What is Inference-based Therapy (I-CBT)?
Updated: Sep 2
I am one of a small handful of clinicians in the U.S. who specializes in a type of therapy called Inference-based Therapy, or Inference-based Cognitive Behavioral Therapy. I-CBT is an evidence-based therapy that offers an alternative to exposure therapy (also known as Exposure & Response Prevention, or ERP), which is currently the predominant form of therapy provided by therapists to treat OCD. While I am trained in ERP, I have come to greatly prefer using I-CBT, and most of my clients do as well. They find it gentler and less daunting than doing exposures while at the same time deeper because it gets to the root of things.
So what is I-CBT?
I-CBT has the goal of helping people with OCD learn to trust themselves and their senses. People with OCD will often have a false story in their mind about who they are that makes them predisposed to interpreting the random thoughts everyone has in a certain way. For example, let's imagine someone is cooking with their partner and notices how sharp the knife is that their partner is using. People without OCD might think "wow, that could really hurt someone," and may even have an image of their partner getting stabbed and bleeding come into their mind. But it wouldn't be a big deal, because we all have weird thoughts like this. They would move on. Someone with OCD, however, if they had a feared imaginary version of themselves as a bad person, might see this knife, notice how sharp it is, and have this same image of their partner getting stabbed, but it wouldn't end there. The feared version of themselves they carry about being a bad person would influence how they interpret that image of their partner being stabbed. Instead of moving on the way someone without OCD would, someone with this narrative about being a bad person would wonder something like, "what if deep down I want to stab my partner?" They might then respond by refusing to be in the kitchen if their partner is around because they don't trust themselves not to suddenly become violent or because they don't want to have to deal with images of themselves that they think are proof that they are a bad person. Someone without OCD wouldn't have the need to do this because they don't have this false story of who they are going on in the background. They would experience the exact same images without any "what if" questions because there is no ongoing imaginary narrative to interpret it as supporting. They know they don't want to kill their partner. Just like they know their favorite color or if they like dogs or feel hungry. But part of having OCD is not trusting who you are and the way you perceive the world.
So part of the work in I-CBT is to help people discern if they are coming across data and then arriving at a conclusion, or if they are coming to a situation with a story already in their mind and then interpreting data as evidence that fit that narrative. When people with OCD are able to recognize that they have been doing the latter, they understand that they have been under a spell that alters the way they interpret reality and who they are. In our work together, you will break the spell of OCD that is causing you to doubt and finally be able to see who you really are and trust your perception of reality.
So how does it differ from the other OCD treatments that are currently out there?
To answer that question, I've got to dig into theory just a little bit. The first wave of OCD treatments followed what is called the habituation model. That is, expose yourself to something so many times until you aren't afraid of it anymore. Exposure therapy is considered very effective, although it's effectiveness rate is only 60%. The major problem with the habituation model is that someone with OCD can do a bunch of exposures and habituate to their fear such that they are no longer afraid but then come back later when their OCD has jumped to something else and then they have to habituate to that new thing. For example, let's say someone has fears of being contaminated. So they do a bunch of exposures where they touch things they consider dirty and then aren't allowed to wash their hands. They do this so many times that they eventually stop being afraid of not washing their hands. Which is great! But then they come back six months later because they are worried they have obsessions about accidentally harming their child or not turning their stove off. Rinse and repeat. So habituation had good results for the target obsession, but it wasn't transferable to other obsessions.
The next wave of treatment was centered around what is called the inhibitory learning model, which mostly shows up in the form of Acceptance & Commitment Therapy (ACT). ACT recognizes that compulsions are largely about avoiding uncomfortable emotions and thoughts. For example, someone with harm OCD might avoid watching the news because certain stories would trigger fears that they might be a violent person, or another person might review social situations in their head over and over to make sure they didn't say anything offensive to avoid having to experience any shame or regret. ACT asserts that uncomfortable feelings aren't inherently dangerous; they are just uncomfortable. Nobody wants to experience anxiety, but anxiety isn't going to kill us. If we can learn to tolerate the presence of anxiety and uncertainty instead of resorting to compulsions, then we are able to carry on and live a life based on our values rather than based on the dictates of the OCD. A huge emphasis in ACT is on accepting uncertainty and learning to be okay with the fact that none of us can ever know anything for certain, but we can live our lives with purpose and intention regardless. OCD treatment that utilizes ACT involves exposures but the goal isn't to get rid of the fear as it is with the habituation model. ACT exposures are about knowing you can feel the fear and do it anyway. The goal of exposures here are to change your relationship with the thoughts and feelings rather than the thoughts and feelings themselves.
Back to I-CBT...
In I-CBT we say, wait a minute, there are some things you do have some certainty about. Sure, we don't know anything 100% for sure. I can't guarantee the sun is coming up tomorrow. But I don't live my life tolerating the uncertainty that it might not. I round up and live my life under the assumption that it will because I have no reason to believe otherwise. If I had a story in my mind that the sun isn't going to come up tomorrow, I'm sure I could convince myself that all sorts of data point to it. For example, it did rise slightly later this morning than it did yesterday morning, and yesterday morning it rose later than the morning before that. So why shouldn't I believe one day soon it won't rise at all?
Just because you can make a case for something, doesn't mean it's worth entertaining or sitting with. Because we can make a case for anything.
Were it not for the false story about who you are in your head, you would not be entertaining things that are irrelevant. In ERP and ACT, the focus is behavioral. The theory is that once you change your behavior, your thinking will follow. In I-CBT, it's the reverse. When getting I-CBT, you will learn how to figure out what is and isn't worth entertaining, how you got this false story about who you are in your head, how to change it so it is more in line with who you really are, which then allows you to feel safe trusting your sense of reality and live the life you want.
How can I learn more?
If you are struggling with OCD and are interested in receiving I-CBT, please using the contact form to reach out to me. If you are a clinician and interested in consultations or my training courses, please check out the information under the TRAINING section in the heading.