行篇 Dokhaeng-pyeon (壬午年, the imo year) (Dongmu Jeojak Jipseong transcription, collated with the Gyeokchigo transcription and the Lee Kyung-sung transcription (1999); not included in the Korean Medicine Classics Database)

The four directions differ from one another, and they are preserved here as distinct rather than merged into one.

The seats at which the four directions are aimed also differ: the heart (心), the gall (膽), the will (志) and the intent (意). In particular, 實 is not a direction of slowing down or reducing anything; it is a direction of filling up by steadily accomplishing what must be done. The phrase stating that unhurriedness brings the greedy person "the remorse that returns to the root (反本之悔)" connects with the Chobongwon passage discussed in subsection 5 below. This paragraph is not cited anywhere in the nine earlier papers.

In relation to this paper's proposal to translate the directions into behavioural tasks rather than corrections of the mind, Taeyul stated in his lectures that the difference between the sage, the noble person, the petty person and bibaktamna arises "not in the mind but in the body", that is, in conduct (行), and explained that solitary conduct is difficult because selfish mind (私心) and idle conduct (怠行) are themselves strong instinctive desires that can seem right "if one reckons only by one's own body" (Taeyul lecture collection pp.214–215 (pages illegible in OCR were collated with and restored from the digital manuscript of the same lecture, 「심학공부 (녹취)」, Simhak Gongbu (transcript)) [transcript]). The assignment of the 鄙, 薄, 貪 and 懦 of the Dokhaeng-pyeon to the Taeyang, Soyang, Taeeum and Soeum constitutions derives from the 東醫四象草本卷 Dongui Sasang Chobongwon (the Draft Volume of Eastern Medicine's Four Constitutions), and earlier research has pointed out that the assignments in the two texts do not coincide; this paper therefore records the directions by designation rather than by constitution name.

3. Target and relationship: one thing only, nothing forced, nothing displaced

On the question of where to begin, the Admonition on Self-Reflection (反省箴) states that "if one overcomes the single thing to which one is most tenaciously attached (膠着之甚者), the remaining shallower desires are overcome of themselves without needing to be overcome". Because this principle was treated in the earlier paper "Self-Reflection and Differential Completion", the present paper carries it over only as a proposal to narrow the first target to a single one.

What must not be done is stated explicitly in the Dongui Suse Bowon.

太陽少陽人, 但恒戒哀怒之過度, 而不可强做喜樂, 虛動不及也. 若强做喜樂, 而煩數之, 則喜樂, 不出於眞情, 而哀怒益偏也.

(Taeyang and Soyang persons should simply guard constantly against excess of sorrow and anger; they must not force joy and pleasure, stirring them emptily when they fall short. If they force joy and pleasure and do so frequently, the joy and pleasure will not come from true feeling, and sorrow and anger will become all the more lopsided.)

— Dongui Suse Bowon, "Discourse on the Four Beginnings", [2-25] (mediclassics.kr/books/182/volume/1#content_65)

An intervention that makes the patient forcibly rehearse the opposite emotion is therefore a method the classics warn against. There is also a principle concerning relationships.

太陽之交遇, 可以怒治之, 而黨與, 不可以怒治之也, 若遷怒於黨與, 則無益於黨與, 而肝傷也. … 太陰之居處, 可以樂治之, 而事務, 不可以樂治之也, 若遷樂於事務, 則無益於事務, 而肺傷也.

(For the Taeyang person, social encounters may be governed by anger, but close associates must not be governed by anger; if anger is transferred to close associates, it brings no benefit to them and injures the liver. … For the Taeeum person, domestic life may be governed by pleasure, but public affairs must not be governed by pleasure; if pleasure is transferred to public affairs, it brings no benefit to those affairs and injures the lungs.)

— Dongui Suse Bowon, "Discourse on Expansion and Enrichment", [3-6] (mediclassics.kr/books/182/volume/1#content_73)

The principle is that emotions have their proper place, and that transferring them into another domain of relationships benefits neither the relationship nor the body. This paper proposes carrying this into the interview as attention to which relationship an emotion arose in and which relationship the patient is pouring it into. The helpers appropriate to each stage of life in the "Discourse on Broad Salvation" (廣濟說, [16-4]), examined in Part 2, provide coordinates for deciding whom to bring into the therapeutic environment. Relationships are not an item to be addressed only at a particular point; they are an element to be observed continuously from the first interview onwards.

4. Time: the stage table of the classics and recounting after relapse

The classics present temporal stages in which medicine and self-cultivation are used together, not under the name of bibaktamna but at the level of disease patterns arising from violent injury (暴傷).

少陽人, 吐血者, 必蕩滌剛愎偏急, 與人並駈爭塗之. 淡食服藥, 修養如釋道, 一百日, 則可以少愈. 二百日, 則可以大愈. 一周年, 則可以快愈. 三周年, 則可保其壽. 凡吐血, 調養失道, 則必再發, 再發, 則前功, 皆歸於虛地, 若再發者, 則又自發日, 計數, 一百日, 少愈, 一周年, 快愈.

(When a Soyang person vomits blood, he must wash away his harsh, obstinate, one-sided and hasty temper and his habit of racing alongside others and contending for the road. If he eats plain food, takes medicine and cultivates himself like a Buddhist, in 100 days he will be somewhat better, in 200 days much better, in one year fully recovered, and in three years he will be able to preserve his lifespan. Whenever vomiting of blood is not properly managed and nurtured, it will surely recur, and when it recurs all the earlier effort comes to nothing. If it recurs, the days are counted again from the day of recurrence: in 100 days he will be somewhat better, and in one year fully recovered.)

— Dongui Suse Bowon, "Soyang Person" (少陽人), [11-3] (mediclassics.kr/books/182/volume/3#content_81)

凡無論某病人, 恭敬其心, 蕩滌慾火, 安靜善心, 一百日, 則其病無不愈, 二百日, 則其人無不完.

(Whatever the illness, if the patient reveres his own mind, washes away the fire of desire and settles the good mind in calm, in 100 days there is no illness that is not healed, and in 200 days there is no person who is not made whole. — author's translation)

— Dongui Suse Bowon, "Taeeum Person" (太陰人), [13-25] (mediclassics.kr/books/182/volume/4#content_42)

What the text says consists of three points. Healing comes in stages; [13-25] distinguishes the healing of the illness (100 days) from the person being made whole (200 days); and [11-3] counts the days again from the day of recurrence when vomiting of blood recurs. The Dongui Sasang Chobongwon likewise records that someone whose vital thread was endangered by a chronic illness from youth, "one day suddenly became reverent, corrected his faults and chose the good (忽一日嬰然恭敬改過選善)", yet even while continuing medicine and nurturing care "passed through the changes of illness with a thousand hardships and ten thousand pains (千辛萬苦經歷病變)", and only on reaching middle age did his vital thread recover somewhat (author's translation; Dongui Sasang Chobongwon, Vol. 2, Section 3, Kim Gu-ik manuscript copy, 1985 transcription).

These day counts and the recounting are attached to the treatment methods for disease patterns such as vomiting of blood and tidal fever. There is no basis for transferring them unchanged to change at the level of personality, and in particular they give no grounds for treating earlier change as if it had never happened when a relapse occurs. This paper's proposal is to take only two elements of the classical structure: setting goals separately for symptomatic improvement and for change in the person, and reassessing the patient's state and the plan when relapse occurs.

5. The prognostic statements of the classics and the problem of their clinical translation

The Dongui Sasang Chobongwon sets out the conditions that separate the possibility of recovery in long illness as follows.

凡病人在痼病久病, 後悔多, 善心發, 以療病爲第一事件, 其他千萬事爲第二事件, 如此者, 命脉雖甚弱, 庶有回生應之也. 病人在痼病久病, 欲心多, 後悔少, 喜人承奉, 以療爲第二事件, 以許多豪侈外欲爲第一件事, 如此者, 命脉雖不堪弱, 無回生之望也.

(Whenever a patient with a chronic or long-standing illness has much remorse, has a good mind awakening, makes the healing of the illness his first concern and all other matters his second, then even if his vital thread is very weak, there is likely to be a response of revival. When a patient with a chronic or long-standing illness has much desire and little remorse, likes to be waited upon by others, makes treatment his second concern and his many extravagant outward desires his first, then even if his vital thread is not so weak, there is no hope of revival. — author's translation)

— Dongui Sasang Chobongwon, Vol. 2, Section 6 (Kim Gu-ik manuscript copy, 1985 transcription by the Yanbian Institute of Ethnic Medicine, collated with the Dongmu Jeojak Jipseong transcription; not included in the Korean Medicine Classics Database)

The text links remorse (後悔) and the priority given to treatment with the possibility of recovery. Translating this into a clinical indicator, however, raises two problems. First, "whether there is much remorse" does not distinguish between reviewing one's own conduct and repetitive self-reproach. This opens the way to the error of reading the excessive self-blame of a depressive state as a sign of good prognosis. Second, where treatment stands among a person's life priorities is heavily influenced by conditions such as livelihood, caregiving and cost. This paper therefore does not transfer the indicators of the text unchanged. Instead, it sets out two newly proposed observation items: whether the patient concretely examines his or her own actions and their consequences, and whether the patient actually attempts the changes agreed in the interview. These are not indicators found in the classics but proposals of this paper, and they will be examined in Part 4 together with the method of recording them. Nor is this sentence of the text an instruction to refuse treatment; it is a statement about prognosis.

6. Boundary: the danger of exposing the wickedness of others

After describing the behaviour of bibaktamna in detail himself, the author of the Dokhaeng-pyeon recorded the danger of that undertaking in the form of a dialogue.

Boundary stated in the text. When someone objects, "Human nature is entirely good, so it is not right for you to expose the wickedness of others", the Recluse of Baeksan (白山處士, Yi Je-ma) replies that "only one who has thoroughly worked on his own wickedness can clearly understand the wickedness of others (熟攻己惡者熟明人之惡也)", and explains that the purpose of exposing the wickedness of others was to let those who come after recognise the deep water and the scorching fire so that they do not step into them lightly. He then writes that "loving the worthy must not be sharp, and hating wickedness must not be pressing (好賢不可銳也, 惡惡不可迫也)" (author's translation; Gyeokchigo, Vol. 3, closing dialogue of the Dokhaeng-pyeon, Dongmu Jeojak Jipseong transcription, collated with the Gyeokchigo transcription and the Lee Kyung-sung transcription (1999); not included in the Korean Medicine Classics Database). What the text states explicitly amounts to these two points: that the capacity to see others extends only as far as one has governed oneself, and that one must not press hard upon others.

Principle derived by this paper. From this the paper draws two principles. First, the designation bibaktamna is not to be used as a diagnostic label that defines a patient. Second, merely withholding the designation from the patient is not enough, because even when the name is not used, the judgement still shapes the therapist's attitude. Accordingly, what is recorded in place of the designation is the behaviour observed, the situation in which it arose, and the uncertainty of the therapist's interpretation. These principles are not stated directly in the classics; they are this paper's proposals, formed by considering the above boundary together with the principles of contemporary clinical practice. The paper comparing bibaktamna with the DSM-5 pointed in the same direction when it warned of its own accord that "the judgement 'that patient is a greedy person' can be misused to justify the therapist's countertransference".

7. Contemporary comparison: evidence for psychotherapy in borderline personality disorder

Bibaktamna is a concept for which a structural analogy with DSM-5 personality disorders has been proposed; it is not the same diagnosis. As to what effect psychotherapy has on problems at the level of personality, the results for borderline personality disorder, where research has accumulated most extensively, can be consulted for reference only. In a meta-analysis pooling 33 randomised controlled trials (2,256 participants), psychotherapy was more effective than control interventions (stand-alone designs Hedges' g 0.32, 95% CI 0.14–0.51; add-on designs g 0.40, 0.15–0.65), and among individual therapies only dialectical behaviour therapy (g 0.34) and psychodynamic approaches (g 0.41) were significantly superior to control conditions. The authors noted that these effects may have been inflated by risk of bias and publication bias and were unstable at follow-up. A network meta-analysis of 43 trials (3,273 participants) likewise reported that no single therapy could be established as the best. These figures are mean differences from control groups; they do not indicate how quickly or how much an individual changes. Both studies concern borderline personality disorder, so they cannot be extended to personality pathology as a whole. What can be said within this scope is that the effectiveness of psychotherapy in borderline personality disorder has been reported, but uncertainty remains about the relative merits of treatments and about long-term effects.

---

4. Cross-Reading

The five items of the intervention hypothesis constructed from the classical material are summarised below. The items are elements to be examined; they do not signify an order or a sequence of stages.

As the tables show, the only elements supported directly under the designation bibaktamna are the direction item and the boundary set out in the dialogue of the Dokhaeng-pyeon. Everything else consists of passages about the constitutions in general or about treatment methods for disease patterns that this paper has carried over to this level.

There is also a tension within the classics. The Dokhaeng-pyeon advises those around such people that there is "nothing to trust in them, nothing to exhort in them, and nothing to regret losing in them", urging them to read the signs and keep away, while at the same time forbidding harsh treatment. The Chobongwon, by contrast, opens a path of revival to the sick person who corrects his faults and chooses the good. This paper reads the two as differing in whom they address. The advice of the Dokhaeng-pyeon concerns the self-protection of people who are being harmed within a relationship, whereas the path of the Chobongwon concerns the recovery of a person who has come of his own accord to have his illness treated. The therapist stands in the latter position. Taeyul's lecture records contain a passage attributing to Dongmu a remark to the effect that such patients should not be treated, but this paper's search of the original texts found no corresponding classical sentence.

---

5. What Remains Unknown

The Sasang psychology literature reviewed in this paper contains no case in which a patient in a state of bibaktamna was managed through the clinical interview. The cases it records are ones in which selfish mind or complexes surfaced as symptoms, not cases judged to be bibaktamna. The five items are therefore a hypothesis constructed from classical material, not a procedure tested in clinical practice.

There are also limitations of citation. Because the Gyeokchigo and the Dongui Sasang Chobongwon are not included in the Korean Medicine Classics Database, they were cited by collating the digital transcriptions held in the author's clinic library against one another. The translations are the author's own and require collation against other editions. The discrepancies between texts, in the designations and constitutional assignments of the Dokhaeng-pyeon and between the types of person in Volume 1 of the Gyeokchigo and the definitions of the "Discourse on the Four Beginnings", also remain unresolved.

The questions carried forward to Part 4 are as follows.

1. In what order should the five items be addressed, and what conditions should govern moving on to the next item?
2. Can the four directions of 謹, 退, 緩 and 實 be translated into concrete behavioural tasks that remain distinct from one another?
3. How should the review of one's own actions and attempts at agreed change be recorded so as to be distinguished from self-reproach and from life circumstances?
4. Can "symptomatic improvement" and "change in the person" be measured separately with different indicators (symptom scales and indicators of functioning and relationships)?
5. What criteria should be set for collaboration with, and referral to, psychiatry for patients in whom a personality-level problem is suspected?

---

6. Classical Citation Cards

The "Text verification" field of each card indicates the extent of collation actually carried out for this paper. Because no formal quality appraisal was performed, no grade of certainty of evidence has been assigned.

Source 1 [KM]

• Source: 東醫壽世保元 Dongui Suse Bowon, Sinchuk edition, "Discourse on the Four Beginnings" [2-2] and [2-25], "Discourse on Expansion and Enrichment" [3-6] and [3-11], "Soyang Person" [11-3], "Taeeum Person" [13-25]
• Author/Era: Yi Je-ma, Joseon (1901 Sinchuk edition)
• MEDICLASSICS: mediclassics.kr/books/182/volume/1#content_42 · #content_65 · #content_73 · #content_78 · volume/3#content_81 · volume/4#content_42
• Text verification: direct collation with the original text | Study type: classical text
• Key point: Definition of bibaktamna, prohibition of forced emotion, prohibition of transferring emotions across domains of relationships, constitution-specific discernment that remains, temporal stages of medicine and self-cultivation.

Source 2 [KM]

• Source: 格致藁 Gyeokchigo, Vol. 1, 「儒略」 Yuryak (four types of person and deficiencies of virtue); Vol. 3, 獨行篇 Dokhaeng-pyeon (corrective directions for bibaktamna, closing dialogue)
• Author/Era: Yi Je-ma, Joseon / Edition: Lee Kyung-sung transcription (1999, based on the 1940 edition)
• Text verification: character-by-character collation of three transcriptions (all quoted passages agree); not included in the Korean Medicine Classics Database; author's translation | Study type: classical text
• Key point: The four directions of 謹, 退, 緩 and 實; the mental states of the shallow, obstinate, weak and base man (薄·頑·懦·鄙夫), which, in the transcriptions followed here, correspond only in part (in Kim Man-san's edition, fully) to the definitions of the "Discourse on the Four Beginnings"; 熟攻己惡 and 惡惡不可迫.

Source 3 [KM]

• Source: 東醫四象草本卷 Dongui Sasang Chobongwon, Vol. 2, Sections 3 and 6
• Author/Era: Yi Je-ma, Joseon / Edition: transcription of the Kim Gu-ik manuscript copy (Yanbian Institute of Ethnic Medicine, 1985)
• Text verification: OCR scan collated with the Dongmu Jeojak Jipseong transcription (quoted passages agree); not included in the Korean Medicine Classics Database; author's translation | Study type: classical text
• Key point: Correcting faults and choosing the good (改過選善) → changes of illness (病變) → recovery; prognostic statements (remorse, 後悔, and the priority given to treatment).

Source 4 [KM]

• Source: 四象心學 (Sasang Simhak)
• Author/Year: Kang Yong-hyeok, Daesung Medical Publishing, 2010
• Text verification: full text (author's clinic library corpus), collation of citations | Study type: school commentary
• Key point: Bibaktamna = a state of having abandoned the virtue that is inherently inferior; caution against turning the types into a manual.

Source 4-1 [KM]

• Source: Lecture transcript of Taeyul (Kim Do-sun), "Advanced Discourse on Expansion and Enrichment" (확충론 심화) (Simhak study transcript)
• Location cited: edited volume "Sasang Psychology Lectures of Taeyul (Kim Do-sun)" (「태율(김도순) 사상심학 강의」) p.210, pp.214–215
• Text verification: pages illegible in the scan OCR → collated with the digital manuscript of the same lecture in the author's clinic library, 「심학공부 (녹취)」 (Simhak Gongbu, transcript) | Study type: transcript record
• Key point: Constitutional differences in the eye for judging people (exposition of [3-11]); the explanation that differences at the level of personality arise in conduct (行).

Source 5 [WM]

• Source: Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis
• Author/Year: Cristea IA et al., 2017, JAMA Psychiatry (PMID 28249086)
• Text verification: abstract | Study type: systematic review and meta-analysis
• Key point: 33 RCTs, 2,256 participants; g 0.32 (stand-alone) and 0.40 (add-on) versus control; only DBT and psychodynamic approaches significant; unstable owing to bias and at follow-up.

Source 6 [WM]

• Source: Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis
• Author/Year: Setkowski K et al., 2023, Psychol Med (PMID 37203447)
• Text verification: abstract | Study type: network meta-analysis
• Key point: 43 RCTs, 3,273 participants; no single best treatment could be established; the evidence for DBT is the most robust.

Source 7 [Author's earlier paper]

• Source: A Contemporary Reinterpretation of Bibaktamna (鄙薄貪懦): A Structural Analogy between the Personality Pathology Theory of Sasang Psychology and DSM-5 Personality Disorders
• Author/Year: Choi Jang-hyuk, 2026, Sowonjae (sowonjae.dongjedang.com/post/2026-03-31-bibaktamna-dsm5-reinterpretation-v5/)
• Study type: theoretical comparative study
• Key point: Route to resolution "not discussed by Yi Je-ma"; warning about misuse in countertransference. The "dominant function" interpretation is corrected in the present paper.

Source 8 [Author's earlier paper]

• Source: Whose Is Bibaktamna? The Hardened Guk (局) and the Sealing of the Mind / Whom Does Bibaktamna Strike? The Contact Surface of the Hardened Guk and Its Guarding
• Author/Year: Choi Jang-hyuk, 2026, Sowonjae (…/post/2026-06-25-bibaktamna-1-guk/ · …/post/2026-06-26-bibaktamna-2-myeon/)
• Study type: interpretive study of classical texts
• Key point: Abandonment of the inherently weak virtue; "making a hardened 局 flow again is the task of the inside of that 局 itself".

Source 9 [Author's earlier paper]

• Source: Where Does Bibaktamna Close? Violent Injury (暴傷) and the Clarity and Turbidity of the Mind / Banseong (反誠) and Differential Completion
• Author/Year: Choi Jang-hyuk, 2026, Sowonjae (…/post/2026-06-30-bibaktamna-4-poksang/ · …/post/2026-06-23-banseong-differential-completion/)
• Study type: interpretive study of classical texts
• Key point: 恒寧靜 is the medicine; 反誠 is an endless returning; target the single most hardened fixation.

---

Choi Jang-hyuk | Doctor of Korean Medicine · Director, Dongjedang Korean Medicine Clinic · Method: narrative review centred on interpretation of the classics (collation with the originals of Dongui Suse Bowon, Gyeokchigo and the Chobongwon)