If you’ve tried Exposure and Response Prevention (ERP) therapy and it hasn’t worked for you, you’re not alone. Inference-Based Cognitive Behavioral Therapy (ICBT) for OCD is a specialized form of CBT that offers an alternative to ERP. ICBT differs from ERP as an OCD treatment in that it targets the underlying thinking process that leads to obsessional doubt and works to unravel it, rather than focusing primarily on reducing compulsions. Compared to ERP, it gives you a different perspective for managing intrusive thoughts.
In this post I’ll tell you more about what ICBT is, what the process looks like, and how to know if it might be an option for you.
What Is Inference-Based CBT?
ICBT is a specific form of CBT, which is considered the gold standard treatment for most anxiety and depression symptoms. ICBT for OCD offers a different treatment approach – one based on the core idea that for some people inferences (or assumptions/conclusions) become confused. People begin making inferences that are off (for example, that food is dangerous, my hands are contaminated, I might do something dangerous, what if I’m evil?) because of problems in the underlying reasoning process.
Inference-Based CBT helps you understand the factors that are leading to these wonky inferences. You develop an understanding of how certain pieces of information are used in inaccurate ways and the logical traps that reliably lead to obsessional doubts. ICBT also helps you build awareness of the imaginary stories that come up about danger, risk, and all possible feared scenarios. These stories set the stage for thoughts to become sticky.
How Does ICBT for OCD Differ from Traditional CBT?
One difference between ICBT and CBT is how they address cognitions. Inference-Based CBT challenges the thinking process, not the conclusion. While traditional CBT often includes “examining the evidence” using an “evidence for” and “evidence against” approach, ICBT is not about challenging the actual content of the intrusive thoughts. For example, we would not try to “prove” that food is safe, or your hands are clean. Instead we would examine the factors that led you to this conclusion in the first place in order to help you see how that process got off track and led you down a rabbit hole toward an inaccurate assumption.
Traditional CBT for OCD, which includes Exposure and Response Prevention, also focuses more on deliberate exposures while ICBT does not. People sometimes struggle with ERP, finding the process overwhelming and struggling to participate fully.
Exposure is not a focus of ICBT. While resuming everyday activities is a goal in ICBT, the assumption is that when you clearly see that your intrusive thoughts are based on a faulty reasoning process and you can resolve the doubts, that “exposure” isn’t necessary because the anxiety no longer seems legitimate.
Key Concepts of ICBT for OCD
ICBT is based on several core ideas. The first is that obsessional doubts (or intrusive thoughts) are the result of faulty reasoning. OCD often takes facts, things that happened to other people, your own personal experience, and other pieces of information and twists them so that they appear to justify a doubt. This twisting of information is the faulty reasoning process that we work to adjust in treatment.
The second ICBT principle is that stories about triggers and stories about the self set the stage for this faulty reasoning. People with OCD often take information and weave it together to construct an entire narrative about the risk involved in a certain behavior. These narratives are usually driven by deeper fears about the kind of person we’re afraid of becoming. For example, if I have a fear that I’m the kind of person who is careless or negligent, I might develop OCD stories about missing important signs that I’m having a health issue.
Finally, ICBT for OCD emphasizes that OCD is driven by a lack of trusting yourself. People with OCD often find they can’t trust their senses, their common sense, or their own inner senses. This distrust is maintained by compulsions like checking, seeking reassurance, googling, redoing behaviors, trying to figure things out “for sure,” and others. These behaviors, in the long run, reinforce the idea that you can’t trust yourself, locking you in a negative cycle. You can read more on the ICBT website.
Benefits of ICBT for OCD
The ultimate goals of ICBT overlap with those of ERP in some ways. The primary goals are almost always to decrease the time spent with unwanted thoughts and time consuming compulsions (mental and physical). ICBT has additional benefits in that people often find that their doubts feel “resolved” and that they have a stronger sense of self. The approach also teaches you how to trust yourself again, building more resilience over time. Finally, ICBT offers an alternative to ERP for those who have tried it before and not benefited or who are not sure if they are ready or willing to work on directly addressing their fears with exposures.
What Does ICBT Look Like In Practice?
ICBT in session is typically highly structured. Each session is designed to teach you a specific concept that you can then immediately start practicing with outside of session. ICBT includes daily homework, which might be a worksheet, log, or practice.
Specific interventions include learning to recognize the faulty logic in OCD and practicing making evidence-based conclusions. This type of conclusion is grounded in real life (not the imagination). You’ll learn to rely less on the idea that because something is possible it deserves attention and action. Strategies will also help you develop a deeper understanding of your feared self (who your OCD says you are or could become if you’re not careful). Finally, to combat your feared self, you’ll develop ways to connect with your true self. This involves learning to trust yourself and your senses.
For example, if you were working through ICBT, you might develop a list of questions to ask yourself to stay grounded in reality and to avoid going into your imagination. Imagine you have health anxiety and you notice some tingling in your foot. You might have an obsessional thought about having multiple sclerosis and feel very anxious.
ICBT would help you to slow down to see where you made the leap from tingling to MS and the reasoning process that led you there. You would work to see the role of your feared self (maybe someone who is vulnerable or unable to cope well) in coming to that conclusion. It might also be helpful for you to develop an alternative interpretation that sticks very closely to reality and facts and avoids relying on possibility.
You might answer questions like:
- What evidence (from my senses, common sense, and existing knowledge) do I have right now to support this doubt? What do I know for sure? (If stuck, use Is This Evidence worksheet).
- Can I describe the OCD story? In other words, what are the “reasons” (out of context facts, hearsay, personal experience, guidelines, it’s possible) your OCD uses to make this doubt seem credible?
- Would I have these doubts if I didn’t have my story and feared self? Is my story influencing the conclusion I’m coming to or would anyone come to this conclusion?
ICBT Group Therapy
Working in a group can be very helpful when learning ICBT for intrusive thoughts for a few reasons. First, it’s so helpful to feel that you’re not alone. To know that you’re not the only person who struggles with obsessional doubts and to feel supported is very valuable. Second, seeing the ways other people become inferentially confused can show you how the process works for themes that aren’t concerning to you. A group program for ICBT can pave the way for seeing how the process works for you.
ICBT offers an alternative to ERP for people with OCD symptoms. ICBT works on the cognitive processes that lead to intrusive thoughts (or obsessional doubts) that cause distress and lead to compulsions. If this approach resonates with you, you can learn more on the ICBT website.
In January 2025 we’re opening the doors to our new ICBT for OCD Group Program. The program includes online access to course materials, resources, and exercises, as well as weekly online group sessions to review the concepts and complete homework for accountability. Learn more about the ICBT for OCD program and join the waitlist.