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

Episode Summary: The Dangers of Suicidal OCD and How to Recognise It

Hosts: Dr. Celin Gelgec and Dr. Victoria (Tori) Miller
Date: June 23, 2025

Episode Overview

This episode tackles the challenging and often misunderstood area of Suicidal OCD (also called Suicide-themed OCD) and how clinicians can differentiate it from genuine suicidal ideation or intent. Dr. Gelgec and Dr. Miller dive deep into the clinical nuances of recognizing, assessing, and treating this subtype of OCD. They emphasize compassionate, non-alarmist risk management, the importance of context, and a flexible, client-centered treatment approach.

Key Discussion Points & Insights

1. Understanding Suicidal OCD: A Taboo but Crucial Topic

• Suicidal OCD is frequently misunderstood or under-discussed due to stigma and fear.

• It often presents as ego-dystonic, intrusive thoughts about dying by suicide—not out of a wish to die, but out of fear of losing control.

• Clinicians must balance the seriousness of suicide risk with an accurate diagnostic understanding.

  "It's not helpful to our clients if we're panicking because they've brought up suicide, and if we go into lockdown, high risk management mode. But we also don't want to be flippant. Navigating that is complex… and so I felt like it was due time to unpack this a little."
  — Dr. Miller (03:27)

2. Clinical Examples and Presentations

• Suicidal OCD can manifest as avoidance of balconies, knives, or train stations—not because of intent, but out of terror of acting impulsively (“What if I lose control and do it?”).

• Sometimes it’s driven by overwhelming guilt or shame (fear: “If I never stop feeling this bad, one day I might see no other option.”).

  "She won't allow herself to go on a balcony… just in case… ‘How can I be sure I won't throw myself off the edge?’"
  — Dr. Miller (04:47)

• Some clients develop compulsions as emotional safeguards (e.g., compulsive confession, checking for meaning/happiness, mental reviews).

  "She's doing this sort of compulsive checking, like, how happy was I today? …as a way of preventing ever one day… needing to die by choice."
  — Dr. Miller (07:23)

3. Differentiating Suicidal OCD from Suicidal Ideation (Depression)

• Suicidal OCD: Ego-dystonic thoughts ("I don't want to die, but I'm terrified of the thought I might"), characterized by high anxiety, avoidance, and uncertainty.

• Suicidal Ideation: Linked to depressive symptoms, hopelessness, and exhaustion ("I can't see a way out, maybe it's the only choice left"), sometimes ambivalent but with loss of hope/connection.

• The importance of context, mood, and motivational factors—what’s driving the thought?

  "I'll ask questions like, can you give me a little bit of context? …How has your mood been lately?"
  — Dr. Gelgec (10:24)

  "Listening for context, mood, circumstance, previous experiences, and hopelessness… versus anxiety and avoidance."
  — Dr. Gelgec (11:33)

4. Assessment: “Be Alert but Not Alarmed” (10:24)

• Adopt a curious, validating stance.
• Assess frequency and triggers of thoughts, emotional tone, and accompanying behaviors.
• Recognize that the boundary between OCD and depressive symptoms can blur over time.

5. Treatment: Tailoring the Response

• If OCD-driven:

  • Psychoeducation about ego-dystonic thoughts.
  • Reassurance and explanatory guidance.
  • Exposure and Response Prevention (ERP): Deliberate exposure to triggering situations (balconies, train stations) or content (media, writing scripts, listening to the "Suicide Song").
  • Address compulsions (mental checking, avoidance, researching, seeking reassurance).
  • Caution against compulsive “emotion checking” to see if thoughts have turned into genuine suicidal intent.

  "It's the application of ERP, which is to invite the thoughts, spend time with the thoughts, reduce the mindfulness around emotions that are evoked… and then reduce the compulsions associated with it."
  — Dr. Miller (16:21)

• If depression-driven/suicidal ideation present:

  • Conduct a full risk assessment.
  • Assess for depressive disorder.
  • Consider pausing or adapting ERP to address depression (CBT, medication, behavioral activation).
  • Utilize support systems: psychiatry, group therapy, family, inpatient/outpatient programs.

  "If they don't already, think about what other avenues you could explore for treatment… group therapy, psychiatry, inpatient admissions, outpatient programs."
  — Dr. Gelgec (20:55)

• Blended/complex cases:

  • Recognize when persistent OCD may lead to genuine depression and suicidal ideation—requires adaptation and holistic care.

6. Holistic, Person-Centered Care

• Don't treat OCD in isolation; examine environmental, relational, and contextual factors.

• Flexibility is key—strict, manualized approaches may neglect the person's broader challenges and resources.

  "We're treating a whole person, not exclusively OCD… ERP is the framework we use, not the rule."
  — Dr. Miller (22:54)

Notable Quotes & Memorable Moments

• On balancing clinical responsibility:

  "Be alert but not alarmed."
  — Dr. Gelgec (10:24)

• On treatment flexibility:

  "ERP is the framework that we use, not the rule."
  — Dr. Miller (23:41)

• On the complexity of client experiences:

  "We don't blame the plant for not thriving… we look at the environment."
  — Dr. Gelgec (22:16)

• On compulsion examples:

  "People can call helplines compulsively… avoid content about suicide, turn up to emergency, spend a lot of time on ChatGPT…"
  — Dr. Miller (15:53)

• On using media and urban legends as exposure:

  "There was this episode… about a Romanian composer who wrote a… 'Suicide Song.' Urban legend… but you can listen to it on Spotify."
  — Dr. Miller (17:55)

• On the danger of missing key context:

  "Sometimes you'll have a client who has suicidal obsessions in an OCD context… but because they've been dealing with it so long, might develop depression, and then it might be something that starts to creep in in terms of actually, there's so much despair here… we need to consider, like, take into more consideration."
  — Dr. Gelgec (12:08)

Important Timestamps

• 00:34 – Suicide as a leading cause of death; warning on episode content
• 02:09 – Why suicidal OCD is hard to talk about (stigma, misinterpretation)
• 04:14–07:23 – Examples of suicidal OCD vs. depressive ideation
• 09:18–10:24 – OCD and secondary depression; complexities in assessment
• 10:24–12:08 – Assessing context, mood, and client experience
• 13:53 – Educating clients to recognize when thoughts shift from OCD to depressive ideation
• 15:16 – Compulsions in suicidal OCD
• 16:21–18:29 – Practical ERP exposures and use of “Suicide Song” as an example
• 20:53–22:17 – Adapting treatment for depression, support options, and environmental assessment
• 22:54 – Treating the whole person, not just the OCD

Key Takeaways

• Clinicians must carefully and compassionately discern between suicidal obsessions in OCD and active suicidal ideation, as both require a tailored and nuanced approach.
• Context, emotional tone, and client motivation are critical in risk assessment and treatment planning.
• Exposure and Response Prevention is effective for suicidal OCD but must be accompanied by psychoeducation, careful monitoring, and sensitivity to comorbid depression.
• Address the whole person—including environment and life context—not just symptom checklists or manualized treatments.

For Further Support

If you or your clients are struggling with these issues, reach out to local healthcare providers or, in Australia, Lifeline at 13 11 14.