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.
What is Exposure and Response Prevention (ERP) Therapy for OCD?
ERP has been the first line treatment for OCD for decades. It involves gradually exposing individuals to the things they fear, helping them learn to tolerate the distress that arises, while also understanding that they can safely interact with their triggers in daily life. ERP also involves response prevention; committing to not engaging in compulsive behaviors when an obsession arises. This helps clients learn they don’t need to engage in compulsions 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.” By changing behavior, a shift in thoughts and feelings will eventually follow. While ERP has proven beneficial to many individuals with OCD, it also poses challenges, particularly for those who find exposures difficult or are unwilling to pursue them. One advantage of ERP is that, because it targets compulsions directly, it can be more “fast-acting,” helping individuals reduce compulsive behaviors more quickly than I-CBT.
Understanding Inference-Based Cognitive Behavioral Therapy (I-CBT)
I-CBT, originating in the 1990s, is increasingly recognized as a valuable treatment modality among OCD specialists. The target of this treatment is the formation of the obsessional doubts. Obsessional doubts are doubts that lack direct sensory evidence to make them credible in the present moment. When these doubts are resolved, the associated anxiety and the urge to engage in compulsive behaviors to prevent the feared consequence, are significantly reduced. From an I-CBT lens, anxiety and compulsions are downstream byproducts of obsessional doubting-In other words, the “doing” follows the “knowing. 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 that needs to be acted upon, despite the lack of sensory evidence in the present moment to support it. The OCD sufferer doubts their senses and self, allowing a hypothetical scenario to override their current reality. 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 then 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 may be a good choice 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 alternative .
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 suggests that obsessions, or obsessional doubts, are inferences resulting from 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. Although the information used to construct these doubts may be factually accurate, the issue lies in how it is applied to the present moment.
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 something will happen, and instead encourages them to accept uncertainty as a part of life. This in turn helps those struggling with OCD to learn into their fears.
I-CBT does not focus on tolerating uncertainty. Instead, it aims to help clients get to a place of certainty within themselves. It is NOT saying clients can feel certain about the future, 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 acknowledges that real uncertainty exists in the world—no one can predict the future with absolute certainty. However, with genuine uncertainty, there is no sensory data available at the moment to answer our questions. In contrast, obsessional doubts involve sensory data that we could be relying on. I-CBT sees “true” uncertainty as unresolvable in the present moment because there isn’t sufficient sensory information to address it.
But isn’t cognitive therapy for OCD ineffective? It sounds like I-CBT is just arguing with the obsession?
I-CBT is not a 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 can NOT reason their way OUT of OCD, as this 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 see the relevance of a doubt by determining if there is 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 that needs to be acted upon, despite the lack of sensory evidence in the present moment to support it. . The OCD sufferer doubts their senses and self, allowing a hypothetical scenario to override their current reality. Inferential confusion occurs when an individual mistakes the OCD narrative—constructed from imagination and filled with arbitrary information and possibilities—for reality. In essence, inferential confusion involves treating an imagined possibility as if it were actual reality, based on flawed logic and a mistrust of sensory information.
Finding the Right OCD Treatment for Your Journey
Both ERP and I-CBT offer unique and effective ways to address the challenges of OCD, and the right approach often depends on individual needs and preferences. If you’re navigating OCD and are curious about which treatment might be the best fit for you, understanding these options is a valuable first step. At The Gateway Institute, we’re committed to providing evidence-based care tailored to each person’s journey. Whether you want to explore ERP, I-CBT, or simply learn more about managing OCD, we’re here to help. Reach out via our online form or call our team today to start a conversation and discover the support that works for you.