What is Inference-Based Cognitive Behavioral Therapy (I-CBT)
Traditionally, OCD treatments have focused primarily on changing behaviors. But what if there were an approach that helps people examine how they arrive at obsessional doubts in the first place?
Inference-Based Cognitive Behavioral Therapy (I-CBT) is an evidence-based approach for treating Obsessive Compulsive Disorder (OCD) that is built around this premise. By learning to recognize when OCD is pulling them away from reality-based information, individuals can develop greater confidence in their own judgment and experiences. I-CBT is a cognitive approach that seeks to address the reasoning errors and obsessional doubts that are at the core of OCD. There is a growing body of evidence to support I-CBT’s efficacy in significant symptom reduction in adults with OCD, and it has been recognized as a second-line treatment for OCD by the International OCD Foundation.
How does Inference-Based Cognitive Behavioral Therapy (I-CBT) work?
The foundation of I-CBT rests in the assertion that OCD is a disorder of reasoning, namely, imaginative, obsessional reasoning that is not rooted in the here-and-now.
OCD pulls us away from the reality-based information we have (the door is locked, I don’t want to cause harm to my loved ones, I’m not showing signs of a medical emergency) and brings us into the world of endless imagined possibilities. Once we leave reality and enter the imaginary, it feels necessary to engage in compulsions as they feel like the only way we can avoid our feared consequences. As we know from first-line OCD treatments like Exposure and Response Prevention (ERP), when we engage in compulsions, we validate and reinforce obsessive thinking, thus entering the maddening OCD cycle. I-CBT suggests that we can challenge and disengage from the obsessional doubt before engaging in compulsions.
In other words, we can work upstream to challenge the cognitive errors that form OCD, rather than working downstream to focus on challenging the compulsions that result from OCD.
The Three Stages of I-CBT
Inferential confusion is the distrust of your own senses, common sense, and reality-based information and an investment in remote, imagined possibilities. I-CBT is designed to help the client understand how OCD creates inferential confusion and how to rebuild trust with yourself and your senses.
Treatment consists of 12 modules and occurs in three stages: first developing an understanding of the process of OCD and inferential confusion, then deconstructing the OCD using a reintegration of your senses and common sense, and finally providing maintenance strategies to prevent relapse.
Phase One
The OCD story is one in which you are the superhero in a disaster story. If you do not act right now (engage in compulsions), then something horrible will happen (feared consequences). In phase one, clients gain an understanding of inferential confusion and the faulty reasoning OCD uses to create this story.
A powerful part of the OCD story is the character of the feared possible self. The feared possible self is often a complete opposite version of the client sitting in front of you. It is who they think they will become if they do not listen to the OCD (a bad person, criminal, pedophile, person undeserving of love, someone who suffers endlessly, etc). The inability to see themselves clearly creates an unbelievable amount of sorrow, grief, pain, and inferential confusion — all debilitating consequences of living with untreated OCD.
Phase Two
When a client begins to leave reality and engage in imaginative doubt, we call this the OCD bubble. Once in the bubble, it can become challenging to see reality and find your way back down to earth. In phase two, we deconstruct the OCD by understanding that obsessional doubt is entirely imaginary, without evidence in the here-and-now, and suggests that just because something is possible, it is probable.
OCD suggests that if you leave the OCD bubble (i.e., do not engage in your compulsion), you will become your feared possible self, resulting in feared consequences. However, if we can recognize that OCD logic is faulty and not based in direct evidence, we can leave the bubble and return to reality. Clients gain tools for reality sensing, identifying and trusting their senses, in order to establish an alternative story. In this story, you are grounded in reality and a version of yourself that you recognize, one that is opposite to the feared self in every way.
Phase Three
The final stage of I-CBT involves rebuilding a stable image of the real self, understanding the tricks OCD uses to pull you back into the bubble, and tools for relapse prevention. Clients identify the vulnerable spots for the OCD story to strike, how to challenge safety behaviors, and continue to keep themselves rooted in the here-and-now.
Can I-CBT Help with My OCD?
Finding an OCD treatment approach that resonates is an important part of the healing process. I-CBT uses cognitive theory and narrative devices to bring clients back to an improved, reliable sense of self and their reality. For people exploring their options for OCD treatment, I-CBT offers another evidence-based approach to consider.
I have found I-CBT to be particularly helpful for those clients with strong self-doubt, inner critics, and active imaginations and creativity. Engaging clients in the deconstruction of their OCD while simultaneously reconstructing a life separate from OCD instills a sense of empowerment, agency, and certainty. It is a privilege to watch someone rediscover who they are and develop an ability to respect and honor their real self. I-CBT allows clients to return to themself and the reality they have worked hard to build.
For more information about I-CBT, check out the I-CBT official website at https://icbt.online/ and resources through the IOCDF: https://iocdf.org/about-ocd/ocd-treatment-guide/i-cbt/.
Or contact us to learn if I-CBT is right for you.