Beyond Exposure: How I-CBT for OCD Targets the Unhelpful Reasoning Processes

If you or someone you love struggles with symptoms of OCD, you are likely very familiar with the concept of Exposure and Response Prevention. Have you considered ERP alternatives? We know ERP does not work for everyone! Have you heard of I-CBT for OCD? Can you imagine an approach for your OCD that does not involve white-knuckling through distressing ERP therapy?

The effectiveness of ERP for OCD is approximately a 50% reduction in symptoms. Therefore, while ERP is beneficial, it does mean that half of the individuals who undergo this treatment do not improve. However, there are other evidence-based interventions available to help people manage their symptoms of OCD, such as I-CBT for OCD. Although this approach might not be as well-known as traditional CBT for OCD, it is a powerful alternative approach that targets obsessional reasoning processes. Research has found I-CBT for OCD to be highly effective for individuals seeking ERP alternatives and wanting an evidence-based treatment approach for their symptoms of OCD. 

This blog will help you explore approaches beyond ERP for OCD. We will explore the idea of doubt and OCD. We will also discuss Inference-Based CBT for OCD in-depth and review how it might be the right treatment for you or your loved one!

What is Inference-Based CBT (I-CBT)?

You might be wondering, what is I-CBT for OCD? Inference-based CBT for OCD is a Cognitive-Behaviour Therapy (I-CBT) that is evidence-based. This approach focuses greatly on ideas surrounding doubt and OCD. These doubts will typically take the form of: “What if”, “Could it be”, or “Might it be”. It is important to identify these obsessional doubts when they happen. This is the first step in realizing that OCD is driven by doubts that are not based on reality.

These obsessional doubts might sound like this:

• I might not have locked the door
• I might be contaminated
• I might be an immoral person
• I might be irresponsible
• I could be a person who harms others

There are many terms and ideas you encounter when beginning inference-based CBT for OCD. Let’s review these concepts so we understand how they contribute to the formation of OCD.

An essential idea within I-CBT for OCD is the emergence of obsessional doubts in OCD. Yes, we all have doubts. Let’s review the idea of an everyday doubt versus an obsessional doubt. You might be able to recall a recent everyday doubt that you experienced: 

• You might wonder: “Will it rain today?” To answer that question, you turn to the  evidence that is available to you. 
• You might check the weather channel, look at the sky, pop your head out the window, etc. 
• These actions provide you with evidence that guides your behavior.

Inference-based CBT for OCD is a type of OCD cognitive therapy that is based on research that OCD-related doubts are different from everyday doubts. However, it is not a traditional cognitive therapy approach, and it is important to make that distinction. This therapy is not about challenging cognitive distortions in OCD. Instead, it is about raising awareness and understanding about the stories that are developed when OCD takes over; why these occur, and how not to engage with them. 

Within this approach is also the important idea that OCD-related doubts do not just emerge out of the blue. They develop due to processes of obsessional reasoning that occur because of:

1. Distrusting in our senses
2. Over-relying on our imagination
3. Irrelevant associations.

These obsessional reasoning processes bring about an obsessional story (or narrative). When the obsessional story is created, we connect with that story, believing it as if it were happening in reality. 

This process (inferring that something is happening in reality when it is not) is called inferential confusion. People believe in stories created within one’s imagination. However, they feel real and as if they are happening here and now. Inferential confusion is responsible for individuals with OCD feeling that it is necessary to act on their obsessions. 

Importantly, I-CBT does not only help a person to understand the reasoning underlying their obsessions. Individuals will also work with their therapist to understand the fears they hold that are related to their identity, which the OCD takes advantage of. Individuals will fear being a certain “type of person” if they do not engage in rituals. This is referred to as the Feared Possible Self within OCD. It has been said that OCD provides a more comprehensive understanding of what underlies obsessional doubts, not just the consequences of not carrying out one’s rituals. 

How I-CBT Differs from Traditional ERP

There are key ways in which I-CBT for OCD serves as an ERP alternative. Let’s discuss the different approaches to ERP and how we understand them to work. 

Traditional ERP typically involves exposure to thoughts or situations that are avoided or endured. During exposure to these triggers, an individual is asked not to engage in any accompanying compulsions or rituals. Exposure over time is said to result in habituation. This means that with enough repeated exposure, an individual will feel less distress over time. 

There are other approaches when using ERP as an intervention for OCD. For example, inhibitory learning theory (ITL) uses another approach when working with individuals in an ERP-based framework. Within this approach, individuals also work with their therapists to approach triggering thoughts or situations. However, individuals are not engaging in exposure therapy to habituate to the distress that they feel. Instead, people will learn skills and tools that will allow them to build new learning strategies that will override the old fears.

In this way, inhibitory learning theory helps people to learn they can handle their fears without doing any compulsions. This approach will allow for new learning and reflections to be built around the realization that nothing bad happens when doing exposure therapy and that one’s expectations do not necessarily align with the outcome.

Acceptance and Commitment Therapy for OCD is another approach that uses ERP-based strategies. When working with a therapist who uses ACT-based ERP interventions, you can expect to focus on your values and what is important and learn more about what OCD is preventing you from doing. Exposure work will be closely aligned with your values. This will ensure that you are not engaging in ERP just to experience anxiety and endure it. Instead, you will do exposure therapy to learn to tolerate difficult thoughts and feelings while moving towards your values and what matters to you. You will also be engaging with thoughts and situations that are important to you. 

These approaches all have a vital place within the landscape of OCD treatment. They do not work for everyone, though. When we turn to using I-CBT for OCD, we are focusing now on understanding distorted reasoning processes that fuel the obsessional doubts. Obsessions are now understood as obsessional doubts that emerge due to inaccurate reasoning and boundless imagination, which results in creative possibilities being mistaken for true threats. There are no longer any exposures that take place as a core feature within this approach. One can imagine that ERP could be understood as “putting out fires”, whereas I-CBT for OCD ensures that the house contains no faulty wiring or fire hazards so that they cannot start in the first place. 

Understanding Doubt and the “Inference” Model of OCD

Let’s delve a little more into the idea of why inferential confusion is unique to our understanding of OCD and how it is understood in I-CBT for OCD treatment. 

As described, I-CBT for OCD focuses on the obsessional doubts that arise within the context of OCD. These obsessional doubts are formed around possibilities, rather than certainties. Many individuals engage in certainty-seeking behaviour. There is nothing wrong with that at times! And, in a way, I-CBT for OCD can help you gauge when you can be more certain of particular situations. 

When it comes to OCD, individuals are often highly focused on thoughts that exist within the domain of probabilities.

For example:

• You lock the door, hear the click, and walk away. A doubt forms in your head: What if I forgot to lock the door?
• You drive home on a quiet Sunday afternoon uneventfully. You turn off the engine and walk into the house, and a doubt emerges: What if I ran someone over while driving home and did not realize it?
• You have a lovely phone chat with a friend, get off the phone, and begin to make dinner. You begin to doubt some things that were said during the conversation and think: I might have said something offensive to my friend, and they are hurt and angry. 

In these instances, the doubts reflect possibilities not supported by direct evidence. Instead, they are imagined possibilities. Of course, the individual likely starts to feel these ideas are real as they move further into the imagined possibilities:

• I am unsure if I heard a full click when I locked the door. It’s possible that I left the door unlocked, and someone might come and steal things from my home.
• I was driving quickly because there was no traffic, and my window was open, making some noise. Maybe I drove over someone and did not hear anything?
• Although my friend said it was nice to talk with me, we did not plan another phone call. Maybe this is a sign that I said something offensive, and I don’t remember?

I-CBT for OCD delves into these thoughts and, through this treatment approach, you will begin to understand everyday doubt versus obsessional doubts and how this sets off a sequence of events that lead to getting lost within the doubt and feeling the urge to engage in compulsions in order to resolve what never actually existed to begin with. The true resolution within this approach is learning that the doubts exist because of your OCD and, therefore, nothing needs to happen. There was nothing to fear to begin with. 

In this way, I-CBT for OCD is not about tolerating uncertainty. It is learning that certainty existed the whole time. Yet, the OCD does a fabulous job, through inferential confusion, of implying that there is something that needs to be done and there is something you should fear. However, in reality, there is not!

There are many key strategies learned within the context of Inference-Based CBT for OCD. It is such a rich and comprehensive approach. We will continue to write about these treatment tenants in another blog!

Here is a brief overview of some of the learning that takes place when engaging in I-CBT for OCD:

• Understanding that obsessional doubts are based on processes related to inferential confusion
• Recognizing and creating your obsessional narratives; this allows you to slow down the processes of obsessional reasoning and understand your obsessional story.
• Learn how to ensure you are identifying reality from your imagination – understanding and correcting inferential confusion is at the heart of I-CBT for OCD.
• Recognize, understand, and push back against the Feared Possible Self.
• Learn what it means to avoid moving into the OCD Bubble – the place where your compulsions take over.
• Learn how to engage in Reality Sensing and be present in the here and now, where you can use all your sense data and remain firmly grounded and not move into the OCD Bubble. 

How I-CBT Fits Into Your OCD Treatment Plan

It is important to remember that no one therapy works for everyone – OCD is heterogeneous in terms of presentation and how it impacts people. You want to work with a therapist who can work from multiple approaches and use different tools and strategies.

I-CBT for OCD can be used as part of an evidence-based OCD treatment plan for you. It can be helpful in several different ways:

• For individuals who have used ERP without the success they want
• For individuals who tried ERP with success but experience a recurrence of symptoms and want to try another evidence-based approach for OCD
• For individuals seeking therapy for the first time who want to try out an approach aligned with OCD cognitive therapy

At Forward Thinking Psychological Services®, we have tremendous experience working with individuals with all types of OCD-related presentations. We ensure that we select approaches tailored to your issues and challenges. We want you to feel comfortable with your treatment plan, and we spend time doing an evidence-based assessment to ensure this. 

We believe that I-CBT for OCD can help you dismantle the challenging reasoning processes found within OCD. It can help you uncover the doubt that fuels the OCD and understand the what and why of your OCD story. 

It is important to ask yourself a few key questions: 

• Are you tired of trying to tolerate uncertainty?
• Have traditional therapy approaches not helped maintain your long-term gains?

If you answered yes to these statements, you might want to try an ERP alternative that is evidence-based and effective for your symptoms of OCD!

Does Forward Thinking Psychological Services offer I-CBT for OCD near me? If you want to learn more about Inference-Based CBT for OCD, then reach out to us at Forward Thinking Psychological Services®; our team offers services for OCD and OCD-related disorders (i.e., hair pulling and skin picking). We also offer assessment and therapy services for teens, adults, and couples. We offer services across Canada in Ontario, Nova Scotia, British Columbia, and New Brunswick. Contact us to learn more!

References

Abramowitz, J. IOCDF Website Article: The Inhibitory Learning Approach to Exposure and Response Prevention

Ardema, F. (2025). Resolving OCD: Understanding Your Obsessional Experience (Volume 1). Mount Royal Publishing. 

Aardema, F. (2025). Resolving OCD: Advanced Strategies for Overcoming Obsessional. Mount Royal Publishing. 

Capel LK, Twohig MP. ACT for OCD: An Example of ACT and Values-Based Exposures. J Clin Psychol. 2025 Feb;81(2):93-101. doi: 10.1002/jclp.23759. Epub 2024 Dec 19. PMID: 39698800.

Öst LG, Havnen A, Hansen B, Kvale G. Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014. Clin Psychol Rev. 2015 Aug;40:156-69. doi: 10.1016/j.cpr.2015.06.003. Epub 2015 Jun 14. PMID: 26117062.

ICBT Online Website

Shroyer, B. ADAA Website Article (2023): Inferential Confusion: A New Treatment Target for OCD.