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

Episode Summary: Values, Paradox, and OCD—Finding Flexibility in the Tension

Hosts: Dr. Celine Gelgec & Dr. Tori (Victoria) Miller
Date: January 12, 2026

Overview of Episode's Main Theme

In this episode, Dr. Celine Gelgec and Dr. Tori Miller explore the concept of paradox in the treatment of OCD, specifically focusing on how values—so often central to exposure and response prevention (ERP) and Acceptance and Commitment Therapy (ACT)—can themselves become “sticky” or fused, much like obsessions and compulsions. The hosts encourage clinicians to move beyond binary thinking and help clients recognize, accept, and flexibly navigate the tension between opposing values. The discussion is open, reflective, and gives practical ideas for working with these complex dynamics in therapy.

Key Discussion Points & Insights

1. Defining Fusion with Thoughts and Values

• Fusion with thoughts (as defined in ACT): When individuals cannot separate themselves from their thoughts, treating them as absolute truths requiring immediate action.
  • Dr. Celine Gelgec (03:31): "It's almost like they've become one with their thoughts and they treat their thoughts as being real, as being serious, as being advice to listen to. They have to act on them straight away..."
• Fusion with values: OCD clients may rigidly adhere to a value (e.g. “being a good person” = “never making mistakes”), making flexibility intolerable.
  • Dr. Celine Gelgec (04:23): "...when someone is fused with their values, someone with OCD, for example, who values being a good person, will go to the nth degree to uphold that and can't even fathom anything different."

2. Paradox in OCD and Binary Thinking

• Looping in paradoxes: Many clients and clinicians get stuck by treating values in all-or-nothing ways—e.g., “perfection or failure,” “certainty or total risk.”
• Binary thinking means striving for 100% of conflicting values, which is impossible and leads to frustration and stuckness.
  • Dr. Tori Miller (06:34): "A lot of people get caught in the tension of wanting one or the other. It's very sort of binary thinking. But both things can be true at the same time. But...you can't be 100% of both of these competing values..."

3. Why Clients Get Stuck in Value Paradoxes

• Inner rebellion: A refusal to compromise on valued identity (“I’ll be damned if I have to sacrifice my standards”).
  • Dr. Celine Gelgec (07:22): "...it's almost like an inner rebellion. Like I'll be damned if I need to have some level of flexibility but let go of this at the same time."
• Personality and cognitive styles: Clients with rigid or perfectionistic thinking are more susceptible.
• Self-battle and avoidance: The result is constant internal conflict and attempts to ignore or suppress the tension.

4. Common OCD Paradoxes Identified

• Perfectionism vs. Flexibility
• Health vs. Safety/Certainty
• Self-Protection vs. Growth
• Responsibility vs. Letting Go
• Purity vs. Imperfection (esp. in intrusive thoughts)
• Harm Avoidance vs. Personal Freedom
• Religious/Moral Integrity vs. Practicality
• Control vs. Trust
• Certainty vs. Paradox
  • Dr. Gelgec & Dr. Miller discuss these practical examples in depth (09:43–11:14), making them highly relatable for clinicians.

5. Spotting Paradox in the Therapy Room

• Clients express a wish for two incompatible things (e.g., “I want to feel totally safe but also live freely”).
• There is visible resistance or distress in discussing giving up one value for another.
• Many aren’t aware these paradoxes are driving their compulsions or avoidance.

6. Therapeutic Strategies for Addressing Value Tension

• Normalizing and mapping the tension: Help clients name and see both values are operating.
  • Dr. Celine Gelgec (13:46): "...when your client is stuck in therapy, one of the first questions to ask is...Is there a value clash here?...Are there values clashing?"
• Values clarification: Don’t assume clients know what their values truly are; explore deeply, not just with token responses (“family,” “success”).
• Identifying personal meanings: What does a value like “family” specifically mean for each client?
• Use of creative tools: Cards, visual mapping, role-based inquiry.
  • Dr. Gelgec (17:58): "I often will tailor the way to build it out based on what the client's preferences are. Sometimes more visual. Some clients just like to talk and brainstorm more..."
• Polarity mapping (from leadership literature): While not fully explained here, the hosts suggest adapting this tool to help clients “map out the tension” (20:46–21:09).

7. Moving Beyond “Sit with Uncertainty”

• Warning against overusing the phrase without context: Simply instructing clients to “accept uncertainty” can feel empty or invalidating.
  • Dr. Tori Miller (21:36): "...we can't just keep saying this to our clients over and over again and expect them to just have radical acceptance one day."
• Instead, clinicians should use value tension conversations to help clients see what meaningful life gains can come through acceptance and compromise.
  • Dr. Miller (23:35): "...if we can go that step further and look at the things they can gain...in terms of being able to attend to other values...I think actually gives a beautiful reason to accept."

8. Recovery and Reclaiming Identity

• Acceptance allows clients to move beyond OCD-defined values to a more authentic self.
  • Dr. Gelgec (23:54): "...you're building a sense of self for your client, which OCD takes away from clients. And when a client can build that sense of self outside of OCD, then life becomes so much more enjoyable."

Notable Quotes & Memorable Moments

• On value fusion:
  Dr. Celine Gelgec (04:23): "I'm not asking you to change your value system. I think it's a beautiful value system to be wanting to be seen as a good person. But that also comes at a cost."
• On binary thinking and paradox:
  Dr. Tori Miller (06:34): "It's very sort of binary thinking. But both things can be true at the same time..."
• On sitting with uncertainty:
  Dr. Tori Miller (21:36): "We can't just keep saying this to our clients over and over again and expect them to just have radical acceptance one day..."
• On the benefit of acceptance:
  Dr. Celine Gelgec (23:54): "...when a client can build that sense of self outside of OCD, then life becomes so much more enjoyable."
• On the future of research:
  Dr. Celine Gelgec (16:19): "...if anyone wants to help us run a research study, please get in touch, because this is something I think we could benefit from hugely."

Timestamps for Important Segments

| Timestamp | Topic / Discussion | |------------|---------------------------------------------------------| | 02:16 | Introduction to today's theme: values and paradox | | 03:31 | Fusion with thoughts and ACT fundamentals | | 04:23 | Fusion with values in OCD: real-world examples | | 06:34 | Paradox and binary thinking | | 09:43 | How paradox shows up in session; common OCD paradoxes | | 13:46 | Spotting value clashes and their role in stuckness | | 17:25 | First therapeutic step: insight and identification | | 17:58 | Deepening values clarification; practical techniques | | 20:46 | Polarity mapping and mapping value tension | | 21:36 | Limits of “sit with uncertainty” as a one-size-fits-all message | | 23:54 | Building selfhood beyond OCD |

Final Thoughts

The episode delivers an in-depth, compassionate look at how paradox and clashing values contribute to the suffering and “stuckness” characteristic of OCD. Dr. Gelgec and Dr. Miller push beyond standard interventions, inviting clinicians to get curious, map out client value tensions, and facilitate flexible, values-based decision-making for recovery.

By broadening clients’ awareness of their values and helping them work with—rather than against—the inherent paradoxes, clinicians can support clients in reclaiming their lives from OCD.

For clinicians:
Consider listening to the full episode to hear more examples and the hosts’ nuanced discussion style. If you’re interested in building your own skill in polarity mapping or creative values clarification, reach out as the hosts welcome further dialogue and potential research collaboration.

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