How is I-CBT Different From ERP?

Exposure and Response Prevention (ERP) and Inference-based CBT (I-CBT) are both evidence-based treatments for OCD, but there are some big differences between them.

Research on ERP goes back to the 1960’s. It has been a first line treatment for OCD for decades. This treatment for OCD focuses on exposing the OCD sufferer to the things they fear. This is done to either to reduce anxiety in the face of the trigger, or to help the OCD sufferer learn they can tolerate distress while simultaneously learning they can safely interact with the trigger. ERP has helped many people with OCD, but it can be hard for some people to complete treatment; and some people with OCD do not want to undergo ERP. ERP also includes response prevention - OCD sufferers are asked to resist doing their compulsions when they interact with an OCD trigger. This helps clients learn that they don’t need the compulsions to relieve their anxiety.

I-CBT dates back to the 1990’s and is rapidly growing as a tool for OCD treatment amongst OCD specialists. I-CBT focuses on helping the OCD sufferer resolve obsessional doubts. If the obsessional doubts can be resolved, then there won’t be any anxiety or need for compulsions. I-CBT does this by targeting a very specific reasoning process that creates obsessional doubts. This process is called Inferential confusion. Inferential confusion occurs when a person with OCD confuses a possibility (“Maybe the oven isn’t off”) with reality even though there isn’t evidence from the senses to support that conclusion (“I see the oven is off, but maybe it really isn't”).

These two treatments can be amazing tools in OCD treatment, but they are very different.

Exposures

ERP uses exposures to feared situations. I-CBT does not. For those who are looking to face their fears head on, ERP could be the right choice and give quick results. For those who do not want to do exposures or ERP hasn’t been a good fit in the past, then I-CBT could be a good fit as it does not include exposure work. For those that want to know the answers to "why do I have these particular doubts" and "how do I get the obsessions to stop", I-CBT could be a good choice.

Random Intrusive Thoughts vs Created Obsessional Doubts

One big difference between ERP and I-CBT is the origin of obsessions. Through an ERP lens, obsessions are seen as random intrusive thoughts that get mis-appraised as dangerous instead of being a silly thought that holds no meaning. Through an I-CBT lens, there are reasons that the person has for why they are afraid of the doubt. That reasoning is not random. Doubts are constructed through a process that is based on facts, rules, hearsay, personal experiences, over-reliance on possibility, and distrust of the senses in the here and now. The information used to build these doubts might be solid on paper, but it is being applied incorrectly to the present moment in time thus causing distress.

Imaginal Exposure vs Getting Out of the Imagination

In ERP, we use imaginal exposures to help clients in situations where real life exposures may be difficult to do. To do these, we have clients write scripts that they can either record or read over and over. The goal is for the stories to get boring and no longer cause anxiety OR for the person to realize that the can tolerate the distress the story creates while also learning that they could be safe in the imagined situation.

In I-CBT, we attempt to get clients out of their imaginations. We want them to trust their senses again in the present moment so that they can see that there wasn’t anything to worry about to begin with. Since doubts are created out of a false narrative, clients learn to trust that any story OCD has is false due to how it is constructed. So, even if it brings along real feelings of anxiety, that is just because the nervous system is getting tricked into feeling anxiety based on a false story. Getting out of the imagination and staying rooted in reality helps to see OCD was wrong all along.

Core Fears vs Feared Possible Self

In ERP, we try to help clients locate their core fears. If they didn't do their compulsions, what is the worst case scenario that might happen? Each obsession can have a different core fear. When we challenge them through exposures, the client sees that they do not happen.

In I-CBT, we help clients look at a theme across all obsessional doubts and find out what type of person the client fears they are or will become. This is called the Feared Possible Self. This concept explains the question, "Why do I get the specific obsessions that I get?" People with OCD will not be triggered by something that doesn't connect to their Feared Possible Self, but this Feared Possible Self doubt, is just another doubt. It is constructed through the same inferential confusion process and therefore can also be resolved.

Tolerating Uncertainty vs Trusting the Senses/Self

Many OCD specialists who use ERP will incorporate the concept of tolerating uncertainty. This is done to help clients stop trying to figure out whether or not something will happen and to instead embrace the uncertainty so they can move on. Clients are taught to say, "Maybe that will happen. Maybe it won't happen."

Clinicians using I-CBT, do not teach tolerating uncertainty. I-CBT states that all obsessional doubts can be resolved by trusting the senses in the here and now (current context). The senses are defined by the main senses (vision, hearing, touch, taste, smell), common sense, internal sense data (true intentions, desires, emotions, etc.), and the real self (who your everyday actions prove you to be, your goals, values, principles, etc.). By staying with the senses, the false narrative that creates obsessional doubts is shown to be false.

Tools are Good Things to Have

It is an exciting time in OCD treatment! Having more than one evidence-based treatment for OCD helps clinicians reach more people. Some will respond well to ERP. Others will respond best to I-CBT. And still others may respond to up and coming treatments like Metacognitive Therapy or Acceptance and Commitment Therapy. The difference between ERP and I-CBT doesn't make one treatment superior to the other. But it does help us get a better fit for an individual suffering with OCD.

If you are clinician who is interested in learning I-CBT - check out our I-CBT Basic Training (we have live virtual trainings or On Demand formats). If you want to get a foundational knowledge of ERP, we have a course for that too! And if you are a person with OCD who wants to learn more about I-CBT - check out our I-CBT Self Help Course offered in partnership with I-CBT Co-Founder, Frederick Aardema, PhD.

Sources

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.).

O’Connor, K. & Aardema, F. (2012). The Clinician`s OCD Manual: Inference Based Therapy. Chichester, UK: Wiley.