Moral Scrupulosity vs OCPD

Summary

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Breaking the Rules: A Clinician’s Guide to Treating OCD

Episode: Moral Scrupulosity vs OCPD

Hosts: Dr. Celine Gelgec & Dr. Tori Miller
Date: January 26, 2026

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Episode Overview

This episode explores the nuanced distinction between moral scrupulosity, a theme of OCD, and Obsessive Compulsive Personality Disorder (OCPD). Drs. Gelgec and Miller discuss how these presentations overlap, how they differ, and—critically—why this distinction matters in clinical practice. The conversation offers practical guidance, real-world examples, and creative intervention ideas for clinicians working with youth and adults.

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Key Discussion Points & Insights

1. Defining the Terms (06:03 – 10:03)

Moral Scrupulosity (OCD Theme):

• Characterized by obsessive concerns about morality, being a "good person," and fears about being seen as bad, wrong, or immoral.

• May present with religious undertones (e.g., blasphemy, offending God) but increasingly centers around secular morals and values.

• Perfectionism in upholding internal and external standards; significant doubt and discomfort.

  "Moral scrupulosity is basically just a theme of OCD where someone is very preoccupied about, or really worried about being seen as a bad person."
  — Dr. Celine Gelgec [06:21]

OCPD (Obsessive Compulsive Personality Disorder):

• A personality disorder—not an anxiety disorder—marked by rigid perfectionism affecting all life domains: work, relationships, appearance, and especially morals/values.

• Noted for inflexibility, righteousness, and being “ego-syntonic” (behaviors feel consistent with self-concept rather than intrusive or distressing).

• Impacts both self and others, often leading to irritability or frustration if others don’t conform.

  “This is the right way. So that cognitive inflexibility, like, these are the rules. This is how it should be. I am right... It's strange that you don’t live your life the same way.”
  — Dr. Tori Miller [09:28]

Crucial Distinction:

• OCD is ego-dystonic: suffers experience thoughts/behaviors as distressing, inconsistent with self.
• OCPD is ego-syntonic: traits feel appropriate and correct.

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2. Presentation Across Ages (04:25 – 07:54)

• Moral scrupulosity is common in both adults and youth—though often harder to spot in kids/teens.

• In youth, compulsions may not be verbally reported but manifest behaviorally (e.g., rule-following, anxiety after minor rule-breaking, rehearsing conversations).

• Adolescents experience conflict between internalized values and the natural push for autonomy (peer parties, minor "naughtiness," etc.).

• Confession and rehearsing conversations frequently surface as compulsions.

  "There can be that tension in adolescence... The desire to be a bit naughty... can leave someone who identifies as being a good, sensible, moral person...feeling very icky and uncomfortable."
  — Dr. Tori Miller [07:34]

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3. The Reluctance to Let Go (10:13 – 13:20)

• Clients may resist exposure or behavioral change because moral values feel fundamental.

• For many, the drive “to be good” is central to identity, shaped by family, culture, or religious influence.

• The therapist’s task is to gently help clients see that striving for perfection can actually undermine well-being—and that moral "messiness" is human.

  "Sometimes I find that clients have a reluctance to want to let this one go. Because... it stems from a desire to be a good person..."
  — Dr. Tori Miller [11:09]

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4. Societal Influences: Social Media & Cancel Culture (16:08 – 18:38)

• Modern social/cultural phenomena (cancel culture, political division, omnipresent social media) intensify anxieties about being “wrong,” shamed, or ostracized.

• The erosion of nuance in public discourse fosters black-and-white moral thinking—triggering or amplifying OCD themes for moral scrupulosity sufferers.

  "There's so much more anxiety about being caught out... The nuance has gone out of a lot of people's positions..."
  — Dr. Tori Miller [16:46 / 17:19]

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5. Typical Compulsions (18:45 – 20:42)

Common compulsions seen in moral scrupulosity include:

• Confessing: to parents, partners, friends—even as adults.

• Comparison & rumination: mentally revisiting conversations, comparing oneself to others, “preparing” scripts.

• Reassurance seeking: from others, internet, AI (ChatGPT).

• Praying: for those with religious themes.

• Over-apologizing & self-monitoring: excessive “sorrys” and hypervigilance in self-observation.

  "Confession for sure. The other one I see a lot... is comparison—not just self and others. I also see lots of rumination."
  — Dr. Celine Gelgec [18:50]

  "Over-apologizing. Oh my gosh. Over-apologizing, yes."
  — Dr. Tori Miller [20:12]

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6. Treatment Approaches for Moral Scrupulosity (20:43 – 26:12)

• Psychoeducation is fundamental due to enmeshment with clients’ real value systems.

  • Share examples of compulsions: over-apologizing, rehearsing conversations, etc.
  • Use questionnaires (e.g., Jonathan Grayson’s assessment) to develop client insight.

• Exposure Therapy (ERP):

  • Practice resisting urges: to confess, apologize, ruminate.
  • Creative exposures: write “lies” or “negative” thoughts, confront fears about being “bad.”
  • Tailor exposures for religious themes (e.g., read “taboo” phrases, put “666” in visible places).

• Encouraging Flexibility:

  • Remind clients: “We’re not trying to change your value system—just bringing in some flexibility.”
  • Normalize “messy” morality: all good people do “bad” things sometimes, and vice versa.
  • Use psychoeducation to promote acceptance of ambiguity.

  “You’ve got to remind yourself... that we're doing this to push back against OCD. It doesn't define who you are... we're just bringing in some flexibility.”
  — Dr. Celine Gelgec [24:30]

  “Help our clients move away from that binary way of thinking... and have a look, because... sometimes we need to give them permission to be human.”
  — Dr. Tori Miller [25:33]

• Balance Psychoeducation vs Reassurance:

  • Provide information once, then notice if repeated questioning becomes compulsive reassurance seeking.

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7. OCPD in Focus: Assessment & Treatment (26:41 – 31:46)

• OCPD often presents as exactly what laypeople incorrectly call “OCD”: extreme perfectionism, rigidity, rule-following.

• Usually, distress is reported by others (family members) rather than the client, who may see no reason for change.

• Treatment Strategies:

  • Schema therapy, DBT, and ACT-based approaches targeting behavioral/cognitive inflexibility.
  • Focus on life impact: work, marriage, parenting, productivity, relationships.
  • Address co-occurring OCD (not uncommon—35% overlap); untangle moral scrupulosity and OCPD when both are present.
  • Process is often slow: rapport, trust, and collaboration are critical.

  “...oftentimes people don’t necessarily present for treatment with OCPD unless they’ve been encouraged by a family member or there are co-occurring difficulties...”
  — Dr. Tori Miller [29:08]

  “Moral scrupulosity feeds off OCPD, and the interplay between those two is so sticky and so messy... You don’t even know where to start pulling it apart from.”
  — Dr. Celine Gelgec [30:35]

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8. The Value of Transparency & Clinical Humility (31:46 – 33:15)

• Encourage clinicians to discuss diagnostic ambiguity openly.

• Collaboratively label emerging patterns with clients (“I wonder, have you heard about OCPD?”).

• Use transparent conversations to break through stuckness and increase motivation for change.

  “To have confidence as a clinician to not be all knowing... To say, ‘What I’m noticing is there’s this cycle going round...’ I think it’s okay to have these sorts of conversations with our clients.”
  — Dr. Tori Miller [31:56]

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Notable Quotes & Memorable Moments

• On adolescent perfectionism:
  “Excuse me for describing it this way, but like the goody two-shoes student who doesn’t ruffle any feathers... Beautiful qualities to have as a person. But it’s okay to kind of mess it up a bit too.”
  — Dr. Celine Gelgec [07:00]

• On society's intolerance for ambiguity:
  “We’re losing touch with the art of ambiguity and gray and debate, which I think for people with moral scrupulosity, it would be really difficult to be sitting with this sort of ambiguity in their minds...”
  — Dr. Tori Miller [17:19]

• On creative exposures:
  “We’d get clients to write down what they really thought of us as the clinician team... and then we’d read it away from them so they couldn’t even gauge our reactions.”
  — Dr. Celine Gelgec [22:45]

• On the humanity of everyone:
  “Even Queen Elizabeth does poo on the toilet. Her shit stinks too.”
  — Drs. Tori Miller & Celine Gelgec [25:49 – 25:59]

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Important Timestamps

• [06:03] – Core definitions: moral scrupulosity vs OCPD
• [09:28] – The role of rigidity & inflexibility in OCPD
• [11:09] – Why clients struggle to let go of moral obsessions
• [16:08] – Social media’s role in fueling scrupulosity
• [18:45] – Typical compulsions in moral scrupulosity
• [20:43] – Assessment tips & exposure hierarchy for scrupulosity
• [24:30] – Therapeutic reminders: honoring values vs interrupting OCD
• [26:41] – Practical OCPD management strategies
• [30:35] – The tangled overlap: scrupulosity within OCPD
• [31:56] – Being transparent and collaborative as a clinician

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Tone & Takeaways

Candid and collegial, Drs. Gelgec and Miller blend clinical rigor with warmth and humor. They emphasize the messiness of human morality, encourage flexibility over perfection, and urge clinicians to foster understanding and transparency in treating both moral scrupulosity and OCPD. The episode underscores the importance of accurate diagnosis, creative and tailored interventions, and compassion—for clients and clinicians alike.

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Transcript

[Dr. Celine Gelgich]

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[Dr. Celine Gelgich]

Hi, I'm Dr. Celine Gelgich.

[Dr. Tori Miller]

And I'm Dr. Tori Miller. Welcome to Breaking the Rules. On Breaking the Rules, we talk about all things OCD.

[Dr. Celine Gelgich]

Obsessive compulsive disorder. OCD impacts up to 1 to 2% of the population. We are here to provide not just education, but to inspire clinicians, families and people who are impacted by OCD to be able to access the treatment they need in order to get better.

[Dr. Tori Miller]

Catch us every fortnight wherever you get your podcasts. Hey, mate.

[Dr. Celine Gelgich]

Hey. How's it going?

[Dr. Tori Miller]

I'm good. How are you?

[Dr. Celine Gelgich]

Good. That was a very enthusiastic hey, how's it going? Oh, my God. Now that we've switched to videos, I've noticed my face is like this serious, like half the time. So I'm gonna be trying to be a bit more Cheerful looking.

[Dr. Tori Miller]

I mean, OCD is a serious topic.

[Dr. Celine Gelgich]

It is very serious. My concentration face my brother. Now I understand why my brother always says, why do you look pissed off? Half the time I'm thinking, I'm not pissed off. Concentrating. Oh.

[Dr. Tori Miller]

So you tell me, Celine, you don't actually hate me. All this time I thought you were just perpetually pissed off with me.

[Dr. Celine Gelgich]

Oh, my God. In all seriousness, how are you?

[Dr. Tori Miller]

Yeah, I'm good. I'm good. Yeah, yeah, yeah.

[Dr. Celine Gelgich]

I'm.

[Dr. Tori Miller]

I'm happy to be back here with you.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Regarding another episode. Yeah.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

No, I'm good. I'm good.

[Dr. Celine Gelgich]

I'm.

[Dr. Tori Miller]

You know we're heading towards the end of the year.

[Dr. Celine Gelgich]

I know.

[Dr. Tori Miller]

Which is really nice.

[Dr. Celine Gelgich]

It's insane. It's November. Well, now it's November, but by the time this comes out, it might not be November, but we're, I think, very much feeling. Yeah, the end of the year.

[Dr. Tori Miller]

Yeah. Yeah. But there's also something about, I don't know, it's like the sun comes out. I don't know, the days get longer and there's something about feeling like there's more time on your hands or things are, I know, relaxing or something. I've really felt the first moments of that yesterday, like, oh, like summer's coming.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

You know, like there's something about yesterday that just. Yeah, yeah. Felt lovely. For just a mere moment.

[Dr. Celine Gelgich]

I can resonate with that.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

In terms of when. Like when you come home from work, it's not pitch black.

[Dr. Tori Miller]

Yeah, yeah, yeah.

[Dr. Celine Gelgich]

I can still do stuff.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

As opposed to going, oh, my God, it's dark already. It's nearly bedtime. Yeah, No, I hear you.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

What are we talking about today?

[Dr. Tori Miller]

Moral scrupulosity and ocpd. Obsessive Compulsive Personality Anxiety disorder. Yeah.

[Dr. Celine Gelgich]

I love this topic.

[Dr. Tori Miller]

Yeah, this is a good one. Yeah, this is a good one. I find this one comes up a lot. Well, at least. Okay. The. I find. I'd be curious to see what you think. I find that moral scrupulosity is incredibly common. Yes, I think that it's. Yeah, it's very common. And what I think is that especially very common in adults, but I also think it's quite common in teens and kids.

[Dr. Celine Gelgich]

Yeah, I would agree.

[Dr. Tori Miller]

And I think I see it almost like sitting underneath, but it's not as easily spotted because I think the compulsions that are more evident because the kids sometimes can't talk about or identify or name in the same way that adults can. It's not as easy to Spot, but it lives there as sort of like a driving force underneath some of the compulsions that they're doing. Yeah, but the compulsions don't always necessarily easily identify this theme, but it's such a good one to identify, particularly I think, because it helps parents understand what's driving their kids behavior. Yeah, yeah. And then the question of OCPD is also a really interesting one because I do think sometimes we're trying to do ERP and work with this presumption of flexibility and an openness in our clients that actually may not be there because in fact the presentation is actually less ocd, more ocpd.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

And so I think that, you know, understanding the difference and knowing how to kind of think about the two concepts and, and how to work with them differently, I think is really important.

[Dr. Celine Gelgich]

Yeah, I would agree. Yeah, that's a nice intro into that, what we're talking about today. So maybe we should define both of those things in case people don't know.

[Dr. Tori Miller]

I agree.

[Dr. Celine Gelgich]

Sometimes I'll flag scrupulosity in a supervision session and they'll be like, what's that?

[Dr. Tori Miller]

I know, yeah.

[Dr. Celine Gelgich]

Or a client would be. That would do the same. So we have moral scrupulosity, which is basically just a theme of OCD where someone is very preoccupied about, or really worried about being seen as a bad person. And it could be. There could be a religious undertone to it. So being worried about blasphemy and offending God and all that sort of stuff. It could be. These days we see it more in terms of people being really worried about their morals and values and upholding those morals and values and holding themselves to a really high standard. So it's quite internal.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

They might be worried that they've offended someone in a conversation and they might rehearse conversations in their mind to make sure that they haven't. Or they're worried that they might be seen as a bad person or that they've done the wrong thing or whatever else it might be. Which is why I agree with you wholeheartedly about teens. Because the perfectionistic kind of. Excuse me for describing it this way, but like the goody two shoes student who doesn't ruffle any feathers, who's kind of rule abiding and all that sort of stuff. Beautiful qualities to have as a person.

[Dr. Tori Miller]

Gorgeous.

[Dr. Celine Gelgich]

But it's okay to kind of mess it up a bit too.

[Dr. Tori Miller]

Yeah, that's right. You know, and there can be that tension in adolescence, isn't there, about, you know, the. The desire to be a bit Naughty. That can then leave someone who kind of identifies as being a good, sensible, moral person. Yes. It can leave them feeling very icky and uncomfortable about, you know, what does it mean? That I. Yeah. These noisy things.

[Dr. Celine Gelgich]

Yeah, exactly. Go out drinking with my friends.

[Dr. Tori Miller]

Yeah. That I lied to my mother.

[Dr. Celine Gelgich]

Yes. How do all of that. Yeah, exactly. So. So that's moral scrupulos. Yeah. Then we have ocpd. Obsessive Compulsive Personality Disorder. Similar. Very similar name to ocd, but couldn't be any more different.

[Dr. Tori Miller]

Agreed.

[Dr. Celine Gelgich]

It's treated differently. First and foremost, it's a personality disorder. It's not an anxiety or. It doesn't come under obsessive compulsive and related disorders, which is why we find it doesn't necessarily respond well to erp. Yeah, Some of it might be helpful, but not. Not really. First and foremost, OCPD can be seen as a really extreme form of perfectionism. And perfectionism in its broadest sense, not just aesthetically or liking things neat and tidy. It's also, again, morals, values, which is why we're talking about both of them together, because we want to tease apart. Well, what comes under moral scrupulosity and OCD versus rigidity around morals and values with ocpd. And so, yes, someone might hold themselves and others to a certain standard, like they might find it hard to finish work and let go of that. There might be a lot of perfectionism around that. Or they might. Yeah. Like the house, neat and tidy in some ways. But again, lots of inflexibility and rigidity around how that is. They might dress a certain way, act a certain way, get quite irritated and angry.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Quite easily. Because others aren't following the rules.

[Dr. Tori Miller]

Yes. There can be some righteousness, like, this is the. The right way. So that cognitive inflexibility, like, these are the rules. This is how it should be. I am right. It's strange that you don't live your life the same way.

[Dr. Celine Gelgich]

Yes, exactly. So you do see a lot of.

[Dr. Tori Miller]

That prickliness and an absence of doubt.

[Dr. Celine Gelgich]

Yes, there is an absence of doubt and much. Which means it's ego syntonic.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

So it's consistent with that person's values and beliefs versus the moral scrupulosity ocd, which is. There's still the ego dissonant nature around it. It's still quite inconsistent.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

So, yeah, we're dealing with something very different.

[Dr. Tori Miller]

Yeah, I think that's a. That's a really lovely distinction and I think, you know, really important one to make because it does impact how you treat.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And I think it's also. OCPD is a good differential to have in mind when treating someone with ocd, if there's a sense of stuckness or if you're having trouble during your assessment, kind of getting someone to identify where the distress is, you know, or if they've got a lack of willingness to change and things like that. Like, OCPD is a good differential to have in your mind. But maybe if we. If we come back to OCD and moral scrupulosity. I. I really enjoy working with my clients in relation to this theme, but what I do find, which I want to talk about with you, Celine, is that sometimes I find that clients have a reluctance to want to let this one go.

[Dr. Celine Gelgich]

Oh, yeah. Like. Yeah.

[Dr. Tori Miller]

Yeah. Because if we drill down.

[Dr. Celine Gelgich]

Right.

[Dr. Tori Miller]

As you were saying before, it stems from a place or a desire or of wanting to be a good person, which I think taps into something that is very understandable as a human being.

[Dr. Celine Gelgich]

Absolutely. Yeah.

[Dr. Tori Miller]

You know, the desire to be good, to treat others well, to not hurt anybody. You know, and I think there are some environmental factors, like if you've grown up in a family or in a culture that. That really values how you treat other people, if you've. If you've got a strong connection to community. Yes. Perhaps if you've had a religious upbringing, and so there's been a strong emphasis on morals. Right. Wrong. Good decision making. And if those are things that you value and that you think are important to you as a person, but also as a foundation to relationships, when you get to certain points in life where either you make a mistake or you start to feel some tension, perhaps competing values, like, I, you know, I. You know, I want to be there for my family, but I also, you know, want to work, you know, some extra hours or whatever, or as a teenager, you know, I want to be good and do my homework and like my parents have said, but also really want to go to this party, you know, I think that that can raise some. Just intense internal pressure and stress that can be very, very difficult for people with lots of anxiety or sort of predisposition to OCD to handle. And the compulsions then feel delicious in that moment for helping them to sort of relieve themselves of some of that internal pressure and distress.

[Dr. Celine Gelgich]

Yeah. And I think that tension, you described it so beautifully in toeing the line between those two things and trying to reconcile.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

That tension is where the treatments have.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Really, in terms. But it's. It's there, and it's so strong and and probably one of the themes where it's the strongest.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

For the reason that you described. I noticed that too. And it can be really hard for clients to, I guess, diffuse from.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

From that tension and kind of find that balance.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

And it's, and it's challenging, but not impossible in a sense that it just takes time.

[Dr. Tori Miller]

Agreed.

[Dr. Celine Gelgich]

Lots of conversation, lots of exposures.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Lots of testing the waters, like, you.

[Dr. Tori Miller]

Know, because I think there's like any theme that you're working with, there is the reduction of the compulsion, which is fine and good and important.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

But then there's the, the, the sort of the conceptual, you know, component that sits underneath, which is, as you say, like the, the reconciling of the tension and the navigating of as human beings and the kind of people we want to be and.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And how we move through this world. That also needs a lot of attention. It's not, it's not enough to just reduce doing compulsions. I mean, compulsions just pop up somewhere else if you haven't been able to reconcile this. But yeah, I see it a lot. In the teen group that we run, in our support group, this comes up so often because there is so much guilt that they carry. There is. They, they move through their, their lives with such good intention, but they're also incredibly fallible. In part because they're humans, in part because they're teenagers, you know, and they're.

[Dr. Celine Gelgich]

Trying to figure it out.

[Dr. Tori Miller]

They're trying to figure it out and they don't necessarily know exactly who they are yet. They're trying to be right to themselves, but good to others as well. And they're just all sitting with so much guilt in relation to, you know, how am I best friends with this person? But also, you know, yeah, you know, can I go to this party that my best friend wasn't invited to? Because I really want to go, but am I letting her down? And, and you know, I see a lot is also kids and teens who, you know, especially, you know, who feel like, you know, they're going against their parents wishes or they're starting to develop their own mind and starting to think things in opposition to their parents. And the guilt that they feel about that feeling that they're a bad person, which often leads to a lot of confessing, you know, oh my God, you wouldn't believe, you know, and it can be so awful. I mean, Penny Moody describes this beautifully in her book about the confessing she did to her mum. But one of my clients, oh, he was so tangled up because he kept confessing to his mum about his sexual development. And he just was so deeply embarrassed. Embarrassed and ashamed to be doing that. And he wanted to stop so badly, but he felt so guilty for what he thought was having, you know, impure, improper thoughts.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

He felt like his mum needed to know who he was and that he was letting her down. Yeah.

[Dr. Celine Gelgich]

It's so fascinating how it presents differently. Like, it's one thing. Right. But it shows up in so many different ways. A question I have for you. Just riffing off what you were describing before.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

And how teens feel. And I think a lot of adults feel the same way because there's a lot of adults who would confess to partners and sometimes still even their mums.

[Dr. Tori Miller]

Yeah, that's true.

[Dr. Celine Gelgich]

Calling their mum for confession time. Do you think the culture that we live in today with, like, social media and, you know, the whole cancel culture and all the rest of it, but also the discussion around political spheres and how strongly people are divided nowadays would influence a lot of that or kind of weighs in a little bit?

[Dr. Tori Miller]

I mean, it's got to.

[Dr. Celine Gelgich]

Right. Yeah.

[Dr. Tori Miller]

I can't. I can't imagine that it wouldn't.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Because I think that. I think that there's so much more anxiety about being caught out.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

I think on one hand, I think because cameras and videos are everywhere and people.

[Dr. Celine Gelgich]

I don't want to be the person on Tick Tock.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And I think, you know, that sense that, you know, that the risks feel higher, that once upon a time, if you made sort of an error or something kind of embarrassing, it would just, you know, eventually it would die with just the people who attended the party, and then it would move on. But now the fact that things get caught on camera, I think this shit lives forever. Right.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

So I do think it probably. Probably puts people more on edge. But I think you're also right in that it seems online because the nuance has gone out of a lot of people's positions because people are sort of presenting their elevator pictures all the time. So people. I think we're seeing people look like they have really, you know, clear morals, kind of more black and white, thinking right and wrong, which I think means that we're losing sort of touch with the art of ambiguity and gray and debate, which I think for people. Yeah. So I think for people with moral scrupulosity, it would be really difficult to be sitting with this sort of ambiguity in their minds and to be sitting in this gray and to not know, like, it's not being Modeled to them what to do with that, how to handle it. And actually that. That's a really normal thing.

[Dr. Celine Gelgich]

Yeah. Or whether they even have permission.

[Dr. Tori Miller]

Yeah. That you don't have to be all knowing all the time. Yeah.

[Dr. Celine Gelgich]

Because it feels like, you know, society doesn't give us permission to do that anymore.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Seemingly.

[Dr. Tori Miller]

Seemingly.

[Dr. Celine Gelgich]

Whereas in treatment we're like, no, you're allowed to be curious.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Stuff. You're allowed to think a little bit of this and a little bit of that.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Whatever else comes in.

[Dr. Tori Miller]

Yeah, that's right. Yeah. Yeah, yeah, yeah. Good question. That's really interesting.

[Dr. Celine Gelgich]

Would weigh into. Yeah, yeah.

[Dr. Tori Miller]

I can really. I could really imagine that being true.

[Dr. Celine Gelgich]

Especially for the youngies.

[Dr. Tori Miller]

Yeah, agreed.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Yeah. So we were talking about confessing being one of the compulsions. What else do you say?

[Dr. Celine Gelgich]

Confession for sure. The other one I see a lot of the time is comparison. Not just self and. Yeah. Self and others. I also see lots of rumination. Ruminations. A big one.

[Dr. Tori Miller]

So much.

[Dr. Celine Gelgich]

And it could look like anything. It could look like looking up things online to scanning conversations you've had in your own head or prepping conversations, which can then look a little bit like social anxiety as well. So that's a differential you've got to be mindful of in this space. And it can. For people who have religious undertones, it can look like lots of praying.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Asking for forgiveness and all that sort of stuff. Yeah. They're probably the more common ones that I noticed. Anything you want to add to that list?

[Dr. Tori Miller]

Maybe I'd add researching as well, particularly sort of scanning online, like Reddit forums and things.

[Dr. Celine Gelgich]

Opinions for others.

[Dr. Tori Miller]

Opinions. Looking for like minded people. Looking for validation or asking.

[Dr. Celine Gelgich]

Chat GPT. Validation. Chat GPT will validate anyone. Just over anything. Over anything. Yes. Everyone's right. Yep.

[Dr. Tori Miller]

And then.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Lots of reassurance seeking.

[Dr. Celine Gelgich]

Yeah. Yes.

[Dr. Tori Miller]

Yeah. So much reassurance seeking. Yeah. And then I think.

[Dr. Celine Gelgich]

Oh, the other one.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Over apologizing.

[Dr. Tori Miller]

Oh my gosh. Over apologizing. Yes.

[Dr. Celine Gelgich]

Just saying sorry all the time. It's like, stop saying sorry.

[Dr. Tori Miller]

Yes. They say such a big one.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Oh my gosh. And then also self monitoring as well. So that kind of preoccupation with action and what I'm doing, you know, to try to prevent anything bad from happening, which can make people very slow and hard to engage and because they're so stuck in their head sort of watching and monitoring as they do things.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Okay.

[Dr. Tori Miller]

So what do we do about it?

[Dr. Celine Gelgich]

I don't know. That's what you want to hear. What do we do about it? Well, first of all, like with anything we gather as much data as we can. But also because I think this one in particular needs a lot of psycho education because there's so much of it that's enmeshed with our clients value system and we talk about something being ego dystonic. There is an element of it that is, but not as clearly as it is with some of the other themes. Because like you mentioned before, there's so much of it that's tied with just generally just wanting to be a good person. Not being an asshole.

[Dr. Tori Miller]

Yeah. In the world.

[Dr. Celine Gelgich]

Like, you know, so providing lots of psychoed and giving lots of examples like, you know, do you ever find yourself over apologizing for things or rehearsing conversations in your mind? Like basically some of the stuff that we just listed off just before. So that means having an understanding of it for yourself too.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

As a clinician. And there are loads of great questionnaires out there. Like Jonathan Grayson's one in his book is a really good detailed one.

[Dr. Tori Miller]

I think that's a really good one too.

[Dr. Celine Gelgich]

Yeah. For clients to kind of go through where it just prompts them where insight might not be readily available.

[Dr. Tori Miller]

That's when I use it as well. Yeah, yeah.

[Dr. Celine Gelgich]

It's a good insight building one. And you've got some of your other ones too, which can be really helpful. But the more you collect that data with your client and just be openly curious about it, then spending time trying to engage in exposure tasks and some of that would feel really uncomfortable. And one, and it could look like, you know, writing the urge to ring and confess or writing the urge to apologize for something that you know you didn't do anything wrong for.

[Dr. Tori Miller]

Yeah. Resisting the urge to ruminate. Yes.

[Dr. Celine Gelgich]

Yeah, that's a big one.

[Dr. Tori Miller]

It could be writing down lies.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Writing down lies or telling lies.

[Dr. Celine Gelgich]

Do you know the other thing that we used to do in the hospital I used to work at? We'd get clients to write down what they really thought of us as the clinician team. You gotta have a thick skin.

[Dr. Tori Miller]

Oh my gosh, I want to do that in groove.

[Dr. Celine Gelgich]

Yeah, that would. Yeah, it would be really hard, but you'd love it. So basically we'd get them to write down what they really thought of us and fold it in half and then we'd read it away from them so they couldn't even gauge our reactions. And then we'd come back and be like, tell me how you really feel. Blah. Like that's great. So we did stuff like that too. You could be so creative with it.

[Dr. Tori Miller]

For people who are sort of struggling with perhaps like compulsive praying and things, who might identify as religious, it might be actually playing around with reading things, you know, that directly contradict the church or even sort of reading some content about Satan, for example, or, you know, as though.

[Dr. Celine Gelgich]

Yeah. You could even write 666 on a cue card and pop it all over your mirrors in the bathroom or something like that.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Or around the house, etc.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

With little post its and things.

[Dr. Tori Miller]

Yeah, yep.

[Dr. Celine Gelgich]

All sorts of things.

[Dr. Tori Miller]

Yeah. There's so. Yeah, yeah, you can get really creative. You like any of the. You can have the themes. Yeah, yeah.

[Dr. Celine Gelgich]

The other thing I was going to say was with exposures in this thing, one thing I. And I don't know how you feel about this, it can maybe lean into a little bit of reassurance. But I often tell my clients, like, you've got to remind yourself at the end of the day that we're doing this to push back against ocd. It doesn't define who you are as a person. We're not trying to change your value system.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

We're just bringing in some flexibility.

[Dr. Tori Miller]

But I think that's what, where, you know, what you're talking about before in relation to the, the tension. No, no, no. The psychoeducation.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

You know. Yeah, that, that's, that's what that component is about, is about. About understanding human development and what it means to be good versus bad. And that, you know, the philosophy. Philosophy of, you know, good people do bad things and bad people do good things and in. And all things in between and, and even just sort of, you know, exploring some of those philosophical sides of human development. Because I think that. So we can help our clients move away from that binary way of thinking. Yeah, yeah. And. And have a look, because I think you're right. Like it can start to tread on the territory of reassurance. So the provision of reassurance. But there is a component which I think our clients do become really fixated on the idea of our must be all good all the time. But in fact, I think sometimes we need to give them permission to be human.

[Dr. Celine Gelgich]

Absolutely.

[Dr. Tori Miller]

And to actually get them to think about, you know, you know, the idea of, you know, people that perhaps they've idealized in their lives and actually challenge the concept that they're all good all the time.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Like when we were growing up. I know the example that was given to me is Mother Teresa.

[Dr. Celine Gelgich]

Oh, yes.

[Dr. Tori Miller]

I think you Know what did someone say to me once? Even Mother. No, even Queen Elizabeth does poo on the toilet.

[Dr. Celine Gelgich]

Her stinks too.

[Dr. Tori Miller]

Her shit stinks too.

[Dr. Celine Gelgich]

Yeah, you know. Yes, it's true. Because to be human is to be messy. Like, we don't have pure perfect thoughts all the time.

[Dr. Tori Miller]

Yeah. Yeah, that's right. So I think that's where I think psycho education, I think, is really important. And I do know that some of my supervisors get really worried about that, about how to navigate reassurance versus psycho education. But as we always say, provide it. Provide it once and then notice if they keep coming back for more and more and more. And that's when you know that's the treatment. That's when you know that's when you pull back. So we've talked a lot about that, but we, we introduced OCPD at the beginning. Let's come, let's come back around to ocpd.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Just as a reminder, we're talking about a personality disorder here. So very different to what Tori and I have just got kind of spoken about in terms of treating it, what to be mindful of, etc. OCPD looks very much like, I'm gonna say probably what people use to describe ocd who have no idea what OCD actually is.

[Dr. Tori Miller]

Yes. Because they're like, so ocd.

[Dr. Celine Gelgich]

Yes. They're probably actually referring to ocpd.

[Dr. Tori Miller]

More, far more.

[Dr. Celine Gelgich]

Really intense perfectionist who likes doing things a certain way, who has certain rules and rigidity around certain things. How the house needs to look, how they dress, their own morals and values. And you often hear. And they'll often present to treatment because it's the people around them that are struggling and want them to get treatment as opposed to them themselves. They'll often say, well, if someone just followed the rules. Yeah, then it would be fine.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

So it's from a treatment perspective, we're often bringing things in like schema therapy approaches, DBT approaches, and some act based approaches to kind of help.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Introduce flexibility, but in a different way.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

And like you said before, it's less about intrusive thoughts and compulsions. It's more about rigidity and behaviors around wanting control.

[Dr. Tori Miller]

Yeah, that's right.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And thinking about, thinking about the areas of their lives where their rigidity is impacting on what they want from their life. So maybe it's impacting their marriage or maybe it's making them late for work all the time or it's making them actually really unproductive at work because they're, you know, Going over emails over and over and over again to make it perfect. So they're not.

[Dr. Celine Gelgich]

Could be impacting their relationship with their kids.

[Dr. Tori Miller]

Yeah, yeah. And so then the work is, is. Is more around flexibility in thinking, but also in behavior to nurture those aspects of their life that they want to see some change in, rather than insisting that it is the world around them that changes for them.

[Dr. Celine Gelgich]

That's right. So you'd probably bring in some interpersonal skill like all the DBT stuff around that too.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

And being able to manage those behaviors, but also relational struggles as well.

[Dr. Tori Miller]

Yeah, that'll happen as well. Yeah.

[Dr. Celine Gelgich]

Typical of any other people.

[Dr. Tori Miller]

Yeah, that's right. And I think what's tricky with OCPD is that oftentimes people, people don't necessarily present for treatment with OCPD unless they perhaps have been really encouraged by a family member or there are some co occurring difficulties that have brought them in. Because oftentimes they're quite content in their world with things though. And they're often do tend to think in a way that sort of suggests that the people around them are the ones that need to change. Which actually means that they don't necessarily see a reason for therapy or a rationale for change.

[Dr. Celine Gelgich]

Exactly.

[Dr. Tori Miller]

But still it can still turn up in the room. So it's really good to watch.

[Dr. Celine Gelgich]

For sure.

[Dr. Tori Miller]

Yeah. Because we can get stuck down a rabbit hole. I think in my experience what it sort of sometimes manifests as, it looks like moral scrupulosity and it looks like an anxious presentation, like I've got to get this right, it's got to be perfect, I've got to go to God, I got to, got to do it. Right. But then they're completely reluctant to engage in ERP and you can just get stuck in motivational interviewing and try.

[Dr. Celine Gelgich]

Why not? And why.

[Dr. Tori Miller]

Yeah, that's right. And you know, and just go round and round in circles trying to convince them to engage in erp when in fact you. It actually is an ERP that you need to be doing because it's not actually ocd.

[Dr. Celine Gelgich]

Yeah, that's right. But I think something else to kind of highlight would be what you mentioned before in terms of the co occurring conditions. It's highly co occurring with ocd.

[Dr. Tori Miller]

Yes, you can have both.

[Dr. Celine Gelgich]

Yeah, you can have both. So not to freak anyone out.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

The freaky part for me, and I've had a couple of clients like this a lot actually over the years is when moral scrupulosity feeds off OCPD and the interplay between those two is so sticky and so messy.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

And your client just finds them so like, you know, there's the moral scrupulosity, which kind of is there to make them feel a bit less of an a hole. And then I said asshole before I know why I'm saying a hole now. And then. And then the OCPD kicks off and it's just like they're just in this ball of twine and you don't even know where to start pulling it apart from. So I think the only thing that really helps is supervision or bouncing your idea, like formulation off with your colleagues.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

But at the same time, like, it will co occur with OCD up to about 35%, so it's fairly decent.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

The other question that's coming up more recently is, is it OCPD or is it autism? But I think that's another episode, so that one.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

But yeah, it's just one of those things that we just need to be mindful of.

[Dr. Tori Miller]

Yeah, absolutely. And in my experience, what I've found is trusting, transparent relationships and, and conversations with your client about this.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And. And to have confidence as a clinician to. To not be all knowing and to not feel like, you know, you've got to sit behind this wall as though, you know everything. And to. To say to your client, you know, what I'm wondering and what I'm noticing is, and what I see us getting stuck on and the things that I'm observing is that there's this sort of, you know, cycle going round or, you know, I'm. I wonder, have you heard about ocpd? It's just on my mind a bit at the moment that maybe this is sort of fueling some of the stuckness that's more complex than just OCD here. And I think that it is okay to have these sorts of conversations with our clients. And then if. If it does end up being diagnosed and that is then the, you know, the, the formulation, then. Then you can start saying, hey, what are we dealing with in this moment? Yeah, you know, call it out, call it out. Where are we at? I'm sensing some rigidity here. Is that from a place of fear? Have. Have we triggered something today in this conversation that's making you want to com, you know, engage in some compulsions and avoid. Or am I talking to your intellectual rigid self who's kind of coming, going, tori, you don't know what the fuck you're talking about? Yeah, I know better than you. And actually, you know, this is the right way to be doing things and this is why. Yeah, yeah. And then, you know, dialogue about it.

[Dr. Celine Gelgich]

Yeah. Beautiful. I love that.

[Dr. Tori Miller]

Yeah. Yeah, yeah. We should wrap up. We could go on and on and on and on and on.

[Dr. Celine Gelgich]

Oh, we could talk about this forever.

[Dr. Tori Miller]

Yeah.

[Dr. Celine Gelgich]

Okay.

[Dr. Tori Miller]

All right. Good one.

[Dr. Celine Gelgich]

Thank you so much for your wonderful insights as always.

[Dr. Tori Miller]

You too, Seline.

[Dr. Celine Gelgich]

Thanks guys for watching and listening. Stay tuned for the next episode.

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