General Differences Between ERP and I-CBT

Exposure and Response Prevention (ERP) and Inference-Based Cognitive Behavioral Therapy (I-CBT) are both evidence-based treatment modalities for Obsessive-Compulsive Disorder (OCD).

ERP has been considered the gold standard in treatment for those struggling with OCD since the 1960s. ERP involves exposing individuals to the thoughts, images, and things they fear while helping them learn they can tolerate the distress that arises, as well as learning they can safely interact with their triggers as they go through life. ERP also involves response prevention, which means committing to not engaging in compulsive behaviors once they experience their obsession. Over time, clients learn they no longer need to participate in compulsive behavior to relieve their anxiety. In ERP, the target is the compulsions, which can be seen as an “upstream” approach. In other words, the “knowing” follows the “doing.” If you change your behaviors, a change in your thoughts and feelings will eventually follow. While ERP has proven beneficial to numerous individuals with OCD, it also poses challenges for some, as well as for those who do not wish to pursue exposures. One of the pros of ERP is that, since it targets the compulsions, it can be more “fast-acting” to help an individual stop compulsive behavior more quickly than I-CBT.

I-CBT, originating in the 1990s, is increasingly recognized as a valuable treatment modality among OCD specialists.

I-CBT focuses on aiding individuals with OCD in resolving their obsessional doubts. Obsessional doubts can be explained as doubts that have no direct evidence from our senses to make them credible in the current context of the here and now moment. If the obsessional doubt is resolved, there will be no anxiety or subsequent need for compulsive behaviors. From an I-CBT lens, anxiety and compulsions are all downstream byproducts of obsessional doubting. In other words, the “doing” follows the “knowing.” Once the obsessional doubt is resolved, someone will not experience anxiety or feel the drive to do a compulsion to prevent the feared consequence. An obsessional doubt is resolved through understanding inferential confusion, which is a specific reasoning process that occurs in those with OCD. Inferential confusion occurs when individuals confuse an imagined possibility for a real possibility they then need to act on, despite not having sensory evidence in the here and now to support it. They are doubting their senses and self, and instead allowing a hypothetical possibility to trump their reality in that moment. While I-CBT may take more time in therapy, it can create a resolution of the confusion caused by OCD, eliminating future obsessions from creating new compulsions. I-CBT does not involve exposures and instead aims to teach clients why they get the doubts they do and how to resolve them.

FAQs on the differences between I-CBT and ERP

Does I-CBT use exposures?
No. I-CBT does not use exposures. I-CBT is a specialized cognitive therapy focused on reasoning, whereas ERP is more of a behavioral approach. For those who are looking to face their fears head-on, ERP may be a more suitable option and give quicker results. However, for those who are not wanting to do exposures or who have found ERP ineffective previously, I-CBT can offer a great alternative as it does not incorporate exposure work. Additionally, for those individuals looking for answers to why they experience specific doubts, I-CBT could be a beneficial choice.

Why does ERP see obsessions as random, and I-CBT says they are not random at all?
This is one of the larger differences between the two treatments. Through an ERP lens, obsessions are seen as random intrusive thoughts and are then misappraised or misjudged as having a lot more meaning and power than they do. This misjudgment is what creates the feelings of distress, and therefore the individual attempts to make these distressing feelings and thoughts go away with compulsive behavior. ERP teaches individuals how to accept and tolerate these unwanted thoughts because they are seen as regular thoughts requiring no action. The focus is on the emotional and compulsive reaction to their thoughts. Through an I-CBT perspective, individuals have specific reasons for having the fears/doubts that they do. I-CBT argues obsessions or obsessional doubts are inferences that are actually the result of a faulty reasoning process. This reasoning process is based on facts, rules, hearsay, personal experiences, over-reliance on possibility, and distrust of the senses in the current moment. While this information used to construct these doubts may all be true on paper, it is the application of that information to the here and now that is the problem.

Tolerating Uncertainty vs. Finding Certainty in Your Self and Senses
Learning to embrace uncertainty is an important objective in ERP. This concept aims to discourage clients from attempting to gain certainty in whether or not something will happen and instead encourages them to accept uncertainty as a part of life. This, in turn, helps those struggling with OCD to lean into their fears. I-CBT does not focus on tolerating uncertainty. Instead, it aims to help clients get to a place of certainty. It is NOT saying clients can feel certain about the future as a whole because the future is uncertain. Unlike ERP, I-CBT does not view OCD as an issue with tolerating uncertainty. It sees the problem with OCD as a mistrust of the self, and I-CBT believes there can be certainty in knowing your real self, common sense, and senses in the here and now. I-CBT agrees there is real uncertainty in the world – no one has certainty about the future. But with “true” uncertainty, there isn't any sense data that we could be relying on at this moment to give us the answer to the question we have. And with obsessional doubts – there IS sense data we could be trusting. I-CBT views “true” uncertainty as unresolvable in the Here & Now because there isn’t sense data/enough information to resolve it.

But isn’t cognitive therapy for OCD ineffective? It sounds like I-CBT is just arguing with the obsession?
I-CBT is not traditional cognitive therapy. It does not utilize methods to dispute, challenge, or debate the obsession. It does not use cognitive restructuring or thought challenging to modify a doubt. I-CBT agrees a person cannot reason their way out of OCD. It does not work. The goal of I-CBT is to help the client understand when they are being tricked by obsessional reasoning so they can dismiss the story. I-CBT allows clients to see why their obsessions are false to begin with, allowing an individual to test the relevance of a doubt by determining if there is the required sense data in the here and now to support it. Once this is understood, clients will learn how they can get back to trusting their senses and staying with reality. This is very different from standard CBT interventions and should not be done by a CBT clinician untrained in I-CBT.

What is Inferential Confusion?
Inferential confusion occurs when individuals confuse an imagined possibility for a real possibility they then feel the need to act on, despite not having sensory evidence in the here and now moment to support it. They are doubting their senses and self and instead allowing a hypothetical possibility to trump their reality in that moment. It is this inferential confusion that results in an individual mistaking the OCD story, which is built in the imagination and full of arbitrary information and possibility, for reality. In short, inferential confusion is treating an imagined possibility as if it were reality based on flawed logic/reasoning and a mistrust of the senses.

At CalmOCD we offer both ERP and I-CBT for the treatment of OCD. Submit an online inquiry to learn more about these interventions and find the right therapist for you!

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