Atlas›Domain XIII · Contemplative & religious disciplines›Guide 263
Guide XIII-263

Ramadan fasting and i'tikaf

A 35 · L 56 · M 915 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: the observance as described in Qur'an 2:184 with the Hanafi commentary Ma'ariful Qur'an (English, on quran.com); i'tikaf as set out by the Mufti of Federal Territory's Department, Malaysia (Shafi'i majority view, with other schools noted) and a Hanafi answer on SeekersGuidance; clinical guidance from the IDF-DAR Diabetes and Ramadan: Practical Guidelines 2021 as summarised for UK primary care (2023), an NHS mental health trust bulletin (2025), Tommy's midwives, Equip and the IOCDF; children's fasting from Sahih al-Bukhari, Birmingham City Council's 2026 schools guidance and a Sidra Medicine paediatrician.

What it is. Ramadan fasting (sawm) is an obligatory religious fast kept by adult Muslims during the month of Ramadan. Food and drink are not taken in daytime, between a pre-dawn meal (suhur) and the sunset meal that breaks the fast (iftar) [source: Equip 2025; Tommy's]. The Qur'an presents it as prescribed for "a set number of days" and itself builds in concessions for the sick and travellers, with make-up days or a charitable compensation (fidyah) [source: Qur'an 2:184 with Ma'ariful Qur'an]. That Ramadan fasting is one of the Five Pillars of Islam is widely taught [uncertain: not verified].

I'tikaf is a devotional retreat: staying in a mosque (or, in some schools, for women, a home prayer area) with the intention of worship. It is classed as a strongly encouraged sunnah, especially in the last ten days of Ramadan, to follow the Prophet's practice and to seek Laylat al-Qadr (the Night of Power) [source: Mufti WP Irsyad al-Fatwa 171, citing al-Nawawi and Q 2:187]. In Hanafi teaching it can be voluntary, a communal sunnah for the last ten days that some in each community should keep, or binding through a vow [source: SeekersGuidance, Rabbani 2009].

Who leads or authorises it. There is no single authorising body. Rulings come from jurists of the schools of law (madhhabs: Hanafi, Maliki, Shafi'i, Hanbali; Shia jurisprudence separately), state mufti offices and fatwa councils, and local imams. Who is exempt is decided between the person, their religious authority and, where health is involved, their doctor [source: Mufti WP; Equip 2025; ELFT 2025].

How the psychotherapist works alongside it. This is a religious observance, not a therapy. The therapist does not prescribe or discourage fasting. The therapist's job is to understand what Ramadan means for the client, assess with the Cultural Formulation Interview, adapt scheduling and treatment, route health and medication questions to the doctor or prescriber, screen for eating-disorder and scrupulosity risk, protect children, and work with clergy when the client wishes. Change, from a clinical standpoint, comes from the client keeping the observance in a way that fits both their faith and their health, using the concessions their own tradition provides [synthesis]. For daily prayer and ritual purity (wudu), see 230.

2. Framework

This is an annual cycle of planning and support, not a phased therapy. No source gives a session count or format; the timing below follows the clinical sources where stated and is otherwise [synthesis].

Phase A: pre-Ramadan (weeks to months before).

  • Goals: learn the client's intentions for fasting and i'tikaf; identify health conditions, pregnancy, medication, eating-disorder history, mental-health risk; prompt medical review; agree scheduling.
  • The IDF-DAR guidance has the healthcare professional stratify risk and deliver structured education about 1–2 months before Ramadan, covering risk, when to break the fast, fluids and diet, glucose monitoring and medication adjustment [source: Gilani 2023, summarising IDF-DAR 2021]. NHS mental health guidance has all medicines reviewed with the pharmacy and medical team before a patient fasts [source: ELFT 2025].
  • Move on when: the client has (or has declined) medical and religious advice, and a written or agreed plan exists for what to do if their health or mood worsens [synthesis].

Phase B: during Ramadan.

  • Goals: adjusted sessions; monitoring of sleep, mood, eating-disorder and scrupulosity signs; space for meaning, community and grief; routing any physical symptom to the doctor.
  • Move on or escalate when: warning signs appear (see 4.3, 4.4, 4.6), in which case the clinical plan agreed with the doctor takes priority [synthesis].

Phase C: last ten nights and i'tikaf (if the client takes part).

  • Goals: plan for a period of reduced contact and reduced sleep; agree how the client can reach help; consider retreat-related risks for clients with psychosis, mania or trauma histories [synthesis].

Phase D: after Ramadan.

  • Goals: review what went well; address guilt about missed fasts and plans for making them up (qada) or fidyah, as the client's authority advises; process any relapse; restore routine [synthesis; qada and fidyah: Qur'an 2:184 with Ma'ariful Qur'an].

3. Guiding principles

  • Describe the tradition, do not rule on it. The therapist explains no fiqh and issues no rulings; exemption questions go to the client's imam or scholar. Practical meaning: "That is a question for your imam; I can help you prepare it." [synthesis]
  • The tradition itself provides exemptions. The Qur'an and jurists exempt the sick (those who cannot fast without great hardship or fear it will worsen their illness) and travellers, with make-up days, and allow fidyah for those permanently unable [source: Qur'an 2:184 with Ma'ariful Qur'an]. Practical meaning: presenting exemptions as part of the faith, not as a medical override, reduces conflict.
  • Health questions go to the doctor; medicine questions go to the prescriber. Risk stratification, break-fast rules and medication timing are clinical decisions [source: Gilani 2023; ELFT 2025]. Practical meaning: never advise on doses, timing or whether to fast.
  • Respect choice and capacity. Some ill people still choose to fast; this should be handled sensitively, with their risks explained [source: ELFT 2025]. Capacity and competency should be considered [source: ELFT 2025]. Practical meaning: explore, inform and coordinate; do not coerce.
  • Use the client's language. Use the client's own terms (sawm, suhur, iftar, i'tikaf, qada, fidyah, imam, shaykh) and the CFI's instruction to substitute the person's own tradition names [source: APA CFI Supplementary Modules].
  • Watch for illness hiding inside devotion. An eating disorder can shift intent from spiritual reflection to weight loss [source: Equip 2025, quoting a psychologist]; scrupulous engagement is driven by fear, guilt or shame rather than meaning [source: IOCDF, For Faith Leaders]. Practical meaning: ask about motive and feeling, not just behaviour.
  • Children are not obliged; safeguarding comes first. Children below puberty are not required to fast, and schools have an overriding safeguarding duty [source: Birmingham City Council 2026]. Practical meaning: any child who is unwell while fasting needs adult action, not encouragement.
  • Collaborate with religious authorities only with consent. Imams are often approached first by people with scrupulosity and rarely refer [source: Jones, Harris & Esfahani 2019]. Practical meaning: a consented, informed link with the client's imam can help both.
  • Stay in role. The therapist is not the client's imam, mufti or spiritual director; avoid dual relationships, and disclose your own religious stance only if it serves the client. Spiritual and religious competency frameworks for psychologists exist (for example Vieten et al. 2013) [uncertain: not verified]. Follow your profession's ethics code on competence, multiple relationships and respect for religion [synthesis].
  • Do not present fasting as treatment. Health claims about fasting are attributed to their sources; this guide makes none [synthesis].

4. Intervention inventory

Everything below is the psychotherapist's work alongside the observance. None of it is a fasting instruction. Example language is illustrative unless quoted.

4.1 Exploring the meaning of Ramadan and i'tikaf in the client's life

  • Purpose and when to use: At the first session before or during Ramadan, with any Muslim client who raises it, and with converts, people returning to practice, or people who have stopped practising. It shows whether Ramadan is a source of strength, conflict or both [synthesis].
  • Steps:
    1. Ask whether Ramadan matters to them and how they usually keep it (fasting, night prayers, Qur'an reading, charity, family iftars, i'tikaf).
    2. Ask what a "good Ramadan" would look like this year, and what would make it hard.
    3. Ask about family and community expectations, and whether these match their own.
    4. Ask about past Ramadans: health, mood, eating, sleep, conflict, grief.
    5. Summarise back in their own terms, and agree which of these belong in therapy.
  • Example language (illustrative): "For some people Ramadan is the high point of the year; for others it brings pressure or old memories. What is it like for you?" / "When you picture this Ramadan going well, what are you doing?"
  • Watch for: guilt or shame when they speak about past missed fasts; fear of family judgement; the client asking you to rule on what is required (redirect, see 4.13). It is working when the client names their own aims and concerns and you can link them to the treatment plan [synthesis].

4.2 Cultural Formulation Interview with the Spirituality, Religion and Moral Traditions module

  • Purpose and when to use: A structured way to assess how religion bears on the presenting problem. The DSM-5 supplementary module aims to clarify how spirituality, religion and other moral traditions affect a person's problems and related stresses. It can be added to the core CFI or used alone [source: APA CFI Supplementary Modules].
  • Steps:
    1. Use the core CFI to establish the client's own account of the problem, cultural identity and help-seeking.
    2. Add the module, which covers four areas: spiritual, religious and moral identity (affiliations, community, family background); the role of these traditions in daily and family life; how traditions, leaders, texts or practices have helped with coping; and whether tradition-related stresses, discrimination or conflict have contributed to the problem [source: APA CFI Supplementary Modules].
    3. Replace the module's placeholder wording with the client's own terms (for example "Islam", "your faith", "the masjid"), as the module instructs [source: APA CFI Supplementary Modules].
    4. For a child or a person who cannot answer, the module allows questions to go to a caregiver; the School-Age Children and Adolescents and Caregivers modules also exist [source: APA CFI Supplementary Modules].
    5. Use the Coping and Help-Seeking and Patient–Clinician Relationship modules if the client is unsure whether a non-Muslim or secular therapist can understand Ramadan [source: module list, APA CFI Supplementary Modules; use: synthesis].
  • Example language (illustrative): "I'd like to understand how your faith fits into what you're going through, both how it helps and whether it's part of the stress. Is that all right?"
  • Watch for: the module is copyrighted by the American Psychiatric Association; clinicians may reproduce it for use with their patients [source: APA CFI Supplementary Modules]. Do not read it as a checklist; let answers lead. It is working when the formulation includes religion as a coping resource and as a possible stressor [synthesis].

4.3 Pre-Ramadan health check-in and routing to the doctor

  • Purpose and when to use: Before Ramadan, with any client who plans to fast and has a physical condition, pregnancy, eating-disorder history, or takes regular medication. The therapist does not assess fitness to fast; the aim is to make sure the client has a medical conversation in time [synthesis].
  • Steps:
    1. Ask whether they plan to fast and whether they have any health condition, pregnancy or regular medicines.
    2. If yes, ask whether they have discussed fasting with their doctor, diabetes team, midwife or prescriber.
    3. Explain that clinical guidance recommends this review in advance. For diabetes, the IDF-DAR guidance has a health professional stratify risk (very high, high, moderate/low), weighing diabetes type, hypoglycaemia risk, medicines, complications, work and social circumstances and previous fasting experience, and give structured education 1–2 months before Ramadan, including when to break the fast [source: Gilani 2023, summarising IDF-DAR 2021].
    4. For pregnancy or breastfeeding, Tommy's midwives advise speaking to a midwife or doctor before deciding; they note that Islamic rulings let pregnant and breastfeeding women choose whether to fast, with later make-up or fidyah, and advise breaking the fast if unwell and contacting a midwife if baby's movements change [source: Tommy's].
    5. With consent, write to or call the GP or specialist to say the client is planning to fast and that mood, sleep or eating are being monitored in therapy [synthesis].
    6. Record what was discussed and who is responsible for the medical plan [synthesis; documentation also advised in ELFT 2025 for inpatients].
  • Example language (illustrative): "Your doctor is the right person to say how fasting fits with your diabetes. Their guidance actually recommends that conversation a month or two before Ramadan. Would it help to plan what you want to ask?"
  • Watch for: the client reporting dizziness, fainting, confusion, vomiting, signs of dehydration (dark urine, headache, weakness) or, in pregnancy, changed fetal movements: these are medical matters for urgent clinical contact [source: Tommy's; Gilani 2023]. Do not quote glucose thresholds or tell a client to break or keep a fast; refer to the plan their team gave them. It is working when the client has a named clinician and a plan [synthesis].

4.4 Routing mental-health medication timing to the prescriber

  • Purpose and when to use: With any client on psychiatric medication who intends to fast. Fasting can change when medicines are taken and how the body handles them, so this is a prescriber's decision [source: ELFT 2025].
  • Steps:
    1. Ask whether the client plans to change when or whether they take medicines during Ramadan.
    2. Explain that an NHS mental health trust advises that all medicines be reviewed with the medical team and pharmacist before fasting; that some medicines need closer monitoring when a person is dehydrated; that some daytime doses may need review; and that some Muslims believe certain routes of administration break the fast, which the team should discuss [source: ELFT 2025].
    3. Encourage the client not to stop or re-time medicines on their own, and to book a review with the prescriber or pharmacist before Ramadan [synthesis, consistent with ELFT 2025].
    4. With consent, inform the prescriber of the client's plan and any mood or sleep concerns [synthesis].
    5. If the client's religious question is whether a medicine route breaks the fast, refer that question to their imam; the clinical question stays with the prescriber [source: ELFT 2025 recommends consulting the local imam or faith leader].
  • Example language (illustrative): "I can't advise on your medication, but your prescriber can often work around fasting times. Can we make sure you see them before Ramadan starts?"
  • Watch for: the client quietly skipping doses to keep the fast; new side effects; mood change after medication changes. Report concerns to the prescriber. It is working when the prescriber has reviewed the plan before the month begins [synthesis].

4.5 Monitoring sleep, mood and relapse risk during the month

  • Purpose and when to use: For clients with bipolar disorder, psychosis, depression, anxiety or a history of relapse, whose routines change with pre-dawn meals, night prayers and late iftars [synthesis]. A paediatric source notes that disrupted sleep in Ramadan can affect mood [source: Sidra Medicine paediatrician, Gulf Times 2026]; adult evidence is [uncertain: not verified].
  • Steps:
    1. Before Ramadan, list the client's own early warning signs and agree what they or family will do if these appear.
    2. Agree a minimal routine they can keep (a protected sleep block, contact with supports).
    3. Check sleep and mood briefly each session through the month.
    4. If warning signs appear, follow the existing relapse plan and inform the treating team; any question about stopping the fast for health is for the doctor and, religiously, for the client's imam [synthesis].
  • Example language (illustrative): "Ramadan nights can get very short. Last time your mood shifted, sleep went first. What would tell us early this year?"
  • Watch for: reduced need for sleep with high energy, increasing religious preoccupation with distress, suicidal thoughts, or withdrawal. Assess risk by your usual standards [synthesis].

4.6 Eating-disorder screening and planning

  • Purpose and when to use: Before Ramadan, with every client who plans to fast, and especially adolescents and anyone with a past or current eating disorder. A case report found that the dietary change of Ramadan may trigger or worsen eating pathology in predisposed teenagers; a dietitian reported more restriction after fasting and more binge episodes among patients [source: Equip 2025, citing Akgül et al. 2014 in the International Journal of Eating Disorders].
  • Steps:
    1. Screen with your usual validated eating-disorder screening instrument and questions about restriction, bingeing, compensatory behaviour, weight and shape concern [synthesis].
    2. Ask about motive: does fasting feel like worship, or like relief from eating, a chance to lose weight, or a cover? An eating disorder can shift intent towards weight loss [source: Equip 2025, quoting a psychologist].
    3. If an eating disorder is active or recent, route the decision to the medical team. A dietitian quoted by Equip reports the advice she received from religious enquiry: a doctor should evaluate each patient, and if fasting would harm them, they should not fast [source: Equip 2025]. An NHS trust's exemption list includes people with eating disorders [source: ELFT 2025].
    4. If the client does not fast, help them find other ways to take part: giving money or food, reading Qur'an, forgiving others, extra prayer [source: Equip 2025].
    5. If the client fasts with medical agreement, the team plan (not the therapist) sets meals; family can help by keeping food available and avoiding talk of dieting, "healthy food" or weight change [source: Equip 2025].
  • Example language (illustrative): "When you think about fasting this year, what part feels like worship, and what part feels like the eating disorder talking?"
  • Watch for: relief at not eating, secret restriction after iftar, bingeing at night, anxiety or fatigue from preoccupation with food [source: Equip 2025]. Involve the medical team at once if these appear. It is working when the client can tell their faith from the illness's voice and has a plan agreed with the team.

4.7 Helping the client explore exemptions and alternative participation

  • Purpose and when to use: When a client is advised not to fast or cannot fast, and feels excluded, guilty or "less Muslim" [synthesis].
  • Steps:
    1. Ask what they understand their tradition to say about people who cannot fast.
    2. Note, as attributed information, that the Qur'an provides for the sick and travellers to make up days later, and for people permanently unable (such as the very elderly and those with an illness not expected to improve, in the Hanafi commentary) to give fidyah; jurists define "sick" as unable to fast without unbearable hardship, or strongly fearing that fasting would worsen the illness [source: Qur'an 2:184 with Ma'ariful Qur'an]. Schools differ on details such as travel distance; refer specifics to their imam [source: Ma'ariful Qur'an; synthesis].
    3. Note that pregnant and breastfeeding women may choose whether to fast and make up or give fidyah later [source: Tommy's], and that an NHS trust's exemption list includes children under 12, frail older adults, chronic and mental-health conditions, eating disorders, pregnancy, breastfeeding, menstruation and long journeys [source: ELFT 2025].
    4. Invite them to take their specific question to their imam or scholar; offer to help them prepare it.
    5. Explore other forms of participation they value (see 4.6, step 4) [source: Equip 2025].
  • Example language (illustrative): "It sounds like not fasting feels like being left out. What does your faith say about people in your situation? Would it help to ask your imam directly?"
  • Watch for: an imam's ruling the client cannot accept, or wishes to override; repeated reassurance-seeking about whether the exemption is valid (see 4.10).

4.8 Accommodating scheduling and treatment

  • Purpose and when to use: Throughout Ramadan, so that therapy does not compete with the observance [synthesis].
  • Steps:
    1. Ask which times of day are hardest (late afternoon fatigue; the run-up to iftar; nights of prayer) and offer sessions at times the client prefers.
    2. Offer shorter or remote sessions if fatigue is high; do not offer food or drink in session without asking.
    3. Postpone demanding work (for example intense exposure or trauma processing) if the client prefers, and agree a date to resume.
    4. Plan around i'tikaf (4.9) and the end of the month.
    5. In services: record who is fasting, adapt care plans and activity schedules, and offer a quiet space [source: ELFT 2025 for inpatient care plans; Birmingham City Council 2026 for quiet spaces in schools].
  • Example language (illustrative): "Would a different time work better during Ramadan? Some people prefer mornings, others after iftar."
  • Watch for: the client feeling they must choose between therapy and worship; non-attendance that is really fatigue. It is working when attendance holds and the client says the arrangement respects their practice [synthesis].

4.9 Supporting a client planning i'tikaf

  • Purpose and when to use: When a client plans to spend some or all of the last ten days in i'tikaf. In the schools described, the person stays in the mosque (or a home prayer area, for women in the Hanafi view) and leaves only for necessities; leaving for other reasons ends the retreat [source: SeekersGuidance, Rabbani 2009; Mufti WP 171]. This means reduced contact with therapy and family [synthesis].
  • Steps:
    1. Ask what the client hopes for from i'tikaf and what it involves in their community.
    2. Agree contact arrangements before it starts: whether they will have a phone, who can reach them, and the plan if they become unwell. Leaving for a health reason is a religious question to raise with their imam beforehand [synthesis; permitted exits vary by school per SeekersGuidance].
    3. For clients with psychosis, bipolar disorder, severe depression, dissociation or trauma, discuss the effects of reduced sleep, intensive devotion and limited contact, and involve the treating psychiatrist before the retreat [synthesis]. Published research documents challenging experiences in intensive contemplative practice (for example Lindahl et al. 2017, PLOS ONE; Farias et al. 2020, Acta Psychiatrica Scandinavica) [uncertain: not verified].
    4. Offer grounding strategies the client already finds helpful, phrased in their own religious language if they wish (for example a familiar short prayer they choose) [synthesis].
    5. Arrange a session soon after the retreat ends.
  • Example language (illustrative): "I'd love to hear what you're hoping for in i'tikaf. Can we also think about what you'd do if you started feeling unwell while you're there?"
  • Watch for: sleep loss with rising energy or unusual beliefs; overwhelming guilt or fear; dissociation. Telling intense religious experience apart from illness needs care: neither pathologise religious experience nor miss psychosis or mania. DSM-5-TR lists a religious or spiritual problem as a focus of clinical attention, code Z65.8. Coordinate with the imam if the client wishes [synthesis].

4.10 Working with scrupulosity (waswas) around fasting and i'tikaf

  • Purpose and when to use: When the client repeatedly doubts whether their fast or retreat is valid (an unintended swallow, intention, ritual purity), seeks reassurance, repeats acts, or avoids practice. The IOCDF describes scrupulosity as an OCD subtype of religious or moral obsessions; it can show as avoidance of practice or fixation on minor details at the expense of central ones. It is driven by fear, guilt or shame rather than meaning, and seeks absolute certainty [source: IOCDF, For Faith Leaders]. Waswas (intrusive whisperings) is the common Islamic term [uncertain: not verified].
  • Steps:
    1. Assess for OCD in the usual way, separating obsessional doubt from ordinary religious questioning [source: IOCDF].
    2. Map the compulsions: reassurance-seeking from family or imams, repeated checking, mental reviewing, avoidance.
    3. With consent, involve a religious authority the client trusts to state the normal standard of practice, so that exposure targets stay within the faith. IOCDF describes faith leaders helping to tell healthy practice from scrupulosity and reducing accommodation in agreement with the treatment team [source: IOCDF].
    4. Build an exposure and response prevention hierarchy within that standard (for example, tolerating uncertainty about a fast's validity without asking again) [synthesis, consistent with IOCDF's step-based approach]. Agree consent, pacing and the right to stop.
    5. Coach family and religious contacts to respond to reassurance requests by validating distress but not the doubt; the IOCDF suggests returning the question to the person [source: IOCDF].
  • Example language (illustrative): "Your imam has told you what's normally expected. The OCD wants a level of certainty no one has. What if we practise leaving that question unanswered?"
  • Watch for: imams may not recognise scrupulosity as OCD; a survey of 64 imams found most unfamiliar with it and with ERP, and only 9% referred to mental-health professionals [source: Jones, Harris & Esfahani 2019]. Expect reassurance from well-meaning religious contacts unless they are briefed. It is working when the client's practice becomes less fearful and less time-consuming [synthesis].

4.11 Working with guilt, shame and moral injury about not fasting

  • Purpose and when to use: When a client who cannot or did not fast (illness, pregnancy, eating disorder, mental illness, lapse in faith) feels condemned by themselves, family or community [synthesis].
  • Steps:
    1. Name the feeling and its source: personal standard, family voice, community talk.
    2. Explore what their tradition offers (exemption, make-up days, fidyah, other worship), with their imam where needed (4.7).
    3. Use self-compassion and cognitive work in the client's own religious terms (for example mercy) if they choose them [synthesis].
    4. Where a family or community member shames them, consider a family session or a conversation with an imam the client chooses [synthesis].
  • Example language (illustrative): "You're holding yourself to a standard your own tradition doesn't seem to ask of you right now. What would you say to a friend in your position?"
  • Watch for: guilt that is persistent and fearful (consider scrupulosity, 4.10) or part of depression; disclosures of coercion at home (see 4.14).

4.12 Grief, loneliness and community

  • Purpose and when to use: Ramadan centres on shared iftars and mosque life. It can intensify grief (first Ramadan after a death), isolation (converts, migrants, people estranged from family or their community) or exclusion (people who cannot fast) [synthesis].
  • Steps:
    1. Ask who they will break fast with, and whether there are empty places.
    2. Explore remembrance practices the client values and supports in their community.
    3. Help them plan contact: invitations, mosque iftars, online communities, or a quiet plan for hard evenings.
    4. For people who have left their faith or community, acknowledge that Ramadan can bring loss and conflict, and follow their lead [synthesis].
  • Example language (illustrative): "This is the first Ramadan without your mother. What would help on the evenings that feel heaviest?"
  • Watch for: complicated grief, depression, suicidal thoughts; respond by usual standards.

4.13 Collaborating with imams, chaplains and scholars

  • Purpose and when to use: When the client wants a religious ruling, faces a decision about exemption, has scrupulosity, or is an inpatient. NHS guidance advises patients to consult their local imam or faith leader and refers to the trust's spiritual care department [source: ELFT 2025].
  • Steps:
    1. Get written consent and agree what may be shared.
    2. Help the client choose the authority they trust (local imam, a chaplain, a scholar of their school).
    3. Agree roles: the imam gives religious guidance; the doctor gives medical advice; the therapist supports the client's decision and treatment [synthesis, consistent with IOCDF and ELFT 2025].
    4. Where useful, give the imam general information (for example, why reassurance maintains OCD) without clinical detail beyond consent [source: IOCDF].
    5. In an inpatient setting where a patient lacks capacity, the trust advises a multidisciplinary discussion including clinician, patient, family or carer, pharmacist and the local spiritual leader [source: ELFT 2025].
  • Example language (illustrative): "Would it help if you, your imam and I were all on the same page? You'd decide what I share."
  • Watch for: the therapist being drawn into theological debate; conflicting advice; the client feeling outnumbered. Stay in role.

4.14 Children and adolescents: fasting, assent and safeguarding

  • Purpose and when to use: When working with children, adolescents or parents about fasting.
  • What scholars and guidance describe: Children below puberty are not required to fast; younger children may practise partial fasts to prepare, ideally under parental supervision; Islamic law allows children to delay fasting if it could harm schoolwork, especially before exams [source: Birmingham City Council 2026, attributing these to Islamic law and Muslim authorities]. A hadith in Sahih al-Bukhari's chapter on children's fasting reports that Companions had their young children keep the voluntary 'Ashura fast and gave them woollen toys to distract them until iftar; it concerns a voluntary fast, not Ramadan [source: Sahih al-Bukhari 1960]. A consultant paediatrician at Sidra Medicine advises against full fasting for children under seven, says partial fasting may suit healthy children without chronic illness, lists children with type 1 diabetes, malnutrition, severe anaemia, heart or kidney disease or daytime medicines as needing to not fast or to get medical advice first, and lists warning signs (dizziness, fainting, severe headache, marked lethargy, pallor, cold sweats, reduced urination, vomiting) for stopping at once [source: Gulf Times 2026]. The 2014 case report on adolescents and eating pathology applies (4.6).
  • Steps:
    1. Ask the child (in age-appropriate terms) and the parents separately what fasting means to them and who decides.
    2. Seek the child's assent and the parent's consent for any plan; respect a child's wish to fast partially or not at all, and a parent's religious wishes, within the child's safety [synthesis].
    3. Route any child with a chronic condition or eating-disorder risk to their paediatrician or GP before Ramadan [source: Gulf Times 2026; Equip 2025].
    4. Share with the family, as attributed information, the warning signs for stopping a fast at once [source: Gulf Times 2026], and that schools will act if a pupil's health, welfare or safety is at risk [source: Birmingham City Council 2026].
    5. If a child is being made to fast while unwell, punished for eating, or shows signs of significant harm, follow your safeguarding procedures; the schools guidance refers to Keeping children safe in education and an overriding safeguarding duty [source: Birmingham City Council 2026]. Never name the child outside the record.
  • Example language (illustrative): To a child: "Some kids try a little fasting and some wait till they're older. What would you like to do? And what would you do if you felt dizzy?" To a parent: "Your doctor can tell you how fasting fits with her asthma. Would you like help setting that up?"
  • Watch for: fasting used as punishment or proof of worth; a teenager using Ramadan to hide restriction; sleep loss affecting school. It is working when child and parents agree a plan the doctor supports [synthesis].

4.15 Inpatient and capacity settings

  • Purpose and when to use: For clinicians in inpatient or residential mental-health services.
  • Steps (as an NHS trust sets out): consider competency or capacity; record who is fasting and why; update care plans for daily living, activities, food, fluids and physical-health monitoring; review medicines with the pharmacist; hold a multidisciplinary discussion including the spiritual leader where a patient lacks capacity and fasting is clinically inappropriate; handle the wishes of ill patients who choose to fast sensitively, with risks explained [source: ELFT 2025].
  • Example language (illustrative): "We want to support your fast safely. Can we go through your care plan together and talk to the pharmacist?"
  • Watch for: blanket bans or blanket permissions; patients concealing fasting. It is working when each fasting patient has a recorded, individual plan [source: ELFT 2025].

5. Handling problems

Most of this section is [synthesis]; source-based points are tagged.

  • Client asks the therapist whether they must fast. Do not rule. Reflect the question, outline that their tradition has its own exemptions (4.7), and help them take it to their imam and, for health, to their doctor. (illustrative) "That's a question your imam can answer far better than I can. What would you want to ask?" [synthesis]
  • Client insists on fasting against medical advice. Respect their choice while making sure risks are understood, as NHS guidance advises for ill patients who choose to fast [source: ELFT 2025]. For diabetes, the 2023 UK primary-care summary of the IDF-DAR guidance says that very-high-risk people who insist on fasting need structured education, close follow-up, regular monitoring and readiness to stop [source: Gilani 2023]. Your role: keep the doctor informed (with consent), agree a safety plan, and monitor mood and eating.
  • Client is not taking medicines to keep the fast. Do not advise on medicines. Express concern, ask about the religious belief behind it (for example, about routes of administration [source: ELFT 2025]), and arrange urgent contact with the prescriber and, if the client wishes, their imam [synthesis].
  • Eating disorder disguised as devotion. If screening suggests restriction or bingeing tied to fasting, share your concern openly and route to the eating-disorder or medical team; use the client's own distinction between worship and illness (4.6) [source: Equip 2025; synthesis].
  • Reassurance loops with imams or family. Brief them, with consent, on why reassurance maintains OCD and how to respond [source: IOCDF]. Expect slippage during Ramadan, when religious contact increases [synthesis].
  • Imam advice conflicts with treatment. Ask the client how they understand both pieces of advice; seek a joint conversation; never ask the client to choose between you and their imam. Survey data show many imams are unfamiliar with scrupulosity and ERP [source: Jones, Harris & Esfahani 2019], so offer information, not argument.
  • Relapse or crisis during the month or i'tikaf. Follow the agreed relapse plan and usual risk assessment; involve the treating team immediately. Religious meaning of stopping a fast or leaving i'tikaf is for the client and their imam afterwards; do not delay safety for it [synthesis].
  • Non-attendance or fatigue. Treat as an accommodation issue first (4.8), not resistance. Re-time or shorten sessions [synthesis].
  • Rupture over religion. If the client feels judged (for example by a non-Muslim therapist's health questions), name it, explain that you ask every fasting client about health, and use the CFI Patient–Clinician Relationship module if helpful [source: APA CFI Supplementary Modules for the module's existence; synthesis].
  • Therapist's own beliefs. Whether you are Muslim, of another faith or none, check that you are not steering the client towards or away from fasting. Seek consultation if you notice strong feelings. Avoid becoming the client's religious adviser [synthesis].
  • Child under pressure. If a child is fasting while unwell or is punished for not fasting, act under safeguarding procedures; schools guidance describes an overriding safeguarding duty and immediate breaking of the fast where health is at risk [source: Birmingham City Council 2026].
  • Pregnant client torn between faith and baby's health. Normalise the choice her tradition gives (to fast or not, with later make-up or fidyah), and route the health decision to her midwife or doctor [source: Tommy's].
  • Client who has left Islam or practises differently from family. Ramadan may bring conflict, hiding, or pressure. Explore safety at home and support their own choices; avoid assuming either faith or rejection [synthesis].
  • Problems the sources do not cover: clients doing shift work or night work, fasting in very long summer days, Ramadan in high latitudes, and converts with no community. Respond with the same principles: meaning, medical routing, accommodation, and referral to a religious authority for rulings [synthesis].

Sources

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