You Don’t Have to Buy Into OCD’s Story
Inference-Based CBT (I-CBT) in San Francisco and Throughout California
What is Inference-Based Cognitive Behavioral Therapy?
Inference-Based Cognitive Behavioral Therapy, also known as I-CBT, is a second-line evidence-based treatment for Obsessive-Compulsive Disorder (OCD).
We all rely on reasoning guided by our senses to get through our day. Sometimes our senses don’t pick up on anything, so we keep moving along. Other times, they may pick up on something that seems off. That is when our mind brings a contextually relevant possibility to our awareness, and we act on it. However, there is a second kind of reasoning process that individuals with OCD slip into, called Inferential Confusion. During this process, individuals distrust/disregard their sense data, the very thing that normally guides our reasoning. This leads the mind to apply factual information in contexts where it doesn’t belong and get caught up in imagined possibilities rather than reality-based ones. This process is what leads to the formation of obsessions. According to I-CBT, obsessions don’t just come out of nowhere; they are formed by Inferential Confusion.
By understanding the inner workings of Inferential Confusion and how obsessions are formed, clients can begin to slow this process and learn to create inferences/conclusions that are reality-based. They can create a new narrative based on sense data, relevancy, and the present moment. Clients can begin to recognize when their mind wants to cross over to Inferential Confusion- and choose not to go there. This leads to less doubt and greater self-trust. By targeting OCD at the reasoning stage, we can stop the obsession from forming. Therefore, the distress/anxiety and urge to perform compulsions don’t occur either.
The goal of I-CBT is not to argue or try and disprove obsessive thoughts. It is to demystify and break down Inferential Confusion, the process that leads one to reason their way into obsessions in the first place. Clients will understand the why and how to their obsessions. Inference-based CBT is a great option for those who may have tried ERP therapy and did not achieve the success they had hoped, or those simply looking for an alternative to exposure-based treatment.
What can I expect when starting Inference-Based CBT?
I-CBT is a cognitive-based approach that involves a lot of education coupled with exercises and in-between session practice to help reinforce concepts. Throughout treatment, we will go through a series of modules, which will be done at the client’s pace. At times, it may be essential to go back and reinforce learning that wasn’t quite grasped the first time. Slowing things down is key to treatment. Treatment starts with education on the OCD sequence, the Inferential Confusion reasoning process, and how it compares to the adaptive reasoning process that we engage in with everything else in life.
Below is an outline of the modules covered in treatment, with a brief description of each:
Module 1: The Obsessional Sequence
This module covers the different parts of the Obsessional Sequence (the OCD cycle) and provides examples of how it can be applied to various OCD doubts. Clients learn to identify where Inferential Confusion shows up for them and how their obsessional doubts fit into the sequence.
Module 2: The Logic Behind OCD
This module covers how OCD uses very real information as evidence to justify the obsessional doubts. This includes rules, facts, hearsay, personal experiences, and possibilities. Obsessional doubts are so believable because they ARE based on real information. However, this information is taken out of context and not applicable to the here and now.
Module 3: The Obsessional Story
This module covers the concept of storytelling and how life is all about our minds creating stories that shape our perceptions and affect our emotional state. Clients will learn how OCD has created a convincing narratives through Inferential Confusion AND that other non-OCD stories can exist.
Module 4: The Feared Possible Self
This module covers the overarching fear that connects all of a client’s obsessional doubts. It is who clients fear they are or will become if they don’t listen to their OCD. That could be fearing that one is a person who harms others, is irresponsible, is negligent, is bad, etc. Clients will identify their Feared Possible Self.
Module 5: Obsessional vs. Everyday Doubts
This module helps us see how obsessional doubts differ from everyday doubts. It covers reality-based reasoning and how it relies on sensory information and direct evidence in the moment. Through examples, clients learn how Inferential Confusion pulls them into their imagination and disconnects them from reality.
Module 6: Possibility is Irrelevant
This module covers the concept of possibility and when it makes sense to attend to it. Possibility is relevant when backed by sense data (which includes more than just the 5 senses) that is present in that moment. Clients learn that possibility is never relevant with OCD due to a lack of sense data.
Module 7: The OCD Bubble
This module covers “The Bubble” that OCD pulls one in, and how scary and threatening OCD’s stories can feel when one is in it. Clients learn to identify their OCD Bubble experience, how to refrain from entering it, and how to get out if they’ve gotten pulled in.
Module 8: Reality Sensing
This module covers the reliance on senses when confronted with OCD’s imaginal stories. Clients learn how to notice when they are on the bridge that connects “Reality” with “OCD/Imagination” and how to pause, realize that they are on it, and stop themselves from crossing it. The more clients practice accepting and relying on their sense data, the easier it becomes to dismiss the obsessional doubt, stay in reality, and put a stop to the rest of the obsessional sequence.
Module 9: The Alternative/Real Story
This module focuses on creating new stories based on reality and sense information to help one stay out of The Bubble and stay grounded in reality. Clients work on making this the story they turn to rather than the false one created by OCD.
Module 10: Tricks and Cheats
This module covers the various ways that OCD tricks you into over-relying on possibility, dismissing actual evidence, and making irrelevant associations. These different tricks have names and clients can identify what relates to them.
Module 11: The Real Self
This module covers who the client really is based on what they know to be true. By comparing the Feared Possible Self to the Real Self, clients are able to observe the discrepancies between the two. Clients learn to identify who they truly are (which is generally the complete opposite of what OCD tries to convince them of).
Module 12: Relapse Prevention
This module goes over what remission looks like and how to reduce the likelihood of relapse. Clients will learn to identify signs of a relapse and what to do when that occurs.
You don’t have to keep getting stuck in the OCD Bubble! I-CBT Therapy in California can help.
If you’re looking for an alternative to ERP Therapy, Inference-Based CBT could be an option for you. Connect with an OCD Therapist in California trained in I-CBT.
What about the Resolving OCD books, will these be used in treatment?
We definitely can! My approach to I-CBT is primarily in the module format, as I am still going through the books. If you have copies of the books, we can use them throughout treatment and go through exercises together. If you don’t have copies of the books, that is okay too. You do not need to purchase or read them (but you can, if you’d like!) I will have my copies in session and will weave in content and practice exercises that I find helpful. I will also send materials after sessions, so you will have plenty of resources to review in your own time and reinforce what you’ve learned in session.
If you are not familiar with the Resolving OCD books (Volumes 1 and 2), they are the latest publications authored by Dr. Fredrick Aardema, one of the co-founders of I-CBT. You can learn more about these books here.
How does Inference-Based CBT differ from Exposure and Response Prevention (ERP)?
Here are a few ways that I-CBT differs from ERP Therapy:
I-CBT targets the reasoning process that leads to the formation of obsessions, which occurs earlier in the OCD cycle. ERP targets anxiety and compulsions, which occur later in the OCD cycle.
I-CBT is more cognitive-focused and can feel more gentle and slower-paced. ERP is more behavior-focused and can feel more intense and action-oriented.
I-CBT teaches clients to trust themselves and their senses by learning how OCD reasoning differs from everyday reasoning, and how to get back on course. ERP teaches clients how to resist compulsions, cope with fear and uncertainty, and relate to their thoughts and discomfort differently.
I-CBT is based on the idea that obsessions are not random; they come from somewhere. The focus is on understanding the how and why of their existence. ERP is based on the idea that obsessions are intrusions that are given too much meaning. The focus is on shifting the relationship with our thoughts/feelings through behavioral changes, so that obsessions are no longer perceived as threats.
Both treatment approaches address OCD differently and both teach some valuable skills!
Where can I learn more about Inference-Based CBT?
The best place would be the official I-CBT website. You can find a ton of resources there, including videos, handouts, and exercise sheets.
Where can I find an OCD therapist trained in I-CBT?
If you are in California or New York, I am an OCD therapist trained in I-CBT and would love to help you. Please feel free to connect with me below!
The official I-CBT website also has a worldwide directory of clinicians trained in this modality. Click here to go to their I-CBT provider directory page.