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Guide XIII-303

Asceticism

A 32 · L 58 · M 1017 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 scholarly account of asceticism in Gavin Flood, The Ascetic Self: Subjectivity, Memory and Tradition (Cambridge University Press, 2004), for what asceticism is; tradition-internal limits as stated in two primary texts (the Buddha's first discourse, SN 56.11, Piyadassi Thera translation; Catechism of the Catholic Church §1430); clinical work alongside it following the IOCDF on scrupulosity, NICE NG225 (2022) on self-harm as summarised by its committee members (Mughal et al. 2023), eating-disorder organisations' guidance on religious fasting, and the DSM-5 Cultural Formulation Interview supplementary module on spirituality, religion and moral traditions.

What it is. Asceticism is not a single practice but a family of disciplines found across religions: restraint of food, sleep, comfort, speech, sexuality and possessions, voluntary poverty, solitude, vigil, penance and monastic rule. Flood, working mainly from Hindu, Buddhist and Christian material (with Jain and other examples), describes asceticism as a voluntary restriction or reversal of the body's habitual drives, especially food and sexuality, undertaken for a greater goal the tradition names. In his words, asceticism is "the reversal of the flow of the body" and "Asceticism is always performed": it is carried out within, and enacts the memory of, a shared tradition that sanctions it, even when done privately. He also notes a built-in paradox: the will that seeks to efface the self is itself an assertion of the self. He argues asceticism is most at home in "cosmological religion", where the self is placed within an ordered cosmos (and, in theistic traditions, in relation to God); where that framework is lost, asceticism tends to become eroded or internalised. [source: Flood 2004, ch. 1 "Setting the parameters", pp. 1–10]

What this guide covers. This guide treats asceticism as a religious observance. Ascetic practice belongs to the client's tradition and its authorities, not to the therapist. The psychotherapist does not prescribe, supervise, intensify or reduce austerities. The therapist's own work runs alongside: understanding what the practice means in the client's life, cultural assessment, accommodation, routing health questions to the doctor, and recognising when something that looks like devotion is driven by an eating disorder, self-harm, scrupulosity (religious OCD) or coercion. No fasting lengths, food rules, sleep or cold targets, or other austerity targets are given here.

Core idea of how change happens (for the therapist's work). Change does not come from the therapist judging the practice. It comes from (a) placing the practice back inside the tradition that gives it meaning and limits, which the client can consult through its own authorities; (b) separating the tradition's practice from what a disorder or a punitive self-relation has made of it; and (c) treating any disorder (eating disorder, self-harm, OCD, depression, psychosis) with the evidence-based care it needs, in a way that respects the client's faith. [synthesis, drawing on Flood 2004; IOCDF; Favazza interview]

2. Framework

There is no manualised protocol for working alongside asceticism; the phases below are [synthesis] built from the cultural-assessment, scrupulosity, eating-disorder and self-harm sources cited. No source gives a session count for this work, and none is stated here. Where a disorder is found, the relevant treatment (for example ERP for OCD, or an eating-disorder pathway) sets its own format.

Phase A: Engagement and meaning.

  • Goal: learn what the practice is, in the client's words, which tradition and authority it comes from, and what it means to them.
  • Format: within ordinary sessions; no special structure.
  • Move on when: you can state the practice, its stated purpose, who authorises it, and how central it is to the client's identity.

Phase B: Assessment.

  • Goal: cultural assessment (CFI, including the spirituality, religion and moral traditions module); functional assessment of the practice; screening for eating disorder, self-harm and suicidal thinking, scrupulosity, depression, psychosis or mania; medical status and medicines (to be handled by the doctor and prescriber).
  • Move on when: you have a working view of whether the practice sits within what the tradition asks, or shows signs of being driven by distress, compulsion, self-punishment or coercion. Any immediate risk is handled at once, not deferred to a later phase.

Phase C: Formulation and shared plan.

  • Goal: a formulation the client recognises, which distinguishes tradition-sanctioned practice from any pathology; agreement on accommodation, medical coordination and (if the client wishes) consultation with a religious authority.
  • Move on when: the client agrees the plan, including who the doctor is and whether clergy are to be involved.

Phase D: Targeted treatment where indicated.

  • Goal: evidence-based treatment of any disorder (ERP for scrupulosity; eating-disorder care; self-harm care with safety planning), adapted to the client's faith.
  • Move on when: the disorder-driven behaviour is reducing and the client's religious life is less dominated by anxiety, shame or compulsion.

Phase E: Review and integration.

  • Goal: the client relates to the tradition's practice on terms its own authorities would recognise, with a relapse plan for high-risk seasons (fasts, retreats, penitential periods).
  • Ending: when goals are met, with a plan for future observance seasons.

3. Guiding principles

  • Attribute, do not adjudicate. Describe religious aims (purification, liberation, union with God, merit, repentance) as the tradition holds them; neither affirm nor dismiss them. Practical meaning: say "in your tradition…" rather than stating doctrine as fact or as error. [synthesis]
  • Asceticism is tradition-embedded. Flood stresses that ascetic practice is performed within, and sanctioned by, a tradition and community. Practical meaning: ask who in the tradition teaches, authorises and limits the practice; a practice cut off from any community or authority deserves closer attention. [source: Flood 2004, pp. 2, 7]
  • Traditions set their own limits. The Buddha's first discourse rejects "addiction to self-mortification" as "painful, unworthy, and unprofitable" and teaches a middle path; the Catholic Catechism says conversion aims first at the heart, not at outward penances such as fasting, and that outward penance without interior conversion is sterile. Practical meaning: a client can be helped to consult the moderating voices within their own tradition, through its authorities, rather than the therapist's opinion. [source: SN 56.11, Piyadassi Thera trans.; CCC §1430]
  • Function over form. Favazza distinguishes culturally embedded body practices, which serve communal, spiritual or healing purposes, from pathological self-injury, which is driven by distress, is often impulsive or compulsive, gives short-term relief, and is usually though not always linked to mental illness. Practical meaning: assess motive, control, context and function, not just the outward behaviour. [source: Favazza interview, WCPRR 8(1)]
  • Health first, routed to the doctor. Physical risks of fasting and other austerities are assessed by medical staff; medication questions go to the prescriber. Practical meaning: never advise on fasting, food, medicines or physical limits yourself. [source: National Alliance for Eating Disorders 2025]
  • No prescriptions. The therapist never sets, endorses or tapers austerity targets. Practical meaning: if asked "how much is safe?", route to the doctor and to the client's religious authority. [synthesis]
  • Scrupulosity is not deeper faith. IOCDF: scrupulous behaviour often goes beyond or ignores religious law, is inconsistent with the wider community, is driven by distress and impairs functioning; "OCD is never helpful" to faith. Practical meaning: treat it as OCD, while respecting the faith it hijacks. [source: IOCDF, What is OCD & Scrupulosity?]
  • Risk formulation, not risk scoring. NICE NG225: do not use risk tools or scales to predict self-harm or decide who gets treatment; do a compassionate psychosocial assessment and individual risk formulation. Practical meaning: ask, understand and plan with the person rather than categorising them. [source: NICE NG225 evidence review on risk assessment and formulation, 2022; Mughal et al. 2023]
  • Client-led involvement of religious authorities. IOCDF says consulting faith leaders is optional and depends on the client's preferences. Practical meaning: involve clergy only with explicit consent and a clear question. [source: IOCDF]
  • Stay in role. The therapist is not a confessor, spiritual director or guru, and does not issue religious rulings. Practical meaning: when a question is doctrinal ("Am I permitted to break the fast?"), help the client take it to the right authority. [synthesis; Vieten et al. 2013 propose spiritual and religious competencies in attitudes, knowledge and skills, individual items [uncertain: not verified]]
  • Even-handedness across traditions. Apply the same curiosity and the same safety threshold to every tradition. [synthesis]
  • Children and coercion get extra protection. Where minors or people under another's control undertake harsh austerities, safeguarding and coercion questions come first. [synthesis; no safeguarding-body source verified: uncertain]

4. Intervention inventory

All of these are the therapist's own work alongside a practice the tradition owns. None of them sets, changes or supervises an austerity. Where a step is not taken from a cited source it is marked [synthesis].

4.1 Opening the conversation about ascetic practice

  • Purpose / when: at intake and whenever the client mentions fasting, vigils, penance, vows, renunciation, monastic rule or "discipline". Many clients do not volunteer this, and practice can also hide disorder (BodyMatters notes fasting "can also disguise eating disorder behaviour"). [source: BodyMatters 2015; synthesis]
  • Steps:
    1. Ask openly about religious or spiritual practices that involve going without (food, sleep, comfort, speech, possessions) or penance.
    2. Ask the client to name the practice in their tradition's own terms (for example tapas, sawm, nesteia, Lenten fast, vigil) and gloss it in their own words.
    3. Ask what it is for, in their tradition and for them personally.
    4. Ask who taught or authorised it, and whether they practise it with a community.
    5. Record without evaluating; note any immediate safety signals for 4.5–4.6.
  • Example language (illustrative): "Some people's faith includes practices of restraint or going without, like fasting, vigils or penance. Is anything like that part of your life? I'm asking so I can understand you, not to judge it."
  • Watch for: reluctance or secrecy (could be privacy, shame, or concealment of disorder); a practice the client cannot place in any tradition or community; language of deserving, punishment or "needing to pay". Working: the client describes the practice freely and links it to their tradition's purposes.

4.2 Cultural Formulation Interview with the spirituality, religion and moral traditions module

  • Purpose / when: structured cultural assessment once ascetic practice is known to matter. The supplementary module is designed to clarify how spirituality, religion and other moral or philosophical traditions shape the person's problems and stresses. [source: APA, DSM-5 CFI Supplementary Modules]
  • Steps (paraphrased; do not read items verbatim from memory; use the published form):
    1. Use the core CFI first, then the module where religion is central.
    2. Cover the module's areas: identity and affiliation (traditions, congregation, family traditions, any additional traditions); the tradition's role in daily and family life; how it helps coping (leaders, texts, prayer, ritual); and tradition-related stresses, conflicts or discrimination.
    3. Substitute the client's own name for their tradition into the questions, as the module instructs; explore each tradition if there are several.
    4. Where the client names a specific practice (here, an austerity), ask about their level of involvement and how it affects coping, as the module directs.
    5. Skip redundant questions if you have used the core CFI.
  • Example language (illustrative): "You've said fasting is part of how you keep your faith. How does it help you, and has it ever made things harder?"
  • Watch for: conflicts between the client and their community about how strictly to practise; discrimination; the practice functioning mainly as coping with distress. Working: you can describe the practice's place in the client's life in terms they endorse. Version note: the module form cited is the DSM-5 version; check the current DSM-5-TR materials for any revisions [uncertain].

4.3 Locating the practice within its tradition

  • Purpose / when: after 4.1–4.2, to understand what the tradition itself asks, permits and limits, including exemptions. Flood describes asceticism as practised within a tradition that sanctions it; traditions also contain moderating teachings. [source: Flood 2004; SN 56.11; CCC §1430]
  • Steps:
    1. Ask the client what their tradition's teachers or texts say about the purpose of the practice.
    2. Ask who decides how it is done and who can grant exemptions (for example a priest, rabbi, imam, abbot, guru, spiritual director).
    3. Ask whether their tradition speaks of limits or a middle way; let the client bring the teaching, rather than quoting scripture at them.
    4. Note whether the client's practice goes beyond what the tradition asks, or is undertaken alone and secretly.
    5. If exemptions are relevant (illness, pregnancy, age, medical treatment), invite the client to ask their own authority; do not issue a ruling.
  • Example language (illustrative): "Who in your community would you ask about how strictly to keep this, or whether it applies when you're unwell?"
  • Watch for: the therapist drifting into theology; the client using the therapist as a religious authority. Working: the client can describe the tradition's own frame, including any limits, and knows who to ask.

4.4 Distinguishing tradition-sanctioned practice from self-injurious or punitive asceticism

  • Purpose / when: whenever there is doubt whether a practice is devotion as the tradition shapes it, or self-harm, self-punishment or disorder in religious clothing. Favazza separates culturally embedded body practices (communal, spiritual or healing purposes) from pathological self-injury (morbid motive, often impulsive or compulsive, short-term relief of distress, usually linked to mental illness). [source: Favazza interview, WCPRR 8(1)]
  • Steps (a functional enquiry about the practice; never ask about or record methods in detail beyond what risk assessment needs):
    1. Motive: is it done for the purposes the tradition names, or mainly to punish oneself, relieve unbearable feelings, or control weight or shape?
    2. Control: is it planned and bounded, or urgent, impulsive, compulsive, hard to stop?
    3. Context: is it shared with or known to a community and authority, or secret and solitary?
    4. Fit with tradition: does it go beyond or against what the tradition asks (IOCDF notes scrupulous behaviour often exceeds or ignores religious law)?
    5. Effect: does it lead to the goods the tradition names, or to escalating harm, injury, medical risk, impairment or isolation?
    6. Self-relation: does the client speak of deserving pain, being disgusting, or needing to pay?
    7. Summarise back what you see and agree next steps (4.5, 4.6, 4.7 as indicated).
  • Example language (illustrative): "When you go without, what's going on inside just before? And afterwards? Does it feel like what your tradition is asking, or does it feel more like punishing yourself?"
  • Watch for: physical injury, any self-harm, which triggers 4.6 immediately; escalation; secrecy from the client's own religious community; relief-of-distress function. Working: the client can tell the two apart in their own experience, and the formulation is shared. This is a judgement, not a scale [synthesis].

4.5 Eating-disorder awareness where ascetic practice involves food

  • Purpose / when: whenever fasting or food restraint is part of practice, especially in people with an eating-disorder history or high eating distress, and around fasting seasons. Eating-disorder organisations report that religious fasting can trigger restriction, binge cycles or purging, and can mask eating-disorder behaviour; BodyMatters cites research suggesting religious faith related to more restriction among people with high eating distress but was protective among those with low distress. [source: National Alliance for Eating Disorders 2025; BodyMatters 2015]
  • Steps:
    1. Ask directly about eating-disorder history, current restriction, bingeing, purging and preoccupation with weight or shape.
    2. Listen for warning signs the National Alliance lists: fasting reviving calorie control or restriction; bingeing or purging around fasts, or fasting used as purging; intensifying "good/bad food" or earning-food thinking; guilt, shame or anxiety at communal meals; feeling that missing a fast means spiritual failure.
    3. Ask about physical warning signs and route them at once to the doctor (the National Alliance names dehydration, electrolyte imbalance, muscle loss and refeeding complications as risks).
    4. If an eating disorder is present or suspected, refer to or coordinate with an eating-disorder team (therapist, physician, dietitian, psychiatrist) before any fast, as the National Alliance recommends.
    5. Invite the client, if they wish, to speak with their spiritual advisor about not fasting, so the decision is validated within their faith.
    6. If the client and team agree that the client will not fast, explore alternative observances the client and their tradition find meaningful (see 4.11).
  • Example language (illustrative): "Some people find that a fast stirs up the old eating-disorder voice. When you think about the next fast, which voice is louder: your faith, or the part that wants to restrict?"
  • Watch for: fasting as a socially accepted cover; weight loss; secrecy around meals; spiritual language for restriction ("purity", "being clean"). Working: the client can name the eating disorder's voice separately from their faith and accepts medical coordination. No food rules, fasting lengths or weight targets are set by the therapist.

4.6 Self-harm awareness: compassionate assessment and risk formulation

  • Purpose / when: whenever an austerity or penance involves bodily injury, pain-seeking, dangerous deprivation, or the client describes wanting to hurt or punish themselves; also when suicidal thinking appears. [source: Mughal et al. 2023 on NICE NG225]
  • Steps:
    1. Ask directly and calmly about self-harm and suicidal thoughts, whatever religious framing the client uses.
    2. Conduct (or arrange) a psychosocial assessment that identifies the circumstances of the behaviour and the person's strengths and needs, as NG225 describes. Do not ask for method detail beyond what is needed to assess medical need.
    3. Do not use risk scales to sort the person into low/medium/high risk or to decide whether they get care; build an individual risk formulation.
    4. Arrange medical assessment for any injury or physical compromise.
    5. Consider a collaborative safety plan, shared with supporters the client chooses and reviewed regularly; include who to contact, reasons for living (which may include faith), and lethal-means safety as current practice describes (storage and removal, not method).
    6. Follow your service's protocols and duties for imminent risk.
  • Example language (illustrative): "You've told me you sometimes hurt yourself as penance. I'm not here to argue with your faith. I do need to understand what happens and keep you safe. Can you tell me about the last time?"
  • Watch for: escalation; injuries hidden by clothing or religious dress; relief after the act; hopelessness; religious themes of being beyond forgiveness. Working: the client engages in assessment and safety planning, and self-injury reduces. Never describe or discuss self-injury methods beyond clinical need.

4.7 Assessing scrupulosity

  • Purpose / when: when penance, confession, purity, fasting rules or moral self-accounting are repetitive, anxious and certainty-seeking. [source: IOCDF, What is OCD & Scrupulosity?]
  • Steps:
    1. Ask about obsessions IOCDF lists: fear of having sinned, of blasphemy or offending God, of punishment or hell; doubts about one's faith; excessive concern with moral purity.
    2. Ask about compulsions: repeated or excessive confession; reassurance-seeking from religious leaders and family; repeating prayers until they feel "just right"; repeated cleansing; acts of self-sacrifice; treating optional practices as obligatory; mental neutralising; pacts with God.
    3. Ask about avoidance: skipping worship or texts for fear of error.
    4. Apply IOCDF's distinguishing features: goes beyond or ignores religious law; fixates on one area while neglecting central ones; inconsistent with the wider community; driven by distress; causes impairment.
    5. Ask the client to rate how much of the practice feels driven by fear versus devotion.
    6. Ask clients whether faith leaders have been a source of repeated reassurance; Rev. McKee's IOCDF blog notes clients may hide faith-based obsessions from clinicians.
  • Example language (illustrative): "When you add extra penance or fasting, is it more like an act of love, or more like trying to get rid of a terrible feeling that you might have done something wrong?"
  • Watch for: extra austerities added to neutralise doubt; endless confession; impairment. Working: the client recognises the OCD pattern as distinct from their faith. [source: IOCDF; McKee, IOCDF blog]

4.8 ERP for scrupulosity, adapted with religious consultation

  • Purpose / when: when scrupulosity is diagnosed. IOCDF names CBT with exposure and response prevention as the primary psychological treatment, with medication handled by prescribers, and says treatment may involve consulting the client's faith leaders so as to separate OCD from the person's values. [source: IOCDF]
  • Steps ([synthesis] where not stated by IOCDF):
    1. Psychoeducation: OCD exploits what matters most; the goal is to free the client to live their faith, not to weaken it.
    2. With consent, consult the client's religious authority about what the tradition actually requires (and what it does not), so exposures stay within religious law. IOCDF frames this involvement as optional and client-led.
    3. Build a hierarchy of exposures to uncertainty that the client and, if involved, their authority agree are religiously permissible (for example, not adding extra penance after a doubt; keeping the standard observance rather than an intensified one) [synthesis].
    4. Response prevention: reduce reassurance-seeking, repeated confession and neutralising austerities; agree with clergy (if involved) how to respond to reassurance requests.
    5. Never design exposures that require the client to commit what they believe is a sin or to act against their tradition [synthesis].
    6. Exposure safety: obtain informed consent, explain the expected rise in anxiety, avoid any exposure involving fasting, physical deprivation or health risk, and pause if self-harm or eating-disorder behaviour rises [synthesis].
  • Example language (illustrative): "Your priest has said the ordinary fast is all that's asked. This week, when the doubt comes, the exposure is to keep only what's asked, and let the doubt be there without adding anything."
  • Watch for: clergy unfamiliar with OCD giving reassurance or stricter rulings: a survey of 64 imams found most were unfamiliar with scrupulosity as OCD and with ERP, and few referred to mental health professionals, so brief, consented psychoeducation for the religious authority may help [source: Jones, Harris & Esfahani 2019, abstract]. Working: fewer compulsions, less distress, more freedom in worship.

4.9 Routing health questions to the doctor and prescriber

  • Purpose / when: whenever an austerity could affect physical health (fasting, sleep loss, exertion, exposure, solitude with poor self-care), or the client takes medication. The National Alliance for Eating Disorders advises consulting the treatment team, including the prescriber when medicines are involved, before any fast. [source: National Alliance for Eating Disorders 2025]
  • Steps:
    1. Ask who the client's doctor is and whether the doctor knows about the practice.
    2. With consent, communicate concerns to the doctor in plain terms (what the practice is, any warning signs observed); do not give medical or medication advice yourself.
    3. Encourage the client to ask the prescriber how the practice might affect any medicines.
    4. Keep a note of agreed medical limits set by the doctor, and of who to contact if warning signs appear.
  • Example language (illustrative): "I'm not the right person to say what's safe for your body. Would you be willing to talk this through with your doctor, and can I share my concerns with them?"
  • Watch for: the client avoiding the doctor to protect the practice; physical warning signs (fainting, rapid weight change, injury). Working: the doctor is informed and the client follows medical advice. Health claims for austerities (for example detoxification or healing) are attributed to their proponents and are not treated here as treatments for physical disease [synthesis].

4.10 Accommodation in scheduling and treatment

  • Purpose / when: during fasts, penitential seasons, retreats or vows of silence. [synthesis]
  • Steps:
    1. Ask about upcoming observance periods and their demands on energy, time and attention.
    2. Adjust appointment times, length or mode where possible (for example, avoiding times when the client is breaking a fast or at worship).
    3. Adapt homework to the observance (for example, no exposure tasks with physical demands during a fast).
    4. Respect vows that affect communication (for example silence) by agreeing in advance how contact and emergencies will work.
  • Example language (illustrative): "Your fasting season starts next month. Shall we look at whether our session times still work, and what we'd do if things got hard?"
  • Watch for: accommodation being used to avoid therapy at high-risk times. Working: the client feels respected and attendance holds through observance periods.

4.11 Exploring alternative or modified observance when health requires it

  • Purpose / when: when the doctor, eating-disorder team or the client's religious authority advises against a food or bodily austerity. Eating-disorder organisations note that many traditions provide for illness and suggest alternatives that honour the spirit of the practice, such as abstaining from technology or spending, or adding prayer, study, charity or volunteering. [source: National Alliance for Eating Disorders 2025; BodyMatters 2015]
  • Steps:
    1. Confirm the advice comes from the doctor or treatment team and, if the client wishes, from their religious authority; exemptions are for the tradition's authorities to state, not the therapist.
    2. Explore with the client what the practice is for in their tradition (from 4.3).
    3. Invite the client to generate alternative ways to serve that purpose, and to check them with their authority.
    4. Address grief or guilt at not keeping the practice (4.13).
  • Example language (illustrative): "If your doctor and your rabbi both say not to fast this year, what else might help you keep the meaning of the day?"
  • Watch for: alternatives becoming new austerities or new compulsions; the eating disorder co-opting the substitute. Working: the client feels they are still keeping faith.

4.12 Working with shame, guilt and possible moral injury

  • Purpose / when: when ascetic practice is driven by unresolved guilt or shame, including after actions the client believes violated their deepest values. [synthesis; no clinical source on moral injury verified: uncertain]
  • Steps ([synthesis]):
    1. Separate guilt about specific acts from global shame ("I am bad").
    2. Explore what repentance, forgiveness and repair mean in the client's tradition, as they understand it, and whether their authority could help with that.
    3. Look for punitive self-relation that exceeds what the tradition asks; compassion-focused work may help where it fits the client's values.
    4. If trauma or moral injury is present, use evidence-based trauma care and refer as needed.
  • Example language (illustrative): "In your tradition, what does it take for something to be forgiven? Does what you're doing to yourself fit that, or go beyond it?"
  • Watch for: self-punishment escalating (go to 4.6); hopelessness about forgiveness. Working: guilt becomes linked to repair, not to punishment.

4.13 Grief, ritual and community

  • Purpose / when: when a client must stop or modify a practice for health reasons, leaves a monastic or ascetic community, or loses community belonging. [synthesis]
  • Steps:
    1. Name the loss: identity, routine, belonging, a sense of closeness to the sacred.
    2. Explore community supports that remain (congregation, spiritual friends) and what the CFI revealed about the social network.
    3. Invite the client to consider rituals of transition their tradition offers.
  • Example language (illustrative): "Stopping this isn't only a health decision. It sounds like a real loss. What has it meant to give it up?"
  • Watch for: depression; isolation; pressure from community to resume. Working: the client keeps meaningful ties to faith and community.

4.14 Collaboration with clergy, chaplains and spiritual directors

  • Purpose / when: when the client wishes, to clarify what the tradition requires, to secure exemptions, to support ERP, or to coordinate care. IOCDF says leaders, family or friends may help clarify a religious institution's stance relevant to recovery. [source: IOCDF; McKee, IOCDF blog]
  • Steps:
    1. Obtain explicit, specific written consent: who, what may be shared, for what purpose.
    2. Agree with the client the question to ask (for example, "Does the tradition require this practice of someone who is ill?").
    3. Offer the religious authority brief psychoeducation if appropriate (for example, why reassurance maintains OCD), given evidence that some clergy are unfamiliar with scrupulosity [source: Jones, Harris & Esfahani 2019, abstract].
    4. Keep roles clear: the authority speaks to religious questions; you speak to the clinical ones.
  • Example language (illustrative): "Would it help if you, or we together, asked your imam what's required when someone is unwell? You decide whether and what I share."
  • Watch for: an authority who encourages harmful austerity or discourages treatment; consider a second authority within the same tradition if the client wishes. Working: religious guidance and clinical plan align.

4.15 Screening for psychosis, mania and depression

  • Purpose / when: when ascetic practice escalates abruptly, with unusual religious preoccupation, bizarre behaviour or sudden changes in appearance. Favazza advises alertness to psychotic patients preoccupied with religion and to sudden changes in appearance or dress. [source: Favazza interview, WCPRR 8(1)]
  • Steps:
    1. Assess for hallucinations, delusions (including commands to punish oneself), elevated mood, reduced need for sleep, and depressive symptoms.
    2. Compare with the client's previous practice and their community's norms.
    3. Refer urgently for psychiatric assessment if psychosis or mania is suspected.
    4. Record a religious or spiritual problem only where it fits DSM-5-TR's own definition (code Z65.8).
  • Example language (illustrative): "Has anything changed recently in how you experience God or in what you feel you must do?"
  • Watch for: command-type experiences directing self-harm (treat as urgent). Working: illness is neither missed nor confused with devotion.

4.16 Safeguarding children and people under another's control

  • Purpose / when: when minors, or adults in dependent or high-control settings, undertake or are subjected to harsh austerities, fasting, or corporal discipline. [synthesis; safeguarding-body guidance not verified: uncertain]
  • Steps ([synthesis]):
    1. Assess whether the austerity is chosen or imposed, and whether the person can refuse.
    2. For minors, consider developmental needs, the young person's own assent, and parental consent separately.
    3. Follow local safeguarding procedures and statutory duties where there is risk of harm.
    4. Explore signs of coercive control (isolation, punishment for non-compliance, restriction of medical care).
  • Example language (illustrative): "What would happen if you said no to this?"
  • Watch for: fear of consequences; health effects; withheld medical care. Working: the person is safe and has a voice.

4.17 Therapist self-reflection and role boundaries

  • Purpose / when: throughout. Vieten et al. (2013) propose 16 spiritual and religious competencies for psychologists in attitudes, knowledge and skills [source: Vieten et al. 2013, abstract; individual items uncertain: not verified].
  • Steps ([synthesis]):
    1. Notice your own reactions to asceticism (admiration, alarm, contempt) and how they could steer the work.
    2. Decide in advance how you handle questions about your own beliefs; disclose only for the client's benefit.
    3. Do not act as spiritual director, confessor or religious judge; avoid dual relationships with the client's religious community.
    4. Seek consultation when your own commitments overlap or conflict with the client's tradition.
  • Example language (illustrative): "I'm not a religious authority, so I won't tell you what your faith requires. I can help you think about what's driving this and who you could ask."
  • Watch for: being pulled into theological debate or rescue. Working: the client experiences you as respectful and clear about your role.

5. Handling problems

Most of this section is [synthesis]; sourced points are tagged.

  • Client hears concern as an attack on their faith. Return to attribution: affirm the practice's place in the tradition, and frame your concern as being about the disorder, distress or health risk, not the faith. IOCDF's framing that the goal is to separate OCD from the person's values is useful wording. (illustrative) "I'm on the side of your faith. I'm concerned about the part of this that seems to be hurting you." [source: IOCDF; synthesis]
  • "My tradition demands this; you can't understand." Agree that you are not the authority; ask who in their tradition is, and whether that person knows the full picture, including health effects. [synthesis]
  • Client asks you for a ruling or a safe amount. Decline in role; route body questions to the doctor and religious questions to the client's authority. Never give durations, amounts or targets. [synthesis]
  • Escalating austerity or self-injury framed as penance. Move to 4.6 at once: compassionate psychosocial assessment, risk formulation rather than risk scoring, medical review, collaborative safety plan, and your service's emergency protocol where risk is imminent. [source: Mughal et al. 2023 on NICE NG225]
  • Eating disorder hiding behind fasting. Name the possibility gently, assess (4.5), coordinate with the eating-disorder team and doctor before the next fast, and, if the client wishes, involve their spiritual advisor about not fasting. [source: National Alliance for Eating Disorders 2025; BodyMatters 2015]
  • Reassurance loops with clergy or therapist. Recognise reassurance as an OCD compulsion; with consent, agree a consistent response with the religious authority; do not supply reassurance yourself. [source: IOCDF; synthesis]
  • Religious authority gives advice inconsistent with treatment. Some clergy may be unfamiliar with OCD and ERP [source: Jones, Harris & Esfahani 2019, abstract]. With consent, offer brief information; respect the authority's religious role; the client may choose to consult another authority within their tradition. [synthesis]
  • Non-adherence to medical advice to stop or modify a practice. Explore the meaning of stopping (4.3, 4.13), the fear behind it (sin, loss of identity, community disapproval) and what the tradition's authorities say about exemptions; keep the doctor informed; reassess capacity and risk if physical danger grows. [synthesis]
  • Overwhelm during ERP or when austerities are reduced. Slow the hierarchy; check for emerging self-harm or eating-disorder behaviour; never use deprivation as an exposure. [synthesis]
  • Rupture over the therapist's perceived bias (secular or religious). Acknowledge it, invite feedback, review your own reactions (4.17) and seek consultation. [synthesis]
  • Coercion by a teacher, family or group. Assess whether the person can refuse; look for isolation, punishment for non-compliance and withheld medical care; follow safeguarding procedures for minors and adults at risk. [synthesis; uncertain: no independent source on specific groups verified]
  • Dramatic religious experiences with escalating deprivation. Screen for psychosis, mania and severe depression (4.15) without pathologising the client's faith; refer urgently if indicated. [source: Favazza interview; synthesis]
  • Interpretations of asceticism in the therapist's own head. Flood's account is a scholarly lens on traditions, not a clinical rule; do not use it to tell clients what their practice "really" means. [synthesis]

Sources

Web pages:

Books and papers cited:

  • Flood, G. (2004). The Ascetic Self: Subjectivity, Memory and Tradition. Cambridge University Press.
  • Favazza, A. R. (2011). Bodies under Siege: Self-mutilation, Nonsuicidal Self-injury, and Body Modification in Culture and Psychiatry (3rd ed.). Johns Hopkins University Press.
  • Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5(3), 129–144.
  • National Institute for Health and Care Excellence (2022). Self-harm: assessment, management and preventing recurrence (NG225), https://www.nice.org.uk/guidance/ng225; with its evidence review on risk assessment and formulation (September 2022), which states that risk tools and scales should not be used to predict self-harm or suicide, that risk stratification should not determine access to treatment and care, and that a risk formulation should be part of every psychosocial assessment: NG225 evidence review G. Also summarised by Mughal et al. 2023.
  • 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
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