The Complexities of ERP Therapy

Summary

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

Episode: The Complexities of ERP Therapy
Hosts: Dr. Celine Gelgec & Dr. Tori Miller
Date: October 6, 2025

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Episode Overview

This episode explores the complexities, boundaries, and ethical considerations of Exposure and Response Prevention (ERP) therapy for OCD. Dr. Celine Gelgec and Dr. Tori Miller discuss the perennial clinician question: How far is too far with ERP? They dissect misconceptions, share personal clinical stories, and offer practical guidance on developing therapist-client trust, reading therapeutic cues, and ensuring exposure tasks are both effective and collaborative.

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Key Discussion Points & Insights

1. The “How Far is Too Far?” Question

• Inspired by a student’s concern regarding a university lecturer bringing a chef’s knife into class for an ERP demonstration (02:23).
• Addresses myths about ERP being “cruel” or “confronting.”
• Dr. Gelgec notes that, while extreme exposures are sometimes part of ERP, "With context, obviously" (03:08), effective implementation is always ethical and carefully considered.

2. Understanding OCD: Ego Dystonic vs. Ego Syntonic

• Effective ERP hinges on recognizing that OCD thoughts are ego dystonic (in conflict with personal values).
• Dr. Miller:

  “It is about the ego syntonic versus the ego dystonic nature…It’s about the distress that it is causing for them. It’s about the existential nature, the conflict…” (05:44)

• Contrasts this with ego syntonic thoughts (e.g., revenge or justified anger), emphasizing the therapist’s role in discerning intent and distress signals.

3. Trust and Assessment in ERP

• Trust in the client is key—clinicians rely on clinical intuition, assessment, and observing emotional dynamics.
• Dr. Miller:

  “I could put a knife in their hands or I could get them to put a…to my throat and…nothing would happen.” (08:23)

• Highlights the clinician’s critical role in “reading the room” emotionally and physically (08:39).

4. Empowerment, Playfulness, and Progress

• Exposure work, when built on trust, can even become “playful”—not sadistic, but joyful in tracking progress as OCD weakens (09:00-09:43).
• Dr. Miller:

  “I’m enjoying seeing OCD suffer. I am enjoying knowing that…this moment is going to amount to something really...” (09:35)

5. Collaboration and Consent

• Ethical ERP is always collaborative.
• Dr. Gelgec:

  “How about you ask your clients? Because it’s their OCD and it needs to be relevant for them…” (14:10)

• Dr. Miller adds that exposure tasks must be consensual, not imposed:

  “We’re not doing exposure to them…as much as we need there to be spontaneity and flexibility, it needs to be worked out with our clients.” (15:20)

6. Parental Roles and Reducing Accommodations

• Discusses nuance when parents reduce signals or behaviors that accommodate a child’s OCD (17:14-17:28).
• The distinction: parents adjust their behavior (reducing accommodation), not force exposure on the child.

7. Navigating Client Readiness & Avoidance

• Encouraging without forcing—balancing assertiveness and respect for readiness.
• Dr. Gelgec:

  “You might not want to do this yet, but it’s on your trigger list…How can we break this up and make it messy?” (21:21)

• Recognizing when resistance is OCD talking, not the client:

  “Know when you’re talking to your clients and know when you’re talking to OCD.” (22:24)

8. Handling Client Distress in Session

• What to do when a client is overwhelmed by exposure:
  • Go straight to grounding, observe, reflect, and check in with the client for next steps (25:28-27:36).
• Dr. Celine:

  “We got this…lots of grounding. I head straight into grounding…What can you see? What can you feel? What is OCD telling you?” (25:38)

9. Safety, Panic, and Therapist as Anchor

• Panic and distress are not dangerous in ERP; therapists should “anchor” the session with grounded presence (28:22-28:39).
• Dr. Celine:

  “If we react to it, we’re teaching our clients it’s scary…We become their anchor…to hold the space, hear it, let it breathe, and regulate.” (28:30-28:55)

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Notable Quotes & Memorable Moments

• On Learning from Experience:
  Dr. Gelgec:

  “I’ve often said this is karma for the last 15 years, exposure therapy with clients.” (01:06)

• On Trust and Assessment:
  Dr. Miller:

  “It’s the way conversations like that feel are really different to conversations that you have with someone who has OCD because they don’t want to actually be engaging in these thoughts.” (07:14)

• On Playfulness in ERP:
  Dr. Miller:

  “My clients sometimes describe me as like, that I seem gleeful when I’m…doing exposure work. Not because I'm enjoying their distress, but…enjoying seeing OCD suffer.” (09:20-09:35)

• On Client Ownership:
  Dr. Gelgec:

  “There’s much more ownership over that…motivation and want, as opposed to us telling them.” (19:01)

• On Therapist Collaboration:
  Dr. Miller:

  “We need our clients to be in charge and to recognize that they can choose and they can follow through on these…that we’re just there to champion them and cheer them on.” (19:12)

• On Anchoring Through Distress:
  Dr. Gelgec:

  “We become their anchor to then be able to provide the space, hold the space, hear it, let it breathe and regulate. And that's co-regulation.” (28:39-28:58)

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Timestamps for Key Segments

• [02:23] – Introduction to the “knife in the room” exposure scenario.
• [04:25] – Clinical story: Supervisor lets a client hold her baby to challenge harm obsessions.
• [05:44] – Ego dystonic vs. syntonic discussion—how it impacts exposure safety.
• [09:00] – The role of playfulness and joy in effective ERP.
• [14:10] – The call for collaborative, individualized exposure tasks.
• [17:14] – Ethics: Parental roles in accommodation and exposure.
• [21:21] – Navigating client resistance and encouraging ownership.
• [25:28] – Managing distress: deciding when to push or pause exposure.
• [28:22] – Fear is not dangerous: importance of therapist as anchor.

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Episode Summary

• Effective ERP is highly individualized, contextual, and collaborative.
• Trust, ongoing assessment, and clinical intuition are essential for safety and progress.
• How far is too far? Ultimately depends on consent, collaboration, and the therapist’s ability to distinguish between client values and OCD-driven resistance.
• Distress is expected but not dangerous—therapists should ground clients, not avoid difficult exposures.
• The goal: Empower clients to become their own therapists and break the cycle of OCD.

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For clinicians new to OCD: trust the process, partner with your client, and know that ERP—when done right—is not about cruelty, but empowerment and transformation.

Transcript

[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. Hello, Celine.

[Dr. Celine Gelgich]

Hello. How are you?

[Dr. Tori Miller]

Yeah, I'm good.

[Dr. Celine Gelgich]

Welcome back, welcome back.

[Dr. Tori Miller]

It's good to be back in our new space.

[Dr. Celine Gelgich]

I know, it's so exciting. I don't think I'm going to get used to it ever. But practice what we preach, right?

[Dr. Tori Miller]

Sit in the discomfort, right?

[Dr. Celine Gelgich]

Yes. Lots of it. This is very different to being in our studies.

[Dr. Tori Miller]

I know. I always imagine in the moments like this that clients that I work with and like.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Suffer.

[Dr. Celine Gelgich]

Yeah. Oh, my God, totally. Sit in it.

[Dr. Tori Miller]

Sit in it.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

I've often said this is karma. For the last 15 years, exposure therapy with clients. Oh, my goodness. What are we talking about today?

[Dr. Tori Miller]

So it's a bit of context. We had a meeting the other day, didn't we?

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

And you raised this beautiful question about how far is too far? And the question come actually had been asked by one of our students. Yes. At the clinic, which I think is a really, really good question because I think for people who don't work with OCD a lot or don't have a lot of experience with erp, I think it is something that they can feel quite anxious about. I think that sometimes there's perhaps a misconception that ERP is quite cruel or really confronting. And I suppose this is an opportunity for us to kind of clear the air. Yeah. Dispel some of those myths and talk about. About what ERP actually looks like and how far we actually go and how we navigate those boundaries and. And for each client, make that decision about, you know, what's. How far is too far and when is enough enough.

[Dr. Celine Gelgich]

Yeah, let's jump in.

[Unidentified Participant]

Yeah. All right.

[Dr. Celine Gelgich]

So a little bit more background when our student was talking to us, provided the example of their uni lecturer coming into their OCD lecture with a chef's knife and talking about doing an exposure while that knife was being held to their throat. And there was a bit of an uproar in the class, understandably, because it's pretty full on and very confronting. It's the last thing you would expect your lecturer to Walk in with a chef's knife into a lecture. And so the question was, how far do you go with ERP and is doing something like that? Okay. And my short answer response was, yeah, we've done it heaps of times.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

With context, obviously. And then we talked about the uproar of. And I think this would probably be an interesting place to start from, was the lack of understanding what actually. What OCD actually is.

[Unidentified Participant]

Yeah. Yeah.

[Dr. Celine Gelgich]

And I think that can bring up a lot of anxiety within us as a clinician in terms of if we're not working, like you said earlier, if we're not working with it a lot and we don't see we're not exposed to the frequent, I guess, reassurance for us as clinicians in terms of the ego dystonic nature of it, which is the inconsistency with their values and beliefs, the level of distress clients have, the sheer terror, the panic, the fear, etc. I remember my supervisor telling me that one of her. When I was very early career, I think I was like two or three years out, she had just had a baby. And so one of her clients had a fear of harming children. So she took her child into therapy and allowed the client to hold her baby with these intrusive thoughts for the duration of the session. And the client was in tears and all this sort of stuff, but also incredibly grateful.

[Dr. Tori Miller]

That's amazing.

[Dr. Celine Gelgich]

For trusting her with that and that my. I remember my supervisor was saying, I don't like the trust is there because it's the last thing you would do.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And so I think being able to have those. When we truly understand what OCD is actually about, our actions as therapists are actually quite empowering. Yes. Reassuring in their own way, which people can get caught up in the reassurance trap.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

But indirectly, it helps build that evidence to go, you can trust your. We need to. I'm trusting you on behalf of yourself to be able to then trust your own judgment again.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Yeah. So how do we. I think maybe it might be helpful to launch into that a little bit in terms of truly understanding what OCD is. Like, what makes you feel comfortable knowing, like, once you've done your assessment and stuff.

[Dr. Tori Miller]

Oh, good question. Like actually bringing, like a knife into a room or if that was me for the client.

[Dr. Celine Gelgich]

Yeah. Like, what would make you feel assured as a clinician?

[Unidentified Participant]

Well.

[Dr. Tori Miller]

Oh, that's so good. How do I unpack that? That sense of trust that I've got in the room? Because it is more than just filling out the why box and just looking like a Y box score, isn't it?

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Do you know what it is? You're right. It's about the ego syntonic versus the ego dystonic nature. It is about the way that our clients talk about what's going through their minds. It's about the distress that it is causing for them. It's about the existential nature, the conflict of being someone who is plagued with thoughts of what if I hurt someone? And just how much conflict and the internal dilemma of that. I. I want to think of myself as a good person. My. My desire as a person in this world is to. Is to help people grow and thrive. I want to love my family. I want to be the best mom or the best wife there is. So why am I having these thoughts? There must be something wrong with me. And so it's that. I think it's the dynamic in the room. You know, it's the way that it feels with these clients who are so conflicted and so. So terrorized by the what ifs that makes me feel very confident that it is, in fact, incredibly ego dystonic. Whereas when you talk with someone, if anyone has had experience with perhaps forensic clients or someone who perhaps was having fantasies about hurting somebody, it's a very different experience in the room.

[Dr. Celine Gelgich]

It really is.

[Dr. Tori Miller]

The thoughts aren't actually ego dystonic. They're very much ego syntonic. They're inviting the thoughts. They're enjoying engaging with the thoughts. And that's not necessarily with someone who might have intent to cause harm. It might even be the rage that someone feels after a breakup. I hope. Yeah, them and their new partner. I hope they, you know, get hit by a car or something. You know, I remember someone a really long time ago talking about they had had just this awful thing happen to them at work with their boss. It had been absolutely terrible, and boss had then subsequently gone and. And I think maybe had developed a brain tumor or something like that and then end up in a terrible car accident. And she was almost gleeful because she, you know, it was just. It was just grief, and it was. It was like karma. Yes, karma, you know, revenge. Absolutely. So she didn't actually necessarily want something bad to happen, but she was kind of gleeful about it. And so the way conversations like that feel are really different to conversations that you have with someone who has ocd because they don't want to actually be engaging in these thoughts. And they. If they would. Honestly, sometimes I think our clients would. Would gladly have a frontal lobotomy if.

[Dr. Celine Gelgich]

Totally.

[Unidentified Participant]

Yeah. Yeah.

[Dr. Tori Miller]

If they could continue to function.

[Unidentified Participant]

Yes.

[Dr. Tori Miller]

They could just cut out all of that thinking.

[Dr. Celine Gelgich]

They would. Yeah, they would.

[Dr. Tori Miller]

So I think that that's how I make my decision with my clients and how I feel like I trust them and feel really confident that I could put a knife in their hands or I could get them to put a. To my throat and. And nothing would happen.

[Unidentified Participant]

Yeah, yeah, yeah, yeah.

[Dr. Celine Gelgich]

Using the room as a barometer. Yeah, I guess to kind of gauge.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Where that sits. Yeah, absolutely. You articulated that really well. Thanks. Way better articulation than I can, but.

[Dr. Tori Miller]

Yeah, but I think. I think that when you really understand OCD as being like, you know, experiencing it that way.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

I think that then it's really easy to trust. It's actually not hard to sit in the room with someone with ocd. And in fact, I think that's why. I mean, we often end up feeling like exposure work is very playful.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Because I don't know about you. I mean, my clients sometimes describe me as like, that I seem gleeful when I'm.

[Dr. Celine Gelgich]

Or sadistic when I'm doing like, you're enjoying this way too much. Yeah, I'm not.

[Dr. Tori Miller]

I. I am kind of enjoying it, actually. Not because I'm enjoying their distress, but because I am enjoying the progress that we're making.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

I'm enjoying seeing OCD suffer. I am enjoying knowing that. That this moment is going to amount to something really.

[Dr. Celine Gelgich]

It's going to empower our client.

[Unidentified Participant]

Right.

[Dr. Celine Gelgich]

And make them.

[Dr. Tori Miller]

So that's. I'm not. I'm not enjoying the playful about the terror. I'm really like. I'm loving the fact that.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

That they're going to get better because of this.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

So it actually. Yeah. So it actually isn't really a hard question to sort of answer about, like, safety and all of that sort of stuff when you really understand ocd.

[Dr. Celine Gelgich]

Absolutely.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Our clients with OCD are the last person or with the. On the planet that they're going to do.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Whatever it is that their thoughts say or indicate that they're going to do.

[Unidentified Participant]

Yeah, that's right. Yeah.

[Dr. Celine Gelgich]

And you have. You've articulated that so beautifully in terms of. It is a different conversation. And it feels. Feels different emotionally, too, as a clinician. Like, you don't feel icky inside and you don't feel nervous. I mean, you might feel a little bit nervous going, well, where is this going when a client first discloses their intrusive thoughts.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Once they start feeling safe. But it's once they keep talking. That nervousness dissipates quite quickly.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Because you can be assured in your own assessment and your own judgment going, okay, yeah, I can. And depending on the background we have as therapists, too, I think if you're coming from. If you're a clinician who works a lot more with trauma or family violence and these sorts of things, I think the alarm bells ring a lot stronger. So there might be a little seed of doubt in there, but trust the conversations that you're having and how it's feeling and pay attention to your body, I guess, ground yourself in that moment and really pay attention to what's going on physically in your own body to read the room as opposed to getting caught up in the thoughts.

[Dr. Tori Miller]

Yeah.

[Unidentified Participant]

Think.

[Dr. Tori Miller]

I think in that, you know, take your assessment. If you are sitting with some alarm bells, take the assessment a little bit further.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And go beyond just what they've said, the content of their thoughts.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Go further and say, how does it feel to have these thoughts? What's it. What's it like? What does it. Motive like? What does it make you want to do? Because what you'll discover with someone with OCD is they'll say that the thoughts make them feel wretched and the choices that they want to make, the behavior that they want to do, is that they want to hide at home, they want to lock the knives away, they want to protect at all costs.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Whereas someone who doesn't have ocd, where actually there might be a bit of risk there, where you need to listen to those alarm bells, they might not actually have safety behaviors in mind. They might feel very justified in their thinking. And so a little bit of further assessment really is all you need to.

[Dr. Celine Gelgich]

Really tease it up, that extra curiosity. Yeah, absolutely.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

I think, too, being able to check in with our clients and asking questions around, just an extension of what you were saying in terms of what's going on for them. Because I know a lot of clients for the. Out of fear that they're going to follow through with whatever the thought is that they need to. That they themselves worry if they're enjoying it or want it or bring on the thoughts or some of them will even sometimes follow through with a compulsion just to check.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

To see if they still feel morally sick about it or if they feel disgusted or whatever else it is that's coming up for them. So it's these sorts of. Because I can imagine if you don't work with it a lot, a client saying to you. Yeah, but I'm worried That I had an arousal response or I'm worried that whatever else it is, you know, and I feel the need to check can seem scary as well. So I guess that leads us into how far is too far with exposure.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

In a sense of how do we construct them, which we've touched on before in the past, but from an ethical perspective.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

I don't know about you. I think I feel like we work fairly similarly in terms of our approach with this, but for me, it's usually around really collaborating with our clients and making sure they're part of that process when it comes to putting together the exposure tasks. I often hear, especially on Facebook forums and stuff that I'm a part of with clinicians who work overseas and stuff, asking for advice on what kind of exposures would you do for contamination, OCD or harm ocd or pedophilic ocd or whatever else it might be. And I'm often responding, going, how about you ask your clients? Because it's their OCD and it needs to be relevant for them and realistic in order for it to hit home, as opposed to feeling like you need to do it to your clients. It's. For me, it's something we do with our clients.

[Dr. Tori Miller]

Yeah, that's right.

[Dr. Celine Gelgich]

I feel like you work very similarly in that.

[Unidentified Participant]

I agree.

[Dr. Tori Miller]

I mean, if we keep going with that example of, like, the knife, Right.

[Unidentified Participant]

Yes. Is that.

[Dr. Tori Miller]

At the. Like, randomly sort of just bringing in a knife and being like, hey, here's a knife on the coffee table, and you just have to kind of deal with it in session? Today has relevance. If what you've discussed with your client is that their fear is about what if a knife is suddenly, like, they go to a friend's house and they're not going to a friend's house, because what if they're in an uncontrolled environment and a knife comes out and they're sitting on the bench and they're sitting next to it, and that makes them not want to go to their friend's house. And so what you've agreed upon is that you'll do an exposure about spontaneously being near knives, and then one day there might just be one in therapy, and they have to keep walking through that door every day not knowing whether today there will or won't be a real trigger. But just. But I think you're right. It's got to be collaborative. It's got to be collaborative.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And it's also got to be consensual.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Because our clients have to be willing. We're not doing exposure to them.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

As much as we need there to be spontaneity and flexibility, it needs to be worked out with our clients. Like, I remember a time where one of my younger clients had emailed me during the week, and I honestly, just. Out of just sheer volume of work that I had that week, I just didn't have time to reply in a timely manner.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And in the meantime, she'd gone to check in with her school psychologist because she. She wasn't doing very well, which is why she'd reached out, just wanting some sort of comfort, really. And. And she spoke to the school psychologist, and she was saying to the school psychologist, I think Tori is doing exposure to me by not. I know.

[Dr. Celine Gelgich]

It's the inad.

[Dr. Tori Miller]

I know.

[Dr. Celine Gelgich]

Right. It's the assumption she made.

[Unidentified Participant]

Yeah, that's right. That.

[Dr. Tori Miller]

That somehow, like, I was. I was working my ERP magic in this moment so that she would learn to be less dependent on me. And she just have to sit with the not knowing about whether I cared or not. And she brought that up with me, and I'm really glad that she did, and I'm glad that her school psychologist encouraged her to.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Because the truth was, I. I just.

[Dr. Celine Gelgich]

That wasn't the intention.

[Dr. Tori Miller]

That wasn't the intention. And we hadn't agreed to that as a. An exposure strategy, and we hadn't agree that that would be something that I would do to sit with the discomfort. And exposure is not something that we don't take charge of and say, you have to do this and you have to do that, and I'm just gonna start whipping you because.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

You know, that's what you need to do.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Your OCD has to go. Yeah, It's. It needs. Our clients need to consent. Now, the. The difference with that. Probably the only line that I would say there, where it's different is when we're talking about parents reducing accommodations, because that is a different kettle of fish.

[Dr. Celine Gelgich]

Right.

[Dr. Tori Miller]

That is where totally the parents are in charge of reducing the behaviors that they are involved in. But even then.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

They're not making their child do.

[Dr. Celine Gelgich]

No, that's right.

[Unidentified Participant]

Anything. It's.

[Dr. Tori Miller]

It's.

[Dr. Celine Gelgich]

Again, it's still considering control of their own behavior.

[Dr. Tori Miller]

They are reducing the compulsions that they are engaged in. So that's probably the only.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Again, a bit of nuance. But I think, you know, I think a lot of clients talk about when they come into the ERP space, and I think some clinicians who haven't got a lot of experience talk about, well, am I supposed to just do this to my client and they just have to kind of sit there and bear it or clients are worried if I start. Erp, are you just going to randomly, you know, just kind of bring out vomit one day or are you just going to, you know, make me stick.

[Dr. Celine Gelgich]

My hands in the toilet water?

[Dr. Tori Miller]

Yeah, yeah, that's right. That one comes up a lot. Are you going to make me?

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And it's like, well, you know, I'm going to present options to you.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And I'm going to perhaps even make recommendations about what I think would be good. And I'm going to encourage you to push yourself and I'm going to help you, you know, take it as far as we think is going to be really helpful. Yeah. But at the end of the day, I can't make you do anything. And I'm not going to do anything to you.

[Dr. Celine Gelgich]

I am your Becomes ineffective anyway, because if it feels forced in the therapy room, your client's going to walk out of there shitty, pissed off. That shit. I'm not doing it.

[Dr. Tori Miller]

Agreed.

[Dr. Celine Gelgich]

You're not going to get consistency at home. And we need consistency.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

So it needs to be collaborative in that way that you described of just looking at their trigger list and going, okay, let's. What are we working on today? Let's pick one. Because we're allowed to be messy with it and unstructured and going, okay, these are some options. What are your thoughts? Did you have any ideas? Yeah, let's jump into it.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

There's much more ownership over that.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And motivation and want, as opposed to us telling them.

[Dr. Tori Miller]

Well, that's a good point, isn't it? Because if we're talking about longevity of therapy.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And about reducing dependency on clinicians and giving our clients the skills to take it out into the world themselves. Us doing therapy to them doesn't break that at all. No, it doesn't. We need our clients to be in charge and to recognize that they can choose and they can follow through on these. On these things and that we're just there to sort of champion them and cheer them on.

[Dr. Celine Gelgich]

Yeah, yeah, we so are.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

We. We are essentially teaching them to be their own therapists.

[Unidentified Participant]

Yeah, that's right. Yeah.

[Dr. Tori Miller]

To make ourselves ultimately redundant.

[Unidentified Participant]

Yeah, yeah.

[Dr. Celine Gelgich]

And because they. They still are the expert of their ocd.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Really? Because they're the ones going through it themselves, right.

[Unidentified Participant]

Yeah. Yeah.

[Dr. Tori Miller]

And also they're the ones living their lives. They're the ones who know how often certain triggers come up.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

How how much a certain compulsions impact their lives, how much functional impact it has. You know, they need to be the ones who choose it. Otherwise we'll just. If you. If you take it, if you build exposures based on sort of this intellectual idea of. Well, the one I think you should work on this week, you know.

[Unidentified Participant]

Yes.

[Dr. Celine Gelgich]

Is, you know, xyz.

[Dr. Tori Miller]

Xyz. But then they're not actually going to be triggered by that.

[Dr. Celine Gelgich]

No.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

What's the point?

[Dr. Celine Gelgich]

Yeah, exactly. Exactly.

[Dr. Tori Miller]

So I think. I think answering the question of how far is too far. I think that us doing exposures to our clients, clients that they haven't consented to or that they're saying they're not ready for yet, and you haven't got that agreement that, you know, or their willingness or their. Or their collaboration. Right. If we did it to them anyway, I think that would be too far. Yeah, I do think that would be too far.

[Dr. Celine Gelgich]

Yeah.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

It's a very fine line. Because we've talked about this before, too, I think, in one of our previous episodes is. No, we have. I think. Have we? Anyway.

[Dr. Tori Miller]

I don't know. I don't know.

[Dr. Celine Gelgich]

Is gently encourage, like encouraging our clients to. And teaching them that they can cope with hard things.

[Unidentified Participant]

Yes. Yeah.

[Dr. Celine Gelgich]

So it's a very fine line between making a suggestion, them going, oh, I don't know, or I don't want to do that. So I often come back with, you might not want to do this yet, but it's on your trigger list.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And you've told me before you want to do it.

[Unidentified Participant]

Yeah, I'm hearing you.

[Dr. Celine Gelgich]

I'm respecting that.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

How can we modify this? How can we break this up and make it messy? So it's still not right.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

How can you take ownership of that?

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

I think is the way to be that. Encouraging clinician on the side, cheerleading them on going, I'm hearing you, but it's a yet because it's there. We've planned for it. You've talked about it and. But. And I know you can do the hard thing, but I'm hearing that you can't. You feel like you can't do it yet.

[Unidentified Participant]

Yeah. Yeah.

[Dr. Tori Miller]

I love that.

[Dr. Celine Gelgich]

I think an important distinction because what I'm hearing in my head is all my supervisees going, but we've talked about, you know, encouraging them to do the hard things. So which one is it? Do I tell them what to do or do I listen? Like. You know what I mean? Like, it becomes this tug of war and we're not wanting you to kind of get lost in the OCD argument either.

[Dr. Tori Miller]

Or, like, my client hasn't consented to do hard things, so therefore we can't do hard things.

[Dr. Celine Gelgich]

Yes. Because that's. We don't want to collude with ocd. So I guess the other thing to mention there is have. And this is the nuance of it as well. Know when you're talking to your clients and know when you're talking to ocd.

[Unidentified Participant]

Yeah. Yeah, that's right.

[Dr. Celine Gelgich]

And what that might sound like is increase in anxiety, like when you're talking to ocd. Increase in anxiety, increase in distress, increase in what if thinking. Maybe some anger.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Frustration. But calling it out and going, I think I'm hearing ocd. We're just gonna pause for a second. Let's put that aside. What are your thoughts?

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

What do you. And they might not know.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

They might be in a free state or a fight flight or whatever else it might be.

[Dr. Tori Miller]

I love that. I love that reflection. It made me think of a young person I'm working with at the moment who turns up begrudgingly to therapy, but then arguably, because of her age, you know, if she really didn't want to come, she wouldn't. Like, you can't make an older teenager do anything, Right.

[Dr. Celine Gelgich]

God, no.

[Dr. Tori Miller]

But she doesn't want to do erp. And every session she comes in and she complains and says, I don't want to do it. I'm too tired. I don't have the energy. It hasn't been so bad this week.

[Unidentified Participant]

Yep.

[Dr. Tori Miller]

But ultimately I know that in those moments she is in the room, which tells me that she does want to work on it.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

But these are expressions of a desire to avoid. Because she's. She doesn't want to feel like shit.

[Unidentified Participant]

Right.

[Dr. Tori Miller]

And of course, who would likes feeling like shit?

[Dr. Celine Gelgich]

So.

[Dr. Tori Miller]

But we have this sort of pre. Because we've got good rapport. Because we've previously talked about it, because we've talked about her ultimate, like, choice to avoid and her wish that she didn't have to avoid anymore, that she ultimately wants to be rid of ocd. I take that as an opportunity to tune into. Not take it too literally. To tune in. To do the check in.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

To bring her back to her ultimate goals and wishes for therapy, even connect it to. Come on. If we keep going, we can end therapy.

[Unidentified Participant]

Right.

[Dr. Tori Miller]

Like, I think you're getting so much better.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Like, why stop now?

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

And then ultimately get to a point where I see it as encouragement, not pressure.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

Where she says, okay, fuck it. All right, let's do it. Yeah, let's do it.

[Dr. Celine Gelgich]

And then also, she ultimately has the. The final say.

[Dr. Tori Miller]

Yeah, that's right.

[Unidentified Participant]

That's right. That's right. Yeah.

[Dr. Tori Miller]

One of the things I was going to ask you about, which I think is really interesting, is that let's say we have a client who is willing.

[Unidentified Participant]

Right.

[Dr. Tori Miller]

And I said, yeah, no problem. Let's go for it.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

But then they spike, Right. They get flooded.

[Dr. Celine Gelgich]

Yeah.

[Dr. Tori Miller]

Anxiety peaks.

[Unidentified Participant]

Right.

[Dr. Tori Miller]

How do you, as a clinician, make the decision about how far you keep pushing and when do you pull back and pause and say, that's actually enough for today? Or. No, no, no. Like, ride this wave. Let's keep going. Let's not. I'm going to trigger you again. I'm going to trigger you again.

[Unidentified Participant]

You know? Yeah.

[Dr. Celine Gelgich]

How do you really make that question?

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

I err on the side of. Well, first of all, my internal reaction is I went too far.

[Unidentified Participant]

And then.

[Dr. Celine Gelgich]

And then externally, I'm like, we got this. Yeah. Basically just lots of grounding. I head straight into grounding in a sense of going, okay, we're right in it together. I'm here with you. Listen to my voice. Like, hear my voice. What can you say? What can you feel? What is OCD telling you? So I go into reflection.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And observe. Like, I go into observing minds, really, in terms of just taking that step back. And I know that the client will struggle to do that because they're right in it. And their frontal lobe shutting down, their amygdala's hijacking everything. So I have to be that voice to. For them to.

[Unidentified Participant]

Then.

[Dr. Celine Gelgich]

And then you can just kind of see the shoulders drop slowly and the breathing kind of smooth out, and I start to hear you, and they start to respond. And then we go, okay. And I always ask my client, I'm like, okay, where are you at? I don't track suds to make sure they're coming down from a habituation perspective. I check. I check them out for myself to see or check in about them for myself to see where we need to pitch it.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

In terms of, like, okay, you're still sitting at an 8 out of 10, or you're still sitting at a 7 or something like that.

[Dr. Tori Miller]

I'm the same.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Yeah. Just for me to kind of gauge.

[Dr. Tori Miller]

Yeah, me too.

[Dr. Celine Gelgich]

Where they're at. And then saying to them, all right, we're just gonna keep sitting with this. So lots of diffusion, lots of grounding, lots of sitting in the discomfort. And then when they're able to talk to me a little bit more freely.

[Unidentified Participant]

Yep.

[Dr. Celine Gelgich]

I'm like, okay, your frontal loop starting to come back online. What do you want to do now? We can do a repetition.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

Would you go again?

[Dr. Celine Gelgich]

Do you want to go again or have you had enough for today? And we can repeat this at home because you need a break.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Sometimes I'll say, can I have a mini break? And I'm happy to go again. Or I want to do it again.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Or yeah, I need a break. Can I do it at home?

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

So that's.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

How I do that.

[Dr. Tori Miller]

Yeah, yeah, me too. And I think the only other thing that I do, which I know you do as well, is like check the clock.

[Dr. Celine Gelgich]

Oh, yeah, totally.

[Dr. Tori Miller]

Like if, if sessions coming to an end.

[Dr. Celine Gelgich]

Oh, you won't, don't repeat. That's a no brainer.

[Dr. Tori Miller]

Because otherwise you'll be leaving your client in a panic state and ushering them out the door. Or you'll be 15 minutes late for your next client while you ground your clients and prepare them for leaving the session.

[Unidentified Participant]

Yeah, yeah, yeah.

[Dr. Tori Miller]

Which is.

[Unidentified Participant]

Yeah, yeah.

[Dr. Tori Miller]

Never a fun experience. Yes. Yeah, I agree. Because I think that question of how far is too far often comes up not to see, sort of broadly conceptually about how do we plan an exposure, but also in the room. Am I hurting my client? And I think we've got to come back to this. To the knowledge that panic and, and fear is not to be feared.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

It's not dangerous.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

It's uncomfortable. Experientially. It's awful. It's distressing. But it's not dangerous.

[Dr. Celine Gelgich]

No. We don't have to react to it. If we react to it. We're teaching our clients. It's scary.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

We're teaching our clients. We. You might as well just keep doing convulsions.

[Unidentified Participant]

Yeah, that's right. That's right.

[Dr. Celine Gelgich]

So if we're the anchor in the room, and this is. I was going to say this before, when you talk about your client as well, we become their anchor to then be able to provide the space, hold the space, hear it, let it breathe.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And, and regulate.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

And that's co regulation.

[Unidentified Participant]

Yeah. Right.

[Dr. Celine Gelgich]

So that's how we go about it.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

This has been such an interesting topic.

[Dr. Tori Miller]

It has, yeah. Okay, so summary, summary, summary, summary. Okay. So having a really good understanding of OCD helps you to really understand the question of how far is too far and how to pitch it.

[Dr. Celine Gelgich]

Yes.

[Dr. Tori Miller]

How far is too far is really client dependent. It's contextual.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

There ultimately is no danger of doing, like having a knife in a room with someone if we're talking about ocd.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

And we need to be able to trust our clients. And how far is too far in relation to our clients? We have to remember that we're not doing it to our clients, that we can go too far if we're not doing it with them and collaboratively. And also, we can think about that question of how far is too far in the session. And just I think there's a lot of what's come out of our discussion today is lots of talk about how the dynamics, the experiential component of therapy, not just the. Oh, your Suds is at 9, therefore we can't proceed. Your sons is at 5, therefore we can.

[Unidentified Participant]

Yeah.

[Dr. Tori Miller]

You know.

[Unidentified Participant]

Yeah.

[Dr. Celine Gelgich]

Not to get caught up in that.

[Dr. Tori Miller]

No, it's.

[Dr. Celine Gelgich]

Yeah, we can. Hold it.

[Unidentified Participant]

Yeah, yeah, yeah.

[Dr. Tori Miller]

Did I miss anything?

[Dr. Celine Gelgich]

No, I think you did a beautiful job.

[Dr. Tori Miller]

Oh, thanks.

[Dr. Celine Gelgich]

All right, thanks, guys, so much for listening. We'll catch you in the next episode.