Living with obsessive compulsive disorder (OCD) can be incredibly challenging, so much so that OCD has been recognized by the World Health Organization as one of the top ten most debilitating health conditions. Obsessions and compulsions can consume a person’s daily life, making even simple tasks feel overwhelming and onerous. Fortunately, there are effective and evidence-based treatments available. Two of the gold standard treatments for OCD are Exposure and Response Prevention (ERP) and Inference-Based Cognitive Behavioral Therapy (I-CBT). While both are highly effective, they take different approaches to help those with OCD. Let’s dive into these treatments, exploring their differences and how they work.
Exposure and Response Prevention (ERP)
ERP is widely considered the gold standard for OCD treatment. It’s a type of Cognitive Behavioral Therapy (CBT) that focuses on exposing individuals to anxiety and OCD triggers while teaching someone how to reduce and eventually eliminate their usual compulsive behaviors. ERP is often accompanied by Acceptance and Commitment Therapy (ACT) that helps someone reduce fear-driven OCD behavior, start living out their values and choose behavior aligned with what matters most to them.
How ERP Works:
1. Exposure: We first want to develop a comprehensive list and understanding of what triggers obsessional and intrusive thoughts, urges, and images, as well as what behaviors (mental or physical) a person engages in to feel safe and neutralize their obsessions. We gradually and thoughtfully expose ourselves to these triggering situations. It is important to note that flooding a person with anxiety is NOT the approach. We gauge readiness by thinking of exposures that are “challenging but doable” to develop a new, more peaceful relationship with triggers as our brains learn that intrusive thoughts and triggers are a false threat to our safety.
2. Response Prevention: During exposure, the person engaged in ERP is encouraged to resist performing their compulsions, decrease avoidance and distraction of internal and external triggers, and increase awareness around reassurance seeking to eliminate this safety seeking behavior. When resisting is too difficult, ERP therapists can aid someone in delaying a compulsion, interrupting a ritual or performing it out of sequence. This helps us learn that our anxiety will naturally decrease over time without the need for compulsive behavior. And thus, we are able to engage in more and more activities mindfully with minimal to no anxiety, even if a trigger is present.
Example: If someone has a fear of contamination, they might be asked to touch a doorknob. Depending on a person’s anxiety level, to engage in response prevention, a person may refrain from washing their hands, delay washing their hands by 10 minutes, or “mess up” the way they wash their hands (performing the ritual out of order or eliminating some steps but not all). Over time, the anxiety linked to this action diminishes, teaching the brain that the compulsion (hand washing) isn’t necessary for reducing anxiety. Additionally, this allows a person to decrease how much time is spent on rituals, freeing up a person to engage in life in a fresh, value-based lens. So, in this example, the person is able to regain their ability to be out in public, mindfully engaged with family and friends without debilitating worry about spreading contamination.
Inference-Based Cognitive Behavioral Therapy (I-CBT)
I-CBT is an alternative method to treating OCD. It is centered on viewing obsessions as abnormal doubts that place more weight on what could be (imagined possibility) over trust in your senses and self (known reality). It is important to mention that those with OCD have a natural ability to trust their senses, common sense, and self, but when OCD is at play, this becomes much more difficult for a person with OCD.
How I-CBT Works:
1. Understanding the Inferential Confusion: I-CBT posits that OCD is driven by “inferential confusion” or “obsessional reasoning” where individuals suffer due to an over-investment in remote or imagined possibilities (“what if”, “could be”, “might be”) over what is actually happening in their reality (“what is”).
2. Foundations: I-CBT teaches a person that their OCD doubts follow a particular sequence, that there are external and internal things that make OCD doubt feel incredibly real, that OCD heavily utilizes the imagination to create stories, and OCD makes a person fear becoming their feared self which is opposite of who you really are as a person.
3. Core lessons: OCD is based in our imagination. OCD is irrelevant: Just because something can occur doesn’t mean there is existing evidence today that proves it will. Slowing down can help us stay out of our OCD imagination and catch when we have accidentally bought into an OCD doubt. You already have the innate ability to trust yourself, your senses, and common sense; OCD can confuse you when it is at play.
4. Integration: Your I-CBT therapist helps teach you how to identify an alternative story to the OCD story so you can choose how we want to show up in the world based on what is most important to you. Creating the alternative story does not focus on disproving OCD’s story but rather disproving the legitimacy of it. Your real self is opposite of what your intrusive thoughts tell you you are or could become; take time to learn about what your values are, who you truly are, and how you want to show up in the world.
Example: If someone fears they might accidentally harm someone, I-CBT would help them understand how this obsessional doubt came to be and how to reframe their thinking to align with reality and trust themselves and their senses.
Comparing ERP and I-CBT
While both therapies aim to reduce the symptoms of OCD, they approach the problem differently. ERP is behavior-oriented, directly confronting the fears and preventing the compulsive response. More often than not in ERP, compulsions are targeted which naturally changes one’s relationship to obsessions. I-CBT, on the other hand, is thought-oriented, focusing on changing the way individuals think about their obsessions. In I-CBT, obsessions are targeted which naturally changes one’s need to engage in compulsions.
Choosing the Right Treatment: The choice between ERP and I-CBT often depends on the individual. Some patients may respond better to one approach over the other. Therapists specializing in OCD and trained in both treatment approaches can help determine the most suitable therapy based on the client’s specific symptoms, preferences, and response to initial treatment efforts.
OCD is Treatable
OCD is a complex and often debilitating condition, but effective treatments are available. OCD is treatable. ERP and I-CBT offer different paths to recovery, each with its strengths and challenges. Understanding these treatments can empower those with OCD to seek the help they need and find a therapeutic approach that works best for them.
Outsmarting Anxiety and OCD Can Help
If you or someone you know is struggling with OCD, reaching out to a trained OCD and anxiety therapist can be the first step towards a better quality of life. At Outsmarting Anxiety and OCD, we are highly trained specialists ready to help you or your child move forward and find joy. Contact us today.