Why I learned I-CBT for OCD

Inference-Based Cognitive Behavioral Therapy is Resonating with My Neurocomplex clients

As a therapist specializing in treating OCD, I’ve long relied on Exposure and Response Prevention (ERP) because it can be so effective. I’ve also appreciated the addition that Acceptance and Commitment Therapy (ACT) can bring, allowing for a wider lens on the process of struggle with OCD. Nevertheless, I’ve noticed that some clients, often my autistic clients, find exposure’s emphasis on tolerating uncertainty and discomfort overwhelming, sometimes in practice, and just as often in theory. Some of my ADHD clients find the process hard to stick with, or have difficulty with response prevention, which relies heavily on redirecting attention and will power.

Recently, I began exploring Inference-Based Cognitive Behavioral Therapy (I-CBT), through training, consultation, and practice, and I’ve been struck by how approachable and effective it feels for certain individuals. While ERP and I-CBT are both evidence-based, I’ve found that I-CBT is a particularly gentle, structured alternative that resonates with clients who struggle with the unpredictability of exposure exercises, as well as those who find some of the ACT metaphors and processes a little too abstract.

What is I-CBT?

I-CBT is a cognitive therapy model developed specifically for OCD (and is also used with Social anxiety and Body Dysmorphic disorder). Instead of focusing on exposure to feared stimuli, I-CBT targets inferential confusion—the tendency to get caught up in imagined possibilities and disregard the present moment data. For example, rather than repeatedly touching doorknobs without washing their hands (an ERP approach), a client with contamination fears in I-CBT might understand the doubting and inference process that had them disregarding the observable state of the doorknob and common sense they would usually use, in favor of remote and intensely frightening possibility.

In ICBT, we are building wisdom with OCD’s predictable process, logic, and tricks. We are identifying where we cross the bridge from the here-and-now into an OCD bubble of feared possibility. We can pinpoint the moment when we had enough information to make a decision or move forward, but doubted that information. We see how engagement in doubt and scary story telling only serves to compound doubt. We learn what vulnerabilities make certain doubt stories irresistible. And we learn how to continuously bring attention to an enduring sense of ourselves and values, the sensory experience, and the relevant here-and-now.

Why I-CBT Resonates with some clients

Less Sensory Overwhelm:

ERP involves exposure to feared situations, which can be particularly distressing for those with heightened sensory sensitivity. I-CBT, by contrast, involves metacognitive processes and grounding in the here-and-now.

Predictability and Structure:

Many people find comfort with predictable, structured routines. The step-by-step cognitive framework of I-CBT, which focuses on challenging faulty reasoning patterns, offers a clear, consistent path—ERP, because it involves elements of surprise (ie, not knowing how your nbody will react today to a challenge) can feel uncertain and emotionally taxing.

Working primarily with thoughts:

Many clients feel more competent and thus comfortable in the cognitive domain. They may have alexithymia or difficulty speaking or moving while emotionally dysregulated, and thus find a model that helps them better understand their thinking process and escape the OCD thinking bubble a more manageable start to treatment.

ICBT has great tools for anticipatory anxiety:

For some folks, the true terror of an experience is the anticipation. In that case, an exposure can feel unmanagable because the person expects to be up all night with an obsession after challenging it, having experienced that before. ICBT helps with the thinking process in general (ie, the process of continuously engaging in those obsessions all night), and can help folks see their process happening and redirecting their attention.

ICBT is well suited for mental compulsions

I am appreciating ICBT for clients with primarily mental compulsions because it targets the inferential confusion that drives the obsessive doubt in the first place. When I do ICBT for mental compulsions, the work feels much more concrete and targeted to address what can feel like a difficult O-C cycle to target with exposure.

ICBT is gentler for certain obsessions

I have heard other clinicians reflect discomfort with certain exposure and response prevention exercises for postpartum OCD and harm OCD. The level of distress associated with “accepting the uncertainty” that a person may hurt their own child or behave in a morally abhorrent way can feel cruel with certain sensitive people. With ICBT, there is no need to accept uncertainty, because the resolution of OCD lies in accepting the current sensory and context data already available. The thinking process goes awry not due to the lack of certainty but due to the disregard of good enough information.

ICBT has a great community and lots of free resources

Implementing ICBT has been made so easy by the materials that came with my training as well as the organized website of free materials, icb.online. As a busy clinician who knows that clients benefit from practice, I’ve appreciated the free worksheets and psychoeducational materials that I can point to for between session practice. IOCDF also has a free ICBT special interest group that meets monthly, and the ICBT Youtube channel has all of its interventions filmed for demonstration along with all of its Friday meetings.

ICBT and ERP: Complementary, Not Competing

It’s important to note that I-CBT is not a replacement for ERP. Both models have strong evidence bases, and many clients benefit from a combination of the two approaches.

I am still an enthusiast of ERP. Sometimes the people who are most afraid of the spontaneous experience of facing fears are most in need of it. I genuinely believe that every person who is mired in compulsions is already doing something harder than exposure, and can ultimately handle exposure. And although exposure practice can sometimes really stretch a person and leave them exhausted, it often involves unexpected positive experiences, like deep insight and even joy.

As my practice evolves, I’m excited to offer both ERP and I-CBT to clients with OCD. I-CBT’s cognitive focus and structured framework make it particularly approachable for autistic clients and others who struggle with exposure-based methods. At the same time, ERP remains a powerful, evidence-based tool that I continue to genuinely love.

Thanks to Kristina Orlova for introducing me to ICBT and to Brittany Goff for her excellent training and materials.

Check out my article on ERP here

Related research:

A 2010 case series by Brown et al. explored the integration of I-CBT and ERP. The authors found that combining the models led to meaningful symptom improvement, suggesting that I-CBT and ERP can complement each other effectively (Brown et al., 2010).

A study by Aardema et al. (2022) comparing I-CBT to traditional appraisal-based CBT found that I-CBT was equally effective but often felt less emotionally aversive. This makes it a compelling option for clients who struggle with the emotional demands of ERP (Aardema et al., 2022).

A 2022 multisite randomized controlled trial by Wolf et al. found that I-CBT was as effective as traditional CBT in treating OCD. The study concluded that I-CBT can serve as a viable alternative, particularly for individuals who find exposure-based approaches challenging (Wolf et al., 2022).