Inference-Based Cognitive Behavioral Therapy (I-CBT) for OCD: Exploring A New Approach

Introduction

What is Inference-Based Cognitive Behavioral Therapy (I-CBT)? Read this blog to learn more about OCD, OCD therapy and the types of CBT approaches to treatment. CBT therapy is an evidence-based treatment approach for individuals suffering from symptoms of OCD. And now people have access to a different type of CBT treatment for OCD. 

Read on to learn more!

OCD can be a challenging mental health illness with regards to long term recovery following treatment. A recent Canadian study by Osland and others in 2018 found, “the prevalence of diagnosed OCD in Canada was 0.93% (95% CI 0.75-1.11)”. It has also been found that people with OCD were younger and had lower incomes. Further, they reported experiencing mood disorders and generalized anxiety.

Research has shown that CBT approaches to treatment for OCD have been shown to be effective. However, obsessive compulsive disorder treatment can sometimes be difficult to endure and not all individuals will finish treatment successfully.

ERP-based CBT Therapy for OCD is often an important place to begin treatment. This type of CBT treatment for OCD involves gradually approaching events and activities that you have been avoiding due to anxiety, distress or, possibly, feelings of disgust. However, Exposure and Response Prevention work can be hard! We all know it is uncomfortable to face our fears. And the idea that we must learn to tolerate uncertainty can be very challenging. Let’s review traditional CBT for OCD and also talk about a new approach, I-CBT for OCD, and what it is all about!

Traditional CBT for OCD

What do we mean by traditional CBT for OCD?

There is often a focus on Exposure and Response Prevention when we do CBT therapy for OCD. Exposure Therapy, for OCD and other anxiety disorders, is focused on helping you to face your fears. Your OCD therapist might suggest facing your fears in a gradual manner (i.e., with the use of a fear hierarchy or fear ladder).

We also might suggest working with you to decide on which fears are most important to face. How will your life change if you can meet a friend for a coffee? What would be involved in that? Would that be a meaningful goal to work towards? Given how difficult it can be to do exposure and response prevention work, we want to make sure that it is meaningful for you and will bring you closer to living a life that feels meaningful. 

The types of strategies and tools you will learn in traditional CBT for OCD in terms of exposure and response prevention would include:

• Learning about anxiety and how it is not dangerous, just uncomfortable
• Learning about Exposure and Response Prevention and how it works
• Creating an exposure hierarchy or fear ladder and decide what you want to focus on, in terms of facing your fears
• Receiving coaching during sessions to practice exposure and response prevention
• Planning for exposure and response prevention work you can do in-between sessions

Another focus in traditional CBT for OCD is about reframing our cognitive appraisals. This is a very important skill to learn as it allows both adolescents and adults to gain perspective from their thoughts. It is easy to get caught up in our thoughts and see them as “fact” rather than something we can question and consider alternative perspectives. 

You might be wondering, what are cognitive appraisals? Cognitive appraisals are thoughts about thoughts.

The Obsessive Compulsive Cognitions Working Group established 6 domains of appraisals that are important in OCD. The beliefs pertain to the following domains:

• Inflated responsibility (hold oneself to a high level of responsibility for preventing possible negative outcomes to oneself or others)
• Over importance of thoughts (believing that a persistent unwanted thought must be important because the individual experiences frequently without actually wanting to)
• Excessive concern about the ability to control one’s thoughts (a belief that one should be able to control one’s thoughts, particularly those that are unwanted; controlling thoughts will allow for the avoidance of something bad happening)
• Overestimation of threat (overestimating the likelihood of something catastrophic happening)
• Intolerance of uncertainty (belief that one must achieve absolute certainty in terms of thoughts or actions; importance of predicting everything that could happen)
• Perfectionism (belief that it is possible to always have/achieve the best response/action to every situation or issue that presents itself)

For example, someone might experience an intrusive thought when touching a doorknob such as, “There are tons of germs on that doorknob”. This thought may, in fact, be true. But the thought about the thought could then be, “If I touch the doorknob, then I will contract a terrible illness” (overestimated threat) or “I must ensure that I do not contaminate my children” (inflated responsibility).

These thoughts are “faulty cognitive appraisals“. We work on reframing these thoughts within the context of CBT treatment for OCD.

The types of strategies and tools you will learn in traditional CBT for OCD in terms of cognitive strategies would include:

• Psycho education about anxious thoughts and what maintains them in the OCD cycle
• Increased awareness regarding anxious thoughts and OCD-related thoughts
• Noticing and recording cognitive appraisals linked to OCD-related thoughts
• Understanding different types of cognitive appraisals 
• Gathering evidence for and against cognitive appraisals
• Creating balanced cognitive appraisals that take into account all the evidence that exists
• Skills to modify ideas regarding inflated responsibility 

Inference-Based CBT: Key Concepts and Advancements

• Research on I-CBT
• Obsessional doubt and obsessional story
• Looking at the process of our thoughts
• Learning about direct evidence, using our senses to help us gain this direct evidence
• Inferential confusion – where people are getting stuck
• Learning to not enter the OCD bubble 
• Recognize the role of our imagination in OCD story

Inference-Based CBT is another type of evidence-based CBT for OCD. What is I-CBT for OCD? In traditional CBT approaches to OCD therapy, obsessions are understood as intrusive thoughts. However, in I-CBT for OCD, we think of obsessions as being the result of obsessional doubts that develop. When we hear ourselves thinking “What It”, “Maybe” or “I/That Might Be” – we might be going down the path of obsessional doubting. 

When obsessional doubting happens, we may conclude that what we believe could happen is actually going to happen! For example, if we have the thought, “What if there are germs on the doorknob” we then jump to the consequence of, “These germs are dangerous and I am contaminated”. However, we have no direct evidence or proof that there are toxic particles on the doorknob and we have actually touched “enough of them” (i.e., in such quantity) that anything problematic will happen at all.

Do microbes exist everywhere? Sure! But do they exist in such quantities that every doorknob we touch is a direct pathway to contamination and death? Definitely not – and we can say that we certainty. 

Therefore, when we engage in I-CBT for OCD, we begin to recognize what our OCD story actually sounds like. Our OCD story can actually convince us that what we believe to be happening (in our imaginations) is actually happening in reality.

This process is referred to as inferential confusion and is a key concept in this type of CBT treatment for OCD. I-CBT for OCD provides you with skills and tools to recognize when your OCD story is taking hold. When this happens, you become caught up with your OCD story and don’t rely on yourself, your senses, or the direct evidence that you have in order.

Your OCD story can be that convincing.

In these moment we often cross the bridge from reality into the story our imagination has created. You move into the OCD bubble and will conduct compulsions or rituals.

I-CBT for OCD will help you to learn ways to understand the process of your thinking and not move into the OCD bubble. You will learn to trust in what is happening around you and recognize your OCD story for what it actually is – not the truth. 

When learning I-CBT you will discover that your obsessional doubts are due to the unhelpful narratives driven by your OCD. You will also learn about the idea of typical doubts. A typical doubt emerges for reasons that are connected to reality, and not our imagination. People often experience typical doubts and we do not need to alter them. Unlike obsessional doubts they will not create the need to engage in compulsions or rituals. 

I-CBT for OCD is a type of CBT therapy that allows one to build trust in themselves. When you engage in this CBT approach to treatment for OCD, you will develop important alternative stories. These stories allow you to believe in your five senses and direct evidence that is happening in reality.

Trusting in your senses and yourself will be an important part of therapy. And often will be empowering and meaningful! You will also learn that you are able to trust your senses and direct evidence in other situations where your OCD is not playing a role. Throughout this CBT treatment for OCD, you will be able to embrace your true self. 

Current research on I-CBT for OCD has found that I-CBT is an effective CBT treatment for OCD. A study from 2022 found that I-CBT treatment for OCD produced similar results to more traditional CBT for OCD. Significant reductions in OCD symptoms were found at the end of treatment. It was also found to be particularly effective for individuals who had an overvalued ideation in terms of their OCD-related thoughts.

Overvalued ideation refers to how individuals with OCD can sometimes have difficulty distinguishing when their thoughts are truly a product of their OCD or when their thoughts more accurately reflect what is happening in the world around them. This study was not a direct comparison of I-CBT to ERP or traditional CBT treatment for OCD. That research is currently underway and results appear to be promising.

The Future of Inference-Based CBT for OCD

Inference-Based CBT for OCD is definitely here to stay! Research supports this approach as being evidence-based and allowing individuals an alternative to traditional ERP-based CBT treatment for OCD. Is there one right approach to start with when I begin CBT therapy for OCD? That question is not yet answered by any research. However, it is a very important conversation to have with your therapist. Depending on your OCD symptoms, its impact on your life and what treatments you have tried in the past, you can discuss what would be the best OCD treatment approach to start with. 

Conclusion: Where Can I find a Therapist Who Does Inference-Based CBT for OCD?

Does FTPS offer Inference-Based CBT for OCD near me? We do! We offer this CBT treatment approach for adults as well as adolescents. Our clinicians have done training in I-CBT and continue to engage in professional development  in order to provide you with the best treatment possible.  We deliver virtual OCD counselling therapy services across Canada, throughout Ontario and British Columbia. We look forward to hearing from you so we can tell you about our treatment approaches and services. Contact us today!

References

Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J-S, O’Connor,K. (2022). Evaluation of inference-based cognitive-behavioral therapy for obsessive-compulsive disorder: A multi-center randomized controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.

Amir, N., Bouvard, M., Carmin, C.N., Clark, D.A., Cottraux, J.A., Eisen, J.L., Emmelkamp, P.M., Foa, E.B., Freeston, M.H., Frost, R.O., Hoekstra, R., Kozak, M.J., Kyrios, M., Ladouceur, R., March, J.S., McKay, D., Neziroglu, F., Pinard, G., Pollard, A., Purdon, C.L., Rachman, S.J., Rhraume, J., Richards, C., Salkovskis, P.M., Sanavio, E., Shafran, R., Sica, C., Simos, G., Sookman, D., Steketee, G., Tallis, F., Taylor, S., Thordarson, D.S., Turner, S.M., van Oppen, P., Warren, R., José, & Yaryura-Tobias (2003). OBSESSIVE COMPULSIVE COGNITIONS WORKING GROUP*.

Burchi E, Hollander E, Pallanti S. From Treatment Response to Recovery: A Realistic Goal in OCD. Int J Neuropsychopharmacol. 2018 Nov 1;21(11):1007-1013. doi: 10.1093/ijnp/pyy079. PMID: 30184141; PMCID: PMC6209853.

Clark, D. A. (2020). Cognitive-behavioral therapy for OCD and its subtypes (2nd ed.). The Guilford Press.

Osland S, Arnold PD, Pringsheim T. The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: A population-based Canadian study. Psychiatry Res. 2018 Oct;268:137-142. doi: 10.1016/j.psychres.2018.07.018. Epub 2018 Jul 11. PMID: 30025284.

www.icbt.online