I-CBT (Inference-Based Cognitive Behavior Therapy) is an evidence-based treatment for OCD (Obsessive Compulsive Disorder). I-CBT is an alternative to ERP (Exposure Plus Response Prevention), typically referred to as the “gold standard” of OCD treatment. I-CBT, while newer, has demonstrated some promising results and is easier to implement for many, as it doesn’t involve the anxiety-provoking exposures that define ERP.
The I in I-CBT stands for inference-based. According to this modality, those with OCD move away from trusting their senses, common sense, and reality-based information and engage in “inferential confusion,” where they start to trust hypothetical scenarios or remote possibilities instead. I-CBT is based on the the premise that the obsessions people with OCD experience (the O in OCD) are abnormal doubts, borne out of possibilities rather than probabilities. Someone with OCD might worry that they left the stove on or that a doorknob is contaminated and touching it will get them sick. While either of these things could happen, with OCD, folks believe that they are happening. They take small possibilities and adopt them as a reality. An analogy is someone who fears that their plane will crash because this is a possibility, despite the published odds.
The I-CBT Model of OCD looks like this:
Trigger —> Obsessional Doubt –> Consequences of Doubt –> Anxiety –> Compulsion
Using the example of someone who experiences OCD symptoms around checking their stove, the trigger would be, for instance, turning off the stove. Obsessional doubt creeps up in the form of thoughts like, “What if I didn’t turn the burner completely off? What if it’s still on?” The consequences of this doubt might be fears around burning down one’s home, killing one’s family members or pets, or anything else that comes to mind as a potential consequence of the doubt being true. Anxiety then arises as a reaction to the threatened consequences and might sound like, “What if that does happen? I’d be responsible. How would I ever cope with this?” And then we see compulsions emerge as a way to manage the anxiety, behaviors like checking and rechecking the stove.
Obsessional doubt, according to I-CBT, is the result of creating a narrative that prioritizes imagination above our senses. Instead of trusting that we did turn off the stove because we were there, saw this action happening, and felt our hands turn the knob (using the senses of vision and touch to confirm our experience), we become focused on what-ifs. “What if I didn’t turn it off completely? What if I turned it twice and now it’s back on?” We second-guess ourselves. We get stuck in obsessional doubt via five pathways: facts, rules, hearsay, personal experience, and possibility.
Sometimes, facts guide our reasoning. We might get caught up in the fact that stoves do get left on at times or that houses do burn down due to oven fires. Rules are laws or cultural norms that dictate our behavior. We might have grown up hearing from firefighters that it’s important to check certain things in our homes to reduce the likelihood of fires. Hearsay is something we’ve heard from others that guides how we’re thinking. Maybe a friend told us a story about a house fire or we watched a story on the news about someone whose house burned down because of their stove. Personal experience might involve having once accidentally left the stove on for a little while after cooking. Finally, possibility evokes the idea that anything can happen (“Anyone could set fire to their home accidentally”)and that because anything is possible, this is what’s happening now.
I-CBT aims to bring resolution to obsessional doubts by comparing them to normal doubts, which arise due to legitimate reasons and are directly relevant in the moment (e.g., I can see some smoke. Maybe there is a fire”). Obsessional doubts, on the other hand, are a function of our imagination – not our senses – and are based on the reasoning above (facts, rules, hearsay, personal experience, possibility). With I-CBT, we encourage folks to trust information from their senses (vision, smell, hearing, taste, touch) and to create a narrative that is based on this sensory information, above the anxiety-based narrative that draws us in. We create another story to replace the one fueled by obsessional doubt.
In I-CBT, we also attend to something called the “Vulnerable Self Theme.” The Vulnerable Self Theme (VST) is what we fear about ourselves. The VST for our example above would be the imaginary idea, “Maybe I’m someone capable of causing a great deal of harm.” Many VSTs involve fears of harming others. This theme typically contradicts reality; it’s generally the thoughtful, compassionate people who have these fears cross their radar. OCD, also imaginary, functions to protect you from your VST, what you most fear about yourself. But the VST, and the OCD story that arises to protect you from it, are simply based on possibilities.
With I-CBT, we talk about people getting stuck in an “OCD bubble.” Here, their OCD symptoms protect them from their VST, but living in the bubble positions them for a lifetime of obsessions and compulsions. Leaving the bubble can be anxiety-provoking, as OCD will activate and warn you that you’re likely to experience your VST) but doing so is what ultimately set you free. To exit the bubble, we identify the first thought that removed us from our sensory reliance (and took us into an imaginal space) and figure out what sense we might trust to re-root in reality.
If you picture a fork in the road, one path has you doubting reality, where you can walk indefinitely on a path of what-if. The other path leads to you to lean into what you know to be true as a function of your senses. In our example, we might bring our attention to the first thought we had about the stove being on (e.g., “Wait, did I turn the stove off?) and consider how this thought triggered an experience of self-doubt. We might picture this thought as placing us at the fork in the road, where we then set down the imaginary/danger-ahead route. But there’s a reality route here too. The key is to rely on your senses the way you do for everything else. You pay for an item at a store and then walk out, knowing you paid because you watched yourself hand your credit card to the clerk and sign the receipt. You accelerate at an intersection because you see the light turn green. You trust your senses in other situations. This is what needs to happen for the stove. You rely on your senses – the visual and touch senses of turning off the appliance – to create a new story. You rely on this story rather than the other story, the what-ifs, the imagination-fueled possibilities. OCD tries to trick you into doubting your senses, telling you things like, “Sure you usually turn off the stove, but maybe this time you didn’t” or it puts you through double jeopardy, “Sure you checked the stove, but maybe you pressed the button so hard that it actually turned on again.”
It’s important to be be mindful of “sneaky” OCD symptoms. For instance, avoidance can sometimes play a role in OCD. In our example, maybe someone just stops cooking so they don’t have to face their fears at all. Maybe they start seeking reassurance or support, asking others to confirm the stove is off or to tell them that they are careful with their actions. These behaviors are “sneaky” because they can keep folks stuck in OCD but aren’t such obvious compulsions.
Finally, it’s important to flesh out your “real self,” since your VST doesn’t exist in reality. Who are you? What kinds of behaviors do you typically engage in? How would you describe yourself based on these behaviors. What are your values? Your intentions and desires? The more solid you get about your real self, the less space your VST has to enter the equation.
Recovery from OCD using I-CBT is possible. It involves not reacting to obsessional doubts (emotionally or behaviorally), using your senses to guide you, and engaging with life as your real self. Note that certain states (e.g., fatigues, stress, other emotions) can bring us back into the OCD bubble, searching for comfort and safety through compulsions. But ultimately, the bubble isn’t helpful, and as bubbles tend to do, it keeps us insulated from a freer and more flexible life.