During PWPA, client reported "I feel like I need to be perfectly clean before I pray, otherwise my prayer won't count." Client is distressed by the time these rituals take, impacting her ability to manage her part-time job and studies.

Aisha’s understanding of "cleanliness" is influenced by Islamic teachings on ritual purity (taharah), which is important before prayer. Her family attributes her symptoms to "weak faith" or being “too sensitive,” and discourage psychological support. She is worried about stigma in her community surrounding mental health and is reluctant to involve her family.

Goals: To stop excessive cleaning and be able to work, study and go out like other people.

Risk: No current or previous risk reported.

During PWPA, Elena kept expressing “My body is here, but my mind is back in Ukraine. I’m not myself anymore.”

Client reported that she worries about finances, her daughters' safety, and the family members she left behind. She avoids all news about the war but becomes distressed if she doesn’t hear from her sister daily. Client reported "If something happens to them, it’s my fault for leaving.”

Elena lost her husband in the conflict and has not processed her grief. She avoids talking about his death. She finds comfort in her Christian Orthodox faith but believes that suffering is part of her burden to bear. She previously worked as a nurse but now feels a loss of identity, saying “I used to help people. Now I am the one needing help.”

Goals: I want to stop worrying about things, I want to sleep normally.

Risk:

• PHQ9 Q9: 1

• fleeting thoughts of suicide reported

• no PIPs

• no history

• safety plan in place

2. What else would you want to know?

3. What could a treatment plan look like for this client?

4. What might you need to be mindful of?

5. What adaptations might help engagement?

• OCD

• Need to be perfect

• Excessive time spent cleaning, changing clothes and washing hands.

• Client finds this distressing

• Having big impact on areas of client's life- studies, job, socialising.

What else would you want to know:

• What does stigma around mental health look like in their community?

• What does this stigma mean for client?

• More about taharah (Islamic teachings on ritual purity) to understand how excessive current cleaning is.

• Exploring around client's faith and what other teachings are important to client in everyday life?

• Understand how client can know if they are 'failing' or doing well at rituals- any signs to look out for

• What family are saying and how this impacts on her

What could a treatment plan look like:

• Would not want to begin intervention too soon

• Spend time developing understanding of client's faith and culture to inform treatment plan (maybe 1-3 sessions)

What might you need to be mindful of:

• beliefs that are part of presentation

• careful around understanding beliefs before jumping into intervention

• families perception of mental health and how this is impacting her.

• how does client feel about use of psychological support.

• how much of presentation requires cognitive work rather than just a behavioural intervention (would it just be a S2 presentation)

What adaptations might help engagement:

• having time in initial sessions to be curious

• longer sessions to consider cultural aspects

• where does client take appointments? If this is at home client may not feel it is a safe space to have appointments if family are around

• consider F2F appointments

• 10 hours of therapy is NICE guidelines for OCD- consider S2 treatment as setting foundation and then consider step up if needed.

• Discuss with client what they feel may be barriers or what might be helpful and can consider implementing adaptations based on this- are there any adaptations you feel would help?

• Consider prayer times- does this impact when client is available? Is it more appropriate for client to have appointments at specific times of the day?

2. What else would you want to know?

-What is the cognitive theme, are there any obsessive thoughts driving compulsions etc.

-How long the cleaning behaviours have been an issue for.

-If is cleaning outside of the times specified.

-What the ritual purity teachings are.

-If the level of cleaning is excessive or ‘normal’ amount.

-Are there any other behaviours that indicate OCD.

-What drives the client to carry out the cleaning rituals to the extent that she is.

-Further exploration of beliefs.

-Are there external pressures or expectations being put on them?

-What does client mean by going out like ‘normal’ people?

-What are the teachings around the purpose of the cleaning rituals and the consequences if these aren’t done properly.

3. What could a treatment plan look like for this client?

-Further exploration and supervision required before this can be determined.

4. What might you need to be mindful of?

-Timings of appointments.

-Differences in cultures between client and therapist.

-Where appointments take place and if the client is able to full engage with where she is.

5. What adaptations might help engagement?

-Flexibility in sessions, taking time in first few sessions to rapport build, ask questions, be curious and formulate.