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

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.

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)

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)

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.

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.

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.