Understanding I-CBT with Mike Heady

Hello! It’s been a while. I’m back now because over the past couple of years I’ve been seeing and hearing more about a new-to-me type of therapy for obsessive-compulsive disorder (OCD), inferenced-based cognitive behavioral therapy (I-CBT). I’ll be frank: I didn’t get it. I can explain exposure and response prevention (ERP) in about a minute, and that includes an example of how it works. I can’t do that with I-CBT—I’ll start to try to explain it to people and I have to stop. That’s frustrating! That’s why I asked Mike Heady to answer a bunch of my questions, which he very graciously did—including my follow-up questions. This is a long one, but I hope you find it helpful.

I was diagnosed with OCD over eighteen years ago, and one of the first things I learned about it was that the “gold standard” treatment was exposure and response prevention (ERP). In the past couple of years I’ve started to hear more about I-CBT. Full transparency: I’ve read a few articles about it, listened to a presentation on it, and attended a panel with OCD therapists who implement it with their clients and I still don’t understand it. I know I’m not the only one who’s a little confused, especially after years of telling people ERP is the best way to treat OCD. I invited you here because you were recommended as someone who’s well versed in I-CBT, and I genuinely want to understand how it all works.

First, tell me about yourself! How long have you been an OCD therapist, and how did you decide to focus on OCD? How long have you been using I-CBT with your clients? Do you still use ERP?

I have been specializing in the treatment of OCD, anxiety disorders, and related conditions for 17 years. After I graduated with my masters, I applied for a year-long mentorship program with the Anxiety & Stress Disorders Institute of MD. Think of it as a post-doc. I had the pleasure of shadowing some incredible clinicians like Carl Robbins and Sally Winston. While I was in the mentorship, I was also an adjunct professor of psychology at McDaniel College where I taught part-time for 10 years. Today, I am one of the owners and directors of the Institute. My decision to focus on these disorders is a mixture of being a fellow anxious person and being committed to understanding the unique puzzle these disorders present. I love to learn how and why things work which, in turn, informs how you approach them.

I began learning I-CBT in 2018 when Carl Robbins, our director of training, brought it to my attention. He had a few email correspondences with the late Kieron O’Connor, who is the co-developer of the approach. Carl was captivated and his curiosity and excitement rubbed off on me. In March of 2020 when the COVID-19 pandemic caused a shutdown, I was able to really dive into the I-CBT manual and start implementing it. So, it’s fair to say I’ve been using I-CBT for just over four years.

In my clinical practice, I continue to use ERP from an ACT-informed perspective when needed. It’s just now I am able to offer clients options that I could not before.

Pretend you’re in line for coffee at the OCD conference and you only have a minute—literally 60 seconds—to explain I-CBT to the person behind you. You have to grab your coffee and go, Mike! What do you say?

I would probably offer you an analogy. Imagine you are attending the best magic show to ever be. This magician is doing the impossible because you are watching an object disappear right before your eyes. You know things don’t just disappear but that is what you experience. You cannot explain it and for a moment you question your senses and reality itself. I-CBT shows you the magician’s secrets to how the illusion was pulled off. The sleight of hand. The misdirection. The showmanship of it all. Now imagine after you learn these secrets, you attend the show again. Do you remain tricked? I-CBT isn’t about tolerating fear or focusing on effortfully removing compulsions. Not that there is anything wrong with those approaches. I-CBT is about showing you how obsessions formed and tricked you into thinking you were in danger or that you were the danger when you clearly are not. If one knows and trusts the obsession to be irrelevant, what is left of OCD?

Now pretend you’re relaxing in the lobby. You have all the time in the world, and someone approaches you and says, “I understand ERP, but I want to learn more about I-CBT. Tell me everything. How does it work? When did it come about? What is research saying about its efficacy?”

I-CBT began when Kieron O’Connor observed that obsessions commonly took the form of a conclusion about a circumstance in the here and now rather than an intrusive thought that got stuck because it was scary. This seemingly innocuous observation has serious implications for how OCD is understood and how it’s treated. Basically, I-CBT would suggest that obsessions are faulty conclusions to doubt something about the here and now that ought not be doubted. They are obsessional doubts as opposed to normal doubts. Obsessional doubts are unique to those with OCD and related conditions (body dysmorphic disorder, eating disorders, and hoarding). There are several reasoning devices that are collectively referred to as inferential confusion, and I-CBT aims to deconstruct these processes through a series of modules, thus helping the client remove obsessional doubting (aka inferential confusion) and re-orient trust back into how they reason (normal reasoning) in all other areas of their life.

If we take the stereotypical case of hit-and-run OCD, a person driving a car to work runs over a pothole and within seconds is feverishly checking mirrors and trying to figure out if they hit someone, and eventually they turn around to check the sides of the road just in case. What happened in those moments, according to this approach, were not intrusive thoughts of maybe hitting a person that were taken as credible because they were scary and sticky. Rather, it was a reasoning process that was initiated once the pothole was hit, which is true of literally everyone who hit that pothole that day, with a significant exception. Most everyone else reasoned that the pothole may have damaged their tire or rim, which led them to keep an eye out for a wobbly car or a low tire pressure signal. But the person with OCD had a very different reasoning process with that pothole. They concluded that it could have somehow been a person rather than a pothole. And this conclusion felt absorbing and credible and urgent. How it was that they concluded what they did and why that conclusion was so credible and absorbing is where I-CBT focuses treatment. In this way I-CBT is said to work upstream from standard treatment models. It does not focus on fear and compulsions, but rather preceding reasoning processes that set them in motion.

Here is a schematic to illustrate this process:

Summary of Data/Efficacy:

It was in 1995 that the first theoretical paper with this observation about how obsessions come about was published. Four years later the first empirical investigation into this kind of doubting process was published by Paul Emmelkamp and Fred Aardema. Eventually, these distinct reasoning processes were collectively operationalized into a process referred to as inferential confusion. In the 25 years since, dozens of peer-reviewed studies on inferential confusion have validated it as a significant predictor of OCD independent from negative mood states and the obsessive beliefs categories noted by the obsessive-compulsive cognitions working group (OCCWG), which were inflated responsibility, perfectionism, intolerance for uncertainty, importance of thoughts, the need to control thoughts, and the overestimation of threat.

There is mounting data showing inferential confusion and feared self predicts OCD symptoms before any of the belief domains arise. This mediator analysis, which was a large replication study of 350 people diagnosed with OCD, demonstrated that inferential confusion and feared possible self sequentially mediated OCD symptoms completely independent of all obsessive belief domains and negative mood states and by itself explained 42 percent of the total variance of OCD. And, since I-CBT accepts that belief domains are relevant in OCD, despite them being downstream processes of inferential confusion and feared self processes, when we add relevant belief domains, total explained variance is about 58 percent, which is very significant. Data is mounting that shows inferential confusion as a mechanism of change, meaning that the resolution of inferential confusion predicts the reduction in OCD symptoms. Approximately six peer-reviewed studies showed this. In fact, a soon-to-be-published moderator analysis of a multisite randomized controlled trial (RCT) that looked at I-CBT, ERP, and mindfulness showed that the only cognitive process to predict the OCD symptom reduction in all groups was inferential confusion. This was directly compared to intolerance for uncertainty/perfectionism, importance and control of thoughts, and responsibility/threat. Aside from data validating inferential confusion as a central cognitive factor in OCD there is also data supporting numerous meaningful distinctions between normal intrusive thoughts that we all get and those that are relevant to OCD. For a more detailed description of these differences see Audet et al. (2020).

Once inferential confusion was demonstrated as distinct from other cognitive factors suggested by other treatment models, a new treatment model was constructed with the explicit purpose of resolving inferential confusion. This treatment was originally called inference-based therapy (IBT) and is now called inference-based CBT (I-CBT). It is primarily a cognitive treatment in that no deliberate or prolonged contact with distress (i.e., exposure) is required nor is any deliberate response prevention. The treatment focuses on helping the client build awareness of how they reasoned themselves into the obsessional doubting (faulty conclusion) so that they can return to their normal reasoning that they trust in all non-obsessional areas of functioning.

The first randomized controlled trial by O’Connor et al. was published in 2005. It showed two important outcomes: First, ERP and I-CBT were both equally effective at reducing OCD symptoms (neither was superior) and the second was that I-CBT appeared to be superior to ERP in helping a subgroup of those OCD sufferers with overvalued ideation. This RCT was small and needed replication in a larger sample. In 2015, an independent lab in the Netherlands conducted the second RCT with a larger sample and replicated the findings of the first RCT. In 2016, a large open trial with a waitlist control group demonstrated I-CBT to be effective across all OCD symptoms dimensions and showed that reduction in inferential confusion predicted the reduction in OCD symptoms. In 2022, the third RCT replicated yet again that I-CBT shows similar effectiveness as ERP at reducing OCD symptoms (neither treatment was superior). Most recently, the group in the Netherlands published a very large (about 100 participants per group) RCT with a non-inferiority design to see if I-CBT was equivalent to ERP as well as whether I-CBT was a more acceptable treatment option. Results on equivalence were inconclusive and both treatments were again shown to be similarly effective at reducing OCD symptoms. However, regarding treatment acceptability, I-CBT was found significantly superior to ERP. Treatment acceptability was measured with the Treatment Acceptability/Adherence Scale. Overall, participants in the I-CBT group found it less exhausting, less distressing to engage with, and less intrusive to their lives compared to the CBT/ERP group. I-CBT was also rated as less likely to drop out of compared to the CBT/ERP group (Wolf et al., 2024). A soon-to-be-published RCT, this one also with a non-inferiority design, will clarify the equivalence of I-CBT to ERP. This means to date there are six controlled trials testing I-CBT’s effectiveness and all agree that I-CBT is effective and not inferior or superior to ERP, albeit, more tolerable.

The body of research supporting I-CBT is substantial and growing. Approximately 100 peer-reviewed studies from independent labs across the world are demonstrating inferential confusion to be a central cognitive factor in OCD as well as I-CBT as a safe and effective treatment for adults with OCD. A growing body of evidence is demonstrating the relevance of feared possible self to OCD symptoms as well as its mediating role between inferential confusion and OCD symptoms. All this to say that the data points toward I-CBT’s assertion that inferential confusion and feared possible self precede other known cognitive factors in the development of OCD.

Can you break down how I-CBT would address the hit-and-run example above? What would you say to the client? What exercises would they work through? How would you know it’s “working”?

The how, in detail, is complex. [Kieron O’Connor wrote a breakdown of a case study that will help explain it, in addition to the description provided below.] I will briefly elaborate on a few modules here but not all.

In the case of hit-and-run OCD, I-CBT would focus on the initial doubt (what if that was a person?) and begin the 12 modules. The first 4 modules are considered psychoeducational. There is not challenging; rather, there is information gathering and organizing. Let’s look module by module how hit-and-run OCD would be addressed:

Module 1: The OCD sequence and identifying the initial doubt. The goal is to help the client be able to organize numerous OCD stories into the sequence and identify the initial doubts. In addition to this, the client also notes that the problem began with the doubting, not with the trigger or with any other part of the sequence. If the doubting were resolved, what would be left?

Hit-and-run OCD sequence:

Trigger: Drove over pothole

Doubt: What if that was a person?

Consequence of the doubt: A person could be hurt or dead.

Emotion: Guilt, fear

Compulsion: Check mirrors, check memory, turn car around to look for body, scan newspaper for report of a hit-and-run, etc.

Module 2: The doubt has its reasons. From the vantage point of the OCD, what about this doubt makes it convincing? Why attend to it rather than discard it? Here the goal is to hear out the client’s reasoning. It’s a validation of what goes on in their mind. We categorize the reasons into Possibility, Hearsay, Personal Experience, Out of Context Facts, and General Rules. The client would apply this to other OCD examples not necessarily their own but to get competent with the reasons.

If I hit a person I would feel a bump and I did feel a bump (out-of-context fact).

Hit-and-runs do occur so its not impossible that I did it (possibility).

Good drivers keep their eyes on the road and I might not have been perfectly attending to the road (general rules).

I heard that distracted drivers are more likely to hit pedestrians (hearsay).

When I was a teen learning to drive I hit a mailbox because I wasn’t paying attention, so that means I am prone to being a distracted driver (personal experience).

Module 3: The obsessional story. Obsessional doubts are not removed from our normal construction of reality, which means they are embedded in a story. The story is powerful in its ability to make things feel real and credible, so we demonstrate the power of the story and how a story’s ingredients absorb you into its reality. In this module the client is made aware of how stories generate a credible account of events even if imagined. Lastly, the client produces a counter-story for their OCD that starts from the same trigger but ends with a different conclusion (it was a pothole or debris that I ran over…). This is not to dispute or refute the obsessional story but rather to bring awareness to the availability of numerous stories that could be constructed with the same triggering event and that their specific obsessional story was just one of many possible stories.

Module 4: Feared possible self. Why this theme of OCD and not another? Here the client explores what underlying vulnerability set them up to reason with the pothole in this way rather than a completely different non-harm OCD situation. We help the client reveal that they have a story about the self that creates a hypervigilance for here-and-now circumstances that are relevant to being a negligent, irresponsible, careless or evil, bad, immoral, polluted . . . kind of person.

Modules 5–8 are intervention modules.

Module 5: OCD doubt is 100 percent imaginary. Here we help the client explore normal versus obsessional doubting. How they are constructed differently. It is their construction that renders them imaginary or not. Through examples the client gets competent at this distinction and then applies their understanding to their own doubting. They will see it is constructed obsessionally (through inferential confusion) and therefore is imaginary or hypothetical and not reality in the here and now.

Module 6: OCD doubt is 100 percent irrelevant. If the doubt is obsessionally constructed and not normally constructed then it is not relevant to the here and now. We explore why possibility is not relevant to reality by itself. We explore how all of the reasons OCD uses do not make the doubt relevant to the here and now. We explore what information would need to exist to make the doubt relevant to the here and now.

Module 7: The OCD bubble. Here we explore the absorbing and dissociative nature that inferential confusion creates. It lures you into its bubble where you are removed from reality in the senses and common sense and instead attend to possibilities and imaginations as more credible and relevant than reality through the senses. It goes into how OCD feels real and credible and urgent by disconnecting you from the present moment. An experiential exercise highlights the crossover point where you were in reality and then were absorbed into the OCD bubble and floated away from reality into your imagination.

Module 8: Reality sensing. Now that you are aware of obsessional versus normal doubting and understand all the ways in which this imagined and irrelevant story has tricked you, you now practice getting in contact with your senses and common sense in previously obsessional circumstances. This means the driver with hit-and-run OCD uses their five senses and common sense to drive down avoided roads and act upon what the senses are saying. If they hit a bump, they are trusting their senses rather than doubting them and indulging imaginations. Some of the practice here would be to help them connect to how they know anything about their present moment. How do you know when the chicken is cooked? How do you know when your spouse is upset with you? How do you know when the car is moving versus still? By making explicit how we know anything about the present moment (through senses) it is then generalized to their previously obsessional areas. This practice helps the client realize they already use and trust their senses without effort in everyday circumstances. Now we just ask them to do that normal sense work in the circumstances where the OCD bubble had previously caused distrust.

Module 9–12: Consolidation/relapse prevention

Module 9: The alternative story. Client is now rooted in reality with their previously obsessional circumstances, and we help them generate a more reality-based story. This story is an elaboration on the module 3 counter-story, but we add in how and why the client knows, through five senses and common sense, that their drive down a bumpy road is just that, a bumpy road. This story is rehearsed in non-obsessional moments (so it does not act as a disputation or refutation or compulsive reassurance). Again, this is not to replace the OCD story but to create an alternative option to be available to the client. Which do we trust and know to be real and which comes from the imagination?

Module 10: Tricks and cheats of the OCD con artist

Module 11: The real self

Module 12: Relapse prevention

While the last three modules are important, they are more connected to resolving the inferential confusion about the self (aka feared possible self) and then troubleshooting problems.

Each module has in-session worksheets, homework, and quizzes to test learning objectives. This is used at the discretion of the clinician based on client need. In short, you know the model is working when the client begins to trust their senses and self in day-to-day moments instead of getting lost in obsessional narratives. A signal of this could be the removal of compulsions and avoidances on their own volition or because it just made sense to not do the compulsions. If one is regimented in their clinical style they could administer the Y-BOCS and Inferential Confusion Questionnaire pre-treatment, midway through treatment, and post-treatment. Scores should ultimately drop below 92 to be in subclinical range. I usually just let my client report back how they are doing.

In summary, I-CBT systematically helps the client reorient themselves to their senses and common sense in situations where OCD had coaxed them away. Through a series of cognitive processes and experiential exercises, the client learns that they have been tricked by a clever and immersive faulty reasoning process applied to selective situations that drew them further into the land of the hypothetical and imagination. In effect, I-CBT breaks the obsessional doubting spell by showing you how it was constructed, selectively applied, and in contrast to how you reasoned in all other areas of living.

Something I’ve been having trouble understanding is how to avoid a spiral into compulsions while engaging in I-CBT. If you told me certainty was possible, I’d want proof of that. If you mentioned reasoning I could easily start to question why I have the obsessions I do—that was a huge problem for me and something I still struggle with. How do you make sure your client doesn’t devolve into reassurance seeking while on their path to certainty?

From an I-CBT perspective, obsessional doubt is when the person has knowledge about a situation in the here and now and then doubts this knowledge. The how and why one doubted is what I-CBT addresses directly. It offers insight into why this obsession and not others and yes, certainty in one’s senses and self in the here and now is as available for those with OCD as those without OCD. The latter doubt what they know. While it is true to note that no one has certainty about the future it is also a red herring. Obsessional doubting is occurring in the here and now, as are the compulsions, not the future. There is sensory and common sense data here and now and those with OCD are reasoning with that information and drawing conclusions in the now. In this way, I-CBT is not disputing or refuting one’s thoughts but rather discovering the process of how they arrived at conclusions about themselves and the world.

The chance of OCD trying to misuse treatment as a compulsion is present for all treatment approaches. So long as one is being guided by a knowledgeable therapist, I think the risk of I-CBT facilitating compulsions is no different than ERP.

And do I have it all wrong? Does I-CBT not say certainty is possible? If it doesn’t, why do you think I could have gotten the impression it does?

Yes, there is certainty; however, I-CBT does not say there is certainty about the future, nor does it say there is certainty in situations that lack sufficient information to draw reasonable conclusions of knowing. For instance, imagine you applied to five universities and have a favorite, but you have yet to hear anything back from the schools. The doubt—what if I didn’t get into my college of choice?—is an example of a situation where not enough information is available to know. Another example: Imagine your doctor orders a biopsy of a lump and it’s not back yet and you say, what if my biopsy results show cancer?

These are all example of situations where there isn’t enough information to know, so true uncertainty exists and must be tolerated. However, if someone says, “What if that pothole was a person?” or “What if I am a violent serial killer?” these situations have available sensory and common sense information (which we all have) that lead to knowing. Those with OCD doubt this knowing. Think of it this way: If you came home from work and saw smoke and flames rising from your house, would you dismiss that sensory and common sense data and instead conclude that I might just be seeing things and you can’t know anything for sure and maybe it’s on fire, maybe it’s not, guess I’ll have to tolerate not knowing? Of course not. You would call 911 and say your house was on fire. You have certainty your house is on fire. So yes, certainty exists in this way and those with OCD have similarly available here-and-now sensory data to know the obsession isn’t true, but they doubt that information. Again, I-CBT is interested in showing you the how and why you doubt this way and how to resolve it.

When I’ve talked to fellow OCD-havers about I-CBT, some of them have said they don’t think they could easily engage with their senses because testing their physical reactions to obsessions is a compulsion. Let’s say someone has pedophilia OCD and they feel arousal but their therapist has just told them to trust what their body is telling them in the moment. How would you ensure they don’t now believe they really are a pedophile because their body has sent them the message that they are?

There is no testing in I-CBT. I-CBT is more than an instruction to engage your senses so the treatment process cannot be taken out of context in this way. The non-concordant arousal you mention is an example of an out-of-context fact from an I-CBT perspective. It could be a fact that arousal occurred, but the context is what makes the information relevant to being a pedophile or not. I-CBT specifically addresses this kind of irrelevant association that OCD uses to confuse you. The same argument could be used for headaches and brain tumors. Sure, brain tumors are associated with headaches but there is a context that makes that association relevant or not. The devil is in these details.

Sorry, I didn’t mean that I-CBT asks clients to test themselves, but I understand how it came across that way. It’s a concern I’ve heard people voice, that since they have struggled with the compulsion to test their senses (did I like that? Did my heartbeat speed up when I thought of stabbing someone? Did I feel it move?) they’re wary of the idea that they would be asked to trust their senses.

What’s an example of context that would make it irrelevant? What if the context is that someone is reading an article about Jeffery Epstein and how he brought girls to his island so people could have sex with them, and then you kinda picture it and you feel a sensation?

If someone reads about or hears about or pictures sex, it is within normal to experience signs of arousal. If I experienced arousal from tight-fitting pants, I am not desiring my pants nor does it speak to my orientation. Stimulation of any kind causes a response. By itself, arousal does not inform desire or consent. Yet the doubting is trying to make it so by inventing a possible context that does not exist, namely desire. (See the comment from your previous question–did I like that?) This is an example of a doubt. We know when we like something. We know when we desire and consent to something. If we are asking if we liked it, we are doubting.

Are there any types of OCD that I-CBT couldn’t treat as well as ERP?

Current evidence would suggest I-CBT is effective for all symptom dimensions of OCD (Aardema et al., 2017). However, to take it one layer further, I would say I-CBT treats all inferential confusion (obsessional doubting). There may be circumstances where a client looks to have OCD but it is really trauma or GAD where inferential confusion is not as significant a factor. 

What is your position on using both I-CBT and ERP?

They can be used together or sequentially; however, care needs to be taken as these are very different interventions for different mechanisms of change. ERP pursues extinction learning via habituation or inhibitory learning. I-CBT pursues the resolution of inferential confusion. One needs to know the distinctions between these two mechanisms, so treatment is coherent.

A few modifications to ERP would remove much of the potential tension. First, focusing on in vivo or interoceptive exposures rather than imaginal exposures is suggested. Imaginal exposures as they are utilized in the RCTs of ERP, pursue the evocation and sustainment of distress often with efforts to increase the reality value of the imaginal script in the pursuit of extinction learning. This specific implementation would go against the effort to resolve inferential confusion as it deliberately draws on the imagination to absorb you into hypothetical scenarios to generate distress. The more reality value the better from the ERP perspective. The second is requiring the client to tolerate uncertainty about situations that do not require such toleration. As noted previously, certain doubts require tolerating uncertainty because there is not enough information to conclude knowledge, as in GAD; however, OCD doubting does not operate this way. These interventions implemented in these ways can create confusion for the client.

Otherwise, these approaches are not in conflict despite seeing OCD differently. In fact, there is data soon to be published that shows inferential confusion predicted OCD symptoms reduction in three treatment groups, I-CBT, MBSR, and ERP. So, ERP can reduce inferential confusion too, but it’s not required.

I’ve noticed division among therapists—some believe only ERP works for OCD, some believe I-CBT is better than ERP, and some are willing to try both as long as it works for their clients. Why do you think this has been a hot-button issue?

It’s unfortunate but not unexpected. Ultimately, I think it is because the contributions of I-CBT are challenging to the status quo. It is disruptive.  Deeply held ideas are slow to adapt. I think of it as pushback rather than division. Some have felt that I-CBT advocates have made claims that outpaced the evidence others are concerned about leading young therapists astray. Neither of these criticisms are about the actual approach. They are more about qualms with isolated comments from individuals. I think these criticisms are equally applicable to CBT/ERP advocates as they are to I-CBT advocates and in my opinion, it’s not about those issues fundamentally. There has been occasional hairsplitting about what constitutes evidence-based which appears an almost moving target at times but to clear up any obfuscation, I-CBT is evidence-based. It satisfies all the fundamental pillars of empirical support for psychotherapies. To be reviewed by the American Psychological Association for their designation of “Empirically Supported Treatments” I-CBT needs to complete a meta-analysis. This is largely a procedural step, and it will be completed soon. More data is always needed but as it is today, I-CBT is a reasonable choice. It is listed as an evidence-based treatment for OCD by Scotland’s NHS.

I do not want to overemphasize the pushback either. By and large, the OCD community of clinicians and sufferers have embraced I-CBT. The community of clinicians interested in and learning about I-CBT in the US began with a dozen or so in 2021 and is now about 4,000 in 2024.