Looking Back, Looking Ahead: Reflections on OCD and Inference-Based CBT

Image: Winter reflections at Lossiemouth Beach, Moray.

As the year ends, I’ve been reflecting on my work with people experiencing OCD, a condition often driven by persistent doubt and “what if” thinking; and on some of the clinical questions that have stayed with me. One of the most enduring has been: how do we know when an anxious thought is OCD, and when it’s a reasonable signal about something in our environment that deserves attention?

In some commonly recognised presentations of OCD (such as repeated handwashing or checking) people often have a clear sense that their behaviour is unnecessary or disproportionate yet still feel compelled to act. In these situations, we talk about people having insight, and exposure and response prevention (ERP); a treatment that involves gradually facing feared situations while resisting compulsive responses, tends to work well.

But in my experience, OCD more often lives in greyer territory. It can be genuinely hard (for clients and therapists alike) to know where OCD ends and personal preference or values begin. Is this a choice, or a compulsion?

Traditional CBT approaches for OCD (such as ERP or appraisal based CBT) begin with an assumption that obsessive thoughts are random intrussions, not to be engaged with, but these approaches don’t offer clear guidance on how to identify that a thought is OCD. And while ERP is a highly effective treatment for many people, I began to notice an unintended consequence in some of my work. By externalising OCD as something separate from the self, clients can start to doubt their own experiences and judgement. I found that people often looked to me for answers: Is this OCD, or a real concern? Should I act on this, or ignore it?

As a clinician who wants to support autonomy and trust in one’s own judgement, this felt uncomfortable. Acting as an authority might offer short-term relief, but over time it risks reinforcing reliance on the therapist’s judgement rather than the client’s own. And, truthfully, there were times when I didn’t know the answer either. I wanted a better way to help people make sense of their doubts for themselves.

This is what led me to inference-based CBT (I-CBT). The I-CBT model understands obsessions as arising from a narrative built on faulty reasoning. Rather than focusing on disproving fears or tolerating uncertainty, I-CBT looks closely at how obsessional doubt is constructed; and how people come to distrust their direct experience in favour of imagined possibilities.

Learning about I-CBT has changed how I understand OCD. Obsessive doubts are not random or meaningless; they are understandable, and they can be dismantled. For people who have struggled with ERP, or who find the idea of exposure intolerable, I-CBT may offer an alternative. As the developer of I-CBT puts it: in I-CBT, you don’t confront fears—you overcome them by realising there is nothing to fear in the first place (Aardema, 2024).

This year, alongside launching my private practice, I’ve been investing time in learning and practising I-CBT. Looking ahead, I want to continue developing this area of expertise and make inference-based CBT more available to people struggling with OCD.

A key resource in the I-CBT approach is the Resolving OCD book series by Dr Frederick Aardema, which lays out the model and practical exercises directly from the developers of I-CBT. The books can be used as a self-help resource or as a complement to therapy.

If you would like to work together using I-CBT for the treatment of OCD, please get in touch or book a compatibility call. If you choose to purchase Resolving OCD to support work we do together, I will deduct the cost of the book(s) from your therapy sessions.

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Notes

I have no financial relationship with the authors or publishers of Resolving OCD. My recommendation is based solely on its clinical relevance to inference-based CBT.

Purchasing the book is entirely optional, and provision of therapy is not conditional on purchase.

The deduction will not be applied to an initial assessment appointment.

A typical course of I-CBT for OCD is around 15–20 sessions; there is no obligation to commit to any number of sessions.