Inference-Based CBT (I-CBT): How it Works, Examples, & Effectiveness

What Is Inference-Based CBT?

Inference-based CBT is a new kind of Cognitive Behavioral Therapy that helps people with Obsessive Compulsive Disorder (OCD) better understand how their mind works to create doubt, obsessions, and compulsive urges. Most CBT approaches focus on helping people identify, challenge and correct faulty or unhelpful thoughts that negatively affect their mood and behavior. I-CBT focuses on correcting the underlying reasoning process beneath these thoughts.^1,4

According to I-CBT, OCD obsessions develop when people mix up possibility with probability, becoming convinced an unlikely outcome will occur. In the I-CBT model, this process is called “inferential confusion,” and is problematic because it sparks doubt, leading to obsessive OCD thoughts. According to I-CBT, identifying and correcting the underlying reasoning or thinking process can alleviate OCD symptoms.^1,2,4

Core Principles of I-CBT

I-CBT is based on the idea that OCD obsessions develop from inferential confusion between what’s possible and what’s likely. According to this theory, people with OCD have a tendency to make incorrect inferences in certain situations, which leads to excessive self-doubt and rumination. I-CBT helps people with OCD understand how this process works, and helps them identify their own faulty inferences that lead to obsessions and compulsions.^1,5,6

In most cases, inferential confusion arises when people:^4,6

• Mistrust their own judgment, senses and perceptions

Example: ‘Did I just lock the door or am I misremembering???’

• Make irrelevant associations

Example: ‘Maybe he’s in a bad mood today because I came in 10 minutes late.’

• Overestimate the likelihood something will occur

Example: ‘If I tell her I can’t go to the party, she’ll break up with me.’

One of the main objectives of I-CBT treatment for OCD is to identify the reasoning processes creating these conclusions, understand where they’re coming from, and adjust them so they align more with reality. I-CBT also helps people learn how to develop more trust in themselves and their perceptions, making it more difficult for doubts to take over.⁴

What Is The Difference Between CBT & I-CBT?

Both CBT and I-CBT are cognitive therapies that work to help people understand and adjust faulty or unhelpful thinking processes. The main difference between CBT and I-CBT is that in CBT, specific OCD obsessions are usually seen as random, illogical, and lacking in meaning. That’s why CBT is focused on changing specific thoughts while I-CBT is focused on understanding the underlying structure that creates them.⁶

In traditional CBT for OCD, the focus might be on coming up with facts and evidence that suggest something bad will happen. In I-CBT, the focus would more likely be on figuring out how the doubts formed in the first place and what faulty inferences are causing them. I-CBT therapists also spend time helping people identify ways they reinforce their OCD doubts (i.e. through checking compulsions) and how they can stop these behaviors.³

How Can I-CBT Help With OCD?

I-CBT can help some people with OCD overcome the debilitating self-doubt that drives their symptoms. Most people with OCD have a tendency to ruminate and overthink, almost like their mind is trying to solve a puzzle without having all of the pieces. I-CBT can provide these missing pieces by helping people analyze and understand the thinking processes that lead to their obsessive thoughts. This may also help to improve insight and awareness into symptoms, which can help prepare them to respond in more effective ways.^2,3

I-CBT can also equip people with the information needed to identify these thinking errors when they occur quickly, and give them strategies to respond differently when they do. For example, I-CBT focuses on helping people become more trusting of themselves and their observations, tuning into their 5 senses and learning to make decisions based on this data. Over time, this can help people re-establish self-trust and avoid the doubt spirals characteristic of OCD.^1,2,4

Is I-CBT Effective?

According to a number of peer-reviewed studies, I-CBT is an effective treatment for OCD. I-CBT is considered an evidence-based treatment for OCD. Still, it is a newer form of CBT that was only developed in the late 1990s, and more research continues to emerge about its efficacy. In studies, I-CBT produced a similar reduction in symptoms as other proven OCD treatments like Exposure and Response Prevention.^5,6

Still, not everyone with OCD will respond to I-CBT treatment. One study found that I-CBT is more effective with people who have a stronger belief that OCD thoughts are real/valid.⁵ The I-CBT treatment model does not include exposure therapy, which means it may be less helpful to people who struggle with OCD-related anxiety and avoidance coping, or those with co-occurring anxiety disorders or phobias.⁶ Overall, a number of studies suggest that I-CBT is an effective treatment for OCD, regardless of the specific subtype or symptoms they have.⁷

I-CBT Therapy Techniques

A variety of techniques are used in I-CBT to help people identify, understand, and correct errors in their reasoning process. Early on, clients receiving I-CBT learn more about the way their mind works, how thoughts are produced, and how OCD doubts and intrusive thoughts arise. Next, they work with a therapist to map out the specific thought processes and sequences that lead to OCD obsessions and compulsions. Finally, they will work with the therapist to develop alternative processes and sequences that can loosen up the old, problematic ones linked to OCD.^1,4,6

Here are some examples of I-CBT therapy techniques:^4,6

1. Identifying Specific OCD Doubts

In I-CBT, clients work to identify specific doubts, fears, and intrusive thoughts linked to their OCD symptoms. Depending on the subtype of OCD a client struggles with, these might be linked to a fear of failure, inflicting harm, developing an illness or a tragic accident occurring. Identifying specific doubts is necessary for the therapist to individualize therapy to the needs of each client.

2. Understanding the Origins of OCD Doubts

Understanding where OCD doubts and fears come from and what past associations, stories, or beliefs are linked to them is another common technique in I-CBT. Sometimes, the origin story of a specific doubt or fear is found in a painful or traumatic past experience. Other times, it’s related to a specific belief or story a client is telling themselves. Understanding the origin story of specific OCD doubts can make it easier for clients to identify triggers, as well as helping the therapist tailor their treatment.

3. Identifying the Doubt Sequences Leading to OCD

I-CBT therapists help their clients map out the sequence of their doubts to show them how they lead to OCD obsessions. Usually, a doubt sequence begins with some kind of trigger that leads to doubt, which then leads them to overestimate the probability of a bad outcome. From there, this can lead to intense anxiety and compulsive urges. Mapping out the doubt sequence prepares clients to interrupt the sequence once they develop the necessary skills and techniques.

4. Finding the Underlying Reasoning Process

A central part of I-CBT involves helping clients identify and understand the reasoning processes that have led them to feel doubt, confusion, and inner conflict. This process usually involves stringing together associations and inferences the person is forming based on irrelevant information. By finding the underlying reasoning process, the client and therapist are able to develop strategies to interrupt the faulty process with more relevant and accurate information.

5. Comparing Real Self to Feared Self

Another I-CBT intervention that is sometimes used is to help clients identify their “real self” from the person they’re afraid of becoming if they give into OCD thoughts and doubts. This intervention helps people encounter the deep-seated fears they hold about the kind of person they are, which is often the source of many OCD-related doubts. By comparing the real self to the feared self, clients can develop a more realistic self-concept and become more confident in themselves.

6. Catching OCD Doubt in Action

Once a client has a solid understanding of the way their mind is forming OCD doubt and obsessions, they are better able to notice the doubt sequence in action. I-CBT therapists might encourage them to track these sequences in a journal or thought log, and eventually prepare them to catch this process in real time. Once they’re able to catch their OCD spirals in the moment, they are able to interrupt them and change the sequence by using CBT skills.

7. Interrupting the Doubt Sequence

Interrupting the doubt sequence is also a common I-CBT intervention. This involves helping people notice doubts when they first arise so they can interject with a more confident thought process. People ground themselves in facts gathered by their momentary perceptions and five senses rather than relying on their imagination to provide those data points. The goal of these interventions is always to starve out the doubt by refusing to feed into it and instead relying on in-the-moment observations and data.

8. Relying on Real-Time Data

Real-time data is information we gather by observing a situation, interaction or the environment to figure out what’s happening and what we need to do in response. Real-time data can come from our five senses (smell, taste, touch, vision, hearing) or other observations formed when paying attention to what’s happening in the present moment. These skills are crucial to I-CBT because they help people learn and practice making more accurate and realistic appraisals rather than relying on their imagination to come up with inferences.

9. Relapse Prevention & Tracking OCD Mind Tricks

Once a client has become able to identify, understand, and interrupt the faulty thought processes driving their OCD, the next step in I-CBT is to focus on relapse prevention. Relapse prevention often entails coming up with a detailed plan on how to manage symptoms long-term, including remembering how to identify and interrupt unhelpful OCD thoughts and doubts. Many therapists help clients make a list of triggers, warning signs, and tricks of the mind they notice when their OCD is flaring up, which can lower the chances of their symptoms returning.

Challenges & Considerations of I-CBT

I-CBT is a proven and effective treatment for OCD, but that doesn’t mean it works for everyone. Studies suggest that I-CBT has comparable success rates to other leading OCD therapies like ACT, ERP, and MBSR.⁵ I-CBT may be slightly less effective when used to treat cases of OCD that involve frequent avoidance, compulsive rituals, and routines, which often respond better to exposure therapies like ERP.^8,9,10

Anxiety and avoidance symptoms may be better treated with exposure-based therapies like ERP or more traditional CBT for anxiety. One potential benefit when compared with exposure therapy is that many clients find I-CBT less distressing since it does not involve uncomfortable exposures to anxiety and OCD triggers.⁵

What to Expect During I-CBT Treatment

I-CBT is a relatively new kind of specialized therapy, and treatment might look a little different depending on the therapist’s personal approach and counseling style. Most forms of I-CBT involve individual therapy sessions where you work on identifying OCD thoughts and doubts, understanding where they come from, and working to adjust the underlying thinking processes that cause them. While the exact length of treatment can vary, 12-24 sessions is fairly standard.^2,3,8,9,10

Examples of I-CBT

I-CBT treatment for OCD can be customized to the specific doubts, fears, and obsessive thoughts of each client. Because people with different subtypes of OCD can experience significantly different kinds of intrusive thoughts and compulsive urges, it can help to have a few examples of what treatment might look like.

Here are some examples of I-CBT therapy for different kinds of OCD:⁴

• Someone with harm OCD might spend time understanding their own fears of becoming a violent, aggressive, or dangerous person and identifying false or inaccurate data points they rely on to form this feared version of themselves
• Someone with contamination OCD may work with their I-CBT therapist to make a list of false alarms that cause them to believe they’re at risk of contracting an illness or infection
• Someone with relationship OCD may be asked to identify an underlying story or belief that they have that causes them to doubt whether their partner is faithful to them constantly
• Someone with checking OCD may be encouraged to evaluate the role that checking and re-checking plays in their doubt sequence to illustrate how checking compulsions make doubt worse, not better

Is I-CBT the Right Choice for You?

I-CBT is considered an evidence-based practice for OCD, which means it has shown success in multiple peer-reviewed studies to work as well or better than other proven treatments. Still, even the most effective and proven treatments won’t work for everyone. While it’s not possible to predict individual treatment responses, there are some people who may be a better fit for I-CBT than others.

I-CBT may be a good treatment option for your OCD if you:^1,2,5,7

• Have a lot of self-doubt and questioning of your own thoughts and perceptions
• Are deeply disturbed by the types of obsessions and don’t understand them
• Want to understand how your mind works and where OCD thoughts come from
• Spend a lot of time thinking about and analyzing your own thoughts
• Feel like you’re lacking in self-awareness or insight into your symptoms
• Don’t have a lot of avoidance behaviors that interfere with your daily routine
• Have tried exposure therapy or other OCD treatments and not had success
• Feel that there is some pattern, logic, or truth to your OCD thoughts and obsessions

What Is the Cost of I-CBT?

The cost of I-CBT varies depending on where you live, what therapist you see, and your insurance coverage. It’s fairly standard to pay $250 or more per hour for therapy in big cities like LA or NYC, but it’s possible to find a therapist for $150 or even $100 if you live in a more rural area. Some people choose to save money with subscriptions to online therapy providers, but it might not be possible to find a therapist trained in I-CBT.

Does Insurance Typically Cover I-CBT?

Most of the time, it’s more cost-effective to see a therapist who is in-network with your insurance plan, but it depends on your coverage. Insurance companies usually pay therapists the same amount of money, no matter what kind of therapy they do (i.e. I-CBT vs CBT vs ACT) so I-CBT shouldn’t cost more than other therapies.

Usually, if you have health insurance, outpatient therapy is covered under your plan, but you may need to meet a deductible or copay before your insurance kicks in. If you have a deductible to meet, it means you have to pay the full cost until you meet a certain dollar amount (i.e. $5,000 per year). If you have a copay or co-insurance, it means you will pay a set amount each session and insurance will cover the rest, assuming the therapist is in-network.

How to Find an I-CBT Therapist

Many people begin their search for a therapist online by using a free online therapist directory that allows them to narrow search results by location, type of therapy, and area of specialty. A therapist directory can be a great resource for finding therapists who provide I-CBT, especially since it is a new and specialized form of treatment. You may also have success conducting an online search for I-CBT therapy near you, and there is also a list of I-CBT therapists on this site.

Other Treatments for OCD

Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Exposure and Response Prevention (ERP) are commonly used to treat OCD.^8,9,10 These therapies are usually provided during individual therapy appointments, and may be combined with antidepressant or antipsychotic medication for better results. Also, because OCD is a specialized area of practice, it’s often necessary to find a therapist who has training and experience in treating OCD.

Types of Therapy for OCD

Certain types of therapy might work better than others for someone with OCD, depending on the type of OCD they have and the severity of their symptoms. People who struggle with a lot of OCD compulsions like cleaning, checking, or hand-washing often benefit most from exposure therapy approaches like ERP.⁸

Those who are interested in alternatives to I-CBT for OCD may consider some of the following proven therapies:^9,10

• Cognitive Behavioral Therapy (or CBT): CBT for OCD teaches people about the relationship between their thoughts, feelings, and behaviors and how to adjust or change unhelpful thoughts that contribute to their symptoms and find healthier alternatives for compulsive routines. Research suggests most people with OCD need 12-14 sessions for optimal results.
• Exposure therapy: Exposure therapy is a kind of CBT treatment for anxiety that is also effective in the treatment of OCD. Gradually, clients receiving this treatment will be encouraged to face feared triggers and use CBT and relaxation skills to manage the anxiety they feel. Research suggests that including exposure therapy in CBT treatment often leads to better and faster results for people with OCD.
• Exposure and Response Preventions (or ERP): ERP is an evidence-based treatment for OCD that aims to expose someone to situations that trigger their symptoms gradually. ERP therapists encourage the use of mindfulness, relaxation, and other skills instead of using compulsive behaviors to cope. Over time, this helps to desensitize people to their triggers, reduce compulsive behaviors, and instill more confidence in using other, healthier coping skills in response to their OCD thoughts and urges.
• Acceptance and Commitment Therapy (or ACT): ACT is another evidence-based therapy that can be used to treat the symptoms of OCD that promotes the use of emotional acceptance and mindfulness skills to help people respond to difficult thoughts and feelings in healthier ways. Research suggests that ACT is just as effective as CBT for OCD.

Medications for OCD

For some people with OCD, therapy in addition to medication, provides the best results. While there are no FDA-approved medications for OCD, there are a number of medications that are used off-label for OCD. The most commonly prescribed medication for OCD symptoms are antidepressants, which work on certain receptors in the brain linked to mood and anxiety. Less commonly, someone with OCD may be prescribed an antipsychotic medication, which can help reduce the number and intensity of obsessive thoughts.¹⁰

When to Seek Professional Support

OCD is widely considered one of the most debilitating forms of mental illness, and many people with the disorder report that their symptoms interfere significantly with their daily lives. Seeking treatment early on, when you first notice signs and symptoms of OCD, will usually provide the quickest and best chances for OCD recovery. Waiting until your symptoms worsen and you are spending hours per day dealing with OCD obsessions and compulsions is not advised.¹⁰

Here are some of the potential signs and symptoms of OCD that indicate a need for professional treatment:

• Uncontrollable rumination and obsessive thoughts and worries that cause distress
• Strong urges and impulses to engage in compulsive routines and rituals
• Compulsive rituals and routines that take up an hour or more per day
• Excessive self-doubt, questioning, and anxiety about things you can’t control
• Rigid and perfectionistic behaviors and routines that interfere with daily functioning
• Severe anxiety, distress, or panic when unable to follow a rigid routine/schedule