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

Episode Title: Unpacking Meta OCD: A Deep Dive
Hosts: Dr. Celine Gelgec & Dr. Tori Miller
Date: November 3, 2025

Episode Overview

In this engaging and insightful episode, Dr. Celine Gelgec and Dr. Tori Miller explore the nuanced and often misunderstood concept of "Meta OCD"—Obsessive-Compulsive Disorder that fixates on OCD itself, diagnosis, and treatment. Speaking directly to mental health professionals, they share clinical definitions, notable client experiences, and strategies for addressing meta OCD in therapy. The tone is conversational, empathetic, and deeply practical, offering both intellectual frameworks and hands-on guidance for clinicians navigating this "frustrating but common" OCD theme.

Key Discussion Points & Insights

1. What is Meta OCD?

Definition & Clinical Experience

• (04:10) Dr. Celine Gelgec: "Meta ocd. In very short, is OCD about fucking ocd? So yes, I know, what the hell."
• Manifested as doubts about the legitimacy of one's OCD diagnosis, persistent questioning about whether treatment is deserved or being done "correctly," and preoccupations with therapy itself.
• (04:33) Practical examples:
  • “Is my therapist sure about my diagnosis?”
  • “But what if I don’t have OCD?”
  • “Do I deserve to be in treatment?”

2. The Perfectionistic & Moral Dimensions

• (04:57) Dr. Tori Miller: "I definitely think there’s a moral component … from moral scrupulosity … clients say, ‘Well, because if I don’t have OCD, that means I’m wasting your time.’”
• Meta OCD often ties into a profound fear of being a "fraud," unworthy, or even manipulative, amplifying shame and self-doubt.
• Clients worry they’re “manipulating” clinicians into treating them for something they don’t have, sometimes with extreme example concerns ("Because I’m really a pedophile…").

3. Why Meta OCD is Disruptive for Treatment

• Extremely frustrating and “disruptive” for both clients and clinicians (02:44).
• Treatment Impact:
  • Can stall or undermine progress in standard OCD therapy (ERP), as clients become fixated on whether they are complying “right” or are “deserving” (07:06).
  • Perfectionism Loop: Clients obsess about completing ERP or skill development exercises with flawless precision, devaluing their own successes (11:22).
• Quote:
  • (12:14) Dr. Celine Gelgec: “The wins are never celebrated … because it never feels enough.”

4. Manifestations in the Therapy Room

• Meta OCD often presents as repeated requests for reassurance, clarification of diagnosis, or “am I doing this right?”
• Can hijack therapy, leading therapists to inadvertently provide reassurance or stall exposure progress (07:28).
• Clients may attempt to indefinitely remain in “skill development” phases, avoiding exposure out of fear of "getting it wrong" (11:22).
• Challenge for clinicians:
  • Balancing empathy and compassion with the risk of enabling reassurance compulsions (08:31).
  • Noticing when reassurance-seeking is a compulsion rather than genuine curiosity.

5. Distinguishing Compulsions from Curiosity

• (17:51) Dr. Tori Miller: "[This is] the nuance and the artistry of the work that we do."
• Not all questions in therapy are compulsive—therapists must approach repeated doubts with curiosity before labeling them.
• Important to gently reflect on patterns: “If you notice that’s happening a lot… you start to sort of wonder out loud about whether this other function is happening…explore it.” (18:12)

6. Client Case Example—OCD Teen Group Exercise

• In a values/strengths selection exercise, teens with OCD struggle to select strengths for themselves due to intrusive perfectionistic meta-thinking and fear of "taking" strengths from others (13:20–15:02).
• (15:35) Dr. Tori Miller: “For most people with OCD, this aspect of wanting to do things well and right and good … causes so much distress.”

7. Metacognition, Self-Worth, and Fusion

• Intellectual and moral compulsions are tightly fused with clients’ self-worth—making them feel "more real" (21:33).
• "It lives in your mind… it feels more like an extension of yourself… gives it a sense of legitimacy." (21:48)

8. Clinical Strategies: Recognizing & Addressing Meta OCD

• Practice curiosity and avoid “OCD police” role (18:34).
• Psychoeducation is crucial—clinicians must tread gently, as clients often respond with defensiveness:
  • "No, no, no, I swear, this is not an OCD thing ..." (20:49)
• Guide clients from merely labeling emotions toward truly experiencing them in the body (19:05).
• Help clients spot mental safety behaviors such as checking, rumination, or replaying therapy assignments—these are forms of compulsions, too (19:36).
• Keep treatment collaborative; validate experiences but avoid enabling reassurance cycles (08:50).

9. Why Manualized Treatments May Fall Short

• Meta OCD often emerges mid-treatment, not at intake or simple assessment (like the Y-BOCS; 23:41).
• (23:06) Dr. Tori Miller: “This theme is a really good example of why ... the traditional manualized sort of treatments don’t necessarily offer the spread or the depth that sometimes conditions like OCD require.”
• Clinicians must allow for flexibility, ongoing assessment, and creativity.

Notable Quotes & Timestamps

• “Meta OCD... is OCD about fucking OCD.”
  — Dr. Celine Gelgec (04:10)

• “It feels more like an extension of yourself… gives it a sense of legitimacy.”
  — Dr. Tori Miller (21:48)

• “The wins are never celebrated … because it never feels enough.”
  — Dr. Celine Gelgec (12:14)

• “Sometimes it is quite legitimately someone with questions and curiosity, and this is the nuance and the artistry of the work that we do.”
  — Dr. Tori Miller (17:51)

• “Let’s not think too much about our thinking.”
  — Dr. Tori Miller (25:12)

Important Timestamps

• 02:05 — What is Meta OCD?
• 04:10 — Defining Meta OCD, Illustrative Examples
• 04:57 — The Moral Component: Scrupulosity, Worthiness
• 07:06 — Meta OCD Derailing Treatment, Perfectionistic Traps
• 11:22 — Perfectionism and Loss of Learning Opportunities
• 13:20–15:02 — Client Group Exercise: Struggling to Acknowledge Strengths
• 17:51 — Questions or Compulsions? Clinical Artistry
• 19:36 — Safety Behaviours, Mental Compulsions
• 21:33 — Fusion with Self, Compulsion Legitimacy
• 23:06 — Limitations of Manualized Treatments
• 25:12 — Episode Wrap-Up, Key Takeaway Moment

Key Takeaways for Clinicians

• Meta OCD is a highly disruptive but common theme, often masked as “good client” behavior or intellectual curiosity.
• Recognize and compassionately challenge compulsive patterns of reassurance-seeking around diagnosis, deservingness, or treatment “correctness.”
• Gently provide psychoeducation, validate emotions, and bring clients into embodied experience, not just cognitive reframing.
• Manualized approaches may not capture the nuance of meta OCD—the best treatment is collaborative, flexible, and attuned to hidden compulsions.
• Remember to celebrate client wins and mitigate the perfectionism that undercuts treatment gains.

“Let’s not think too much about our thinking.”
— Dr. Tori Miller (25:12)

Tune in next episode for more in-depth, real-world strategies on building confidence in OCD treatment.