Atlas›Domain XIII · Contemplative & religious disciplines›Guide 292
Guide XIII-292

Fasting

A 32 · L 57 · M 1119 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: religious fasting as named institutions and authorities publish it — the US Conference of Catholic Bishops (Latin Catholic Lent), the Greek Orthodox Archdiocese of America yearbook pastoral guidelines by Stanley S. Harakas (Orthodox Christian fasting seasons), Rabbi Eliezer Melamed's Peninei Halakha rulings (Yom Kippur, one Orthodox Jewish halakhic authority among many), the Notes to the Kitáb-i-Aqdas (the Bahá'í Fast), Swami Harshananda's encyclopaedia as summarised by Hindupedia and Banglapedia (Hindu upavāsa), and Islamic Ramadan exemptions as summarised by UK eating-disorder and diabetes clinicians. Clinical guidance follows the IDF–DAR International Alliance quick-reference guide (2016) for diabetes, and eating-disorder guidance from the British Dietetic Association (2022), NEDA, the National Alliance for Eating Disorders (2025) and The Psychologist (BPS, 2021). Assessment follows the DSM-5-TR Cultural Formulation Interview (CFI) and its Spirituality, Religion and Moral Traditions module; scrupulosity follows the IOCDF.

Fasting is not a therapy and not a single practice: it is a family of religious observances found across many traditions, each with its own meaning, calendar, rules and authorities. This guide does not teach or prescribe any fast and gives no fasting lengths or food rules. It describes, as the traditions' institutions publish them, what fasting means and who is exempt, and then sets out the psychotherapist's own work alongside it: understanding what the fast means in the client's life, cultural assessment, accommodation, routing health and medication questions to the client's doctor and prescriber, eating-disorder awareness, scrupulosity, guilt and community, and collaboration with clergy when the client wishes. [source: USCCB; Harakas; Melamed; Kitáb-i-Aqdas Note 31; Hindupedia; BDA 2022]

Core idea of change (therapist's side) [synthesis]: the therapist does not decide whether a client fasts. The work is to help the client hold faith and health together — to understand the fast in their own religious terms, to get accurate medical and religious information (including the exemptions their own tradition grants), and to make a decision they can live with, without the fast becoming a vehicle for an eating disorder, OCD or shame.

How traditions frame the fast (attributed, not stated as fact):

  • Latin Catholic (Lent): one of three Lenten practices with prayer and almsgiving, to "practice self-control" and seek inner conversion; Good Friday fasting honours Christ's suffering. Obligations are set by the bishops' conference and apply only within stated age bands; the ill, including those with chronic illness such as diabetes, and pregnant or nursing women are excused. The USCCB states that "ill persons should not further jeopardize their health by fasting." [source: USCCB, What is Lent?]
  • Orthodox Christian: fasting is the counterpart of feasting, not "a legalistic observance of dietary rules"; without intensified prayer and charity it "inevitably becomes a source of pride." The Church recognises that not everyone can fast to the same degree, and each person follows the fast set by their spiritual father. [source: Harakas, Pastoral Guidelines: Fasting]
  • Judaism (Yom Kippur): in Melamed's account the fast is central to atonement — withdrawing from bodily activity to turn inward. Pikuach nefesh (saving life) overrides the fast; the determination of danger is entrusted to a physician; one who must eat is not at fault, and refusing to eat when life may be at risk is itself the transgression. Rulings on the ill, pregnancy and nursing are detailed and differ between fasts and between authorities, so they belong to the client's rabbi. [source: Melamed, Fasting on Yom Kippur] [uncertain: other authorities rule differently]
  • Islam (Ramadan): the BDA article lists as exempt those who are ill, pregnant or nursing, menstruating, travelling, young children and the elderly, and states that the Qur'an allows fidya (a donation of food or money to people in need) for those unable to fast through illness. [source: BDA 2022] [uncertain: Qur'anic and juristic texts not verified directly; detailed rulings belong to the client's scholar or imam]
  • Bahá'í Faith: the Notes to the Kitáb-i-Aqdas describe exemptions for travellers, the ill, those of advanced age, women in their courses, pregnant and nursing women, and those engaged in heavy labour (who are advised to eat with frugality and in private), describing the exemptions as a token of God's grace. [source: Bahá'u'lláh, The Kitáb-i-Aqdas, Notes, Note 31] [uncertain: wording not verified against the official edition]
  • Hindu (upavāsa, vrata): described as spiritual discipline, part of religious rites or expiation, accompanied by worship, repeating the divine name, silence, vigil and devotional singing; old persons, patients and children are not advised to keep it. Banglapedia adds that severity depends on physical condition and capacity, and that some who cannot fast fully take light food. [source: Hindupedia, Upavāsa; Banglapedia, Upavasa] [uncertain: Jain, Buddhist and other traditions not verified]

Health claims for fasting made within traditions (e.g. that it promotes health) are attributed only; this guide presents no fast as treatment for any physical or mental illness. [source: Banglapedia] Related guides in this domain: 156 (Teshuvah and the Yom Kippur cycle), 179 (the Orthodox fasting calendar), 180 (Ethiopian Tewahedo fasting cycle), 263 (Ramadan fasting and i'tikaf) and 274 (Bahá'í obligatory prayer and the Nineteen-Day Fast).

2. Framework

There is no manualised protocol. The sources describe a timeline around each observance; the phases below organise it. No source gives a session count or format; work is integrated into ongoing therapy. [synthesis, built on IDF–DAR 2016; Alliance 2025; BDA 2022]

Phase A — Ahead of the season.

  • Goal: know which observances the client keeps and when; open the conversation before the season, not during it.
  • Sources: the IDF–DAR guide places pre-Ramadan medical assessment and structured education 6–8 weeks before Ramadan; the BDA advises clinicians to raise Ramadan before it begins; the Alliance advises starting with the treatment team before any decision. [source: IDF–DAR 2016; BDA 2022; Alliance 2025]
  • Move on when: the observance, its meaning for the client, relevant health conditions and the people involved (doctor, prescriber, dietitian, religious authority) are identified.

Phase B — Assessment.

  • Goal: cultural formulation (CFI core plus spirituality module), medical risk routed to the doctor, eating-disorder and OCD screen, family and community pressures.
  • Move on when: medical opinion has been sought where any health condition, medication, pregnancy, eating disorder or major mental illness is present; the client's motive and meaning are understood.

Phase C — Decision and plan.

  • Goal: a client-led decision — to fast, to fast in a modified form their authority permits, to take an exemption, or to observe through non-food practices — made with medical opinion and, if the client wishes, religious guidance. For eating-disorder clients the Alliance advises agreeing a plan with the treatment team, spiritual advisor and client before the fast. [source: Alliance 2025; IDF–DAR 2016]
  • Move on when: there is a written or clearly agreed plan, including when to stop and whom to contact.

Phase D — During the observance.

  • Goal: monitoring, accommodation in scheduling, shame and pressure, relapse warning signs; readiness to break the fast when the doctor's agreed criteria are met. [source: IDF–DAR 2016; Alliance 2025]

Phase E — After.

  • Goal: review; post-fast eating plan for ED clients (Alliance notes risk around breaking an extended fast and advises a structured plan); for diabetes, IDF–DAR flags risk during the Eid festival and post-Ramadan regimen review by the diabetes team. Debrief meaning, guilt, and plans for next season. [source: Alliance 2025; IDF–DAR 2016]

3. Guiding principles

  • The decision belongs to the client. Practical meaning: explore and inform; do not instruct the client to fast or not to fast. The BPS article cautions clinicians against automatically advising against fasting, weighing harm to religious identity against relapse risk. [source: BPS 2021]
  • Describe the tradition in its own terms. Practical meaning: use the client's words (Lent, sawm, ta'anit, vrata, the Fast) and attribute religious meanings; do not assert or dismiss them. [synthesis]
  • Exemptions are part of the religion, not a lapse from it. Practical meaning: most authorities sourced here build exemptions into the law itself (pikuach nefesh, the USCCB's "common sense should prevail", the Aqdas exemptions as grace); help the client find their own authority's position. [source: USCCB; Melamed; Kitáb-i-Aqdas Note 31; NEDA]
  • Health questions go to the doctor; medication questions go to the prescriber. Practical meaning: never advise on whether, how or when to take medicines while fasting; the IDF–DAR guide places medication adjustment with clinicians, and the Alliance advises involving the prescriber because fasting can affect timing, absorption and mood. [source: IDF–DAR 2016; Alliance 2025]
  • Religious rulings go to the client's religious authority. Practical meaning: the therapist is not a rabbi, imam, priest, spiritual father or guru; refer rulings, and collaborate only with consent. [synthesis; source: Harakas (spiritual father sets the fast); Melamed (physician determines danger)]
  • Eating-disorder vigilance. Practical meaning: assume fasting can trigger relapse and can mask restriction, bingeing or purging. [source: BDA 2022; NEDA; BPS 2021; Alliance 2025]
  • Motive matters. Practical meaning: ask what the fast is for; NEDA links fasting used for weight control, and religiosity driven by pressure or an anxious relationship with God, to more disordered eating; the IOCDF distinguishes fear-, guilt- and shame-driven practice from value-driven practice. [source: NEDA; IOCDF]
  • No numbers from the therapist. Practical meaning: give no fasting lengths, food rules, glucose thresholds or meal targets; those come from the tradition and the medical team. [synthesis]
  • Shame is a clinical target. Practical meaning: not fasting can carry stigma and loss of religious identity; address it directly. [source: BDA 2022; BPS 2021]
  • Timing and accommodation. Practical meaning: plan sessions, homework and group meals around the observance. [synthesis]
  • Children are protected by the traditions' own age limits and by safeguarding duties. Practical meaning: know the ages the authority sets (e.g. USCCB) and act on any risk to a child. [source: USCCB; Hindupedia] [synthesis for safeguarding]
  • Stay in role. Practical meaning: no dual relationships; disclose your own religious commitments only if it serves the client. [synthesis] [uncertain: Vieten et al. 2013 spiritual and religious competencies not verified]

4. Intervention inventory

These are the psychotherapist's tasks alongside a client's fast. None of them is a fasting instruction. Example language is illustrative unless quoted and cited.

4.1 Mapping the client's observances ahead of the season

  • Purpose: find out early which fasts the client keeps, so assessment and medical input can happen in time. Use at intake and when a season approaches. [source: IDF–DAR 2016 (assessment weeks ahead); BDA 2022 (raise it before Ramadan)]
  • Steps: (1) At intake, ask about religious and cultural observances that affect eating, sleep or schedule. (2) Note the client's tradition, community, and the dates they expect (dates move between years in lunar and lunisolar calendars — ask the client). (3) Put a reminder in your diary to raise the topic well before the season. (4) Ask who else is involved: doctor, prescriber, dietitian, religious authority, family.
  • Example language (illustrative): "Are there religious times in your year when eating, sleep or your routine changes? I'd like to plan around them with you rather than be caught out."
  • Watch for: the client minimising ("it's nothing") when an eating disorder, diabetes or major mental illness is present; it is working when the client raises upcoming observances themselves.

4.2 Exploring the meaning of the fast in the client's life

  • Purpose: understand what the fast is for, in the client's terms, before any health conversation; this protects the alliance and shows where non-food observance might carry the same meaning. [source: Harakas (fasting with prayer and charity); USCCB (self-control, conversion); Melamed (atonement, turning inward); Hindupedia (discipline, expiation, devotion)]
  • Steps: (1) Ask what the observance means spiritually, and personally. (2) Ask what it is joined with — prayer, charity, study, vigil, community meals — since the sources pair fasting with these. (3) Ask what it has meant in past years, good and hard. (4) Ask how their family and community observe it. (5) Reflect back in the client's own vocabulary.
  • Example language (illustrative): "When you keep the fast, what are you hoping happens between you and God, or in yourself?" / "What else belongs to this season for you besides not eating?"
  • Watch for: meaning that is mostly about the body, weight, control or punishment rather than the stated religious purposes (see 4.6); fear or guilt as the main driver (see 4.11). Working when the client can name a purpose that is not only about food.

4.3 Cultural Formulation Interview, with the spirituality module

  • Purpose: structured cultural assessment of the problem, causes, supports, coping and help-seeking. [source: DSM-5-TR CFI; CFI Supplementary Modules]
  • Steps: (1) Use the core CFI's four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; cultural factors affecting current help-seeking. (2) Take the client's own term for the problem from the first question and use it throughout, as the CFI directs. (3) Add Module 5, Spirituality, Religion and Moral Traditions, which covers religious or moral identity and affiliations, the tradition's role in daily, family and community life, how it has helped the person cope (leaders, texts, practices), and how it may have contributed to the problem, distress, discrimination or conflict. (4) Where family is closely involved in the fast, consider the informant version. Do not reproduce items; use the published forms. (5) Treat the result as an aid to understanding, not a diagnosis.
  • Example language (illustrative): "You've called it 'struggling with Ramadan'. Can I ask a few questions about how your faith fits with that — both how it helps and where it's been hard?"
  • Watch for: the module revealing community conflict, discrimination or religious distress around eating; working when you understand the fast's place in the person's identity and who the trusted religious voices are.

4.4 Health screen and routing to the client's doctor

  • Purpose: identify any condition where fasting may be risky and make sure the client has medical opinion before deciding. The therapist screens and routes; the doctor judges. [source: IDF–DAR 2016; Melamed (physician determines danger); USCCB (chronic illness excused)]
  • Steps: (1) Ask about long-term conditions (e.g. diabetes, kidney disease, heart disease), pregnancy or breastfeeding, age-related frailty, current or past eating disorder, and serious mental illness. (2) For diabetes, tell the client that the IDF–DAR guide asks for a medical assessment weeks before Ramadan, places people in risk categories, and in the highest categories advises not fasting — and that their diabetes team, not the therapist, applies this. (3) Encourage the client to book that appointment; with consent, write to or call the doctor about mental-health factors relevant to the decision (eating disorder, mood instability, cognition). (4) Ask the client to bring back the doctor's advice, including the signs on which the doctor says to break the fast. (5) Record that health questions were routed.
  • Example language (illustrative): "I'm not the right person to say whether fasting is safe with your diabetes. Your diabetes team can assess that before the month starts. Would you be willing to book that, and shall I let them know what we've been working on?"
  • Watch for: clients avoiding the doctor for fear of being told not to fast; clinical risks the sources name — hypoglycaemia and hyperglycaemia in diabetes (IDF–DAR), dehydration and electrolyte imbalance, and in severe eating disorder cases organ dysfunction and refeeding risk after a fast (Alliance). Working when the decision is made with current medical opinion.

4.5 Routing medication questions to the prescriber

  • Purpose: medicines may need their timing, dose or type changed during a fast; this is the prescriber's decision only. [source: IDF–DAR 2016 (clinicians adjust medication); Alliance 2025 (fasting can affect timing, absorption and mood; involve the prescriber)]
  • Steps: (1) Ask whether the client takes any regular medicines, including psychiatric medicines. (2) Ask whether they plan to change when or whether they take them during the fast. (3) Do not advise on any change. (4) Ask the client to discuss the fast with the prescriber before it starts; with consent, contact the prescriber. (5) If the client has already stopped or moved doses, encourage prompt contact with the prescriber. (6) Note that some traditions' authorities address medicines directly (Melamed discusses tasteless medication on Yom Kippur) — the client's rabbi or scholar answers the religious question, the prescriber the medical one.
  • Example language (illustrative): "Changing when you take your medicine is a question for the person who prescribes it. Can you ask them before the fast starts? If it helps, we can write down your questions now."
  • Watch for: unplanned stopping of mood stabilisers, antipsychotics or antidepressants around a fast; mood change, sleep loss or agitation — alert the prescriber. Working when the prescriber has given a plan.

4.6 Eating-disorder screen and motive exploration

  • Purpose: fasting can trigger relapse and can disguise restriction, bingeing or purging as devotion. [source: BDA 2022; BPS 2021; NEDA; Alliance 2025]
  • Steps: (1) Ask about current or past eating disorder, weight and shape concerns, compensatory behaviours. (2) Ask directly about motive: whether part of the fast is about weight, body or control. NEDA notes higher risk when fasting is used for weight control or when religiosity is driven by pressure or an anxious relationship with God. (3) Ask what happens at the meals that open and close the fast; the BDA describes overeating at iftar followed by purging, and restriction worsening because not eating is socially accepted. (4) Ask about pre-dawn and evening meals being skipped. (5) Share findings with the treatment team (with consent).
  • Example language (illustrative): "Some people find that part of them is fasting for God and part of them is glad of a reason not to eat. Is any of that true for you?" / "What happens for you at iftar?"
  • Watch for (sources): skipping pre-dawn or evening meals; overeating then vomiting or laxative use; increased restriction; constant thoughts about food or fasting; guilt and shame [source: BDA 2022]; return of restriction or using fasting as purging; good/bad food thinking; food as reward or punishment [source: Alliance 2025]. Working when the client can separate devotional motive from eating-disorder motive.

4.7 Collaborative fasting decision for clients with an eating disorder

  • Purpose: reach a decision the treatment team judges safe and the client can hold religiously. [source: Alliance 2025; BPS 2021; NEDA; BDA 2022]
  • Steps: (1) Start with the treatment team (therapist, psychiatrist, dietitian, physician) to judge whether fasting is medically and psychologically safe at this stage of recovery. (2) Lay out options the client's own authority may allow (full observance, a modified observance the authority permits, exemption with any substitute the tradition gives such as fidya in Islam, non-food observance). (3) Weigh, with the client, relapse risk against the harm of a fractured religious identity — the BPS article warns against automatic prohibition; the BPS piece also reports that under Islamic teaching people in earlier stages of eating-disorder treatment are exempt. (4) If the client decides not to fast, suggest they speak with a faith leader who can affirm that choice in light of health (Alliance; BDA). (5) Write down the decision and who agreed it.
  • Example language (illustrative): "This is your decision. My job is to make sure you have what your treatment team thinks and what your faith actually asks of someone who is ill. Then we can work out what you can live with."
  • Watch for: the team giving numbers or meal plans the therapist then repeats without the dietitian (stay in role); NEDA notes many spiritual advisors describe food as necessary medical treatment for people with eating disorders — a useful frame if the client accepts it. Working when the plan has the team's and the client's agreement.

4.8 Exemption and shame work

  • Purpose: reduce shame and fear of being judged when a client takes an exemption or cannot fast. [source: BDA 2022; BPS 2021; Melamed; USCCB; Kitáb-i-Aqdas Note 31]
  • Steps: (1) Ask what not fasting would mean to them and what they imagine others will think. (2) Invite them to find out (from their own authority or texts) how their tradition treats those who are ill — e.g. Melamed's ruling that the One who commanded the fast commanded eating when life is at risk; the USCCB's statement that the ill should not jeopardise their health; the Aqdas notes describing exemptions as grace. Let the client bring this back rather than the therapist preaching it. (3) Explain, as the BDA advises, that an eating disorder (or other illness) is a genuine illness, not weakness of faith. (4) Work on self-compassion and on family or peer pressure. (5) Plan what they will say to family.
  • Example language (illustrative): "What does your tradition say about someone who is ill and doesn't fast? Would you like to find that out from someone you trust, so it isn't just my word?"
  • Watch for: shame, guilt or feeling weak in faith; pressure to fast from family or peers (BDA). Working when the client can describe the exemption as part of their religion.

4.9 Non-food observance (client-led)

  • Purpose: keep the meaning and community of the season when food fasting is not safe or chosen. [source: BDA 2022; NEDA; Alliance 2025; BPS 2021]
  • Steps: (1) Ask what else the season includes for them. (2) List with the client the practices the sources name: reading and reflecting on scripture, extra prayer, charity and volunteering, community and evening prayers (BDA, e.g. Qur'an and Taraweeh); fasting from screens, social media or other comforts with the time used for prayer or service (NEDA; Alliance); gratitude and community (BPS). (3) The client chooses; check with their religious authority if they want. (4) Plan to include the person at family meals even if not fasting (BDA).
  • Example language (illustrative): "If food isn't the safe way this year, which parts of the season matter most to you, and how could you put more of yourself into those?"
  • Watch for: substitute practices becoming rigid, punishing or compulsive (see 4.11). Working when the client reports feeling part of the season.

4.10 Relapse-prevention plan for a client in eating-disorder recovery who fasts

  • Purpose: when the team and client agree the client will fast, reduce relapse risk. [source: Alliance 2025; BDA 2022; BPS 2021]
  • Steps: (1) The dietitian (not the therapist) sets a structured meal plan for the days before the fast and for the non-fasting hours, and a post-fast plan; the therapist supports adherence. (2) Name a trusted support person (BDA) and a peer or support-group contact (Alliance). (3) Agree grounding or mindfulness skills for urges and non-food activities for high-risk times (Alliance). (4) Write down the warning signs from 4.6 and agree an explicit stop rule: the Alliance states that stopping is acceptable if fasting becomes harmful. (5) Schedule extra monitoring and team review during the season (BPS; Alliance). (6) Prepare for fullness after the evening meal: the BDA notes fullness is normal and can trigger purging urges.
  • Example language (illustrative): "Let's write down, now while you're calm, the signs that would tell us the fast has turned into the eating disorder — and what you'll do if you see them."
  • Watch for: missed meals within the plan, purging after the evening meal, secrecy, physical strain (dizziness, fainting) — route physical symptoms to the doctor. Working when the client uses the plan and reports early.

4.11 Scrupulosity screen and ERP adapted with the religious authority

  • Purpose: fasting rules, purity and atonement can become OCD material (e.g. fear that a swallowed drop has invalidated the fast, repeated checking, excessive self-accounting). [source: IOCDF, For Faith Leaders] [the fasting examples are synthesis; the IOCDF page does not mention fasting]
  • Steps: (1) Distinguish by extent and motive: the IOCDF describes OCD-driven practice as fuelled by fear, guilt or shame, and healthy practice by meaning, peace, hope or gratitude; OCD doubt loops for certainty. (2) Look for fixation on minor details while neglecting the core meaning, avoidance of practice, reassurance-seeking, and repeated confession. (3) If OCD is present, offer exposure and response prevention by a trained clinician: build a hierarchy, reduce compulsions and reassurance. (4) With consent, involve the client's religious authority to state what the tradition actually requires, so exposures stay within the client's faith; the IOCDF describes faith leaders helping distinguish healthy practice from scrupulosity, avoiding reassurance, and, for confession, a single trusted confessor with gradually reduced frequency. (5) Plan accommodation reduction jointly with family and the faith leader.
  • Example language (illustrative): "When you ask whether the fast still counts, does the answer settle things for long? If the doubt comes back, that pattern may be OCD rather than conscience."
  • Watch for: the therapist being drawn into giving rulings (reassurance); exposures that ask the client to break religious law without the authority's agreement. Working when the client can tolerate uncertainty and returns to the fast's meaning.

4.12 Other mental-health conditions

  • Purpose: fasting and the changed sleep and routine around it may affect some conditions. The BPS article cites a systematic review (Heun 2018) reporting that Ramadan fasting generally has little negative effect on mental health but may raise relapse risk in schizophrenia and bipolar disorder. [source: BPS 2021, citing Heun 2018] [uncertain: review not verified directly]
  • Steps: (1) For clients with bipolar disorder, psychosis or recurrent severe depression, discuss the season early. (2) Route the medical and medication questions to the psychiatrist or prescriber (4.4, 4.5). (3) Agree early-warning signs (sleep loss, mood elevation, agitation) and whom to contact. (4) Increase contact during the season if needed.
  • Example language (illustrative): "Your sleep is one of the first things that slips before a high. The fast changes your sleep — let's plan with your psychiatrist how to watch it."
  • Watch for: early-warning signs of relapse; religious themes in emerging psychosis or mania, which call for psychiatric assessment while respecting genuine religious experience. [synthesis] DSM-5-TR lists a religious or spiritual problem as a focus of clinical attention, code Z65.8.

4.13 Accommodation in scheduling and treatment

  • Purpose: keep therapy accessible and respectful during observances. [synthesis]
  • Steps: (1) Offer session times that fit the client's day (e.g. avoiding the hour before the fast is broken). (2) Do not schedule eating-based exposures, food diaries with meal targets, or group meals that conflict with the fast unless the plan has the team's agreement. (3) Expect lower energy and adjust homework load. (4) In inpatient or day programmes, coordinate with the dietitian and chaplaincy on meal times. (5) Ask before assuming: some clients prefer no change.
  • Example language (illustrative): "Would a different time work better for you during the fast?"
  • Watch for: the client hiding the fast to avoid being 'a problem'; working when attendance and engagement hold.

4.14 Guilt and moral injury around fasting

  • Purpose: some clients feel they have betrayed God, family or community by not fasting, or feel ashamed of past fasting driven by illness. [source: BDA 2022; BPS 2021 (shame, stigma, religious identity)] [synthesis for moral-injury framing]
  • Steps: (1) Name the guilt and its content. (2) Separate guilt (a breach of their own values) from shame and from OCD doubt (4.11). (3) Explore what their tradition offers for repair — repentance, making up, charity, substitute observance — as the client's authority teaches it. (4) Support self-compassion. (5) Refer complex religious questions to the authority.
  • Example language (illustrative): "It sounds like part of you believes being ill made you a worse Muslim. What would the scholars you trust say to that?"
  • Watch for: persistent self-condemnation, suicidal ideation (assess per current standards). Working when guilt becomes proportionate and actionable.

4.15 Community, family and grief

  • Purpose: fasts are communal; not fasting, or fasting during bereavement or isolation, affects belonging. [source: BDA 2022 (communal meals, family remarks)] [synthesis]
  • Steps: (1) Ask how the community and family observe and where the client sits. (2) Prepare for communal meals: the BDA notes distress and feeling judged at shared meals and advises families to avoid critical remarks, include the person, and not pressure them to eat more or to fast. (3) With consent, hold a family session. (4) For a first season after a death, separation or migration, explore grief and what remembered rituals mean. (5) Help the client find community roles not centred on food.
  • Example language (illustrative): "Who will you be sitting with when the fast is broken, and what would help that meal go well?"
  • Watch for: family pressure or criticism; isolation. Working when the client feels included.

4.16 Collaboration with clergy, chaplains and faith leaders

  • Purpose: religious rulings and pastoral support come from the client's authority; therapist and authority each stay in role. [source: BDA 2022 (imam experienced in mental health); Alliance 2025; IOCDF; Harakas (spiritual father sets the fast); Melamed]
  • Steps: (1) Ask whether the client wants their religious leader involved, and whom they trust. (2) Obtain written consent and agree what will be shared. (3) Ask the leader about the tradition's position on illness and exemptions; share only the clinical information the client agrees to. (4) For eating disorders, the BDA suggests an imam experienced in mental health who can explain that fasting is meant for those who are healthy (acknowledging this can be hard to arrange). (5) Agree consistent messages; the IOCDF describes leaders reinforcing the care plan. (6) Use hospital or service chaplaincy where available. [synthesis]
  • Example language (illustrative): "Would it help if your imam and I were saying the same thing? Only if you want that, and you decide what I share."
  • Watch for: a leader whose advice conflicts with medical advice — return to the doctor and to the client's choice of authority; working when the client feels both supports agree.

4.17 Children and adolescents

  • Purpose: traditions set their own age thresholds and many do not ask children to fast; clinicians also hold safeguarding duties. [source: USCCB (fasting and abstinence apply from stated ages); Hindupedia (children not advised to keep upavāsa); BDA 2022 (young children exempt)]
  • Steps: (1) Ask the young person and parents what is expected, by whom. (2) Seek the young person's assent and the parent's consent for any plan. (3) Route health questions to the paediatrician or GP. (4) Screen for eating disorders (adolescence is a high-risk period) [synthesis]. (5) If a child is being made to fast in a way that harms health, follow local safeguarding procedures. [synthesis] [uncertain: specific safeguarding-body guidance on fasting not verified]
  • Example language (illustrative): "What does fasting mean to you, and is it something you want to do, or something you feel you have to do?"
  • Watch for: weight loss, dizziness, secrecy, coercion; working when the young person's voice is in the plan.

4.18 Post-observance review

  • Purpose: learn from the season and plan the next. [source: IDF–DAR 2016 (post-Ramadan follow-up, festival risk); Alliance 2025 (post-fast plan)]
  • Steps: (1) Review what went well, warning signs that appeared, and how the plan worked. (2) Check eating behaviour during the feast that follows. (3) Remind the client to attend medical follow-up. (4) Record lessons for next year.
  • Example language (illustrative): "Looking back on this Lent, what helped you keep both your faith and your recovery?"
  • Watch for: rebound bingeing or continued restriction after the season.

4.19 Role boundaries and the therapist's own beliefs

  • Purpose: keep the therapeutic frame. [synthesis] [uncertain: Vieten et al. 2013 competencies not verified]
  • Steps: (1) Do not give religious rulings, lead worship, or act as spiritual director. (2) Do not fast or break fast with the client as a therapeutic act. (3) Disclose your own religious stance only if it serves the client. (4) Notice your own reactions (approval or disapproval of fasting) and seek supervision. (5) Refer to clergy or spiritual directors for religious questions.
  • Example language (illustrative): "That's a question for your priest; what I can help with is how it's affecting you."
  • Watch for: the client seeking the therapist's religious approval; working when the client uses each source for its own purpose.

5. Handling problems

  • Client insists on fasting against medical advice. IDF–DAR describes supporting the decision of a high-risk patient who chooses to fast, with close monitoring by the diabetes team. Respond: respect autonomy, make sure the doctor knows, agree warning signs and a stop rule, and increase contact; assess capacity if judgment seems impaired by illness (e.g. severe anorexia). [source: IDF–DAR 2016] [synthesis for capacity]
  • Client will not see the doctor for fear of being told not to fast. Name the fear; explain the doctor's role is to make the fast as safe as possible or confirm an exemption, which the client's own tradition grants; offer to help write questions. [synthesis]
  • The fast is masking an eating disorder and the client denies it. Stay curious, not accusatory; return to motive (4.6) and to concrete behaviours at the meals that open and close the fast; involve the treatment team; consider the religious leader if the client consents. [source: BDA 2022; NEDA] [synthesis]
  • Client feels the therapist is against their religion. Rupture repair: acknowledge, re-state that the decision is theirs and that you want their faith and health both protected; ask what you misunderstood; consider a faith leader as co-support. [synthesis; BPS 2021 cautions against automatic advice not to fast]
  • Family or community pressure. Use the BDA's family guidance (no critical remarks, include the person at meals, no pressure to eat more or to fast); hold a family session with consent; prepare scripts for the client. [source: BDA 2022]
  • Religious leader and medical advice conflict. Do not adjudicate religion. Return the medical question to the doctor and invite the client to consult another authority they trust, or to put the doctor and leader in touch (Melamed entrusts the determination of danger to a physician). [source: Melamed] [synthesis]
  • Client stops or moves medicines without telling anyone. Do not advise on medicines; encourage urgent contact with the prescriber; if signs of relapse or physical danger appear, follow your service's urgent pathway. [source: Alliance 2025 (involve prescriber)] [synthesis]
  • Scrupulosity: endless questions about whether the fast is valid. Treat repeated rule questions as possible reassurance-seeking; do not answer them; refer to one trusted religious authority and work on the doubt loop with ERP. [source: IOCDF]
  • Overwhelm, guilt or suicidal thoughts during the season. Assess risk following current standards; slow down; reduce homework; link with support. Do not treat religious guilt as pathology by default, but do not miss depression. [synthesis]
  • Non-adherence to the agreed plan (missed meals, skipped check-ins). Review without blame, revisit warning signs and stop rule, inform the team as agreed. [source: Alliance 2025] [synthesis]
  • Physical warning signs reported in session (fainting, confusion, chest pain, severe dizziness). Treat as medical, not psychological: advise the client to seek medical help now, using emergency services if severe. [synthesis]
  • Therapist uncertainty about a tradition. Ask the client to teach you; consult a chaplain; seek supervision. Do not rely on generalisations across traditions — exemptions and meanings differ, and within one tradition authorities differ (e.g. Jewish rulings on the ill on different fast days). [source: Melamed] [synthesis]
  • Child or adolescent fasting under pressure. Hear the young person alone; involve the paediatrician; follow safeguarding procedures if health is harmed. [synthesis]

Sources

Web sources:

Cited at second hand [uncertain: not verified]:

  • Heun, R. (2018). Systematic review on Ramadan and mental health. Global Psychiatry, 1(1), 7–16 (as cited in Alidina 2021).
  • Harshananda, Swami. A Concise Encyclopaedia of Hinduism. Ramakrishna Math, Bangalore (as cited by Hindupedia).

Also cited [uncertain]: Vieten et al. (2013) spiritual and religious competencies; safeguarding-body guidance on children and fasting; Jain and Buddhist fasting sources; primary Qur'anic and juristic texts on Ramadan exemptions.

ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances

American Psychological Association, Ethical Principles of Psychologists and Code of Conduct, https://www.apa.org/ethics/code

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