Inference-Based CBT (ICBT)
When ERP Doesn’t Work: Try Inference Based Cognitive Behavioral Therapy
Have you been struggling with OCD? Tried ERP but it didn’t work for you? Are you feeling stuck, frustrated, or worried that nothing will help? While ERP is often considered the gold standard for treating OCD, it’s not always the right fit for everyone. That’s where a newer approach, inference based cognitive behavioral therapy, can be a meaningful alternative. ICBT is designed for those who find ERP too distressing or who haven’t had much success with traditional exposure-based methods.
The therapists at Anxiety Center of Tampa are pleased to offer this approach as part of our specialized OCD treatment services. If you’re overwhelmed by intrusive obsessions and compulsions that don’t respond well to exposure work, ICBT might be a better path forward. We provide both in-person and telehealth options for clients throughout the Tampa Bay area and across Florida.
What is ICBT?
Inference-Based Cognitive Behavioral Therapy helps clients recognize the reasoning errors that fuel their obsessive thoughts and guides them to trust their senses in the “here and now” rather than becoming entangled in imagination.
This approach also helps shift negative beliefs about the self that drive obsessive doubt and anxiety.
According to ICBT:
Uncomfortable obsessions are internally generated doubts, not random, intrusive thoughts.
These obsessions stem from reasoning about what is possible in the future, not what is probable.
These imagined outcomes are driven by a frightening story, or “obsessional narrative,” which is replayed whenever a trigger is encountered.
The obsessional narrative does not factor in current reality, common sense, or evidence from the person’s senses.
The OCD story removes the person from the present. They lose connection with the “here and now” and become stuck in an “OCD bubble.” The imagined story feels so real that it creates distress and anxiety.
Compulsions are often an effort to reduce that anxiety and delay the feared scenario from unfolding.
These actions reinforce belief in the obsessional narrative.
Obsessional themes are not random. They often reflect a “Feared Self,” such as a person worrying in Harm OCD that they might be the kind of person who’s dangerous. This distorted self-perception is a core focus of inference based cognitive behavioral therapy, which works to challenge and reframe these beliefs.
An Alternative to ERP?
ERP has long been considered the first line treatment of choice for OCD, and it can be very effective for those who complete treatment. However, many people find it difficult to tolerate the anxiety involved in facing their fears and either refuse to participate in treatment or drop out due to the distress encountered during prolonged exposure. Often, even in those who complete ERP, residual symptoms may remain or recur after treatment ends.
ICBT does not use prolonged exposure, and instead focuses on strengthening reality-based reasoning. This approach may be especially helpful for those who have not had success with ERP, do not want to tolerate the anxiety involved in planned exposures or who firmly believe their obsessions are realistic and reasonable.
Studies have found that ICBT is just as effective as ERP in reducing OCD symptoms and has a higher rate of remission. This means that people who were treated using ICBT were able to return to and maintain normal functioning in greater numbers than those who went through ERP.
You can find more peer-reviewed studies related to ICBT at the following link: https://icbt.online/publications/
What to Expect from Inference-Based Cognitive Behavioral Therapy
You may be wondering what to expect from ICBT and how it will be different from the techniques used by other therapies for OCD. As noted earlier, inference-based cognitive behavioral therapy is centered on addressing reasoning errors that contribute to obsessive doubt, rather than simply reducing anxiety through exposure. Instead, you will work with your therapist to:
Develop an understanding of the obsessional doubt that fuels your anxiety and compulsions.
Recognize the stories OCD tells you that make your doubts seem true. These often include “what if” or “maybe” statements.
Observe the reasoning errors in the OCD story that lead you to believe your feared outcome is possible.
Compare the story you think in OCD situations to the way you think in other situations. For example, if you look both ways before crossing the street and see no cars, you most likely don’t doubt what you saw and then get lost in a story about “what if there was a car coming and I didn’t see it?” ICBT trains you to trust your senses.
Learn to recognize the doubt for what it is: a made-up story that doesn’t need to be taken seriously.
Develop a more reality-based “alternative story” that is grounded in facts, common sense, and actual evidence that your senses give in the present moment.
Recognize the obsessional doubt when it arises and become aware of when you cross over into your imagined story. When that happens, you will practice taking a moment to reflect on what is happening and see that you have a choice to stay grounded in the alternative story or become absorbed in imagination.
Identify and confront your “feared self/vulnerable self theme” and see that there is another view of who you are as a person.
Look for the facts about your “real self” and gain confidence in who you are. Gaining confidence is an important part of the program.
Practice feeling confident in your senses and start to deal with OCD situations the same way you do in non-OCD situations.
Anxiety Center of Tampa’s Approach to OCD Treatment
At Anxiety Center of Tampa, you’ll have access to highly individualized therapy designed to meet you where you are in your recovery. Whether you need brief check-ins or a more intensive option, our therapists will guide your work using evidence-based approaches such as inference-based cognitive behavioral therapy. If your treatment plan includes real-world exposures, our therapists can meet you in public locations. You and your therapist will work together to decide the frequency and location that best suits your needs, and continue adjusting that plan as therapy progresses.