Inference-Based CBT (I-CBT) in Louisiana
ERP isn’t the only evidence-based treatment for OCD
A Specialized, Evidence-Based Approach to Treating OCD
Inference-Based Cognitive Behavioral Therapy, or I-CBT, is a specialized psychological treatment developed specifically for Obsessive-Compulsive Disorder (OCD). Unlike traditional CBT, which often focuses on evaluating and changing thoughts, and Exposure and Response Prevention (ERP), which focuses on approaching feared situations while reducing compulsions, I-CBT focuses on how OCD creates doubt in the first place.
I-CBT is based on the idea that OCD often begins with a shift away from what is actually happening and into a hypothetical possibility. You may know, for example, that you locked the door. But then OCD introduces the possibility that you somehow didn't. You may know that you love your partner. But OCD introduces the possibility that you don't really love them, or that your feelings aren't what they should be. You may have no evidence that you harmed someone. But OCD introduces the possibility that you somehow did and simply don't remember.
The result is a question that feels like it needs to be answered: "But what if...?"
You then begin checking, analyzing, reviewing memories, comparing feelings, researching online, asking for reassurance, or trying to reason your way to certainty. I-CBT takes a different approach to this process. Rather than spending more time trying to answer the question OCD has created, treatment focuses on understanding how the doubt was created in the first place.
What is Inference-Based CBT (I-CBT)?
Inference-Based Cognitive Behavioral Therapy is a relatively new form of CBT developed specifically for OCD. It was developed by psychologists Kieron O'Connor and Frederick Aardema and has been studied as a distinct psychological treatment for OCD for several decades.
The central concept in I-CBT is inferential confusion. Inferential confusion occurs when someone begins treating an imagined possibility as though it represents a genuine possibility in the present situation. This doesn't mean that people with OCD are unable to tell the difference between reality and imagination in general. Most people with OCD reason perfectly well in most areas of their lives. The problem tends to occur specifically around their obsessions.
OCD can cause someone to distrust what they can directly observe and instead become absorbed in a hypothetical story about what might be happening.
For example:
The door is locked, but what if I somehow didn't lock it?
My partner says they love me, but what if I don't actually love them?
I don't remember hurting anyone, but what if I did and somehow forgot?
The doctor says I'm healthy, but what if they missed something?
I-CBT helps people with OCD distinguish between doubts that are reasonable and doubts that are obsessional (and therefore not deserving of their attention).
What does I-CBT treatment focus on?
I-CBT addresses several interconnected concepts that maintain OCD. Treatment explores inferential confusion, the process by which the mind treats an imagined possibility as though it were a real and present danger. It also addresses the feared possible self, the OCD-driven narrative about who you might secretly be or become, which often underlies the most distressing obsessional themes. And it examines the difference between everyday doubt, the normal uncertainty that resolves through direct experience, and obsessional doubt, which persists regardless of evidence because it was never really based on evidence to begin with.
Working through these concepts collaboratively, clients typically find that OCD thoughts lose their grip not because they've been exposed to them repeatedly, but because the reasoning that made them feel credible has been examined and dismantled.
What is Inferential Confusion?
Inferential confusion is essentially a problem with how OCD reasons from what is known to what is possible. Imagine that you are walking into your house and notice that the front door is open. There is direct evidence that the door is open. You don't need to reason your way into that conclusion. OCD can work differently. It can take something that is merely imaginable and make it feel as though it is something that needs to be investigated.
You might think:
"I don't see anyone outside, but what if someone is hiding behind the house?"
"I know I didn't hurt anyone, but what if I somehow did and can't remember?"
"I love my partner, but what if I don't actually love them enough?"
'“I see no signs that this surface is contaminated, but what if it is and I just can’t sense it?”
"I've never experienced psychosis, but what if some of the things I'm experiencing are early signs of schizophrenia?"
These questions are difficult precisely because they cannot be disproven with absolute certainty. There is almost always another hypothetical possibility that can be imagined.
Once the possibility is taken seriously, the person begins looking for evidence. They may check, research, review memories, analyze their feelings, compare possibilities, ask other people for reassurance, or simply spend hours thinking about the question. The more they investigate, the more important the question seems.
I-CBT focuses on helping clients recognize this shift from what is actually known or directly observable to the hypothetical story that OCD has constructed around it.
How is I-CBT Different from ERP?
ERP and I-CBT are both evidence-based treatments for OCD, but they approach the disorder differently.
Exposure and Response Prevention (ERP) involves intentionally approaching situations, thoughts, images, sensations, or other experiences that trigger OCD while reducing the compulsions and avoidance that normally follow. ERP has been studied extensively for decades and has the strongest and most established evidence base among psychological treatments for OCD.
Inference-Based CBT (I-CBT) focuses on the reasoning process that produces obsessional doubt. Rather than primarily using exposure to feared situations, I-CBT helps people recognize how OCD moves them from direct evidence into hypothetical possibilities and why those possibilities begin to feel as though they require investigation.
I-CBT is newer than ERP and therefore has a smaller research base.At the same time, it is not simply a theoretical treatment or an untested alternative to ERP. Research, including randomized controlled trials, supports I-CBT as an effective treatment for OCD, and its evidence base continues to develop.
There is also no reason to assume that one approach will be preferable for every person with OCD. Some people find the behavioral approach of ERP to be a good fit. Others find that I-CBT's focus on obsessional doubt and reasoning makes more sense of what they have been experiencing.
The choice of treatment should be based on the way OCD is presenting, the person's treatment history and preferences, and what approach is most appropriate clinically.
Frequently Asked Questions about I-CBT
Is I-CBT evidence-based?
Yes. I-CBT has been evaluated in clinical research, including randomized controlled trials, and is considered an evidence-based treatment for OCD. It is important to distinguish this from ERP, however. ERP has a much larger and more established research base because it has been studied for considerably longer.
Is I-CBT the same thing as regular CBT?
No. I-CBT is a specific treatment model developed for OCD. Although it falls under the broader CBT family, its theory and treatment procedures are quite different from the generic cognitive restructuring that people often associate with CBT.
Does I-CBT involve exposure?
Exposure is not the primary mechanism of I-CBT. Unlike ERP, treatment does not center on deliberately exposing yourself to feared situations while preventing the associated compulsions. Instead, I-CBT focuses on the reasoning process that creates and maintains obsessional doubt.
Can I-CBT help with "Pure O"?
Yes. I-CBT can be relevant when OCD involves primarily mental compulsions such as rumination, reviewing, analyzing, comparing, and reassurance seeking.
Is I-CBT better than ERP?
There isn't good evidence to conclude that I-CBT is generally better than ERP. ERP has a considerably larger evidence base and remains the most established psychological treatment for OCD. I-CBT is a newer evidence-based option that may be a good fit for some people.
How long does I-CBT take?
Treatment length varies depending on the person and the complexity of their OCD. I-CBT is a structured treatment, and treatment typically involves regular sessions as well as practicing the concepts between sessions. Generally, speaking, there are about a dozen modules of material to cover, each one taking 1-2 sessions.
Who is I-CBT a good fit for?
I-CBT tends to be a particularly good fit for people who have tried ERP and found it ineffective or only partially helpful, people who feel that exposure-based treatment isn't right for them, and people who want to understand and address the cognitive roots of their OCD rather than working primarily through behavioral exercises. It is also used with adolescents and young adults.
I-CBT is not limited to one particular OCD "subtype." OCD can attach itself to almost anything, and the subject matter of the obsession is generally less important than the process occurring underneath it.
I-CBT may be used to treat concerns involving:
Relationship OCD (ROCD)
Harm OCD
Scrupulosity and moral OCD
Mental health OCD
Health-related OCD
Contamination OCD
False memory OCD
Real event OCD
Sexual or taboo obsessions
Sensorimotor OCD
"Pure O" and primarily mental compulsions
Perfectionism, symmetry, and "just right" OCD
OCD about OCD
For example, the content of a relationship obsession may be very different from the content of a harm obsession. However, both can involve treating a hypothetical possibility as though it needs to be resolved before the person can move forward.
This is one reason I-CBT focuses less on the theme of OCD and more on the way the person has become caught up in the doubt/the way the doubt is constructed.
I-CBT for OCD in Louisiana
I-CBT is still relatively uncommon compared with ERP, particularly outside of specialized OCD practices. If you are specifically looking for an I-CBT therapist in Louisiana, finding someone who has received formal training in the model can be difficult.
I have completed specialized training in I-CBT and provide this treatment to adults throughout Louisiana through telehealth. I also provide in-person OCD therapy in Lake Charles.
I do not exclusively treat OCD with I-CBT. I also provide ERP, and I think it is important for people seeking OCD treatment to have access to both approaches rather than assuming that one treatment is appropriate for everyone.
During an initial assessment, we can discuss what your OCD looks like and whether ERP or I-CBT seems like the better fit.
Ready to start?
If you are considering seeking out specialized treatment for OCD I encourage you to reach out. I am available for in-person sessions in Lake Charles, Louisiana and online throughout Louisiana. Reach out today for more information or to schedule a free consultation.