ICBT: Your unofficial guide to reality instead of imagined possibility

If you were to ask the average person “What is OCD?” They would most likely answer with “It’s about being clean”, “everything needs to be lined up perfectly” or “germaphobe”. While these answers can somewhat be correct most interpretations of OCD are often misused and cause significant harm to those who have it.

Because you see, OCD is dark. It’s a terrifying disorder that creates a narrative of the sufferer’s worst possible fear to replay in their head from the moment they open their eyes to the dreams they have at night. It’s an incessant disorder that has been played off by the media as “cute” “quirky” and overall an individual problem versus the actual mass destruction it leaves in its wake.

OCD consists both of physical compulsions that we can see and mental compulsions that the sufferer often endures alone. OCD can have a multitude of themes; these themes are carefully created by OCD based on each individual core fears or in this case vulnerable self theme.

OCD lasts because the sufferer engages in compulsions which teaches the brain this is how we need to respond to this threat when in reality there is no threat at all. This impact creates a difficult cycle for the sufferer, continuously making their world smaller and smaller to satisfy OCD all while making themselves feel miserable.

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What Is ICBT: An Overview of Inference-based Cognitive Behavioral Therapy

A Little History

Since the discovery of OCD previous clinicians attempted to use talk therapy, mindfulness, psychodynamic, existential, and more to help aid in the recovery of OCD, and yet none of this worked, it actually ended up making OCD worse.

Due to the nature of the disorder attempting to solve it in any way aids in the OCD cycle and continues to keep the

sufferer stuck. It wasn’t until ERP was created that there was finally a modality that helped those with OCD feel relief from their symptoms.

ERP consists of exposing yourself to your fears and responding without doing compulsions. For a long time, this along with components of acceptance and commitment therapy was the only form of treatment for OCD, until 1997.

Intro To ICBT

Inference-based cognitive behavioral therapy is a cognitive approach to the treatment of OCD. ERP is a behavioral approach that is cyclical; triggers to anxiety to compulsion to relief, reinforcing the idea that this belief means we solved the problem, ultimately teaching the brain it needs to react this way to the perceived threat.

ERP believes the issue lies within compulsions and aims at stopping the sufferer from performing them.

When this behavior is changed it teaches the brain there is no need to continue to perform it because nothing happened when they didn’t engage in the behavior; meaning they are safe despite OCD saying otherwise.

ICBT takes a different approach. It believes the issue in OCD is the doubts we create from the inferential confusion we experience. That was a mouthful, let me explain. ICBT has a different sequence.

Trigger, to obsessional doubt, to consequence, to anxiety, to compulsion. ICBT aims at using cognition to stop the sufferer at the doubt, getting to the point where they don’t even feel the anxiety piece of the OCD sequence. But how?

Inferential Confusion

The main issue ICBT sees with those who experience OCD is inferential confusion. Inferential confusion is when the sufferer confuses reality with imagined possibility using the inferences we make throughout our life to fill in the gaps to create that imagined possibility. Everyone gets inferentially confused and has doubts, the difference is those with

OCD get obsessive doubts instead of reasonable doubts. The aim of ICBT is to work through the understanding of how OCD gets us sucked into this obsessional narrative, teaching us how to slow down and trust our common sense, logic, and 5 senses in the here and now.

All of this is done to resolve these doubts before even stepping into possible consequences for doubts that have no basis in reality.

ICBT believes experiences we have throughout life create inferences that OCD uses to provide “evidence” for these obsessive doubts. For example, if a sufferer is experiencing relationship OCD and they are on a date with their partner and don’t feel love they could have a doubt “What if I don’t love my partner?” The typical response is anxiety and then compulsion.

In ICBT we would want the sufferer to slow down and question “How am I getting here?” NOT “Is it true or not”.

An inference pulling them in in this case could be “Well I saw a movie once where the main character started to fall out of love with their partner when they were on a date.” or “My friend told me she always feels love for her partner.”

The suffer is linking there doubt to these past experiences and using them as evidence to identify if she does or does not love her partner. The cognitive approach gives the sufferer space to allow thoughts to happen.

Not questioning if they are true or not but instead slowing down, recognizing how they got there, and then with time/tools/practice making a different choice.

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Benefits of ICBT for OCD: Advantages and Effectiveness

Quick Clarification

When it comes to any treatment modality for OCD I want to make it clear: ONE IS NOT BETTER OR WORSE THEN THE OTHER. Having multiple modalities to treat a disorder is about choice. In the same way we don’t all like broccoli we won’t all like ICBT

however we still need to eat our vegetables so instead we’ll have carrots or asparagus but either way we are still getting the nutrients we need to survive. We should think about OCD treatments the same way.

Some people may not respond to ERP and then use ICBT and it works for them. The same goes for ICBT to ERP. It’s all about choice. One modality may be better for a particular person but that does not mean the other isn’t also helpful and effective for someone else.

I am making this statement because I’ve seen numerous discussions surrounding the validity of ICBT or a growing source of debate between the two modalities when instead it should be about choice. When something is evidence-based based we should use it.

With OCD being such a difficult and under-treated, under-researched, and with limited treatments shouldn’t we be excited about the possibility of more?!

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Advantages of ICBT

Now with all that said the term “advantages” is relative but I will be going over a few ways ICBT can be seen as an advantage for both the client and some clinicians. The number one difference is no exposures.

ICBT focuses solely on the cognitive process and does not utilize exposures as a way to bring on the fear in order to reduce it. This can be highly attractive to clients because exposures are scary and can feel overwhelming at times.

It’s attractive to clinicians because exposure work is again, scary, although the clinician isn’t scared of the exposure it’s a difficult process to see your client struggle.

As mentioned in ( O’Connor, Koszegi, Aardema, van Niekerk, & Taillon 2009) ICBT is working upstream helping the client understand the narrative process in which they ended up in that imagined world. In which long term, ICBT teaches you to trust yourself over your OCD.

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This can be done with ERP but in ICBT a larger emphasis on choosing yourself and learning who you truly are while trusting is a key component of ICBT. It teaches you that your thoughts are not random (Julien, O’Connor, Aardema, F. 2009).

While that sounds scary it can be helpful for a client to recognize the how. ICBT again will never attempt to argue or reason with OCD for the why but understanding the how allows clients a very clear picture of how OCD bates you into its games.

These games in the ICBT model very clearly sees the sufferer in a dissociative state (Soffer-Dudek, Lassri, Soffer-Dudek, Shahar 2015) This dissociative state not being the physical or typical dissociation you often hear of; but instead, this dissociation being due to us believe the narrative and inferences we link to whatever we fear; going from reality to perceived imagination.

Now again while this may appear scary it can help the client see that going into this dissociative process is separate from who they are as well as a state of being that they can and will get out of.

How ICBT Works: A Step-by-Step Guide to the Therapy Process

ICBT is a 12-module process where in each module you learn something about OCD, yourself, or a tool, with inferential confusion being the main driving issue for clinicians to get clients to understand.

From personal experience, I see ICBT as split into two large halves with a whole lot of complexities mixed in; overall bringing everything together and eventually having that aha moment.

The Psycho-Education Phase

The first few modules go over both psychoeducation on OCD and the way ICBT views OCD. You learn what inferential confusion is (which ICBT sees as the main problem), the OCD sequence, reasoning categories, how OCD creates stories, the imaginative process of OCD, your vulnerable self theme, and more.

These first few modules encourage the client to slow down and begin recognizing the OCD sequence taught within those modules. The psycho-education within ICBT helps teach the client the importance of recognition and attempting to understand how we got from trigger to compulsion so quickly.

Most sufferers aren’t even aware at times why they even feel such a sense of urgency to compulse, ICBT wants to understand that how.

A key difference I want to note here is yes we are turning and looking at our thoughts and attempting to understand them, but I want to make it clear we are NOT trying to understand our obsessions or attempt to know if something is or is not true we are attempting to understand the how in the cognitive process in order to better understand the man behind the curtain. OCD.

The Self-Trust Phase

Once the client comprehends the psychoeducation part of ICBT as well as recognizes the way in which they are getting stuck, the clinician can move on to the second half of the issue; self-trust. Gaining that self-trust instead of trusting OCD is essential in the ICBT process. Within ICBT we go deep into understanding the vulnerable self theme.

Essentially the VST is another doubt and OCD’s biggest lie. Overall it is the biggest doubt and the thing we overall fear will come true if our obsessions are true. Via ICBT we learn to understand we are the opposite of our VST and that this is just another way OCD tries to bait you into playing its games.

A wide range of techniques are used in order for the client to get a better grasp on not getting sucked into the OCD bubble (another ICBT concept).

Tools such as the bridge (a tool overall allowing the client to make a choice) the void (an understanding of experience) the tricks and cheats of OCD (a list of tangible examples to notice what you’re experiencing and then refocus) creating counter stories (the creation of other possibilities besides the one OCD created)

Reasoning categories (understanding and labeling different reasons you’re getting sucked in) reality sensing (the use of your 5 senses, common sense, and logic to pull you out of the imagination and into reality) who is your real self? (Noticing ways you are the opposite of your VST), and more.

Each module is designed to be used in order however after some of the psychoeducation pieces are done you can jump around a bit at the best judgment of the therapist. Many times after going through all the modules the client and clinician can assess for what needs to be gone over again as a refresher or what didn’t stick the first time.

Overall using this 12-module process to get the client to choose reality over the imagined possibility created by OCD through infereintal confusion.

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Online Resources for OCD and ICBT: Where to Seek Help

With ICBT being so new there aren’t any programs specific to ICBT yet. However, there are many clinicians out there who are open for outpatient services as well as group work with ICBT. Some clinicians have even created self-help programs specific to ICBT. But a good place to start if you’re looking for ICBT resources is the ICBT website.

The website goes in-depth about its process, provides free resources for both sufferers and clinicians, research relating to the validity of ICBT, books, worksheets, online videos on each module, and more. Instagram is also a great place to find ICBT providers or to see more in-depth ideas about its concepts.

If you want to learn more you can follow my own account @obsessivelystrong and some other wonderful clinicians spreading ICBT knowledge: @christinacounsels, @ocdwhisperer, @anxiouslybalanced, @anxietyocdtreatment, @ocdfamilypodcast