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

Episode: Perinatal Mental Health and OCD
Hosts: Dr. Celin Gelgec (B), Dr. Victoria Miller (C)
Date: December 1, 2025

Episode Overview

This episode explores the unique challenges and approaches involved in treating Obsessive Compulsive Disorder (OCD) during the perinatal period. Dr. Celin Gelgec and Dr. Victoria Miller discuss the vulnerability that new and expectant parents face, how OCD can capitalize on this, and how clinicians can provide meaningful, compassionate, and effective support during this critical time. They focus on clinician self-awareness, psychoeducation, practical planning, and the importance of creating a collaborative and nonjudgmental therapeutic space.

Key Discussion Points & Insights

1. The Vulnerability of the Perinatal Period (02:22 – 04:45)

• The perinatal period (before and after birth) is an especially vulnerable time for both mothers and fathers.
• OCD can "love that vulnerability," often seizing on the major changes and anxieties around parenthood.
• Not just postpartum, but conception and recovery periods are all considered high-risk for OCD flare-ups.

Notable Quote:
"OCD just bloody loves that vulnerability." – Dr. Victoria Miller (03:09)

2. Therapy Experience: A Dividing Line (04:45 – 07:26)

• Clients with prior therapy experience are generally better equipped to recognize and articulate OCD symptoms if they emerge during the perinatal period.
• Those without previous therapy often feel more blindsided and face increased difficulty identifying and disclosing intrusive thoughts.
• Time pressure (upcoming birth) intensifies the drive to “fix” issues quickly.

Notable Quote:
"It hits them harder... it's more difficult for them to understand what it is they're experiencing and why, while there's this enormous pressure which is: baby is coming, or baby is here." – Dr. Victoria Miller (06:12)

3. The Nature of Intrusive Thoughts & Barriers to Disclosure (07:44 – 11:27)

• Intrusive thoughts in new parents can be extremely distressing (e.g., harming the baby, contamination, or sexual themes) and are often accompanied by intense shame.
• Clients may lack the language to distinguish between intrusive thoughts and intentions, leading to increased fear, secrecy, and self-stigma.

Memorable Moment:
Examples of harm thoughts:

• "I'm having intrusive thoughts about just smashing my baby's head against the counter every time it cries..." (08:10)
• Highlighting the importance of clinicians normalizing distressing thoughts to reduce shame and encourage disclosure.

4. Psychoeducation and Building Safety (11:27 – 12:27)

• Early, overt psychoeducation is crucial—prepares clients for possible symptoms and normalizes the experience.
• Building trust ensures clients feel safe to share their distress without fear of judgment or repercussions.

Notable Quote:
"We can offer a lot in terms of providing psychoeducation about what to expect and what is okay for them to tell us." – Dr. Victoria Miller (10:48)

5. Dealing with Shame and the Importance of Open Dialogue (12:33 – 14:24)

• Even with strong rapport, shame around perinatal OCD can inhibit clients from disclosing new or deeply stigmatized symptoms.
• Clinicians must actively invite discussion about these experiences rather than waiting for clients to bring them up.

Notable Quote:
"The more rapport you have, the more afraid your client will be sometimes to bring stuff... there's a bigger vulnerability there." – Dr. Celin Gelgec (14:07)

6. Clinician Self-Reflection and Managing Internal Reactions (14:25 – 16:28)

• Clinicians must be aware of their own biases, discomfort, and reactions to confronting intrusive thoughts—clients are intuitive to these cues.
• It's crucial to be "alert but not alarmed" and understand the ego-dystonic nature of OCD.

Notable Quote:
"...the phrase you use is 'alert but not alarmed'." – Dr. Celin Gelgec (16:09)

7. Proper Assessment and Avoiding Harmful Reactions (16:28 – 20:41)

• Be diligent in assessing risk, but avoid alarmist reactions that could worsen symptoms or damage trust.
• Anecdote: A previous therapist’s inappropriate response to sexual harm obsessions resulted in trauma for the client, underlining the cost of misunderstanding OCD.

Memorable Moment:
"A client... had thoughts about harming his children in a sexual way and the therapist told him to bring his wife to the next session. [The therapist said,] 'I'm concerned for the welfare of your children. You need to call the police. You need to remove your children from your husband.'... It was just intrusive thoughts." – Dr. Celin Gelgec (16:45)

8. Practical Strategies for Perinatal OCD Care (20:41 – 27:20)

• Increase session frequency to support clients during pregnancy and after birth.
• Proactively schedule sessions around due dates and early postpartum periods—even brief telehealth check-ins can be invaluable.
• Coordinate care with medical professionals (GPs, obstetricians) to enhance support.
• Be flexible about having babies in therapy—allows exposure work and can reduce barriers to treatment attendance.

Memorable Moment:
"I love having babies in therapy. I love it. Yeah, I'm so open to that." – Dr. Celin Gelgec (23:32)

9. Exposures and Using Real-Life Context (26:01 – 27:20)

• Including the baby in therapy sessions facilitates exposures relevant to the client’s obsessions (e.g., feeding, changing, managing fears around SIDS or harm).
• Flexibility and client autonomy: support clients’ preferences regarding bringing their baby to sessions.

Notable Quote:
"If a new parent is having intrusive thoughts about sort of pedophilic themes, harm themes, contamination themes...having baby in therapy is actually really helpful." – Dr. Victoria Miller (26:26)

10. Building the “Village” and Sustained Support (28:01 – 30:49)

• Therapy can and should integrate both reflective space and proactive, practical planning.
• Clinicians help parents construct and maintain a support network—"the village"—before and after birth, including boundaries, connection, and collaborative care.

Notable Quote:
"That really is part of that process of creating the village around parents... help them feel supported... helping them manage boundaries, helping them manage their treatment..." – Dr. Celin Gelgec (29:08)

Final Reflections (30:24 – 30:39)

• The perinatal period is both special and chaotic for parents.
• Clinicians have a vital role in grounding clients, offering both reflective and practical support, and navigating the complexity with compassion and confidence.

Closing Quote:
"I hope that that helps clinicians feel a little bit more grounded in what the role is... during this time and things to watch out for and spaces to take for therapy." – Dr. Victoria Miller (30:28)

Summary Table: Key Takeaways, Moments & Timestamps

| Segment | Topic / Message | Notable Quote/Speaker | Timestamp | |------------------------|-----------------------------------------------------------|----------------------------------|-------------| | Perinatal Vulnerability| OCD loves the vulnerability of this life stage | "OCD just bloody loves that vulnerability." – C | 03:09 | | Therapy Experience | Prior therapy helps, pressure intensifies symptoms | — | 06:12 | | Intrusive Thoughts | Disclosure is hard, language often missing | — | 08:10 | | Psychoeducation | Normalizing thoughts, encouraging openness | "We can offer...psychoeducation..." – C | 10:48 | | Shame barrier | Rapport may hinder disclosure | "The more rapport you have..." – B | 14:07 | | Clinician Self-Work | Alert but not alarmed | "Alert but not alarmed" – B | 16:09 | | Mistaken reactions | Importance of assessment vs. alarmism | Client anecdote – B | 16:45 | | Practical Strategies | Frequency, advanced scheduling, medical collaboration | — | 21:04+ | | Babies in Sessions | Encouraged for flexibility and exposures | "I love having babies in therapy." – B | 23:32 | | Building the Village | Ongoing support system after birth | "That really is part of...creating the village..." – B | 29:08 | | Clinician Role | Blend reflection, direction, and care | — | 30:28 |

Concluding Thoughts

This episode is an invaluable listen for clinicians working with perinatal populations. Gelgec and Miller deftly combine clinical wisdom, empathy, and real-world strategies—demystifying common OCD presentations and emphasizing the centrality of curiosity, normalizing, and genuine support. Their reflections on clinician self-care, collaborative planning, and advocacy for client autonomy offer listeners both reassurance and practical direction in navigating the complex, emotion-charged perinatal landscape.