Inference-based Cognitive Behavioral Therapy (I-CBT) is a structured, evidence-based treatment for OCD that takes a different approach compared to other common therapies like Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT). Rather than focusing primarily accepting uncertainty or resisting compulsions, I-CBT addresses the reasoning process that gives intrusive doubts their power in the first place. At its core, I-CBT teaches clients to spot and correct a mental error called inferential confusion, which is a type of faulty reasoning where imagined possibilities are treated as equally real as tangible evidence.
For example, a person might imagine that they left the stove on, and even though they clearly remember turning it off and can see that it’s off, the imagined scenario still feels just as believable. This “what if” thinking sets off the OCD cycle, and I-CBT practitioners suggest that this focus can help stop the OCD cycle “upstream,” as opposed to focusing on resisting compulsions “downstream” that come as a byproduct of this inferential confusion. By retracing the mental steps that led to the obsession, clients learn to identify the moment their mind shifted from evidence-based reality reasoning to imagination-based possibility. This process helps weaken the obsession’s believability and can help makes desired compulsions less urgent. Over time, the brain becomes better at trusting real-world evidence over these imagined threats.
What is it like to do I-CBT?
Similar to other forms of cognitive behavioral therapy, I-CBT is highly collaborative and structured. Sessions often involve mapping out the “OCD narrative,” which is the detailed story your mind tells when an intrusive doubt shows up. Together, therapist and client track the thoughts backwards to the very first leap of faulty reasoning and inferential confusion, and once that leap is spotted, it can be challenged and replaced with more grounded, reality-based reasoning. Unlike ERP, where clients intentionally confront feared situations and then resist compulsions, I-CBT works to undermine the obsession before it spirals. If it works, it means clients may find themselves naturally approaching situations they once avoided with less distress because the obsession simply is not perceived as believable anymore and therefore doesn’t arise.
“So, if I do I-CBT I don’t have to do exposures?”
Well, kind of. It is the case that I-CBT does not use the term exposure, but the truth is it depends on how you define the idea. While I-CBT does not create step-by-step exposure hierarchies, it does involve facing feared situations, though often indirectly, and reconsidering the reasoning that makes those situations feel threatening. This can be very appealing to those suffering from OCD who are looking at treatment options but are worried about the distress exposure work might bring on. However, in my opinion, is not unlike asking a client to engage in meaningful life events and experiences, which might feel like exposures, and engaging in response prevention by way of resisting rumination (such as pre-game analysis), internal compulsions, or fusion to intrusive “what if” thoughts. Where these modalities align is that both encourage a fuller life while resisting engagement with OCD, but they differ in how they define, plan, and discuss that resistance.
There is often a lot of focus on trying to show these two modalities as distinctly different, with some suggesting that ERP’s focus is to create anxiety and distress. However, as noted in a previous blog post The Ethics of ERP: Leading with Compassion, well-trained ERP therapists understand that the goal is not simply to cause distress and foster resilience within it, but to help clients move towards living fuller lives that are in-line with their personal desires, beliefs, and values. I would suggest that when ERP is viewed from this lens, the goals and directionality of these modalities are similar. If the obsession loses credibility, whether by way practicing increasing our willingness to experience distress or uncertainty, or by way of resisting and correcting faulty inferential confusion, the anxiety and avoidance often fade as well. So, again, kind of. Some I-CBT clients discover that they are naturally “doing exposures” in daily life because they’re no longer buying into OCD’s imagined scenarios, and this is often still challenging and means putting in some hard work.
How does I-CBT Compare to ACT?
While Acceptance and Commitment Therapy (ACT) and I-CBT take different routes, they also share some common ground. Both aim to change a person’s relationship to their thoughts rather than trying to eliminate them. Each encourages awareness of the thinking process and the utilization of present moment focus. Moreover, they work to help clients step back from automatic mental patterns and emphasize living in alignment with values rather than getting stuck in compulsive cycles. In ACT, this is achieved through acceptance and defusion from unhelpful thoughts and cognitive distortions, whereas in I-CBT it’s achieved by identifying and correcting faulty reasoning. In both, the goal is greater freedom and flexibility.
What the Research Says
I-CBT has a growing number of clinical studies and randomized controlled trials that support it’s use. There are still some unknowns, and the research is not as comprehensive in the United States as that regardingERP as most of the studies are coming out of Europe and Canada. But so far, these studies have shown that many clients experience a significant reduction in symptoms and report improved quality of life following the use of I-CBT. There is also evidence from laboratory-based experimental studies to support the role of inferential confusion and vulnerable-self (like Core Fears but about the self) as creating and maintaining OCD symptoms. Recent research, including a 2024 multi-center randomized controlled trial in the Netherlands ,found that I-CBT significantly reduces OCD symptoms and can be as effective as traditional CBT. Some evidence even suggests higher treatment acceptability for certain clients with mental compulsions, overvalued ideation (feeling like your obsessions are true), or those who have struggled to tolerate ERP.
The Big Picture
I-CBT isn’t designed to replace ERP or ACT, but it offers a fresh and empowering option, especially for those who feel stuck or discouraged with other approaches. By addressing OCD at the thought process level, it can make intrusive doubts less believable and render compulsions less urgent. For many, this means living more fully in the present, trusting real-world evidence, and reclaiming life from the grip of OCD. As an OCD therapist, this is my goal for my clients, and I am often looking to add more tools to my toolbox. I am open to exploring multiple evidence-based therapeutic modalities that give broader options, insights, and understandings for my clients as I know treatment is never one size fits all.
At the Nashville OCD &Anxiety Treatment Center, we do our best to investigate and get training in multiple modalities so that we have the flexibility to use them all based on our clients’ needs and symptoms. Many of our sessions will employ aspects ofERP, ACT, I-CBT, DBT (Dialectical Behavioral Therapy), Mindfulness, and other modalities in a single session as we approach our clients as whole people, and not just their symptoms.
