What Is Inference-Based CBT (ICBT) for OCD? Insights from an OCD Therapist
For a long time, OCD was treated primarily with one intervention called Exposure and Response Prevention (ERP). And yes, ERP is a very effective modality for OCD, but it's not perfect. I have seen ERP be life-changing for most of my clients, but I've also seen some clients get stuck in the midst of ERP treatment. For this reason, I got trained in ICBT (Inference-Based Cognitive Behavioral Therapy), as I wanted to offer an alternative for people who were having challenges with ERP for OCD.
How ICBT for OCD Differs From Traditional CBT
ICBT is not traditional CBT (Cognitive Behavioral Therapy), which for the most part is not the best treatment for OCD. Instead, ICBT is a cognitive therapy designed specifically for people suffering from OCD.
So what does it mean that it's a cognitive therapy? It means it focuses on thoughts and thinking patterns rather than behaviors. In short, there aren't exposures in ICBT. Many people do not want to do exposure work for a variety of reasons, and I find it so helpful to be able to offer ICBT to these folks. Exposures work by targeting behavior (the compulsion), while ICBT focuses on what comes before the compulsion-our thinking patterns. The idea is that if you can change the thinking pattern that drives compulsive behaviors, then the behaviors will change, and compulsions will no longer be necessary. Therefore, exposures are not needed.
Am I a Good Fit for ICBT?
So who would be a good fit for ICBT? Well, really anyone with OCD. Research shows that both ICBT and ERP are effective treatments. I think many clients benefit from trying different modalities to find what resonates most with them. However, there are a couple of groups that I often recommend try ICBT first.
People Who Feel Stuck in ERP Therapy
The first group is people who have already done ERP and are still feeling stuck in their OCD treatment.
Taboo OCD Themes
The second group is people dealing with taboo OCD themes. These can include fears of being a murderer, a sexual predator, taboo sexual themes, or sexual identity concerns (not that this is inherently taboo, but we still live in a world where anything related to sexuality can feel shameful). Essentially, these are obsessions that feel awkward, scary, or deeply uncomfortable to talk about.
For example, if you're scared of being a sexual predator, it can be really hard to explain that you don't want to harm others, but you're afraid you might. For many people, these thoughts feel embarrassing and are often accompanied by a lot of shame, which makes them even harder to share.
How ICBT Helps Reduce Shame and Rebuild Self-Trust
As an OCD therapist, I often like to start with ICBT for people experiencing taboo obsessions because it works to help rebuild self-trust and reduce shame. In ICBT, we look at how someone may be relying on their imagination to generate scenarios or possibilities that don't actually reflect their history, values, intentions, or desires. Then, instead of relying on imagined possibilities as evidence, we work on grounding in what we do know to be true about the person.
A Hypothetical Example of ICBT for Harm OCD
For example, let's say Tanya has an obsession that she is secretly evil and might act violently toward her roommates. She feels scared while cooking that she might stab someone, push a roommate off the balcony, or run someone over in the garage. She knows she doesn't want to do these things. She has no history of violence, she cares about her roommates, and she wants them to live long, happy lives. But part of her can't stop focusing on the "what ifs":
What if she does want to hurt them?
What if she could snap one day and suddenly change?
Even though she knows she wouldn't act on these thoughts, there's still a part of her that won't let it go. As a result, she begins isolating herself in her bedroom and avoiding her roommates.
If we were doing ERP, we would focus on her avoidance behaviors and help her spend time around her roommates while accepting the uncertainty that she could one day snap and hurt them. The idea is that, through repeated exposure to this uncertainty, her fear would decrease, and she would eventually recognize that she isn't actually a danger to others-her mind was just creating false alarms.
In my experience, though, it can sometimes feel awkward or even wrong to sit with someone and say, "Yes, maybe you will snap one day and become a murderer." I think this is often where people get stuck with ERP and why I like to offer clients alternatives to ERP.
Rebuilding Trust in Yourself Through ICBT
Instead, in ICBT, we would help Tanya reflect on the actual evidence: Does she have a history of violence? Has she ever hurt her roommates? What are her values, intentions, and desires-and how are these reflected in her life? These are the kinds of questions we would explore to help her rebuild trust in herself-her values, intentions, and character-as well as trust in her direct, observable experience (what she can see, feel, and know).
How Jen Lescher, LCSW Can Support You
If you've struggled with OCD therapy in the past, felt overwhelmed by exposure work, or found yourself stuck in shame and self-doubt, ICBT may be a helpful alternative to explore.
Jen Lescher, LCSW, offers ICBT and OCD counseling for adults in Boston, MA and San Diego, CA through virtual therapy sessions. My approach combines evidence-based OCD treatment with a compassionate, grounded understanding of how intrusive thoughts, rumination, shame, and fear can impact daily life and relationships.
Whether you're dealing with harm OCD, moral OCD, ROCD, or another OCD subtype, therapy can help you begin rebuilding trust in yourself instead of constantly listening to fear and "what if" thinking.
I'll talk more about ICBT in my next blog. Stay tuned.
Find Therapy for OCD Today in San Diego, CA & Boston, MA
Want to learn more about ICBT? I would love to hear from you. Jen Lescher, LCSW, offers ICBT and OCD counseling in Boston, MA and San Diego, CA for adults who feel stuck in fear, shame, self-doubt, and compulsive thinking patterns.
Explore more blog posts to learn about OCD, intrusive thoughts, rumination, and evidence-based OCD therapy.
Start building a different relationship with fear, uncertainty, and self-trust-one that isn't driven by OCD.
Additional Services Offered
Along with one-on-one OCD therapy, I also offer supportive resources that address challenges many clients face outside of sessions. On the Common OCD Themes page, you can explore detailed insights into recurring thoughts and behaviors. The OCD and Social Life page offers guidance for managing friendships, dating, and relationships while living with OCD and anxiety.
About OCD Therapist Jen:
Hi, I'm Jen.
I'm a therapist, coffee enthusiast (honestly, it's my favorite ritual of the day), and a big believer in finding small moments of presence-whether that's through mindfulness, photography, or a quiet walk with my camera in hand. Photography helps me stay grounded and see the world with a little more curiosity, and that same mindset shows up in my work with clients. I've been drawn to spirituality and healing work since I was a teenager, exploring everything from meditation to energy practices. But I'm also someone who loves blasting music in the car and getting lost in a true crime podcast. I think healing can include both stillness and movement, reflection and laughter. Therapy should have room for all of that. Since 2007, I've worked in a range of mental health settings, which taught me that healing isn't one-size-fits-all. It's personal, evolving, and sometimes messy-but always possible.
Training & Background:
Inference-Based CBT (ICBT) for OCD - The OCD Training School & The Cognitive Behavioral Institute
Certified in Exposure and Response Prevention (ERP) - The Cognitive Behavioral Institute
Gottman Method Couples Therapy - Level 1
Master's in Social Work - Portland State University, 2012
