Fasting for my eating disorder or God?

For one month every year, Muslims around the world celebrate the month of Ramadan. We fast from sunrise to sunset every day, refraining from eating, drinking and smoking. The month follows the lunar calendar, changing every year. When Ramadan falls in spring and summer, fasts can be up to 20 hours in the UK. 

Fasting is not entirely about not eating or drinking. The month is mainly about spirituality and gaining closeness to God. We are encouraged to give time or money to charity, help others, practice patience and kindness, and engage in extra prayers both individually and with our wider Muslim community. One of my favourite parts of the month is spending time with my family and community, which involves enjoying 'Iftar' together – the evening meal after breaking the fast.

Fasting in Ramadan does not generally have a negative impact on mental health (Heun, 2018). But for those with or in recovery from an eating disorder (ED), Ramadan can be a huge challenge. For people in the earlier stages of treatment and recovery, the physical act of refraining from food and water is not possible, and so they are, as per the teachings of Islam, exempt from fasting. Similarly, exemptions apply to those who are pregnant, menstruating, travelling, or suffering with a physical or mental illness if their health could be harmed through fasting. For people who have completed formal treatment for an ED, fasting can be a major trigger.

Refraining from food and water for long hours is difficult and can be all-encompassing. Individuals with anorexia who are fasting can mask their ED and be validated and accepted for behaviour that otherwise would be concerning. Those with bulimia or binge-eating disorder may overeat at sunset, as overindulging can be seen as acceptable after not eating all day.

Stigma and shame

Although Islam clearly teaches that those with health needs do not have to fast, refraining from fasting is associated with stigma and shame. Those who are physically unwell or visibly pregnant are easily accepted as exempt. But for many women, even not fasting while menstruating is hidden from others in their family. 

Mental illness continues to be heavily stigmatised within many Muslim communities around the world, so not fasting can raise eyebrows and unwelcome questions or judgements. I am lucky to have a loving and supportive family, but I have often faced my own internal dilemma and self-stigmatisation, which is a different sort of struggle. Breaking the fast with family and friends who have been fasting all day when I haven't can feel isolating and take away from the valued community spirit that is so prominent throughout the month. For those without a supportive family environment, Ramadan could be especially isolating and lead to a feeling of disconnection from religious self-identity and from others.  

Throughout my life I have often found that my sense of religious identity directly impacts my wellbeing. Strong religious identity is correlated with improving self-esteem and positive affect and lessening depressive symptoms in religious believers (Davis & Kiang, 2016). Engaging in religious rituals and practices is strongly and positively correlated to psychological wellbeing (Jasperse et al., 2011). The negative associations of refraining from fasting for physical or mental health reasons may impact personal security in religious identity, with the potential for exacerbation by internal or external perceptions of shame. 

Social comparisons are common in society, and it's no different in a tightknit Muslim community. I often find myself questioning whether I do enough as a Muslim – am I praying enough, giving enough to charity, taking enough time to study the Quran, and maintaining a good enough lifestyle, one which is often a world apart from that of my peers and colleagues? In many Muslim communities, we are taught from a young age that we hold the responsibility of representing our religion and faith in a world which scrutinises us. While this can feel pressurising, it can also strengthen our identity. 

Someone with an ED who has been medically cleared to fast may question their own motivation. Like many others, I have previously found myself asking whether I am fasting to build my relationship with God, or for other reasons. If I am not sure of the answer, what does that mean for me? Am I still a 'good Muslim'? These questions have the power to negatively impact on religious identity, leading to further psychological distress at an already challenging time. 

Person-centred formulation and support

It is essential for healthcare professionals to approach these challenges with cultural sensitivity. For a professional, the natural response may be to encourage someone with or recovering from an ED to refrain from fasting – particularly if the ED is based on calorie restriction and periods of fasting. This could lead to a positive outcome in preventing significant psychological harm such as relapse. But it is essential to consider the potentially greater psychological harm from a fractured identity that not fasting during Ramadan may bring.

Using more person-centred formulations, healthcare professionals can understand which outcomes may be more likely for different individuals, while also considering the practicality of fasting in relation to physical health. Those who are able to fast and wish to do so can be supported to maintain a healthy weight through the creation of a tailored meal plan for the hours between sunset and sunrise, when eating and drinking is allowed. Given the increased vulnerability to relapse during this time, additional support should be provided to monitor physical and mental wellbeing. 

Those who are medically unable to fast or wish to refrain from fasting for their mental health also need support and monitoring because of the potential shame from internal or external stigmatisation, plus the potential fractured sense of religious identity. Healthcare professionals should support these individuals in continuing to engage in Ramadan without the physical act of fasting. Many Muslims volunteer and give to charity, and are strongly encouraged to practice gratitude throughout the month, which positively impacts subjective wellbeing (e.g. Watkins et al., 2004). Engaging in the many aspects of Ramadan aside from fasting allows people to maintain their religious identity and connection to families and communities at such a social time. Encouraging these activities may facilite self-acceptance alongside the realisation that physical and mental health always come first.  

Ramadan is one of the most celebrated, loved and important times for Muslims. It is often a chance for self-improvement – both in religious spirituality and the development of character traits such as kindness and gratitude. Our society is diverse, yet there is a lack of representation of that diversity in psychology. It can be challenging for healthcare professionals to practice in a culturally sensitive manner in situations they are not prepared for. Developing an understanding of factors that can impact mental health within different communities is a valuable step in providing person-centred and empathetic care for all.

-       Sumayya Alidina, Assistant Psychologist working in community CAMHS in Kent as part of NELFT NHS

References

Davis III, R. & Kiang, L. (2016). Religious Identity, Religious Participation, and Psychological Well-Being in Asian American Adolescents. Journal of Youth and Adolescence, 45(3), 532-546.

Heun, R. (2018). A systematic review on the effect of Ramadan on mental health: Minor effects and no harm in general, but increased risk of relapse in schizophrenia and bipolar disorder. Global Psychiatry, 1(1), 7-16.

Jasperse, M., Ward, C. & Jose, P. (2011). Identity, Perceived Religious Discrimination, and Psychological Well-Being in Muslim Immigrant Women. Applied Psychology, 61(2), 250-271.

Watkins, P.C. (2004). Gratitude and Subjective Well-Being. The Psychology of Gratitude, 167-192.