Introduction & History

Behavioural treatment for Obsessive Compulsive Disorder (OCD) is traditionally based

on an Exposure and Response Prevention (ERP) model; an approach which is evidence-based

but often under-used. Since high levels of distress can be experienced during treatment it can be

difficult for the patient to fully engage and, in some cases, for the therapist to deliver therapy.

The recommended frequency (15-20 sessions), duration (90 minutes), and setting (community

rather than office-based) make it challenging for services to deliver optimized treatment.

Inference Based Treatment (IBT) offers an alternative treatment option. In contrast to the

cognitive appraisal model which informs ERP, IBT theorizes that obsessions arise through a

faulty reasoning system which leads to recurrent doubts and faulty inferences. Cognitive

interventions in IBT focus on helping patients to identify the reasoning errors that lead to

obsessions. IBA is traditionally delivered in a clinic setting, in time limited sessions, and does

not generate the levels of anxiety that are a necessary component of ERP.

Inference-based therapy (IBT) originated as a form of cognitive therapy developed for

treating obsessive-compulsive disorder. IBT followed the observation that people with OCD

often inferred danger on the basis of inverse inference (inferring reality from hypothetical

premises). Later the model was extended to inferential confusion, where inverse inference leads

to distrust of the senses and investment in remote possibility. In this model, individuals with

obsessive-compulsive disorder are hypothesized to put a greater emphasis on an imagined

possibility than on what can be perceived with the senses, and to confuse the imagined

possibility with reality (inferential confusion). According to inference-based therapy, obsessional

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thinking occurs when the person replaces reality and real probabilities with imagined

possibilities; the obsession is hypothesize to concern a doubt about a possible state of affairs.

According to inference-based therapy, individuals with obsessive-compulsive disorder

attempt to resolve the doubt by modifying reality (via compulsions and neutralizations) which

merely increase the imaginary pathological doubt rather than resolve it since reality is not the

problem. Obsessions are hypothesized to begin with the initial doubt (“Maybe I could be dirty”)

which is not a normal intrusion but a sign that the person is already in obsessional thinking.

Inference-based therapy hypothesizes that the doubt and investment in possibilities leave

the person vulnerable to spiral into further imagined connections and dissociative absorption in

what could further transpire.

Inference Based Treatment (IBT)

In contrast to cognitive appraisal model which informs ERP IBT theorizes that obsessions

arise through a faulty reasoning system which leads to recurrent doubts and faulty inferences.

Inference-based therapy was developed in the late 1990s for treating obsessive-

compulsive disorder. Initially, the model was developed mostly for obsessive-compulsive

disorder with overt compulsions and for individuals presenting obsessive-compulsive disorder

with overvalued ideas (i.e., obsessions with a bizarre content and strongly invested by the

individual, such as feeling dirty after seeing a dirty person), given that the model revolves around

the imaginative, often idiosyncratic nature of the obsession. The model was expanded to all types

of obsessions and compulsions. Inference-based therapy is now applied to anyone of the OCD

spectrum disorder and believed to be applicable to other disorders as well.

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Founders

Dr. Kieron O'Connor , Frederick Aardema, Marie-Claude Pélissier

Education

Kieron Philip O’Connor, PhD was born in Malta and and later his family moved to

England in Somerset and settled there. Kieron completed his Bachelor of Science degree at

London University and Master Degree in Experimental Psychology (1979) at University of

Sussex, Brighton, England, and his doctoral degree in Psychology at the Institute of Psychiatry in

London (1984) under Hans Eysenck. He also completed a British Psychology Society Diploma

in Clinical Psychology in 1986 and after going back and forth between England, Europe, Canada

and Australia.

Kieron currently holds professional and clinical credentials from the British

Psychological association, the Canadian Behavioral and Cognitive association, the Ordre des

psychologues du Quebec and is an associate fellow of the British Psychological Society and

Fellow of Canadian Psychology Association.

He has published over 200 peer-reviewed papers and 60 books and chapters and given

over 400 presentations. Kieron is a regular invited speaker and trainer at scientific meetings

locally and internationally.

Based on his clinical observations of patients with OCD, Kieron noted that people with

obsessions were not properly phobic about objects, but about what could be there or could have

occurred despite their senses. Kieron developed a novel approach to viewing obsessions as a

product of inductive reasoning and in particular inverse inference where people mistake

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imaginary probability for real possibilities initially with Sophie Robillard and Marie-Claude

Pélissier, PhD.

Frederick Aardema was born in 1971 in Netherlands. In 1990, after finishing an academically

oriented secondary education, Frederick Aardema pursued a university education at the

University of Groningen and completed a Master’s degree in clinical psychology in 1997. He

was awarded a doctoral degree from the University of Amsterdam in 2005 under Prof. Dr. Paul

Emmelkamp – the first clinical researcher in the world to compare cognitive treatment of

Obsessive-Compulsive Disorder (OCD) with purely behavioral interventions.

In the year 2000, Frederick Aardema emigrated to Montreal Canada where he began

collaborating with Dr. Kieron O’Connor. At the same time, Frederick Aardema pursued a

doctoral degree in clinical psychology investigating reasoning processes in OCD during which

expanded the inference based model of OCD to include those with repugnant obsessions. It was

also during this time that Frederick Aardema wrote the first treatment manual for Inference

Based Therapy as published in the book Beyond Reasonable Doubt.

In the year 2000, immigrated to Montreal Canada and began collaborating with Kieron

O’Connor. He wrote the first treatment manual for Inference Based Therapy as published in the

book Beyond Reasonable Doubt.

What is IBA?

Inference based therapy (IBT) is grounded in an inference based approach (IBA) to OCD

which emphasizes the role of reasoning in the development and maintenance of OCD.

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  The treatment is based on the central idea that obsessions are doubts that arise due to

reasoning errors (e.g. “I might have left the stove on”; “I might be contaminated”; “I might be a

deviant”). According to this approach, such doubts entirely rely on an imaginary narrative,

making obsessional doubts feel very real, even though they have no basis in reality. However,

because this is often not completely recognized by the person with OCD, due to confusion

between imagination and reality during reasoning, these doubts continue to persist and remain

unresolved.

IBT aims to bring resolution to obsessional doubts by showing the client how obsessional

doubts come about due to reasoning errors, and how these errors in reasoning completely

invalidate the reality of obsessional doubts. The client is educated that obsessional doubts are not

the same as normal doubts. Normal doubts come about for legitimate reasons, whereas

obsessional doubts always come about without any basis in objective reality. Also, the client is

shown how an underlying imaginary narrative gives credibility to the doubt, and is encouraged to

explore alternative narratives that are more in line with reality and the senses. Throughout

treatment, the client is taught to trust objective reality and their senses within OCD-triggering

situations. Consequently, the client realizes that any compulsive acts are superfluous and able to

no longer engage in compulsive behaviours.

Treatment outcome studies have shown IBT to be an effective treatment for OCD. It is

also an effective treatment for the treatment of resistant cases of OCD, and those who have been

unable to benefit from other treatments.

IBT formulation

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 The image below shows how formulation works in IBT. It is based on the treatment of

repugnant obsessions, which are those obsessions associated with fears of paedophilia and

similar concerns. They are often difficult to treat because developing a hierarchy-based treatment

programme can be difficult.

IBT formulation for repugnant obsessions

ERP is undoubtedly more 'established' but IBT is developing an evidence base to support

its use. We have compared the number of RCTs (randomized controlled trials) involving both

treatments and this is summarized in the table below.

IBT offers an alternative treatment option for difficult-to-treat sexual intrusions which are

less likely to respond to standard exposure and response prevention (ERP) approaches.

Additionally, providing appropriate exposures for people with paedophilic intrusions may prove

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to be difficult, and cause anxieties for clinicians and teams. IBT may also be a treatment that

some patients find easier to adhere to; particularly those experiencing repugnant obsessions since

the levels of anxiety and distress are less, and treatment does not depend on generating increased

anxiety that the patient has to habituate to.

A comparison of CBT/ERP and IBT

The following table draws some comparisons between 'traditional' CBT/ ERCP and IBT.

Characteristic CBT/ERP IBT

Main theory Learning theory Reasoning theory

Nature of intrusions Extension of normal beliefs Intrusions are not necessarily normal

Underlying error Appraisal (and meaning) is atReasoning is faulty

fault

Focus of treatment Appraisal Doubt

Intervention In vivo exposure and responseImaginal ‘exposure’ and no response

prevention prevention. Behavioural experiments are

used for ‘reality testing’.

How do IBA and CBT compare?

Inference Based Treatment (IBT) is a cognitive-behavioral treatment (CBT), but is

different from CBT from how it is usually applied in treating OCD. The main difference is that

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an Inference Based Approach (IBA) has a different explanation on the cause of OCD than most

other cognitive models. And because of these different explanations, the cognitive and

behavioral techniques IBT utilizes in treating OCD are not the same than those applied in

standard CBT.

Standard CBT is based on the idea that intrusive cognitions and doubts are normal, but

that these thoughts develop into obsessions depending on how the person interprets them. For

example, according to this approach, a person with thoughts about harming someone will

develop obsessions if these thoughts are given importance or negatively interpreted. If on the

other hand, they are simply dismissed as insignificant thoughts by the person with OCD then

they will no longer provoke distress and cause compulsions. For this reason, cognitive

interventions in standard CBT are often focused on changing the appraisal of intrusive cognitions

in OCD so that they no longer provoke distress and compulsions.

IBA views this explanation of OCD as incorrect. While it is true that intrusive thoughts

are normal, and they occasionally occur to everyone, something very different is happening

when a person has OCD. In fact, in IBA to OCD, there is no such thing as an “intrusion”.

Instead, in IBA, obsessions are conceptualized as inferences or doubts (e.g. “I could be a child

molester”; “I might be contaminated”) that do not arise in the same way as intrusions in the

general population. Instead, they come about through reasoning, which occurs prior to any

appraisal. Moreover, in the case of OCD, these inferences or doubts are the result of specific

reasoning errors, which makes these thoughts feel very real, even though they are false and

incorrect. Consequently, cognitive interventions in IBT focus on teaching people with OCD to

identify the reasoning errors that lead to obsessions. And by realizing how obsessions are

incorrect, negative appraisals and compulsions will naturally disappear.

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 So the treatment targets of IBA and CBT are very different. IBA focuses on how

obsessions arise due to reasoning. CBT focuses on the consequences of the intrusion or

obsession. We can schematically present this as follows:

Above figure is an Illustration of the principal cognitive treatment targets of the Inference

Based Approach (IBA) and standard Cognitive-Behavioral Therapy (CBT) in the obsessional

sequence.

Another important difference between IBT and standard CBT is that IBT does not

include exposure in vivo and response prevention (ERP). This behavioral technique consists of

exposing oneself to feared objects and situations without engaging in any rituals or compulsions

to overcome OCD. However, while this can be an effective technique, not all OCD patients

benefit from ERP and there are a lot of people with OCD who have difficulty completing the

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exercises needed for this approach to work. However, it is still an important part of standard

CBT, often more so than cognitive interventions.

IBT is a far more cognitive approach. The reason is that when the cognitive interventions

in IBT are successful, which aim to show the person with OCD that the obsession is false, then

there is no reason to be distressed anymore, nor is there a need to engage in rituals or

compulsions. IBT does involve doing certain things, but these focus on learning how to trust

reality in OCD triggering situations, not by repeated exposure to feared objects to habituate to it.

In sum, standard CBT focuses primarily on behavioral techniques, as well as the

appraisal of intrusive cognitions, by helping the person to no longer give these thoughts

significance and importance to relieve distress and compulsions. IBT focuses on helping the

person to achieve resolution of obsessional doubt by seeing how obsessions are false and

incorrect, because once the obsession is no longer experienced as a credible doubt or idea,

distress, negative appraisal and compulsions will naturally disappear.

Advantages and Disadvantages

Advantages

 The therapy can be delivered via videoconferencing - a significant advantage during a

pandemic.

 The evidence base, although not as large as ERP, suggests comparable effectiveness.

 It doesn't rely on increasing anxiety via exposure in order for it to work. This can be

helpful in particular cases:

 Where someone has repugnant obsessions (e.g. paedophilic intrusions) and exposure-

based treatment is challenging.

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  Where someone finds it hard to engage in exposure because of the anxiety.

 If someone has already tried ERP but it has not resulted in significant improvement.

Disadvantages

 Not everyone has the IT equipment or confidence to engage in videoconference-based

therapy.

 Some people may have such severe symptoms that they need inpatient treatment.

 If it is being delivered remotely, it is a little harder to engage in the family work that is

important for all OCD treatment.

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