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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 order to get better.
Dr. Tori Miller
Catch us every fortnight, wherever you get your podcasts. Hey, mate.
Dr. Celine Gelgich
Hello. Hello. How's it going?
Dr. Tori Miller
We've got to get better at this.
Dr. Celine Gelgich
I know. We do have to get better at it. What else can we say? Hello. Howdy. How's it going? What you doing? How are you today? Today we're talking about extinction bursts.
Dr. Tori Miller
Yes.
Dr. Celine Gelgich
What the hell is an extinction burst? Well, well, it's your Brain's way of having a hissy fit before you change the rules on it. That's how I like to think of it.
Dr. Tori Miller
Yeah. I think that's pretty, pretty accurate.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
Yeah.
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Because if we think about it like,
Dr. Celine Gelgich
our brain is a muscle. No, it's an organ. Sorry, get that right. It's my Anatomy 101, the Wonderline. 2007. Was it 2007? No, 2004. Fuck, I'm old. Yes. So the brain is an organ, but it functions like a muscle, is what I was trying to say. In that it likes rules and repetition and same, same, same. If we don't do same, same, it freaks the fuck. It likes patterns, all of that stuff. And when we don't do that, the minute we start to try and change the rule, it has a hissy fit, it freaks out. And it will say to you, no, no, no, you're doing it wrong, you're doing it wrong, you're doing it wrong. It's this, it's this, it's this, it's this. And it just spits out the same messages to you so that you get your shit together. Because your brain thinks you're losing your marbles.
Dr. Tori Miller
Yep.
Dr. Celine Gelgich
And wants you to get back in line. Yeah. But then when we change the rule or the rules, it. Yeah, it has its freak out and wants you to get back into it. So why are we talking about extinction bursts? An extinction burst is the fancy way of saying hissy fit for your brain, I would say. So why are we talking about them? Because they're such an important part of exposure and response prevention in the work that we do. And this is where our clients. I'm going to say trip up.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
I'm not going to say fail. I'm going to say trip up. Because it. And it gets them every single time. Because what happens is if you think about how long someone's been doing their compulsions for. It's the same rule for however many years. Right. Not even a few months. Years sometimes. Actually, a lot of the time, if we think about how long someone's been doing the same thing for the same pattern for. Can you imagine how much of a hissy fit our brain's going to have if you try and change that?
Dr. Tori Miller
Yeah. It's huge.
Dr. Celine Gelgich
So the brain's like the. The density of the. Of the neural pathways and the neural wiring is so intense trying to change that. Of course the brain's reaction is going to be massive. So there's lots of bells, whistles, alarms going every. Every time we try and modify A compulsion. Remove a compulsion or change it up in some way. The brain's like, yeah, what are you doing? So an extinction burst happens, which means it gets. The messages get louder, they get nastier, they get more frequent, they get more intense. And so in that moment, our clients then misinterpret that as, something's wrong. ERP is not working. OCD is getting worse. I can't handle this. I'm doing it wrong. What's wrong with me? And it's in those moments that we then have to hold that and go, actually, no, this is part of the process. Your brain's having an extinction burst. If we can sit through the burst, the light is at the end.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And we get through the tunnel. Yeah. And then change is going to happen.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
But holding through that process is a challenging part. Yeah. But if we don't name it and we don't know, we get pulled into that anxiety and we don't ourselves understand what's going on as an. As a clinician, then we can easily get pulled into that. And the chop and change happens.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And then we send mixed messages.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
Well, because I think. I mean, look, the. The extinction burst, I think, is a really understandable response. Yes. To. To attempt to change our behavior.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
And I can really, you know, I can really understand what the underlying mechanism is, is that, you know, we've been reinforcing a perception of safety for a long time, and our brain wants us to maintain a sense of safety. And so when we're shaking that up and doing something that is leaving us with ambiguity about our safety, of course it's going to say, no, no, do that thing that you've been doing for a really long time that keeps us safe. Of course that's going to happen. I mean, why would our brain not, like, sort of switch on the protective mechanism?
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
I think it's just really tricky because I think this comes down to. I think there's sort of that overlay of, like, the. The medicalization of health and things, which is, you know, the notion that healthy or being well means no discomfort, means no pain, and. And a wish or an expectation that intervention and treatment is going to result in feeling relaxed, feeling happy, feeling good, feeling relief, and no intrusive thoughts. Absolutely. And it's. And it's really a surprise, I think, to people that one of the first things you can feel when you try to change things is actually an increase in discomfort or an increase in anxiety or stress or fear. I mean, I think this notion is. Is pretty like I know that sort of in outside of OCD spaces, if we're talking about, say parenting kids, you know, when we're talking about adapting behavior, we often talk about how things get worse before they get better.
Dr. Celine Gelgich
Yes.
Dr. Tori Miller
You know, kids up the ante, they test the limits, the boundaries, like. Well, if, you know, as a way of trying to maintain proximity, it's like it's an attachment based behavior.
Dr. Celine Gelgich
Right.
Dr. Tori Miller
You know, which again comes back to that idea of safety. And so it's like if, if kids who are stressed or frightened or fearful are using behav to, you know, sort of, you know, using like different challenging behaviors or whatever, you know, and we're asking parents to help their children make different choices or whatever, whereas that we often say to parents like, it gets worse before it gets better. Trust the process.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
But I feel like people don't automatically think about that same process when treating something like ocd. I think they, that's a really, I think that's, I think we'll kind of understand that in the relationship space. But when it comes to ocd. But it's the same kind of idea. And you're right. We hear it all the time. People saying ERP didn't work.
Dr. Celine Gelgich
Yep.
Dr. Tori Miller
It doesn't work for me. It got worse. And I have heard some parents talk about how the, the escalation of their children's behavior frightened them.
Dr. Celine Gelgich
Yes.
Dr. Tori Miller
And some people have talked about. Because they didn't understand that it was an extinction burst, which says to me that I didn't adequately prepare my clients or explain it in a way that they really sort of understood that. They either feel kind of frightened and alarmed, like, I'm getting worse, therapy doesn't work for me. Or they self blame and go down the shame line of I'm not doing therapy. Right. I'm doing it wrong. I've, you know, ERP works, but not for me because I'm not doing it adequately kind of thing.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
And it becomes a really, a really significant barrier.
Dr. Celine Gelgich
It does, it really does. Because it becomes a hurdle where people easily buy into the story.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Because there's evidence for it too. But it's misplaced in a sense or mislabeled in a sense of things aren't moving or shifting the way that they want them to. And so it can very easily. When you seemingly have evidence for what you're thinking, then it's easier to end up buying into, which is then harder to shift.
Dr. Tori Miller
Right.
Dr. Celine Gelgich
And it's harder to then. Especially when people learn through experience. Right. As we all do.
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to do list doesn't stop, and neither does the pressure to keep up with it. If you've been running on fumes. Grow Therapy makes it easier to find care that's covered by insurance and actually built around you, whether it's your first time in therapy or your 50th. Grow makes it easier to find a therapist who fits you, not the other way around. You can search by what matters like insurance, specialty, identity, or avail and get started in as little as two days. And if something comes up, you can Cancel up to 24 hours in advance at no cost. Grow helps you find therapy on your time. Whatever challenges you're facing, Grow Therapy is here to help. Grow accepts over 100 insurance plans. Sessions average about $21 with insurance, and some pay as little as $0, depending on their plan. Visit growththerapy.com acast today to get started. That's growthherapy.com acast growththerapy.com acast availability and coverage vary by state and insurance plan.
Dr. Celine Gelgich
They're kind of trusting our word for it. Yeah, in a sense. And so that then becomes difficult to work with too, but it's not impossible. And so I think if we can focus on that psychoeducation component of talking through extinction bursts and setting up those expectations very early on, it can be really, really powerful way of holding clients.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And going, you know it. We're gonna get there. We just have to ride this out.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
If we can get through this burst, then the extinction is going to happen.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Right. Yeah. And I think that behavior and I
Dr. Tori Miller
think helping our clients see that the extinction burst is evidence of intervention effectiveness.
Dr. Celine Gelgich
Yes, it is. Yeah.
Dr. Tori Miller
It might just not be what they're expecting, what you're expecting. But in fact, if OCD is getting louder, if your intrusive thoughts are becoming. Becoming more intense, if the urges are getting stronger, that means your brain is responding to change. It's activating this part of you that's. That's saying, no, no, no, go back to the way it was. So it means that your brain is relearning and. And that is actually a good thing.
Dr. Celine Gelgich
So it is.
Dr. Tori Miller
Stay with it. Yes. Yeah. Discomfort isn't dangerous.
Dr. Celine Gelgich
No, not at all. Not at all. An analogy I used to use is we can't just, you know, run once or walk once and expect to be fit.
Dr. Tori Miller
Yeah, that's right.
Dr. Celine Gelgich
And we can't run or walk going la la la the whole time. Once that heel comes, you're like,
Dr. Tori Miller
it's
Dr. Celine Gelgich
like, you know, you're breathing out of your butt. It's painful. Your lungs are on fire. Everything hurts. Especially the next day when you can't sit down because your legs are sore or whatever. Especially when you haven't worked out for a while or something like that, or moved your body for a while. It's pain. Absolutely pain. And we're trying to change our body or make up, you know, in terms of increasing fitness or whatever. It might be any change that we're working on. Yeah, we have to go through that little painful part first.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Before the good stuff happens.
Dr. Tori Miller
Yeah, that's right. Yeah, that's right.
Dr. Celine Gelgich
Yeah. So what are some ways you think we could coach our clients through an extinction burst? Like, what comes to mind?
Dr. Tori Miller
I mean, I think the. I think the first thing that comes to my mind is the importance of psychoeducation.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
I think that's got to be step one and probably one that I used to miss.
Dr. Celine Gelgich
Yeah. I think, yeah.
Dr. Tori Miller
If I think back, yep, maybe I did, or maybe I. Perhaps it was how I was explaining it. But I would say that, starting with psycho education, about the fact that sort of this is a thing to be expected and this is what it might feel like. And I could also I'm. What I do now, which I didn't used to do, is invite my clients to observe it and so to sort of sit in a position of just neutral observer of the experience and sort of report back, so to speak. So that, that way they're sort of going into it with eyes wide open. They're expecting it, they're curious. So taking sort of that non judgmental neutral stance I think really helps them sort of, sort of move through it. I think rather, rather than sort of like resisted or fight it or, you know, so that's, that's one thing that I do.
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What about you?
Dr. Celine Gelgich
I usually encourage clients to try and lean into it as much as possible in the moment. So I often bring it in to exposure sessions. So for example, if we're actively doing an exposure therapy session and the, the reflection is, this is really hard. I'm finding this really challenging or whatever it might be that the client is saying, just being curious. And I often think out loud going, I wonder if an extinction burst is Happening.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And let's observe that and see what happens. And so we just kind of be curious.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And then also set it up for homework. So thinking, okay, we've been working on this stuff. How is OCD going to show up?
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
What's it going to say? What's it going to do? How loud is it going to get? All burst language in terms of, like, what's the hissy feet going to look like?
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
So that you can go in prepared.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
And then what tools can you use?
Dr. Tori Miller
Being reluctantly willing, Right.
Dr. Celine Gelgich
Yeah. Reluctantly willing. And what tools can you use to help you sit through the burst until you can write it out? And oftentimes, clients will come back going, it was really. It was too hard. I, you know, I couldn't or whatever. And that's fine. There's not that, you know, it's hard. Change is hard. And so it's like, okay, well, what showed up? How did it show up? What surprised you? And what can we do differently next time? How? Because everything's data, right?
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Every time an extinction burst happens, you learn what it looks like and you learn about how you respond to it, too. And I think that data is really important because then what? The next time it happens, you can go in differently and approach it differently. And at the same time, I think what can happen too, is start to recognize the pattern of the bursts and recognize too, that the length of time between burst and your ability to cope gets longer and longer, which is change.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
Right. And it's not that they're never going to happen again.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
They are still going to show up. It's just less frequent and less intense.
Dr. Tori Miller
Yeah, yeah, yeah.
Dr. Celine Gelgich
So a really handy thing to think about to help shift clients. Yeah.
Dr. Tori Miller
And I think that, that, you know, that that idea of. I know we've talked about this before about the use of data, and data collection with OCD is an interesting one. It's certainly sort of like a. A big component of CBT therapy.
Dr. Celine Gelgich
Yes.
Dr. Tori Miller
And I think that got a valuable role to play. However, we've also talked about how doing things like collecting suds, you know, subjective, you know, distress scale, getting people to focus on. On, like, what level of intensity your distress is at can be problematic because then people can become. It sort of. It can interrupt acceptance of distress. And success can sometimes be measured in terms of how low your distress is, as opposed your willingness to accept and to sit with. Or your ability to move through discomfort.
Dr. Celine Gelgich
Yes.
Dr. Tori Miller
Which is not the right message because a lot of this distress can't be extinguished. You know, so.
Dr. Celine Gelgich
That's right.
Dr. Tori Miller
So I think data collection, I think can needs to be used carefully in this space. However, I do think that this is one of those places where it's useful because if you can, if, if you can help your clients to see it to, to use data and sort of like a, A neutral, non judgmental, curious, like let's just be curious about.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
You know, how.
Dr. Celine Gelgich
What's going.
Dr. Tori Miller
About what's going on.
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
As opposed to let's measure and then we can celebrate if your distress comes down. Yes, I think.
Dr. Celine Gelgich
Exactly.
Dr. Tori Miller
Really different. Yeah, yeah.
Dr. Celine Gelgich
I think the thing to celebrate is how did I cope through that? And cope doesn't mean I got through without pain. It's. Was I able to handle it? Yeah, I guess is what I'm trying to say. Yeah, yeah.
Dr. Tori Miller
How did I move through?
Dr. Celine Gelgich
How did I move through it? I think.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
To remove those expectations of did I do it pain free? Did I do it? What kind of.
Dr. Tori Miller
How did I take care of myself?
Dr. Celine Gelgich
Yes.
Dr. Tori Miller
Yeah. What kind of choices did I make?
Dr. Celine Gelgich
Yeah.
Dr. Tori Miller
What were the things that I did that really helped me and nurture me? What kind of things did I choose to do that kind of made it worse or. Yeah. You know.
Dr. Celine Gelgich
Yeah. Was in line with my treatment.
Dr. Tori Miller
Yeah, yeah, yeah.
Dr. Celine Gelgich
My values as a person.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
All those things.
Dr. Tori Miller
Yeah, yeah, yeah.
Dr. Celine Gelgich
I agree with you. I think you can get bogged down in the data part. Yeah. In an unhelpful way.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
For sure. Yeah.
Dr. Tori Miller
But I think that's a lovely example.
Dr. Celine Gelgich
Yeah. Of being curious.
Dr. Tori Miller
Yeah. Okay. So we've talked about. Okay, so extinction bursts. They happen. Yeah. They're evidence of change.
Dr. Celine Gelgich
Change.
Dr. Tori Miller
Which is actually quite an exciting things. So if you can help your client through psycho education, expect.
Dr. Celine Gelgich
Yep.
Dr. Tori Miller
To be curious about and then to recognize them as evidence of meaningful change, then that's something to be excited about. But also to watch out for our clients expectations about what the change process is going to look like and bring it into session in the moment. Observations you talked about, which I thought was such a good tip about using the language, having really normalized the language to help normalize the presence of extinction bursts in the process.
Dr. Celine Gelgich
And setting it up for homework.
Dr. Tori Miller
And setting it up for homework.
Dr. Celine Gelgich
Yeah. And all of that really just helps manage expectations. Yeah, yeah, yeah. Which will be, which is important because I think one of the biggest gripes, not just clinic that clinicians have that they bring to supervision is how stuck their clients can get.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
But also our clients complain about. It's a complaint. But like our clients talk about that too.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
You know, in that they go, you know, I just feel stuck all the time. Yeah. So, yeah, if we want to get unstuck.
Dr. Tori Miller
Yeah.
Dr. Celine Gelgich
We gotta manage the bursts.
Dr. Tori Miller
Yeah, that's right.
Dr. Celine Gelgich
Hate to burst your bubble. How many burst references can we do? Oh, my goodness. Beautiful recap.
Dr. Tori Miller
Fabulous.
Dr. Celine Gelgich
Amazing. All right, all right. Thank you. Lovely. Thanks, everyone for watching and for listening. If you like what you see in here, please hit subscribe and you won't miss out on episodes. See you next time.
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Dr. Celine Gelgich
Acast powers the world's best podcasts. Here's the show that we recommend.
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Hi, I'm Xin Yi Pai. Five years ago, I sat down in front of a microphone with a simple goal to share stories from the Asian American experience and to do that by talking about everyday objects. Now, 10,000 Things is headed into its fifth and final season and we've got a new set of stories about coming fully into oneself. Weird and wild and inspired. Tune in to the final season of 10,000 things from Acast Creative Studios, a podcast about modern day artifacts of Asian American life and the stories they reveal. Listen on Apple Podcasts, Spotify, Amazon Music, or wherever you get your podcasts.
Dr. Celine Gelgich
Acast helps creators launch, grow and monetize their podcasts everywhere. Acast.com.
Podcast: Breaking the Rules: A Clinician's Guide to Treating OCD
Hosts: Dr. Celine Gelgec & Dr. Victoria (Tori) Miller
Air Date: May 4, 2026
Episode Theme: Understanding Extinction Bursts in OCD Treatment
This episode delves into the concept of "extinction bursts"—a crucial but often misunderstood phase in the treatment of Obsessive Compulsive Disorder (OCD), particularly during Exposure and Response Prevention (ERP) therapy. Dr. Gelgec and Dr. Miller explain why clients frequently experience intensified symptoms before improvement sets in, how to prepare both clinicians and clients for this phenomenon, and practical strategies to navigate it successfully.
Definition & Analogy
Drs. Gelgec and Miller provide a practical, compassionate, and often humorous guide to understanding and managing extinction bursts in OCD treatment. By setting realistic expectations and reframing discomfort as a sign of neurological change, clinicians can help clients persist through the hardest—but often most fruitful—parts of recovery. Their advice centers on clear psychoeducation, normalization, and a focus on resilience over symptom elimination.