I-CBT Skills Series: How to use off-theme examples in Inference based CBT for OCD

If you’ve worked as an OCD therapist for long, you’ll notice something peculiar. Clients have vastly different concerns from one another. While some are concerned of contamination, others feel they have to monitor themselves for signs of illness. Others still are worried about their sexual orientation changing from under their feet, or the possibility of their unwanted thoughts having the power to change reality for the worse.

This is a boon for clinicians, who have a menagerie of doubts to choose from when working to illustrate concepts to clients. All throughout inference based CBT (I-CBT), we use off-theme examples, this means that we are illustrating concepts using obsessions that are not triggering to the client in front of you. The more unbelievable the obsession is to the client in front of you, the better.

Why?

I-CBT is an insight building process. We also know that OCD is very selective - no one is going to be susceptible to every theme of obsession. By using examples that are beyond belief for the client in front of you, the therapist can illustrate that the client’s OCD works in the same way as the OCD that is beyond belief, and thus renders the client’s obsession equally ridiculous. This is a critical exercise in I-CBT because it is the way that the obsession is constructed that always renders the obsession false.

Let’s take a detour into the kitchen for a moment. Your friend bakes a cake. They find their recipe, purchase all of the ingredients, and bake it. They go to taste it, and it’s terrible. It’s dry, bland and unappetizing. You take the recipe they used and try to recreate the cake. Unsurprisingly, your cake is also completely inedible. What went wrong? 

It’s probably the recipe! We want the client in front of us to see that their obsessional reasoning, or the recipe, is the issue. If the therapist can get the client to see that their obsession is constructed in the exact same way as an obsession that is not credible to them, the client is on the way to resolving inferential confusion, and their OCD.

Pick a story from their OCD’s arsenal of narratives.

Here is an example:

My sister is leaving town for the weekend. I think that she could get into a car accident. She’s not the most careful driver, and I-91 has a bunch of lunatics. The last time I drove up to Boston, we witnessed a near-accident on I-91. Nobody has called me to tell me she’s been hurt, but it’s possible that she might not be paying close enough attention to the road, or maybe she could get hit by a drunk driver. She’s driving up there on St. Paddy’s day weekend for the parade, and you know how people are. Think about it, car accidents happen. Years ago, I had a dream about her getting into an accident once that was so, so vivid - and some people believe that dreams have special significance. There’s whole books on the significance of dreams, and some people say that dreams can even be prophetic, so what if because I dreamt it, it happens? I’ve begged her to take the backroads, but I know she won’t listen. I had her send me a live view of her location so I can track her to make sure she’s there safely, since it’s possible that she could get into a car accident and be incapacitated and not able to call for help. Yeah, I checked it several times and it says that she’s safe, but she might not be.

Look closely at how the obsessional story is constructed. These are the three reasoning categories in inferential confusion, or obsessional reasoning. Irrelevant associations are highlighted in yellow, over-reliance on possibility is blue, and distrust of senses and self is green.

My sister is leaving town for the weekend. I think that she could get into a car accident. She’s not the most careful driver, and I-91 has a bunch of lunatics. The last time I drove up to Boston, we witnessed a near-accident on I-91. Nobody has called me to tell me she’s been hurt, but it’s possible that she might not be paying close enough attention to the road, or maybe she could get hit by a drunk driver. She’s driving up there on St. Paddy’s day weekend for the parade, and you know how people are. Think about it, car accidents happen. Years ago, I had a dream about her getting into an accident once that was so, so vivid - and some people believe that dreams have special significance. There’s whole books on the significance of dreams, and some people say that dreams can even be prophetic, so what if because I dreamt it, it happens? I’ve begged her to take the backroads, but I know she won’t listen. I had her send me a live view of her location so I can track her to make sure she’s there safely, since it’s possible that she could get into a car accident and be incapacitated and not able to call for help. Yeah, I checked it several times and it says that she’s safe, but she might not be.

Now let’s construct a similar storyline and use the same ingredients, but we will change a few details of the story. Those ingredients again are over-reliance on possibility, distrust in the senses and self, and irrelevant associations. And one more time, irrelevant associations are highlighted in yellow, over-reliance on possibility is blue, and distrust of senses and self is green.

My wife is leaving the house to walk the dog. I think that she could step in pesticides. She’s not the most cautious person, and they just sprayed the lawn down the street. The last time I took the dog for a walk, I saw those little flags saying pesticide had been applied. I didn’t see anything on the sidewalk, but it’s possible that she might not be paying close enough attention to where she walks, or maybe they over-sprayed the lawn onto the sidewalk. She doesn’t know anything about pesticides, and you know how careless those lawn people can be. Think about it, when surfaces are wet you get that liquid on your shoes. Years ago, I had a dream about her getting sick once that was so, so vivid - and some people believe that dreams have special significance. There’s whole books on the significance of dreams, and some people say that dreams can even be prophetic, so what if because I dreamt it, it happens? I’ve begged her to not go that way, but I know she won’t listen. I had her send me a live view of her location so I can track her to make sure she’s not going near the house with the pesticides, since it’s possible that she could be totally careless and step in it and track it inside the house, which would contaminate the whole house. Yeah, I checked it several times and it says that she didn’t go that way, but she could have walked past it while I wasn’t looking at the app.

We’ve changed some details. Instead of a sister, it’s a wife, and instead of the concern about someone’s safety, it’s concern about contamination. Yet, the over-reliance on possibility, irrelevant associations, and distrust in senses/self are the same. These are two stories about what could happen, supported by irrelevant associations. Notice also what is also missing - in both vignettes, there is no direct evidence of a problem in the here and now. As a matter of fact, in both vignettes, the client did have sense evidence that there was actually no problem, and chose to ignore it. 

The first client will likely believe that their obsession is credible, and the second obsession is not. What we want the client to notice is that the two obsessions are constructed identically, and both are equally irrelevant because both are stories about what could be rather than what is. There is no direct evidence in either of these stories, rather they are constructed using indirect evidence, which renders an obsession irrelevant to reality. Again, this is a critical exercise in I-CBT because it is the way that the obsession is constructed that renders the obsession false. The obsession is always false. However, I-CBT never uses disputation as an intervention. Rather, we are demonstrating exactly why the obsession is false, because it is done so using dysfunctional reasoning with no evidence in the here and now.

Adapted by Katie Marrotte from: O’Connor, K., & Aardema, F. (2012). Clinician’s handbook for obsessive compulsive disorder: Inference-based therapy. Chichester: Wiley-Blackwell. www.icbt.online