Treating OCD Without Exposures

(Below is the transcript from the video in case you'd rather read than watch the video)

I recently took a training on I-CBT (Inference-Based Cognitive Behavioral Therapy). When I started the training, I became really uncomfortable when I started to hear some differences between this model and ERP (Exposure and Response Prevention). The agreement between the two is that both really emphasize the importance on avoiding or preventing compulsions from happening in order to cope with OCD. But there were two big differences. ERP really encourages exposures, they do exposures making people intentionally uncomfortable, to help people learn how to sit with uncertainty in their OCD symptoms. While I-CBT actually teaches and encourages people to gain certainty with their OCD symptoms. Other other big difference is ERP views obsessions/doubts/intrusive thoughts as pretty meaningless. Whereas, I-CBT really focuses on being able to track and understand these obsessions to see if it is a way of understanding how you see the world around you or how you view yourself.

I-CBT theorizes that OCD happens when there is inferential confusion in the picture; when people have a failure to discriminate between imagined possibilities that are happening around them right now and the actual reality that is happening around them. This can happen in a couple of different ways. When people are distrusting their senses. For example, I am walking away form my car and my doubt/fear/obsession is, "Wait, did I lock my car? Maybe I didn't lock my car. Maybe I only think I locked my car." Another way inferential confusion comes in is when we are over reliant on possibilities. [For example, having the thought], "Oh man, I almost got in a car accident a couple of weeks ago so now I have to be very hyper-vigilant and kind of have my head on a swivel in order to avoid getting into a car accident and hurting people in the future." Another way differential confusion can happen is by irrelevant association. A thought for example can be, "Oh gosh, I heard a story that most serial killers are left hand dominate. I am left hand dominate, so maybe I have a higher likelihood of becoming a serial killer."

The I-CBT model has 12 different modules/steps you go through and each step is walking the client through being able to understand their OCD symptoms and patterns. For examples, ways of faulty reasoning with themselves, and moving them to actually trusting their sensations so that they have a firm grip on the "here-and-now" rather than relying on compulsions to give them the reassurance from that anxiety they feel.

There are a few things that I really appreciated about the I-CBT model. The first one is that is doesn't really focus on exposures. While it can incorporate them, its not really an essential like it is for exposure and response prevention. Exposure and response prevention therapy is a fantastic model I practice with my clients but there is a high level of buy in that needs to happen. This is because exposures, by their definition, are supposed to be uncomfortable. It is really hard for people to willing walk into therapy and say, "Ok, I am ready to be uncomfortable." When treating OCD with I-CBT, we don't have to do that. You can make a lot of really good progress with your OCD symptoms without doing the exposure exercises. So I really like, that this lowers the bar for people to enter the therapy process and treat their OCD symptoms. The second thing I really like about I-CBT is that it emphasizes this gaining of understanding or recognizing patterns of OCD. With ERP, there can a lot of times be this really defeating process where people have specific obsession (i.e. fear of touching door knobs, or faucets). So they work really hard and do a bunch of exposure exercises, allow themselves to feel uncomfortable, to make some success only to have their OCD switch and move onto another obsession. [As a result] they fall all the way back down and say, "Man, I got start all this exposure work over again so I can work on my new fear/obsession." However, I-CBT really focuses on recognizing the patterns and having people recognize, "OH this is how my OCD works, it always gives me an obsession/doubt, it always tells me there is a big scary consequence, and tells me that maybe there's something really wrong with me if I were to allow that consequence to happen. Then it forces me to do this compulsion so that I minimize the risk of it happening and here it is again." It helps us to be able to take those obsessions/fears/doubts less seriously by simply recognizing the pattern. I compare this to when you recognize the scheme or way that a door-to-door salesman is trying to sell you something. You can call it out in your head, "Oh that's the foot-in-the-door scheme. I know what he is trying to do to me. So therefore I am not falling for it." It works the same way with OCD symptoms.

The last thing I really liked about I-CBT is that it introduced me to the idea of the "feared-self." The idea is that sometimes with OCD you can notice even though your obsessions will pivot to slightly different obsessions (i.e. fear of neglecting an animal, fear of leaving the doors unlocked or fear of leaving a stove or appliance on and burning down the house). While those are all different obsessions, we can recognize there is a theme. All of those have to do with some amount of neglect. The fear is that "I am going to neglect either my animal, or locking the doors and someone is going to break in because I didn't do anything or I am going to cause a fire because I forgot to turn off this appliance." So what I really love about this is that we are better able to understand and cope with the OCD when we can recognize these patterns and recognize what we call a "feared-self" that at the core, beneath all the specific obsessions; there is a core fear of us being a negligent person that drives all those different obsessions on the surface. When we can recognize that this is another salesman's trick, "OH that is what my OCD is after. My OCD is trying to poke at me again and make me believe that I'm not a responsible person." Then when we recognize the thought, it becomes less powerful.

If any of this sounds interesting or helpful, feel free to reach out to me either by email or phone call. I'd love to hear from you and see if we are a good match for therapy.