Ramadan and Mental Health
Ramadan Kareem! Ramadan is a beautiful month that many Muslims look forward to. Fasting during Ramadan is one of the key pillars of Islam, making it obligatory for all Muslims (there are some exceptions). It’s a month of connecting with Allah and Islam, your family and your community. During this month, Muslims of different cultural backgrounds have their own traditional foods that they serve for Iftar (the pre-meal, or appetizers before the main meal, to open their fast at sunset). They may also follow the tradition of decorating the house for Ramadan with their family. During Ramadan, families may go together for the recommended, but not obligatory, Taraweeh prayers, specifically prayed during Ramadan after the fifth prayer of the day, Isha. Each family has their own way of celebrating practices expected for this month and within Islamic guidelines. For Muslims, Ramadan is a blessed month full of multiple opportunities to obtain piety and grow close to Allah (God).
As much excitement as Ramadan can bring, it can also be a time of difficulty for those with severe mental health disorders (such as bipolar disorder, schizophrenia etc), eating disorders and those on psychiatric medications. Ramadan can bring its own challenges for these followers and, with it, feelings of sadness, confusion, embarrassment, fear and isolation at the thought of possibly giving up fasting to maintain their mental and emotional wellness. Many may find it hard to talk to their fellow Muslims about their feelings of stress and impending struggle with Ramadan, for fear of being judged. However, we need to validate and address these feelings with empathy and compassion. We need to discuss how those with mental health disorders can still take care of themselves while practicing their faith and strengthening their connection to Allah during this holy month.
For those individuals with bipolar disorder, the limited hours of sleep and disruptions in sleep, especially when Ramadan is in the summer and early fall, can trigger an onset of hypomania, mania or severe depression. Dysregulated sleep is one of the big triggers for bipolar disorder as the need for long, quality sleep is important in the regulation of bipolar symptoms. Research has shown that during Ramadan, individuals diagnosed with bipolar disorder and schizophrenia (along with metabolic syndrome) have a higher chance of relapsing.
For those diagnosed with an eating disorder, for example anorexia, fasting during Ramadan may become another way to continue their harmful relationship with food. It can undo progress the client may have made with their therapist with regards to having a healthier relationship with eating and food. It can be hard for them and their families to see how fasting during Ramadan is actually counterproductive to their treatment and, in fact, harmful to their health and well-being.
Those on psychiatric medications have prescribed times to take their medications, with some having to take it three times a day (which would therefore mean once during the day and while fasting). This becomes a concern as ingesting anything while fasting breaks the fast. Clients may stop taking their medications, skip doses or simply forget when they wake up for the pre-dawn meal, suhoor.
As therapists, we are aware of the consequence of missing psychiatric medications, falling back into the harmful patterns of eating disorders and not having regulated sleep. Because we are ethically mandated to be multiculturally competent when working with our clients and ensuring we do no harm while providing them with autonomy, it is imperative that we have knowledge about the different populations we work with. This article was written to help therapists who are not Muslim have a clearer idea and understanding of how to support their Muslim clients during this month.
Given that Ramadan is so important for Muslims, your Muslim clients may struggle with the thought of not fasting because of the religious importance of fasting in Ramadan. Giving up fasting during Ramadan is not a decision to be made lightly, which will make your clients even more stressed. As their therapist, it’s important to validate their feelings of sadness, confusion, even guilt and whatever else they may be feeling, and to explore what Ramadan means to them. Remember, your guidance must be balanced with your client’s beliefs. While we cannot operate outside of our areas of expertise from an ethical and legal perspective and therefore can’t give any religious or theological guidance, there are still a few ways you can support your clients to ensure their well-being.
Here’s what you can do:
- To better understand your clients’ background, it will be helpful to expand your knowledge about Islam. You can view recommended articles and books about Islam (including some on counseling Muslims) here. You can also read articles about Islam and mental health and other related topics here . Finally, there are Mental Health Toolkits specifically about mental health for the Muslim community here.
- Increase your knowledge about what Ramadan is. For specific information about Ramadan, you can review these toolkits compiled by Muslim mental health organizations.
- Encourage your client to talk to their psychiatric medication prescriber. If either their PCP or psychiatrist is Muslim, all the better. Encourage your client to sign a consent form so you can contact their provider and discuss your concerns.
- Link them to a local Imam (leader of the community at the mosque with extensive knowledge of Islam) who can address their concerns about fasting. It is important to link them to someone who has an understanding of mental illness as, unfortunately, there is still stigma around mental illness. If you do not know of anyone, encourage your client to reach out to scholars who have knowledge of Islam and mental health and illnesses. They can contact this center and request a religious consultation. This will help alleviate your clients’ concerns about the magnitude of not fasting. The consensus is that Muslim clients should get complete information from a religious context when deciding how to approach Ramadan.
- Explore with your client how severe mental health disorders and eating disorders are considered diseases from a medical model and especially when they are being prescribed medications. Remind them of the risk of relapse for bipolar disorder and the disorders for which they are taking medication. Remind them of the negative impact on their treatment progress for their eating disorder. Explore with them their understanding of what Islam says about exempting those who are sick, pregnant and with cognitive disabilities from fasting. Younger ones are not obligated to fast (those who have not yet reached puberty). Those who are sick can “make up” their fasts by giving a certain amount of money to those in need (the amount is enough to cover the cost of one meal for each day not fasted). You can read more here about how this is a nuanced matter. You can also share the article with your client.
- Encourage them to identify other ways they can grow their spiritual connection during the month of Ramadan. They can read the Qur’an, recite or listen to the Qur’an, listen to Islamic lectures, recite Allah’s Names (zikr) and be consistent with their prayers. They can work on focusing on being more mindful of their language, managing their anger in their responses to others and, overall, find other activities to help them become more spiritual.
- Help them identify themes of Allah’s mercy in Islam (both in the Qur’an and Allah’s 99 Attributes) and how self-compassion is important during these times, especially as Muslims believe that Allah is the Most Merciful.
- Explore with them how they want to pray taraweeh (the highly recommended, but not obligatory, prayers during Ramadan which are prayed during the night). During the summer Ramadans, the prayers can end very late, which means individuals will only have a few hours of sleep before waking up for suhoor (the pre-dawn meal). Again, the limited sleep can be a trigger for their bipolar disorder symptoms. They can always pray a few units of Taraweeh, especially as this prayer is not obligatory. The nights that are recommended for one to stay up and pray can also be a trigger and it is recommended they discuss this with the scholars of their local community or by requesting a religious consultation.
Ultimately, we know that our clients will make a decision they feel is best for them, even if we may disagree due to its impact on their mental health and emotional well-being. In those cases, we support them, even as we reach out to their other providers to stress our concerns. We, again, let our clients know our concerns and remind them of the beginning signs of mania and depression, and what to do if they find themselves experiencing symptoms (follow up with a psychiatrist, be consistent with weekly therapy, if experiencing severe symptoms, call their local crisis lines or mobile crisis unit for wellness checks). We again remind them of how their treatment for their eating disorder will be impacted and how their physical and mental health will be greatly impacted in their case. It might also help to follow up with their psychiatrist and/or PCP after the client informs you of their decision for continuity of care. It might also be helpful to have the client sign a consent form for a family member you can check in with if you are concerned about their well-being and need reassurance especially during this time. Finally, if you would like more information, please don’t hesitate to contact us.
Here are some additional articles:
Articles on Ramadan, fasting and mental illness
Eating Disorders:
Bipolar Disorder